Improved success rate in reoperative parathyroidectomy with intraoperativePTH assay

Objective The clinical usefulness of preoperative localization and intraope rative PTH assay (QPTH) in primary hyperparathyroidism have been establishe d. However, without the use of QPTH, the parathyroidectomy failure rate rem ains 5% to 10% in large reported series and is probably much higher in the hands of less experienced parathyroid surgeons. Persistent hypercalcemia re quires another surgical procedure. The authors compared the outcomes in 50 consecutive patients undergoing more difficult secondary parathyroidectomy with and without the adjunctive support of QPTH. Methods Two groups of similar patients underwent reoperative parathyroidect omy for failed surgery or recurrent disease. The successful return to normo calcemia in group I. with QPTH used to localize and confirm complete excisi on of all hyperfunctioning glands, was compared with group II, who did not have this intraoperative adjunct. Results In 31/33 patients in group I, calcium levels returned to normal. Wi th good preoperative localization studies, 17 patients underwent successful straightforward parathyroidectomies as predicted by QPTH. In the other 14 patients, QPTH assay proved extremely beneficial by facilitating localizati on with differential venous sampling: measuring the increase in hormone sec retion after massage of specific areas; recognizing suspicious nonparathyro id tissue excised without a decrease in hormone levels, avoiding frozen-sec tion delay; and correctly identifying the excision of abnormal tissue despi te false-positive/false-negative sestamibi scans. In group II, who underwen t surgery before QPTH was available, 4 of 17 patients (24%) remained hyperc alcemic after extensive reexploration. Conclusion With the intraoperative hormone assay used to facilitate localiz ation and confirm excision of all hyperfunctioning tissue, the success rate of reoperative parathyroidectomy has improved from 76% to 94%.