August 1997

Efficacy of Selective Unilateral Exploration in Hyperparathyroidism Based on Localization Tests

Author Affiliations

From the Departments of Surgery (Drs Ryan and Pado and Ms Lee) and Radiology (Dr Eisenberg), Virginia Mason Medical Center, Seattle, Wash.

Arch Surg. 1997;132(8):886-891. doi:10.1001/archsurg.1997.01430320088014

Objectives:  To determine the success of unilateral exploration vs bilateral exploration for primary hyperparathyroidism and to analyze the validity of preoperative localization tests.

Design:  Case-control study of patients who underwent surgical exploration (unilateral, n=43; bilateral, n=57) by 1 surgeon from January 1991 through May 1996 and who had ultrasound examination of the neck and thallium-technetium scintigraphy performed before parathyroid surgery. Initially, unilateral exploration was used sparingly, but it became the standard approach in 1994 if localization was correct.

Setting:  Urban multispecialty clinic, teaching hospital.

Patients:  One hundred consecutive patients who underwent surgical exploration for primary hyperparathyroidism.

Interventions:  Ultrasonography of the neck, thalliumtechnetium scintigraphy, and parathyroidectomy.

Main Outcome Measures:  Imaging success, operative success, and operative time.

Results:  In 94 patients with solitary adenomas, the adenoma was demonstrated by ultrasound scans in 66%, by thallium-technetium scintigraphy in 83%, and by either test in 87%. Correct identification by ultrasonography was 59%; by thallium-technetium scintigraphy, 75%; and together, 73%. Of 6 patients with multiple-gland disease, 2 were correctly identified by localization tests and 9 of 15 abnormal glands were demonstrated. Of the 43 unilateral explorations, 43 single adenomas and no cases of multiple-gland disease were identified; of the 57 bilateral explorations, 51 single adenomas and 6 cases of multiple-gland disease were identified. No complications occurred in either group. Hypercalcemia persisted in 3 patients who underwent bilateral exploration and recurrent hypercalcemia developed in 1 patient in each group. The average operative time for the unilateral procedure was 105 minutes, and for the bilateral procedure, 184 minutes (P<.001). Since 1994, 31 (66%) of 47 patients have had unilateral exploration based on correct localization tests.

Conclusions:  Unilateral exploration that is based on the results of localization tests requires less operative time and produces results similar to bilateral exploration.Arch Surg. 1997;132:886-891