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Heidtmann J, Dunkler D, Hargitai L, Scheuba C, Niederle B, Riss P, Selberherr A. Primary Hyperparathyroidism and Intraoperative Parathyroid Hormone Monitoring: Application of a Modified Interpretation in Patients With "Parathyroid Hormone Spikes". J Surg Res 2023; 282:9-14. [PMID: 36244226 DOI: 10.1016/j.jss.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Intraoperative parathyroid hormone (PTH) spikes occur in up to 30% of patients during surgery for primary hyperparathyroidism. This can lead to a prolonged PTH decline and cause difficulties in using current interpretation criteria of intraoperative PTH monitoring. The aim of this study aim was to evaluate an alternative interpretation model in patients with PTH spikes during exploration. METHODS 1035 consecutive patients underwent surgery for primary hyperparathyroidism in a single center. A subgroup of patients with intraoperative PTH spikes of >50 pg/mL were selected (n = 277; 27.0%). The prediction of cure applying the Miami and Vienna criteria was compared with a decay of ≥50% 10 min after excision of the enlarged parathyroid gland using the "visualization value" (VV; =PTH level immediately after visualization of the gland) as basal value. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated. RESULTS Using the VV, sensitivity was 99.2% (Vienna 71.0%; Miami 97.7%), specificity was 18.2 (Vienna 63.6%; Miami 36.4%), and accuracy was 92.8 (Vienna 70.4%; Miami 92.8%). Of 255 single-gland disease patients, 72 were identified correctly as cured by applying the VV (P < 0.001), yet 10 of 22 patients with multiple-gland disease were missed compared with the Vienna Criterion (P = 0.002). The comparison with the Miami Criterion showed that six more patients were correctly identified as cured (P = 0.219), whereas four patients with multiple-gland disease were missed (P = 0.125). CONCLUSIONS Using the VV as a baseline in patients with intraoperative PTH spikes may prove to be an alternative and therefore can be recommended. However, if the VV is higher than the preexcision value, it should not be applied.
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Affiliation(s)
- Julian Heidtmann
- Section of Endocrine Surgery, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Section of Endocrine Surgery, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Lindsay Hargitai
- Section of Endocrine Surgery, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Scheuba
- Section of Endocrine Surgery, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Bruno Niederle
- Section of Endocrine Surgery, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Riss
- Section of Endocrine Surgery, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
| | - Andreas Selberherr
- Section of Endocrine Surgery, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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Hargitai L, Bereuter CM, Dunkler D, Geroldinger A, Scheuba C, Niederle B, Riss P. The value of intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism and varying baseline parathyroid hormone levels. BJS Open 2022; 6:6901339. [PMID: 36515670 PMCID: PMC9749480 DOI: 10.1093/bjsopen/zrac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND When applying intraoperative parathyroid hormone monitoring (IOPTH) to patients with primary hyperparathyroidism (PHPT), there are established criteria predicting biochemical cure in patients with basal parathyroid hormone (PTH) levels in the medium range (100-400 pg/ml); however, there is a challenge concerning patients with low (less than 100 pg/ml) or high (more than 400 pg/ml) basal PTH levels. The aim of this study was to investigate the value of the 'Vienna criterion' applied during IOPTH in patients with PHPT and various basal PTH concentrations. METHODS Consecutive patients between 1999-2009 with a biochemical diagnosis of PHPT who underwent surgical parathyroidectomy were included. Based on preoperative PTH levels they were divided into three groups: group 1 (low) (<100 pg/ml), group 2 (medium) (100-400 pg/ml) and group 3 (high) (>400 pg/ml) basal PTH. PTH was measured at the start of the operation, when the gland was excised and then at 5, 10 and 15 min after. Calcium and PTH levels were measured at 7 days and 12 months postoperatively. Sensitivity, specificity, positive and negative predictive value, as well as accuracy of IOPTH were calculated for the different groups postoperatively. RESULTS 675 patients with PHPT were analysed. Sensitivity and specificity were 83.7 per cent and 66.7 per cent in group 1 (n = 187), 90.7 per cent and 69.2 per cent in group 2 (n = 433), and 94.4 per cent and 100 per cent in group 3 (n = 55) to predict cure. Preoperative creatinine (p = 0.002) showed significant statistical difference between the groups but was not related to intraoperative PTH decline. At 12 months follow-up normocalcaemia was documented in 98.9 per cent in group 1, 99.0 per cent group 2, and 98.0 per cent of group 3 patients. CONCLUSION Normocalcaemia was predicted intraoperatively by applying the 'Vienna criterion' in 98 to 100 per cent and was confirmed after 12 months follow-up in up to 99.0 per cent of patients. Low specificity and a high false-negative rate in patients with low basal PTH show that other criteria might be better suited for this group.
