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Sitges-Serra A. Some thoughts on surgery for primary hyperparathyroidism. Am J Surg 2024; 234:179-180. [PMID: 38365558 DOI: 10.1016/j.amjsurg.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
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Bellamkonda N, Highland J, McCrary HC, Slattery L, King B, Teames C, LeBaron K, Wiggins RH, Abraham D, Hunt JP. Four-Dimensional Computed Tomography for Parathyroid Adenoma Localization: A Pre-Operative Imaging Protocol. Ann Otol Rhinol Laryngol 2024; 133:441-448. [PMID: 38321924 DOI: 10.1177/00034894241230353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE Primary hyperparathyroidism (PHPT) affects approximately 0.86% of the population, with surgical resection as the treatment of choice. A 4D computed tomography (CT) is a highly effective tool in localizing parathyroid adenomas; however, there is currently no defined role for 4D CT when stratified against ultrasonography (USG) and nuclear medicine Technetium Sestamibi SPECT/CT (SES) imaging. STUDY DESIGN Retrospective Study. SETTING University Hospital. METHODS All patients who underwent parathyroidectomy for PHPT between 2014 and 2019 at a single institution were reviewed. Patients who had a 4D CT were included. We compared outcomes of 4D CT as a second line imaging modality to those of USG and SES as first line modalities. An imaging algorithm was proposed based on these findings. RESULTS There were 84 patients identified who had a 4D CT after unsuccessful first line imaging. A 4D CT localized parathyroid adenoma to the correct quadrant in 64% of cases, and to the correct laterality in 75% of cases. Obese patients had significantly lower rates of adenoma localization with USG (33.4%), compared to non-obese patients (67.5%; P = .006). In determining multigland disease the sensitivity of 4D CT was 86%, while the specificity was 87%. CONCLUSIONS A 4D CT has impressive rates of accurate localization of parathyroid adenomas; however due to the radiation exposure involved, it should remain a second line imaging modality. PHPT patients should first be evaluated with USG, with 4D CT used if this is unsuccessful and patients are greater than 40 years old, have a high BMI, or are having revision surgery.
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Affiliation(s)
- Nikhil Bellamkonda
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Julie Highland
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Hilary C McCrary
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lauren Slattery
- Department of Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Brody King
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Charles Teames
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kaylee LeBaron
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Richard H Wiggins
- Department of Radiology, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Dev Abraham
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jason P Hunt
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Utah, Salt Lake City, UT, USA
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McClean A, England RJA. Revision parathyroid surgery - challenges and considerations in comparison to primary surgery. J Laryngol Otol 2023; 137:1233-1236. [PMID: 36938821 DOI: 10.1017/s002221512300049x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Revision parathyroidectomy is made necessary by recurrent or persistent parathyroid disease. This study aimed to identify challenges in revision surgery compared to primary parathyroid surgery. METHODS All revision parathyroidectomies performed by one surgeon over a 17-year period were assessed for demographics, imaging, histology, biochemistry, cure rate, gland weight, gland location and gland ectopia, and compared to a series of 100 primary parathyroidectomies. RESULTS Twenty-eight revision surgical procedures were identified. Sestamibi scanning for gland localisation was superior to ultrasound in both primary and revision surgery. Pre-operative calcium and gland weight were significantly higher in revision cases. There were no significant differences in post-operative calcium levels, pre- or post-operative parathyroid hormone levels, or gland location. 36 per cent of glands excised in revision surgery were ectopic, compared to 25 per cent in primary procedures. The cure rate was significantly lower in revision surgery. CONCLUSION Revision parathyroidectomy patients present with higher pre-operative calcium and larger adenomas; the cure rate is significantly lower in these patients.
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Affiliation(s)
- A McClean
- Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - R J A England
- ENT, Hull University Teaching Hospitals NHS Trust, Hull, UK
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The difficult parathyroid: advice to find elusive gland(s) and avoid or navigate reoperation. Curr Probl Surg 2023; 60:101262. [PMID: 36894218 DOI: 10.1016/j.cpsurg.2022.101262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Perrier N, Lang BH, Farias LCB, Poch LL, Sywak M, Almquist M, Vriens MR, Yeh MW, Shariq O, Duh QY, Yeh R, Vu T, LiVolsi V, Sitges-Serra A. Surgical Aspects of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2373-2390. [PMID: 36054175 DOI: 10.1002/jbmr.4689] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022]
Abstract
Parathyroidectomy (PTX) is the treatment of choice for symptomatic primary hyperparathyroidism (PHPT). It is also the treatment of choice in asymptomatic PHPT with evidence for target organ involvement. This review updates surgical aspects of PHPT and proposes the following definitions based on international expert consensus: selective PTX (and reasons for conversion to an extended procedure), bilateral neck exploration for non-localized or multigland disease, subtotal PTX, total PTX with immediate or delayed autotransplantation, and transcervical thymectomy and extended en bloc PTX for parathyroid carcinoma. The systematic literature reviews discussed covered (i) the use of intraoperative PTH (ioPTH) for localized single-gland disease and (ii) the management of low BMD after PTX. Updates based on prospective observational studies are presented concerning PTX for multigland disease and hereditary PHPT syndromes, histopathology, intraoperative adjuncts, localization techniques, perioperative management, "reoperative" surgery and volume/outcome data. Postoperative complications are few and uncommon (<3%) in centers performing over 40 PTXs per year. This review is the first global consensus about surgery in PHPT and reflects the current practice in leading endocrine surgery units worldwide. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Nancy Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Brian H Lang
- Department of Surgery, Queen Mary Hospital, Pokfulam, Hong Kong
| | | | - Leyre Lorente Poch
- Endocrine Surgery Unit, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mark Sywak
- Endocrine Surgery Unit, University of Sydney, Sydney, Australia
| | - Martin Almquist
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Menno R Vriens
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center, Utrecht, The Netherlands
| | - Michael W Yeh
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Omair Shariq
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, UK
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Randy Yeh
- Memorial Sloan Kettering Cancer Center, Molecular Imaging and Therapy Service, New York, NY, USA
| | - Thinh Vu
- Neuroradiology Department, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Virginia LiVolsi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Sandqvist P, Sundin A, Nilsson IL, Grybäck P, Sanchez-Crespo A. Primary hyperparathyroidism, a machine learning approach to identify multiglandular disease in patients with a single adenoma found at preoperative Sestamibi-SPECT/CT. Eur J Endocrinol 2022; 187:257-263. [PMID: 35666799 DOI: 10.1530/eje-22-0206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/06/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Successful preoperative image localisation of all parathyroid adenomas (PTA) in patients with primary hyperparathyroidism (pHPT) and multiglandular disease (MGD) remains challenging. We investigate whether a machine learning classifier (MLC) could predict the presence of overlooked PTA at preoperative localisation with 99mTc-Sestamibi-SPECT/CT in MGD patients. DESIGN This study is a retrospective study from a single tertiary referral hospital initially including 349 patients with biochemically confirmed pHPT and cured after surgical parathyroidectomy. METHODS A classification ensemble of decision trees with Bayesian hyperparameter optimisation and five-fold cross-validation was trained with six predictor variables: the preoperative plasma concentrations of parathyroid hormone, total calcium and thyroid-stimulating hormone, the serum concentration of ionised calcium, the 24-h urine calcium and the histopathological weight of the localised PTA at imaging. Two response classes were defined: patients with single-gland disease (SGD) correctly localised at imaging and MGD patients in whom only one PTA was localised on imaging. The data set was split into 70% for training and 30% for testing. The MLC was also tested on a subset of the original data based on CT image-derived PTA weights. RESULTS The MLC achieved an overall accuracy at validation of 90% with an area under the cross-validation receiver operating characteristic curve of 0.9. On test data, the MLC reached a 72% true-positive prediction rate for MGD patients and a misclassification rate of 6% for SGD patients. Similar results were obtained in the testing set with image-derived PTA weight. CONCLUSIONS Artificial intelligence can aid in identifying patients with MGD for whom 99mTc-Sestamibi-SPECT/CT failed to visualise all PTAs.
