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Am Fam Physician. 2005;71(7):online-only-

to the editor: In the article,1 "Hyperparathyroidism," in the January 15, 2004, issue of American Family Physician, the discussion of surgical options mentions the traditional approach of bilateral neck exploration and the minimally invasive parathyroidectomy (MIP). To contemplate an MIP, preoperative localization studies, usually a Sestamibi scan and ultrasound, are necessary.

Dr. Taniegra reports that MIP can be video-assisted, endoscopic, radioguided, or image-guided. While these are indeed all options, the first three approaches have significant drawbacks. The video-assisted approach requires two incisions and usually is performed under general anesthesia. The endoscopic approach requires three incisions and expert endoscopy skills, inflates most of the central neck, and does not allow the surgeon to make a tactile assessment.2 Finally, a recent study3 recommended against the routine use of a radioguided approach because it is usually unnecessary, and it provided "confusing and inaccurate information" in 48 percent of cases. Image-guidance (combined with an intraoperative parathyroid hormone assay) is both feasible and cost-effective; it eliminates the risk of general anesthesia, requires one small incision, and has been proven to decrease operating time and length of stay.4,5

Preoperative localization allows for appropriate planning of the incision and directs the surgeon to the abnormality. Dissection is localized to the specific locale of the abnormality, minimizing pain and preventing extensive scarring. The remainder of the neck is left undisturbed. Image-guided MIP is the most effective alternative to the traditional bilateral approach when preoperative studies localize the adenoma and can be recommended as the most effective alternative to bilateral exploration.

in reply: I basically agree with the discussion of Dr. Lopchinsky and Ms. Love that image-guided minimally invasive parathyroidectomy (MIP) is the most effective alternative to bilateral exploration in the surgical management of primary hyperparathyroidism.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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