Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach.
BACKGROUND
Advances in preoperative imaging and use of intraoperative parathyroid hormone (IOPTH) levels are changing the approach to reoperative parathyroidectomy (ReopPTX). We sought to develop a protocol for imaging and IOPTH monitoring that allows for a focused, successful operative approach.


METHODS
We reviewed our prospective database of consecutive patients with primary hyperparathyroidism who underwent ReopPTX with IOPTH monitoring between December 1999 and June 2007.


RESULTS
Thirty-nine patients underwent 43 ReopPTXs for persistent (79%)/recurrent (21%) disease. All underwent ultrasonography and sestamibi imaging; 24 cases (56%) underwent additional imaging studies. Sensitivity of ultrasonography was 56%, sestamibi 53%, both studies 67%, computed tomography (CT) 48%, magnetic resonance imaging (MRI) 67%, and selective venous sampling (SVS) 50%. IOPTH monitoring predicted accurately cure in 100% and failure in 78%. A focused/unilateral approach was performed in 60%; median operative time was 45 minutes (range, 12-127). At last follow-up, 36 (92%) patients were normocalcemic.


CONCLUSIONS
We propose that ultrasonography and sestamibi studies should be done before all ReopPTXs; failure to localize should prompt sequential CT, MRI, and SVS until localization is achieved. IOPTH monitoring defines cure and is recommended for all ReopPTXs. This algorithm allows for a focused operative approach in >50% of ReopPTXs with operative times comparable with first-time, minimally invasive parathyroidectomy.
Section of Endocrine Surgery, Division of General Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA. tyen@mcw.edu
Tina W F
TW
Yen
Tracy S
TS
Wang
Kara M
KM
Doffek
Elizabeth A
EA
Krzywda
Stuart D
SD
Wilson
D000328:Adult; D000368:Aged; D000465:Algorithms; D003952:Diagnostic Imaging / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006961:Hyperparathyroidism / Q000175:diagnosis* / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D010281:Parathyroid Hormone / Q000032:analysis*; D016105:Parathyroidectomy / Q000009:adverse effects / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D012008:Recurrence; D012042:Registries; D012086:Reoperation / Q000379:methods; D018570:Risk Assessment; D017751:Safety Management; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D017256:Technetium Tc 99m Sestamibi; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler
D010281:Parathyroid Hormone; D017256:Technetium Tc 99m Sestamibi