The actual role of classic bilateral cervicotomic approach for primary hyperparathyroidism in the era of minimally invasive surgery

Recent advances in preoperative localisation of parathyroid adenomas and intraoperative prove of complete removal of hyperfunctioning parathyroid tissue have fostered less invasive operative procedures which directly target the diseased gland. Such strategies have partially replaced the previous gold standard procedure of bilateral neck exploration. We herein report on our own series of 1099 consecutive operations for primary hyperparathyroidism performed in a 16 year period and provide information and arguments for primary bilateral exploration in selected cases. 97.1% of patients were cured by the primary operation. From 1999 through 2001, 200 patients underwent bilateral neck exploration, whereas 63 unilateral operations were performed (33 patients were treated by minimally invasive video-assisted parathyroidectomy (MIVAP) and 30 by minimally invasive open parathyroidectomy (MIOP). In the remaining 200 patients minimally invasive unilateral parathyroid surgery was not feasible due to concomitant goiter (n = 102), lack of preoperative localisation (n = 30), previous thyroid surgery (n = 10), suspected multiglandular disease (n = 10), or other reasons (n = 8). In 40 patients the decision for bilateral neck exploration was made despite feasibility of a unilateral approach. CONCLUSION: Whereas unilateral exploration produced excellent cure rates in older patients, it is not recommended in patients with a high likelihood of multiglandular disease, presence of a large or multinodular goitre, high PTH levels, giant adenoma, unclear MIBI scans or an unreliable OPTH assay. Contrasting recent reports on a dramatic shift of technique towards minimally invasive procedures unilateral parathyroid surgery may not be preferably advisable in a majority of patients from countries with insufficient iodine supplementation.     

Surgeon Performed Ultrasound Facilitates Minimally Invasive Parathyroidectomy by the Focused Lateral Mini-incision Approach

Background Minimally invasive parathyroidectomy (MIP) is now widely accepted where a single adenoma can be localized preoperatively. In our unit, MIP is offered once a parathyroid adenoma is localized with a sestamibi (MIBI) scan, with or without a concordant neck ultrasound. The aim of this study was to compare the accuracy of surgeon performed ultrasound (SUS) with radiologist performed ultrasound (RUS) in the localization of a parathyroid adenoma in MIBI-positive primary hyperparathyroidism (PHPT). Patients and Methods This is a prospective study of patients undergoing parathyroidectomy for sporadic primary hyperparathyroidism (PHPT) from April 2005 to October 2006 at the University of Sydney Endocrine Surgical Unit. Patients were then divided into those who underwent preoperative RUS or SUS. Results Two-hundred eighteen patients formed the study group. One hundred forty-eight (66%) patients had RUS and 87 (39%) had SUS. Overall, RUS correctly localized the parathyroid adenomas in 121 of 148 (82%) patients. Surgeon performed ultrasound correctly localized the abnormal parathyroid adenoma in 72 of 87 (83%) of cases. There was no significant difference in the proportion of patients with single gland disease, double adenomas, or hyperplasia correctly localized by SUS or RUS. Incorrect interpretation of ultrasound imaging was due to cystic degeneration in thyroid nodules, lymph nodes, retro-esophageal location of adenomas and ectopic and small parathyroid glands. Conclusions Surgeon performed ultrasound is a useful adjunctive tool to MIBI localization for facilitating MIP and when performed by experienced parathyroid surgeons, it can achieve accuracy rates equivalent to that of a dedicated parathyroid radiologist.     

