title: Successful minimally invasive surgery for primary hyperparathyroidism: influence of preoperative imaging and intraoperative parathyroid hormone levels.
abstract: OBJECTIVE
  Adenoma is the main parathyroid disorder leading to primary hyperparathyroidism (PHP). Minimally invasive parathyroidectomy (MIP) is recognized as a valid procedure for adenoma-related PHP. It requires precise preoperative localization combining Tc-99m-MIBI (methoxy-isobutyl-isonitrile) scintigraphy and single-photon emission computed tomography (SPECT) with x-ray computed tomography (CT) and intraoperative confirmation of successful excision by change in intact parathormone (iPTH) levels. The study aim was to assess the surgery success in relation to these two parameters.
  
  
  METHODS
  All patients operated on for PHP from 2005 to mid-2014 at our institution were retrospectively reviewed. MIP was performed in case of precise preoperative adenoma localization on scintigraphy, absence of past cervical surgery, and absence of concomitant thyroid resection necessity. In these patients, iPTH levels were monitored intraoperatively. Confirmation criteria for iPTH values were a return to normal level or a decrease >50 % of basal iPTH level.
  
  
  RESULTS
  There were 197 PHP operations during the study period: 118 MIP and 79 bilateral neck explorations (BNEs). The MIP success rate was 95 % (112/118) with a preoperative MIBI scan ± CT accurate in 94 % (111/118) of the patients and with correct iPTH in 90 % (106/118) of the cases. Among the 12 iPTH levels that did not meet the confirmation criteria, 10 returned to normal range by postoperative day 2. Treatment failure appeared in three patients (one BNE, two MIPs).
  
  
  CONCLUSIONS
  Tc-99m-MIBI dual-phase scintigraphy with SPECT/CT is the key examination for functional and morphological parathyroid adenoma localization. If preoperative scintigraphy is obvious and intraoperative assessment is clear, one could possibly safely omit iPTH, as it may lead to unnecessary BNE in primary PHP.
authors.affiliation: Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
authors.forename: Gaëtan-Romain
authors.initials: GR
authors.lastname: Joliat
authors.affiliation: Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Demartines
authors.affiliation: Department of Endocrinology, University Hospital CHUV, Lausanne, Switzerland.
authors.forename: Luc
authors.initials: L
authors.lastname: Portmann
authors.affiliation: Department of Nuclear Medicine, University Hospital CHUV, Lausanne, Switzerland.
authors.forename: Ariane
authors.initials: A
authors.lastname: Boubaker
authors.affiliation: Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland. maurice.matter@chuv.ch.
authors.forename: Maurice
authors.initials: M
authors.lastname: Matter
mesh_terms: D000236:Adenoma / Q000150:complications / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D064847:Multimodal Imaging; D010281:Parathyroid Hormone / Q000097:blood; D010282:Parathyroid Neoplasms / Q000150:complications / Q000601:surgery; D016105:Parathyroidectomy / Q000379:methods*; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D016896:Treatment Outcome
chemical_list: D010281:Parathyroid Hormone; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi
keywords: Intraoperative parathyroid level; Minimally invasive surgery; Parathyroidectomy; Scintigraphy