Minimally invasive video-assisted parathyroidectomy

BACKGROUND: The standard surgical procedure for parathyroidectomy consists of bilateral cervical exploration and the visualization of all four parathyroid glands. However, improved preoperative localization techniques and the availability of intraoperative intact parathyroid hormone (iPTH) monitoring now allow single adenomas to be treated with minimally invasive techniques. METHODS: Patients with primary hyperthyroidism (pHPT), who were found to have one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, rapid electrochemiluminescense immunoassay was used to measure iPTH levels shortly before and 5, 10, and 15 mins after excision of the adenoma. The operation was considered successful when a >50% decrease in preexcision iPTH levels was observed after 5 min. RESULTS: Between November 1999 and May 2000, 10 of 22 patients with pHPT were deemed eligible for the minimally invasive approach. In all cases, the adenoma was removed successfully. However, in two cases, intraoperative iPTH monitoring did not show a sufficient decrease in iPTH values. Subsequent cervical exploration revealed a double adenoma in one case and hyperplasia in the other. CONCLUSIONS: Even when high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy are used, the presence of multiple glandular desease cannot be ruled out entirely. When the minimally invasive approach is contemplated, intraoperative iPTH monitoring is indispensible to ensure operative success. However, in selected cases, minimally invasive parathyroidectomy represents an excellent alternative to the conventional technique.     

Primary hyperparathyroidism: clinical symptoms, diagnostic significance and localisation--a retrospective analysis

BACKGROUND: The primary hyperparathyroidism (pHPT) is one of the most frequent metabolic diseases. Due to improvement in diagnostics it is a point of interest whether patients with pHPT still suffer from the typical symptoms. Moreover, the question of the best localisation-diagnostics and the most frequent localisation of the adenoma is not yet clarified. New operation strategies and more cost-efficient strategies for diagnostic and therapy could be developed due to the clinically established electrochemiluminescence immunoassay for intraoperative monitoring of intact parathyroid hormone (iPTH). PATIENTS AND METHODS: 121 patients with pHPT were operated and retrospectively evaluated between November 1998 and September 2004. Apart from blood parameters, clinical symptoms were examined. As preoperative localisation techniques the ultrasound, the Tc-SestaMIBI scintigraphy, the CT scan and the MRI were used. The monitoring of the iPTH was performed with a special PTH-assay. The histological slices were estimated by a skilful pathologist. RESULTS: All patients showed an increased PTH level (> 65 ng / l). Nearly 50 % of the patients suffer from more than one symptom. Gastrointestinal- and neuromuscular symptoms were the most frequent symptoms. The best preoperative diagnostic procedure for localisation of the adenoma of the parathyroid gland, in non preoperated patients, seemed to be the combination of ultrasound and scintigraphy. The most common localisation of the adenoma was caudal, on the left side. Intraoperatively, we recognized in 28 from 34 patients an iPTH decrease of more than 50 % of the base value so that the operation could be finished as minimal invasive unilateral cervical exploration. CONCLUSION: Patients suffering from pHPT should be treated in a centre with all diagnostic possibilities and surgical experience. Today, the combination of iPTH-monitoring and minimal invasive unilateral cervical exploration should be considered as standard in the surgery of the adrenal gland. Due to our data we recommend an exploration of the left caudal parathyroid gland first if the localisation of the adenoma could not be clarified preoperatively.     

Intraoperatives Monitoring des intakten Parathormons (iPTH) in der Chirurgie des primären Hyperparathyreoidismus mit einem neuen Schnelltest

