Most surgeons reported using intraoperative parathyroid hormone monitoring, but approaches to imaging and intraoperative criteria varied, particularly in secondary and tertiary disease
Primary, secondary, and tertiary hyperparathyroidism
Key Mechanisms
Intraoperative parathyroid hormone monitoring (IOPTH) to guide parathyroid surgery
Target Population
Patients undergoing parathyroid surgery for hyperparathyroidism
Care Setting
Surgical setting, primarily in North America
Key Highlights
88% of surveyed surgeons use IOPTH during parathyroid surgery, with higher use in primary hyperparathyroidism (92%) than secondary (76%) or tertiary (77%).
Imaging practices vary, with ultrasonography most commonly used, followed by scintigraphy and 4D CT.
Operational challenges include prolonged operative time due to IOPTH turnaround times, often 16-30 minutes or longer.
Guideline-Based Recommendations
Diagnosis
Use ultrasonography as the primary imaging modality for hyperparathyroidism.
Employ scintigraphy and four-dimensional computed tomography as adjunct imaging techniques.
Management
Utilize IOPTH monitoring during parathyroidectomy, especially in primary hyperparathyroidism.
Apply Miami or modified Miami criteria intraoperatively in primary hyperparathyroidism to guide surgical decisions.
Select subtotal parathyroidectomy for renal hyperparathyroidism, particularly in patients with planned transplantation.
Monitoring & Follow-up
Obtain at least two postexcision PTH measurements, commonly at 10 minutes post-excision.
Recognize that turnaround times for IOPTH testing may prolong operative time.
Risks
Prolonged operative time associated with IOPTH monitoring due to laboratory turnaround delays.
Practice heterogeneity may affect surgical outcomes, especially in renal hyperparathyroidism.
Patient & Prescribing Data
Patients undergoing surgery for primary, secondary, or tertiary hyperparathyroidism
Surgeons trained with IOPTH are more likely to use it; minimally invasive parathyroidectomy guided by IOPTH is preferred for image-positive primary hyperparathyroidism.
Clinical Best Practices
Adhere to Miami or modified Miami criteria for intraoperative decision-making in primary hyperparathyroidism.
Reserve bilateral neck exploration for multigland disease or image-negative cases in primary hyperparathyroidism.
Use subtotal parathyroidectomy for secondary and tertiary hyperparathyroidism, especially with planned renal transplantation.
Consider operational workflow to minimize delays caused by IOPTH testing, possibly by adopting point-of-care assays.