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Affiliation(s)
- Patricia Sandqvist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Sundin
- Department of Radiology, Section for Molecular Imaging, Institution for Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Inga-Lena Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Per Grybäck
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Alejandro Sanchez-Crespo
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
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Parathyroidectomy Results in Primary Hyperparathyroidism: Analysis of the Results From a Single Center. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:173-178. [PMID: 34349592 PMCID: PMC8298071 DOI: 10.14744/semb.2021.72681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/14/2021] [Indexed: 11/20/2022]
Abstract
Objectives The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may develop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery for PHPT in our clinic. Methods The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and 2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidectomy were included in the study. Surgical cure and persistent and recurrent disease rates were evaluated in patients. Results During this period, 368 interventions were performed in 357 patients (293 F and 64 M) who were operated for PHPT in our clinic, with a mean age of 54.9±13.1 years. In the first surgery, 116 patients (32.5%) had bilateral neck exploration, 251 patients (67.5%) had unilateral neck exploration (UNE) or focused parathyroid surgery (FPS). In the first operation, 343 patients (96.1%) had cure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS was performed to 10 patients (90.9%); partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these patients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Four patients remained persistent (1.1%). Recurrent disease developed in four patients during follow-up (1.1%). Total cure rate was 97.8%. Conclusion The only definitive treatment for PHPT is surgery. High surgical cure can be achieved by pre-operative evaluation and appropriate surgical planning. However, persistent PHPT may develop, especially due to double adenoma or ectopic location. Patients with persistent PHPT can be evaluated with repeat imaging methods and with appropriate surgical planning, a high cure rate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.
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Bergenfelz A, van Slycke S, Makay Ö, Brunaud L. European multicentre study on outcome of surgery for sporadic primary hyperparathyroidism. Br J Surg 2021; 108:675-683. [PMID: 34157082 DOI: 10.1002/bjs.12025] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/17/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND International multicentre outcome studies of surgery for primary hyperparathyroidism (pHPT), especially for rate of conversion to bilateral neck surgery and persistent hypercalcaemia, are scarce. METHODS Eurocrine® is a European database for endocrine surgery. Data are entered according to predefined data fields. Outcomes for patients who underwent first surgery for sporadic pHPT were analysed. Multivariable analysis was performed to identify risk factors for adverse outcome using Cox regression with constant follow-up. RESULTS A total of 5861 patients were registered between 2015 and 2018. Preoperative localization procedures were used in most patients, with moderate sensitivity. Intraoperative parathyroid hormone (ioPTH) measurement was used in three-quarters of patients. Bilateral surgery was performed in 1574 patients (26·9 per cent). Among 4683 patients (79·7 per cent) for whom unilateral or focused operation was planned, the procedure was converted to bilateral surgery in 396 (8·5 per cent). The risk of conversion decreased with the use of ioPTH monitoring (relative risk (RR) 0·77). Persistent hypercalcaemia was registered in 253 patients (4·3 per cent), and was less likely with the use of two (RR 0·55) or three (RR 0·44) localization procedures. In patients with a concordant localized single lesion, the rate of persistent hypercalcaemia was 2·5 per cent. The risk of persistent hypercalcaemia decreased with the use of ioPTH measurement, but was increased in patients with negative localization procedures and conversion to bilateral surgery. CONCLUSION The use of ioPTH measurement decreased the risk of conversion and persistent hypercalcaemia. The use of two or three localization procedures decreased the risk of persistent hypercalcaemia; in patients with a concordant single lesion, the risk of persistent hypercalcaemia was low.
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Affiliation(s)
- A Bergenfelz
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Surgery and Gastroenterology, Skåne University Hospital, Lund, Sweden
| | - S van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw Hospital Aalst, Aalst, Belgium
| | - Ö Makay
- Department of Surgery, Ege University Hospital, Izmir, Turkey
| | - L Brunaud
- Multidisciplinary Unit of Metabolic, Endocrine and Thyroid Surgery, Department of Surgery, Université de Lorraine, Centre Hospitalier Régional Universitaire Nancy, Vandoeuvre-lès Nancy, France
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De Pasquale L, Lori E, Bulfamante AM, Felisati G, Castellani L, Saibene AM. Evaluation of Wisconsin and CaPTHUS Indices Usefulness for Predicting Monoglandular and Multiglandular Disease in Patients with Primary Hyperparathyroidism through the Analysis of a Single-Center Experience. Int J Endocrinol 2021; 2021:2040284. [PMID: 34671396 PMCID: PMC8523259 DOI: 10.1155/2021/2040284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/26/2021] [Accepted: 09/29/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The main challenge for treating primary hyperparathyroidism (PHPT) is to understand if it is caused by a single adenoma (80-85% of the cases) or by a multiglandular disease (15-20%), both preoperatively and intraoperatively. For this reason, some preoperative scores were proposed in the literature, to perform focused parathyroidectomy, avoiding intraoperative parathormone assay (ioPTH). The most known are the CaPTHUS test and the Wisconsin index. We applied them to our experience. METHODS A retrospective cohort study on 462 patients referred for parathyroidectomy to Thyroid and Parathyroid Unit at Santi Paolo e Carlo Hospital, Milan, Italy, from 2011 to 2021. Only patients affected with benign PHPT and neck ultrasound performed at our institution were included. Both patients for whom preoperative imaging agreed with the localization of a single diseased parathyroid and those with only ultrasound or scintigraphy positive for parathyroid localization underwent Mini-Invasive Video-assisted parathyroidectomy. In all cases, ioPTH assay was performed. The conversion to bilateral neck exploration was decided based on the drop in ioPTH. CaPTHUS score and the Wisconsin index (Win) were applied to the series. CaPTHUS score ≥3 and Win index >1600, according to the original studies of the literature, were considered at high probability of monoglandular disease. Outcomes in these two groups were examined. RESULTS 236 patients were eligible for the study. The pathology resulted in multiglandular disease in 24 patients (10.2%). Among these, 18 (75.0%) obtained a CaPTHUS score ≥3, and 20 (83.3%) had a Win index>1600. Intraoperative PTH allowed to identify multiglandular disease in 16 of 18 cases with CaPTHUS ≥3 and in 18 of 20 cases with win >1600, who could have been lost, based only on the results of these 2 tests. CONCLUSION Based on our experience, CaPTHUS test and Wisconsin index were not so useful in predicting multiglandular disease as ioPTH.
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Affiliation(s)
- Loredana De Pasquale
- Thyroid and Parathyroid Surgery Service (Head Dott. Loredana De Pasquale)-Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
| | - Eleonora Lori
- Department of Surgical Science, “Sapienza” University of Rome, Rome 00161, Italy
| | - Antonio Mario Bulfamante
- Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
| | - Giovanni Felisati
- Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
| | - Luca Castellani
- Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
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Comparing the diagnostic accuracy of 4D CT and 99mTc-MIBI SPECT/CT for localizing hyperfunctioning parathyroid glands: a systematic review and meta-analysis. Nucl Med Commun 2020; 42:225-233. [PMID: 33306636 DOI: 10.1097/mnm.0000000000001331] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To compare the diagnostic accuracy of dual-phase 99mTc-MIBI single photon emission computed tomography/computed tomography (SPECT/CT) and 4D CT for the localization of hyperfunctioning parathyroid glands, a systematic review and meta-analysis was performed. Whether 4D CT combined to SPECT/CT [contrast-enhanced (CE)-SPECT/CT] had a better diagnostic performance than SPECT/CT alone in this scenario was also evaluated. MATERIAL AND METHODS PubMed and Embase databases were searched for eligible studies. To reduce interstudy heterogeneity, only studies with clear head-to-head comparison were included. Publication bias was assessed by the Deeks funnel plot. The pooled sensitivity, specificity and the area under the curve (AUC) for 4D CT, SPECT/CT and CE-SPECT/CT were determined by random-effect analysis, respectively. RESULTS Nine studies met the inclusion criteria, with a total of 911 participants. The sensitivity and specificity of 4D CT were 0.85 [95% confidence interval (CI), 0.69-0.94] and 0.93 (95% CI, 0.88-0.96), whereas the sensitivity and specificity for SPECT/CT were 0.68 (95% CI, 0.51-0.82; P = 0.048 compared with 4D CT) and 0.98 (95% CI, 0.95-0.99; P = 0.014 compared with 4D CT), respectively. CE-SPECT/CT is comparable to SPECT/CT in specificity and AUC, but it may improve the sensitivity (although there was a lack of statistical difference, 0.87 vs. 0.78; P = 0.125). CONCLUSION Although 4D CT shows comparable AUC and borderline better sensitivity than SPECT/CT, its clinical application is confined by relatively low specificity and high radiation exposure. CE-SPECT/CT may improve the sensitivity without compromising the specificity and AUC of SPECT/CT.