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Affiliation(s)
- Lindsay Hargitai
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Carmen Maria Bereuter
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Section for Clinical Biometrics, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Angelika Geroldinger
- Section for Clinical Biometrics, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Christian Scheuba
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Bruno Niederle
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.,Senior Clinical investigator - Endocrine Surgery, former Chief of the Section of Endocrine Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Riss
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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Silveira AA, Brescia MDG, do Nascimento CP, Magnabosco FF, Arap SS, de Menezes Montenegro FL. PTH Spikes During Surgical Treatment for Secondary and Tertiary Hyperparathyroidism: A Prospective Observational Study. World J Surg 2022; 46:1693-1701. [PMID: 35262789 DOI: 10.1007/s00268-022-06506-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of the present study was to determine whether PTH spikes in renal hyperparathyroidism can interfere with the interpretation of intraoperative PTH monitoring and to determine its frequency and characteristics. METHODS This was a prospective observational study of consecutive patients who underwent surgical treatment in a single tertiary institution. Patients were divided into two groups: spike and no spike. Patients with secondary and tertiary hyperparathyroidism were analyzed separately. Intraoperative PTH monitoring by venous serial samples: two samples were taken before the excision of the parathyroid gland, and two others were taken after resection. RESULTS PTH spikes occurred in 23.5% (53 of 226), and their occurrence was similar between secondary and tertiary hyperparathyroidism patients (p = 0.074). The relative PTH spike intensity was higher in transplanted patients than in dialysis patients (55 vs. 20%, p = 0.029). A characteristic of the secondary hyperparathyroidism patients was the highest frequency of surgical failure (23 vs. 7.5%, p = 0.016) and the higher occurrence of supernumerary glands in the spike group (23 vs. 10.3%, p = 0.035). Supernumerary parathyroid was associated with surgical failure [19.1 (6.5-55.7) odds ratio [confidence interval], p < 0.001). In the studies evaluating the diagnostic test validity for patients on dialysis and experiencing spikes, the most significant impacts were in the sensitivity, accuracy, and negative predictive value of the method. CONCLUSIONS PTH spikes occurred in up to 23.5% of renal hyperparathyroidism surgical treatments and can negatively influence the intraoperative parathyroid hormone monitoring. Regarding the phenomenon of PTH spikes, it is prudent to think about the possibility of a hyperplastic supernumerary gland.
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Affiliation(s)
- Andre Albuquerque Silveira
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil. .,Head and Neck Surgery, Department of Surgery, University Hospital, Federal University of Paraiba, João Pessoa, Brazil.
