Endocrine Abstracts (2001) 2 P37

Minimally invasive parathyroid surgery with intra-operative PTH measurement: an economical approach to the management of primary hyperparathyroidism

EM Gurnell1, A Poultsidis2, I McFarlane4, A Sarkar4, SE Curran1, M Hitchcock3, I Munday3, PR Raggatt4, KK Balan5, OM Edwards1, GC Wishart2 & VKK Chatterjee1

1Department of Medicine, University of Cambridge, Cambridge, UK; 2Department of General Surgery, Addenbrookes Hospital, Cambridge, UK; 3Department of Anaesthesia, Addenbrookes Hospital, Cambridge, UK; 4Department of Clinical Biochemistry, Addenbrookes Hospital, Cambridge, UK; 5Department of Nuclear Medicine, Addenbrookes Hospital, Cambridge, UK.

BACKGROUND: Primary hyperparathyroidism (HPT) is increasingly diagnosed, particularly in an older population. Recent studies indicate improvement in bone mineral density (BMD) and psychological wellbeing even following treatment of apparent asymptomatic disease, supporting a lower threshold for surgical intervention. With disease being due to a solitary adenoma in most (83%) cases, we have utilised preoperative imaging together with intra-operative parathyroid hormone (IOPTH) measurement to undertake minimally invasive surgery (MIS) in this disorder.

METHODS: With Ethical Committee approval, 13 consecutive patients (mean age 68, range 50-88 years) with HPT (mean ca 2.82mM, range 2.67-3.25; mean PTH 146ng/L, range 35-682), fulfilling NIH criteria for intervention (symptoms; lithiasis or hypercalciuria; reduced BMD), underwent imaging with either 99TcSestamibi alone (n=10) or with ultrasound (n=3) to localise a single lesion. Following informed consent, these patients underwent unilateral neck exploration. PTH was measured intraoperatively before and 5, 10, 20 minutes post excision of the abnormal gland. Patients were discharged within 23 hours on calcium and vitamin D supplementation. This was discontinued two weeks later and serum calcium measured.

RESULTS: In all patients, an abnormal parathyroid congruent with preoperative localisation was easily identified and resected (operating time: mean 32 min (range 22-38)). Plasma PTH fell by >50% of baseline levels at 5min (n=10), 10min (n=2) or 20min (n=1) post excision of parathyroid. None of the patients developed symptomatic or biochemical hypocalcaemia immediately or two weeks post operatively enabling cessation of oral supplements. Following this, all patients were normocalcaemic (mean 2.31mM ( range 2.13-2.39)). Histological examination showed a parathyroid adenoma (n=12) or carcinoma (n=1).

CONCLUSIONS: We have shown that patients with primary HPT, in whom pre-operative imaging localises uniglandular disease, can be successfully and safely managed by MIS with IOPTH measurement. This approach also shortens hospital stay from 4 days to 23h, representing more economical management of the disorder.