PROMISING TECHNIQUES FOR INITIAL PARATHYROID EXPLORATION
Three technological advancements have made selective exploration strategies viable in the initial exploration of the neck. These advances are (a) the ability to rapidly (in 10–15 minutes) and accurately measure the serum level of PTH; (b) the improved ability to localize abnormal parathyroid tissue with technetium Tc 99m sestamibi (99mTc sestamibi) scanning, using either preoperative imaging or intraoperative handheld gamma probe localization; and (c) the improvement of videoscopic surgical instruments. A variety of strategies have been described that use combinations of these technologies to treat primary hyperparathyroidism. As the standard full neck exploration cures ˜95% of patients, these newer strategies are designed to match those outcome results, with less surgical trauma. The long-term evaluations of these approaches remain to be accomplished; however, the early results are very promising.
CONCISE PARATHYROIDECTOMY
The term “concise parathyroidectomy” was first used to describe a unilateral exploration approach.14 This approach uses preoperative 99mTc sestamibi imaging to select one side of the neck for exploration. During the operation, parathyroid hormone (PTH) levels are measured before and after the removal of the localized abnormal parathyroid tissue. If the PTH level falls sufficiently after the resection, then the exploration is terminated. If the PTH level does not fall, then the neck is explored further.15 This approach avoids bilateral neck exploration in a significant number of patients, and may shorten both operative time and the risk of recurrent laryngeal nerve injury on the side contralateral to the abnormal parathyroid tissue. The more limited exploration may also facilitate the use of local or regional anesthesia with sedation, avoiding the morbidity of general anesthesia.
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