Feasibility of video-assisted bilateral neck exploration for patients with primary hyperparathyroidism and failed or discordant localization studies

Purpose

Minimally invasive video-assisted parathyroidectomy (MIVAP) is generally adopted for patients affected by primary hyperparathyroidism (pHPT) with clear preoperative localization. Standard bilateral neck exploration (BNE) is considered the obligate surgery for patients with unlocalized glands. We reviewed our experience of minimally invasive video-assisted BNE in patients with pHPT and negative or discordant localization studies.

Methods

From a prospective series of 576 MIVAP for pHPT, 107 patients (19 males, 88 females; mean age 58 years) with failed localization studies underwent BNE using the video-assisted technique. Operative time, complications, conversions to standard cervical exploration, and cure rate were analyzed.

Results

MIVAP with BNE was successfully completed in 99 (93 %) patients with 8 conversions. Mean operative time was 57?±?37 min (range 20–180 min). Permanent recurrent laryngeal nerve palsy occurred in one patient. Biochemical cure was achieved in 104 patients (97 %). Five patients required a reoperation in the immediate postoperative period, which achieved cure in four. Two patients remained with persistent disease; one developed recurrence disease 3 years after the first exploration.

Conclusion

In experienced hands, video-assisted BNE for pHPT is feasible and safe and provides results equivalent to the conventional open technique.     

4D Parathyroid CT as the Initial Localization Study for Patients with De Novo Primary Hyperparathyroidism

Background

Preoperative localization of parathyroid tumors of primary hyperparathyroidism (pHPT) is required for minimally invasive parathyroidectomy (MIP). Parathyroid four-dimensional computed tomography (4DCT) has mainly been used as an adjunct to other imaging modalities in the remedial setting. 4DCT was evaluated as the initial localization study in de novo patients with pHPT.

Materials and Methods

A total of 87 consecutive patients underwent parathyroidectomy for pHPT from August 2008 to November 2009. 4DCT was introduced as the preferred imaging modality instead of sestamibi with SPECT (SeS) in April 2009. Results of the imaging studies [4DCT, SeS, and ultrasonography (US)], operative and, pathologic findings, and biochemical measurements were evaluated.

Results

In this study, 84% of patients (73 of 87) underwent an US, 59.8% (52 of 87) a SeS, and 38.0% (33 of 87) had a 4DCT. 4DCT had improved sensitivity (85.7%) over SeS (40.4%) and US (48.0%) to localize parathyroid tumors to the correct quadrant of the neck (P < 0.005) as well as to localize (lateralize) the parathyroid lesions to one side of the neck (93.9% for 4DCT vs. 71.2% for US and 61.5% for SeS; P < 0.005). 4DCT correctly predicted multiglandular disease (MGD) in 85.7% (6 of 7) patients, whereas US and SeS were unable to detect MGD in any case. All patients achieved cure based on intraoperative parathyroid hormone (PTH) measurements and normalization of intact PTH and S-Ca during follow-up.

Conclusions

4DCT provides significantly greater sensitivity than SeS and US for precise localization of parathyroid tumors of pHPT. Additionally, it correctly predicted MGD in a majority of patients.     

Quality of Life is Modestly Improved in Older Patients with Mild Primary Hyperparathyroidism Postoperatively: Results of a Prospective Multicenter Study

Background

The objectives of this study were to evaluate, in mild primary hyperparathyroidism (pHPT) patients, the quality of life (QoL) using the SF-36 questionnaire before and after parathyroidectomy and to detect preoperatively patients who benefit the most from surgery. Most pHPT patients present a mild pHPT defined by calcemia ≤11.4 mg/dL. For these patients, there is debate about whether they should be managed with surveillance, medical therapy, or surgery.

Methods

A prospective multicenter study investigated QoL (SF-36) in patients with mild pHPT before and after parathyroidectomy in four university hospitals. Laboratory results and SF-36 scores were obtained preoperatively and postoperatively (3, 6, and 12 months).