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Uludağ M, Aygün N, İşgör A. Main Surgical Principles and Methods in Surgical Treatment of Primary Hyperparathyroidism. SISLI ETFAL HASTANESI TIP BULTENI 2019; 53:337-352. [PMID: 32377107 PMCID: PMC7192302 DOI: 10.14744/semb.2019.67944] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 08/24/2019] [Indexed: 12/28/2022]
Abstract
The only curative treatment for primary hyperparathyroidism (pHPT) is surgery. The most important factors that increase the success rate of a parathyroidectomy are the establishment of the correct diagnosis and the surgeon's good knowledge of anatomy and embryology. The lower parathyroid glands develop from the dorsal portion of the third pharyngeal pouch, and the upper parathyroid glands from the fourth pharyngeal pouch. Humans typically have 4 parathyroid glands; however, more than 4 and fewer than 4 have been observed. Typically, the upper parathyroid glands are located in the cricothyroid junction area on the posterolateral portion of the middle and upper third of the thyroid, while the lower parathyroids are located in an area 1 cm in diameter located posterior, lateral, or anterolateral to the lower thyroid pole. Ectopic locations of parathyroid glands outside the normal anatomical regions due to the abnormal migration during embryological development or acquired ectopy due to migration of enlarged parathyroids are not uncommon. There are various surgical techniques to treat HPT; however, 2 main surgical options are used: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP). While there are open, endoscopic, and video-assisted MIP (MIVAP) approaches, most often an open lateral MIP technique is used. In addition, endoscopic or robotic parathyroidectomy methods performed from remote regions outside the neck have been reported. Although currently MIP is the standard treatment option in selected patients with positive imaging, BNE remains the gold standard procedure in parathyroid surgery. In 80% to 90% of patients with pHPT, a pathological parathyroid gland can be detected with preoperative imaging methods and MIP can be applied. However, the pathological gland may not be found during a MIP procedure as a result of false positive results. The parathyroid surgeon must also know the BNE technique and be able to switch to BNE and change the surgical strategy if necessary. If the intended gland is not found in its normal anatomical site, possible embryological and acquired ectopic locations should be investigated. It should be kept in mind that MIP and BNE are not alternatives to each other, but rather complementary techniques for successful treatment in parathyroid surgery.
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Affiliation(s)
- Mehmet Uludağ
- Department of Genaral Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Nurcihan Aygün
- Department of Genaral Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan İşgör
- Department of Genaral Surgery, Bahcesehir University, Faculty of Medicine, Istanbul, Turkey
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Aygün N, İşgör A, Uludağ M. The Effectiveness of Preoperative Ultrasonography and Scintigraphy in the Pathological Gland Localization in Primary Hyperparathyroidism Patients. SISLI ETFAL HASTANESI TIP BULTENI 2019; 53:379-384. [PMID: 32377112 PMCID: PMC7192300 DOI: 10.14744/semb.2019.37097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Primary hyperparathyroidism (pHPT) is a common disease, and its curative treatment is surgical. Nowadays, preoperative localization studies have become standard before surgical treatment, and the first stage imaging methods are ultrasonography and/or scintigraphy. With the contribution of these studies to the localization of the pathological gland, focused surgery has become the first standard of choice. In this study, we aimed to evaluate the efficacy of ultrasonography and scintigraphy in the preoperative localization of the pathologic gland or glands in patients who underwent surgical treatment and cure for pHPT. METHODS In this study; the data of the biochemically diagnosed pHPT patients, who had Tc 99m-MIBI scintigraphy and/or ultrasonography for localisation preoperatively, were evaluated retrospectively. The lesion, which was positive in USG or scintigraphy for localization, was evaluated according to the neck side or neck quadrant, and the results were compared with intraoperative localization findings. The effectiveness of both methods and combinations was evaluated with the localization rates, sensitivity and positive predictive values (PPV). The three methods were compared with the Youden index (J). RESULTS The mean age of 380 patients included in this study was 54.8±12.8 years (20-83). Three hundred eight of them were female, and 72 were male. Scintigraphy was performed in 339 patients, USG was performed in 344 patients, and both USG and scintigraphy were performed in 306 patients. One hundred twenty patients (32%) underwent bilateral neck exploration (BNE), and 260 patients (68.4%) underwent minimally invasive parathyroidectomy (MIP) (unilateral exploration or focused surgery). Single adenoma was detected in 358 (94%), double adenoma in 10 (3%) and hyperplasia in 12 (3%) patients.Localization rates of USG, scintigraphy, USG and scintigraphy combinations were 53%, 74%, 75%; their sensitivity was 56%, 85%, 89%; PPDs were 90%, 86%, 83%. The efficiency of scintigraphy is higher than USG (J: 0.743 vs 0.527). The contribution of scintigraphy to USG in combination with USG was limited (J: 0.743 vs 0.754).The localization rates of USG, scintigraphy, USG and scintigraphy combinations were 46%, 64%, 66%; their sensitivity was 51%, 83%, 88%; PPDs were 79%, 74%, 73%. The efficiency of scintigraphy is higher than that of USG (J: 0.64 vs 0.427). The contribution of scintigraphy to USG in combination with USG was limited (J: 0.64 vs 0.66). CONCLUSION In patients with pHPT, scintigraphy is a more effective method for USG as the first step preoperative imaging and should be preferred as the first method if there is no contraindication. A combination of scintigraphy with USG may contribute minimally to the efficacy of scintigraphy. It may be advantageous for early detection of the pathologic gland in patients with incompatible two imaging and initiating surgery on the positive side of the first scintigraphy. Scintigraphy and USG methods may allow successful MRP surgery in the majority of patients with pHPT.
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Affiliation(s)
- Nurcihan Aygün
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan İşgör
- Department of General Surgery, Bahcesehir University, Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Uludağ
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Iacobone M, Scerrino G, Palazzo FF. Parathyroid surgery: an evidence-based volume-outcomes analysis : European Society of Endocrine Surgeons (ESES) positional statement. Langenbecks Arch Surg 2019; 404:919-927. [PMID: 31595330 DOI: 10.1007/s00423-019-01823-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The interest in correlation between hospital and surgeon practice volume and postoperative outcomes has grown considerably over the last decades; it has been suggested that surgery is likely to be associated with higher cure rates, lower morbidity and more favourable results in cost-effectiveness when performed in a high-volume setting. The aim of this paper is to undertake an evidence-based literature review of the relationship between surgical volume and clinical outcomes in parathyroidectomy for primary hyperparathyroidism. We used accepted quality markers to identify the relationship between volume and outcome with a view to defining a reproducible minimal surgical volume-related standard of care in parathyroid surgery. METHODS A peer review literature analysis of volume and outcomes in parathyroid surgery was carried out and assessed from an evidence-based perspective. Results were discussed at the 2019 Conference of the European Society of Endocrine Surgeons devoted to "Volumes, Outcomes and Quality Standards in Endocrine Surgery". RESULTS Literature reports no prospective randomised studies; thus, a low level of evidence may be achieved. CONCLUSIONS Parathyroid surgery is at increased risk of failures, morbidity and need for reoperations and cost when performed in low-volume settings; thus, it should be concentrated in dedicated settings, with adequate annual volume and expertise. Acceptable results may be achieved moving parathyroid surgery cases away from low-volume settings (< 15 parathyroidectomies/year). Challenging procedures (primary hyperparathyroidism without unequivocal preoperative localization, hereditary variants, paediatric patients, reoperations) should be confined to high-volume settings (> 40 parathyroidectomies/year).
