During parathyroid surgery for primary hyperparathyroidism, four-gland exploration reveals three enlarged glands and one normal-sized gland. Intraoperative PTH drops by only 42% fifteen minutes after removing the three adenomas. The correct interpretation and next step is:
- A Adequate; close the wound as >40% drop confirms cure
- B Inadequate (Miami criterion requires >50% drop); explore and remove the remaining gland or subtotal fourth-gland resection ✓
- C Inadequate; obtain urgent sestamibi scan in theatre
- D Adequate; a 42% drop with multigland disease is the accepted threshold
Correct answer: B. Inadequate (Miami criterion requires >50% drop); explore and remove the remaining gland or subtotal fourth-gland resection
Explanation
The Miami criterion for successful parathyroidectomy requires intraoperative PTH to fall by >50% from the highest pre-excision value within 10–15 minutes. A 42% drop does not meet this threshold, indicating residual hyperfunctioning parathyroid tissue. The surgeon should explore and remove or subtotally resect the remaining gland. Intraoperative sestamibi scanning is not standard practice mid-procedure; preoperative localisation is preferred.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.