Abstract
Although there remain situations when conventional bilateral parathyroid exploration is the operation of choice for primary hyperparathyroidism, focused, single-gland exploration (minimally invasive parathyroidectomy [MIP]) has become the standard operation for most patients. Successful surgery requires accurate preoperative imaging and measurement of PTH intraoperatively (IOPTH).
IOPTH is measured prior to the beginning of anesthesia, at the time the adenoma is removed and at varying time intervals thereafter. Failure to measure IOPTH at the time of excision of the adenoma can result in failure to detect a spike in IOPTH and result in incorrect interpretation of subsequent values. Decrease of IOPTH of at least 50 % from baseline and into the normal range or to an absolute level of <40 pg/ml is indicative of successful surgery. This algorithm works even if the baseline PTH is in the normal range.
In some patients, bilateral exploration identifies enlarged, hypercellular parathyroids when the IOPTH decrease appears adequate. The clinical significance of this is uncertain. The significance of persistently elevated PTH postoperatively in patients who have successful parathyroidectomy with a decrease of calcium into the normal range also is uncertain. The performance of MIP without an adjunct assessment of the adequacy of surgery, whether IOPTH or the use of a gamma probe, can result in a higher failure rate. IOPTH is also useful when bilateral parathyroid exploration or reoperative surgery for persistent hyperparathyroidism is performed.
Keywords
- Parathyroid Gland
- Parathyroid Adenoma
- Minimally Invasive Parathyroidectomy
- Single Adenoma
- Invasive Parathyroidectomy
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsRecommended Reading
Alhefdhi A, Pinchot SN, Davis R, Sippel RS, Chen H. The necessity and reliability of intraoperative parathyroid hormone (PTH) testing in patients with mild hyperparathyroidism and PTH levels in the normal range. World J Surg. 2011;35(9):2006–9. Epub 2011/06/30.
Bergson EJ, Sznyter LA, Dubner S, Palestro CJ, Heller KS. Sestamibi scans and intraoperative parathyroid hormone measurement in the treatment of primary hyperparathyroidism. Arch Otolaryngol Head Neck Surg. 2004;130(1):87–91. Epub 2004/01/21.
Berson SA, Yalow RS, Aurbach GD, Potts JT. Immunoassay of bovine and human parathyroid hormone. Proc Natl Acad Sci USA. 1963;49(5):613–17. Epub 1963/05/01.
Carneiro DM, Solorzano CC, Nader MC, Ramirez M, Irvin 3rd GL. Comparison of intraoperative iPTH assay (QPTH) criteria in guiding parathyroidectomy: which criterion is the most accurate? Surgery. 2003;134(6):973–9; discussion 9–81. Epub 2003/12/12.
Carneiro-Pla D. Effectiveness of “office”-based, ultrasound-guided differential jugular venous sampling (DJVS) of parathormone in patients with primary hyperparathyroidism. Surgery. 2009;146(6):1014–20. Epub 2009/12/05.
Greene AB, Butler RS, McIntyre S, Barbosa GF, Mitchell J, Berber E, et al. National trends in parathyroid surgery from 1998 to 2008: a decade of change. J Am Coll Surg. 2009;209(3):332–43. Epub 2009/09/01.
Heller KS, Blumberg SN. Relation of final intraoperative parathyroid hormone level and outcome following parathyroidectomy. Arch Otolaryngol Head Neck Surg. 2009;135(11):1103–7. Epub 2009/11/18.
Hong JC, Morris LF, Park EJ, Ituarte PH, Lee CH, Yeh MW. Transient increases in intraoperative parathyroid levels related to anesthetic technique. Surgery. 2011;150(6):1069–75. Epub 2011/12/06.
Irvin 3rd GL, Dembrow VD, Prudhomme DL. Operative monitoring of parathyroid gland hyperfunction. Am J Surg. 1991;162(4):299–302. Epub 1991/10/01.
Kebebew E, Hwang J, Reiff E, Duh QY, Clark OH. Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model. Arch Surg. 2006;141(8):777–82; discussion 82. Epub 2006/08/23.
Libutti SK, Alexander HR, Bartlett DL, Sampson ML, Ruddel ME, Skarulis M, et al. Kinetic analysis of the rapid intraoperative parathyroid hormone assay in patients during operation for hyperparathyroidism. Surgery. 1999;126(6):1145–50; discussion 50–1. Epub 1999/12/22.
Mazzaglia PJ, Berber E, Kovach A, Milas M, Esselstyn C, Siperstein AE. The changing presentation of hyperparathyroidism over 3 decades. Arch Surg. 2008;143(3):260–6. Epub 2008/03/19.
Norman J, Lopez J, Politz D. Abandoning unilateral parathyroidectomy: why we reversed our position after 15,000 parathyroid operations. J Am Coll Surg. 2012;214(3):260–9. Epub 2012/01/24.
Nussbaum SR, Thompson AR, Hutcheson KA, Gaz RD, Wang CA. Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism. Surgery. 1988;104(6):1121–7. Epub 1988/12/01.
Perrier ND, Ituarte P, Kikuchi S, Siperstein AE, Duh QY, Clark OH, et al. Intraoperative parathyroid aspiration and parathyroid hormone assay as an alternative to frozen section for tissue identification. World J Surg. 2000;24(11):1319–22. Epub 2000/10/19.
Richards ML, Thompson GB, Farley DR, Grant CS. An optimal algorithm for intraoperative parathyroid hormone monitoring. Arch Surg. 2011;146(3):280–5. Epub 2011/03/23.
Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, et al. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008;248(3):420–8. Epub 2008/09/16.
Suliburk JW, Sywak MS, Sidhu SB, Delbridge LW. 1000 minimally invasive parathyroidectomies without intra-operative parathyroid hormone measurement: lessons learned. ANZ J Surg. 2011;81(5):362–5. Epub 2011/04/27.
Wang TS, Ostrower ST, Heller KS. Persistently elevated parathyroid hormone levels after parathyroid surgery. Surgery. 2005;138(6):1130–5; discussion 5–6. Epub 2005/12/20.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2014 Springer Science+Business Media New York
About this chapter
Cite this chapter
Heller, K.S. (2014). Use of Intraoperative Parathyroid Hormone Assay. In: Terris, D., Singer, M. (eds) Minimally Invasive and Robotic Thyroid and Parathyroid Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-9011-1_15
Download citation
DOI: https://doi.org/10.1007/978-1-4614-9011-1_15
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4614-9010-4
Online ISBN: 978-1-4614-9011-1
eBook Packages: MedicineMedicine (R0)