Results

One hundred sixteen patients were included. After surgery, the biochemical cure rate was 98%. Preoperatively, the mental component summary and the physical component summary (PCS) were 38.69 of 100 and 39.53 of 100, respectively. At 1 year, the MCS and the PCS were 41.29 of 100 and 42.03 of 100. The subgroup analysis showed a more significant improvement in patients < 70 years and with calcemia ≥10.4 mg/dL. Postoperative PCS was correlated with age and preoperative PCS: variation = 32.11 ? 0.21 × age ? 0.4 × preoperative PCS. Men did not improve their MCS postoperatively. Only women with a preoperative MCS <43.6 of 100 showed postoperative improvement.

Conclusions

This study showed, in patients with mild pHPT, an improvement of QoL 1 year after parathyroidectomy. Patients <70 years and with calcemia ≥10.4 mg/dL had a more significant improvement.     

Is Unilateral Neck Surgery Feasible in Patients with Sporadic Primary Hyperparathyroidism and Double Negative Localisation?

Introduction

Ultrasound and Tc99mMIBI scans are used to localise parathyroid tumours in sporadic primary hyperparathyroidism (pHPT). Intra-operative PTH (ioPTH) assay facilitates unilateral neck exploration (UNE). When both ultrasound and MIBI are negative, it is our policy to explore the left side of the neck and only proceed to bilateral neck exploration (BNE) when either a tumour is not found or when ioPTH does not fall to >50% of the highest pre-excision value. The aim of this study was to investigate the outcome of our approach to ‘double negative’ patients.

Methods

A retrospective analysis of patients undergoing primary parathyroidectomy for pHPT. Data were obtained from a prospective surgical database and the hospital electronic patient record.

Results

Between January 2004 and November 2014, 746 patients underwent a parathyroidectomy for pHPT. Those who did not have both pre-operative scans, ioPTH or a minimum of 6-month follow-up were excluded. Of 552 patients, 111 (20%) had double negative scans (group A), and in 441, either one or both scans were positive (group B). Median age was 61.5 years (range 10–88). Pre-operative PTH level was significantly lower in group A: 11.8 pmol/l (range 3.1–38.8) versus 14.9 pmol/l (range 2.8–101.6; P < 0.01). Median tumour weight was significantly lower in group A: 280 mg (range 50–3710) versus 573 mg (range 10–12,000; P < 0.01). Overall rate of multiple gland disease (MGD) was 11%; 24% in group A and 7% in group B (P < 0.01). Overall rate of UNE in Group A was 28% and converse to the rate in Group B (76%; P < 0.01). Sensitivity and specificity of ioPTH to detect MGD were 98 and 98% in Group A versus 98 and 100% in Group B. First-time cure rate was 92.7% in group A and 96.8% in group B (P < 0.05).

Conclusion

A double negative scan is associated with small tumours and higher rates of MGD. Despite these challenges, surgery is successful in this group of patients reinforcing the message that negative localisation is not a contraindication for parathyroidectomy. We demonstrated that it is feasible to offer unilateral neck surgery to 28% of patients with double negative scans. A randomised trial is needed to compare BNE with ioPTH/UNE in this select population.

     

Shifting Incidence of Solitary Adenomas in the Era of Minimally Invasive Parathyroidectomy. A Multi-Institutional Study

Background

Previously, when a conventional neck exploration (CNE) without preceding diagnostic imaging was the surgical treatment for patients with primary hyperparathyroidism (pHPT) solitary adenomas were observed in 69–88% of patients. The advent of minimally invasive parathyroidectomy (MIP), aiming at a preoperatively identified parathyroid abnormality may be associated with a different incidence of solitary and multiglandular parathyroid disease.

Materials and Methods

In a cohort of 467 patients with sporadic pHPT who preferentially underwent MIP in four hospitals in the same geographical region, the incidence of solitary adenomas, multiple adenomas, and multiglandular hyperplasia (MGD) was evaluated.

