An individual approach to intraoperative parathyroid hormone measurement during total thyroidectomy.

PURPOSE: Hypocalcemia is a common complication of thyroidectomy. Measurement of the intraoperative serum parathyroid hormone (PTH) levels became an established technique but it requires further improvements. We aimed to assess intraoperative PTH level testing results against the hypothesis that the PTH assay may be performed almost immediately after thyroid gland removal. METHODS: A retrospective cohort study. During total thyroidectomy surgery, the patients had PTH levels measured at the cutting time and again immediately after the thyroid gland is removed. Post-operatively, serial total blood calcium levels were obtained twice daily and recorded. RESULTS: Among 63 enrolled patients, 39 had multinodular goiter, 15 thyroid carcinoma, and nine had Graves' disease. The mean age was 59.8 ± 15.3 years, 43 females. The mean PTH level before surgery was 45.8 ± 22.0 pg/mL. Post-operatively, 11/63 patients developed hypocalcemia with serum calcium levels <8 mg/dL. Four patients with ≥50 % decrease in PTH concentration were normocalcemic a day after surgery and were discharged early. Four patients with ≥70 % PTH decrease were treated accordingly during prolonged hospitalization and did not suffer from permanent hypocalcemia. The cut-off value of 70 % decrease after the gland removal was able to predict postoperative hypocalcemia with a sensitivity of 100 %, specificity 82.9 %, PPV 60.0 % and NPV 100 %. CONCLUSION: Measurements of intraoperative PTH may not be performed at fixed time intervals but after 1-2 min after removal of the thyroid gland. Defining those not at risk would allow the majority of patients to be waived from post-operative blood calcium testing and safely discharged early after surgery.

A >50% Intraoperative Parathyroid Hormone Decrease Into Normal Reference Range Predicts Complete Excision of Malignancy in Patients With Parathyroid Carcinoma.

INTRODUCTION: The mainstay of successful treatment for parathyroid carcinoma remains complete surgical excision. Although intraoperative parathyroid hormone (ioPTH) monitoring is a useful adjunct during parathyroidectomy for benign primary hyperparathyroidism, its utility for parathyroid carcinoma remains unclear. METHODS: A retrospective review of 796 patients who underwent parathyroidectomy with ioPTH monitoring for primary hyperparathyroidism revealed 13 patients with parathyroid carcinoma on final pathology from two academic institutions. A systematic review yielded 5 additional parathyroid carcinoma patients. Complete excision of malignancy, or operative success (eucalcemia ≥6 mo. after parathyroidectomy); operative failure (persistent hypercalcemia <6 mo. after parathyroidectomy); and perioperative complications were evaluated. Comparison of the >50% ioPTH decrease alone to >50% ioPTH decrease into normal reference range was analyzed using Chi-squared, Kolmogorov-Smirnov, Kruskal-Wallis tests. RESULTS: All 18 parathyroid carcinoma patients achieved a >50% ioPTH decrease, and 14 patients also had a final ioPTH level decrease into normal reference range. 93% of patients who met normal parathyroid hormone reference range had operative success, whereas only two of the four (50%) patients with parathyroid carcinoma with a >50% ioPTH decrease alone demonstrated operative success. CONCLUSIONS: Parathyroidectomy guided by a >50% ioPTH decrease into normal reference range may better predict complete excision of malignant tissue in patients with parathyroid carcinoma compared to >50% ioPTH decrease alone. IoPTH monitoring should be used in conjunction with clinical judgment and complete en bloc resection for optimal treatment and success.

Findings of pilot study following the implementation of point of care intraoperative PTH assay using whole blood during surgery for primary hyperparathyroidism.

