Mesh hernia repair and male infertility: a retrospective register study.

BACKGROUND: Previous studies have suggested that the use of mesh in groin hernia repair may be associated with an increased risk for male infertility as a result of inflammatory obliteration of structures in the spermatic cord. In a recent study, we could not find an increased incidence of involuntary childlessness. The aim of this study was to evaluate this issue further. METHODS: Men born between 1950 and 1989, with a hernia repair registered in the Swedish Hernia Register between 1992 and 2007 were cross-linked with all men in the same age group with the diagnosis of male infertility according to the Swedish National Patient Register. The cumulative and expected incidences of infertility were analyzed. Separate multivariate logistic analyses, adjusted for age and years elapsed since the first repair, were performed for men with unilateral and bilateral repair, respectively. RESULTS: Overall, 34,267 men were identified with a history of at least 1 inguinal hernia repair. A total of 233 (0.7%) of these had been given the diagnosis of male infertility after their first operation. We did not find any differences between expected and observed cumulative incidences of infertility in men operated with hernia repair. Men with bilateral hernia repair had a slightly increased risk for infertility when mesh was used on either side. However, the cumulative incidence was less than 1%. CONCLUSION: Inguinal hernia repair with mesh is not associated with an increased incidence of, or clinically important risk for, male infertility.

Male infertility after mesh hernia repair: A prospective study.

BACKGROUND: Several animal studies have raised concern about the risk for obstructive azoospermia owing to vasal fibrosis caused by the use of alloplastic mesh prosthesis in inguinal hernia repair. The aim of this study was to determine the prevalence of male infertility after bilateral mesh repair. METHODS: In a prospective study, a questionnaire inquiring about involuntary childlessness, investigation for infertility and number of children was sent by mail to a group of 376 men aged 18-55 years, who had undergone bilateral mesh repair, identified in the Swedish Hernia Register (SHR). Questionnaires were also sent to 2 control groups, 1 consisting of 186 men from the SHR who had undergone bilateral repair without mesh, and 1 consisting of 383 men identified in the general population. The control group from the SHR was matched 2:1 for age and years elapsed since operation. The control group from the general population was matched 1:1 for age and marital status. RESULTS: The overall response rate was 525 of 945 (56%). Method of approach (anterior or posterior), type of mesh, and testicular status at the time of the repair had no significant impact on the answers to the questions. Nor did subgroup analysis of the men ≤40 years old reveal any significant differences. CONCLUSION: The results of this prospective study in men do not support the hypothesis that bilateral inguinal hernia repair with alloplastic mesh prosthesis causes male infertility at a significantly greater rate than those operated without mesh.

Surgery for patients with primary hyperparathyroidism and negative sestamibi scintigraphy--a feasibility study.

BACKGROUND: We report the surgical treatment of a consecutive series of scan negative patients with the intention of unilateral parathyroid exploration with the aid of intraoperative quick PTH (qPTH). MATERIALS AND METHODS: The study included 35 consecutive sestamibi scan negative patients (27 women, eight men) with sporadic pHPT subjected to first time surgery. Median age was 70 years and median preoperative calcium level 2.8 mmol/L. RESULTS: Thirty-three patients had a histological diagnosis of a parathyroid adenoma (median weight 0.48 g [range 0.12 g-2.5 g]). Nineteen patients were explored bilaterally and 16 patients (46%) were operated unilaterally. The median operation time was 40 min in the unilateral group and 95 min in the bilateral group (p < 0.001). Three patients were treated for postoperative hypocalcemia after bilateral exploration versus none in the unilateral group (p = 0.23). With a minimum of 12 months of follow-up, 33 patients (94.3%) were cured. One case of recurrent HPT presented after bilateral exploration with visualization of four glands. One case of persistent HPT was observed after unilateral exploration. qPTH was predictive of operative failure in both patients. CONCLUSION: Forty-six percent of the patients in our study could be operated unilaterally with a total cure rate of 94%. Patients in the unilateral group had a significant shorter operation time and a lower incidence of postoperative hypocalcemia. In conclusion our investigation shows that limited parathyroid exploration can safely be performed on patients with negative sestamibi scintigraphy by the aid of qPTH.

