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GUEST EDITORIAL
Year : 2009  |  Volume : 55  |  Issue : 4  |  Page : 239-240

Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring: When and why?


Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University, College of Medicine, 37 Pradnicka Street, 31-202 Krakow, Poland

Date of Web Publication14-Jan-2010

Correspondence Address:
M Barczynski
Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University, College of Medicine, 37 Pradnicka Street, 31-202 Krakow
Poland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.58923

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How to cite this article:
Barczynski M. Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring: When and why?. J Postgrad Med 2009;55:239-40

How to cite this URL:
Barczynski M. Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring: When and why?. J Postgrad Med [serial online] 2009 [cited 2020 Feb 21];55:239-40. Available from: http://www.jpgmonline.com/text.asp?2009/55/4/239/58923


Minimally invasive parathyroidectomy (MIP) has gained worldwide acceptance in the surgical treatment of sporadic primary hyperparathyroidism (pHPT), replacing the gold standard of bilateral neck exploration in patients' with a presumed solitary parathyroid adenoma. [1],[2] Recent advances in parathyroid imaging allow for highly accurate selection of patients with pHPT for MIP. [3] Quick intraoperative parathyroid hormone assay (IOPTHA) is used to monitor intraoperatively the quality of surgery, whereas local anesthesia can be used for this operation to shorten the hospital stay. [4] The cost-effectiveness of these adjuncts in improving outcomes of parathyroid surgery were discussed in detail at the 3 rd Workshop of the European Society of Endocrine Surgeons (ESES) in Lund, Sweden (March 19-21,2009) and briefly summarized as the propositional statement of the ESES on modern techniques in pHPT surgery. [5]

The article by Haciyanli et al. entitled "Minimally invasive focused parathyroidectomy without using intraoperative parathyroid hormone monitoring or gamma probe", despite the relatively small number of patients involved, provides a well-organized analysis of the major problems frequently encountered by the surgeon offering MIP to the patients with pHPT living in endemic goiter region. [6]

Both ultrasound of the neck and parathyroid scintigraphy are usually performed as initial localization studies, with a good overall diagnostic accuracy, reaching 90-99% in patients without concomitant goiter. The coexistence of thyroid disease with pHPT, particularly true in the case of nodular goiter, has been reported to increase the rate of false-positive observations to as much as 15-20% of studies because of difficulties in distinguishing an enlarged parathyroid gland from other cervical masses. This issue remains a serious problem in countries with a high prevalence of nodular goiter due to iodine deficiency limiting the number of candidates for MIP to 50-67% of all pHPT patients. [3],[7],[8]

There are many different techniques of MIP (open, video-assisted, or endoscopic), but regardless of the technique all these minimally invasive operations share the same philosophy of the image-guided selective removal of a single parathyroid adenoma. The term "selective parathyroidectomy" should be probably preferred because it implies removal of a single adenoma, it means leaving functional parathyroid tissue behind, and it emphasizes the need for appropriate patient selection. [1],[2],[5] The issue of appropriate patient selection plays a fundamental role in achieving a high success rate of MIP approaching 100%. When concordant results of sestamibi and ultrasound performed by an experienced investigator are obtained, MIP can be safely recommended. [1],[5] The prevalence of multiglandular parathyroid disease among patients with pHPT and concordant imaging tests varies from 1 to 3.5%. [7] Thus, when preoperative localization with sestamibi and ultrasound is concordant for single-gland disease, the use of IOPTHA is of little value. However, if preoperative localization with sestamibi and ultrasound is not concordant and the surgeon wishes to perform a minimally invasive "selective" operation, the use of IOPTHA is recommended as the prevalence of multiglandular disease in this subgroup of pHPT patients approaches 17%.[4],[5],[8] Similarly, the use of IOPTHA is recommended for patients undergoing selective parathyroidectomy on the basis of a single preoperative localization study. [4],[8]

On the other hand, the accuracy of IOPTHA in the detection of patients with multiglandular disease is highly dependent on the criteria applied. Our recent study has shown that Miami criterion [9] followed by Vienna criterion [10] is the best balanced among other criteria, with the highest accuracy in intraoperative prediction of cure. [7] However, Rome criterion [11] followed by Halle criterion [10] is most useful in intraoperative detection of multiglandular disease. [7] Nevertheless, their application in patients qualified for MIP with concordant results of sestamibi scanning and ultrasound of the neck would result in a significantly higher number of negative conversions to bilateral neck explorations and only a marginal improvement in the success rate of primary operations. [7]

