Initial Parathyroidectomy

From 294 consecutive patients with more than 6 months of follow-up (an average of 34 months [range, 6 to 98 months]), including all known operative failures, 262 had initial parathyroidectomies. Two-hundred-fifty-seven patients (98%) had successful procedures and five were operative failures. During the operative procedure, QPTH correctly predicted postoperative outcome in 254 (97%) of 262 patients, including 4 of 5 operative failures. Using the protocol and the criterion described in this chapter, QPTH wrongly predicted the postoperative outcome in eight patients, with one false-positive result and seven false-negative results. The false-negative results did not lead to unnecessary neck exploration in these patients since a 20-minute postexcision sample was drawn that showed a sufficient hormone drop to lead the surgeon to suspend further exploration. The delayed hormone drop was probably due to a premature timing of the pre-excision sampling or unavailability of this important sample because of venous access problems. A false delayed drop is the result of a missed peak of the hormone level and not due to a delayed metabolism. There was one false-positive result leading to an operative failure within this 9-year period. This patient had a parathyroid cyst ruptured during dissection with an increase in the peripheral PTH level to 1100 pg/mL. With a drop of 62% in 10 minutes and 80% in 20 minutes, further neck exploration was not performed. Even though this is only a hypothesis, we believe that this fluid, with a high content of PTH spilled in the operative field, altered the hormone dynamic, thus generating a false-positive result. On the other hand, QPTH predicted the presence of MGD in 8 of 9 patients. The incidence of MG in this group presenting with a success rate of 98% is 3.4%. In addition, QPTH pointed out, with a specificity of 100%, the continued presence of a hyperfunctioning gland in patients in whom nonparathyroid tissue was mistakenly resected as a gland (26 of 35 patients with true-negative results not caused by MGD).

Using this operative approach with QPTH guiding an initial limited parathyroidectomy, 238 (91 %) of 262 patients had a successful unilateral neck exploration. In terms of length of stay, 183 (70%) of 262 patients were discharged on the day of surgery or stayed at the hospital overnight for social reasons (living alone or out of town). The average operative time for these 262 initial patients was 60 minutes (range, 15 to 300 minutes).

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