| | - Marilia D'Elboux Guimaraes Brescia
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Climerio Pereira do Nascimento
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Felipe Ferraz Magnabosco
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Sergio Samir Arap
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
| | - Fabio Luiz de Menezes Montenegro
- Head and Neck Surgery, Department of Surgery, Parathyroid Unit (LIM 28), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, n 255, Cerqueira Cesar, São Paulo, SP, 05403-000, Brazil
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Huang H, Li M, Pan J, Tong W, Cheng M, Liang J, Zheng Y, Xie X. Ultrasound combined with biochemical parameters can be used to differentiate parathyroid carcinoma from benign tumors in patients with primary hyperparathyroidism. Clin Hemorheol Microcirc 2021; 76:351-359. [PMID: 32675398 DOI: 10.3233/ch-200846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) results from excessive secretion of parathyroid hormone from parathyroid tumors. Differentiating parathyroid tumors can be challenging before operation. OBJECTIVES To differentiate parathyroid carcinoma from benign tumors in patients with PHPT by the application of ultrasound and biochemical parameters. METHODS This study is a retrospective study. The study enrolled 17 patients with parathyroid carcinoma (PC) and 57 patients with parathyroid adenoma (PA), confirmed by postoperative pathology, between September 2010 and July 2017. This study retrospectively compared the ultrasonic features of the tumors included echotexture, maximum lesion diameter, shape, margin, blood flow inside the mass, intralesional calcifications, cysts in the mass, and biochemical parameters included serum calcium, phosphorus, parathyroid hormone (PTH), alkaline phosphatase (ALP) levels, gender distribution and age of patients between patients with PC and those with PA. RESULTS In the US images, the two groups showed significant differences in heterogeneity, the appearance of a taller-than-wide shape, irregular or lobulated margins, and intralesional calcifications (p < #x003C;< #x200A;0.05). However, no significant difference was found in echogenicity, maximum lesion diameter, blood flow, and cystic components of the mass (p > #x003E;> #x200A;0.05). The mean PTH levels were significantly different between the two groups (p < #x003C;< #x200A;0.05). The PC and PA patients did not differ significantly in terms of mean serum calcium, mean serum phosphorus, and mean ALP levels (p > #x003E;> #x200A;0.05). There were significant differences to distinguish PC from PA in calcifications in mass or/and taller-than-wide shape combine with PTH > #x003E;> #x200A;1000 pg/mL (p < #x003C;< #x200A;0.05). Significant difference existed in the age between the two groups (p < #x003C;< #x200A;0.001). No significant difference existed in the gender distribution between the two groups (p > #x003E;> #x200A;0.05). CONCLUSION Ultrasound features especially intralesional calcifications and taller-than-wide shape combine with an extremely high serum PTH (>1000 pg/mL) are helpful in differentiating between benign and parathyroid tumors in patients with PHPT.
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Affiliation(s)
- Hui Huang
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Manying Li
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jiamin Pan
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wenjuan Tong
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Meiqing Cheng
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jinyu Liang
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yanling Zheng
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoyan Xie
- Department of Medical Ultrasound, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Bhangu JS, Riss P. The role of intraoperative parathyroid hormone (IOPTH) determination for identification and surgical strategy of sporadic multiglandular disease in primary hyperparathyroidism (pHPT). Best Pract Res Clin Endocrinol Metab 2019; 33:101310. [PMID: 31409538 DOI: 10.1016/j.beem.2019.101310] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Jagdeep Singh Bhangu
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Philipp Riss
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Riss P, Dunkler D, Selberherr A, Brammen L, Heidtmann J, Scheuba C. Evaluating a shortened interpretation criterion for intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism: 5‐minutes criterion in primary hyperparathyroidism and intraoperative algorithm. Head Neck 2018; 40:2664-2669. [DOI: 10.1002/hed.25453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/29/2018] [Accepted: 08/15/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Philipp Riss
- Section of Endocrine Surgery, Division of General Surgery, Department of SurgeryMedical University of Vienna Vienna Austria
| | - Daniela Dunkler
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics, and Intelligent Systems (CeMSIIS)Medical University of Vienna Vienna Austria
| | - Andreas Selberherr
- Section of Endocrine Surgery, Division of General Surgery, Department of SurgeryMedical University of Vienna Vienna Austria
| | - Lindsay Brammen
- Section of Endocrine Surgery, Division of General Surgery, Department of SurgeryMedical University of Vienna Vienna Austria
| | - Julian Heidtmann
- Section of Endocrine Surgery, Division of General Surgery, Department of SurgeryMedical University of Vienna Vienna Austria
| | - Christian Scheuba
- Section of Endocrine Surgery, Division of General Surgery, Department of SurgeryMedical University of Vienna Vienna Austria
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Intraoperative parathormone spikes during parathyroidectomy may be associated with multiglandular disease. Surgery 2017; 163:393-396. [PMID: 29174058 DOI: 10.1016/j.surg.2017.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/31/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The importance of intraoperative parathormone "spikes" during parathyroidectomy remains unclear. This study compared patients with and without intraoperative parathormone spikes during parathyroidectomy using the criterion of a > 50% parathormone and determined the effect of intraoperative parathormone spikes on operative outcome. METHODS We performed a retrospective review of prospectively collected data on 683 patients who underwent parathyroidectomy guided by intraoperative parathormone monitoring. An intraoperative parathormone "spike value" was calculated by subtracting the preincision intraoperative parathormone value from the pre-excision intraoperative parathormone value (SV = PE - PI). An intraoperative parathormone spike was defined as having a positive spike value ≥9 pg/mL (≥10th percentile of all spike values). RESULTS Of 683 patients, 224 (33%) had intraoperative parathormone spikes and a greater rate of multiglandular disease (8% vs. 3%, P < 0.05) and bilateral neck exploration (10% vs. 5%, P < 0.05) compared with patients without intraoperative parathormone spikes. Overall, there were no differences between parathyroidectomy patients with and without intraoperative parathormone spikes in terms of operative success (98.2% vs. 98.0%), failure (1.8% vs. 2.0%), or recurrence rates (0.4% vs. 1.3%). CONCLUSIONS Although the presence of intraoperative parathormone spikes may increase suspicion for multiglandular disease, the ability of intraoperative parathormone monitoring to predict operative success after parathyroidectomy is not affected by spikes.