Contrary to the relatively common use of IOPTHA during parathyroid surgery which is employed by 68% members of the International Association of Endocrine Surgeons (IAES), the intraoperative use of the gamma probe to localize parathyroid lesions is seldom employed by endocrine surgeons, as only 14% of IAES members admit to using this technique in their practice. [12]

Finally, it should be stressed that MIP can be recommended only for surgeons with the appropriate experience in conventional parathyroid surgery (bilateral neck exploration). It is not the operation for "beginners", as there are many potential entrapments which can be encountered during this, easy at first sight, operation. Experience and sound clinical judgment cannot be replaced by any novel technological adjunct.

 
 :: References Top

1.Mihai R, Barczyñski M, Iacobone M, Sitges-Serra A. Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations. Langenbecks Arch Surg 2009;394:785-98.  Back to cited text no. 1      
2.Sitges-Serra A, Rosa P, Valero M, Membrilla E, Sancho JJ. Surgery for sporadic primary hyperparathyroidism: Controversies and evidence-based approach. Langenbecks Arch Surg 2008;393:239-44.  Back to cited text no. 2      
3.Mihai R, Simon D, Hellman P. Imaging for primary hyper parathyroidism-An evidence-based analysis. Langenbecks Arch Surg 2009;394:765-84.  Back to cited text no. 3      
4.Harrison B, Triponez, F. Intraoperative adjuncts in surgery for primary hyperparathyroidism. Langenbecks Arch Surg 2009;394:799-809.  Back to cited text no. 4      
5.Bergenfelz A, Hellman P. Harrison B, Sitges-Serra Antonio, Dralle H. Positional statement of the European Society of Endocrine Surgeons (ESES) on modern techniques in pHPT surgery. Langenbecks Arch Surg 2009;394:761-4.  Back to cited text no. 5      
6.Haciyanli M, Genc H, Damburacý N, Oruk G, Tutuncuoglu P, Erdogan N. Minimally invasive focused parathyroidectomy without using intraoperative parathyroid hormone monitoring or gamma probe. J Postgrad Med 2009;55:242-6.  Back to cited text no. 6    Medknow Journal  
7.Barczyñski M, Konturek A, Hubalewska-Dydejczyk A, Cichon S, Nowak W. Evaluation of Halle, Miami, Rome, and Vienna intraoperative iPTH assay criteria in guiding minimally invasive parathyroidectomy. Langenbecks Arch Surg 2009;394:843-9.  Back to cited text no. 7      
8.Barczyñski M, Konturek A, Cichoñ S, Hubalewska-Dydejczyk A, Go³kowski F, Huszno B. Intraoperative parathyroid hormone assay improves outcomes of minimally invasive parathyroidectomy mainly in patients with a presumed solitary parathyroid adenoma and missing concordance of preoperative imaging. Clin Endocrinol 2007;66:878-85.  Back to cited text no. 8      
9.Caneiro DM, Solorzano CC, Nader MC, Ramirez M, Irvin GL III. Comparison of intraoperative iPTH assay (QPTH) criteria in guiding parathyroidectomy: Which criterion is the most accurate? Surgery 2003;134:973-9.  Back to cited text no. 9      
10.Riss P, Kaczirek K, Heinz G, Biglmayer C, Niederle B. A "defined baseline" in PTH monitoring increases surgical success in patients with multiple gland disease. Surgery 2007;142:398-404.  Back to cited text no. 10      
11.Lombardi CP, Raffaelli M, Traini E, Di Stasio E, Carrozza C, De Crea C, Zuppi C, Bellantone R. Intraoperative PTH monitoring during parathyroidectomy: The need for stricter criteria to detect multiglandular disease. Langenbecks Arch Surg 2008;393:639-45.  Back to cited text no. 11      
12.Sackett WR, Barraclough B, Reeve TS, Delbridge LW. Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy. Arch Surg 2002;137:1055-9.  Back to cited text no. 12      



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