World Journal of Surgery

, 33:2256 | Cite as

Minimally Invasive Parathyroidectomy: Benefits and Requirements of Localization, Diagnosis, and Intraoperative PTH Monitoring. Long-Term Results

  • Douglas L. FrakerEmail author
  • Hasly Harsono
  • Robert Lewis



Surgery is the only curative treatment for primary hyperparathyroidism. Initial parathyroidectomy procedures fail due to ectopic gland location and unappreciated multigland disease.


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.


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.


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.


Adenoma Parathyroid Gland Primary Hyperparathyroidism Parathyroid Adenoma Parathyroid Carcinoma 
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.


  1. 1.
    Rubin MR, Bilezikian JP, McMahon DJ, Jacobs T, Shane E, Siris E, Udesky J, Silverberg SJ (2008) The natural history of primary hyperparathyroidism with or without parathyroid surgery after 15 years. J Clin Endocrinol Metab 93:3462–3470PubMedCrossRefGoogle Scholar
  2. 2.
    Bilezikain JP, Silverberg SJ (2004) Asymptomatic primary hyperparathyroidism. N Engl J Med 350:1746–1751CrossRefGoogle Scholar
  3. 3.
    Edwards ME, Rotramel A, Beyer T, Gaffud MJ, Djuricin G, Loviscek K, Solorzano CC, Princ RA (2006) Improvement in the health-related quality-of-life symptoms of hyperparathyroidism is durable on long-term follow-up. Surgery 140:655–664PubMedCrossRefGoogle Scholar
  4. 4.
    Walgenbach S, Hommel G, Junginger T (2000) Outcome after surgery for primary hyperparathyroidism: ten-year prospective follow-up study. World J Surg 24:560–564CrossRefGoogle Scholar
  5. 5.
    Jaskowiak N, Norton JA, Alexander HR, Doppman JL, Shawker T, Skarulis M, Marx S, Spiegel A, Fraker DL (1996) A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 224:308–322PubMedCrossRefGoogle Scholar
  6. 6.
    Yen TWE, Wang TS, Doffek KM, Krzywda EA, Wilson SD (2008) Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach. Surgery 144:611–621PubMedCrossRefGoogle Scholar
  7. 7.
    Fraker DL (2007) Parathyroid cancer. In: DeVita V, Rosenberg SA, Lawrence T (eds) Cancer: principles and practice of oncology, 8th edn. Lippincott, Philadelphia, pp 1702–1720Google Scholar
  8. 8.
    Tezelman S, Shen W, Shaver JK, Spierstein AE, Duh QY, Klein H, Clark OH (1993) Double parathyroid adenomas, clinical and biochemical characteristics before and after parathyroidectomy. Ann Surg 218:300–309PubMedCrossRefGoogle Scholar
  9. 9.
    Ruda JM, Hollenbeak CS, Stack BC (2005) A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg 132:359–372PubMedCrossRefGoogle Scholar
  10. 10.
    Westerdahl H, Bergebfekz A (2004) Sestamibi scan-directed parathyroid surgery: potentially high failure rate without measurement of intraoperative parathyroid hormone. World J Surg 28:1132–1138PubMedCrossRefGoogle Scholar
  11. 11.
    Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, Milas M (2008) Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, intraoperative parathyroid hormone. Analysis of cases 1158. Ann Surg 248:420–428PubMedGoogle Scholar
  12. 12.
    Sugg SL, Krzywda EA, Demeure MJ, Wilson SD (2004) Detection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy. Surgery 136:1303–1309PubMedCrossRefGoogle Scholar
  13. 13.
    Carneiro-Pla DM, Solorzano CC, Irvin GL (2006) Consequences of targeted parathyroidectomy guided by localization studies without intraoperative parathyroid hormone monitoring. J Am Coll Surg 202:715–722PubMedCrossRefGoogle Scholar
  14. 14.
    Chen H, Mack E, Starling JR (2005) A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy. Which is most reliable? Ann Surg 242:375–383PubMedGoogle Scholar
  15. 15.
