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EDITORIALS: F Fausto Palazzo and Gregory P Sadler Minimally invasive parathyroidectomy BMJ 2004; 328: 849-850 [Full text]

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Intra-operative parathyroid hormone measurement in parathyroid surgery – useful or not

Gordon C Wishart, Sudeep K Thomas, Eleanor M Gurnell, Krishna K Chatterjee   (23 April 2004)

Patients in whom to avoid day-case minimally invasive parathyroidectomy

Neil JL Gittoes, Yuk Ting Ma, Andrew Ready, Andrew Toogood, and David Heath   (26 November 2004)

Intra-operative parathyroid hormone measurement in parathyroid surgery – useful or not 23 April 2004
Gordon C Wishart, Consultant Breast & Endocrine Surgeon Addenbrookes Hospital, Hills Road, Cambridge CB2 2QQ, Sudeep K Thomas, Eleanor M Gurnell, Krishna K Chatterjee Send response to journal: Re: Intra-operative parathyroid hormone measurement in parathyroid surgery – useful or not	We welcome the recent editorial by Palazzo and Sadler on minimally invasive parathyroidectomy (MIP) (BMJ 2004;328: 849-850). Despite much evidence from Europe, Australia and North America that a minimally invasive or “focused” approach is both safe and effective, UK endocrine surgeons have been slow to embrace this technique. In a recent survey of UK endocrine surgeons, 97% of respondents favoured bilateral neck exploration via a collar incision to a more focused approach1. However, our own group has shown that, following accurate localization of uniglandular disease, patients may be managed successfully and safely with MIP as a day-case procedure under general anaesthesia2. While the role of accurate pre-operative localization is crucial to a successful outcome from minimally invasive parathyroidectomy, the role of intra-operative parathyroid hormone (iPTH) measurement remains unclear. The authors argue, based on their unpublished data that the use of iPTH measurement is not cost-effective and has been abandoned. They do not comment however on whether iPTH measurement contributes to a higher cure- rate from primary surgery. In our published series, multiglandular disease was detected by iPTH measurement in 1 of 50 cases2. Since then iPTH has proved useful in two out of 20 further cases, one further case of multigland disease and another where the imaging was misleading (unpublished). Parathyroid surgery was completely successful in 69 of 70 cases, suggesting that, in our experience, iPTH measurement may enhance successful cure by up to 4%. Such additional benefit from iPTH measurement may seem low but may be vital in achieving the current target of a 95% cure rate for initial parathyroid surgery, set by the British Association of Endocrine Surgeons (BAES). When combined with day-case parathyroidectomy it may also contribute to a more cost-effective treatment option for patients with primary hyperparathyroidism. We argue, therefore, that at present there is not sufficient data to abandon the use of iPTH measurement completely and we will continue to assess the value of this technique in our own prospective study. 1. Ozbas S, Pain S, Tang T, Wishart GC. Surgical management of primary hyperparathyroidism- results of a national survey. Ann R Coll Surg Engl 2003; 85: 236-241. 2. Gurnell EM, Thomas SK, McFarlane I, Munday I, Balan KK, Berman L, et al. Focused parathyroid surgery with intraoperative parathyroid hormone measurement as a day-case procedure. Br J Surg 2004; 91: 78-82. Competing interests: None declared
Patients in whom to avoid day-case minimally invasive parathyroidectomy 26 November 2004
Neil JL Gittoes, Senior lecturer endocrinology Queen Elizabeth hospital, Birmingham, B15 2TH, Yuk Ting Ma, Andrew Ready, Andrew Toogood, and David Heath Send response to journal: Re: Patients in whom to avoid day-case minimally invasive parathyroidectomy	Dear Sir Minimally invasive parathyroidectomy (MIP) is currently in vogue for the management of primary hyperparathyroidism, and is advocated as a day case procedure. There is still broad acceptance, however, that open parathyroidectomy with visualisation of all four glands is the recommended definitive treatment of choice. There are undoubted potential benefits to minimally invasive surgery, and perhaps foremost is the potential cost saving associated with a reduced length of stay. This is offset significantly however by the costs of pre-operative localising techniques (ultrasound and sestamibi scanning). We have recently surveyed the outcome of 249 consecutive patients with primary hyperparathyroidism who underwent open parathyroidectomy by one of three experienced parathyroid surgeons over a 7 year period. No preoperative localisation studies were performed. Biochemical cure was achieved in 94% after initial surgery (99% after second operation using localising imaging). Postoperative morbidity was low (9% hypocalcaemia requiring parenteral calcium, 0.4% recurrent laryngeal nerve palsy) and there was no postoperative mortality. Patients who developed significant postoperative hypocalcaemia (requiring intravenous calcium) had significantly higher PTH and alkaline phosphatase (ALP) concentrations at diagnosis (p<0.0001). We recommend that patients with primary hyperparathyroidism who present with a very elevated PTH concentration and raised ALP should not be subjected to day case MIP as such patients appear to have a significant risk of post-operative hypocalcaemia requiring parenteral calcium administration. Careful selection of cases of primary hyperparathyroidism for MIP should be undertaken with close liaison between endocrinologist and endocrine surgeon. Competing interests: None declared