OBJECTIVES: Intraoperative differentiation between adenoma and hyperplasia during surgery for primary hyperparathyroidism (pHPT) is sometimes difficult, but essential for good results. The aim of our study was to evaluate a new highly sensitive electrochemiluminescence immunoassay (ECLIA) for intraoperative monitoring of intact parathyroid hormone (iPTH) following parathyroidectomy as an adjunct for identification of solitary adenoma in patients with pHPT. METHODS: Thirty consecutive patients with pHPT (2 with recurrent pHPT) were examined following a standardized protocol: Immediately before and 5, 10 and 15 min following parathyroidectomy of the enlarged gland, iPTH was measured with a new ECLIA (Roche-Diagnostics, Mannheim, Germany). The results were available within 15-20 min. Besides 20 conventional bilateral neck explorations, parathyroidectomy was carried out in a minimally invasive video-assisted technique (MI-VAP) in 10 patients. RESULTS: Among the 30 patients we found 24 with solitary adenoma (80%), 5 with hyperplasia (17%) and one with a double adenoma (3%). Five minutes after removal of a solitary adenoma the level of iPTH had decreased by 65 (12)% [mean (+/- SD)], after 10 min by 76 (8)% and after 15 min by 81 (8)%. All patients with multiple gland disease could be clearly identified, as iPTH after 15 min did not fall below 50% of basal value. Only after removal of all hyperplastic glands did iPTH decrease to the normal range. Sensitivity and specificity for prediction of a solitary adenoma were 92% and 100% (decline of iPTH more than 50% from baseline value 5 min after parathyroidectomy). In one patient with recurrent pHPT intraoperative sampling from different sites in both internal jugular veins could predict the quadrant of the enlarged gland. Correlation (r) between the results of the quick and the conventional assay, which requires 24 h of incubation, was 0.955. All patients had normal or low calcium levels postoperatively. CONCLUSIONS: (1) Intraoperative monitoring of iPTH with this new quick assay allows safe identification of patients with solitary adenoma during surgery for pHPT. (2) It represents a valuable adjunct to surgical skill not only in primary operations for pHPT but especially in cases of recurrent surgery for pHPT. (3) With this test available minimally invasive techniques for parathyroidectomy may be employed in cases of preoperatively localized adenoma (ultrasound, sesta-mibi scan), avoiding bilateral neck exploration with its higher potential for complications.     

Radioguidance is not necessary during parathyroidectomy

BACKGROUND: Improvements in the accuracy of preoperative localization and the availability of the rapid parathyroid hormone assay have permitted minimally invasive parathyroidectomy in patients with primary hyperparathyoidism. HYPOTHESIS: The use of intraoperative radioguidance is beneficial during targeted parathyroid operations. DESIGN: A retrospective analysis of a prospective database of patients. SETTING: Tertiary care referral center. PATIENTS: During a 2(1/2)-year period, 130 patients underwent minimally invasive, targeted parathyroidectomy with intraoperative monitoring of the parathyroid hormone level. Of these, 60 patients underwent radioguided parathyroidectomy. Prior to surgery, a solitary parathyroid adenoma was visualized on technetium Tc 99m sestamibi scintigraphy in all patients selected for radioguided parathyroidectomy. A gamma probe was used to guide the surgical dissection. RESULTS: All patients were cured following radioguided parathyroidectomy. In 29 patients (48%), the probe provided confusing or inaccurate information; however, a unilateral neck exploration with excision of a parathyroid adenoma was successfully completed in each of these patients. Forty-three cases were completed under local anesthesia and 85% were discharged home on the same day of surgery. There was 1 temporary recurrent laryngeal nerve palsy. CONCLUSION: In the era of improved preoperative localization and intraoperative parathyroid hormone monitoring, the routine use of radioguidance is not recommended during parathyroidectomy.     