Objective: To report findings of pilot study using a novel point of care (POC) intraoperative parathyroid hormone (IOPTH) assay for parathyroid hormone (PTH) using whole blood during surgery for primary hyperparathyroidism (PHPT). Methods: Patients undergoing surgery for primary hyperparathyroidism from March to November 2022 where intraoperative PTH assay was performed using the NBCL CONNECT IOPTH and the laboratory PTH assay were included (group 1). The biochemistry results were reviewed to determine concordance between NBCL and lab PTH values and diagnostic test parameters of the NBCL CONNECT assay. 'In-theatre' times were then compared with a historical cohort (group 2) where the lab-based IOPTH assay alone was used. Results: Of the 141 paired samples in group I, correlation between NBCL and the lab assay was high (rho=0.82; p<0.001). PTH levels using the NBCL assay dropped satisfactorily (>50% of the basal or 0 min sample; whichever was lower - i.e. positive test) in 23 patients; giving a positive predictive value of 100%. Of the 9 patients that did not demonstrate a drop, two were true negative (negative predictive value of 22%) leading to cure after excision of another gland. Group 1 (150 mins) had a significantly shorter 'in-theatre' time compared to group 2 (167 mins) (p=0.007); despite much higher use of near infra-red autofluorescence (NIRAF) (72% vs 11.6% in group I and 2 respectively). Conclusion: The NBCL CONNECT POC IOPTH assay gives comparable results to lab based PTH assays and can be performed without need for a centrifuge or qualified technicians. Surgeons, however, need to be aware of the potential for false-negative results.

Operative success is achieved regardless of ioPTH criterion used during focused parathyroidectomy for sporadic primary hyperparathyroidism.

BACKGROUND: Focused parathyroidectomy (F-PTX) guided by intraoperative parathormone (ioPTH) monitoring may result in higher operative failure rates from missed multiglandular disease (MGD) in patients with sporadic primary hyperparathyroidism (spHPT) when ioPTH levels do not reach normal range. METHODS: A retrospective review included 690 patients with spHPT who underwent F-PTX and ioPTH monitoring were divided into 2 groups: >50% ioPTH decrease to normal range, and >50% ioPTH decrease to above normal range. Operative success, recurrence, bilateral/unilateral neck exploration (BNE/UNE), MGD were evaluated. RESULTS: 533 patients demonstrated >50% ioPTH decrease to normal range, and 157 patients >50% ioPTH decrease to above normal range. There were no differences in operative success 99% vs. 97%, recurrence 2.5% vs. 5%, BNE 12% vs. 11%, UNE 4% vs. 5%, or MGD 4% vs. 4%, (p > 0.05) with 46 months mean follow-up. CONCLUSIONS: There were no differences in operative success, failure, BNE, UNE or MGD regardless of ioPTH criterion used for F-PTX.

Evolution of the Diagnosis and Treatment of Primary Hyperparathyroidism.

This study aims to present the evolution of our center's approach to treating primary hyperparathyroidism (PHPT) from diagnosis to intraoperative interventions. We have also evaluated the intraoperative localization benefits of indocyanine green fluorescence angiography. This retrospective single-center study involved 296 patients who underwent parathyroidectomy for PHPT between January 2010 and December 2022. The preoperative diagnostic procedure included neck ultrasonography in all patients, [99mTc]Tc-MIBI scintigraphy in 278 patients, and, in 20 doubtful cases, [18F] fluorocholine positron emission tomography (PET) computed tomography (CT) was performed. Intraoperative PTH was measured in all cases. Indocyanine green has been administered intravenously since 2020 to guide surgical navigation using a fluorescence imaging system. The development of high precision diagnostic tools that can localize an abnormal parathyroid gland in combination with intra-operative PTH assay (ioPTH) enables the surgical treatment of PHPT patients with focused approaches and excellent results that are stackable with bilateral neck exploration (98% of surgical success). Indocyanine green angiography has the potential to assist surgeons in identifying parathyroid glands rapidly and with minimal risk, especially when pre-operative localization has failed. When everything else fails, it is only an experienced surgeon who can resolve the situation.

The Co-occurrence of Multiple Parathyroid Adenomas: A Case Report.

