Endoscopic total parathyroidectomy by the anterior chest approach for renal hyperparathyroidism

Endoscopic total parathyroidectomy via anterior chest approach with forearm autotransplantation for secondary hyperparathyroidism: a comparison of surgical results with open total parathyroidectomy with autotransplantation

Objective

This paper aimed to evaluate the clinical value of performing an endoscopic total parathyroidectomy through anterior chest approach with autotransplantation (EACtPTx+AT) in treating secondary hyperparathyroidism (SHPT) to summarize and share the clinical experience.

Methods

24 patients with SHPT were retrospectively analyzed:11 patients underwent open total parathyroidectomy with autotransplantation (OtPTx+AT Group) and 13 patients underwent endoscopic parathyroidectomy through anterior chest approach with autotransplantation (EACtPTx+AT Group). Comparing the two groups regarding the following factors: (1) operating conditions, such as the blood loss during the operation, the length of time spent on the operating table, the number of parathyroid glands removed, postoperative drainage volume and hospital stay. (2) clinical efficacy, parathyroid hormone (PTH) and serum calcium (Ca) levels. (3) postoperative complications.

Results

First, there were no significant differences in the number of parathyroid gland resection, operation time, intraoperative blood loss and hospital stay between the two groups. While there were significant differences in postoperative drainage volume between the two groups. Second, the two groups preoperative PTH and preoperative serum calcium decreased significantly compared with those of the two groups after surgery and there was a statistically significant difference. Thirdly, there was no postoperative bleeding, hoarseness or choking in the two groups and no conversion to open surgery case in EACtPTx+AT group.

Conclusion

Endoscopic treatment of SHPT using the anterior chest approach with forearm autotransplantation significantly improves clinical symptoms and lowers levels of PTH and serum calcium after the operation. The results confirm the operation's safety and effectiveness.

Minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional parathyroidectomy for renal hyperparathyroidism: a retrospective multicenter study

To compare minimally invasive video-assisted parathyroidectomy (MIVAP) versus conventional surgery for renal hyperparathyroidism (rHPT). Between 2006 and 2020, 53 patients underwent MIVAP and 182 underwent conventional parathyroidectomy for rHPT at the Kliniken Essen-Mitte and Knappschaftskrankenhaus Bochum, respectively. Two propensity score-matched groups were retrospectively analyzed: the MIVAP group (VG; n = 53) and the conventional group (CG; n = 53). To assess long-term results, the patients were questioned prospectively (VG; n = 17, and CG; n = 26). The VG had a smaller incision (2.8 vs. 4.8 cm), shorter operation duration (81.0 vs. 13.9 min), and shorter duration of stay (2.4 vs. 5.7 days) (p < 0.0001) but a smaller drop in parathyroid hormone (PTH) postoperatively (81.3 vs. 85.5%. p = 0.022) than the CG. The conversion rate was 9.4% (n = 5). The VG had better Patient Scar Assessment Scale (PSAS) scores (10.8 vs. 11.7 p = 0.001) but worse SF-12 health survey scores (38.7 vs. 45.8 for physical health and 46.7 vs. 53.4 for mental health) (p < 0.0001). The PTH level at follow-up was higher in the VG (162.7 vs. 59.1 ng/l, p < 0.0001). There were no differences in morbidity, number of removed parathyroid glands, disease persistence, late rHPT relapse and need for repeat surgery between groups. MIVAP was superior to conventional parathyroidectomy regarding aesthetic outcomes and cost effectiveness. Conventional surgery showed better control of PTH levels and health scores on follow-up than MIVAP, without any impact on rHPT relapse and need for repeat surgery.

Trail registration number and date of registration: DRKS00022545 on 14.12.2020.

