RESUMEN
BACKGROUND: Preoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. METHODS: Patients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. RESULTS: Parathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. CONCLUSION: Parathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results.
Asunto(s)
Hiperparatiroidismo/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Paratiroidectomía/métodos , Radiografía Intervencional/métodos , Reoperación/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hiperparatiroidismo/sangre , Hiperparatiroidismo/diagnóstico , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Glándulas Paratiroides/irrigación sanguínea , Glándulas Paratiroides/cirugía , Hormona Paratiroidea/sangre , Cintigrafía , Recurrencia , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Venas , Adulto JovenRESUMEN
BACKGROUND: Surgery is the only curative treatment for primary hyperparathyroidism. Initial parathyroidectomy procedures fail due to ectopic gland location and unappreciated multigland disease. METHODS: An evidence-based literature review was performed,which surveyed all human studies in PubMed, searching for parathyroidectomy in humans between 1990 and 2009. Between 10 and 30% of patients have multigland disease caused by double adenomas or hyperplasia. Use of preoperative imaging studies and intraoperative PTH monitoring helps parathyroid surgeons overcome these obstacles. RESULTS: Sestamibi nuclear scan and neck ultrasound identify 70-80% of abnormal glands in patients with single adenomas. The sensitivity of ultrasound or sestamibi to identify all abnormal glands in patients with multigland disease is extremely low. Intraoperative PTH monitoring should be utilized in all patients who undergo neck exploration for primary hyperparathyroidism to reduce failures due to multigland disease. Blood samples should be drawn from peripheral veins only and a postresection level 10-15 min after gland removal should have a >50%decrease from baseline preoperative levels, and also must go to the normal range for the PTH assay being used. CONCLUSIONS: Contemporary prospective studies (level of evidence III/IV) show that by combining preoperative imaging and IOPTH it is possible to maximize performance of successful outpatient minimally invasive parathyroidectomy.