Effect on bone density of postoperative calcium and vitamin-D supplementation in patients with primary hyperparathyroidism: A retrospective study.

BACKGROUND: Primary hyperparathyroidism (pHPT) is associated with decreased bone density and increased fracture risk. A significant number of pHPT patients have low calcium intake and suffer from vitamin deficiency. Thus, we adopted a policy of postoperative supplements with calcium and vitamin D after parathyroid surgery. In this study, we investigated if this policy enhanced the postoperative increase in bone density. PATIENTS/METHODS: Forty-two consecutive patients (83% female) were studied. The first 21 patients received no supplements, whereas the following 21 patients received 1,000 g calcium and 800 IU hydroxy D: -vitamin daily (Ca-D group) for 1 year postoperatively. The patients were monitored with bone density and biochemistry pre- and at 1 year postoperatively. RESULTS: Preoperatively, the patients without vitamin D supplementation (non-Ca-D group) did neither differ in biochemistry, clinical features, nor in bone density from patients in Ca-D group. Postoperatively, there was a tendency that patients in Ca-D group increased their bone density, at all sites measured, in a greater extent than patients that did not receive calcium and vitamin D supplementation. CONCLUSION: In conclusion, based on our results, it is difficult to give a recommendation of vitamin D supplementation in routine use following surgery for primary hyperparathyroidism. Based on the present data, a calculation of sample size for a future randomized controlled trial is presented.

Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: long-term follow-up of a randomized controlled trial.

BACKGROUND: We have conducted a randomized controlled trial of totally extraperitoneal hernia repair (TEP) versus tension-free open repair (Lichtenstein repair); we have presented the results previously up to 1 year after the operation. The aim of this study was to compare patient outcome in both groups at a median follow-up of 7.3 years after operation. METHODS: Of 168 patients included in a prospective, randomized controlled trial designed to compare TEP with an open tension-free technique, 154 patients (92%) answered a questionnaire and 147 patients (88%) were followed up at an outpatient clinic after a minimum of 6 years after operation. RESULTS: Overall, 89% of patients in the TEP group and 95% of patients in the open group reported complete long-term recovery (P = .23). Permanent impaired inguinal sensibility was more common in the open group (P = .004), whereas the proportion of patients with reported testicular pain was higher in the TEP group (P = .003). Three recurrences were found in the TEP group, and 4 recurrences were found in the open group (P = .99). Four patients in the TEP group underwent operations for complications related to the hernia repair (small bowel obstruction, umbilical hernia, testicular pain, and neuralgia). CONCLUSION: Overall, both groups showed good long-term results with low rates of recurrences. However, the TEP group was associated with a higher proportion of patients with long-term testicular pain, whereas impaired inguinal sensibility was more common in the open group.

Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial.

OBJECTIVE: To compare long-term patient outcome in a prospective randomized controlled trial between unilateral and bilateral neck exploration for primary hyperparathyroidism (pHPT). SUMMARY BACKGROUND DATA: Minimal invasive and/or focused parathyroidectomy has challenged the traditional bilateral neck exploration for pHPT. Between 1997 and 2001, we conducted the first unselected randomized controlled trial of unilateral versus bilateral neck exploration for pHPT. The results showed that unilateral exploration is a surgical strategy with distinct advantages in the early postoperative period. However, concerns have been raised that limited parathyroid exploration could increase the risk for recurrent pHPT during long-term follow-up. METHODS: Ninety-one patients with the diagnosis of pHPT were randomized to unilateral or bilateral neck exploration. Preoperative scintigraphy and intraoperative parathyroid hormone measurement guided the unilateral exploration. Gross morphology and frozen section determined the extent of parathyroid tissue resection in the bilateral group. Follow-up was performed after 6 weeks, 1 year, and 5 years postoperatively. RESULTS: Seventy-one patients were available for 5-year follow-up. There were no differences in serum ionized calcium and parathyroid hormone, respectively, between patients in the unilateral and bilateral group. Overall 6 patients have been found to have persistent (n = 3) or recurrent (n = 3) pHPT; 4 patients in the unilateral group (3 of these 4 patients were bilaterally explored) and 2 patients in the bilateral group. Three of 6 failures were unexpectedly found to have multiple endocrine neoplasia mutations. One patient with solitary adenoma in the bilateral group still required vitamin D substitution 5 years after surgery. CONCLUSION: Unilateral neck exploration with intraoperative parathyroid hormone assessment provides the same long-term results as bilateral neck exploration, and is thus a valid strategy for the surgical treatment of pHPT.