Benefits of surgeon-performed ultrasound for primary hyperparathyroidism

Background  Focused, minimally invasive parathyroidectomy (MIP) is widely accepted when preoperative imaging localizes a single parathyroid adenoma. Many surgeons use ^99mTc-sestamibi scintigraphy (MIBI) +/−, a cervical ultrasound for preoperative localization. We propose that surgeon-performed ultrasound (SUS) is the only imaging modality required in most patients with primary hyperparathyroidism (pHPT), resulting in patient convenience and reduced cost. Materials and methods  Since July 2006, patients with pHPT underwent MIP based solely on a positive SUS. Intraoperative parathyroid hormone assay was used to determine the extent of operation. A retrospective review from July 2006 through December 2008 identified 160 patients who underwent parathyroidectomy after SUS on their initial office visit. Results  SUS correctly identified an enlarged parathyroid gland in 119/160 (74%) patients. In 41 patients, SUS was the only localizing study. MIBI was done in 119 patients. In 54 patients, SUS confirmed the MIBI, and in 28 patients with a negative MIBI, SUS was positive. In the 41 patients with a negative SUS, an MIBI was positive in ten. Ninety-eight patients had MIP. Theoretically, 85 MIBIs were unnecessary because of a positive SUS corresponding to a potential cost savings of at least $90,000. Conclusion  SUS to localize parathyroid adenomas is accurate and facilitates MIP. It provides substantial cost savings and patient convenience and should be the first diagnostic procedure performed for patients suspected to have pHPT. MIBI can be reserved for those patients in whom ultrasound has failed to localize a parathyroid gland. Best of endocrine surgery in Europe 2009.     

Cervical thymectomy for intrathymic parathyroid adenomas during minimally invasive parathyroidectomy

BACKGROUND: The development of an intrathymic parathyroid adenoma is common, and thymectomy is a significant component of the parathyroid surgeon's technical armamentarium. Over the last decade, minimally invasive parathyroidectomy (MIP) has become the standard technique for removal of an abnormal parathyroid gland, and the requirement for thymectomy should remain unchanged during the era of minimally invasive techniques. The aim of this paper was to assess the feasibility and outcomes of cervical thymectomy for intrathymic parathyroid adenomas during MIP. METHODS: This is a retrospective case series. The study group comprised all patients undergoing parathyroidectomy in the University of Sydney Endocrine Surgical Unit during a 5-year period (January 2001 to December 2005). Patients undergoing MIP and open parathyroidectomy with a concomitant cervical thymectomy were compared. RESULTS: A total of 840 patients underwent parathyroid surgery for primary hyperparathyroidism (PHPT) during this period. A total of 30 MIP procedures with concurrent thymectomy were performed, and 99 open bilateral neck explorations with cervical thymectomy were performed. Of the MIP thymectomy group, there were 25 female and 5 male patients; the average age was 57 years (range, 22 to 82). A mean length of 34 mm of thymus was extracted via the minimally invasive approach (range, 8 to 85 mm). In 5 cases, only fatty tissue was identified histologically, and, in 5 cases, a small supernumerary parathyroid gland was identified in the histologic specimen. Only 1 patient suffered temporary, recurrent laryngeal nerve palsy; there were no cases of postoperative hemorrhage requiring return to the operating room. CONCLUSIONS: Cervical thymectomy for removal of intrathymic parathyroid adenomas can be performed during lateral focused mini-incision MIP with a safety and efficacy equivalent to open bilateral neck explorations.     

Chasing ��Shadows��: Discovering the Subtleties of Sestamibi Scans to Facilitate Minimally Invasive Parathyroidectomy

Background  

With the advent of sestamibi scans, high-resolution ultrasonography (US), and intraoperative intact parathyroid hormone (PTH) measurements, minimally invasive parathyroidectomy (MIP) is considered the standard of care for patients with primary hyperparathyroidism (PHPT). Preoperative imaging, however, can be negative more than 20% of the time.     

Radioguided parathyroidectomy via VATS combined with intraoperative parathyroid hormone testing: the surgical approach of choice for patients with mediastinal parathyroid adenomas?

Despite the excellent results with bilateral exploration, minimally invasive parathyroidectomy has become the procedure of choice for patients with hyperparathyroidism in which a single parathyroid lesion can be localized preoperatively. In this article, we discuss a patient who presented with primary hyperparathyroidism for the first time and had a Tc-99m sestamibi scan to localize a single parathyroid lesion in the left, anterior mid-mediastinum. We subsequently performed a radioguided parathyroidectomy via video-assisted thoracoscopic surgery (VATS) to resect this parathyroid adenoma and used intraoperative parathyroid hormone (PTH) testing to confirm cure and avoid neck exploration. We concluded that radioguided parathyroidectomy via VATS combined with intraoperative PTH testing is an effective approach for patients with primary hyperparathyroidism and mediastinal parathyroid lesions, and perhaps should be the technique of choice.     