Solitary parathyroid adenoma is the most common cause of primary hyperparathyroidism; however, multiple parathyroid adenomas are an uncommon phenomenon. In this case report, we discuss a patient presenting with two concurrent ipsilateral parathyroid adenomas, and we review the literature. A 61-year-old African American female with a history of hypertension and kidney stones presented for the evaluation of hypercalcemia. Elevated serum calcium of 11 mg/dL was found on routine laboratory tests and low25 hydroxyvitamin-D level. Parathyroid hormone (PTH) was elevated at 172.5 pg/mL and increased to 443 pg/mL after correction of vitamin D deficiency. Renal function tests and thyroid function tests revealed normal findings. Imaging studies with 99mTc-Sestamibi scintigraphy raised concern for the possibility of either a parathyroid adenoma or hyperplasia. Minimally invasive parathyroidectomy with intraoperative PTH monitoring was planned. During surgery, the right superior parathyroid gland was found to be enlarged and was excised. However, intraoperative PTH monitoring showed an initial decrease to 203 pg/mL from a baseline of 443 pg/mL and a subsequent increase to 293 pg/mL suggesting the persistence of hyperparathyroidism. Further exploration of the neck revealed an enlarged right inferior parathyroid gland and two normal left parathyroid glands. Intraoperative PTH monitoring then revealed an appropriate decrease in PTH level to 56 pg/mL 10 minutes after excision of the right inferior parathyroid gland. More than a 50% decrease in PTH was achieved, and further exploration of the opposite side revealed no evidence of four-gland hyperplasia. Pathology reported two concurrent right superior and inferior parathyroid adenomas. Successful and curative parathyroidectomy for primary hyperparathyroidism was achieved. Although rare, multiple parathyroid adenomas occur in a significant minority of cases. Intraoperative PTH monitoring along with preoperative imaging provides guidance for curative parathyroidectomy. Additionally, more sensitive imaging such as four-dimensional computed tomography scans could lead to better localization, visualization, and identification of the second parathyroid adenoma.

Estudios preoperatorios coincidentes para el diagnóstico de hiperparatiroidismo primario por adenoma simple: ¿podemos evitar la PTH intraoperatoria? / Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring?

Introducción: La causa más frecuente de hiperparatiroidismo primario (HPP) es el adenoma paratiroideo (único en el 80 a 85% de los casos y doble en un 4%, aproximadamente). El resto de los casos obedece a una hiperplasia de las glándulas paratiroides, o de forma más infrecuente, a un carcinoma paratiroideo. Nuestro objetivo es determinar la utilidad de la hormona paratiroidea intraoperatoria (PTHio) en pacientes con ecografía cervical y centellograma coincidentes preoperatorios, en el HPP por un adenoma simple. Métodos: Se realizó un estudio retrospectivo, unicéntrico, incluyendo a todos los pacientes sometidos a paratiroidectomía mini-invasiva (PMI) por HPP, por adenoma simple. Definimos estudios coincidentes cuando ambos localizaron el adenoma. La PTHio fue medida en tres ocasiones: en la inducción anestésica, inmediatamente antes y a los 15 minutos de la escisión de la glándula. El éxito se definió como la caída de al menos el 50% del valor máximo de la hormona paratiroidea (PTH) luego de remover la glándula. Se analizaron variables demográficas, intraoperatorias, postoperatorias y la utilidad de la PTHio. Resultados: Se realizaron un total de 499 paratiroidectomías, de estas, 218 presentaron un adenoma localizado en la ecografía y gammagrafía. La edad fue de 60,1 años y 85% eran mujeres. Luego de 15 minutos de la escisión del adenoma, la PTHio no descendió en nueve pacientes (4,2% OR 1,9 a 7,69%); todos ellos fueron a una exploración cervical bilateral. El valor agregado de la PTHio para la cura de la enfermedad fue de 3,6%. Hubo un 99% de curación de enfermedad. El tiempo operatorio fue de 66,4 minutos y el de espera de la PTHio fue de 31 minutos. La PTHio encareció el procedimiento al doble. Conclusiones: La ecografía y el centellograma preoperatorios coincidentes para la localización de un adenoma en HPP podrían evitar la medición de la PTHio durante las PMI. (AU)

Introduction: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. Methods: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 minutes after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50%compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. Results: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 minutes after its excision, IOPTH did not decrease in 9 patients (4.2% OR 1.9% - 7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 minutes and the waiting time for the third IOPTH result was 31minutes. Performing IOPTH monitoring made the surgery about twice more expensive. Conclusions: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies. (AU)

Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring?

INTRODUCTION: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. METHODS: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 min after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50% compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. RESULTS: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 min after its excision, IOPTH did not decrease in 9 patients (4.2%. OR 1.9%-7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 min and the waiting time for the third IOPTH result was 31 min. Performing IOPTH monitoring made the surgery about twice more expensive. CONCLUSIONS: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies.