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Carr AA, Yen TW, Wilson SD, Evans DB, Wang TS. Using parathyroid hormone spikes during parathyroidectomy to guide intraoperative decision-making. J Surg Res 2017; 209:162-167. [DOI: 10.1016/j.jss.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/21/2016] [Accepted: 10/05/2016] [Indexed: 11/28/2022]
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Promberger R, Ott J, Bures C, Freissmuth M, Seemann R, Hermann M. Perioperative kinetics of parathyroid hormone in unilateral, primary thyroid surgery. Endocrine 2015; 48:293-8. [PMID: 24858628 DOI: 10.1007/s12020-014-0300-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 05/09/2014] [Indexed: 02/01/2023]
Abstract
Dysfunction of the parathyroid glands is an important cause of complications after thyroid surgery. Intraoperative monitoring of the function of the parathyroid glands can be performed using parathyroid hormone (PTH) kinetics. Unilateral thyroid surgery is associated with a decreased risk for postoperative hypocalcemia (POH) and permanent hypoparathyroidism (PEH). We focused on unilateral thyroid surgery by monitoring the functionality of the parathyroid glands and comparing the perioperative PTH kinetics of patients with and without POH. In a prospective study, 143 patients scheduled for unilateral thyroid surgery underwent monitoring of perioperative changes in serum PTH and serum calcium levels, and of clinical symptoms of hypocalcemia. The rates of POH and PEH were 18.2 and 0%, respectively. In patients without POH, PTH significantly increased from the time of skin incision to the end of the operation and after the operation (20.1 pg/ml, IQR 15.5-26.8 vs. 21.4 pg/ml, IQR 16.4-29.5; p=0.005), which was not the case in patients who developed POH. In a multivariate analysis of predictive factors for POH, two parameters became significant, namely female gender (odds ratio 6.87, 95% confidence interval 0.92-51.01) and lower initial serum calcium levels (odds ratio 3.54*e(-8), 95% confidence interval 3.63*e(-12); 0.00). The rate of POH was unexpectedly high. Rather than intraoperative PTH declines, an unstable balance of factors that influence calcium metabolism likely is the major contributor to POH after unilateral thyroid surgery. There was no case of PEH after unilateral, primary thyroid surgery, which underlines the need for an individualized approach to the extent of resection.
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Affiliation(s)
- Regina Promberger
- Second Department of Surgery "Kaiserin Elisabeth", Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030, Vienna, Austria
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Riss P, Krall C, Scheuba C, Bieglmayer C, Niederle B. Risk factors for “PTH spikes” during surgery for primary hyperparathyroidism. Langenbecks Arch Surg 2013; 398:881-6. [DOI: 10.1007/s00423-013-1097-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 06/24/2013] [Indexed: 10/26/2022]
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Abstract
Intraoperative parathyroid hormone measurement (IOPTH) has proved to be an important promoter for focused and minimally invasive parathyroidectomy procedures in primary hyperparathyroidism. IOPTH enables multiglandular disease to be excluded with a high degree of certainty at the time of operation. The choice of the cut-off value for IOPTH as the criterion for success is of utmost importance with respect to the prognosis for operative success (biochemical healing). Advantages and disadvantages of the variety of existing IOPTH success criteria are confusing and their assessment is contradictory. Particularly with respect to cost-benefit aspects the standard application of IOPTH as "biochemical frozen section" even in conventional open parathyroidectomy remains a matter of controversy. This article gives an up-date on current knowledge and provides practical guidelines for clinical use of IOPTH.
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