Results

A total of 367 patients were scheduled for MIP; 100 patients underwent a planned CNE. The overall surgical success rate of the first operation was 93%, and the cumulative success rate, including a second operative procedure, was 99%. Normocalcemia resulted from removing 1 abnormal PG in 426 patients (91%) and more than one abnormal gland in 35 patients (8%). A parathyroid carcinoma was diagnosed in four of the 426 patients with a single abnormal gland. Four gland hyperplasia was observed in 1 patient. In hospitals where diagnostic workup usually consisted of ultrasound (US) and computed tomography (CT) the incidence of solitary adenomas was 88%, compared with 96% in hospitals where MIBI, US, and CT were used preoperatively (P = 0.007).

Conclusions

A higher frequency of solitary adenomas was observed than historically reported. The extent of the preoperative workup influences the number of observed solitary adenomas.     

Primary Hyperparathyroidism: An Analysis of Failure of Parathyroidectomy

Background

Preoperative imaging in patients undergoing surgery for primary hyperparathyroidism (PHPT) is used primarily to facilitate targeted parathyroidectomy. Failure of preoperative localisation mandates a bilateral exploration. It is thought that the results of imaging may also predict the success of surgery. The aims of this study were to assess whether the findings on preoperative localisation influenced outcomes following parathyroidectomy for PHPT and to explore factors underlying failure to cure at surgery.

Methods

We analysed outcomes of all patients who underwent first-time surgery for PHPT in two centres over a 5-year period to determine an association with demographic characteristics and findings on preoperative imaging. Records of patients not cured by initial surgery were reviewed to explore factors underlying failure to cure.

Results

The failure rate (persistent disease) in the entire cohort was 5 % (25/541) (bilateral neck explorations, 5 %; unilateral exploration, 7 %; targeted approach, 4 %), while two patients developed recurrent disease. In patients who had undergone dual imaging with an ultrasound scan and ^99mTc-sestamibi scintigraphy, failure rates with “lateralised and concordant” imaging, “nonconcordant” imaging, and “dual-negative” imaging were 2, 9, and 11 %, respectively (p = 0.01). Of the 25 patients with persistent disease, multigland disease (MGD) was present in 52 % (13/25) and ectopic adenoma in 24 % (6/12).

Conclusions

Patients with PHPT who do not have lateralised and concordant dual imaging are at higher risk of persistent disease. A significant proportion of failures are due to the inability to recognise the presence and/or extent of MGD.     

Utility of Intraoperative Parathyroid Hormone Monitoring in Patients with Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism Undergoing Initial Parathyroidectomy

Background

Intraoperative parathyroid hormone monitoring (IOPTH) is a widely used adjunct for primary hyperparathyroidism (pHPT). However, the benefit of IOPTH in familial pHPT, such as in multiple endocrine neoplasia type I (MEN1), remains unclear.

Methods

We performed a retrospective analysis of 52 patients with MEN1-associated pHPT undergoing initial parathyroidectomy with IOPTH monitoring at our institution. Parathyroid hormone (PTH) levels were measured before skin incision and 10 min after resection of the last parathyroid gland. Variables analyzed included percent drop of PTH from baseline and the final PTH level compared to the normal reference range (RR).

Results

A total of 52 patients underwent initial subtotal parathyroidectomy with IOPTH. An IOPTH decrease cutoff of ≥75 % from baseline had the highest biochemical cure rate (87 %). In the remaining 13 % who met this cutoff, all had persistent pHPT, with ≥90 % drop of PTH from baseline. The remaining patients, who did not meet the ≥75 % cutoff, were cured. Follow-up was available for three of four patients with final IOPTH levels above the RR: one had persistent pHPT, two had hypoparathyroidism (50 %). When a postresection PTH level was within the RR, 88 % of patients were cured. While considered cured from pHPT, 7 % of patients in this group developed permanent hypoparathyroidism. When the final PTH level dropped below the RR, 28 % developed permanent hypoparathyroidism.

