Minimally Invasive Video-Assisted Parathyroidectomy Versus Open Minimally Invasive Parathyroidectomy for a Solitary Parathyroid Adenoma: A Prospective, Randomized, Blinded Trial

Background A variety of minimally invasive parathyroidectomy (MIP) techniques have been currently introduced to surgical management of primary hyperparathyroidism (pHPT) caused by a solitary parathyroid adenoma. This study aimed at comparing the video-assisted MIP (MIVAP) and open MIP (OMIP) in a prospective, randomized, blinded trial. Materials and Methods Among 84 consecutive pHPT patients referred for surgery, 60 individuals with concordant localization of parathyroid adenoma on ultrasound and subtraction Tc^99m-MIBI scintigraphy were found eligible for MIP under general anesthesia and were randomized to two groups (n = 30 each): MIVAP and OMIP. An intraoperative intact parathyroid hormone (iPTH) assay was routinely used in both groups to determine the cure. Primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. Secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within 7 postoperative days (SF-36), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. Results All patients were cured. In 2 patients, an intraoperative iPTH assay revealed a need for further exploration: in one MIVAP patient, subtotal parathyroidectomy for parathyroid hyperplasia was performed with the video-assisted approach, and in an OMIP patient, the approach was converted to unilateral neck exploration with the final diagnosis of double adenoma. MIVAP versus OMIP patients were characterized by similar operative time (44.2 ± 18.9 vs. 49.7 ± 15.9 minutes; P = 0.22), transient hypocalcemia rate (3 vs. 3 individuals; P = 1.0), lower pain intensity at 4, 8, 12, and 24 hours after surgery (24.9 ± 6.1 vs. 32.2 ± 4.6; 26.4 ± 4.5 vs. 32.0 ± 4.0; 19.6 ± 4.9 vs. 25.4 ± 3.8; 15.5 ± 5.5 vs. 20.4 ± 4.7 points, respectively; P < 0.001), lower analgesia request rate (63.3% vs. 90%; P = 0.01), lower analgesic consumption (51.6 ± 46.4 mg vs. 121.6 ± 50.3 mg of ketoprofen; P < 0.001), better physical functioning aspect and bodily pain aspect of the quality of life on early recovery (88.4 ± 6.9 vs. 84.6 ± 4.7 and 90.3 ± 4.7 vs. 87.5 ± 5.8; P = 0.02 and P = 0.003, respectively), shorter scar length (17.2 ± 2.2 mm vs. 30.8 ± 4.0 mm; P < 0.001), and higher cosmetic satisfaction rate at 1 month after surgery (85.4 ± 12.4% vs. 77.4 ± 9.7%; P = 0.006). Cosmetic satisfaction was increasing with time, and there were no significant differences at 6 months postoperatively. MIVAP was more expensive (US$1,150 ± 63.4 vs. 1,015 ± 61.8; P < 0.001) while the mean hospital stay was similar (28 ± 10.1 vs. 31.1 ± 9.7 hours; P = 0.22). Differences in serum calcium values and iPTH during 6 months of follow-up were nonsignificant. Transient laryngeal nerve palsy appeared in one OMIP patient (P = 0.31). There was no other morbidity or mortality. Conclusions Both MIVAP and OMIP offer a valuable approach for solitary parathyroid adenoma with a similar excellent success rate and a minimal morbidity rate. Routine use of the intraoperative iPTH assay is essential in both approaches to avoid surgical failures of overlooked multiglandular disease. The advantages of MIVAP include easier recognition of recurrent laryngeal nerve (RLN), lower pain intensity within 24 hours following surgery, lower analgesia request rate, lower analgesic consumption, shorter scar length, better physical functioning and bodily pain aspects of the quality of life on early recovery, and higher early cosmetic satisfaction rate. However, these advantages are achieved at higher costs because of endoscopic tool involvement. The paper was presented at the 41st World Congress of Surgery, 21– 25 August 2005, Durban, South Africa.     

Lithium-Associated Hyperparathyroidism: Surgical Strategies in the Era of Minimally Invasive Parathyroidectomy

Background  

Lithium remains an effective treatment of bipolar affective disorder. The long-term use of lithium is associated with an alteration in parathyroid function that may culminate in hyperparathyroidism. The long-term effects of lithium use are variable due to its complex effects on calcium homeostasis and bone metabolism, and as a consequence the indications for surgery remain poorly defined. The optimal surgical strategy for lithium-associated hyperparathyroidism in the era of minimally invasive surgery is also the subject of debate. The aim of the present study was to evaluate the variable findings of lithium-associated parathyroid disease.     

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.     

