Parathyroid reoperation with use of technetium 99m sestamibi radiolocalization and an intraoperative gamma counter

To describe a new intraoperative technique for localization of abnormal parathyroid tissue.

We report a case and discuss the difficulties encountered in reexploration of the neck area.

Parathyroid reoperation remains a formidable challenge to even the most experienced endocrine surgeon. Despite the advances in radiographic imaging and localization techniques, accurate intraoperative identification of abnormal parathyroid tissue in a scarred field with obliterated anatomic planes is frequently tedious and occasionally unsuccessful. In a 48-year-old woman with hyperparathyroidism, extensive exploration of the area identified (on the basis of preoperative magnetic resonance imaging and technetium 99m sestamibi scans) as suspicious for the presence of abnormal parathyroid tissue revealed only an aberrant vein. With use of a handheld gamma counter to provide intraoperative guidance during parathyroid reexploration after preoperative intravenous injection of technetium 99m sestamibi, quick identification of a small, intrathyroidal, fifth gland adenoma responsible for persistent primary hyperparathyroidism was facilitated.

Because of suboptimal precision and specificity, current preoperative localization studies can occasionally provide misleading information. Particularly in difficult cases of parathyroid reexploration, an instrument capable of localizing abnormal parathyroid tissue, which can be used intraoperatively with ease, can be an invaluable tool to ensure a safe, expedient, and successful surgical outcome.