Minimally invasive endoscopic-assisted parathyroidectomy for primary hyperparathyroidism

Background: Minimally invasive surgery for primary hyperparathyroidism (pHPT) depends on both an accurate preoperative localization and the availability of intraoperative parathyroid hormone monitoring. Methods: Patients with sporadic pHPT and one unequivocally enlarged parathyroid gland on preoperative imaging underwent endoscopic-assisted parathyroidectomy. Intraoperative rapid parathyroid hormone (quick PTH) monitoring was performed, and surgical success was confirmed when there was a >50% decrease in quick PTH level 10 min after excision as compared with the baseline level at induction. The surgical outcome and the use of preoperative localization, together with the role played by quick PTH assay in enhancing the operative success, were evaluated. Results: From 1999 to 2002, 66 of 107 patients (62%) were selected for this approach. The accuracy of ^99mTc-Sestamibi scintigraphy and ultrasonography was 97% and 70%, respectively. Conversion was required in four cases due to technical problems, and four additional patients failed to show a significant decline in quick PTH levels postexcision. Two patients underwent cervical exploration without the finding of any additional pathology, and another two patients had a delayed drop in quick PTH that was confirmed 30 min postexcision. All patients had a solitary adenoma and were cured of hypercalcemia during a median follow-up of 9 months. Conclusions: Minimally invasive endoscopic-assisted parathyroidectomy can be performed expeditiously in a select group of patients based on ^99mTc-Sestamibi scintigraphy. The use of quick PTH assay can ensure surgical success, but careful interpretation of the results is mandatory.     

Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy.

BACKGROUND: Intraoperative parathyroid hormone (iPTH) testing often is used during minimally invasive parathyroidectomy for primary hyperparathyroidism (1 degrees HPT). However, several investigators report that these assays are not cost effective and do not improve outcomes significantly. METHODS: To determine the impact of iPTH testing on the outcomes of patients with 1 degrees HPT, we reviewed our experience. From January 1990 to June 2004, there were 345 consecutive patients with 1 degrees HPT and positive localization studies for a single parathyroid adenoma who were candidates for minimally invasive parathyroidectomy. Group 1 patients (n = 157) underwent parathyroid exploration without iPTH testing and group 2 patients (n = 188) had an operation with iPTH testing. RESULTS: Of the group 1 patients, 15 (10%) still were hypercalcemic postoperatively owing to additional unidentified hyperfunctioning parathyroid glands. In contrast, among 188 group 2 patients, 170 (90%) had resection of a single parathyroid adenoma, a greater than 50% decrease in iPTH levels, and were cured. The remaining 18 (10%) patients did not have an adequate reduction in iPTH levels and underwent bilateral neck exploration with resection of additional parathyroids. Of these 18 patients, 9 had double adenomas and 9 had 3- or 4-gland hyperplasia. Importantly, all patients in group 2 were cured. CONCLUSIONS: iPTH testing improves cure rates in patients undergoing minimally invasive parathyroidectomy. iPTH testing allowed intraoperative recognition and resection of additional hyperfunctioning parathyroids missed by preoperative imaging studies. Consequently, we strongly advocate the routine use of iPTH testing in patients who undergo minimally invasive parathyroidectomy for 1 degrees HPT.     

Targeted Parathyroidectomy in the Era of Intraoperative Parathormone Monitoring

A combination of preoperative localization and intraoperative parathormone (PTH) monitoring permits targeted parathyroidectomy. Multiple approaches have been developed, ranging from unilateral neck exploration (UE) to radio-guided parathyroidectomy (RP) to endoscopic parathyroidectomy (EP). The purpose of this study was to evaluate the efficacy of these approaches in the management of primary hyperparathyroidism. From June 1998 to November 2000 a total of 110 targeted parathyroid operations were performed at a university medical center. All patients underwent technetium-99m-sestamibi scanning, ultrasonography, or both prior to surgery. Intraoperative PTH monitoring was utilized in all cases. Thirty-seven patients underwent UE, 59 underwent RP, and 14 underwent EP. Follow-up ranged from 1 to 24 months. All patients were cured following parathyroidectomy as predicted by a more than 50% reduction of the intraoperative PTH level following removal of all hypersecreting glands. Altogether, 103 patients had a solitary adenoma (95%), and 1 patient had a parathyroid carcinoma. Six patients (5%) had multigland disease, including four cases of hyperplasia and two patients with a double adenoma. Eighty-three patients (75%) were discharged the day of surgery. The use of preoperative localization and intraoperative PTH monitoring permits a targeted approach to the treatment of primary hyperparathyroidism. Endocrine surgeons should be facile in all minimally invasive parathyroid techniques to individualize the operative approach.     