Serum levels of uric acid and diabetes mellitus influence survival after surgery for primary hyperparathyroidism: a prospective cohort study.

BACKGROUND: Primary hyperparathyroidism (pHPT) is associated with an increased mortality attributable to cardiovascular disease (CVD), suggested to be alleviated by surgery. The exact mechanism of the beneficial influence of parathyroidectomy on survival is unknown. Furthermore, studies suggest that there is no increased mortality compared to the mortality rate in the general population during recent years. This study therefore investigated relative survival (RS), as well overall mortality associated with the clinical and biochemical variables in patients undergoing operation for sporadic pHPT. Furthermore, the influence of surgery on biochemical variables associated with pHPT was analyzed. METHODS: A group of 323 patients with sporadic pHPT operated between September 1989 and July 2003 were followed from surgery over a 10-year period. The median and mean follow-up time was 69 and 70 months, respectively (range: 1-120 months). Relative survival (RS) was calculated, and the impact of clinical and biochemical variables on overall death were evaluated. RESULTS: Postoperatively, serum levels of triglycerides and uric acid decreased. Glucose levels and glomerular filtration rate remained unchanged. A decreased RS was evident during the latter part of the 10 year follow-up period. In the multivariate Cox-analysis, diabetes mellitus (hazard ratio [HR] = 2.8, 95%; confidence interval [CI] 1.2-6.7), and the combination of an increased level of serum uric acid and cardiovascular disease (CVD) (HR = 8.6, 95%; CI 1.5-49.7) was associated with a higher mortality. The increased risk of death was evident for patients with persistently increased levels of uric acid postoperatively (HR = 4.8, 95%; CI = 1.4-16.01). CONCLUSIONS: Patients undergoing operation for pHPT had a decreased RS during a 10-year follow-up compared to the general population. This decrease in RS is associated with diabetes mellitus and increased levels of uric acid pre-and postoperatively.

Parathyroid surgical failures with sufficient decline of intraoperative parathyroid hormone levels: unobserved multiple endocrine neoplasia as an explanation.

HYPOTHESIS: A sufficient decline in levels of parathyroid hormone measured intraoperatively (ioPTH) precludes early and late surgical failures. DESIGN: A case series of consecutive patients undergoing parathyroidectomy with ioPTH measurement. SETTING: A university hospital. PATIENTS AND INTERVENTION: Two hundred sixty-nine consecutive patients with sporadic primary hyperparathyroidism who underwent first-time parathyroid surgery with ioPTH measurement were followed up for as long as 10 years after surgery. Data on all patients have been collected in a prospective database. MAIN OUTCOME MEASURES: Surgical failures up to 10 years after parathyroid surgery. RESULTS: With an average follow-up of 3.6 years (range, 6-120 months), the overall cure rate was 96%. The ioPTH level correctly predicted long-term outcome in 248 (92%) of 269 patients. Six patients had a false-positive ioPTH finding. Five of these patients were found to have germline mutations in the gene for multiple endocrine neoplasia. The remaining patient has not undergone genetic testing. The mutations have rarely (n = 1) or never (n = 4) been described before, to our knowledge. CONCLUSIONS: Intraoperative measurement of PTH level has a high overall accuracy with a mean follow-up of 3.6 years. However, among the late surgical failures with false-positive ioPTH findings, overlooked mutations in the multiple endocrine neoplasia gene should be suspected, and therefore genetic analyses in these patients are of great importance.

Sestamibi scan-directed parathyroid surgery: potentially high failure rate without measurement of intraoperative parathyroid hormone.

