A new approach to parathyroidectomy

To decrease the operative time for parathyroidectomy in patients with hypercalcemic (primary) hyperparathyroid disease, a combination of preoperative localization of a parathyroid tumor with an effective nuclear scan (scintigram) and intraoperative monitoring of parathyroid hormone (quick parathyroid hormone measurement) to ensure excision of all hyperfunctioning tissue was studied.

For many years, persistent hypercalcemia after parathyroidectomy (3% to 10%) has been constant and is usually due to the surgeon's failure to remove all hyperfunctioning glands. A marked decrease in parathormone level after excision of a single large gland predicts operative success and a return to normal calcium levels. Conversely, persistent high levels of parathyroid hormone indicate excess secretion by another gland(s) and the need for further exploration. Recently Tc-99m-sestamibi (MIBI) scintigraphy was shown to be more effective in localizing parathyroid tumors than previous methods. A combination of both techniques could be useful to the surgeon if they improve the operative success rate and are cost-effective.

Parathyroidectomy was performed on 18 patients with primary hyperparathyroid disease, with tumors localized by MIBI scintigrams. When excision of the identified parathyroid gland was accomplished, the operation was terminated and quick parathyroid hormone was measured to confirm that all hyperfunctioning tissue was removed.

Sixteen patients with positive results of scintigram had successful parathyroidectomies confirmed by quick parathyroid hormone measurement with a cervical approach. Two patients with mediastinal tumors localized by MIBI scintigraphy could not be resected using this approach. One false-positive/false-negative scintigram was obtained. Compared with patients having parathyroidectomy without localization and hormone monitoring, the average operative time was shortened from 90 to 36 minutes.

Localization and successful excision of parathyroid tumors with confirmation that no other hyperfunctioning glands were present by quick parathyroid hormone monitoring can predict a return to normal calcium levels and a decrease in operative time in parathyroidectomy.