Determination of calcium and parathyroid hormone levels following hemithyroidectomy.

BACKGROUND AND OBJECTIVE: Hypocalcemia is one of the main complications of thyroid surgery. We hypothesized that hemithyroidectomy may have an impact on serum parathyroid hormone (PTH) and calcium levels despite only one thyroid lobe is manipulated. The objective of this study was to analyze changes in serum PTH and calcium levels following hemithyroidectomy. METHODS: This is a prospective study of 53 patients who underwent thyroid lobectomy. The serum PTH level was determined in the preoperative period, 15 min after extraction of the surgical specimen, and 24 h and 3 weeks after surgery. Serum ionized calcium was also measured in the preoperative period and at 6 h, 24 h and 3 weeks after surgery. We assessed the postoperative calcium value and its relationship with the extent of fall in PTH levels in the postoperative period. RESULTS: None of the patients had the postoperative serum ionised calcium level less than 4 mg/dl. The decrease in postoperative calcium was statistically significant at 6 and 24 h after surgery; there was no difference at 3 weeks post-surgery. The change in post-operative serum PTH levels followed a similar trend to postoperative serum calcium levels. CONCLUSIONS: Although serum calcium level decreased after a lobectomy, it always remained above 4 mg/dl. We conclude that hypocalcaemia is rare following hemithyroidectomy.

Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring? / Estudios preoperatorios coincidentes para el diagnóstico de hiperparatiroidismo primario por adenoma simple: ¿podemos evitar la PTH intraoperatoria?

INTRODUCTION: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. METHODS: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 minutes after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50%compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. RESULTS: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 minutes after its excision, IOPTH did not decrease in 9 patients (4.2% OR 1.9% - 7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 minutes and the waiting time for the third IOPTH result was 31minutes. Performing IOPTH monitoring made the surgery about twice more expensive. CONCLUSIONS: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies.

A rare cause of neonatal hypercalcemia: Neonatal severe primary hyperparathyroidism: A case report and review of the literature.

INTRODUCTION: Neonatal severe primary hyperthyroidism is an extremely rare disorder that occurs in the first six months of life. Early recognition and prompt surgical intervention are of vital importance for survival and to avoid neurological sequel. Hypotonia, lethargy, respiratory distress, and growth and developmental delay occur in association with elevated serum parathormone levels and hypercalcemia (Gannon et al., 2014). Definitive therapy involves total parathyroidectomy. CASE PRESENTATION: We are presenting a patient with Neonatal severe primary hyperparathyroidism, who successfully underwent total parathyroidectomy. The patient had been followed up with medical therapy until he was seven months old, with no adequate clinical response to medical therapy. Parathormone levels rapidly declined following total parathyroidectomy, and the parathormone level fell to zero after removal of the ectopic tissue with a second surgery, and the patient was discharged with full recovery. DISCUSSION: Sestamibi scintigraphy might not always show an ectopic parathyroid gland. In such conditions, confirmation of parathyroid glands excised with total parathyroidectomy by frozen biopsy is not sufficient to terminate surgery. Intraoperative parathormone monitoring is particularly important at this point. Persistently elevated parathormone levels should suggest a remnant parathyroid tissue at the surgical site or an ectopic parathyroid gland that needs to be excised. CONCLUSION: Neonatal severe primary hyperparathyroidism is a life-threatening condition. Early surgery is life-saving in cases in whom medical therapy fails to control the disease.

Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy.