Cost-effectiveness of scan-directed parathyroidectomy

BACKGROUND: Concordant parathyroid localization with sestamibi and ultrasound scans allows minimally invasive parathyroidectomy (MIP) to be performed in patients with non-familial primary hyperparathyroidism (PHPT). AIM: To investigate the financial implications of scan-directed parathyroid surgery. METHODS: Analysis of hospital records for a cohort of consecutive unselected patients treated in a tertiary referral centre. RESULTS: Two hundred patients (138F:62M, age 18-91years) were operated for non-familial PHPT between Jan 2003 and Oct 2007. MIP was performed in 129 patients, with a mean operative time was 35 +/- 18min. Some 75 patients were discharged the same day and the others had a total of 72 in-patient days. Bilateral neck exploration (BNE) was performed in 71 patients with negative/non-concordant scans. Mean operative time was 58 +/- 25min. Only nine patients were discharged the same day and a total of 93 in-patient days were used ( approximately 1.3days/patient). The estimated total costs incurred were pound215,035 ( approximately 290,000). These costs would have been covered by the National Tariff ( pound2,170 per parathyroidectomy) but were higher than those possibly incurred if all 200 patients would have undergone BNE without any radiological investigations ( pound166,000 approximately 224,100). CONCLUSION: Shorter operative time and day-case admission for MIP generate costs savings that compensate only partially for the additional costs associated with parathyroid imaging studies.     

Minimally invasive parathyroid surgery

The standard bilateral neck exploration in primary hyperparathyroidism (HPTH) has been challenged in the recent years by the general trend toward less invasive surgery. The development of more reliable preoperative imaging techniques such as Sestamibi scanning and high definition ultrasonography coupled with improvements in intraoperative rapid assays of intact parathyroid hormone have allowed unilateral explorations in most patients with primary HPTH. This article reviews the currently available preoperative parathyroid localization studies as well as the currently used minimally invasive parathyroidectomy (MIP) techniques, such as open approaches, radioguided surgery and endoscopic procedures. While some techniques are more popular than others, careful selection of patients with primary HPTH has resulted in comparable cure rates to the standard bilateral parathyroid exploration.     

Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism

BackgroundThe aim of this study was to determine whether minimally invasive radioguided parathyroidectomy (MIRP) and intraoperative parathyroid hormone–guided parathyroidectomy (ioPTH) have equivalent intermediate-term outcomes in primary hyperparathyroidism (PHPT).MethodsA retrospective study of 244 patients who underwent parathyroidectomy for PHPT in a 25-month time period was conducted. Patients who either underwent MIRP- or ioPTH-guided parathyroidectomies were included. The primary outcome was persistent disease. Conversion to bilateral exploration, complications, and multigland disease (MGD) were secondary outcomes.ResultsThere was 1 MIRP patient and no ioPTH patients who had persistent disease. The ioPTH group had more conversions to a bilateral exploration (bilateral neck exploration [BNE]) (3.7% vs 13%, P = .024). In the MIRP group, no patients were found to have MGD. In the ioPTH group, 7 patients with double adenomas and 6 patients with MGD were found (0 vs 13, P = .0028).ConclusionsioPTH facilitates successful minimally invasive parathyroidectomy (MIP) when compared with MIRP and provides cure rates similar to BNE.     

Minimally invasive videoscopic parathyroidectomy by lateral approach

Methods: A videoscopic parathyroidectomy was performed in 22 patients presenting with primary hyperparathyroidism (PHPT). No patient had undergone previous neck surgery, presented with goiter or had a history of familial PHPT. Ultrasonography and Sestamibi scanning were performed preoperatively. Rapid intact parathormone assay was used during surgery. Through a 15-mm transversal skin incision on the anterior border of the sternocleidomastoid muscle (SCM), the fascia connecting the lateral portion of the strap muscles and the thyroid lobe with the carotid sheath was gently divided, far enough to visualize the prevertebral fascia. Once enough space was created, three trocars were inserted: a 12-mm trocar through the incision and two 2.5-mm trocars on the line of the anterior border of the SCM, above and below the first trocar. Carbon dioxide was insufflated to 8 mmHg. Unilateral video-assisted parathyroid exploration was then carried out using a 10-mm O° endoscope. Once the adenoma had been identified, the trocars were removed. Then, directly through the skin incision, the thyroid lobe was retracted medially and the adenoma was extracted after clipping its pedicle. Results: Among the 23 enlarged glands, 20 (80%) were correctly identified by endoscopic exploration: mean weight 843 mg (100 mg to 5 g). The exploration was unilateral in 17 patients but bilateral in 5. Mean time of unilateral endoscopic exploration was 84 min (40–130 min). Morbidity was represented by two superficial hematomas. All 22 patients were biochemically cured, follow-up ranging from 3 months to 14 months. Conclusions: This preliminary study demonstrates that minimally invasive videoscopic parathyroidectomy by lateral approach is a feasible surgical procedure. Received: 24 November 1998 Accepted: 3 March 1999     

Does Intraoperative Quick Parathyroid Hormone Assay Improve the Results of Parathyroidectomy?