A scoping review of approaches used for remote-access parathyroidectomy: A contemporary review of techniques, tools, pros and cons

After our coauthors described the first remote-access parathyroidectomy (RAP) series in 2000, several other approaches were developed. No systematic review has been performed to classify and evaluate RAP techniques. We performed a literature search using PubMed and Cochrane Library (CENTRAL). A total of 71 studies met our inclusion/exclusion criteria. RAP can be categorized into five approaches: (1) endoscopic and robotic axillary, (2) anterior chest, (3) transoral, (4) retroauricular, and (5) a combination of these approaches. The limited data in the literature suggest that the cure rates and safety of RAP are in no way inferior to those of open parathyroidectomy. Each approach has its advantages and disadvantages, and the recommendations for the selection of each approach are listed. The selection of approach methods might depend on the surgeon's experience and familiarity and the patient's preference and disease status.

Single-Port Access Endoscopic Thyroidectomy via Axillary Approach for the Benign Thyroid Tumor: New Aspects from Vietnam

Background

This study aims to describe our new experience with single-port totally endoscopic thyroidectomy via the axillary approach in patients with unilateral thyroid benign tumors. In parallel with that, we also discuss here the challenges and novelty highlights we have confronted and solved and the details of our operative technique.

Methods

Between August 2018 and May 2020, the study involved 54 patients who underwent a single-port single-incision endoscopic thyroidectomy via the axillary approach for benign thyroid tumor at the National Hospital of Endocrinology (Hanoi, Vietnam). Surgical patient indications were in working age, goiter classification of grade 1 or grade 2, the thyroid with mononuclear or multinucleated, lesion diameter of less than 4 cm, unilateral thyroid benign lesion and no previous history of neck surgery or irradiation.

Results

No mortality was observed. Morbidities included transient voice change in 8 patients, swallowing disorders in 2 patients, transient skin paresthesia in 2 patients and wound hematoma in 2 patients. Mean amount of postoperative drainage was 70.2 mL, mean duration of postoperative drainage was 2.7 days, and mean postoperative hospital day was 6.6 days. Mean total operation time was 66.0 minutes and mean blood loss was 13.3 mL. Regarding medium-term follow-up outcomes following surgery, we recorded the hypothyroidism in 3 patients (5.6%) and the hypocalcemia in 1 case (1.8%). Most patients felt normal neck movement and sensation (79.6%), 3 patients were painful (5.6%) and 8 those were numb (14.8%). We saw the soft incision scar in 35 patients (64.8%), convex scar in 14 patients (25.9%), and hard scar in 5 patients (9.3%).

Conclusion

Single-port endoscopic thyroidectomy via axillary approach is a safe and feasible treatment option for removing benign thyroid tumor, delivering favorable surgical outcomes with ideal cosmetic effect and reduction in injury to the anterior neck tissue.

Is total endoscopic parathyroidectomy an acceptable treatment for patients with primary hyperparathyroidism due to a presumed solitary adenoma?-comparison of minimally invasive total endoscopic parathyroidectomy and open minimally invasive parathyroidectomy

Background

Remote-access thyroidectomy and its cosmetic merit have been widely accepted, but remote-access parathyroidectomy has not become common. There are few reports about the risks and effectiveness of a remote-access endoscopic parathyroidectomy. Herein, we evaluated the risks and benefits of total endoscopic parathyroidectomy (TEP) for patients with primary hyperparathyroidism (PHPT). We retrospectively compared the surgical outcomes of TEP and open minimally invasive parathyroidectomy (MIP).

Methods

We analyzed the cases of 28 patients with PHPT who were scheduled to undergo a MIP at Mita Hospital (Tokyo) during the period from April 2015 to March 2019, all of whom were presumed preoperatively to have a single adenoma.

Results

Eleven of the patients underwent a TEP (10 females, one male; mean age 54.2 years). The other 17 patients underwent an open MIP (11 females, 6 males; mean age 63.5 years). The younger patients and the females tended to select endoscopic surgery as their treatment. The operation time was significantly longer in the TEP group compared to the open MIP group (106 vs. 50 min; P<0.001). Common postoperative complications (such as recurrent laryngeal nerve paralysis and seroma) did not occur in this series. For the TEP patients who did not undergo a partial thyroidectomy, the mean amount of drainage on the first postoperative day was only 19±10 mL. The operative cure rate of the minimally invasive parathyroidectomies was 96.4%.

