Contemporary parathyroidectomy: exploiting technology

Abstract

Background

Conventional parathyroidectomy, as practiced only 10 years ago, has given way to considerable change, largely as a result of the evolution of technology. Several of these important technologies include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and rapid intraoperative parathyroid hormone (IOPTH) monitoring. Modern parathyroid surgeons should maintain familiarity with the appropriate role of these approaches.

Study design

Evidence-based analysis of state-of-the-art approaches to the diagnosis and management of primary hyperparathyroidism.

Methods and materials

Four distinct technologies are analyzed in detail, with particular attention to their impact on the practice of parathyroid surgery. These include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and IOPTH.

Results

Each of the technologies examined has substantial value in the current practice of parathyroidectomy. Judicious implementation of these technologies will vary from practice to practice. Radio-guided surgery may obviate the need for IOPTH monitoring, therefore resulting in the fastest procedural times. Ultrasound imaging is useful as an adjunct to sestamibi scanning to localize adenomatous parathyroid glands. Endoscopic techniques facilitate visualization through small openings and may help surgeons achieve minimal access incisions. Finally, the use of IOPTH is a useful adjunct to directed explorations, and it imparts confidence that all hyperfunctioning parathyroid tissue has been removed.

Conclusions

The practice of parathyroid surgery has undergone tremendous change in the past decade, and this change has largely been a technology-driven phenomenon. Acquisition of familiarity and skill with these new technologies will be necessary for the endocrine head and neck surgeon wishing to stay abreast of modern surgical techniques and provide quality care.

Introduction

The past decade has seen considerable advances in the techniques of parathyroid surgery, largely by virtue of the advent of new technology. Progress has been made in several stages of the management of patients with hyperparathyroidism, including the preoperative localization of adenomatous parathyroid glands (ultrasound imaging and sestamibi scanning), intraoperative identification of hyperplastic parathyroid tissue (radio-guided surgery), the minimally invasive removal of abnormal parathyroid glands (high-resolution endoscopic visualization), and the rapid intraoperative confirmation of surgical efficacy (IOPTH monitoring).

Ultrasound imaging has been used medically for several decades. In recent years, the development of high-resolution transducers has improved the accuracy of ultrasound in the evaluation of cervical pathology, and the ultrasound has found an increasingly important role in the preoperative localization of abnormal parathyroid glands [1], [2]. The ultrasound is the least expensive of all preoperative localization studies, it does not involve ionizing radiation, it is readily repeatable, and it may offer some advantages over other preoperative localization tests in the setting of concomitant thyroid disease.

Sestamibi-guided parathyroid surgery was first reported by Martinez et al [3] in 1995 and was popularized by Norman and Chheda [4]. It has become an established technique in many centers.

Endoscopic surgery has been widely used in a number of surgical disciplines but was only adapted for use in the neck in the past several years [5], [6]. An endoscopic-assisted technique has emerged as one effective approach to accomplish a minimally invasive and directed management of primary hyperparathyroidism [7].

Intraoperative confirmation that all hyperfunctioning parathyroid tissue has been removed is now possible with the use of rapid IOPTH monitoring [8]. This capability, coupled with robust localization techniques, has been responsible for the dramatic paradigm shift in the approach to individuals with sporadic primary hyperparathyroidism. Four-gland parathyroid exploration, considered standard of care only a decade ago, has largely been abandoned in favor of directed or focused exploration.

The current report presents a brief description of these new technologies and an evidence-based analysis of their value in the management of patients with primary hyperparathyroidism.