Conclusions

A cutoff in IOPTH decrease of ≥75 % from baseline has the highest biochemically cure rate in patients with pHPT associated with MEN1. However, a 75 % cutoff in IOPTH decrease does not exclude persistent pHPT. The absolute IOPTH value does not accurately predict postoperative hypoparathyroidism.     

Initial Surgery for Benign Primary Hyperparathyroidism: An Analysis of 1,300 Patients in a Teaching Hospital

Background

Success rates of initial surgery for primary hyperparathyroidism (pHPT) are greater than 95 % in specialized centers, mostly referring to single-surgeon experiences. The present study was performed to identify changes in clinical manifestations, diagnostic procedures, surgical strategies, and outcome of initial parathyroid interventions in a teaching hospital during the past 25 years with special regard to the surgical expertise.

Methods

Clinical data of patients who underwent an initial neck exploration for benign pHPT between 1985 and 2010 at the University hospital Marburg were retrospectively evaluated. All data were analyzed particularly with regard to the implementation of additional pre- and intraoperative procedures and to the particular surgical strategy. In addition, operative results were furthermore analyzed with regard to the experience of the responsible surgeons.

Results

An initial neck exploration for benign pHPT was performed in 1,300 patients. Of these, 1,035 patients had a bilateral cervical exploration (BCE) and 265 patients had a focused, minimally invasive parathyroidectomy (MIP). Cure rates did not differ between focused surgeries and BCE (98.9 vs. 98.3 %, p = 0.596) after a mean follow-up of 33.4 (± 44.3) months. Postoperative transient hypoparathyroidism was significantly lower in the MIP group (11 vs. 47 %, p < 0.0001). The rate of permanent recurrent laryngeal nerve palsies (0.4 vs. 2 %, p = 0.064) and nonsurgical complications (0 vs. 1.4 %, p = 0.0875) tended to be lower in the MIP group. Success and complication rates of chief surgeons (n = 2), attending surgeons (n = 20), and residents (56 < 3 years, 30 > 3 years) were similar, despite a significantly shorter operating time in the chief surgeon group (p < 0.01).

Conclusions

Despite the implementation of several diagnostic procedures and significant changes concerning the surgical strategy, high success rates of primary interventions for pHPT did not change over the past three decades. High success rates also can be achieved in a teaching hospital, provided that surgery is supervised by an experienced endocrine surgeon. MIP is the treatment of choice in patients with benign sporadic pHPT and positive preoperative localization studies.     

Changing Intraoperative Parathyroid Hormone Collection Sites from Peripheral to Central Does Not Affect Predictive Accuracy during Minimally Invasive Parathyroidectomy

Background

Intraoperative parathyroid hormone (ioPTH) monitoring (IPM) is vital to minimally invasive parathyroidectomy. Techniques vary in assay sampling, potentially affecting predictive accuracy of operative success. Initial guidelines were established using peripheral sites, but central sites may be preferred or necessary when peripheral access is not feasible. We hypothesize that changing collection sites from preexcision peripheral sites to postexcision central sites would not affect IPM accuracy.

Methods

Analysis of 64 consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism was undertaken. PTH assays were collected simultaneously from a peripheral vein (PV) and central vein (CV) preexcision and at a 10-min interval after initial parathyroid excision. IPM success was defined as PTH decrease ≥50% 10 min after initial excision. Predictive accuracy was determined by the need to resect another abnormal gland and biochemical normalization in the postoperative clinic. Receiver operating characteristic (ROC) method with area under the curve (AUC) compared diagnostic accuracy of different assay approaches.