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Affiliation(s)
- Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Gregorio Scerrino
- General and Emergency Surgery Unit, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - F Fausto Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, London, UK
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Bhangu JS, Riss P. The role of intraoperative parathyroid hormone (IOPTH) determination for identification and surgical strategy of sporadic multiglandular disease in primary hyperparathyroidism (pHPT). Best Pract Res Clin Endocrinol Metab 2019; 33:101310. [PMID: 31409538 DOI: 10.1016/j.beem.2019.101310] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intraoperative PTH monitoring (IOPTH) made minimally invasive parathyroidectomy in patients with primary HPT possible. However, with the increasing accuracy of preoperative localization studies there is a growing discussion if IOPTH is necessary in patients with localized single gland disease (concordant preoperative localization studies). Different interpretation criteria have been developed - each with their particular advantages and disadvantages, but the "perfect" criterion is still missing. Despite several pitfalls, which can be recognized intraoperatively and do not necessarily lead to a more extensive surgery, IOPTH seems to be a useful adjunct in surgery for PHPT. However, according to current guidelines, selected patients may be operated without IOPTH but need to be informed about the possibly increased risk of recurrent disease.
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Affiliation(s)
- Jagdeep Singh Bhangu
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Philipp Riss
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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15
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Bollerslev J, Schalin-Jäntti C, Rejnmark L, Siggelkow H, Morreau H, Thakker R, Sitges-Serra A, Cetani F, Marcocci C. MANAGEMENT OF ENDOCRINE DISEASE: Unmet therapeutic, educational and scientific needs in parathyroid disorders. Eur J Endocrinol 2019; 181:P1-P19. [PMID: 31176307 PMCID: PMC6598862 DOI: 10.1530/eje-19-0316] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
PARAT, a new European Society of Endocrinology program, aims to identify unmet scientific and educational needs of parathyroid disorders, such as primary hyperparathyroidism (PHPT), including parathyroid cancer (PC), and hypoparathyroidism (HypoPT). The discussions and consensus statements from the first PARAT workshop (September 2018) are reviewed. PHPT has a high prevalence in Western communities, PHPT has a high prevalence in Western communities, yet evidence is sparse concerning the natural history and whether morbidity and long-term outcomes are related to hypercalcemia or plasma PTH concentrations, or both. Cardiovascular mortality and prevalence of low energy fractures are increased, whereas Quality of Life is decreased, although their reversibility by treatment of PHPT has not been convincingly demonstrated. PC is a rare cause of PHPT, with an increasing incidence, and international collaborative studies are required to advance knowledge of the genetic mechanisms, biomarkers for disease activity, and optimal treatments. For example, ~20% of PCs demonstrate high mutational burden, and identifying targetable DNA variations, gene amplifications and gene fusions may facilitate personalized care, such as different forms of immunotherapy or targeted therapy. HypoPT, a designated orphan disease, is associated with a high risk of symptoms and complications. Most cases are secondary to neck surgery. However, there is a need to better understand the relation between disease biomarkers and intellectual function, and to establish the role of PTH in target tissues, as these may facilitate the appropriate use of PTH substitution therapy. Management of parathyroid disorders is challenging, and PARAT has highlighted the need for international transdisciplinary scientific and educational studies in advancing in this field.
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Affiliation(s)
- Jens Bollerslev
- Section of Specialized Endocrinology, Oslo University Hospital
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Camilla Schalin-Jäntti
- Division of Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Heide Siggelkow
- Endokrinologikum Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Hans Morreau
- Pathology, Leiden University Medical Center, Leiden, Netherlands
| | - Rajesh Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Oxford, UK
| | - Antonio Sitges-Serra
- Endocrine Surgery Unit, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Filomena Cetani
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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16
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Aygün N, Uludağ M. Surgical Treatment of Primary Hyperparathyroidism: Which Therapy to Whom? SISLI ETFAL HASTANESI TIP BULTENI 2019; 53:201-214. [PMID: 32377085 PMCID: PMC7192265 DOI: 10.14744/semb.2019.56873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
Primary hyperparathyroidism (pHPT) is characterized by an increase in the levels of PTH and Ca, or one of these (Ca, PTH) as a result of a dysregulation of calcium (Ca) metabolism due to inappropriate excess parathyroid hormone (PTH) autonomously produced from one or more than one parathyroid glands. Ninety to 95% of pHPT is a sporadic type, which is not associated with the familial history and other endocrine organ tumors, and 5-10% of it is hereditary. While 80-85% of pHPT arises from a single parathyroid adenoma, 4-5% is caused by a double adenoma, 10-15% by multigland hyperplasia and less than 1% by parathyroid cancer. The diagnosis of pHPT is reached biochemically. The only curative treatment of pHPT is surgery. The choice of surgery in pHPT may vary depending on whether the patient has hereditary HPT or thyroid disease requiring surgical treatment, preoperative localization studies and the findings in these studies, the possibilities of using intraoperative PTH and the preference of the surgeon. The preoperatively determined surgical strategy can be revised according to intraoperative findings in case of need to achieve excellent results. The two main approaches in the surgical treatment of pHPT are BNE (bilateral neck exploration) and MIP (minimal invasive parathyroidectomy). Although BNE is a consistently valid option that has excellent results in the surgical treatment of pHPT and is considered the gold standard, MIP is the ideal approach in selected patients with clinically and radiologically considered a single-gland disease. Negative imaging is not a contraindication for parathyroid surgery and is not a criterion for the presence or absence of surgical indication. Although both methods are safe and effective in the surgical treatment of sporadic pHPT, there is still controversy regarding the effectiveness of both methods. Surgical intervention should establish the risk-benefit balance well, minimize the risk of persistent and recurrent disease and provide the highest cure rate without increasing the risk of complications. Complication rates are higher in the secondary surgery, thus in secondary procedures, selective surgery should be performed under guidance of an imaging modality. The surgical strategy should be determined to achieve maximum cure with minimum dissection and minimal morbidity. In this study, we aimed to determine the type of surgical treatment and pHPT patients suitable for the surgical treatment.
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Affiliation(s)
- Nurcihan Aygün
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Uludağ
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Vu TH, Schellingerhout D, Guha-Thakurta N, Sun J, Wei W, Kappadth SC, Perrier N, Kim EE, Rohren E, Chuang HH, Wong FC. Solitary Parathyroid Adenoma Localization in Technetium Tc99m Sestamibi SPECT and Multiphase Multidetector 4D CT. AJNR Am J Neuroradiol 2018; 40:142-149. [PMID: 30523145 DOI: 10.3174/ajnr.a5901] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 10/14/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Minimally invasive parathyroid surgery relies critically on image guidance, but data comparing the efficacy of various imaging modalities are scarce. Our aim was to perform a blinded comparison of the localizing capability of technetium Tc99m sestamibi SPECT, multiphase multidetector 4D CT, and the combination of these 2 modalities (technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT). MATERIALS AND METHODS We reviewed the records of 31 (6 men, 25 women; median age, 56 years) consecutive patients diagnosed with biochemically confirmed primary hyperparathyroidism between November 2009 and March 2010 who underwent preoperative technetium Tc99m sestamibi SPECT and multiphase multidetector 4D CT performed on the same scanner with pathologic confirmation by resection of a single parathyroid adenoma. Accuracy was determined separately for localization to the correct side and quadrant using surgical localization as the standard of reference. RESULTS Surgical resection identified 14 left and 17 right parathyroid adenomas and 2 left inferior, 12 left superior, 11 right inferior, and 6 right superior parathyroid adenomas. For left/right localization, technetium Tc99m sestamibi SPECT achieved an accuracy of 93.5% (29 of 31), multiphase multidetector 4D CT achieved 96.8% accuracy (30 of 31), and technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT achieved 96.8% accuracy (30 of 31). For quadrant localization, technetium Tc99m sestamibi SPECT accuracy was 67.7% (21 of 31), multiphase multidetector 4D CT accuracy was 87.1% (27 of 31), and technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT accuracy was 93.5% (29 of 31). Reader diagnostic confidence was consistently ranked lowest for technetium Tc99m sestamibi SPECT and highest for technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT. CONCLUSIONS For left/right localization of parathyroid adenomas, all modalities performed equivalently. For quadrant localization, technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT is superior to technetium Tc99m sestamibi SPECT.
