Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is the preferred operation for patients with primary hyperparathyroidism (HPT) and positive preoperative imaging. This non-randomized case series assessed the long-term results of MIP performed without the use of intraoperative parathyroid hormone (ioPTH) monitoring. METHODS: The study involved prospective collection of demographic, biochemical and operative details on a consecutive, unselected cohort of 298 patients who underwent surgery for non-familial primary HPT during a 5-year interval. The mean preoperative serum calcium level was 3.00 mmol/l with a mean parathyroid hormone concentration of 25.8 pmol/l. (99m)Tc-labelled sestamibi scanning and neck ultrasonography were performed in 262 patients. RESULTS: Sestamibi scan showed unilateral uptake in 182 patients and a single parathyroid adenoma was confirmed on ultrasonography in 161 patients. MIP was performed in 150 patients. The mean duration of operation was 25 (range 8-65) min. Four patients needed conversion to conventional neck exploration. There was one postoperative haematoma and three cases of temporary recurrent laryngeal nerve neuropraxia. All but four patients were normocalcaemic after MIP. All the parathyroid tumours removed were adenomas, with a mean weight of 1.3 (range 0.1-17.4) g. No patient developed recurrent HPT after a median follow-up of 16 (range 3-48) months. CONCLUSION: The outcome of MIP without ioPTH monitoring was comparable to that reported in series that used ioPTH monitoring.     

原发性甲状旁腺机能亢进患者术中监测甲状旁腺激素的临床意义

目的：探讨原发性甲状旁腺机能亢进症（PHPT）患者术中动态监测甲状旁腺激素（IOPTH）的临床价值。 方法：回顾性分析1998年1月—2012年1月行手术治疗的36例PHPT患者的临床资料,其中2005年以后术中行IOPTH监测患者22例（IOPTH组）,2005年以前术中未行IOPTH监测的患者14例（常规组）,比较两组的术中情况与治疗效果。 结果：与常规组比较,IOPTH组手术时间明显缩短[（72.95±24.34）min vs.（81.86±29.46）min,P=0.000],术后短期（1个月内）甲状旁腺功能恢复患者比例增加（90.9% vs. 57.1%,P=0.018）,永久性甲状旁腺功能减退发生率明显减少（4.5% vs. 28.6%,P=0.042）。IOPTH监测对于判断高功能病灶完全切除与否的敏感度为100%,准确率为95.5%。 结论：PHPT手术中,在术前定位基础上联合IOPTH,有助于判断功能亢进腺体是否全部切除,避免遗漏多发病变腺体及不必要的双侧探查,缩短手术时间,疗效确切。     

Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring

Background

Reoperative parathyroidectomy (R-PTX) in primary hyperparathyroidism (1HPT) has increased failure rates and morbidity. This study evaluated R-PTX during the era of minimal-access PTX with intraoperative parathyroid hormone (IOPTH) monitoring.

Methods

Two thousand sixty-five patients with 1HPT who underwent PTX were assessed for R-PTX. Preoperative studies, operative findings, and outcomes were evaluated.

Results

Two hundred twenty-eight patients underwent 236 R-PTX procedures. Imaging performed included sestamibi (89%), ultrasound (US; 56%), computed axial tomography/magnetic resonance imaging (5%), and selective venous sampling (1%). Sestamibi was more sensitive than US (84% vs 68%). Curative surgery was performed in 89% of patients. IOPTH was 99% sensitive. There was no relationship between cure and the following parameters: preoperative calcium or PTH levels, persistent or recurrent disease, or use of IOPTH. Solitary gland disease and a single previous operation were associated with increased likelihood of cure (P = .06). Hypoparathyroidism was decreased using IOPTH monitoring (2% vs 9%). One patient had recurrent laryngeal nerve palsy.

Conclusions

R-PTX can be performed effectively with minimal complications. IOPTH is an accurate predictor of cure and may decrease the frequency of permanent hypoparathyroidism.     

