Intraoperative Monitoring of PTH

Intraoperative measurement of intact PTH concentration during parathyroidectomy was first described by Nussbaum and associates.26 A highly sensitive intact PTH assay was modified, enabling the incubation time to be shortened to about 15 minutes. After removal of a parathyroid adenoma, there is a sharp decrease in the PTH level if the PHPT was due to a solitary parathyroid adenoma (Fig. 49-2). Several groups27"31 have subsequently reported similar findings. An even shorter turnaround time is possible when the analytic equipment, including proper laboratory personnel, is situated in the operating room.32 When a macroscopic diagnosis is strongly suggestive of a solitary adenoma, the wound may be closed but the patient is kept under anesthesia. When the PTH level fails to drop after removal of the suspected adenoma, the removed gland either is not of parathyroid origin or is a normal parathyroid gland (Fig. 49-3). When the removed lesion is of parathyroid origin and the PTH level decreases less than 60% at 15 minutes after gland removal, parathyroid hyperplasia or double parathyroid adenoma should be suspected and a comprehensive bilateral neck exploration performed (Fig. 49-4).29 The quick intact PTH assay offers the advantage of a functional evaluation of the surgical procedure and therefore renders intraoperative histologic examination unnecessary.

Some surgeons have proposed that when the same solitary parathyroid tumor is identified by both sestamibi scintigraphy

Surgical Approach Excision of enlarged parathyroid gland

Time (min)

FIGURE 49-2. Decline of intact parathyroid hormone (PTH) after excision of one enlarged parathyroid gland in 43 patients with primary hyperparathyroidism due to a solitary parathyroid adenoma. Results are shown as a percentage of baseline value and means (± SD).

Time (min)

FIGURE 49-2. Decline of intact parathyroid hormone (PTH) after excision of one enlarged parathyroid gland in 43 patients with primary hyperparathyroidism due to a solitary parathyroid adenoma. Results are shown as a percentage of baseline value and means (± SD).

and ultrasonography, a focused parathyroid exploration can be done with a 95% success rate.33 Other surgeons suggest that from a cost-effective standpoint, same-day PTH testing for minimal invasive parathyroidectomy is superior to intraoperative PTH monitoring.34 Clearly, these issues can only be definitively resolved by a multicenter, prospective, randomized trial.

Excision of enlarged parathyroid gland 1

Excision of enlarged parathyroid gland 1

Time (min)

•—• Patients with parathyroid adenoma N = 43 ^—û No. 11

- -v No. 2 I Patients with primary parathyroid 0---0 No. 3 [ hyperplasia □---o No.4j

FIGURE 49-4. Decline of intact parathyroid hormone (PTH) in four patients with primary parathyroid hyperplasia at 15 minutes after removal of one enlarged gland compared with 43 patients with primary hyperparathyroidism due to solitary parathyroid adenomas. Individual values are shown for the patients with hyperplasia, whereas for those with parathyroid adenoma the mean is shown (±2 SD).

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