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Dear Sir,

It is timely that Aspinall et al have drawn attention to the growing importance of accurate pre-operative localisation of abnormal parathyroid glands. In our institution parathyroid ultrasonography (US) is undertaken on a general US list which makes it difficult for an individual to scan sufficient numbers to gain any great experience. An audit in our hospital showed a positive predictive value of 74% and a negative predictive value of 39%. Minimally invasive parathyroid surgery (MIPS) requires better scanning than this. We tried to restrict parathyroid scanning to particular radiologists but without success. Our results in patients with persistent hyperparathyroidism are even worse (1).

This paper supports scanning done by a single enthusiastic and dedicated surgeon who then operates and can confirm or otherwise his prediction. This immediate confirmation, when scan appearances are fresh in the mind, is not available to the radiologist.
An imaging department scan is still done, so there is no reduction in patient care while the surgeon is on the “learning curve”. With proper training and adequate patient numbers, this seems an excellent way for surgeons to improve pre-operative imaging and thus increase the number of successful MIPS procedures.

1. O’Connell RL, Afors K, Thomas MH. Re-explorative Parathyroid Surgery for Persistent and Recurrent Primary Hyperparathyroidism. WJOES. 2011; 3 (3): 107-111

I agree with O'Connell's comments. Successful MIPS needs accurate pre-operative parathyroid localisation which is best achieved by an appropriately-trained, dedicated parathyroid sonographer - from either a radiological or surgical background. Surgeon-based ultrasonography has the advantage of immediate feedback from the operative findings that are not available to the radiologist. The surgeon uses ultrasonography as a tool to identify a surgical target and so neck ultrasound in the radiology department is still needed not only for parathyroid localisation but also to comment on any co-existing neck (particularly thyroid) pathology. How to go about training surgeons in neck ultrasonography will be the next priority, if surgeon-based ultrasonography is accepted as a useful adjunct to parathyroid surgery in the UK.