Conclusions

TEP is a good surgical procedure for hyperparathyroidism caused by a single adenoma, and it achieves superior cosmetic results without increasing the rate of complications.

Endoscopic parathyroidectomy: a retrospective review of 27 cases

BACKGROUND

Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP).

METHODS

Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection.

RESULTS

Eleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104 min and 34 mL in trans-vestibular approach, respectively, while they were 47 min and 68 mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids.

CONCLUSION

Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.

Practice Patterns in Parathyroid Surgery: A Survey of Asia-Pacific Parathyroid Surgeons

BACKGROUND

Practice variations exist amongst parathyroid surgeons depending on their expertise and resources. Our study aims to elucidate the choice of surgical techniques and adjuncts used in parathyroid surgery by surgeons in the Asia-Pacific region.

METHODS

A 25-question online survey was sent to members of five endocrine surgery associations. Questions covered training background, practice environment and preferred techniques in parathyroid surgery. Respondents were divided into three regions: Australia/New Zealand, South/South East Asia and East Asia, and responses were analysed according to region, specialty, case volume and years in practice.

RESULTS

One hundred ninety-six surgeons returned the questionnaire. Most surgeons (98%) routinely perform preoperative imaging, with 75% preferring dual imaging with ^99mTcsestamibi and ultrasound. Ten per cent of surgeons use parathyroid 4DCT as first-line imaging, more commonly in East Asia (p = 0.038). Minimally invasive parathyroidectomy is the favoured technique of choice (97%). Most surgeons reporting robotic or endoscopic approaches are from East Asia. Rapid intraoperative parathyroid hormone is accessible to just under half of the surgeons but less available in Australian/New Zealand (p < 0.001). The use of intraoperative neuromonitoring is not commonly used, even less so amongst Asian surgeons (p = 0.048) and surgeons with low case load (p = 0.013).

CONCLUSION

Dual localisation techniques are the preferred choice of investigations in preparation for parathyroid surgery, with minimally invasive surgery without neuromonitoring the preferred approach. Use of adjuncts is sporadic and limited to certain centres.

[Pectoral-retroauricular approach for endoscopic parathyroidectomy (experimental study)]

AIM

To develop and investigate in the experiment the method of endoscopic parathyroidectomy in order to prevent intraoperative 'conflict of the instruments' and to reduce surgical trauma via extracervical approach.

MATERIAL AND METHODS

The results of 10 experimental endoscopic parathyroidectomies with original pectoral-retroauricular approach were analyzed.

RESULTS

Mean time of surgery was 77.8±10.2 minutes (65-97), mean time of surgical exposure - 50.3±6.7 minutes (41-59). Visualization and identification of parathyroid glands were achieved in 100% of cases. Recurrent laryngeal nerve was preserved in 100% of cases.

CONCLUSION

Original endoscopic pectoral-retroauricular approach for parathyroidectomy is methodologically and technically justified and can be recommended for clinical application.

Transoral endoscopic parathyroidectomy vestibular approach: a novel scarless parathyroid surgery

BACKGROUND

Natural orifice transluminal endoscopic surgery developed for neck surgery become increasing popular. Herein, an innovative transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) was developed for primary hyperparathyroidism (PHPT) and renal hyperparathyroidism (rHPT).

METHODS

Incisions were made at the oral vestibule under the inferior lip. A 10-mm trocar was inserted through the center of the oral vestibule with two 5-mm trocars laterally. The subplatysmal space was created down to the sternal notch, and carbon dioxide pressure was insufflated at 6 mmHg to maintain the working space. Parathyroidectomy was performed using laparoscopic instruments. Intraoperative parathyroid hormone level and frozen section were conducted. Autotransplantation of the parathyroid gland was performed at the non-dominant forearm in an rHPT patient.