Results

Centrally, a statistically higher mean pre- and postexcision ioPTH of 391 pg/ml and 58 pg/ml was found compared with peripheral means of 156 pg/ml and 49 pg/ml, respectively (p < 0.001). The AUC when changing from a PV preexcision to a CV postexcision ioPTH was 0.89, comparable to AUC for peripheral or central assay collections alone (AUC = 0.83 and 0.85, respectively).

Conclusions

This study suggests that altering collection sites does not alter assay validity. In cases where peripheral sampling is compromised, changing from a peripheral to central sites will not likely alter the predictive accuracy of IPM significantly.     

Vitamin D3 Deficiency is Associated with Late-Onset Hypocalcemia After Minimally Invasive Parathyroidectomy in a Vitamin D Borderline Area

Background

Concurrent vitamin D₃ deficiency is common in primary hyperparathyroidism (pHPT). We aimed to examine the clinicopathologic features and short-term outcomes of vitamin D₃-deficient patients after minimally invasive parathyroidectomy (MIP).

Methods

Over 2-year period, 80 consecutive MIP patients had preoperative-fasting 25-hydroxyvitamin D₃ (25OHD₃) checked. Forty-five patients had a 25OHD₃ level <20 ng/ml and were defined as deficient. Intraoperative parathyroid hormone (IOPTH) assay was used for all MIP. Postoperative adjusted calcium (Ca) was checked at 6, 16 (with intact PTH), and 24 h. Oral calcium and vitamin D supplements were given if hypocalcemic symptoms developed or Ca < 2.00 mmol/l. Late-onset hypocalcemia (LOH) was defined as symptoms developed after 24 h.

Results

Both deficient and nondeficient groups had similar demographic data and bone density scores. The deficient group had significantly higher PTH (190 vs. 121 pg/ml, p = 0.015). Although IOPTH in the deficient group were higher at induction and 0 min after excision, the percentage drop from induction to 10 min after excision was similar. Ca was similar at 6 and 16 h in the two groups but was significantly lower in the deficient group at 24 h (2.10 vs. 2.45 mmol/l, p = 0.033). At 1 week, the proportion of LOH was significantly higher in the deficient group (12/42 vs. 3/34, p = 0.043) and in those with preoperative PTH > 100 pg/ml (15/57 vs. 0/19, p = 0.013).

Conclusions

Vitamin D₃ deficiency was associated with a higher preoperative PTH level and a greater risk of LOH after MIP. However, the likely cause of LOH remains unclear as both low preoperative vitamin D₃ and high PTH levels could be responsible.     

Results of a Fifteen-Year Follow-up Program in Patients Operated with Unilateral Neck Exploration for Primary Hyperparathyroidism

Background

Since the introduction of unilateral parathyroidectomy for primary hyperparathyroidism (pHPT) it has been debated wherever this approach is associated with greater long-term risk for recurrence compared to bilateral neck exploration.

Methods

This is a prospective study based on a structured 15-year follow-up program in patients with non-hereditary, sporadic pHPT, undergoing first time surgery with unilateral or focused neck exploration (unilateral procedures), with the use of intraoperative PTH (iOPTH) between 1989 and 2010.

Results

292 patients were analyzed. The median age of the patients was 66 years [interquartile range (IQR) 57–75], and 234 (80.4 %) were female. The median preoperative level of total calcium was 2.74 mmol/L (IQR 2.63–2.85 mmol/L) and the median PTH level was 10 pmol/L (IQR 7.4–14 pmol/L). The median follow-up time was 5 years (IQR 1–10 years). Some 275 patients were followed for 1 year (94.2 %/275 person-years/5 patients deceased), 164 for 5 years (56.2 %/820 person-years/31 patients deceased), 70 for 10 years (24.0 %/700 patient-years/57 patients deceased) and 51 (17.5 %/765 patient-years/69 patients deceased) for 15 years after surgery. Three patients (1.1 %) had signs of persistent disease. One patient recurred in pHPT at 5 years postoperatively during 15 years of follow-up. Histopathology indicated solitary parathyroid adenoma at primary surgery.

