title: Is intraoperative parathyroid hormone monitoring necessary with ipsilateral parathyroid gland visualization during anticipated unilateral exploration for primary hyperparathyroidism: a two-institution analysis of more than 2,000 patients.
abstract: BACKGROUND
  Intraoperative parathyroid hormone (ioPTH) monitoring during focused parathyroidectomy for primary hyperparathyroidism (PHPT) is used commonly, but some argue that ioPTH adds little if a normal ipsilateral parathyroid gland (IPG) is visualized. This hypothesis was tested for validity.
  
  
  METHODS
  The prospective databases of consecutive patients with PHPT undergoing initial parathyroidectomy with ioPTH at two academic institutions were queried. Patients with ectopic adenoma, familial PHPT, previous parathyroidectomy, planned bilateral exploration, or <6 months follow-up were excluded. Persistence was defined as hypercalcemia at <6 months.
  
  
  RESULTS
  From 1998 to 2013, 2,162 patients met inclusion criteria, and the rate of persistent disease was 1.5%. Most (n = 1,353; 63.5%) underwent single-gland resection with ioPTH and no IPG visualization, with 1% persistence. Among patients with a single adenoma resected and a normal IPG visualized, 15.2% had contralateral disease. Resection based on IPG appearance alone would have resulted in 13% persistent disease.
  
  
  CONCLUSIONS
  In PHPT, the cure rate for initial unilateral exploration guided by ioPTH is 98.5% versus a predicted rate of 87% when decision making is based on IPG appearance alone. Routine visualization of IPG is not necessary during exploration for suspected single adenoma guided by ioPTH. ioPTH remains useful in optimizing outcomes.
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, WI.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Rajaei
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, WI. Electronic address: oltmann@surgery.wisc.edu.
authors.forename: Sarah C
authors.initials: SC
authors.lastname: Oltmann
authors.affiliation: Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Cameron D
authors.initials: CD
authors.lastname: Adkisson
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, WI.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Elfenbein
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, WI.
authors.forename: Herbert
authors.initials: H
authors.lastname: Chen
authors.affiliation: Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Sally E
authors.initials: SE
authors.lastname: Carty
authors.affiliation: Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Kelly L
authors.initials: KL
authors.lastname: McCoy
mesh_terms: D000236:Adenoma / Q000150:complications / Q000473:pathology / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000097:blood / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010280:Parathyroid Glands / Q000473:pathology* / Q000601:surgery; D010281:Parathyroid Hormone / Q000097:blood*; D010282:Parathyroid Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery*; D016105:Parathyroidectomy; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D010281:Parathyroid Hormone