Preoperative sestamibi (MIBI) and ultrasonography (US) are used to localize parathyroid tumors in patients with primary hyperparathyroidism (pHPT). The intraoperative quick PTH assay (qPTH) has been recommended to determine whether all hyperfunctioning parathyroid tissue has been removed. We questioned whether qPTH improves the results of parathyroidectomy in patients with pHPT. We analyzed 115 unselected patients with pHPT without a family history or multiple endocrine neoplasia but who had undergone parathyroidectomy. All 115 patients had successful operations without complications. Of these patients, 88 (77%) had solitary adenomas, 13 had double adenomas, 1 had triple adenomas, 12 had hyperplasia, and 1 had carcinoma. Overall, MIBI was correct in 72% (76/106), US in 49% (49/99), and qPTH in 80% (92/115). For preoperative studies showing a single tumor, MIBI was correct in 83% (73/88), US was correct in 71% (45/63), and combined MIBI and US were correct in 95% (37/39). Adding qPTH in this subgroup did not improve the successful focused approach: 70% for MIBI, 65% for US, and 87% for combined MIBI and US. However, adding qPTH improved the overall success of parathyroidectomy (MIBI 92%, US 86%, combined MIBI and US 97%), but at the cost of unnecessary further exploration (MIBI 13%, US 6%, combined MIBI and US 8%). We conclude that when the same solitary tumor is identified by both MIBI and US, a focused exploration can be done with a 95% success rate. Adding qPTH to MIBI or US can improve the success rate but at a significant cost. General exploration of all parathyroid glands, however, has the highest success rate (100%).     

Preoperative technetium Tc 99m sestamibi SPECT imaging in the management of primary hyperparathyroidism in patients with concomitant multinodular goiter

HYPOTHESIS: Preoperative parathyroid and thyroid imaging using technetium Tc 99m sestamibi scintigraphy-single-photon emission computed tomography (Tc 99m MIBI SPECT) and technetium Tc 99m sodium pertechnetate, respectively, in patients with parathyroid adenomas and concomitant multinodular goiters enables the selection of those suitable for minimally invasive radio-guided surgery. DESIGN: One hundred thirty patients with primary hyperparathyroidism were treated surgically during a 30-month period. Forty-one of these 130 patients had an associated multinodular goiter. All patients underwent planar and SPECT parathyroid scintigraphy using Tc 99m MIBI, and thyroid scintigraphy with technetium Tc 99m pertechnetate 2 to 5 days before surgery. On the morning of surgery each patient was reinjected with Tc 99m MIBI for intraoperative localization and validation. Minimally invasive radio-guided parathyroidectomy was performed using a handheld gamma-detection device with a thyroid probe. Removed glands were submitted for histopathologic examination for comparison with the scintigraphic results. Quantitative analysis of parathyroid activity was performed. RESULTS: Minimally invasive, radioguided parathyroidectomy was successfully performed in 21 (51%) of 41 patients who had a concomitant multinodular goiter. The remaining 20 patients underwent standard neck exploratory surgery because of associated thyroid disease; 5 of them had malignant thyroid disease. Among the 41 patients planar scintigraphy correctly identified 28 adenomas (68%). Single-photon emission computed tomographic imaging identified an additional 11 adenomas for a sensitivity of 95% and a specificity of 100%. Moreover, SPECT imaging correctly identified malignant thyroid nodules in 4 of 5 patients. Technetium Tc 99m MIBI retention was noted in only 25 adenomas (61%) while the remaining adenomas demonstrated a rapid washout. The average uptake ratio of parathyroid counts to maximum thyroid activity was significantly correlated with parathyroid hormone levels before surgery (P = .04). CONCLUSIONS: Our data encourage the use of preoperative SPECT imaging of parathyroid adenomas in patients who have multinodular goiters to select those suitable for minimally invasive radioguided surgery. This technique also offers important information regarding thyroid nodules that are suspicious for malignancy. The intraoperative gamma-probe technique enables the surgeon to focus his or her search, provides instant feedback regarding the progress of the operation, reduces surgical trauma and complications, and yields better cosmetic results. Patients with higher presurgical parathyroid hormone levels may especially benefit from radioguided surgery.     