Conclusion

Patients with pHPT operated with unilateral procedures and iOPTH, had a low risk for long-term recurrence during a 15 years follow-up program.

     

Intraoperative parathormone spikes during parathyroidectomy may be associated with multiglandular disease

Background

The importance of intraoperative parathormone “spikes” during parathyroidectomy remains unclear. This study compared patients with and without intraoperative parathormone spikes during parathyroidectomy using the criterion of a?>?50% parathormone and determined the effect of intraoperative parathormone spikes on operative outcome.

Preoperative localizing studies for initial parathyroidectomy in MEN1 syndrome: is there any benefit?

Background  

The objective of the present study was to evaluate the utility of preoperative localizing studies in patients with MEN1 undergoing initial bilateral neck exploration (BNE) and parathyroidectomy for pHPT.     

The Small Abnormal Parathyroid Gland is Increasingly Common and Heralds Operative Complexity

Background

Over decades, improvements in presymptomatic screening and awareness of surgical benefits have changed the presentation and management of primary hyperparathyroidism (PHPT). Unrecognized multiglandular disease (MGD) remains a major cause of operative failure. We hypothesized that during parathyroid surgery the initial finding of a mildly enlarged gland is now frequent and predicts both MGD and failure.

Methods

A prospective database was queried to examine the outcomes of initial exploration for sporadic PHPT using intraoperative PTH monitoring (IOPTH) over 15 years. All patients had follow-up ≥6 months (mean = 1.8 years). Cure was defined by normocalcemia at 6 months and microadenoma by resected weight of <200 mg.

Results

Of the 1,150 patients, 98.9 % were cured and 15 % had MGD. The highest preoperative calcium level decreased over time (p < 0.001) and varied directly with adenoma weight (p < 0.001). Over time, single adenoma weight dropped by half (p = 0.002) and microadenoma was increasingly common (p < 0.01). MGD risk varied inversely with weight of first resected abnormal gland. Microadenoma required bilateral exploration more often than macroadenoma (48 vs. 18 %, p < 0.01). When at exploration the first resected gland was <200 mg, the rates of MGD (40 vs. 11 %, p = 0.001), inadequate initial IOPTH drop (67 vs. 79 %, p = 0.002), operative failure (6.6 vs. 0.7 %, p < 0.001), and long-term recurrence (1.6 vs. 0.3 %, p = 0.007) were higher.

Conclusions

Single parathyroid adenomas are smaller than in the past and require more complex pre- and intraoperative management. During exploration for sporadic PHPT, a first abnormal gland <200 mg should heighten suspicion of MGD and presages a tenfold higher failure rate.     

Transoral parathyroid surgery—a new alternative or nonsense?

Purpose

In recent years, several endoscopic techniques have been explored in thyroid and parathyroid surgery, but only few gained acceptance among patients and surgeons. Based on extensive human cadaver and animal studies, we developed a technique for transoral partial parathyroidectomy (TOPP), which was performed for the first time in a patient with primary hyperparathyroidism (pHPT). We now report on results and the acceptance of this new technique 2 years after its implementation.

Methods

A pilot study was initiated to recruit a total of 10 patients with benign sporadic pHPT and a preoperatively localized parathyroid adenoma eligible for initial parathyroidectomy. The study protocol was approved by the ethics committee, and an insurance for unforeseen complications and risks was procured. Data of all patients evaluated and operated were prospectively collected, and follow-up examinations were carried out for 19 months on average, which included clinical examinations; ultrasonography; Ear, Nose, and Throat (ENT) investigations; and blood testing.