Minimally invasive video-assisted parathyroidectomy – selective approach to localized single gland adenoma

Background: The valid operative standard for primary hyperparathyroidism (pHPT) consists of cervicotomy and presentation of all parathyroid glands. This operative technique features the macroscopic identification of the responsible adenoma. It also has the advantage of detecting multiglandular disease. The increasing sensitivity of preoperative localization methods and the possibility of intra-operative measurement of parathyroid hormone prepared the way for minimally invasive procedures. Methods: All patients with pHPT were examined by cervical sonography and sestamibi scintigraphy of the parathyroid glands. Patients eligible for the described procedure had to comply to the following inclusion criteria: biochemical evidence of pHPT, localization of one unequivocally enlarged parathyroid gland on two corresponding imaging results; no former surgery or radiation to the neck; no multinodular goiter; no suspected carcinoma of the thyroid; and no secondary or recurrent hyperparathyroidism. We used an operative technique first described by Miccoli in 1997. Before preparation and at 2, 10 and 15 min after exstirpation of the parathyroid adenoma, peripheral blood was drawn. The operation was terminated when a 50% decrease of preoperative PTH levels was reached. Results: During a 12-month period (1 December 1997 to 30 November 1998), 13 patients with pHPT of a total of 59 patients (22%) with hyperparathyroidism (pHPT and sHPT) were operated on employing this minimally invasive procedure. In three patients, the operative technique had to be converted to the conventional procedure due to superior adenomas in two cases and a dorsoesophageal adenoma in one case. The procedure could thus be successfully completed in ten patients. The overall failure rate was zero in all patients with regard to the underlying disease. There was one temporary, recurrent laryngeal-nerve palsy. The mean overall length of the hospital stay was 3 days. Conclusion: The minimally invasive video-assisted parathyroidectomy for localized single-gland adenoma is a new and attractive surgical therapy option for primary hyperparathyroidism due to improved patient comfort, shortened length of hospital stay and favorable cosmetic results. This may lead to one-day surgery and, therefore, to a reduction of overall costs. Received: 8 December 1998 Accepted: 3 June 1999     

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.     

Minimally Invasive Video-assisted Parathyroidectomy: Multiinstitutional Study

Unilateral and minimally invasive parathyroidectomies with endoscopic and video-assisted technique have been introduced. Most of these procedures utilize preoperative localization and intraoperative monitoring of parathyroid hormone. There are only a few reports on these procedures. The objective of this study was to evaluate video-assisted parathyroidectomy (MIVAP) for surgery in patients with primary hyperparathyroidism (pHPT). From February 1997 to June 1999 a series of 123 consecutive patients with pHPT at four surgical centers were evaluated. The patients' ages ranged from 18 to 77 years (median 50 years). Preoperatively, sestamibi scintigraphy and ultrasonography for localization were performed for all patients. Selection criteria for a MIVAP procedure excluded patients with negative localization, suspicion of multiglandular disease (MGD) or thyroid malignancy, a large thyroid mass, and prior surgery or irradiation to the neck. MIVAP was performed with a 1.5 cm suprasternal incision; the operation was then done through this incision with a 30 degree 5 mm endoscope and microsurgical instruments with brief CO₂ insufflation for adenoma identification. We then proceeded with an open technique through the small incision under video-assistance. Intraoperative monitoring of intact parathyroid hormone (iPTH) assays was used in all patients. Among the 123 patients in whom MIVAP was attempted, the procedure was accomplished in 109 (89%). Conversion to conventional cervicotomy was required in 14 (11%) patients because of failed localization, failure of the iPTH level to fall appropriately, or technical problems. There was no persistent or recurrent HPT during the 3 to 12-month follow-up. Oral calcium replacement for symptomatic hypocalcemia postoperatively was given in 7 (6%) cases. A unilateral transient laryngeal nerve palsy, resolving within 6 months postoperatively, occurred in two (2%) patients. The median hospital stay was 1.5 days (range 0.5–5.0 days). This study showed the feasibility of MIVAP as an alternative surgical treatment for pHPT in a selected group of patients. Further studies are necessary to evaluate the efficacy and rationale of MIVAP compared to other techniques for parathyroidectomy in pHPT patients.     