    Bergson EJ, Sznyter LA, Dubner S, Palestro CJ, Heller KS (2004) Sestamibi scans and intraoperative parathyroid hormone measurement in the treatment of primary hyperparathyroidism. Arch Otolaryngol Head Neck Surg 130:87–91PubMedCrossRefGoogle Scholar
  16. 16.
    Buell JF, Fraker DL, Doppman JL, Shawker TH, Skarulis MC, Spiegel AM, Marx SJ, Alexander HR (1995) High cervical intravagal hypercellular parathyroid gland as the etiology of severe persistent primary hyperparathyroidism. Am Surg 61:943–946PubMedGoogle Scholar
  17. 17.
    Doppman JL, Skarulis MC, Chen CC, Chang R, Pass HI, Fraker DL, Alexander HR, Niederle B, Marx S, Norton JA, Wells SA, Spiegel AM (1996) Parathyroid adenoma in the aortopulmonary window. Am J Radiol 201:442–456Google Scholar
  18. 18.
    Carter AB, Howanitz PJ (2003) Intraoperative testing for parathyroid hormone: a comprehensive review of the use of the assay and the relevant literature. Arch Pathol Lab Med 127:1424–1442PubMedGoogle Scholar
  19. 19.
    Inabnet WB (2004) Intraoperative parathyroid hormone monitoring. World J Surg 28:1212–1215PubMedCrossRefGoogle Scholar
  20. 20.
    Shindo M (2004) Intraoperative rapid parathyroid hormone monitoring in parathyroid surgery. Otolaryngol Clin North Am 37:779–787PubMedCrossRefGoogle Scholar
  21. 21.
    Palazzo FF, Delbridge LW (2004) Minimal-access/minimally invasive parathyroidectomy for primary hyperparathyroidism. Surg Clin N Am 84:717–734PubMedCrossRefGoogle Scholar
  22. 22.
    Carling T, Udelsman R (2008) Focused approach to parathyroidectomy. World J Surg 32:1512–1517PubMedCrossRefGoogle Scholar
  23. 23.
    Tibblin S, Bondeson AG, Ljungberg O (1982) Unilateral parathyroidectomy in hyperparathyroidism due to single adenoma. Ann Surg 195:245–252PubMedCrossRefGoogle Scholar
  24. 24.
    Bergenfelz A, Lindblom P, Tibblin S, Westerdahl J (2002) Unilateral versus bilateral neck exploration for primary hyperparathyroidism. Ann Surg 236:543–551PubMedCrossRefGoogle Scholar
  25. 25.
    Westerdahl J, Bergenfelz A (2007) Unilateral versus bilateral neck exploration for primary hyperparathyroidism: 5-year follow-up of a randomized controlled trial. Ann Surg 246:976–981PubMedCrossRefGoogle Scholar
  26. 26.
    Taillefer R, Boucher Y, Potvin C, Lambert R (1992) Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). J Nucl Med 33:1801–1807PubMedGoogle Scholar
  27. 27.
    Kettle AG, O’Doherty MJ (2006) Parathyroid imaging: how good is it and how should it be done? Semin Nucl Med 36:206–211PubMedCrossRefGoogle Scholar
  28. 28.
    Pons F, Torregrosa JV, Fuster D (2003) Biological factors influencing parathyroid localization. Nucl Med Commun 24:121–124PubMedCrossRefGoogle Scholar
  29. 29.
    Mehta NY, Ruda JM, Kapadia S, Boyer PJ, Hollenbeak CS, Stack BC (2005) Relationship of technetium Tc 99m sestamibi scans to histopathological features of hyperfunctioning parathyroid tissue. Arch Otolaryngol Head Neck Surg 131:493–498PubMedCrossRefGoogle Scholar
  30. 30.
    Calva-Cerqueira D, Smith BJ, Hostetler ML, Lal G, Menda Y, O’Dorisio TM, Howe JR (2007) Minimally invasive parathyroidectomy and preoperative MIBI scans: correlation of gland weight and preoperative PTH. J Am Coll Surg 205:538–544CrossRefGoogle Scholar
  31. 31.
    Krausz Y, Lebensart PD, Klein M, Weininger J, Blachar A, Chisin R, Shiloni E (2000) Preoperative localization of parathyroid adenoma in patients with concomitant thyroid nodular disease. World J Surg 24:1573–1578PubMedCrossRefGoogle Scholar
  32. 32.
    Zheng YX, Xu SM, Wang P, Chen L (2007) Preoperative localization and minimally invasive management of primary hyperparathyroidism concomitant with thyroid disease. J Zheijang Univ Sci B 8:626–631CrossRefGoogle Scholar
  33. 33.
    Nichols KJ, Tomas MB, Tronco GG, Rini JN, Kunjummen BD, Heller KS, Sznyder LA, Palestro CJ (2008) Preoperative parathyroid scintigraphic lesion localization: accuracy of various types of readings. Radiology 248:221–232PubMedCrossRefGoogle Scholar