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Affiliation(s)
- T H Vu
- From the Departments of Diagnostic Radiology (T.H.V., D.S., N.G.-T.)
| | - D Schellingerhout
- From the Departments of Diagnostic Radiology (T.H.V., D.S., N.G.-T.)
| | - N Guha-Thakurta
- From the Departments of Diagnostic Radiology (T.H.V., D.S., N.G.-T.)
| | - J Sun
- Biostatistics (J.S., W.W.)
| | - W Wei
- Biostatistics (J.S., W.W.)
| | | | | | - E E Kim
- Department of Radiological Sciences (E.E.K.), University of California at Irvine, Orange, California
| | - E Rohren
- Baylor College of Medicine (E.R.), Houston, Texas
| | - H H Chuang
- Nuclear Medicine (H.H.C., F.C.W.), The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - F C Wong
- Nuclear Medicine (H.H.C., F.C.W.), The University of Texas MD Anderson Cancer Center, Houston, Texas
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18
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Stack BC, Tolley NS, Bartel TB, Bilezikian JP, Bodenner D, Camacho P, Cox JPDT, Dralle H, Jackson JE, Morris JC, Orloff LA, Palazzo F, Ridge JA, Scott-Coombes D, Steward DL, Terris DJ, Thompson G, Randolph GW. AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons. Head Neck 2018; 40:1617-1629. [PMID: 30070413 DOI: 10.1002/hed.25023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/13/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present. METHODS A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness. RESULTS Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed. CONCLUSION Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.
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Affiliation(s)
- Brendan C Stack
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Neil S Tolley
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | | | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Donald Bodenner
- Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Pauline Camacho
- Department of Medicine, Division of Endocrinology, Loyola University, Chicago, Illinois
| | - Jeremy P D T Cox
- Department of Metabolic Medicine, Imperial College Hospital, NHS Healthcare Trust, London, UK
| | - Henning Dralle
- Sektion Endokrine Chirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinisches Zentrum, Germany
| | - James E Jackson
- Department of Imaging, Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John C Morris
- Department of Medicine, Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Lisa Ann Orloff
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Fausto Palazzo
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | | | - David L Steward
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - David J Terris
- Department of Otolaryngology - Head and Neck Surgery, Augusta University, Augusta, Georgia
| | | | - Gregory W Randolph
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts
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19
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Scott-Coombes DM, Rees J, Jones G, Stechman MJ. Is Unilateral Neck Surgery Feasible in Patients with Sporadic Primary Hyperparathyroidism and Double Negative Localisation? World J Surg 2018; 41:1494-1499. [PMID: 28116482 DOI: 10.1007/s00268-017-3891-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Ultrasound and Tc99mMIBI scans are used to localise parathyroid tumours in sporadic primary hyperparathyroidism (pHPT). Intra-operative PTH (ioPTH) assay facilitates unilateral neck exploration (UNE). When both ultrasound and MIBI are negative, it is our policy to explore the left side of the neck and only proceed to bilateral neck exploration (BNE) when either a tumour is not found or when ioPTH does not fall to >50% of the highest pre-excision value. The aim of this study was to investigate the outcome of our approach to 'double negative' patients. METHODS A retrospective analysis of patients undergoing primary parathyroidectomy for pHPT. Data were obtained from a prospective surgical database and the hospital electronic patient record. RESULTS Between January 2004 and November 2014, 746 patients underwent a parathyroidectomy for pHPT. Those who did not have both pre-operative scans, ioPTH or a minimum of 6-month follow-up were excluded. Of 552 patients, 111 (20%) had double negative scans (group A), and in 441, either one or both scans were positive (group B). Median age was 61.5 years (range 10-88). Pre-operative PTH level was significantly lower in group A: 11.8 pmol/l (range 3.1-38.8) versus 14.9 pmol/l (range 2.8-101.6; P < 0.01). Median tumour weight was significantly lower in group A: 280 mg (range 50-3710) versus 573 mg (range 10-12,000; P < 0.01). Overall rate of multiple gland disease (MGD) was 11%; 24% in group A and 7% in group B (P < 0.01). Overall rate of UNE in Group A was 28% and converse to the rate in Group B (76%; P < 0.01). Sensitivity and specificity of ioPTH to detect MGD were 98 and 98% in Group A versus 98 and 100% in Group B. First-time cure rate was 92.7% in group A and 96.8% in group B (P < 0.05). CONCLUSION A double negative scan is associated with small tumours and higher rates of MGD. Despite these challenges, surgery is successful in this group of patients reinforcing the message that negative localisation is not a contraindication for parathyroidectomy. We demonstrated that it is feasible to offer unilateral neck surgery to 28% of patients with double negative scans. A randomised trial is needed to compare BNE with ioPTH/UNE in this select population.
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Affiliation(s)
- D M Scott-Coombes
- Department of Endocrine Surgery, C2 Office, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.
| | - J Rees
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - G Jones
- Department of Clinical Chemistry, University Hospital of Wales, Cardiff, UK
| | - M J Stechman
- Department of Endocrine Surgery, C2 Office, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
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20
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The Results of Ultrasonography-Guided Percutaneous Radiofrequency Ablation in Hyperparathyroid Patients in Whom Surgery Is Not Feasible. Cardiovasc Intervent Radiol 2017; 40:596-602. [DOI: 10.1007/s00270-016-1544-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/09/2016] [Indexed: 01/20/2023]
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A 20-year study on 190 patients with primary hyperparathyroidism in a developing country: Turkey experience. Int Surg 2016; 100:648-55. [PMID: 25875546 DOI: 10.9738/intsurg-d-14-00094.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The aim of this study was to present our 20-year experience regarding primary hyperparathyroidism (PHPT). PHPT patients who underwent parathyroidectomy in our clinic were reviewed retrospectively. There were 190 PHPT patients, of whom 137 were asymptomatic (72%). The mean serum calcium at the time of diagnosis was 11.9 ± 2.2 mg/dL. The mean parathyroid hormone (PTH) level was 467 ± 78 pg/mL. Ultrasonography (USG) identified all abnormal glands accurately (82.6%) and Technetium-99m sestamibi scintigraphy (MIBI) was used in 89.4% of the patients and magnetic resonance imaging (MRI) in 61%. The common use of USG and MIBI detected 92% of the lesions. Bilateral neck exploration (BNE) was performed in 12.2% of the patients and focused unilateral neck exploration (FUNE) in the remaining 87.8%. Surgical intervention was unsuccessful in 1 patient (0.5%). The conversion ratio from FUNE to BNE was 5.2%. The mean operation time and mean hospital stay decreased significantly in patients with FUNE. Pathologic examination revealed single adenoma in 93% of the patients. New imaging techniques result in the conversion of surgical treatments of PHPT. FUNE in parathyroidectomy performed by an experienced surgeon may provide successful treatment rates.
