Directed parathyroidectomy - Feasibility and performance in 100 consecutive patients with primary hyperparathyroidism

Hypothesis: Directed parathyroidectomy (DP) can be successfully completed in most patients with primary hyperparathyroidism. Design and Setting: Retrospective review at a tertiary referral center. Patients: One hundred consecutive patients with untreated, sporadic primary hyperparathyroidism operated on by a single surgeon from April 1, 1999, through December 31, 2001. Interventions: Following preoperative imaging with sestamibi scintigraphy and ultrasonography, patients underwent parathyroidectomy with intraoperative parathyroid hormone monitoring using a focused approach through a limited neck incision (DP) or bilateral neck exploration (BNE) through a standard collar incision. Main Outcome Measures: Extent of exploration, operative time, length of stay, morbidity, and cure. Results: Directed parathyroidectomy was completed in 70 patients and BNE in 30. Bilateral neck exploration was performed as the initial procedure in 13 patients and following intraoperative conversion from attempted DP in 17. Indications for predetermined BNE were failed preoperative localization (n = 8) and concomitant thyroid disease that required operative treatment (n = 5). The need for predetermined BNE decreased as preoperative localization improved. Intraoperative factors that necessitated conversion to BNE included persistently elevated intraoperative parathyroid hormone levels that accurately predicted multiglandular disease (n=6), incorrect localization (n = 5), and inadequate exposure (n = 6). Operative time and length of stay were less for DP compared with BNE patients (66 vs 165 minutes and 0.5 vs 1.6 days, respectively). One patient had a temporary vocal cord paresis. All patients were eucalcemic in follow-up (4 months to 3 years). Conclusions: With accurate preoperative localization and intraoperative parathyroid hormone monitoring, DP can be successfully completed in most patients with sporadic primary hyperparathyroidism. Patients benefit from DP, which reduces operative time and length of stay and facilitates rapid convalescence.