Surgical management of primary hyperparathyroidixsm

Bilateral neck explorations for primary hyperparathyroidism have a high cure rate (> 95%) and a low rate of morbidity when performed by experienced surgeons. Despite this, there have been many efforts to minimize the procedure in terms of length and region of incision, cost, extent of exploration, and length of hospital stay, while maintaining an excellent outcome. A renewed interest in unilateral neck exploration for primary hyperparathyroidism developed upon the introduction of sestamibi scintigrams as a new preoperative localization technique. The localization of adenomas using this technique was much more accurate than that of previous localization studies, allowing unilateral procedures to become feasible. Several surgeons have advocated a unilateral approach using preoperative sestamibi scanning. Sestamibi-guided parathyroidectomies enable parathyroidectomies to be performed much more rapidly through a significantly less invasive dissection. This procedure results in a very high cure rate with fewer complications, a smaller neck incision, and less use of postoperative narcotics. In patients with hyperparathyroidism, the intraoperative quick PTH assay allows the success of the procedure to be predicted intraoperatively. The intraoperative quick PTH assay is not only helpful in standard initial parathyroidectomies, but also improves the success rate of reoperative procedures. Its use is mandatory in all minimally invasive procedures. Initial reports regarding this innovation have been extremely positive. Nevertheless, some questions have been raised regarding the accuracy and utility of this procedure. Endoscopic parathyroidectomies offer several opportunities for innovation. Various approaches have been shown to be technically feasible, such as endoscopic procedures that rely on CO₂ insufflation to create a working space or video-assisted procedures in which the working space is maintained through conventional external retraction. (C) 2000 Editions scientifiques et medicales Elsevier SAS.