Advantages of QPTH and Criterion

The QPTH as used with the described criterion not only can determine when complete resection of all hypersecreting tissue is accomplished but the assay can also guide the surgeon in localizing the offending gland(s).

Pre-incision Pre-excision 5 min 10 min Timed operative blood samples FIGURE 52-3. Representation of intraoperative hormone monitoring in a patient with a single gland involved. During resection of the parathyroid gland, the intact parathyroid hormone (PTH) level increased significantly, leading to a 76% drop in 10 minutes after gland resection and predicting operative success. This graph shows the importance of the pre-excision sample sample in some patients. If only the preincision sample had been measured, the criterion would not have been met in 10 minutes with a drop of only 40%. This false-negative result can and was prevented by a correct registration of the peak of the hormone caused by gland manipulation.

PTH pg/mL 76% from pre-excision 250

(145

40% from pre-incision optional and is measured in an attempt to predict a rapid fall in the PTH level before the lQ»minute interval, allowing the surgeon to close the cervical incision earlier. Manipulation of normal parathyroid glands can elevate PTH; therefore, before the 5-minute sample is taken, cervical manipulation, except for fascia and skin closure, should not be performed. Since only 81 % of successfully treated patients have a 50% or greater drop in hormone level at 5 minutes, a sample taken 10 minutes after gland resection is always indicated. This last measurement will determine operative success or not. If a significant hormone level drop is not found in 10 minutes, the surgeon should continue further neck exploration for an additional hyperfunctioning gland(s). The same protocol is used for each gland or suspected tissue resected with pre-excision, and 5 and 10-minute levels measured.

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