Minimally invasive parathyroidectomyBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7444.849 (Published 08 April 2004) Cite this as: BMJ 2004;328:849
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Minimally invasive parathyroidectomy (MIP) is currently in vogue for
the management of primary hyperparathyroidism, and is advocated as a day
case procedure. There is still broad acceptance, however, that open
parathyroidectomy with visualisation of all four glands is the recommended
definitive treatment of choice. There are undoubted potential benefits to
minimally invasive surgery, and perhaps foremost is the potential cost
saving associated with a reduced length of stay. This is offset
significantly however by the costs of pre-operative localising techniques
(ultrasound and sestamibi scanning).
We have recently surveyed the outcome of 249 consecutive patients
with primary hyperparathyroidism who underwent open parathyroidectomy by
one of three experienced parathyroid surgeons over a 7 year period. No
preoperative localisation studies were performed. Biochemical cure was
achieved in 94% after initial surgery (99% after second operation using
localising imaging). Postoperative morbidity was low (9% hypocalcaemia
requiring parenteral calcium, 0.4% recurrent laryngeal nerve palsy) and
there was no postoperative mortality. Patients who developed significant
postoperative hypocalcaemia (requiring intravenous calcium) had
significantly higher PTH and alkaline phosphatase (ALP) concentrations at
diagnosis (p<0.0001). We recommend that patients with primary
hyperparathyroidism who present with a very elevated PTH concentration and
raised ALP should not be subjected to day case MIP as such patients appear
to have a significant risk of post-operative hypocalcaemia requiring
parenteral calcium administration. Careful selection of cases of primary
hyperparathyroidism for MIP should be undertaken with close liaison
between endocrinologist and endocrine surgeon.
Competing interests: No competing interests
We welcome the recent editorial by Palazzo and Sadler on minimally
invasive parathyroidectomy (MIP) (BMJ 2004;328: 849-850). Despite much
evidence from Europe, Australia and North America that a minimally
invasive or “focused” approach is both safe and effective, UK endocrine
surgeons have been slow to embrace this technique. In a recent survey of
UK endocrine surgeons, 97% of respondents favoured bilateral neck
exploration via a collar incision to a more focused approach1. However,
our own group has shown that, following accurate localization of
uniglandular disease, patients may be managed successfully and safely with
MIP as a day-case procedure under general anaesthesia2.
While the role of accurate pre-operative localization is crucial to a
successful outcome from minimally invasive parathyroidectomy, the role of
intra-operative parathyroid hormone (iPTH) measurement remains unclear.
The authors argue, based on their unpublished data that the use of iPTH
measurement is not cost-effective and has been abandoned. They do not
comment however on whether iPTH measurement contributes to a higher cure-
rate from primary surgery. In our published series, multiglandular
disease was detected by iPTH measurement in 1 of 50 cases2. Since then
iPTH has proved useful in two out of 20 further cases, one further case of
multigland disease and another where the imaging was misleading
(unpublished). Parathyroid surgery was completely successful in 69 of 70
cases, suggesting that, in our experience, iPTH measurement may enhance
successful cure by up to 4%.
Such additional benefit from iPTH measurement may seem low but may be
vital in achieving the current target of a 95% cure rate for initial
parathyroid surgery, set by the British Association of Endocrine Surgeons
(BAES). When combined with day-case parathyroidectomy it may also
contribute to a more cost-effective treatment option for patients with
primary hyperparathyroidism. We argue, therefore, that at present there
is not sufficient data to abandon the use of iPTH measurement completely
and we will continue to assess the value of this technique in our own
1. Ozbas S, Pain S, Tang T, Wishart GC. Surgical management of
primary hyperparathyroidism- results of a national survey. Ann R Coll
Surg Engl 2003; 85: 236-241.
2. Gurnell EM, Thomas SK, McFarlane I, Munday I, Balan KK, Berman L,
et al. Focused parathyroid surgery with intraoperative parathyroid
hormone measurement as a day-case procedure. Br J Surg 2004; 91: 78-82.
Competing interests: No competing interests