Intraoperative paratyhuroid hormone (IOPTH)
IOPTH is used to determine the appropriateness of parathyroid tissue resection to confirm the resection of hypersecreting parathyroid gland(s). IOPTH levels should drop following resection of all hypersecreting glands. When levels remain elevated after excision of suspected gland, conversion from focus exploration to a bilateral neck exploration may be necessary to locate the remaining hypersecreting tissue.35 IOPTH is measured according to a set of criteria first developed in Miami, in which at least 50% drop from the highest PTH level drawn to the PTH level measured 10 minutes after gland excision, and it has an overall accuracy of 97%. A preincision PTH level is drawn and a pre-excision level because of the possibility of gland manipulation with a further increase in PTH from the original baseline value.34 Good peripheral access should be obtained preoperatively.
Comprehensive rehydration preoperatively is needed in hypercalcemic patients, in fact; some patients need urinary catheterization and central venous pressure monitoring. After rehydration, to decrease renal calcium reabsorption and promote urinary excretion, loop diuretics can be used. Calcitonin in the dose of 200 IU every 8 hours might be helpful in decreasing albumin-adjusted calcium. Bisphosphonates, corticosteroids, calcium chelators, or dialysis are occasionally indicated in severe cases. However, preoperatively, intravenous bisphosphonates should not be used to avoid sever hypocalcaemia postparathyroidectomy. Hypertension, diabetes, or any other cardiac complication if present should be also controlled.
Either standard general anesthesia or local anesthesia can be used for patients undergoing parathyroidectomy. Local anesthesia usually is used because of patient preference or patient cormorbidities, however conversion to general anesthesia should consider in case of complications, unexpected findings, or patient discomfort. Local anesthesia achieved via injection of 1% lidocaine...