Background: Hypoparathyroidism is one of the most common complications for patients undergoing total thyroidectomy. Our study's primary objective was to assess if intraoperative PTH levels correlate with parathyroid gland function recovery time in pediatric patients following total thyroidectomy. Methods: Retrospective review of pediatric patients who underwent thyroid surgery at CHOP for demographics and laboratory test values (calcium, phosphorus, and parathyroid hormone). We defined Time of Recovery (TOR) as the time difference from first intra-operative parathyroid hormone level (ioPTH) timepoint until normalization of PTH (> 10 pg/mL) post-thyroidectomy. Calcium and vitamin D supplements were weaned following normalization of calcium and phosphorous levels postoperatively. Patients were excluded if they lacked three intraoperative PTH timepoints or were missing postoperative follow-up PTH data. Results: 65 patients (54 female), median age 15 (range 5-23 years), underwent thyroid surgery and met study inclusion criteria. The correlations of 2nd and 3rd ioPTHs with TOR were statistically significant (p < 0.05): the lower the ioPTH, the greater the recovery time. Stratifying patients into high-risk (2nd ioPTH ≤ 10 pg/mL), moderate-risk (2nd ioPTH between 10 and 20 pg/mL), and low-risk (2nd ioPTH ≥ 20 pg/mL) tertiles, the TOR decreased by orders of magnitudes from an average of 43.13 ± 76.00 to 6.10 ± 17.44 to 1.85 ± 6.20 days. These differences were statistically significant (p < 0.05). Conclusions: Our study results confirm the usefulness of intraoperative PTH levels to predict pediatric patient recovery post-surgery and provides useful anticipatory guidance to optimize timing and frequency of postoperative laboratory surveillance.

Focused Parathyroidectomy Using Accurate Preoperative Imaging and Intraoperative PTH: Tertiary Care Experience.

INTRODUCTION: The cure rate after focused parathyroidectomy (FP) is dependent upon two critical adjuncts- concordant preoperative imaging and intraoperative parathyroid hormone (PTH), a technique which can reliably determine whether any other hyperfunctioning gland or glands are still present after resection of the lesion shown by imaging. We wanted to see the cure rate of FP by using these two adjuncts. We also sought to discern whether utilizing the central lab rapid PTH assay will lead to wider acceptance of this FP with intraoperative PTH in resource-constrained countries. This analysis was also undertaken to find out cost-effective way of doing intraoperative PTH by minimizing the samples for intraoperative PTH study. RESULT: Data were collected on 83 patients with sporadic primary hyperparathyroidism (PHPT) who underwent parathyroidectomy in two tertiary centers between '2009 and 2017'. A total of 75 patients had concordant imaging, while seven had discordant imaging. The sensitivity and specificity of intraoperative PTH in FP was 100%. All the 78 patients who had fall in intraoperative PTH (50%) at 10 min also had fall of more than 50% at 5 min except one patient (98.7%). CONCLUSION: We strongly advocate routine use of intraoperative PTH in all patients undergoing minimally invasive parathyroidectomy, as this adjunct offers maximum safety for the patient and confidence for the surgeon. Cost can be minimized by utilizing the central laboratory and reducing the number of samples.

The role of intraoperative parathyroid hormone (IOPTH) determination for identification and surgical strategy of sporadic multiglandular disease in primary hyperparathyroidism (pHPT).

Intraoperative PTH monitoring (IOPTH) made minimally invasive parathyroidectomy in patients with primary HPT possible. However, with the increasing accuracy of preoperative localization studies there is a growing discussion if IOPTH is necessary in patients with localized single gland disease (concordant preoperative localization studies). Different interpretation criteria have been developed - each with their particular advantages and disadvantages, but the "perfect" criterion is still missing. Despite several pitfalls, which can be recognized intraoperatively and do not necessarily lead to a more extensive surgery, IOPTH seems to be a useful adjunct in surgery for PHPT. However, according to current guidelines, selected patients may be operated without IOPTH but need to be informed about the possibly increased risk of recurrent disease.

Additional 20-Minute Intraoperative Parathormone Measurement Can Minimize Unnecessary Bilateral Neck Exploration.

BACKGROUND: Parathyroidectomy guided by intraoperative parathormone (ioPTH) monitoring for primary hyperparathyroidism (pHPT) confirms removal of all hyperfunctioning parathyroid glands. This study evaluates the utility of an additional 20-min ioPTH measurement in patients who fail to meet the >50% ioPTH drop criterion. METHODS: A retrospective review of prospectively collected data of 706 patients with pHPT who underwent parathyroidectomy guided by ioPTH monitoring was performed. When a >50% ioPTH decrease from the highest either preincision or preexcision level was achieved after 10 min, parathyroidectomy was completed. If this criterion was not met, further exploration was performed or an additional 20-min ioPTH measurement was obtained. RESULTS: Of 706 patients, 72 (10%) patients did not meet the >50% ioPTH drop criterion at 10 min. Of these patients, 67% (48/72) underwent immediate bilateral neck exploration (BNE). For the other 33% of patients (24/72), a 20-min parathormone (PTH) measurement was drawn. Of patients with an additional 20-min PTH measurement, 46% (11/24) had a >50% ioPTH decrease at 20 min where BNE was avoided and parathyroidectomy completed, whereas 54% (13/24) did not. Compared to patients with insufficient ioPTH drop at 10 min and subsequent BNE, there was a statistically significant 46% reduction of BNE in patients with a 20-min PTH level (P < 0.01). CONCLUSIONS: A 20-min ioPTH measurement is useful in preventing unnecessary BNE in some patients who undergo focused parathyroidectomy with a delayed >50% ioPTH drop.