Minimally invasive parathyroidectomy without intraoperative localization.

Minimally invasive parathyroidectomy (MIP) is gaining popularity as an alternative to traditional bilateral exploration for patients with primary hyperparathyroidism. The success of MIP relies on the ability of preoperative and intraoperative localization studies to guide a directed exploration for resection of a diseased gland. We hypothesize that excellent results can be achieved with MIP when only technetium-99m sestamibi (MIBI) is used for localization. We conducted a prospective analysis of all patients presenting with a biochemical diagnosis of primary hyperparathyroidism between January 1997 and November 2000. Patients meeting inclusion criteria were given a choice of MIP and directed exploration versus traditional bilateral exploration. Fifty patients chose MIP. Three patients who chose MIP had a negative MIBI, which left 47 patients in the primary study group. The MIBI correctly identified a parathyroid adenoma in 42 patients (89.3%). In two other patients MIBI was inaccurate; however, directed exploration was successfully converted to a bilateral exploration. Overall 44 of 47 (93.6%) patients in the study group were rendered normocalcemic after the initial operation. Three patients experienced persistent hypercalcemia and subsequently underwent successful bilateral exploration. Including those patients choosing a bilateral exploration, a total of 59 positive MIBI scans were evaluated. There were 54 true positives (positive predictive value 91.5%), and if all patients had chosen a MIP 94.9 per cent would have been successfully treated at the initial operation. Mean operative time for MIP was 54.6 minutes, and in 32 patients (68.1%) MIP was performed with local anesthesia and sedation. Twenty-six patients (55.3%) were discharged the same day of the procedure. There were no significant complications in any group analyzed. We conclude that MIP can be successfully performed on the basis of a positive MIBI scan. The present study highlighting many of the advantages of MIP questions the necessity of additional adjuncts such as intraoperative parathyroid hormone measurement and gamma-probe localization.     

Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: A prospective randomized trial

Background Quick intraoperative parathormone assay (qPTHa) during paratyroidectomy has become a standard procedure for patients with primary hyperparathyroidism (PHPT). This paper aims to compare endoscopic bilateral neck exploration (BE) versus focused parathyroidectomy plus qPTHa during minimally invasive video-assisted parathyroidectomy (QM). The endpoints of the study are the mean operative time and outcome of the surgical procedure (PTH and calcemia normalization at one and six months postoperatively). Methods Forty patients with PHPT, positive to preoperative localization studies (ultrasonography evaluation and ⁹⁹Tc-MIBI scan) for a single parathyroid adenoma, were randomly allotted into two groups. In the first group (QM), 20 patients (17 women, three men, mean age 57.6 years) underwent focused endoscopic parathyroidectomy (MIVAP tecnicque) plus qPTHa . In the second group (BE) 20 patients (17 women, three men, mean age 59.6 years) underwent endoscopic parathyroidectomy plus bilateral exploration in order to check the integrity of the remaining glands. Results There were no significant differences between groups at baseline. No conversion to cervicotomy was required. No postoperative complications were reported. The mean operative time was 32.0 vs 33.1 min [BE and QM group respectively, p = not significant (ns)]. A second macroscopically enlarged gland was removed in four patients in the BE group. Only one out of four glands was reported to be hyperplastic in the final histology. All patients were discharged on the first postoperative day. Calcemia levels were normalized in all patient of both groups, despite persistently high level of serum PTH in one patient in the QM group. Conclusions BE can be performed endoscopically, avoiding both the time necessary for qPTHa and its cost, with the same effectiveness, but might in few cases lead to the unjustified removal of parathyroid glands slightly enlarged but not necessarily pathologic.     