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Laird AM, Libutti SK. Minimally Invasive Parathyroidectomy Versus Bilateral Neck Exploration for Primary Hyperparathyroidism. Surg Oncol Clin N Am 2016; 25:103-18. [PMID: 26610777 DOI: 10.1016/j.soc.2015.08.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Primary hyperparathyroidism is a disease that is caused by excess parathyroid hormone (PTH) secretion from 1 or more of the parathyroid glands. Surgery is the only cure. Traditional surgical management consists of a 4-gland cervical exploration. Development of imaging specific to identification of parathyroid glands and application of the rapid PTH assay to operative management have made more minimal exploration possible. There are distinct advantages and disadvantages of minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE). The advantages of MIP seem to outweigh those of BNE, and MIP has replaced BNE as the operation of choice by many surgeons.
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Affiliation(s)
- Amanda M Laird
- Montefiore Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 3400 Bainbridge Avenue, 4th Floor, Bronx, NY 10467, USA.
| | - Steven K Libutti
- Montefiore Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 3400 Bainbridge Avenue, 4th Floor, Bronx, NY 10467, USA
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23
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Bellantone R, Traini E, Raffaelli M, Lombardi CP. Surgical Technique in Reoperations. Updates Surg 2016. [DOI: 10.1007/978-88-470-5758-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Thier M, Nordenström E, Almquist M, Bergenfelz A. Results of a Fifteen-Year Follow-up Program in Patients Operated with Unilateral Neck Exploration for Primary Hyperparathyroidism. World J Surg 2015; 40:582-8. [DOI: 10.1007/s00268-015-3360-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Thier M, Nordenström E, Bergenfelz A, Almquist M. Presentation and Outcomes After Surgery for Primary Hyperparathyroidism During an 18-Year Period. World J Surg 2015; 40:356-64. [DOI: 10.1007/s00268-015-3329-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Iacobone M, Carnaille B, Palazzo FF, Vriens M. Hereditary hyperparathyroidism--a consensus report of the European Society of Endocrine Surgeons (ESES). Langenbecks Arch Surg 2015; 400:867-86. [PMID: 26450137 DOI: 10.1007/s00423-015-1342-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hereditary hyperparathyroidism has been reported to occur in 5-10 % of cases of primary hyperparathyroidism in the context of multiple endocrine neoplasia (MEN) types 1, 2A and 4; hyperparathyroidism-jaw tumour (HPT-JT); familial isolated hyperparathyroidism (FIHPT); familial hypocalciuric hypercalcaemia (FHH); neonatal severe hyperparathyroidism (NSHPT) and autosomal dominant moderate hyperparathyroidism (ADMH). This paper aims to review the controversies in the main genetic, clinical and pathological features and surgical management of hereditary hyperparathyroidism. METHODS A peer review literature analysis on hereditary hyperparathyroidism was carried out and analyzed in an evidence-based perspective. Results were discussed at the 2015 Workshop of the European Society of Endocrine Surgeons devoted to hyperparathyroidism due to multiple gland disease. RESULTS Literature reports scarcity of prospective randomized studies; thus, a low level of evidence may be achieved. CONCLUSIONS Hereditary hyperparathyroidism typically presents at an earlier age than the sporadic variants. Gene penetrance and expressivity varies. Parathyroid multiple gland involvement is common, but in some variants, it may occur metachronously often with long disease-free intervals, simulating a single-gland involvement. Bilateral neck exploration with subtotal parathyroidectomy or total parathyroidectomy + autotransplantation should be performed, especially in MEN 1, in order to decrease the persistent and recurrent hyperparathyroidism rates; in some variants (MEN 2A, HPT-JT), limited parathyroidectomy can achieve long-term normocalcemia. In FHH, surgery is contraindicated; in NSHPT, urgent total parathyroidectomy is required. In FIHPT, MEN 4 and ADMH, a tailored case-specific approach is recommended.
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Affiliation(s)
- Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128, Padova, Italy.
| | - Bruno Carnaille
- Department of Endocrine Surgery, Université de Lille, Lille, France
| | - F Fausto Palazzo
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital and Imperial College, London, UK
| | - Menno Vriens
- Department of Surgical Oncology and Endocrine Surgery, Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
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de la Plaza Llamas R, Ramia Ángel JM, Kühnhardt Barrantes AW, Gonzales Aguilar JD, Valenzuela Torres JDC. Minimally invasive parathyroidectomy in patients with previous thyroid surgery. ACTA ACUST UNITED AC 2015; 62:414-6. [PMID: 26050582 DOI: 10.1016/j.endonu.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Roberto de la Plaza Llamas
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - José Manuel Ramia Ángel
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
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Pasieka JL. What Should We Tell Our Patients? Lifetime Guarantee or is it 5- to 10-year Warranty on a Parathyroidectomy for Primary Hyperparathyroidism? World J Surg 2015; 39:1928-9. [DOI: 10.1007/s00268-015-3043-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Barczyński M, Gołkowski F, Nawrot I. The current status of intraoperative iPTH assay in surgery for primary hyperparathyroidism. Gland Surg 2015; 4:36-43. [PMID: 25713778 DOI: 10.3978/j.issn.2227-684x.2015.01.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/30/2014] [Indexed: 11/14/2022]
Abstract
Intraoperative intact parathyroid hormone (iPTH) monitoring has been accepted by many centers specializing in parathyroid surgery as a useful adjunct during surgery for primary hyperparathyroidism. This method can be utilized in three discreet modes of application: (I) to guide surgical decisions during parathyroidectomy in one of the following clinical contexts: (i) to confirm complete removal of all hyperfunctioning parathyroid tissue, which allows for termination of surgery with confidence that the hyperparathyroid state has been successfully corrected; (ii) to identify patients with additional hyperfunctioning parathyroid tissue following the incomplete removal of diseased parathyroid/s, which necessitates extended neck exploration in order to minimize the risk of operative failure; (II) to differentiate parathyroid from non-parathyroid tissue by iPTH measurement in the fine-needle aspiration washout; (III) to lateralize the side of the neck harboring hyperfunctioning parathyroid tissue by determination of jugular venous gradient in patients with negative or discordant preoperative imaging studies, in order to increase the number of patients eligible for unilateral neck exploration. There are many advantages of minimally invasive parathyroidectomy guided by intraoperative iPTH monitoring, including focused dissection in order to remove the image-indexed parathyroid adenoma with a similar or even higher operative success rate, lower prevalence of complications and shorter operative time when compared to conventional bilateral neck exploration. However, to achieve such excellent results, the surgeon needs to be aware of hormone dynamics during parathyroidectomy and carefully choose the protocol and interpretation criteria that best fit the individual practice. Understanding the nuances of intraoperative iPTH monitoring allows the surgeon for achieving intraoperative confidence in predicting operative success and preventing failure in cases of unsuspected multiglandular disease, while safely limiting neck exploration in the majority of patients with sporadic primary hyperparathyroidism. Thus, parathyroidectomy guided by intraoperative iPTH monitoring for the management of sporadic primary hyperparathyroidism is an ideal option for the treatment of this disease entity. However, the cost-benefit aspects of the standard application of this method still remain a matter of controversy.