Results

Between January 2010 and May 2012, 75 patients with pHPT and a preoperative localized parathyroid adenoma were eligible for TOPP. After detailed information about the transoral procedure, only five (7 %) female patients consent to undergo TOPP. In three patients, a parathyroid adenoma could be removed via the transoral access, In two patients, the procedure had to be converted to the conventional technique. Median time until resection of a parathyroid adenoma was 122 min (range, 45–175). One patient had a transient recurrent laryngeal nerve palsy, while one patient suffered from a transient palsy of the right hypoglossal nerve and a slight but persisting dysgeusia. Three patients developed a hematoma of the mouth floor and swallowing problems. In four patients, the visual analog scale (VAS) pain score was high (>7) within the first 2 postoperative days.

Conclusions

Although TOPP is feasible, it is poorly accepted by patients and its complication rate is high. Thus, TOPP is nonsense with currently available devices.     

Parathyroid Surgery in the Elderly: Should Minimally Invasive Surgery Be Abandoned?

Background

Single adenoma is the cause of 80 % of primary hyperparathyroidism (PHPT) resulting in wide acceptance of minimally invasive parathyroidectomy (MIP). The incidence of PHPT increases with age. Little information is available regarding the prevalence of multiglandular disease (MGD) in older patients.

Methods

The records of 537 patients that underwent parathyroid surgery between January 2005 and October 2012 at two endocrine surgery referral centers were retrospectively reviewed. Comparison was performed between patients younger than 65 and older than 65 years of age. Clinical variables included preoperative laboratories and imaging, extent of neck exploration, number of glands excised, and intraoperative parathyroid hormone levels during surgery.

Results

There were 374 (70 %) patients in the younger age group (YG) and 163 (30 %) patients in the older age group (OG). The mean age was 50 ± 0.5 and 71 ± 0.4 years, respectively. There was no difference between the groups in terms of gender or laboratory results. MGD was significantly more common in the OG (24 % vs. 12 %; p = 0.001) and similarly MIP was less commonly completed in the OG (49 % vs. 68 %; p < 0.001). Cure rates were comparable between the OG and YG (93 % vs. 95 %; p = 0.27). In the OG, patients with MGD had significantly smaller glands as compared to patients with single adenomas in this group (331 ± 67 vs. 920 ± 97 mg; p = 0.006, respectively).

Conclusions

MGD in PHPT was found to be more prevalent in older patients. Planning a bilateral neck exploration should be considered in older patients, especially when a relatively small gland is suggested by imaging or encountered during surgery.     

The Optimal Surgical Treatment for Primary Hyperparathyroidism in MEN1 Patients: A Systematic Review

Background

The optimal surgical approach for patients with primary hyperparathyroidism (pHPT) and multiple endocrine neoplasia 1 (MEN1) is controversial. We sought to determine the optimal type of surgery for pHPT in MEN1.

Methods

We collected data on clinical presentation, surgery, and follow-up for MEN1 patients with pHPT at the University Medical Center Utrecht and affiliated hospitals between 1967 and 2008. Furthermore, we performed a systematic review of the literature and meta-analysis. Surgical procedures were classified into less than subtotal (Results Fifty-two patients underwent primary surgery for pHPT, of which 29 had Conclusion We believe that SPTX is the best surgical therapy for pHPT in MEN1. MEN1 patients with pHPT should not be treated with 相似文献   

Preoperative Localization Strategies for Primary Hyperparathyroidism: An Economic Analysis

Background

Strategies for localizing parathyroid pathology preoperatively vary in cost and accuracy. Our purpose was to compute and compare comprehensive costs associated with common localization strategies.

Methods

A decision-analytic model was developed to evaluate comprehensive, short-term costs of parathyroid localization strategies for patients with primary hyperparathyroidism. Eight strategies were compared. Probabilities of accurate localization were extracted from the literature, and costs associated with each strategy were based on 2011 Medicare reimbursement schedules. Differential cost considerations included outpatient versus inpatient surgeries, operative time, and costs of imaging. Sensitivity analyses were performed to determine effects of variability in key model parameters upon model results.

