Minimally invasive endoscopic-assisted parathyroidectomy for primary hyperparathyroidism

Image-guided Endoscopic Parathyroidectomy Using the Axillo-breast Approach in the Treatment of Primary Hyperparathyroidism

BACKGROUND

Focused parathyroidectomy is currently performed using minimal access techniques. Here, we aim to evaluate the outcomes of the axillo-breast totally endoscopic approach (ABTEA) in patients with primary hyperparathyroidism caused by a single parathyroid adenoma.

PATIENTS AND METHODS

Ten patients with primary hyperparathyroidism were retrospectively evaluated. In all patients, the presence of a single parathyroid adenoma was confirmed using cervical ultrasonography by an expert radiologist with or without the use of parathyroid scintigraphy. All patients underwent focused parathyroidectomy using ABTEA. Clinicopathologic characteristics, surgical outcomes, biochemical cure rates, and cosmetic outcomes were evaluated.

RESULTS

The parathyroid adenoma was successfully excised in all patients without significant complications and without conversion to open approach. All patients were cured, with ≥6 months of follow-up. Temporary hoarseness of the voice was observed in 1 case. The mean surgical time was 91±17.61 minutes. The mean blood loss was 20 mL. The postoperative pain scores were satisfactory and 90% of patients were extremely satisfied with the procedure.

CONCLUSION

With accurate preoperative sonographic localization of a single parathyroid adenoma, focused parathyroidectomy using ABTEA is a safe and feasible technique even for posteriorly located parathyroid adenomas.

Outcomes of Parathyroidectomy in Patients with Primary Hyperparathyroidism: A Systematic Review and Meta-analysis

BACKGROUND

Parathyroidectomy is a definitive treatment for primary hyperparathyroidism. Patients contemplating this intervention will benefit from knowledge regarding the expected outcomes and potential risks of the currently available surgical options.

PURPOSE

To appraise and summarize the available evidence regarding benefits and harms of minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE).

DATA SOURCES

A comprehensive search of multiple databases (MEDLINE, EMBASE, and Scopus) from each database's inception to September 2014 was performed.

STUDY SELECTION

Eligible studies evaluated patients with primary hyperparathyroidism undergoing MIP or BNE.

DATA EXTRACTION

Reviewers working independently and in duplicate extracted data and assessed the risk of bias.

DATA SYNTHESIS

We identified 82 observational studies and 6 randomized trials at moderate risk of bias. Most of them reported outcomes after MIP (n = 71). Using random-effects models to pool results across studies, the cure rate was 98 % (95 % CI 97-98 %, I (2) = 10 %) with BNE and 97 % (95 % CI 96-98 %, I (2) = 86 %) with MIP. Hypocalcemia occurred in 14 % (95 % CI 10-17 % I (2) = 93 %) of the BNE cases and in 2.3 % (95 % CI 1.6-3.1 %, I (2) = 87 %) with MIP (P < 0.001). There was a statistically significant lower risk of laryngeal nerve injury with MIP (0.3 %) than with BNE (0.9 %), but similar risk of infection (0.5 vs. 0.5 %) and mortality (0.1 vs. 0.5 %).

LIMITATIONS

The available evidence, mostly observational, is at moderate risk of bias, and limited by indirect comparisons and inconsistency for some outcomes (cure rate, hypocalcemia).

CONCLUSION

MIP and BNE are both effective surgical techniques for the treatment of primary hyperparathyroidism. The safety profile of MIP appears superior to BNE (lower rate of hypocalcemia and recurrent laryngeal nerve injury).

[The minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism]

AIM

To study feasibility, effectiveness and safety of minimally invasive video-assisted parathyroidectomy in patients with primary hyperparathyroidism; to define the advantages and disadvantages of this technique compared with conventional open surgery.

MATERIAL AND METHODS

The study includes the results of 33 minimally invasive video-assisted parathyroidectomies performed in patients with primary hyperparathyroidism. The control group included 36 patients who underwent conventional open surgery.

RESULTS

There were significantly increased time of surgery in the main group (41.2±12.7 min vs. 28.4±10.9 min, p<0.05), decreased need for postoperative analgesia (1,2±0.3 vs. 1.9±0.5 days, p<0.05) and significantly longer postoperative scar (1.8±0.2 vs. 6.2±0.5 cm, p<0.01). Incidence of complications was similar in both groups (6.1% vs. 8.3%, p>0.05).