Reassessment of parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism after 2 preoperative localization studies

HYPOTHESIS: For patients with primary hyperparathyroidism and patients with 2 localization studies showing the same single location of parathyroid disease, use of intraoperative parathyroid hormone (IOPTH) measurement does not significantly increase the success of minimally invasive parathyroidectomy. DESIGN: Retrospective cohort study. SETTING: Experience of 2 academic centers over 5 years (at Brigham and Women's Hospital, Boston, Mass) and almost 4 years (at Rhode Island Hospital, Providence). PATIENTS: A total of 569 patients with primary hyperparathyroidism who underwent technetium Tc 99m sestamibi (MIBI) parathyroid imaging and neck ultrasonography (US). MAIN OUTCOME MEASURES: Incidence of correct prediction of location and extent of disease. RESULTS: In 322 patients (57%), MIBI and US imaging identified the same single site of disease. In 319 (99%) of these 322 patients, surgical exploration confirmed a parathyroid adenoma at that site, and the IOPTH levels normalized on removal. In 3 (1%) of the 322 patients, IOPTH measurement identified unsuspected additional disease. In 3 (1%) of the remaining 319 patients, IOPTH-guided removal of a single adenoma failed to correct hypercalcemia. Therefore, the failure rate of surgery in patients with positive MIBI and positive US imaging was 1% with IOPTH measurement and 2% without IOPTH measurement (P = .50). In 201 (35%) of the 569 patients, only 1 of the 2 studies recognized an abnormality or the studies disagreed on location. In these cases, either MIBI imaging or US imaging (if MIBI imaging was negative) failed to predict the correct site or extent of disease in 76 (38%) of the 201 patients (P<.001 vs concordant studies). CONCLUSIONS: In primary hyperparathyroidism, concordant preoperative localization with MIBI and US imaging is highly accurate. Use of IOPTH measurement in these cases adds only marginal benefit. When only 1 of the 2 studies identifies disease or the studies conflict, however, IOPTH measurement remains essential during minimally invasive parathyroidectomy.     

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy,patient selection,surgical access,and reoperations

Purpose  Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration. Materials and methods  Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence. Results  Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia. Conclusions  Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy. This paper was presented at the “Primary HPT Symposium” organized by the European Society of Endocrine Surgeons (Lund, Sweden, March 19–21, 2009).     

Limits and drawbacks of video-assisted parathyroidectomy

BACKGROUND: Minimally invasive video-assisted parathyroidectomy (MIVAP) is a novel minimally invasive approach to primary hyperparathyroidism (PHPT). It is a gasless operation characterized by a single central incision and external retraction. This paper describes the drawbacks and limitations of this procedure based on a 5-year experience and 260 operations. METHODS: Of 364 patients with PHTP, 260 were selected for MIVAP. In most patients a unilateral minimally invasive exploration was performed. RESULTS: MIVAP was carried out successfully in 239 patients with a mean operating time of 40 (range 20-180) min. Conversion to cervicotomy was required in 21 patients (8.1 per cent). Complications included recurrent nerve palsy in two patients (0.8 per cent), haemorrhage that required reoperation 6 h after parathyroidectomy in one patient (0.4 per cent) and transient hypoparathyroidism in six patients (2.5 per cent). In five patients (2.1 per cent) persistent PHPT developed shortly after surgery. CONCLUSION: After 5 years of experience, MIVAP appears to be feasible, safe and applicable to the majority of patients with PHPT.     

One hundred consecutive minimally invasive parathyroid explorations

OBJECTIVE: To review the outcomes of 100 consecutive minimally invasive parathyroid explorations. SUMMARY BACKGROUND DATA: Minimally invasive parathyroidectomy (MIP) has challenged the traditional approach of bilateral neck exploration for patients with primary hyperparathyroidism. Most patients with primary hyperparathyroidism have a single adenoma that when resected results in cure. It therefore appears logical to perform a directed approach to adenoma extirpation. MIP involves high-quality sestamibi images obtained with single photon emission computed tomography to localize enlarged parathyroid glands in three dimensions, limited exploration after surgeon-administered cervical block anesthesia, rapid intraoperative parathyroid hormone assay to confirm the adequacy of resection, and discharge within 1 to 3 hours of surgery. METHODS: MIP was offered to 100 selected consecutive patients during an 18-month period beginning in March 1998. RESULTS: Ninety-two cases were accomplished under cervical block anesthesia and 89 of these on an ambulatory basis. The cure rate was 100%, and there were no long-term complications. The mean hospital charge for MIP was less than 40% of that associated with traditional exploration. CONCLUSIONS: Outpatient MIP appears to be the procedure of choice for most patients with primary hyperparathyroidism.     

