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Do All Patients Undergoing Parathyroidectomy Require Additional Neck Exploration When Intraoperative PTH Levels Do Not Decrease Appropriately?
Patrick B. O'Neal, Vitaliy Poylin, Peter Mowschenson, Sareh Parangi, Gary Horowitz, Pravin Pant, Per-Olof Hasselgren
Beth Israel Deaconess Medical Center, Boston, MA

Objective: To analyze management of patients undergoing parathyroidectomy for primary HPT and in whom the intraoperative PTH level did not decrease appropriately after removal of enlarged parathyroid gland.
Design: Retrospective analysis of prospective data base.
Setting: Tertiary care center.
Patients:
Patients undergoing surgery for primary HPT and monitored with intraoperative PTH measurements during the 3-year period 2004-2006.
Main Outcome Measures: Serum PTH level determined before (on call to the operating room) and 10-15 min after excision of enlarged parathyroid gland. A decrease of PTH by >50% and into normal range (15-65 pg/ml) was considered appropriate.
Results: During the study period, 189 patients (137 women; 52 men; mean age 58 years) underwent 193 operations for primary HPT. In 48 cases (25%), the initial post-excisional PTH level did not fall appropriately. In 11 patients, it was elected to obtain a repeat PTH level before deciding to perform additional neck exploration. In 6 of these patients (12.5% of patients in whom the initial post-excisional PTH level did not fall as expected), the repeat PTH level fell appropriately (pre-op level: 209±80; first post-excisional level: 95±17; repeat PTH level: 30±5 pg/ml) and no further neck exploration was performed. In all of these patients, the operative finding matched preoperative imaging (sestamibi and ultrasound) whereas in the 5 patients in whom the repeat PTH level remained elevated, no such match was found.
Conclusions: In patients with primary HPT in whom an enlarged parathyroid gland is found where indicated by preoperative imaging tests and in whom post-excisonal PTH level does not decrease as expected, it may be worthwhile to repeat intraoperative PTH measurement rather than performing additional neck exploration.


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