Revisiting the ESES Position Statement on pHPT: Contemporary Insights into Minimally Invasive Parathyroidectomy
- Carlos E Costa Almeida
- há 3 horas
- 4 min de leitura
Parathyroid surgery for primary hyperparathyroidism (pHPT) has evolved significantly since the description of the unilateral surgical approach by Dr. Sten Tibblin from Sweden in 1982(1), presenting at that time several advantages over the bilateral neck exploration: “reduced hypocalcemia in the early postoperative course”; “decreased risk of complications in terms of nerve damage and persisting hypoparathyroidism”; “reduce operative time”; “more favorable technical conditions if a reoperation should be necessary”. Today, every effort should be made to perform a targeted parathyroidectomy – that is, a minimally invasive approach directed at a preoperatively localized diseased gland.
Accurate preoperative localization of the adenoma is therefore essential. In fact, it is a key prerequisite for undertaking a targeted parathyroidectomy.
In 2009, the European Society of Endocrine Surgeons (ESES) published a position statement on modern techniques for pHPT surgery. This document remains highly relevant, although some concepts may be evolving. It emphasizes the importance of precise preoperative localization. The authors recommend minimally invasive parathyroidectomy (MIP) – i.e., targeted parathyroidectomy – only when sestamibi scintigraphy and ultrasound (US) are concordant. When only one imaging modality is positive, unilateral neck exploration is advised, whereas bilateral neck exploration is recommended when both studies are negative or discordant.
This distinction is important because MIP is safe and cost-effective, associated with lower complication rates (particularly a lower incidence of postoperative hypocalcemia), and does not increase the risk of persistent or recurrent hyperparathyroidism. Therefore, all efforts should be made to enable a targeted approach. Today, newer imaging modalities offer improved diagnostic performance. When sestamibi and US are not concordant, additional imaging—such as 4D CT, 4D MRI, or choline PET/CT—should be considered prior to surgery. In my clinical practice, 57% of patients do not have concordant preoperative imaging. In these cases, we routinely perform choline PET/CT, achieving highly accurate localization that correlates with surgical findings, sometimes even altering the presumed side of the diseased gland. Although more expensive, I am convinced that choline PET/CT should become a first-line imaging modality.
Another important point is the definition of minimally invasive parathyroidectomy. The ESES statement includes “open mini-incision parathyroidectomy, video-assisted parathyroidectomy, and endoscopic parathyroidectomy,” noting no clear superiority among them in terms of recurrence or complications. In my opinion, however, only the first two approaches are truly minimally invasive, since the extent of dissection required in the endoscopic approach is considerably greater (is it not more invasive than the open?). A targeted parathyroidectomy through a small open incision (3 cm) can be completed in approximately 20 minutes, which is particularly advantageous in patients with elevated calcium levels and increased anesthetic risk. All surgeries must be performed with high technical quality in the shortest possible time.
The ESES statement also addresses intraoperative parathyroid hormone monitoring (ioPTH) as an adjunct. It suggests that when sestamibi and US are concordant, ioPTH provides limited additional value. I do not fully agree with this position. First, sestamibi and US are not 100% accurate; they may miss small adenomas or lesions adjacent to the thyroid. Moreover, choline PET/CT performed after a positive sestamibi scan can reveal additional adenomas. Therefore, ioPTH can provide valuable confirmation that all hyperfunctioning parathyroid tissue has been removed (ok, false positives are possible). Second, a decline in ioPTH greater than 80% may be associated with an increased risk of postoperative hypocalcemia, warranting closer postoperative monitoring. Third, ioPTH does not increase surgical morbidity. Fourth, operative time is not a major concern with modern rapid-assay systems, which can provide results within approximately 5 minutes. In my view, there is little clinical justification for omitting ioPTH, aside from cost considerations.
Bergenfelz et al. also note the lack of consensus regarding the optimal criteria for interpreting ioPTH. Several protocols exist, including the Miami, Vienna, Rome, Halle, Rotterdam, Aarhus, and Ann Arbor criteria. I personally use the Miami Criteria, which are the most widely adopted. These define success as a ≥50% decline from the highest pre-incision or pre-excision PTH level within 10 minutes after removal of the hyperfunctioning gland(s). It is important to select one set of criteria, understand it thoroughly, and apply it consistently. I have obtained excellent results using the Miami Criteria in all cases.
In conclusion, two concordant preoperative imaging studies are essential for performing a MIP, helping to avoid unnecessary unilateral or bilateral neck exploration and reducing the risk of postoperative hypocalcemia. Newer imaging modalities (e.g. choline PET/CT) offer significant advantages over traditional sestamibi and US, and should be considered before proceeding to neck exploration, I think. Surgeons must do everything possible to achieve cure at the first operation. Accurate indication combined with precise localization leads to optimal outcomes in pHPT surgery.
Link to position statement (ESES 2009):
(1) Tibblin S, Bondeson AG, Ljungberg O. “Unilateral parathyroidectomy in hyperparathyroidism due to single adenoma.” Annals of Surgery. 1982;195(3):245‑252.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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