Four-Gland Exploration Versus Four-Dimensional Computed Tomography in Patients with Nonlocalized Primary Hyperparathyroidism

Abstract

The surgical management of patients with primary hyperparathyroidism (PHPT) varies greatly among parathyroid surgeons, as well as across institutions. Four gland exploration, or bilateral neck exploration (BNE) has long been the “gold standard” operation for PHPT; it involves direct visualization of all parathyroid glands, with removal of enlarged parathyroid tissue, and has yielded excellent cure and complication rates, when performed by experienced surgeons. However, given that approximately 85% of patients with PHPT have single-gland disease, unilateral, minimally-invasive approaches have been advocated. The latter approaches require preoperative localization studies to identify the abnormal gland(s). While non-invasive imaging studies are routinely employed before index parathyroid surgery, negative, discordant or equivocal non-invasive localization studies are not uncommon, even in the unexplored patient. In this setting, an experienced parathyroid surgeon will still find and cure PHPT in the vast majority of patients. While bilateral neck exploration remains an excellent operation, controversy has developed in recent years, regarding the potential superiority of more focused, minimally invasive approaches. To address this issue, we evaluated the available literature for recommendations regarding the use of preoperative four-dimensional computed tomography (4DCT) versus direct, four gland exploration in patients with negative sestamibi and/or neck ultrasound studies. We summarize the available data and provide recommendations on how to surgically treat patients undergoing parathyroidectomy for PHPT.