The present study evaluated sestamibi scan-directed parathyroidectomy with intraoperative parathyroid hormone (PTH) assessment (ioPTH). The preoperative sestamibi scintigraphies were compared with the intraoperative findings for 103 patients undergoing first exploration for sporadic primary hyperparathyroidism (pHPT). Data were collected prospectively. Ninety-nine patients (96%) were cured. Patients with persistent pHPT (n = 4) all had an incorrect scintigram as well as an insufficient decline of ioPTH. At operation, 90 patients (87%) had solitary parathyroid adenoma; 12 patients had multiglandular disease. In one patient no enlarged parathyroid gland was found. Overall 77 of 118 abnormal glands (65%) were correctly identified by sestamibi scintigraphy. The sensitivity for localizing a single parathyroid adenoma was 80%. Patients with incorrect scintigrams had a higher proportion of upper pole adenomas than patients with correct scans. High glandular weight and high level of serum PTH were important factors for detectability. Sestamibi scintigraphy did not predict multiglandular disease. However, the use of ioPTH identified 8 of the 9 patients with a positive scan (a solitary focus) and multiglandular disease. In contrast, false-negative ioPTH led to four unnecessary bilateral explorations in the 63 patients with a scan-identified adenoma. With the help of ioPTH, a focused parathyroidectomy was accomplished in 43% of scan-negative patients with a solitary adenoma. In conclusion, sestamibi scintigraphy is an acceptable method for localizing a solitary parathyroid adenoma. However, the technique alone does not reliably predict multiglandular disease. Potentially the failure rate in scan-directed parathyroidectomy could increase, with up to 10% of patients without ioPTH.

Long-term follow-up of patients with elevated PTH levels following successful exploration for primary hyperparathyroidism.

Several studies have documented elevated parathyroid hormone (PTH) levels after seemingly successful exploration for primary hyperparathyroidism (pHPT). It is not known if this is a transient phenomenon after pHPT surgery or if it predisposes to recurrent disease. A series of 99 consecutive patients with pHPT who had solitary parathyroid adenomas were followed for 5 years. Serum levels of PTH and biochemical variables reflecting PTH activity were measured before operation, at 8 weeks postoperatively, and then yearly for 5 years. All patients were normocalcemic after exploration. At 8 weeks after operation 28% of the patients had elevated serum PTH levels; at 5 years this figure decreased to 16%. During the 5-year follow-up one group of patients normalized their PTH levels, another group's PTH levels fluctuated, and still another group had consistently normal PTH levels. Patients with fluctuating PTH levels had increased levels of serum calcium and phosphate. Some of these patients (15%) showed signs of impaired renal function. Two patients with consistently elevated PTH levels showed signs of mild renal dysfunction, and one of them developed recurrent HPT. Elevated PTH levels after successful parathyroid surgery is not a transient phenomenon. An increased risk for recurrent disease is postulated for some of the patients who do not normalize their PTH levels postoperatively, and long-term surveillance of these patients is suggested.

Recovery of bone mineral density in 126 patients after surgery for primary hyperparathyroidism.

Primary hyperparathyroidism (pHPT) is associated with increased fracture risk and decreased bone mass. The recovery of bone mass after surgery varies; therefore tests that predict the increase in bone mass after parathyroidectomy would be desirable. Preoperatively and at 1 year after surgery bone mineral content (BMC) in the distal radius and bone mineral density (BMD) in the lumbar spine and hip, as well as biochemical variables, were measured in 126 pHPT patients (95 women, 31 men). The mean +/- SD age of the patients was 63 +/- 15 years. The mean +/- SD serum calcium level was 2.78 +/- 0.16 mmol/L. Altogether, 60% of the patients had a low oral calcium intake, and 18% had a 25-hydroxyvitamin D3 deficiency. Preoperatively, postmenopausal women had lower Z-scores for BMD in the hip (p < 0.001) and lumbar spine (p < 0.05) than did premenopausal women. One year after surgery the bone density had increased in about 50% of the patients. The multiple logistic regression analysis showed that there was a weak association between the change in BMD in the hip, the serum 1,25-dihydroxyvitamin D3 level (p < 0.05), and renal function (p < 0.05), respectively. We concluded that about 50% of patients have increased bone mass after pHPT surgery, but the increase in the bone density is difficult to predict for the individual patient. Because many pHPT patients have low oral calcium intake and a vitamin D deficiency, it would be of interest to evaluate the role of postoperative calcium/vitamin D supplements.

Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: a prospective randomized controlled trial.

BACKGROUND: This study was designed to compare an open tension-free technique (Lichtenstein repair) with a laparoscopic totally extraperitoneal hernia repair (TEP). METHODS: One hundred sixty-eight men aged 30 to 65 years with primary or recurrent inguinal hernia were randomized to TEP or open mesh technique in the manner of Lichtenstein. Follow-up was after 1 and 6 weeks, and 1 year. RESULTS: Eighty-one patients were randomized to TEP, and 87 to open repair. For 1 patient in each group, the operation was converted to a different type of repair. No difference was seen in overall complications between the 2 groups. However, 1 patient in the TEP group underwent operation for small bowel obstruction after surgery. A higher frequency of postoperative hematomas was seen in the open group (P <.05). Patients in the TEP group consumed less analgesic after surgery (P <.001), returned to work earlier (P <.01), and had a shorter time to full recovery (P <.01). Two recurrences occurred in the TEP group 1 year after surgery. CONCLUSION: The TEP technique was associated with less postoperative pain, a shorter time to full recovery, and an earlier return to work compared with the open tension-free repair. No difference was seen in overall complications. However, 2 recurrences did occur after 1 year in the TEP group.

Patients with elevated serum parathyroid hormone levels after parathyroidectomy: showing signs of decreased peripheral parathyroid hormone sensitivity.

We have previously shown that patients with elevated levels of parathyroid hormone (PTH) after surgery for parathyroid adenoma have normal parathyroid and renal function but demonstrate signs of remineralization of cortical bone, decreased calcium absorption, and low levels of vitamin D. We hypothesized that decreased peripheral PTH sensitivity could also be of importance for this condition. Thirteen patients operated on for a solitary parathyroid adenoma, with a mean +/- SD preoperative serum level of calcium of 2.72 +/- 0.12 mmol/L, were investigated 6 weeks after surgery with a standardized PTH (1-34) infusion test for 6 hours. The eight patients with elevated PTH levels had less increase in serum levels of ionized calcium (0.02 +/- 0.03 mmol/L) than did the five patients with normal PTH levels (0.06 +/- 0.02 mmol/L) (p < 0.05). Patients with elevated PTH also showed less decrease in serum phosphate levels (p < 0.05) and a trend to a larger decrease in the excretion of urinary calcium (p = 0.08). The increase in 1,25-dihydroxyvitamin D(3) did not differ between the two groups of patients. Thus patients operated on for parathyroid adenoma with postoperatively elevated serum PTH levels showed decreased peripheral sensitivity to PTH.

Preoperative normal level of parathyroid hormone signifies an early and mild form of primary hyperparathyroidism.

Contemporary patients are often diagnosed with mild or intermittent hypercalcemia. In addition, most studies demonstrate patients with parathyroid (PTH) levels in the upper normal range. The aim of the present investigation was to define subgroups of patients with mild primary hyperparathyroidism (pHPT), which could be of importance in the decision for or against surgical treatment. Two-hundred and eleven patients, operated for pHPT were investigated with biochemical variables known to reflect PTH activity, renal function, and bone mineral content. The preoperative diagnosis of pHPT was based on the presence of hypercalcemia combined with an inappropriate serum concentration of PTH. The mean age of the patients was 64 +/- 14 years and the mean serum level of calcium was 2.78 +/- 0.19 mmol/L. One hundred and sixty-two patients (77%) had raised levels of calcium and PTH the day before surgery (overt pHPT), 25 patients (12%) had a normal level of calcium and a raised PTH level (normal calcium group), and 20 patients (9%) had a raised level of calcium and a normal level of PTH (normal PTH group). In four patients the level of calcium and PTH was normal. Between-group analysis demonstrated no major difference in symptom and signs of pHPT. Except for lower adenoma weight, patients in the normal calcium group did not essentially differ from the patients in the overt pHPT group. However, patients in the normal PTH group were a decade younger, and had better renal function, lower bone turnover, and a preserved bone density compared with patients in the overt pHPT group. In conclusion, the data from the present investigation show that pHPT patients with a preoperative normal PTH level have an early and mild form of the disease. Furthermore, the serum calcium concentration does not reflect disease severity in pHPT.

Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial.

OBJECTIVE: To compare unilateral and bilateral neck exploration for primary hyperparathyroidism in a prospective randomized controlled trial. SUMMARY BACKGROUND DATA: Based on the assumption that unilateral neck exploration for a solitary parathyroid adenoma should reduce operating time and morbidity, a variety of minimally invasive procedures have challenged the idea that bilateral neck exploration is the gold standard for the surgical treatment of primary hyperparathyroidism. However, to date, no open prospective randomized trial has been published comparing unilateral and bilateral neck exploration. METHODS: Ninety-one patients with the preoperative diagnosis of primary hyperparathyroidism were randomized to unilateral or bilateral neck exploration. Preoperative scintigraphy and intraoperative parathyroid hormone measurement guided the unilateral exploration. Gross morphology and frozen section determined the extent of parathyroid tissue resection in the bilateral group. The primary end-point was the use of postoperative medication for hypocalcemic symptoms. RESULTS: Eighty-eight patients (97%) were cured. Histology and cure rate did not differ between the two groups. Patients in the bilateral group consumed more oral calcium, had lower serum calcium values on postoperative days 1 to 4, and had a higher incidence of early severe symptomatic hypocalcemia compared with patients in the unilateral group. In addition, for patients undergoing surgery for a solitary parathyroid adenoma, unilateral exploration was associated with a shorter operative time. The cost for the two procedures did not differ. CONCLUSIONS: Patients undergoing a unilateral procedure had a lower incidence of biochemical and severe symptomatic hypocalcemia in the early postoperative period compared with patients undergoing bilateral exploration. Unilateral neck exploration with intraoperative parathyroid hormone assessment is a valid surgical strategy in patients with primary hyperparathyroidism with distinct advantages, especially for patients with solitary parathyroid adenoma.

Multifactorial risk profile for bone fractures in primary hyperparathyroidism.

Primary hyperparathyroidism (pHPT) is associated with an increased fracture risk, and decreased bone density thus has been considered an indication for surgery. However, many pHPT patients have a multifactorial risk profile for osteoporosis and bone fractures. The aim of the present study was to evaluate variables associated with fracture risk within the group of pHPT patients. A series of 203 consecutive patients operated for pHPT were investigated with bone mineral content and biochemical and clinical risk factors for bone fracture. Seventeen patients (8%) had a history of at least one bone fracture up to 5 years before pHPT surgery. Twenty-six patients (13%) had a history of at least one fracture during the 10-year period prior to surgery. In the univariate analyses corticosteroid treatment, serum levels of alkaline phosphatase, 25-hydroxyvitamin D3, type I collagen telopeptide, and bone mineral content were found to be associated with a history of bone fractures up to 10 years before surgery. Additionally, age and menopausal status were of importance for fractures during the 10-year-period, whereas a history of cardiovascular disease was important for fractures during the 5-year-period prior to surgery. Multivariate analyses showed that serum level of PTH was independently associated with bone fractures during the 5-year period prior to pHPT surgery and further that serum level of 25-hydroxyvitamin D3 was associated with fractures up to 10 years before surgery. In conclusion, serum levels of 25-hydroxyvitamin D3 and PTH were independently associated with a history of bone fractures in pHPT. These variables should be considered when evaluating patients for parathyroid surgery.

Hypersensitivity to noradrenaline in human omental vein but not artery isolated from a patient with idiopathic orthostatic hypotension.

We investigated the smooth muscle contraction in response to noradrenaline (NA), endothelin-1 (ET) and 5-hydroxytryptamine (5-HT) in the omental artery and vein segments from a 67-year-old woman with idiopathic orthostatic hypotension. The blood vessels were obtained during the abdominal surgery and investigated in vitro. Noradrenaline, endothelin-1 and 5-hydroxytryptamine all induced a contraction in the artery and vein segments. Compared to the literature, the sensitivity to noradrenaline was 10 times higher than expected in the vein. In the artery, the sensitivity to noradrenaline and in both the artery and vein, the sensitivity to endothelin-1 and 5-hydroxytryptamine was similar to that reported in the literature. These results suggest that the patient had developed an isolated hypersensitivity to noradrenaline in the veins, probably due to an impairment of the sympathetic activity.

