In a survey of North American surgeons, most reported using intraoperative parathyroid hormone monitoring during parathyroid surgery, although practices varied in imaging and intraoperative decision-making, especially in secondary and tertiary hyperparathyroidism. Findings suggest strong adherence to clinical guidelines in primary hyperparathyroidism, but less consensus in renal hyperparathyroidism, where guidance is more limited.
In a cross-sectional electronic survey distributed to four North American surgical societies between August and November 2024, researchers analyzed responses from 523 surgeons (response rate, 70.5%) to characterize contemporary management of primary, secondary, and tertiary hyperparathyroidism. The primary outcome was use of intraoperative parathyroid hormone monitoring (IOPTH), along with imaging practices and intraoperative adjuncts.
Among 426 respondents to the primary outcome, 88% (376 surgeons) reported using IOPTH during parathyroid surgery. Use was higher among US surgeons (98%) compared with those in Canada (69%) and other regions (67%). IOPTH was used most frequently in primary hyperparathyroidism (92%), compared with 77% in tertiary and 76% in secondary hyperparathyroidism. Use was also more common among surgeons who trained with IOPTH.
Among surgeons treating primary hyperparathyroidism, 64% reported using Miami or modified Miami criteria to guide intraoperative decision-making, and 76% obtained at least two postexcision hormone measurements, most commonly at 10 minutes. In contrast, 28% of surgeons reported not using defined IOPTH criteria in secondary hyperparathyroidism and 25% in tertiary hyperparathyroidism.
Ultrasonography was the most commonly reported imaging modality (45% in primary, 53% in secondary, and 52% in tertiary hyperparathyroidism), followed by scintigraphy and four-dimensional computed tomography. Across all disease types, the most commonly reported intraoperative adjuncts were IOPTH (44%) and frozen section analysis (39%), whereas autofluorescence (7%) and radioguidance (4%) were used less often.
Surgical approach varied by disease context. For image-positive primary hyperparathyroidism, 80% of surgeons reported using IOPTH-guided minimally invasive parathyroidectomy, while 93% reserved bilateral neck exploration for multigland or image-negative disease. In renal hyperparathyroidism, surgeons most often selected subtotal parathyroidectomy, with reported use of 74% in secondary hyperparathyroidism with planned transplantation, 70% without transplantation, and 74% in tertiary hyperparathyroidism.
Operational challenges were common. Among surgeons who used IOPTH, 87% reported that it prolonged operative time. Turnaround times were most often 16 to 30 minutes, and 27% of surgeons reported turnaround times longer than 30 minutes. Most surgeons relied on central laboratory testing rather than point-of-care assays, which may contribute to longer turnaround times.
The study was limited by its cross-sectional design and by overrepresentation of US, academic, and English-speaking surgeons, which may limit generalizability.
“Parathyroid surgeons adhere to modern clinical recommendations, but there remains practice heterogeneity in the use of imaging and intraoperative technologies to guide parathyroid surgery, especially in renal hyperparathyroidism,” wrote lead study researcher Phillip Staibano of McMaster University in Canada, and colleagues.
The researchers reported no conflicts of interest.
Source: American Journal of Otolaryngology–Head and Neck Medicine and Surgery