RESULTS

From March 2015 to June 2016, TOEPVA was successfully performed in 12 patients (six PHPT and six rHPT). The mean operative time for parathyroidectomy in PHPT patients was 107.5 min (range 88-127) and 185.8 min in rHPT patients (range 155-214). One patient experienced a transient recurrent laryngeal nerve injury which was spontaneously resolved within 1 month. No permanent recurrent laryngeal nerve injury was found. Serum calcium level returned to normal range in all patients. The serum parathyroid hormone level of the PHPT and the rHPT group at 30 days was 36.38 ± 7.1 pg/mL (range 27.7-46.5) and 60.35 ± 15.94 pg/mL (range 38.7-87.2), respectively. The postoperative cosmetic outcome was excellent. No mental nerve injury or infection was found.

CONCLUSIONS

TOEPVA is a feasible, safe, and reasonable surgical option for patients with hyperparathyroidism, especially those with cosmetic concerns.

Endoscopic and robotic parathyroidectomy in patients with primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is one of the most common endocrine disorders for which parathyroidectomy is the most effective therapy. Until late 1970s, the standard approach to parathyroidectomy was a four-gland exploration using a large skin incision. However, 80 to 85 percent of cases of PHPT are caused by a single adenoma. As such, the concept of performing a bilateral exploration in order to visualize all four glands has been argued to be excessive since in the majority of cases, there is only one abnormal gland. Focused exploration (one gland) is currently the standard technique for parathyroidectomy worldwide. Despite a rapid acceptance of minimally invasive approaches in most endocrine surgery centers, the use of an endoscope with or without the use of a robotic system to perform parathyroidectomy remains controversial. The goal of this study was to review current available data about surgical approaches using an endoscope with or without the use of a robotic system in the management of patients with PHPT. For conventional endoscopic and video assisted parathyroidectomy, several comparative studies have demonstrated some advantages in terms of reduced postoperative pain, better cosmetic results and higher patient satisfaction compared to open non-endoscopic minimally invasive parathyroidectomy. Robot-assisted transaxillary parathyroidectomy has the advantage of leaving no scar in the neck but its role has not yet been delineated clearly given the limited number of published series. Subjective postoperative cosmetic evaluation is good by concealing the scar in the axilla or infraclavicular area. However, this approach is associated with more extensive dissection than during conventional open or endoscopic neck access surgical procedures. Patients with true ectopic mediastinal parathyroid glands are good candidates for conventional or robot-assisted thoracoscopic approaches because these glands are in remote and narrow anatomical locations.

Robotic total parathyroidectomy by the axillo-bilateral-breast approach for secondary hyperparathyroidism: a feasibility study

BACKGROUND

The aim of this study was to evaluate the clinical application and superiority of the da Vinci(®) Si Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) in total parathyroidectomy for secondary hyperparathyroidism.

MATERIALS AND METHODS

Total parathyroidectomy was performed with the da Vinci Si Surgical System by the four-trocar axillo-bilateral-breast approach. The patients were placed in the supine position, and the operation procedure included creating the workspace, docking, and consoling stages. The camera arm is centered in the working space. Three working arms are then placed adjacent to the camera. The Harmonic(®) scalpel (Ethicon Endo-surgery, Inc., Cincinnati, OH) was used for hemostasis and gland resection, and dissected parathyroid was taken out by a specimen pouch.

RESULTS

Total parathyroidectomy with trace amounts of parathyroid tissue autotransplantation in 6 patients was successfully performed with the da Vinci Si Surgical System. There were no operation-related complications and no conversions to open or endoscopic surgery. Mean operation time was 156 minutes. Patients were discharged from the hospital 6 days after surgery. The postoperative cosmetic result was satisfactory, with minimal numbness and tingling on the anterior chest.

CONCLUSIONS

This initial study shows that robotic total parathyroidectomy via the axillo-bilateral-breast approach is a safe and feasible alternative to selected patients, especially those with esthetic concerns.

A comparison of minimally invasive video-assisted parathyroidectomy and traditional parathyroidectomy for parathyroid adenoma

Background: Pre-operative imaging techniques for sporadic primary hyperparathyroidism (SPHPT) and intraoperative parathyroid hormone (ioPTH) have led to the wide spread use of minimally invasive surgical approaches.