  34. 34.
    Johnson NA, Tublin ME, Ogilvie JB (2007) Parathyroid imaging: technique and role in the preoperative evaluation of primary hyperparathyroidism. AJR Am J Roentgenol 188:1706–1715PubMedCrossRefGoogle Scholar
  35. 35.
    Solorzano CC, Carneiro-Pla DM, Irvin GL (2006) Surgeon-performed ultrasonography as the initial and only localizing study in sporadic primary hyperparathyroidism. J Am Coll Surg 202:18–24PubMedCrossRefGoogle Scholar
  36. 36.
    Milas M, Stephen A, Berber E, Wagner K, Miskulin J, Siperstein A (2005) Ultrasonography for the endocrine surgeon: a valuable clinical tool that enhances diagnostic and therapeutic outcomes. Surgery 138:1193–1201PubMedCrossRefGoogle Scholar
  37. 37.
    Stephens AE, Milas M, Garner CN, Wagner KE, Siperstein AE (2005) Use of surgeon-performed ultrasound and parathyroid fine needle aspiration for complex parathyroid localization. Surgery 138:1143–1151CrossRefGoogle Scholar
  38. 38.
    Ruda JM, Stack BC, Hollenbeak CS (2006) The cost-effectiveness of additional preoperative ultrasonography or sestamibi-SPECT in patients with primary hyperparathyroidism and negative findings on sestamibi scans. Arch Otolaryngol Head Neck Surg 132:46–53PubMedCrossRefGoogle Scholar
  39. 39.
    Lumachi F, Zucchetta P, Marzola MC, Boccagni P, Angelini F, Bui F, D’Amico DF, Favia G (2000) Advantages of combined technetium-99m-sestamibi scintigraphy and high-resolution ultrasonography in parathyroid localization: comparative study in 91 patients with primary hyperparathyroidism. Eur J Endocrinol 143:755–760PubMedCrossRefGoogle Scholar
  40. 40.
    Lumachi F, Tregnaghi A, Zucchetta P, Marzola MC, Cecchin D, Marchesi P, Fallo F, Bui F (2004) Technetium-99m sestamibi scintigraphy and helical CT together in patients with primary hyperparathyroidism: a prospective clinical study. Br J Radiol 77:100–103PubMedCrossRefGoogle Scholar
  41. 41.
    Rodgers SE, Hunter GJ, Hamberg LM, Schellingerhout D, Doherty DB, Ayers GD, Shapiro SE, Edeiken BS, Truong MT, Evans DB, Lee JE, Perrier ND (2006) Improved preoperative planning for directed parathyroidectomy with four-dimensional computed tomography. Surgery 140:932–941PubMedCrossRefGoogle Scholar
  42. 42.
    Sacks BA, Pallotta JA, Cole A, Hurwitz J (1994) Diagnosis of parathyroid adenomas: efficacy of measuring parathormone levels in needle aspirates of cervical masses. AJR Am J Roentgenol 122:3–1226Google Scholar
  43. 43.
    Lee LS, Canter RJ, Fraker DL (2006) Intraoperative jugular venous sampling aids detection of undescended parathyroid adenomas. World J Surg 30:620–623PubMedCrossRefGoogle Scholar
  44. 44.
    Lew JI, Solorzano CC, Montano RE, Carneiro-Pla DM, Irvin GL (2008) Role of intraoperative parathormone monitoring during parathyroidectomy in patients with discordant localization studies. Surgery 144:299–306PubMedCrossRefGoogle Scholar
  45. 45.
    Libutti SK, Alexander HR, Bartlett DL, Sampson ML, Ruddel ME, Skarulis M, Marx SJ, Spiegel AM, Simmonds W, Remaley AT (1999) Kinetic analysis of the rapid intraoperative parathyroid hormone assay in patients during operation for hyperparathyroidism. Surgery 126:1145–1151PubMedCrossRefGoogle Scholar
  46. 46.
    Karakousis GC, Han D, Roses RE, Neemani D, Karmachaya J, Rapaport-Kelz R, Fraker DL (2007) Interpretation of intraoperative PTH changes in patients with multi-gland primary hyperparathyroidism. Surgery 142:845–850PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2009

Authors and Affiliations

  • Douglas L. Fraker
    • 1
    Email author
  • Hasly Harsono
    • 1
  • Robert Lewis
    • 1
  1. 1.Department of SurgeryUniversity of Pennsylvania Health SystemPhiladelphiaUSA

Personalised recommendations