Reoperative parathyroidectomy: An algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach

Background. Advances in preoperative imaging and use of intraoperative parathyroid hormone (IOPTH) levels are changing the approach to reoperative parathyroidectomy (ReopPTX). We sought to develop a protocol for imaging and IOPTH monitoring that allows for a focused, successful operative approach. Methods. We reviewed our Prospective database of consecutive patients with primary hyperparathyroidism who underwent ReopPTX with IOPTH monitoring between December 1999 and June 2007. Results. Thirty-nine patients underwent 43 ReopPTXs for persistent (79%)/recurrent (21%) disease. All underwent ultrasonography and sestamibi imaging; 24 cases (56%) underwent additional imaging studies. Sensitivity of ultrasonography was 56%, sestamibi 53%, both studies 67%, computed tomography (CT) 48%, magnetic resonance imaging (MRI) 67%, and selective venous sampling (SVS) 50%. IOPTH monitoring predicted accurately cure in 100% and failure in 78%. A focused/unilateral approach was performed in 60%; median operative time was 45 minutes (range, 12-127). At last follow-up, 36 (92%) patients were normocalcemic. Conclusions. We propose that ultrasonography and sestamibi studies should be done before all ReopPTXs; failure to localize should Prompt sequential CT, MRI, and SVS until localization is achieved. IOPTH monitoring defines cure and is recommended for all ReopPTXs. This algorithm allows for a focused operative approach in > 50% of ReopPTXs with operative times comparable with first-time, minimally invasive parathyroidectomy.