Pitfalls of intraoperative quick parathyroid hormone monitoring and gamma probe localization in surgery for primary hyperparathyroidism

HYPOTHESIS: Intraoperative quick parathyroid hormone (qPTH) monitoring and gamma probe (GP) localization greatly aid the surgeon. DESIGN: Prospective case series of patients undergoing parathyroidectomy (PTX) with preoperative localization studies, operative data (including intraoperative qPTH values and GP localization), and outcomes. Follow-up was complete (mean, 4.2 months). SETTING: University teaching hospital. PATIENTS: We studied 57 consecutive patients with primary hyperparathyroidism from December 1, 1999, through November 30, 2000. Of these, 51 underwent first-time PTX, and 6, reoperative PTX (rePTX). MAIN OUTCOME MEASURES: Cure rate and morbidity after PTX or rePTX; sensitivity and accuracy of preoperative localization studies; prediction of cure from results of qPTH monitoring (comparing Nichols [>50% fall from the highest baseline level and lower than the lowest baseline] or normal-limit [>50% fall from first baseline level and lower than upper limit of the reference range] criteria); and value of GP localization. RESULTS: Patients were cured in 50 (98%) of 51 PTX and 6 (100%) of 6 rePTX for single adenomas (n = 49), double adenomas (n = 4), and multigland hyperplasia (n = 3). Nichols criteria for qPTH monitoring correctly categorized 45 (92%) of 49 cured single adenomas 10 minutes after excision. Only 35 (71%) of these adenomas were correctly categorized as cured by means of the normal-limit criteria. In double adenomas, both sets of criteria in the 10-minute samples indicated unresected glands in only 2 of 4 cases. Preoperative sestamibi parathyroid scans correctly localized 38 (76%) of 50 single adenomas. The GP was used in 54 of 57 cases. All adenomas measured greater than 20% of background ex vivo, but 6 thyroid nodules also measured greater than 20% ex vivo. In double adenomas, the GP helped locate the second adenoma in only 1 of 4 cases. The GP was graded as crucial in 2 cases with dense scar (both rePTX), helpful in 12 (22%) of 54 cases (particularly in retroesophageal glands), confirmatory in 32 (59%), and not helpful in 8 (15%). The GP helped localize 3 (43%) of 7 glands not seen on sestamibi parathyroid scans. CONCLUSIONS: Intraoperative qPTH monitoring confirmed cure in most cases. For single adenomas, use of the Nichols criteria for qPTH assessment allowed more accurate and faster confirmation than the normal-limit criteria. The GP was less useful but was crucial in 2 rePTX cases; it was not specific for parathyroid tissue. Both techniques have potential pitfalls that could result in surgical failure.     

A successful application of the intraoperative parathyroid hormone assay in tertiary hyperparathyroidism

The role of the intraoperative parathyroid hormone (IOPTH) assay in patients with tertiary hyperparathyroidism (3HPT) is not well defined. To evaluate the utility of the IOPTH in 3HPT, we compared its use in 72 patients with primary hyperparathyroidism (1HPT) and 3HPT undergoing parathyroidectomy. Sixty-three patients with 1HPT and nine patients with 3HPT were identified. There were 30 men and 42 women (mean age, 58 years). The mean serum calcium and preoperative intact PTH levels in 1HPT were 11.1 mg/dL and 214 pg/mL compared with 11.2 mg/dL and 849 pg/mL in 3HPT (Ca, non significant; PTH, P < 0.05). Intraoperatively, a solitary abnormal gland was found in 62 of 72 (86%) patients. Seven patients with 3HPT had three- or four-gland hyperplasia. The two groups were compared to determine if a 10-minute postexcision IOPTH decline > 50 per cent would have similar success rates. Seventy-one of 72 (98.6%) patients had a > 50 per cent decline from the baseline IOPTH at the end of the operation. The average reduction from baseline was 85.3 per cent in 1HPT and 88.6 per cent in 3HPT (not significant). Average follow-up was 9.8 months for 1HPT and 11.1 months in 3HPT. Three of 63 patients (4.8%) with 1HPT and five of nine patients (55.6%) with 3HPT had inappropriate elevations in PTH (P < 0.05). All patients with 3HPT were normocalcemic compared with 62 of 64 (97%) patients with 1HPT (not significant). The IOPTH assay can be used in 3HPT in an identical fashion with an equivalent rate of normocalcemia compared with its applications in 1HPT.     