Long-Term Outcome in Patients with Primary Hyperparathyroidism who Underwent Minimally Invasive Parathyroidectomy

Background  

Minimally invasive parathyroidectomy (MIP) has become a well-accepted treatment for selected patients with primary hyperparathyroidism (PHPT). However, few studies have evaluated long-term outcomes for this operative approach. We therefore chose to examine both the long-term symptom resolution and biochemical cure following MIP for PHPT.     

Operative Failure in Minimally Invasive Parathyroidectomy Utilizing an Intraoperative Parathyroid Hormone Assay

Background

Minimally invasive parathyroidectomy (MIP) is a targeted operation to cure primary hyperparathyroidism utilizing intraoperative parathyroid hormone monitoring (IOPTH). The purpose of this study was to quantify the operative failure of MIP.

Methods

Utilizing institutional parathyroid surgery database, demographic, operative, and biochemical data were analyzed for successful and failed MIP. Operative failure was defined as <6 months of eucalcemia after operation.

Results

Five hundred thirty-eight patients (96.6 %) had successful MIP with mean follow-up of 13 months, and 19 (3.4 %) had operative failure. The major cause of operative failure (11 of 19) was the result of surgeons’ inability to identify all abnormal parathyroid glands. The remaining eight operative failures were the result of falsely positive IOPTH results. Eleven of 19 patients whose MIP had failed underwent a second parathyroid surgery. All but one of these patients achieved operative success, and 9 patients had missed multigland disease. Only 46 (8.3 %) of 557 patients had conversion to bilateral cervical exploration (BCE). Eighty percent of patients had more than 70 % IOPTH decrease, and all had successful operations. Patients with a marginal IOPTH decrease (50–59 %) had a treatment failure rate of 20 %.

Conclusions

The most common cause of operative failure in MIP utilizing IOPTH was the result of surgeons’ failure to identify all abnormal parathyroid glands. Falsely positive IOPTH is rare, and a targeted MIP utilizing IOPTH can achieve an excellent operative success rate without routine BCE. Selective BCE on patients with marginal IOPTH decrease may improve surgical outcome.     

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.     

Durability of Focused Minimally Invasive Parathyroidectomy in Young Patients with Sporadic Primary Hyperparathyroidism

Background

Historically, multigland hyperplasia was believed to be the predominant cause of primary hyperparathyroidism (PHPT) in young patients, and hence a relative contraindication for minimally invasive parathyroidectomy. Recent studies, however, demonstrate that the most common aetiology across all age groups is a solitary functioning adenoma. The aim of this study was to compare long-term outcomes in young patients (≤45 years), especially those under 30 years of age, with their older counterparts (>45 years) following focused minimally invasive parathyroidectomy (FMIP).

Materials and Methods

Patients ≤45 years who underwent FMIP between January 1999 and December 2007 were identified from an endocrine surgery database and compared with a matched control group of patients >45 years old also undergoing FMIP within that time period. The patients’ most recent calcium levels (≥6 months postoperatively) were examined to establish recurrence rates. Recurrence was defined as an elevation of serum calcium more than 6 months after surgery following initial postsurgical normocalcemia.

Results

A total of 117 patients ≤45 years and 160 patients >45 years who underwent FMIP were examined. Follow-up calcium levels were available for 72% of patients. The median length of follow-up was 46 months. No recurrences were identified in both the younger and older cohort of patients; therefore, no statistically significant difference in rates of recurrence could be determined between age groups.

Conclusion

Recurrence of PHPT following FMIP is rare with no evidence of a higher incidence in younger patients. FMIP can be safely offered to young patients as a long-term durable treatment option.     

Surgical Management of Epiphrenic Diverticula in the Minimally Invasive Era

Background:

Epiphrenic diverticula are rare outpouchings of the distal esophagus that infrequently require surgical intervention for the treatment of symptoms. In cases where surgical therapy is indicated, the traditional approach is through a thoracotomy. Advances in minimally invasive techniques have led to thoracoscopic and more recently laparoscopic management of epiphrenic diverticula. The purpose of this article is to review the literature on minimally invasive surgery for epiphrenic diverticula with particular attention to the operative approach and technique, surgical mortality and morbidity, and symptomatic outcomes.

Methods:

A review of the literature limited to studies in the English language and performed on humans was conducted on PubMed using the following key words: “esophageal diverticula” and “epiphrenic”. Articles retrieved by the PubMed search were reviewed.

Conclusions:

A minimally invasive approach to epiphrenic diverticula offers reduced operative mortality, decreased length of stay, and similar symptom relief compared with open surgery in the hands of experienced laparoscopic surgeons.     