Results

Ultrasound (US) followed by 4D-CT was the least expensive strategy ($5,901), followed by US alone ($6,028), and 4D-CT alone ($6,110). Strategies including sestamibi (SM) were more expensive, with associated expenditures of up to $6,329 for contemporaneous US and SM. Four-gland, bilateral neck exploration (BNE) was the most expensive strategy ($6,824). Differences in cost were dependent upon differences in the sensitivity of each strategy for detecting single-gland disease, which determined the proportion of patients able to undergo outpatient minimally invasive parathyroidectomy. In sensitivity analysis, US alone was preferred over US followed by 4D-CT only when both the sensitivity of US alone for detecting an adenoma was ??94?%, and the sensitivity of 4D-CT following negative US was ??39?%. 4D-CT alone was the least costly strategy when US sensitivity was ??31?%.

Conclusions

Among commonly used strategies for preoperative localization of parathyroid pathology, US followed by selective 4D-CT is the least expensive.     

Bilateral Neck Exploration Decreases Operative Time Compared to Minimally Invasive Parathyroidectomy in Patients with Discordant Imaging

Background

Unilateral parathyroidectomy for primary hyperparathyroidism (PHPT) has a high success rate in patients with concordant imaging by sestamibi and ultrasound. However, the optimal procedure when imaging is discordant remains controversial; therefore we compared unilateral exploration with intraoperative parathyroid hormone (IOPTH) monitoring to bilateral neck exploration without IOPTH monitoring in patients with discordant localization studies.

Methods

We conducted a retrospective study of 324 consecutive patients with PHPT treated at our institution from October 2005 to September 2009. We collected information regarding imaging, localization site, procedure performed, operative time, and calcium/PTH measurements.

Results

Of the 324 patients in the study, 79 (24 %) had discordant imaging by sestamibi and ultrasound. Of these, 62 patients (78 %) underwent bilateral neck exploration without IOPTH monitoring, and 14 patients (18 %) had unilateral exploration with IOPTH monitoring. IOPTH monitoring during unilateral exploration correctly predicted removal of single adenomas in 10/14 patients (71 %) and altered operative management in 4/14 cases (29 %), resulting in conversion to bilateral neck exploration. Operative time for unilateral exploration with IOPTH [median time: 96 min (range: 51–153 min)] was significantly increased relative to bilateral exploration [median time: 52 min (range: 28–149 min)]; p = 0.0027. We identified single-gland disease in 53/76 patients (70 %), double adenomas in 13/76 patients (17 %), and multiglandular hyperplasia in 10/76 patients (13 %). There was no difference in cure rate between these two surgical approaches (p = 1.0)

Conclusions

In contrast with prior studies, we found that operative time for unilateral exploration with IOPTH was significantly increased compared to bilateral neck exploration. In patients with discordant imaging, IOPTH is a useful adjunct in limiting exploration to a single side despite a high false negative rate.     

Influence of morbid obesity on parathyroidectomy outcomes in primary hyperparathyroidism

Background

We sought to evaluate the influence of morbid obesity in patients undergoing parathyroidectomy for primary hyperparathyroidism (pHPT).

Methods

All patients with pHPT who underwent parathyroidectomy at a single institution between July 2002 and October 2008 were included. Body mass index (BMI), laboratorie vlaues, operative findings, and outcomes were examined.

Results

Two hundred thirteen of the 776 patients identified (28%) were morbidly obese (BMI ≥35 kg/m²). When compared with nonmorbidly obese patients, the morbidly obese patients were younger, had higher preoperative intact parathyroid hormone (iPTH) levels, heavier parathyroids, and required overnight stay more often (P <.05 for all). However, the rates of complications, eucalcemia, and recurrence were similar for all patients.

Conclusion

In this study, more than a quarter of the patients who underwent parathyroidectomy for pHPT were morbidly obese and had significantly higher preoperative iPTH levels, heavier parathyroids, and longer hospital stay but similar rates of complications and operative success.