Procedimiento radioguiado en la cirugía mínimamente invasiva del hiperparatiroidismo primario

Minimally invasive parathyroidectomy, of choice in most cases of primary hyperparathyroidism, shows a high detection rate, based on precise preoperative localization by MIBI scintigraphy (SPECT/CT) and neck ultrasound. Radio-guided minimally invasive parathyroidectomy is an even more effective technique, which shortens surgical times, maintains minimal incision and few complications, allows immediate verification of parathyroid adenoma removal and is especially interesting in patients with ectopic lesions or cervical surgical history. In this paper, the indications, protocols and differences between the two available radio-guided parathyroid surgery procedures (MIBI and ROLL) are exposed.     

Effectiveness of parathyroid-hormone measurement in detecting patients with multiple gland disease causing primary hyperparathyroidism

Background and aim Intraoperative parathyroid hormone measurement (iPTH) has strengthened the successful use of minimal-invasive approaches in surgery of primary hyperparathyroidism (pHPT). The aim of the study was to evaluate the efficacy of iPTH monitoring in treating pHPT resulting from multiple gland disease. Materials and methods In this retrospective study, 58 patients with pHPT underwent surgery (minimally invasive or open exploration) between January 2003 and July 2005. iPTH levels were routinely measured at the start of anesthesia, in any case before skin incision, and 10 as well as 15 min after removal of abnormal gland(s). A drop in iPTH >50% after 10 min and >60% after 15 min was considered adequate to prove the success of the removal of the abnormal gland(s). The removed tissue was examined histologically by immediate frozen section. Results A single gland disease was found in 51(88%) cases, a multiple gland disease (double adenoma or hyperplasia) in 7(12%) cases. In all cases of single adenoma, an adequate drop of iPTH was seen after removal of the pathologic gland. In contrast, in all cases with a second adenoma, an adequate drop in iPTH was detected only after removal of both adenoma/hyperplasia. Immediate sectioning was only helpful for identification of removed tissue, but was no help in deciding whether to search for an additional gland. The follow-up showed no late disease recurrence. Conclusion The measurement of iPTH is an effective and safe means in treating single gland disease as well as multiple gland disease (adenoma/hyperplasia) causing pHPT and also allows a successful limited dissection via minimally invasive parathyroidectomy.     

Intraoperative Parathyroid Hormone Monitoring

The principles of minimally invasive parathyroidectomy include the successful preoperative localization of a solitary adenoma, a targeted operative approach that does not disturb the normal parathyroid glands, and intraoperative confirmation of excision of all hypersecreting parathyroid tissue. By providing real-time feedback to the surgical team, the rapid PTH assay allows surgeons to assess the completeness of parathyroid resection without visualizing all the parathyroid glands. Intraoperative PTH monitoring facilitates the use of local anesthesia, decreases the duration of surgery, and allows ambulatory surgery in most patients. This article reviews current recommendations and controversies surrounding the use of intraoperative PTH monitoring during parathyroidectomy.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.     

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.     

Surgery for sporadic primary hyperparathyroidism: controversies and evidence-based approach

Introduction Sporadic primary hyperparathyroidism is due to single adenoma in over 90–95% of instances. Careful medical history and precise preoperative identification of the enlarged gland by parathyroid Tc-mibi scintigraphy and neck ultrasound allow selecting patients for minimally invasive parathyroidectomy, a focused intervention with minimal skin opening and tissue dissection. Small (<300 mg) adenomas continue to challenge preoperative imaging, and most of them will still require a bilateral exploration. Conclusion Surgery should never be indicated on the basis of positive or negative preoperative localization studies. Intraoperative quick parathyroid hormone measurements seem particularly helpful for cases with equivocal localization studies. The best minimal access approach is still a matter of debate, and options include small central incision, video-assisted parathyroidectomy, minimal lateral open approach, and purely endoscopic access via lateral approach. Radioguided surgery does not seem to have a role in routine cases but may be useful to find adenomas during reintervention on scarred difficult surgical fields.     