Low parathyroid hormone levels after thyroid surgery: a feasible predictor of hypocalcemia.

BACKGROUND: Selecting patients with a low risk of hypocalcemia is mandatory if patients are to be discharged on the first day after bilateral thyroidectomy. This study investigated the predictive value of intraoperative parathyroid hormone (PTH). METHODS: Thirty-eight patients underwent total or near-total thyroidectomy. Patients with or without biochemical and symptomatic hypocalcemia were compared regarding intraoperative PTH levels and previously suggested risk factors. The accuracy of intraoperative PTH to predict patients at risk for postoperative hypocalcemia was compared with a calcium concentration of less than 2.00 mmol/L (8.0 mg/dL) on the first postoperative day. RESULTS: PTH levels after resection of the second lobe, age, and number of parathyroid glands identified intraoperatively were independently associated with the reduction in serum calcium concentration measured at nadir on the first or second postoperative day. PTH levels after resection of the second lobe were lower among patients who developed biochemical (P <.001) and symptomatic hypocalcemia (P <.01) compared with those who did not. Low levels of intraoperative PTH identified the 3 patients who required intravenous calcium during the first 24 postoperative hours. An intraoperative PTH level below reference range and a calcium concentration of less than 2.00 mmol/L measured 1 day postoperatively both predicted biochemical hypocalcemia with a similar sensitivity (90% vs 90%) and specificity (75% vs 82%). Intraoperative PTH was slightly better than a serum calcium concentration of less than 2.00 mmol/L on postoperative day 1 to predict symptomatic hypocalcemia, with a sensitivity of 71% vs 52% and a specificity of 81% vs 76%, respectively. CONCLUSIONS: Parathyroid gland insufficiency is the main determinant of transient hypocalcemia after bilateral thyroid surgery. Low intraoperative PTH levels during thyroid surgery are therefore a feasible predictor of postoperative hypocalcemia.

Measurement of intraoperative parathyroid hormone predicts long-term operative success.

HYPOTHESIS: A decrease in the intraoperative parathyroid hormone (PTH) level predicts long-term operative success. DESIGN: A case series of consecutive patients undergoing parathyroidectomy with intraoperative PTH measurement. SETTING: A university hospital. PATIENTS AND INTERVENTION: One hundred two patients with sporadic primary hyperparathyroidism underwent parathyroidectomy according to the principles of unilateral exploration with intraoperative PTH measurement. MAIN OUTCOME MEASURES: Longitudinal effects on levels of serum calcium and PTH. RESULTS: In 94 of 98 patients who underwent primary exploration because of a solitary adenoma, intraoperative PTH decreased at least 60% 15 minutes after gland excision. The 4 cases in which PTH fell to less than 60% were classified as false negatives. Patients examined for multiglandular disease (n = 4) were correctly predicted not to have an adenoma. Twenty-two patients (22%) were unavailable for 5-year follow-up. These patients were followed up for 2 months to 48 months (median, 24 months), and none developed recurrent primary hyperparathyroidism. Of the remaining 80 patients (78%), all but 1 patient had normal or slightly decreased serum calcium levels (mean +/- SD, 9.24 +/- 0.4 mg/dL [2.31 +/- 0.10 mmol/L]) at 5-year follow-up. One patient with hypercalcemia (10.6 mg/dL [2.65 mmol/L]) was interpreted to have developed renal failure with secondary hyperparathyroidism. Thirty-four patients had elevated serum PTH levels at least once during the postoperative study period, with normal or slightly decreased calcium concentrations. The prediction of late postoperative normocalcemia by means of intraoperative PTH measurement had an overall accuracy of 95%. CONCLUSIONS: The measurement of intraoperative PTH during surgery for primary hyperparathyroidism accurately differentiates between single- and multiple-gland disease and ensures good long-term results.