Niche point-of-care endocrine testing - Reviews of intraoperative parathyroid hormone and cortisol monitoring.

Point-of-care (POC) testing, which provides quick test results in near-patient settings with easy-to-use devices, has grown continually in recent decades. Among near-patient and on-site tests, rapid intraoperative and intra-procedural assays are used to quickly deliver critical information and thereby improve patient outcomes. Rapid intraoperative parathyroid hormone (ioPTH) monitoring measures postoperative reduction of parathyroid hormone (PTH) to predict surgical outcome in patients with primary hyperparathyroidism, and therefore contributes to the change of parathyroidectomy to a minimally invasive procedure. In this review, recent progress in applying ioPTH monitoring to patients with secondary and tertiary hyperparathyroidism and other testing areas is discussed. In-suite cortisol monitoring facilitates the use of adrenal vein sampling (AVS) for the differential diagnosis of primary aldosteronism and adrenocorticotropic hormone (ACTH)-independent Cushing syndrome. In clinical and psychological research settings, POC testing is also useful for rapidly assessing cortisol in plasma and saliva samples as a biomarker of stress. Careful resource utilization and coordination among stakeholders help to determine the best approach for implementing cost-effective POC testing. Technical advances in integrating appropriate biosensors with microfluidics-based devices hold promise for future real-time POC cortisol monitoring.

Robotic transaxillary parathyroidectomy.

We recently reported on the safety and feasibility of robotic transaxillary approaches for parathyroid surgeries with benefit of avoiding a visible cervical scar. Herein, we demonstrate our technique with utilization of intraoperative nerve monitoring and indocyanine green (ICG) imaging. The patient was discharged a few hours after the surgery.

Simultaneous Incidental Parathyroid Carcinoma and Intrathyroid Parathyroid Gland in Suspected Renal Failure Induced Hyperparathyroidism.

Hyperparathyroidism is a common disorder affecting more than hundreds of thousands of people annually. While most commonly secondary to an adenoma, it may also arise from four-gland hyperplasia or malignancy. In the case of primary hyperparathyroidism, the number of glands involved may be unknown prior to surgery. In contrast, the metabolic disorder associated with renal failure induced hyperparathyroidism ensures a hyperplasia picture. Despite the uniform hyperplasia seen in tertiary disease and the preoperative expectation for four-gland exploration, our case demonstrates the continued need for a surgeon's vigilance during dissection to identify all glands and appropriately use intraoperative parathyroid hormone (PTH) testing. In addition, while intraoperative PTH assessment is an effective method for confirming adequacy of treatment for hyperparathyroidism, only surgical pathology can confirm malignancy, which should be considered with PTH levels > 1,000. The case also underscores the importance of comprehensive surgery management and mindful interpretation of intraoperative PTH levels in the management of hyperparathyroidism. Standard surgical technique includes complete exploration of the central compartment, and thyroid lobectomy when the aforementioned exploration fails to reveal the necessary parathyroid tissue, especially with a persistently elevated PTH. Without a standardized progressive compartment exploration and judicious use of intraoperative hormone testing, intrathyroidal parathyroid glands can be missed.

Updates in primary hyperparathyroidism.

This is a review of the latest papers on PHPT with the purpose of assessing the most recent evidence in the management of PHPT and to give updated recommendations for its evaluation, diagnosis, and treatment. I used my personal experience to collect papers that reinforce my ideas for the diagnosis and treatment of PHPT. Perhaps, in the near future, we will have more information about genetics, localization studies, surgical techniques, medical treatments, and statements that we have presented today will be obsolete.