Study Design: In our prospectively collected database, 157 subjects with SPHPT and a preoperative diagnosis of parathyroid adenoma were treated with parathyroidectomy between January 2003 and November 2011. Subjects in group A were enrolled between January 2003 to September 2006, and underwent traditional parathyroidectomy with intraoperative frozen section and bilateral neck exploration. Subjects in group B were enrolled between September 2006 to November 2011, and underwent minimally invasive video-assisted parathyroidectomy (MIVAP) with ioPTH. Operative times and post-operative pain levels were compared between groups. Subjects were followed for a minimum of 6 months post-operatively and recurrence rates and complication rates were measured between groups.

Results: 81 subjects were enrolled in group A, and 76 subjects were enrolled in group B. Pre-operative evaluation demonstrated that the groups were statistically similar. Significantly decreased operative times (28min vs. 62min) and post-operative pain levels were noted in group B. Recurrence rates were similar between group A (3.7%) and group B (2.6%).

Conclusions: MIVAP with ioPTH demonstrated significantly improved operative times and post-operative pain levels, while maintaining equivalent recurrence rates.

Imaging techniques in parathyroid surgery for primary hyperparathyroidism

As more patients present with the incidental diagnosis of primary hyperparathyroidism due to biochemical screening, treatment guidelines have been developed for the treatment of hyperparathyroidism. Management of primary hyperparathyroidism has evolved in recent years, with considerable interest in minimally invasive approaches. Successful localization of the diseased gland(s) by nuclear imaging and anatomical studies, along with rapid intraoperative parathyroid hormone assay, has allowed for focused and minimally invasive surgical approaches. Patients in whom the localization studies have identified single-gland adenoma or unilateral disease are candidates for such focused approaches instead of the traditional approach of bilateral exploration. These imaging techniques have also been critical in the successful management of patients with persistent or recurrent disease.

Video-assisted bilateral neck exploration in patients with primary hyperparathyroidism and failed localization studies

BACKGROUND

In primary hyperparathyroidism (pHPT) positive preoperative localization studies are accepted as a precondition for applying minimally invasive surgical techniques. Without localization, open bilateral neck exploration (BNE) is considered the standard option. The present study analyzes the feasibility and effectiveness of minimally invasive video-assisted BNE in patients with pHPT and negative or discordant localization studies.

METHODS

From a prospective series of 380 minimally invasive video-assisted parathyroidectomies (MIVAP) performed in 367 patients for pHPT (1999-2009), 68 patients (10 male, 58 female; mean age: 58 years) were selected. These patients had failed localization studies and underwent BNE with the MIVAP technique. Operative time, complications, conversions to open technique, and cure rate were determined.

RESULTS

Mean operative time was 52 +/- 26 min (range: 20-180 min). MIVAP with BNE was successfully completed in 66 (97%) patients with two conversions to open technique. Recurrent laryngeal nerve palsy occurred in one patient. Biochemical cure was achieved in 67 patients (98.5%), in 65 patients (95.5%) after the first operation and in two more patients by video-assisted re-exploration on the first postoperative day. One patient remained with persistent disease even after repeated open BNE.

CONCLUSIONS

In experienced hands, video-assisted BNE with the MIVAP technique, for pHPT and failed localization studies, is feasible, safe, and gives results equivalent to the conventional open technique.

Minimally invasive video-assisted parathyroidectomy (MIVAP) for secondary hyperparathyroidism: report of initial experience

BACKGROUND

Minimally invasive video-assisted parathyroidectomy (MIVAP) has become a well-accepted procedure for patients with primary hyperparathyroidism. Because it allows bilateral neck exploration, the authors began using this technique for patients with secondary hyperparathyroidism. In this preliminary study, the authors report their initial experience.