微创经皮肾取石术治疗独立肾结石

目的：探讨微创经皮肾取石术治疗孤立肾结石的临床疗效与手术技巧。方法：利用微创经皮肾取石术治疗孤立肾结石18例,14例患者行一期微创经皮肾取石．4例行经皮肾穿刺造瘘术,5～7天后行二期取石术。结果：结石清除15例（83．3％）。在结石残留的3例患者中,1例残留结石下移至输尿管下段,用输尿管镜将结行取出;余2例结石残留。肾内,未作进一步处理,本组患者术后肾功能基本恢复正常或好转。结论：微创经皮肾取石术治疗独立肾结石是一种安全、有效的方法。     

Open Versus Minimally Invasive Resection of Gastric GIST: A Multi-Institutional Analysis of Short- and Long-Term Outcomes

Background

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences.

Methods

A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection.

Results

There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05).

Conclusions

An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.     

Comparison of Consumer Information on the Internet to the Current Evidence Base for Minimally Invasive Parathyroidectomy

Background  

The Internet is increasingly used as a source of health information by patients. Under these circumstances, the opportunity exists for Internet sites ostensibly providing patient information to act to promote surgical referrals based on exaggerated claims. This study aims to assess quantitatively and qualitatively the Internet-based consumer health information for minimally invasive parathyroidectomy (MIP) techniques.     

The Incidence of Hiatal Hernia After Minimally Invasive Esophagectomy

Introduction

Minimally invasive esophagectomy (MIE) has evolved as a means to minimize the morbidity of an operation which is traditionally associated with a significant risk. However, this approach may have its own unique postoperative complications. In this study, we describe the incidence and outcomes of hiatal hernia in a cohort of MIE patients.

Methods

Clinical follow-up data on 114 patients who had undergone minimally invasive esophagectomy between 2003 and 2011 were retrospectively reviewed. Clinical presentation and computed tomography (CT) scans of the chest and abdomen were used to establish the diagnosis of hiatal herniation after minimally invasive esophagectomy. Age, gender, presenting complaint, comorbid conditions, clinical tumor stage, surgical specimen size, length and cost of hospital admissions, operation performed for hiatal herniation, and mortality were all recorded for analysis.

Results

Nine (8 %) of the 114 patients who underwent MIE had postoperative hiatal herniation. Five of these patients were asymptomatic. All patients except two who presented emergently were repaired laparoscopically on an elective basis. The average length of stay after hiatal hernia repair was 5.5 days (range 2–12) at an average charge of $40,785 (range $25,264–$83,953). At follow-up, one patient complained of symptoms associated with reflux.

Conclusion

Hiatal herniation is not a rare event after MIE. It is also associated with significant health-care cost and may be lethal. Most occurrences appear to be asymptomatic and, if detected, can be repaired with good resolution of symptoms, minimal associated morbidity, and no mortality.     

Minimally Invasive or Conventional Aorto-bifemoral By-pass. A Randomised Study

INTRODUCTION: open transperitoneal aorto-bifemoral by-pass is still associated with a relatively high morbidity and mortality. To decrease this surgical stress, minimally invasive direct aortic surgery (MIDAS) was developed, utilizing a minilaparotomy and a retroperitoneal approach to the aorta. OBJECTIVES: to compare in a randomised controlled trial whether mortality and morbidity could be reduced with MIDAS. METHODS: from October 1997 to September 2000, 300 patients were randomised to either MIDAS (n=150) or conventional aorto-bifemoral by-pass surgery (n=150). RESULTS: the perioperative (30 days) mortality (2.6%), was equal in both groups. MIDAS were significantly reduced length of hospital stay (3.1 days), and pulmonary dysfunction. CONCLUSIONS: MIDAS reduced trauma and pain, which resulted in a shorter hospital stay, and a reduction in costs.     

微创经皮肾取石术治疗孤立肾铸型结石的疗效观察

目的：探讨微创经皮肾取石术（MPCNL）治疗孤立肾铸型结石的安全性及有效性。方法：回顾性分析2007年4月-2008年12月应用MPCNL治疗34例孤立肾铸型结石患者的临床资料：34例患者结石平均表面积（2314±179）mm^2,肾积脓5例。4例先行穿刺造瘘术,5～7天后行二期经皮肾镜取石术,其余患者均行一期取石术。其中单通道取石18例,双通道取石15例,三通道取石1例。结果：3例一期取石时残余小结石,结合ESWL清除小残石,结石总清除率为91．2％（31／34）。1例出现感染性休克,1例术后大出血行介入栓塞治疗,无死亡患者。术后随访4～18个月,19例肾功能不全患者中,11例肾功能恢复正常,6例肾功能有不同程度改善,2例发展为尿毒症期行血液透析,其中1例为术后大出血行介入栓塞的患者。结论：微创多通道MPCNL治疗孤立肾铸型结石安全可行,效果确切,具有创伤小、恢复快、可反复操作等优点,可作为孤立肾铸型结石的首选治疗方法。     

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.