Minimally Invasive Parathyroidectomy: Benefits and Requirements of Localization, Diagnosis, and Intraoperative PTH Monitoring. Long-Term Results

Background Surgery is the only curative treatment for primary hyperparathyroidism. Initial parathyroidectomy procedures fail due to ectopic gland location and unappreciated multigland disease. Methods An evidence-based literature review was performed, which surveyed all human studies in PubMed, searching for parathyroidectomy in humans between 1990 and 2009. Between 10 and 30% of patients have multigland disease caused by double adenomas or hyperplasia. Use of preoperative imaging studies and intraoperative PTH monitoring helps parathyroid surgeons overcome these obstacles. Results Sestamibi nuclear scan and neck ultrasound identify 70-80% of abnormal glands in patients with single adenomas. The sensitivity of ultrasound or sestamibi to identify all abnormal glands in patients with multigland disease is extremely low. Intraoperative PTH monitoring should be utilized in all patients who undergo neck exploration for primary hyperparathyroidism to reduce failures due to multigland disease. Blood samples should be drawn from peripheral veins only and a postresection level 10-15 min after gland removal should have a > 50% decrease from baseline preoperative levels, and also must go to the normal range for the PTH assay being used. Conclusions Contemporary prospective studies ( level of evidence III/IV) show that by combining preoperative imaging and IOPTH it is possible to maximize performance of successful outpatient minimally invasive parathyroidectomy.