VALUE OF
PREOPERATIVE LOCALIZATION STUDIES IN PRIMARY HYPERPARATHYROIDISM
In the
past, bilateral neck exploration was the gold standard in the management of
primary hyperparathyroidism (PHPT). However, recent advances in imaging currently
resulted in accurate localization of the hyperfunctioning parathyroid parenchyma,
thereby allowing a minimally invasive approach in the management of PHPT, the
so-called focused parathyroidectomy, which has been adopted in many centers of
endocrine surgery.
Preoperative
localization studies:
-
Minimize
the extent of surgical dissection and therefore of tissue injury
-
Minimize
surgical morbidity
-
Minimize
the length of surgical incision, resulting in a better cosmetic result
-
Are
necessary to identify concurrent thyroid pathology, which can be treated simultaneously
at the time of parathyroidectomy
-
Can
detect ectopic hyperfunctioning parathyroid parenchyma, thereby increasing success
rate of surgery
Preoperative
localization studies are of particular importance in persistent or recurrent
PHPT or in patients with previous neck surgery. Fibrosis due to previous
operation and alterations in parathyroid gland location may be responsible for many
difficulties in identifying at surgery the hyperfunctioning parathyroid
parenchyma. Surgical morbidity (including recurrent laryngeal nerve injury,
permanent hypoparathyroidism and persistent disease) is higher in patients with
recurrent/persistent PHPT. Without positive localization studies, success rate
of reintervention in this group of patients is ~ 60 %. In contrast, using
preoperative localization studies, success rate increases significantly (~ 95
%).
It should
however be emphasized that the use of preoperative localization studies does not
override the recommendation that parathyroid surgery should only be performed
by highly experienced endocrine surgeons. Important is also the experience of
the radiologist in identifying preoperatively hyperfunctioning parathyroid parenchyma.
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