Limitations of technetium 99m sestamibi scintigraphic localization for primary hyperparathyroidism associated with multiglandular disease

Successful surgical treatment of primary hyperparathyroidism requires the localization and excision of the parathyroid tissue responsible for excessive parathyroid hormone secretion while ensuring that the patient will have sufficient endogenous parathyroid hormone production to maintain eucalcemia. In selecting patients with primary hyperparathyroidism for unilateral parathyroidectomy the surgeon should be able to diagnose multiglandular disease either preoperatively or intraoperatively. We performed a retrospective review of 123 patients who underwent surgical treatment for primary hyperparathyroidism to determine the potential feasibility of selecting patients for minimally invasive surgery based on preoperative imaging studies. All patients were studied preoperatively with 99m technetium-sestamibi scintigraphy. High-resolution ultrasonography was performed in 119 of these patients. All patients except one underwent bilateral cervical exploration. A patient with an intrathoracic adenoma was successfully diagnosed by scintigraphy thereby allowing treatment by a limited thoracotomy. One hundred eight patients had solitary adenomas and 15 had multiglandular disease. In none of the patients with bilateral multiglandular disease were all abnormal glands localized preoperatively. Patients in our study with primary hyperparathyroidism and multiglandular disease were underdiagnosed by preoperative imaging. A minimally invasive approach based solely on preoperative imaging studies may result in treatment failure in patients with multiglandular involvement.     

Three-dimensional ultrasonography before minimally invasive focused parathyroidectomy: The importance of coronal images

Purpose  To evaluate the usefulness of three-dimensional (3D) ultrasonography (US) as a noninvasive preoperative localization procedure before performing minimally invasive focused parathyroidectomy in patients with primary hyperparathyroidism (pHPT). Methods  Seventy-six patients with a solitary adenoma detected by US underwent minimally invasive focused parathyroidectomy. The value of 3D US was assessed by dividing patients into a 2D group and a 3D group. Age, the preoperative serum intact parathyroid hormone (PTH) level, operative time, length of skin incision, and weight of the resected specimen were compared between the groups, and multivariate analysis of the operative time was performed. Results  There were no significant differences between the 2D group and the 3D group in age, the preoperative intact PTH level, length of skin incision, or weight of the resected specimen, but the mean operative time was significantly longer in the 2D group (P < 0.01). Multivariate analysis revealed that 3D US and the weight of the resected specimen were correlated with the operative time (P < 0.05). Conclusion  The coronal images obtained by 3D US assist in the precise localization of parathyroid masses in patients with pHPT undergoing minimally invasive focused parathyroidectomy for a solitary adenoma.     

Minimally invasive parathyroidectomy with operative ultrasound localization of the adenoma

Background Minimally invasive parathyroidectomy is the procedure of choice for primary hyperparathyroidism due to parathyroid adenoma. Adequate perioperative adenoma localization is essential for this operation. We describe a technique using ultrasound to perform minimally invasive parathyroidectomy.Methods ^99mTc sestamibi scanning was performed on patients with primary hyperparathyroidism to localize parathyroid adenomas; no intraoperative gamma probe was used. We also performed pre- and intraoperative ultrasound scanning to localize these adenomas.Results All patients underwent successful localization and removal of their parathyroid adenomas. At follow-up, all patients were well, with calcium within normal limits.Conclusion The use of intraoperative ultrasound facilitates minimally invasive parathyroidectomy and may obviate the need for intraoperative ^99mTc sestamibi scanning.     