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Affiliation(s)
- Marcin Barczyński
- 1 Department of Endocrine Surgery, Third Chair of General Surgery, 2 Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland ; 3 Department of General, Vascular and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Filip Gołkowski
- 1 Department of Endocrine Surgery, Third Chair of General Surgery, 2 Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland ; 3 Department of General, Vascular and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Ireneusz Nawrot
- 1 Department of Endocrine Surgery, Third Chair of General Surgery, 2 Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland ; 3 Department of General, Vascular and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Issoufou I, Belliraj L, Rabiou S, Ghalimi J, Rchachi M, Lakranbi M, Ajdi F, Ouadnouni Y, Smahi M. Intrathymic Parathyroid Adenoma. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/crcm.2015.48059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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A retrospective case-controlled study of video-assisted versus open minimally invasive parathyroidectomy. Wideochir Inne Tech Maloinwazyjne 2014; 9:537-47. [PMID: 25561991 PMCID: PMC4280416 DOI: 10.5114/wiitm.2014.45087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 08/10/2014] [Accepted: 08/14/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Minimally invasive parathyroidectomy (MIP) with intraoperative parathyroid hormone assay (IOPTH) has successfully replaced conventional neck exploration in most patients with primary hyperparathyroidism (pHPT) and preoperatively localized parathyroid adenoma. AIM To compare outcomes of video-assisted MIP (MIVAP) to open MIP (OMIP). MATERIAL AND METHODS A retrospective case-controlled study of 455 patients with sporadic pHPT undergoing MIP with IOPTH at our institution in 2003-2012 was undertaken. The primary outcome measure was postoperative pain. Secondary outcome measures were: duration of surgery, recurrent laryngeal nerve (RLN) identification rate, conversion rate, length of hospital stay, cure rate, patients' satisfaction with cosmetic outcome, morbidity, costs, and diagnostic accuracy of IOPTH. RESULTS Of 455 patients with pHPT and a solitary parathyroid adenoma on preoperative imaging, 151 underwent MIVAP and 304 had OMIP. The following outcomes were favourable for MIVAP vs. OMIP: lower pain intensity during 24 h postoperatively (p < 0.001), lower analgesia request rate (p < 0.001), lower analgesics consumption (p < 0.001), higher recurrent laryngeal nerve identification rate (p < 0.001), shorter scar length (p < 0.001), and better cosmetic satisfaction at 1 month (p = 0.013) and at 6 months (p = 0.024) after surgery. However, MIVAP vs. OMIP had longer duration of surgery (p < 0.001), and was more expensive (p < 0.001). No differences were noted in the conversion rate, length of hospital stay, and morbidity. CONCLUSIONS Both MIVAP and OMIP approaches were equally safe and effective. However, the outcomes of MIVAP operations were superior to OMIP in terms of lesser postoperative pain, lower analgesics consumption, and better cosmetic satisfaction resulting from a smaller scar.
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Taieb A, Seman M, Menegaux F, Trésallet C. Surgical technique parathyroidectomy through a minimally invasive gland-centered localized approach for primary hyperparathyroidism. J Visc Surg 2013; 150:403-6. [PMID: 24183298 DOI: 10.1016/j.jviscsurg.2013.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- A Taieb
- Service de chirurgie générale, viscérale et endocrinienne, CHU Pitié-Salpêtrière, université Pierre-et-Marie-Curie (Paris VI), 47-83, boulevard de l'Hôpital, 75651 Paris, France
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Kim BS, Eom TI, Kang KH, Park SJ. Radiofrequency ablation of parathyroid adenoma in primary hyperparathyroidism. J Med Ultrason (2001) 2013; 41:239-43. [DOI: 10.1007/s10396-013-0501-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 08/19/2013] [Indexed: 10/26/2022]
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Kelly CWP, Eng CY, Quraishi MS. Open mini-incision parathyroidectomy for solitary parathyroid adenoma. Eur Arch Otorhinolaryngol 2013; 271:555-60. [PMID: 23653305 DOI: 10.1007/s00405-013-2443-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 03/08/2013] [Indexed: 10/26/2022]
Abstract
Parathyroid surgery is the acceptable definitive treatment for primary hyperparathyroidism (pHPT) due to parathyroid adenoma. Open mini-incision parathyroidectomy (O-MIP) has an excellent cure rate and minimal morbidity. We aim to demonstrate the safety, efficacy and subjective patient satisfaction of O-MIP and investigate the accuracy of pre-operative radiological localisation in relation to operative findings. A retrospective review of patients who underwent O-MIP for pHPT due to solitary parathyroid adenoma from April 2006 to August 2012 was performed. All patients were initially investigated by an endocrinologist to confirm pHPT with pre-operative localisation imaging using ultrasound scan (USS) and 99mTc-sestamibi (MIBI). One hundred and fifty consecutive patients were included with a median age of 62 years. Pre-operative USS and MIBI scans were concordant in 71 % of cases. In combined modality (USS and MIBI), localisation was 94.8 % accurate. There was 95.5 % identification of parathyroid tissue confirmed by intra-operative frozen section. Ninety-one percent of patients were treated as a day case. The median operative time was 60 min. The mean pre-operative calcium level was 2.98 mmol/l, and the short-to-medium term mean calcium level was 2.49 (Paired t test, p < 0.001). There was no significant complication. O-MIP confers significant advantages over the traditional gold standard treatment of bilateral neck exploration. Accurate localisation is the key to successful O-MIP. In experienced hands, ultrasound and MIBI may be the only pre-operative investigations required for accurate localisation.
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Herrera MF, Zárate X. [Impact of minimally invasive techniques in endocrine surgery]. Cir Esp 2011; 89:337-9. [PMID: 21496790 DOI: 10.1016/j.ciresp.2011.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 02/02/2011] [Indexed: 11/20/2022]
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Abstract
In recent years, parathyroid surgery has evolved from traditional bilateral neck exploration to minimal invasive parathyroidectomy. This trend became possible due to preoperative localization imaging that guides the surgeon in the search for a parathyroid adenoma. Intraoperative adjuncts are complementary to preoperative localization and assist in localizing parathyroid glands, confirming parathyroid tissue and establishing a cure. Institutions and surgeons utilize different intraoperative adjuncts in different protocols with varying results. The purpose of this article is to review the available intraoperative adjuncts to parathyroid surgery and critically evaluate their utility, accuracy and their added value to the surgeon.
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Affiliation(s)
- Haggi Mazeh
- a Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, H4/722 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Herbert Chen
- a Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, H4/722 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
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Abstract
The prevalence of primary hyperparathyroidism (PHPT) will increase with the growth of the elderly population. Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in elderly patients with PHPT, the majority of them reporting increased fracture-free survival and symptomatic relief postoperatively and thus experiencing improved quality of life. Introduction. The prevalence of primary hyperparathyroidism (PHPT) is expected to increase in developed nations as the aged population grows. This review discusses issues related to PHPT in the elderly population with a focus on differences in disease presentation, medical and surgical management, and outcomes. Methods. Literature review of English-language studies of PHPT or parathyroidectomy (PTx) in the elderly was performed. Surgical literature reviewed included original clinical studies published after 1990. Priority was given to studies with >30 patients where institutional practice and outcomes have not changed significantly over time. Results. Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. They have equivalent surgical outcomes, including morbidity, mortality, and cure rates, compared with younger patients, although their length of hospital stay is significantly longer. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in an elderly population. Patients are referred for PTx less frequently with each advancing decade, although surgical referral patterns have increased over time in centers that offer minimally invasive parathyroidectomy. Elderly patients experience increased fracture-free survival after PTx. The majority of elderly patients report symptomatic relief postoperatively. Conclusion. PTx can offer elderly patients with PHPT improved quality of life. PTx is safe and effective in elderly patients, and advanced age alone should not deter surgical referral.
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Affiliation(s)
- Lilah F. Morris
- Endocrine Surgical Unit, Department of General Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Juliette Zelada
- Endocrine Surgical Unit, Department of General Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Bian Wu
- Endocrine Surgical Unit, Department of General Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Theodore J. Hahn
- VA Greater Los Angeles Geriatric Research, Education and Clinical Center and Division of Geriatric Medicine, Los Angeles, California, USA
| | - Michael W. Yeh
- Endocrine Surgical Unit, Department of General Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2010; 17:568-80. [PMID: 21030841 DOI: 10.1097/med.0b013e328341311d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Intraoperative parathyroid hormone measurement (IOPTH) has proved to be an important promoter for focused and minimally invasive parathyroidectomy procedures in primary hyperparathyroidism. IOPTH enables multiglandular disease to be excluded with a high degree of certainty at the time of operation. The choice of the cut-off value for IOPTH as the criterion for success is of utmost importance with respect to the prognosis for operative success (biochemical healing). Advantages and disadvantages of the variety of existing IOPTH success criteria are confusing and their assessment is contradictory. Particularly with respect to cost-benefit aspects the standard application of IOPTH as "biochemical frozen section" even in conventional open parathyroidectomy remains a matter of controversy. This article gives an up-date on current knowledge and provides practical guidelines for clinical use of IOPTH.
