Elsevier

Surgery

Volume 164, Issue 1, July 2018, Pages 130-136
Surgery

Endocrine
Preoperative localization modalities in primary hyperparathyroidism: Correlation with postoperative cure

https://doi.org/10.1016/j.surg.2018.02.016Get rights and content

Abstract

Background

Accurate preoperative localization is critical to the success of minimally invasive parathyroidectomy. This investigation aimed to assess the correlation among preoperative imaging results, intraoperative findings, and postoperative cure rates in patients undergoing operation for primary hyperparathyroidism.

Methods

A retrospective review of all patients who underwent operation for primary hyperparathyroidism between June 2010 and March 2016 was performed.

Results

During the study period, 398 patients underwent parathyroidectomy. The overall cure rate was 97.5%. The ultrasonography performed by the surgeon was superior to the ultrasonography performed by the radiologist and to the sestamibi scan in lateralizing the adenoma correctly (80% vs 62% vs 70%, P < .001, respectively), and had the greatest sensitivity (93%) and accuracy (80%) among all tests (P < .001). Age ≥65 was found to be associated with lesser cure rates (94% vs 99.2%, P = .003). The number of positive preoperative studies correlated with cure rate, ranging from 80% for patients with 0 positive studies, to 100% in those with 4 positive studies (P = .0004). In patients with a negative sestamibi and an ultrasonography performed by the radiologist, there was no significant difference in the cure rates among those with no preoperative computed tomography, a positive preoperative computed tomography, or a negative preoperative computed tomography.

Conclusion

An ultrasonography performed by an experienced surgeon is an extremely valuable preoperative localization modality. The cure rate obtained is proportional to the number of positive imaging studies. In patients with negative ultrasonography performed by a nonexperienced radiologist and a negative sestamibi scan, the performance of computed tomography does not seem to increase cure rate. Patients with no positive preoperative scans represent a challenging subgroup, with cure rates of approximately 80%.

Section snippets

Methods

A retrospective review of the patient databases of the surgery departments at Hadassah – Hebrew University Medical Center, Mount Scopus and Rambam Hospital identified patients who underwent PTX for pHPT at these 2 institutions between June 1, 2010 and March 31, 2016. The study was approved by the institutional review board committees. Operative treatment was offered to symptomatic and asymptomatic patients with pHPT according to previously published guidelines.18, 19, 20

All patients managed

Results

Between July 2010 and March 2016, a total of 398 patients underwent PTX due to pHPT. Their mean age was 57±15 years, and 212 (53.3%) were females. The patients had mean preoperative serum calcium and PTH levels of 11.2±0.8 mg/dL and 170±203 pg/mL, respectively. With regard to preoperative localization, the mean number of imaging studies performed per patient was 2.7±0.6 studies, with a median of 3 studies per patient. Of the 398 patients, 221 (55.5%) underwent MIP, 54 (13.6%) underwent

Discussion

PTX is the only established definitive treatment for pHPT. Historically, bilateral neck exploration represented the standard of care in parathyroid surgery with long-term cure rates exceeding 95%.22 An improvement in preoperative localization modalities, in addition to the development of IoPTH testing, enabled the transition to MIP as an operative approach to patients with pHPT.1, 8 This approach provides the possible benefits of smaller incisions, lesser duration of operations, decreased

Conclusion

The US performed by an experienced surgeon is an extremely valuable preoperative localization modality in pPHT. The cure rate obtained is proportional to the number of positive imaging studies. In patients with negative US performed by a radiologist and a negative sestamibi scan, the performance of CT does not seem to increase cure rate. Patients with no positive preoperative scans represent a challenging subgroup, with cure rates of approximately 80%.

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