METHODS

From July 2006 to November 2008, 12 patients (6 women, 6 men; mean age, 45.5 +/- 16.9 years (range, 23-71 years) underwent MIVAP with bilateral exploration for secondary hyperparathyroidism. The operation was performed through a central 2-cm to 3-cm skin incision; a 30 degrees 5-mm endoscope was used for magnification.

RESULTS

MIVAP was successfully completed in 11 patients (92%). The mean operative time was 81 +/- 37 minutes (range, 35-130 minutes). No major complications were registered. After a mean follow-up period of 11.4 months (range, 3-30 months), 1 patient showed recurrence.

CONCLUSIONS

MIVAP appears to be a safe and feasible procedure in patients with secondary hyperparathyroidism.

Surgical management of primary hyperparathyroidism: state of the art

This article reviews the current state of the art regarding therapy for primary hyperparathyroidism. Clinical evaluation and indications for parathyroidectomy are described, followed by a review of surgical techniques currently being practiced and possible outcomes involved. Focused parathyroidectomy has become a successful alternative to conventional bilateral cervical exploration.

Fluorescence-guided minimally invasive parathyroidectomy: a novel surgical therapy for secondary hyperparathyroidism

Secondary hyperparathyroidism (SHPT) is a severe and frequent complication in patients with advanced chronic kidney disease, characterized by hyperplasia of all parathyroid glands and elevated serum parathyroid hormone levels. When surgery is required to prevent cardiovascular consequences, bone pain, osteoporosis, or even soft-tissue calcifications, detection of the enlarged glands often can be difficult because of their variability in number and location. A novel surgical technique, fluorescence-guided minimally invasive parathyroidectomy, may facilitate intraoperative localization of parathyroid glands. A 52-year-old woman with SHPT underwent minimally invasive videoscopic-assisted parathyroidectomy after photosensitization with aminolevulinic acid (ALA): Under special fluorescence illumination by D-Light (Karl Storz Co, Tuttlingen, Germany), bilateral neck exploration was performed. All enlarged parathyroid glands were identified because of their ALA-induced intense red fluorescence. Such surrounding structures as thyroid, lymph nodes, and soft tissue remained nonfluorescent and could be distinguished easily from parathyroid glands. Total parathyroidectomy with autotransplantation into the sternocleidoid muscle was performed. In patients with SHPT, exploration of all parathyroid glands during surgery is mandatory. However, to date, there is no convincing technical aid for the surgeon to facilitate this procedure. The ALA-induced fluorescence technique represents an innovative visual detection method for intraoperative identification of parathyroid glands. The technique serves as an additional tool requiring only moderate technical and clinical expenditure.

The surgeon's armamentarium to the surgical treatment of primary hyperparathyroidism

Parathyroidectomy cures the vast majority of patients with primary hyperparathyroidism (HPT). While bilateral neck exploration has been the mainstay of therapy, recent advances in technology have revolutionized the field making a focused approach to parathyroidectomy a reality. The development of accurate pre-operative localization with sestamibi scanning, effective unilateral, endoscopic and video-assisted techniques, and rapid intra-operative parathyroid hormone (PTH) testing have made it possible to cure patients with the least amount of surgical dissection possible. In this paper, we will explore the role of focused parathyroidectomy in the surgical treatment of primary HPT.

Endoscopic parathyroidectomy

This article describes the techniques of endoscopic and endoscopic assisted parathyroidectomy, with a special emphasis on the accumulated experience as well as the advantages and drawbacks of these novel techniques.

Primary hyperparathyroidism

PURPOSE OF REVIEW

This contribution presents research progress concerning primary hyperparathyroidism (pHPT), and the background for recent notable changes in treatment policy.

RECENT FINDINGS

Research has clarified that most patients with pHPT require surgery due to risk for osteoporosis, renal stones, and possibly silent complications of renal impairment, cardiovascular disease, and common psychiatric disability. Genetic studies have advanced, but the cause of the disease remains unclear for most patients. Localization methods for parathyroid tumors have improved and increased the interest for less invasive operative methods with shorter hospital stays and reduced costs for the patient. It is important to delineate when this really will imply progress and to use the new diagnostic methods in discussions of appropriate treatment strategies. It has also become evident that older pHPT patients especially could benefit from medical treatment of bone mineral deficit, and they may also need vitamin D or vitamin D analogues to prevent progress of the disease.

