A changing experience with primary hyperparathyroidism at group health cooperative, Seattle

Abstract

Background: Since 1996 new technologies have been brought to bear on the treatment of primary hyperparathyroidism. The Tc 99m sestamibi scan is useful in defining the location of a solitary adenoma, and used in combined with the gamma probe, it facilitates the removal of a solitary adenoma with a degree of accuracy and a cure rate previously not available. Intraoperative measurement of parathyroid hormone is also being used to judge immediately if the surgery has been successful. Methods: This is a retrospective review of all cases of primary hyperparathyroidism treated surgically at Group Health Cooperative, Seattle, Washington, from April 1997 until June 2000. Results: Of the 49 procedures in 47 patients, 44 had a sestamibi scan preoperatively. Fifteen patients had a combination of the sestamibi scan done on the day of surgery and the intraoperative use of the gamma probe. This has been labeled minimally invasive radioguided parathyroidectomy (MIRP). The procedures are divided into two groups. The 28 procedures before the advent of MIRP are labeled group A. The 22 procedures after the advent of MIRP are labeled group B. One patient with two procedures is represented in both groups. They are further differentiated into three groups in terms of surgical difficulty: routine, difficult, and complex. Eleven procedures are in the difficult category and 3 procedures are classified in the complex category. Since the start of MIRP on May 14, 1999, there have been 15 MIRPs and 7 procedures requiring a standard incision. Group A is compared with group B using a variety of parameters. Conclusions: The combination of the Tc 99m sestamibi scan on the day of surgery and the use of the gamma probe intraoperatively is a major advance in the treatment of primary hyperparathyroidism. A significant number of difficult and complex cases must still be treated with bilateral neck exploration, including patients with hyperplasia, double adenoma, carcinoma and patients with underlying thyroid pathology. There is a “surgery time” advantage to the surgeon who does more than 10 cases per year.