A NEW APPROACH TO PARATHYROIDECTOMY

Objective To decrease the operative time for parathyroidectomy in pati ents with hypercalcemic (primary) hyperparathyroid disease, a combinat ion of preoperative localization of a parathyroid tumor with an effect ive nuclear scan (scintigram) and intraoperative monitoring of parathy roid hormone (quick parathyroid hormone measurement) to ensure excisio n of all hyperfunctioning tissue was studied. Summary Background Data For many years, persistent hypercalcemia after parathyroidectomy (3% t o 10%) has been constant and is usually due to the surgeon's failure t o remove all hyperfunctioning glands. A marked decrease in parathormon e level after excision of a single large gland predicts operative succ ess and a return to normal calcium levels. Conversely, persistent high levels of parathyroid hormone indicate excess secretion by another gl and(s) and the need for further exploration. Recently Tc-99m-sestamibi (MIBI) scintigraphy was shown to be more effective in localizing para thyroid 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. Methods Parathyroidectomy was performed o n 18 patients with primary hyperparathyroid disease, with tumors local ized by MIBI scintigrams. When excision of the identified parathyroid gland was accomplished, the operation was terminated and quick parathy roid hormone was measured to confirm that all hyperfunctioning tissue was removed. Results Sixteen patients with positive results of scintig ram had successful parathyroidectomies confirmed by quick parathyroid hormone measurement with a cervical approach. Two patients with medias tinal tumors localized by MIBI scintigraphy could not be resected usin g this approach. One false-positive/false-negative scintigram was obta ined. Compared with patients having parathyroidectomy without localiza tion and hormone monitoring, the average operative time was shortened from 90 to 36 minutes. Conclusions Localization and successful excisio n of parathyroid tumors with confirmation that no other hyperfunctioni ng glands were present by quick parathyroid hormone monitoring can pre dict a return to normal calcium levels and a decrease in operative tim e in parathyroidectomy.