Preoperative Localization of Parathyroid Adenoma in Patients with Concomitant Thyroid Nodular Disease

We have previously demonstrated the role of high-resolution ultrasonography (US) in preoperative localization of parathyroid adenoma in patients with primary hyperparathyroidism (PHPT) and no thyroid abnormalities. The present study prospectively evaluated the possible additional value of ^99mTc-sestamibi (MIBI) in patients with PHPT and concomitant multinodular thyroid disease (MND). Patients with PHPT underwent US and MIBI scintigraphy prior to neck exploration. Imaging data were correlated with the site and pathology of the parathyroid tissue removed and were analyzed separately for patients with MND and those with a normal thyroid gland. Among 77 patients with a solitary parathyroid adenoma at surgery, 40 had concomitant MND, whereas 37 patients had no morphologic changes in the thyroid gland, on US or at surgery. Prior to surgery, MIBI scintigraphy depicted 58 of the 77 adenomas (75%) and US localized 51 (66%); the combined sensitivity was 87% (67/77). Among the 37 patients with no thyroid nodules, MIBI located 29 (78%) and US identified 30 (81%) of the adenomas; the combined sensitivity was 89%. In the 40 patients with MND, MIBI identified 29 adenomas (73%) and US localized only 53% (21/40); the combined sensitivity was 85%. Overall, the positive predictive value (PPV) of MIBI for detecting a solitary parathyroid adenoma was 94%, for US it was 88%, and with the two tests combined it was 97%. In patients with no thyroid abnormalities, the PPV of MIBI and US was 97%, but it decreased to 91% and 78%, respectively, in patients with MND. Two patients with false-positive findings on both MIBI and US had associated thyroid disease. Hence MIBI scintigraphy contributes to localization of a solitary parathyroid adenoma mainly in patients with concomitant MND. The combined MIBI and US modalities result in sparing these patients bilateral neck exploration.     

Video-assisted parathyroidectomy in the management of patients with primary hyperparathyroidism

INTRODUCTION: In recent years, different minimally invasive techniques of parathyroidectomy have been described. We performed a retrospective study to evaluate the indications and results of video-assisted parathyroidectomy (Vap) in the management of our patients with primary hyperparathyroidism (PHPT). MATERIALS AND METHODS: During the last 5 years (1998-2002), we operated on 528 patients with PHPT. Vap was proposed for patients with sporadic PHPT, without associated goiter and without previous neck surgery, in whom a single adenoma was localized by means of sonography and/or sestamibi scanning. Vap was performed by lateral approach with insufflation for patients with adenoma located deeply in the neck and by gasless midline approach for patients with adenoma located anteriorly. A quick parathyroid (qPTH) assay was used during the surgical procedures. Calcemia, phosphoremia and PTH were systematically evaluated in patients on days 1 and 8, 1 month and 1 year after surgery. All patients underwent pre-operative and postoperative investigations of vocal cord movements. RESULTS: Among 528 patients with PHPT, 228 (43%) were not eligible for Vap: associated nodular goiter (99 cases), previous neck surgery (42 cases), suspicion of multiglandular disease (25 cases), lack of pre-operative localization (48 cases), and miscellaneous causes (14 cases). Vap was performed in 300 patients with sporadic PHPT: 282 lateral access, 17 midline access and 1 thoracoscopy. Median operative time was 50 min (20-130 min). Conversion to conventional parathyroidectomy was required in 42 patients (14%): missed adenomas (11 cases), difficulties of dissection (7 cases), multiglandular disease correctly predicted by qPTH (10 cases); qPTH assay false negative results (3 cases), sestamibi scan false positive results (10 cases) and 1 sonography false positive result. One patient presented definitive recurrent nerve palsy. One patient had a persistent PHPT and one other patient had a recurrent PHPT. CONCLUSION: Vap can be proposed for more than half of patients with PHPT. In our experience Vap and conventional parathyroidectomy are complementary. Immediate results of Vap are similar to those obtained with conventional parathyroidectomy but no conclusions can be drawn in terms of influence of Vap on the outcome of the patients operated for PHPT.