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Is Bilateral Exploration Still the Standard of Care for Primary Hyperparathyroidism?

by Zachary J. Cappello, BS, and Jeffrey M. Bumpous, MD •

Trio Best Practice

Background

Primary hyperparathyroidism (HPT) is a relatively common surgical disease caused principally by single-gland enlargement and hyperfunction. In experienced hands, 95% of patients are rendered normocalcemic after parathyroidectomy, with minimal morbidity. Traditionally, a bilateral neck exploration (BNE) is the technique of choice. However, new methods are continually being explored to further increase the success rate and decrease the morbidity, including intraoperative ultrasonography, methylene blue localization, selective venous sampling, intraoperative intact parathyroid hormone monitoring, sestamibi scanning, four-dimensional computed tomography, and the use of radio guidance. In this Triological Society Best Practice review, we examined the evidence regarding the use of intraoperative radio guidance for parathyroidectomy in primary HPT compared to the use of the traditional BNE procedure.

Best Practice

Based on the literature review and statistical analysis, the use of intraoperative radio guidance for parathyroidectomy does not decrease the rate of complications when compared to BNE, and cure rates (eucalcemia) are equivalent between radio-guided parathyroidectomy and bilateral neck exploration. Gamma probe incorporation into unilateral parathyroid exploration may improve rapid localization with more experienced investigators, but there may be a learning curve. Therefore, it is felt that either procedure can be implemented with confidence that the patient will be rendered normocalcemic. However, it should be noted that intraoperative PTH can be used as an adjunct in focused explorations to assure biochemical success.

Finally, when cost is the driving force, MIRP where appropriate (localizable single gland disease) is preferred. By using MIRP, the operator not only reduces the cost to both the hospital and the patient, but importantly, also decreases the time under anesthesia, which decreases the chance of harm to the patient. Read the full article in The Laryngoscope.