Is Focused Minimally Invasive Parathyroidectomy Appropriate for Patients With Familial Primary Hyperparathyroidism?

Background  

The aim of this study was to determine whether a focused minimally invasive parathyroidectomy (MIP) for patients with primary hyperparathyroidism and concordant pre-operative localization studies is appropriate for patients with a family history of the disease. Familial hyperparathyroidism may be seen as a chronic disease in which recurrence is inevitable. Patients frequently undergo subtotal or total parathyroidectomy for perceived 4-gland parathyroid hyperplasia in an attempt to reduce this risk. Controversy remains regarding whether a MIP is appropriate in this setting.     

The Negative Sestamibi Scan: Is a Minimally Invasive Parathyroidectomy Still Possible?

Background Tc-99-sestamibi scanning is utilized to determine whether patients with primary hyperparathyroidism (HPT) are candidates for minimally invasive parathyroidectomy (MIP). However, if the result of this scan is negative, many surgeons recommend bilateral parathyroid exploration because of possible multi-gland disease. The objectives of this study were to determine whether patients with primary HPT and negative sestamibi scans can benefit from additional imaging studies and are still potential candidates for MIP. Methods Between March 2001 and April 2006, 578 consecutive patients with HPT underwent parathyroidectomy by a single surgeon. Pre-operative sestamibi scans had been done in 458 (79%) of these patients, 90 (20%) of which had negative results. These patients formed our study cohort. Results Of the 90 patients, 60 (67%) had a single adenoma, 17 (19%) double adenomas and 13 (14%) 3- to 4-gland hyperplasias. In 74 (82%) patients, localization was further investigated with one or more studies including thallium subtraction scans (n = 30), ultrasound (n = 15) and intra-operative internal jugular venous sampling (n = 49). Additionally, the use of radio-guided techniques intra-operatively facilitated minimally invasive techniques. Of these 90 patients, 47 had positive results from preoperative studies, including 12 positive thallium, 5 positive ultrasound and 13 positive internal jugular sampling results. In addition, positive results were observed for 17 patients using radio-probe techniques in the operating room. Accordingly, minimally invasive techniques were attempted in these 47 patients; 42 (89%) had single adenomas and in 5 the technique was converted to bilateral exploration for double adenoma/hyperplasia. In the setting of a negative sestamibi, the sensitivities of thallium scans and ultrasound were 30% and 27%, respectively. The overall cure rate in the 90 patients with negative sestamibi scans was 99%. Conclusion In patients with primary HPT and a negative sestamibi scan, most patients (67%) will have a single adenoma. These patients benefitted from additional localization tests, which yielded a positive result in 52% of patients. Therefore, even in the setting of a negative sestamibi scan, the majority of patients with primary HPT are still candidates for MIP.     

Cost-effective Minimally Invasive Surgery: What Procedures Make Sense?

Because laparoscopic surgery has emerged during a time of medical cost-consciousness, emphasis has been placed on the economic implications of this emerging field. The cost of these procedures, however, is just one component in determining their overall value to most of the stakeholders in the health care system. The value of a treatment is proportional to its appropriateness and quality per unit cost. Several confounding factors affect the variables in this equation and contribute to the difficulty in this type of assessment of an emerging technology. By understanding the mechanics of value assessment and certain caveats for specific procedures, the surgeon will be better able to determine what procedures makes sense (or are of value) in their practice and for their patients.     

Minimally Invasive Parathyroidectomy Using the Lateral Focused Miniincision Approach: Is There a Learning Curve for Surgeons Experienced in the Open Procedure?

BACKGROUND: Minimally invasive parathyroidectomy (MIP) has gained acceptance as the standard of care for management of primary hyperparathyroidism in which a single adenoma can be localized. The aim of this study was to determine if there is a learning curve for MIP using the lateral focused miniincision approach performed by surgeons experienced in open parathyroidectomy. STUDY DESIGN: This is a retrospective case series comprising all parathyroid operations undertaken by three surgeons in the University of Sydney Endocrine Surgical Unit from 2003 to 2005. Outcomes of the experienced surgeon were compared with those of the two surgeons commencing practice. RESULTS: There were 699 parathyroidectomies performed in the Unit during the 36-month period (experienced surgeons: 438 versus commencing physicians: 261). Of the parathyroidectomies performed, 57% done by experienced surgeons were minimally invasive compared with 38% of those performed by surgeons commencing practice (p < 0.001). There were no differences in the number of complications (p = 0.21), conversions to open exploration (p = 0.6), and cure rates (p = 0.9) in the MIP patients in both groups. The initial (first 131 patients) and subsequent (next 130 patients) parathyroidectomy experiences of surgeons commencing practice were examined. In the initial experiences, 28% of the cases were minimally invasive compared with 48% in the subsequent experiences (p < 0.001). There were no differences in the number of complications (p = 0.3), conversions to open exploration (p = 0.9), and cure rates (p = 0.9). CONCLUSIONS: For surgeons experienced in open parathyroidectomy, there is no technical learning curve using the lateral focused miniincision technique for MIP. There is, however, a learning curve for patient selection.     

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.     

Local Anesthesia: A Strategy for Reducing Surgical Site Infections?

Background  

Surgical site infections (SSIs) contribute to increased morbidity, mortality, and hospitalization costs. A previously unidentified factor that may reduce SSIs is the use of local anesthesia. The objective of this study was to determine if the use of local anesthesia is independently associated with a lower incidence of SSIs compared to nonlocal anesthesia.     

What are the limits for the Ross operation?

The Ross operation is physiologically the best approach for aortic valve replacement. At the Hospital de Santa Cruz 22 consecutive pulmonary autograft operations have been performed in patients with a mean age of 49 (range 17–65) years. Six patients had mitral valve disease, two had aortic aneurysms and one had a ventricular septal defect. Subcoronary implantation of the autograft was performed in 20 patients. A partial inclusion aortic root replacement technique was used in one and the aortic root was replaced in another. There were no hospital or late deaths. Two patients required autograft replacement at 3 and 9 months postoperatively because of regurgitation. One of these cases was caused by an abnormality of the pulmonary valve and since then echocardiographic assessments of this valve have been performed routinely and have detected significant pulmonary incompetence in four patients who otherwise would have been operated on using the Ross procedure. Copyright 2 1996 The International Society for Cardiovascular Surgery.     

Update on the Minimally Invasive Approach in Paediatric Urology: Remote Help for Human Hands?

The innovations of minimally-invasive surgery have successfully been applied to pediatric surgery. Some special caveats apply to children, however. Confinements of space and the small intravsacular blood volume pose special risks in small infants. Unlike in adults, placement of the first troikar should always be under direct vision. There is no consensus whether minimally-invasive approaches should be used in children under one year of age.Single-port approaches have also been used in children and for renal surgery both the transabdominal and the retroperitoneosocopic approach are feasible. Pneumovesicoscopy has successfully been used for ureteral reimplantation and robotic-assisted surgery for children has also been established. The cost-effectiveness of many techniques remains an unsolved problem.