World Journal of Surgery

, Volume 36, Issue 5, pp 1175–1181 | Cite as

A Predictive Model of Suitability for Minimally Invasive Parathyroid Surgery in the Treatment of Primary Hyperthyroidism

  • Dara O. Kavanagh
  • Patricia Fitzpatrick
  • Eddie Myers
  • Rory Kennelly
  • Stephen J. Skehan
  • Robert G. Gibney
  • Arnold D. K. Hill
  • Denis Evoy
  • Enda W. McDermott



Improved preoperative localizing studies have facilitated minimally invasive approaches in the treatment of primary hyperparathyroidism (PHPT). Success depends on the ability to reliably select patients who have PHPT due to single-gland disease. We propose a model encompassing preoperative clinical, biochemical, and imaging studies to predict a patient’s suitability for minimally invasive surgery.


For the purposes of the present study, 180 consecutive patients were included for analysis. A 5-variable model based on preoperative ionized serum calcium (>1.4 mmol/l), intact parathyroid hormone level (≥2 times the upper limit of normal), positive sestamibi scan for a single affected gland, positive ultrasound scan for a single gland, and concordance between the two imaging modalities for single-gland disease at a similar location was employed, where a score of 1 was allocated for each variable present.


Of the 180 patients, 62 (34%) underwent bilateral exploration, 63 (36%) underwent unilateral exploration, and 55 (30%) underwent minimally invasive parathyroidectomy. The results showed that 92% had single-gland disease, 3% had double adenomas, and 5% had hyperplasia. Biochemical cure was achieved in 98.9%. Mean follow-up was 153 days (range: 80–342 days). With the predictive scoring model, a score of ≥3 had a positive predictive value of 100% for single-gland disease.


A scoring model encompassing preoperative biochemical and imaging data can be successfully employed to predict suitability for minimally invasive surgery in the majority of patients with single-gland disease.