Influence of concurrent chronic kidney disease on intraoperative parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism

Background

The influence of chronic kidney disease on intraoperative parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism has not been well-established. We hypothesize that chronic kidney disease influences intraoperative parathyroid hormone degradation kinetics during parathyroidectomy.

The role of intraoperative parathyroid hormone assay in the surgical management of hyperparathyroidism

Surgical management of primary hyperparathyroidism has undergone several chances in recent years and historically has required bilateral neck exploration with identification of the parathyroid adenoma together with three normal glands. The intraoperative hormone assay allows a more limited procedure by confirming complete removal of hypersecreting tissue. The Authors report surgical treatment of 24 consecutive hyperparathyroidism and conclude that evaluation of intraoperative hormone assay accurately predicts the determination of adequacy of resection and the correct outcome of surgery in patients with parathyroid adenomas.     

Contemporary surgical treatment of primary hyperparathyroidism without intraoperative parathyroid hormone measurement

Introduction

Primary hyperparathyroidism (pHPT) is usually the result of a single adenoma that can often be accurately located preoperatively and excised by a focused operation. Intraoperative parathyroid hormone (IOPTH) measurement is used occasionally to detect additional abnormal glands. However, it remains controversial as to whether IOPTH monitoring is necessary. This study presents the results of a large series of focused parathyroidectomy without IOPTH measurement.

Methods

Data from 2003 to 2014 were collected on 180 consecutive patients who underwent surgical treatment for pHPT by a single surgeon. Preoperative ultrasonography and sestamibi imaging was performed routinely, with computed tomography (CT) and/or selective venous sampling in selected cases. The preferred procedure for single gland disease was a focused lateral approach guided by on-table surgeon performed ultrasonography. Frozen section was used selectively and surgical cure was defined as normocalcaemia at the six-month follow-up appointment.

Results

Focused surgery was undertaken in 146 patients (81%) and 97% of these cases had concordant results with two imaging modalities. In all cases, an abnormal gland was discovered at the predetermined site. Of the 146 patients, 132 underwent a focused lateral approach (11 of which were converted to a collar incision), 10 required a collar incision and 4 underwent a mini-sternotomy. At 6 months following surgery, 142 patients were normocalcaemic (97% primary cure rate). Three of the four treatment failures had subsequent surgery and are now biochemically cured. There were no complications or cases of persistent hypocalcaemia.

Conclusions

This study provides further evidence that in the presence of concordant preoperative imaging, IOPTH measurement can be safely omitted when performing focused parathyroidectomy for most cases of pHPT.     

Impact of intraoperative parathyroid hormone monitoring on the prediction of multiglandular parathyroid disease

Optimal interpretation of the results of intraoperative parathyroid hormone (IOPTH) monitoring during neck exploration for primary hyperparathyroidism (pHPT) is still controversial. The reliability of the 50% rule in multiglandular disease (MGD) is often disputed, mostly because of competing pathophysiologic paradigms. The aim of this study was to ascertain and corroborate the ability of IOPTH monitoring to detect MGD in a practice, combining conventional and alternative parathyroidectomy techniques. This is a retrospective single institution analysis of 69 consecutive patients undergoing cervical exploration for pHPT by various approaches. The IOPTH measurements were performed after induction of anesthesia but prior to skin incision and 10 minutes after excision of the first visualized enlarged parathyroid gland. In this series, 55 patients (80%) had single adenomas, and 14 patients (20%) had MGD. In 8 of the 14 patients with MGD, IOPTH levels were obtained sequentially after removal of every enlarged gland. Of these 8 patients, 6 (75%) had a false-positive decrease (decrease below 50% of baseline value in presence of another enlarged gland) failing to predict the presence of a second enlarged gland. In 2 cases IOPTH monitoring provided a true-negative result, correctly predicting MGD. If MGD is defined by gross morphologic criteria, IOPTH monitoring fails to predict the presence of MGD reliably. However, if MGD is defined by functional criteria, the course of these patients does not seem significantly affected. The importance of these findings must be further investigated, especially with regard to the outcome of minimally invasive parathyroid procedures.     