Focused Cervical Exploration for Primary Hyperparathyroidism without Intraoperative Parathyroid Hormone Monitoring or Use of the Gamma Probe

Selected patients with primary hyperparathyroidism (pHPT) who have a positive preoperative sestamibi scan can be managed safely and successfully with a focused cervical exploration without either adjuvant intraoperative parathyroid hormone (PTH) monitoring or use of a gamma probe. This article reports a retrospective analysis of a consecutive series of patients surgically treated at a tertiary referral center. From August 1998 to August 2002, 100 patients (68 women, 32 men; mean age 63 years [range: 29–89 years]) underwent a focused cervical approach without intraoperative PTH monitoring or use of the gamma probe after perioperative sestamibi injection. The study group comprised 9% of all patients (n = 1063) undergoing cervical exploration for pHPT during the study period. Ninety patients underwent an initial exploration, and 10 others underwent repeat cervical exploration following prior parathyroid (n = 7) or thyroid (n = 3) operation. Sestamibi scanning correlated with one enlarged parathyroid gland in all patients. Other enlarged glands were, however, not demonstrated in three patients (true positive = 97%; false negative = 3%). The single enlarged glands excised in all patients had a mean weight of 795 mg (range: 90–3640) and were histologically compatible with an adenoma. Postoperatively, 97% of patients were eucalcemic. Three patients remained hypercalcemic (3%). Of the three patients with persistent hypercalcemia, one underwent successful re-exploration with excision of a 500 mg second adenoma, whereas the other two patients (with confirmed familial HPT) remained hypercalcemic. Mean hospitalization was 0.5 days (range: 0–3 days). There was no operative mortality. No patients had permanent hypocalcemia. Postoperative morbidity occurred in three patients: two self-limiting cervical hematomas and one permanent vocal cord paralysis. Selected patients with pHPT due to single-gland disease and an unequivocally positive preoperative sestamibi scan can safely and successfully be managed with a focused unilateral cervical exploration without either intraoperative PTH monitoring or use of the gamma probe. Further experience with this surgical approach seems warranted to determine the overall cure rate, operative morbidity, and the sensitivity and specificity of preoperative localization studies.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14-17, 2004.     

Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial

OBJECTIVE: To compare long-term patient outcome in a prospective randomized controlled trial between unilateral and bilateral neck exploration for primary hyperparathyroidism (pHPT). SUMMARY BACKGROUND DATA: Minimal invasive and/or focused parathyroidectomy has challenged the traditional bilateral neck exploration for pHPT. Between 1997 and 2001, we conducted the first unselected randomized controlled trial of unilateral versus bilateral neck exploration for pHPT. The results showed that unilateral exploration is a surgical strategy with distinct advantages in the early postoperative period. However, concerns have been raised that limited parathyroid exploration could increase the risk for recurrent pHPT during long-term follow-up. METHODS: Ninety-one patients with the diagnosis of pHPT were randomized to unilateral or bilateral neck exploration. Preoperative scintigraphy and intraoperative parathyroid hormone measurement guided the unilateral exploration. Gross morphology and frozen section determined the extent of parathyroid tissue resection in the bilateral group. Follow-up was performed after 6 weeks, 1 year, and 5 years postoperatively. RESULTS: Seventy-one patients were available for 5-year follow-up. There were no differences in serum ionized calcium and parathyroid hormone, respectively, between patients in the unilateral and bilateral group. Overall 6 patients have been found to have persistent (n = 3) or recurrent (n = 3) pHPT; 4 patients in the unilateral group (3 of these 4 patients were bilaterally explored) and 2 patients in the bilateral group. Three of 6 failures were unexpectedly found to have multiple endocrine neoplasia mutations. One patient with solitary adenoma in the bilateral group still required vitamin D substitution 5 years after surgery. CONCLUSION: Unilateral neck exploration with intraoperative parathyroid hormone assessment provides the same long-term results as bilateral neck exploration, and is thus a valid strategy for the surgical treatment of pHPT.