IOPTH Measurement Minimally Invasive Parathyroidectomy Bilateral Neck Exploration Invasive Parathyroidectomy Enlarge Parathyroid Gland 
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.
    Lew JI, Solorozano CC (2009) Surgical management of primary hyperparathyroidism: state of the art. Surg Clin N Am 89:1205–1225PubMedCrossRefGoogle Scholar
  2. 2.
    Bilezikian JP, Potts JT Jr, Fuleihan GEH et al (2002) Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. J Bone Miner Res 17(Suppl 2):N2–N11PubMedGoogle Scholar
  3. 3.
    Bergenfelz A, Kanngiesser V, Zielke A et al (2005) Conventional bilateral cervical exploration versus open minimally invasive parathyroidectomy under local anaesthesia for primary hyperparathyroidism. Br J Surg 92:190PubMedCrossRefGoogle Scholar
  4. 4.
    Greene AB, Butler RS, McIntyre S et al (2009) National trends in parathyroid surgery from 1998 to 2008: a decade of change. J Am Coll Surg 209:332–343PubMedCrossRefGoogle Scholar
  5. 5.
    AACE/AAES Task Force on Primary Hyperparathyroidism (2005) The American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons position statement on the diagnosis and management of primary hyperparathyroidism. Endocr Pract 11:49–55Google Scholar
  6. 6.
    Russell CF, Dolan SJ, Laird JD (2006) Randomised clinical trial comparing scan-directed unilateral versus bilateral cervical neck exploration for primary hyperparathyroidism due to solitary adenoma. Br J Surg 93:418–421PubMedCrossRefGoogle Scholar
  7. 7.
    Aarum S, Nordenstrom J, Reihner E et al (2007) Operation for primary hyperparathyroidism: the new versus the old order. A randomised controlled trial of preoperative localisation. Scand J Surg 96:26–30PubMedGoogle Scholar
  8. 8.
    Westerdahl J, Bergenfelz A (2007) Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomised controlled trial. Ann Surg 246:976–980PubMedCrossRefGoogle Scholar
  9. 9.
    Kebebew E, Hwang J, Reiff E et al (2006) Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model. Arch Surg 141:777–782PubMedCrossRefGoogle Scholar
  10. 10.
    Monchik JM (1995) Normocalcaemic hyperparathyroidism. Surgery 118:917–923PubMedCrossRefGoogle Scholar
  11. 11.
    Williams JG, Wheeler MH, Aston JP et al (1992) The relationship between adenoma weight and intact parathyroid hormone level in primary hyperparathyroidism. Am J Surg 163:301–304PubMedCrossRefGoogle Scholar
  12. 12.
    Moalem J, Guerrero M, Kebebew E (2009) Bilateral neck exploration in primary hyperparathyroidism—when is it selected and how is it performed? World J Surg 33:2282–2291. doi: 10.1007/s00268-009-9941-5 PubMedCrossRefGoogle Scholar
  13. 13.
    Sidhu S, Neill AK, Russell CF (2003) Long-term outcome of unilateral parathyroid exploration for primary hyperparathyroidism due to presumed solitary adenoma. World J Surg 27:339–342. doi: 10.1007/s00268-002-6695-8 PubMedCrossRefGoogle Scholar
  14. 14.
    Tublin ME, Pryma DA, Yim JH et al (2009) Localisation of parathyroid adenomas by sonography and technetium Tc 99m sestamibi single-photon emission computed tomography before minimally invasive parathyroidectomy: are both studies really needed? J Ultrasound Med 28:183–190PubMedGoogle Scholar
  15. 15.
    Rafferty MA, Hill AD, Zbar AP et al (1997) Cervical exploration for primary hyperparathyroidism—a 25 year experience. Ir Med J 90:188–189PubMedGoogle Scholar
  16. 16.
    Solorzano CC, Lee TM, Ramirez MC et al (2005) Surgeon-performed ultrasound improves localisation of abnormal parathyroid glands. Am Surg 71:557–562PubMedGoogle Scholar
  17. 17.
    Soon PS, Delbridge LW, Sywak MS et al (2008) Surgeon performed ultrasound facilitates minimally invasive parathyroidectomy by the focused lateral mini-incision approach. World J Surg 32:766–771. doi: 10.1007/s00268-007-9436-1 PubMedCrossRefGoogle Scholar
  18. 18.
    Adil E, Adil T, Fedok F et al (2009) Minimally invasive radioguided parathyroidectomy performed for primary hyperparathyroidism. Otolaryngol Head Neck Surg 141:34–38PubMedCrossRefGoogle Scholar
  19. 19.
    Dijkstra B, Healy C, Kelly LM et al (2002) Parathyroid localisation—current practice. J R Coll Surg Edinb 47:599–607PubMedGoogle Scholar
  20. 20.
    Mihai R, Palazzo FF, Gleeson FV et al (2007) Minimally invasive parathyroidectomy without parathyroid hormone monitoring in patients with primary hyperparathyroidism. Br J Surg 94:42–47PubMedCrossRefGoogle Scholar
  21. 21.
    Ollila DW, Caudle AS, Cance WG et al (2006) Successful minimally invasive parathyroidectomy for primary hyperparathyroidism without using intraoperative parathyroid hormone assays. Am J Surg 191:52–56PubMedCrossRefGoogle Scholar
  22. 22.
    Inabnet WB, Fulla Y, Richard B et al (1999) Unilateral exploration under local anaesthesia: the approach of choice for asymptomatic primary hyperparathyroidism. Surgery 126:1004–1010PubMedCrossRefGoogle Scholar
  23. 23.
    Udelsman R, Donovan PI, Sokoll LJ (2000) One hundred minimally invasive parathyroid explorations. Ann Surg 232:331–339PubMedCrossRefGoogle Scholar
  24. 24.
    Carneiro DM, Irvin GL (2000) Late parathyroid function after successful parathyroidectomy guided by intraoperative hormone assay compared with the standard bilateral neck exploration. Surgery 128:925–929PubMedCrossRefGoogle Scholar
  25. 25.
    Stalberg P, Sidhu S, Sywak M et al (2003) Intraoperative parathyroid hormone measurement during minimally invasive parathyroidectomy: does it “value- add” to decision-making? J Am Coll Surg 203:1–6CrossRefGoogle Scholar
  26. 26.
    Cayo AK, Sippel RS, Schaefer S et al (2009) Utility of intraoperative PTH for primary hyperparathyroidism due to multigland disease. Ann Surg Oncol 16:3450–3454PubMedCrossRefGoogle Scholar
  27. 27.
    Hwang RS, Morris LF, Ro K et al (2010) A selective Bayesian approach to intraoperative PTH monitoring. Ann Surg 251:1122–1126PubMedCrossRefGoogle Scholar
  28. 28.
    Siperstein A, Berber E, Barbosa GF et al (2008) Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg 248:420–428PubMedGoogle Scholar
  29. 29.
    Clane CM, Norman GL, Beecroft ML et al (2000) Albumin corrected calcium and ionised calcium in stable haemodialysis patients. Nephrol Dial Transpl 15:1841–1846CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2011

Authors and Affiliations

  • Dara O. Kavanagh
    • 1
  • Patricia Fitzpatrick
    • 2
    • 3
  • Eddie Myers
    • 1
  • Rory Kennelly
    • 1
  • Stephen J. Skehan
    • 4
  • Robert G. Gibney
    • 4
  • Arnold D. K. Hill
    • 1
  • Denis Evoy
    • 1
  • Enda W. McDermott
    • 1
  1. 1.Department of Breast & Endocrine SurgerySt. Vincents University HospitalDublin 4Ireland
  2. 2.Department of Medicine, Physiotherapy & Population Science, School of Public Health MedicineUniversity College DublinDublin 4Ireland
  3. 3.School of Medicine & Medical ScienceUniversity College DublinDublin 4Ireland
  4. 4.Department of RadiologySt. Vincents University HospitalDublin 4Ireland

Personalised recommendations