Transcervical endoscopic-assisted mediastinal parathyroidectomy with intraoperative parathyroid hormone monitoring

Ectopic mediastinal parathyroid adenomas are rare lesions that typically necessitate either median sternotomy or thoracotomy. More recently, video-assisted thoracoscopy has been used to excise mediastinal parathyroid adenomas. Herein we describe a novel technique in which we used a minimally invasive transcervical endoscopic-assisted approach to excise an anterior mediastinal parathyroid adenoma in a young man with a history of spontaneous pneumothorax. Intraoperative parathormone monitoring confirmed the excision of all hypersecreting parathyroid tissue, thereby obviating the need for a conventional neck exploration.     

Successful parathyroidectomy guided by intraoperative parathyroid hormone monitoring for primary hyperparathyroidism is preserved in mild and moderate renal insufficiency

Background

The effect of altered parathyroid hormone metabolism in renal insufficiency on intraoperative parathyroid hormone monitoring during parathyroidectomy is not well known. This study evaluates operative outcomes in patients undergoing parathyroidectomy guided by intraoperative parathyroid hormone monitoring for primary hyperparathyroidism with mild and moderate renal insufficiency.

Intraoperative monitoring of intact parathyroid hormone during surgery for primary hyperparathyroidism

The aim of the present study was to evaluate a new immunometric assay for intraoperative parathyroid hormone monitoring. The test was applied in 70 patients who underwent surgery for primary hyperthyroidism (pHPT) between 6/1999 and 6/2001. Among these patients, 61 showed a solitary adenoma, eight a hyperplasia and one a double adenoma. Intraoperative iPTH samples were taken at the beginning of the operation and 5, 10 and 15 min after removal of the parathyroid gland. Criterion for a successful operation were a decrease of iPTH levels of more than 50 % within 5 min and of more than 60 % within 15 min after parathyroidectomy. Following the removal of a solitary adenoma, iPTH levels decreased by 63 % (+/- 13 %) after 5 min and by 76 % (+/- 10 %) after 15 min respectively. In case of hyperplasia, a significant decrease of iPTH levels was not observed until a subtotal parathyroidectomy had been carried out. In the present study there were 2 false negative and one false positive results corresponding with a sensitivity of 97 % and a specificity of 89 % for prediction of a solitary adenoma. In our opinion, intraoperative iPTH monitoring using this new assay allows the safe distinction between adenoma and multiglandular disease. It represents a valuable adjunct to surgical skill as it permits minimally invasive operations for solitary adenomas, and in case of recurrent surgery helps to detect the region of interest by selective venous sampling for parathyroid hormone.     

Effects of propofol on intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism undergoing parathyroidectomy: a randomized control trial

Purpose

Serial measurements of parathyroid hormone (PTH) serum concentrations aid parathyroidectomy surgery. There are concerns that propofol may increase PTH concentrations and/or interfere with PTH assays. The primary purpose of this study is to determine the effects of propofol on PTH concentrations in patients with primary hyperparathyroidism and to determine its effect on PTH assays.

Methods

Thirty patients with primary hyperparathyroidism were assigned randomly to induction and maintenance with either propofol or sevoflurane. Blood samples for PTH assays were obtained pre-induction, immediately after induction, ten minutes after induction, and after excision of parathyroid adenoma. The primary endpoint was the PTH concentration at ten minutes after induction. This endpoint was compared between groups using analysis of covariance adjusting for pre-induction PTH. An in vitro study was performed with four different pools of PTH concentrations that were spiked with increasing concentrations of propofol. Serum PTH was measured in duplicate in each sample and analyzed using repeated measures analysis of variance.

Results

At ten minutes after induction, PTH concentrations did not differ significantly between groups (least square mean difference ?7.0 pg·mL^?1; 95% confidence interval, ?34.2 to +20.2). The PTH level in vitro did not change significantly with increasing propofol concentrations.

Discussion

Parathyroid hormone concentrations in patients with primary hyperparathyroidism were not affected by the type of anesthesia (propofol vs sevoflurane). Furthermore, propofol was found not to interfere with PTH assays at clinically relevant concentrations. There is no evidence to support the avoidance of a propofol anesthetic for parathyroid surgery.