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Results of surgery for sporadic primary hyperparathyroidism in patients with preoperatively negative sestamibi scintigraphy and ultrasound. Langenbecks Arch Surg 2010; 396:83-90. [DOI: 10.1007/s00423-010-0724-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Accepted: 10/18/2010] [Indexed: 11/30/2022]
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Sitges-Serra A, Díaz-Aguirregoitia FJ, de la Quintana A, Gil-Sánchez J, Jimeno J, Prieto R, Sancho JJ. Weight difference between double parathyroid adenomas is the cause of false-positive IOPTH test after resection of the first lesion. World J Surg 2010; 34:1337-42. [PMID: 20107797 DOI: 10.1007/s00268-010-0413-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Some patients with double parathyroid adenoma show a greater than 50% decline in intraoperative parathyroid hormone (IOPTH) after resection of the first lesion. The present study was designed to test the hypothesis that significant adenoma weight differences may explain this inappropriate decline of IOPTH. METHODS We reviewed prospective database records at two tertiary institutions. Patients with a histopathologic diagnosis of double adenoma and no familial history of hyperparathyroidism were included. Diagnosis of double adenoma was confirmed either preoperatively (double uptake), intraoperatively (bilateral exploration), or at reintervention. IOPTH was determined following the Miami protocol. The 10-min postexcision sample was considered as the 0-min sample for IOPTH determinations at the time of resection of the second lesion. RESULTS Thirteen patients met the inclusion criteria. After resection of the first lesion, IOPTH failed to decline in four patients and a second adenoma was removed. They had similar weight (404 vs. 598 mg). In nine patients IOPTH showed a false greater than 50% decline. These patients had the largest adenoma removed first (846 +/- 226 mg), and only two had normal PTH serum concentrations 10 min after resection. The second adenoma was always smaller (284 +/- 177 mg; P = 0.02) and its resection either during the same operation (7 cases) or at reoperation (2 cases) led to normalization of IOPTH at 10 min in all cases. CONCLUSIONS Two-thirds of patients with double parathyroid adenoma show a false-positive decline of IOPTH after resection of the first adenoma. This appears to be due to the initial removal of the larger lesion.
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Fouquet T, Germain A, Zarnegar R, Klein M, De Talance N, Claude Mayer J, Ayav A, Bresler L, Brunaud L. Totally endoscopic lateral parathyroidectomy: prospective evaluation of 200 patients. ESES 2010 Vienna presentation. Langenbecks Arch Surg 2010; 395:935-40. [PMID: 20694475 DOI: 10.1007/s00423-010-0687-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 07/05/2010] [Indexed: 12/25/2022]
Abstract
PURPOSE Several new minimally invasive techniques (mini-open, video-assisted, and endoscopic procedures) for parathyroidectomy have been described. However, totally endoscopic lateral approach parathyroidectomy (Henry technique) is not routinely performed. METHODS This is a prospective study of 200 consecutive patients that underwent totally endoscopic lateral parathyroidectomy. RESULTS Two hundred of 387 patients (52%) with primary hyperparathyroidism were included. Fifty-six patients (28%) were converted to open parathyroidectomy. Causes for conversion were lack of intraoperative localization (11%), difficult dissection (10%), bleeding (4%), failure of normalization of IOPTH results (2%), and other causes (1%). Gland localization (areas 1 to 2 versus area 3) and CaPTHus score (<3 versus ≥3) were not associated with the risk of conversion. Mean postoperative follow-up was 13 months, and 196 patients (98%) were cured. CONCLUSIONS Totally endoscopic lateral approach can be proposed in more than half of the patients with good immediate results. Conversion rate remains important and may explain low acceptance rate of this technique.
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Affiliation(s)
- Thibaut Fouquet
- Department of Digestive, Hepatobiliary, and Endocrine Surgery, CHU Nancy-Brabois (Hopital Adultes), University of Nancy, 11 allée du morvan, 54511 Vandoeuvre-les-Nancy, France
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Iacobone M, Mondi I, Viel G, Citton M, Tropea S, Frego M, Favia G. The results of surgery for mediastinal parathyroid tumors: a comparative study of 63 patients. Langenbecks Arch Surg 2010; 395:947-53. [PMID: 20623135 DOI: 10.1007/s00423-010-0678-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 06/23/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE Parathyroidectomy for ectopic mediastinal hyperfunctioning glands could be performed by transcervical approach, sternotomy, thoracotomy, and recently by thoracoscopic and mediastinoscopic approaches. This study was aimed to analyze the results of traditional and video-assisted parathyroidectomy for mediastinal benign hyperfunctioning glands. METHODS Fifty-one upper mediastinal exploration by a conventional cervicotomy, 12 by video-assisted approaches (two thoracoscopy and 10 transcervical mediastinoscopy) and six by sternotomy were performed in 63 patients with primary hyperparathyroidism. RESULTS Video-assisted and sternotomic parathyroid explorations achieved biochemical cure in all cases; following conventional transcervical mediastinal exploration, a persistent hyperparathyroidism occurred in 11.8% of patients, who were subsequently cured by sternotomic approach. No complications occurred after video-assisted parathyroidectomy, while an overall morbidity rate of 50% and 10% was found after sternotomic and conventional cervicotomic approaches. Postoperative pain and hospital stay were significantly increased following sternotomy; patient's subjective cosmetic satisfaction was significantly higher after video-assisted and conventional cervicotomic approaches. CONCLUSIONS Conventional cervicotomic parathyroidectomy may achieve satisfactory results, especially for upper mediastinal glands. Sternotomic approaches are effective, but should be limited because of invasiveness and increased morbidity. In case of deep and lower hyperfunctioning mediastinal parathyroids, video-assisted approaches represent a less invasive, effective, and safe alternative and might be the technique of choice.
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Affiliation(s)
- Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgical and Gastroenterological Sciences, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy.
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Almquist M, Bergenfelz A, Mårtensson H, Thier M, Nordenström E. Changing biochemical presentation of primary hyperparathyroidism. Langenbecks Arch Surg 2010; 395:925-8. [PMID: 20623136 DOI: 10.1007/s00423-010-0675-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 06/21/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE Patients with primary hyperparathyroidism, pHPT, present with milder symptoms than previously. Some, but not all studies, suggest that this change in clinical pattern also implies lower preoperative parathyroid hormone (PTH) and/or calcium levels and smaller adenomas. This is important since reports indicate that smaller adenomas are more difficult to detect on preoperative imaging, possibly increasing the risk of surgical failure. METHODS There were 640 patients with histologically confirmed single-gland pHPT identified in a prospectively collected database. Median values of preoperative calcium, PTH, as well as adenoma weight were compared in three different time periods: 1990-1995, 1996-2000, and 2000-2007. Correlation between the preoperative levels of calcium and PTH and adenoma weight was calculated. RESULTS Preoperative ionized calcium decreased significantly over time (p < 0.001). There was a positive correlation between preoperative PTH and adenoma weight (r = 0.32, p < 0.001). The magnitude of this correlation decreased over time. In women, adenoma weight decreased significantly over time (p = 0.03). Median (25th-75th percentile) adenoma weight in women was 750 (400-1,380) mg, 650 (350-1,205) mg, and 520 (305-1,065) mg in the first, second, and third period, respectively. CONCLUSION From 1990 to 2007, there was a significant trend to operate pHPT patients with lower preoperative serum ionized calcium levels. In women, the adenoma weight decreased. This trend could potentially lead to decreased sensitivity in preoperative localization procedures.
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Affiliation(s)
- Martin Almquist
- Department of Surgery, Lund University Hospital, 221 85 Lund, Sweden.
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Bilateral Neck Exploration with Intraoperative iPTH Assay in the ERA of Minimaly Invasive Parathyroidectomy. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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