SUMMARY

pHPT is a common disorder among postmenopausal women, in whom most commonly applied surgical treatment has proven markedly efficient. There is now increased interest to better understand possible causes of the disease and schedule the most efficient surgical and medical treatment and discuss possible prophylaxis.

Total endoscopic parathyroidectomy

During the last five years, minimally invasive procedures have been adopted for the surgical treatment of hyperparathyroidism, because preoperative localization studies such as high-resolution ultrasonography and sestamibi scintigraphy, guidance by intraoperative scans, and the use of quick, intraoperative parathyroid hormone assay have improved. Endoscopic parathyroidectomy was performed by Gagner in 1996, and surgical procedures using endoscopy have been devised. The endoscopic procedures range from the "pure" endoscopic approach characterized by constant gas insufflation to video-assisted gasless techniques. We adopted the "pure" endoscopic approach, because a small incision can be made far from the neck and the cosmetic result is excellent. We report our technique with no scars in the neck region for endoscopic unilateral neck exploration with primary hyperparathyroidism and for endoscopic bilateral neck exploration with renal hyperparathyroidism.

Total endoscopic thyroidectomy: axillary or anterior chest approach

We have developed endoscopic thyroidectomy by an anterior chest approach and an axillary approach. In this study, we evaluate the efficacy of these two types of endoscopic procedures and conventional open surgery. The degree of surgical invasiveness and the nature of patients' complaints after surgery were compared using the results of the operation and a questionnaire. The mean operating time for the endoscopic procedure was significantly longer than that for open surgery; however, there was no difference in postoperative pain in the three groups. Three months after surgery, the incidence of discomfort while swallowing in open surgery was higher than that in endoscopic surgery. All the patients who were treated using the axillary approach were satisfied with the cosmetic results. However, five patients (25%) who were treated using the anterior chest approach and 15 patients (75%; P < 0.01) who underwent open surgery complained abut the cosmetic results. The incidence of postoperative complaints after endoscopic surgery is significantly lower than that after open surgery. Patients who were treated using the axillary approach can obtain superior cosmetic results, compared with those who received other procedures.

Clinical benefits in endoscopic thyroidectomy by the axillary approach

BACKGROUND

Surgical treatments for thyroid diseases require skin incisions that can result in prominent scars, complaints resulting from adhesions, hypesthesia, and paresthesia in the neck. We have developed an endoscopic thyroidectomy using an axillary approach. In this article, we compare our original technique with conventional open surgery from the aspects of surgical invasiveness and patients' complaints after surgery.

STUDY DESIGN

Each procedure was performed in 20 patients with follicular tumors. The two groups were similar for age, gender, and the mean diameter of the thyroid tumor. No statistically significant difference in the final pathological diagnosis was found between the two groups. Surgical invasiveness and patients' complaints after surgery were compared using results of the operation and a questionnaire.

RESULTS

The operating time for open surgery was significantly shorter than that for endoscopic surgery (p < 0.01). In the endoscopic surgery group, the patient questionnaires revealed that 4 patients had severe anterior chest pain on the first postoperative day. The postoperative pain decreased after, and we could not find any difference between the two groups with regard to postoperative pain. Three months after surgery, one patient who had received an endoscopic procedure complained of slight hypesthesia, and none of the patients complained of discomfort while swallowing. Among the patients who underwent open surgery, 13 patients (65%; p < 0.01) complained of hypesthesia or paresthesia and 6 patients (30%; p < 0.05) complained of discomfort while swallowing. All of the patients treated using the endoscopic procedure were satisfied with the cosmetic results, but 15 patients who underwent open surgery complained of unsatisfactory cosmetic results (p < 0.01).

CONCLUSIONS

The incidence of postoperative complaints after endoscopic surgery is considerably lower than that after open surgery.