CONCLUSION

Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism is feasible, safe and effective intervention that improves early postoperative course and cosmetic outcomes.

Use of minimally invasive parathyroidectomy techniques in sporadic primary hyperparathyroidism: systematic review

The past two decades have seen rapidly changing attitudes towards the surgical management of primary hyperparathyroidism. Advances in localisation techniques and confidence with endoscopy have led to the development of numerous minimally invasive parathyroidectomy approaches, including open minimal incision and endoscopic and video-assisted parathyroidectomy. This paper systematically reviews the evidence for these methods to determine: (1) whether these new, minimally invasive techniques are comparable to conventional bilateral neck exploration methods in terms of success and complication rate; and (2) if they are comparable, which technique is likely to be best for cosmesis, patient safety and patient satisfaction. A search of the Medline, Cochrane Reviews and Scopus databases was conducted, using a defined list of search parameters. Abstracts were compared against inclusion and exclusion criteria, before the full text was sought and analysed for data. The evidence from each study was then assessed, based on study quality, and a recommendation made based on the level of evidence available. There is level 1b evidence that minimally invasive surgery is comparable to bilateral neck exploration in terms of efficacy and complication rates. This paper recommends that the treatment of choice for solitary adenoma (in most healthcare centres) should be open minimal incision parathyroidectomy, due to advantages in operative duration, learning curve and cost-effectiveness.

Endoscopic parathyroidectomy in primary hyperparathyroidism

During the past decade, endoscopic video-assisted parathyroidectomy (EP) for primary hyper parathyroidism (PHPT) has gained wider acceptance. The endoscopic gasless procedure described by P. Miccoli (1997-1998) offers an attractive technique. A routine preoperative localization study was performed with both ultrasonography and 99m TC-Sestamibi scintigraphy for each patient with sporadic PHPT. The criteria to select patients eligible for EP included absence of significant nodular goiter, a previous neck surgery, a need for concomitant thyroidectomy, a significant obesity, and multiple enlarged parathyroid glands. The surgical outcome and the use of preoperative localization together with the operative strategy were evaluated. From 2005 to 2009, 59 out of 75 patients (78%) were potentially candidates for this approach. An enlarged parathyroid gland was located by both types of imaging for 34 patients (57%) and by 99 m Tc-Sestamibi scintigraphy for 46 patients (77%). Conversion was required in 11 cases (18%). Nine patients had a negative preoperative imaging study and five underwent a successful EP. The operating time ranged from 35 to 120 min (median 45 min). Usually patients were discharged home at 48 h. There were no cases of permanent hypocalcemia or recurrent laryngeal nerve palsy. Postoperative review showed that all calcium and parathyroid hormone levels remained normal at 3 months except for 1 patient with a double adenoma. EP is a quick, safe, and effective procedure in a selected group of patients. Our results show that this technique can be easily introduced into a general head and neck practice.

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations

PURPOSE

Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration.

MATERIALS AND METHODS

Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence.

RESULTS

Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia.

CONCLUSIONS

Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy.

Contemporary parathyroidectomy: exploiting technology

BACKGROUND

Conventional parathyroidectomy, as practiced only 10 years ago, has given way to considerable change, largely as a result of the evolution of technology. Several of these important technologies include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and rapid intraoperative parathyroid hormone (IOPTH) monitoring. Modern parathyroid surgeons should maintain familiarity with the appropriate role of these approaches.

STUDY DESIGN

Evidence-based analysis of state-of-the-art approaches to the diagnosis and management of primary hyperparathyroidism.

METHODS AND MATERIALS

Four distinct technologies are analyzed in detail, with particular attention to their impact on the practice of parathyroid surgery. These include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and IOPTH.

RESULTS

Each of the technologies examined has substantial value in the current practice of parathyroidectomy. Judicious implementation of these technologies will vary from practice to practice. Radio-guided surgery may obviate the need for IOPTH monitoring, therefore resulting in the fastest procedural times. Ultrasound imaging is useful as an adjunct to sestamibi scanning to localize adenomatous parathyroid glands. Endoscopic techniques facilitate visualization through small openings and may help surgeons achieve minimal access incisions. Finally, the use of IOPTH is a useful adjunct to directed explorations, and it imparts confidence that all hyperfunctioning parathyroid tissue has been removed.

CONCLUSIONS

The practice of parathyroid surgery has undergone tremendous change in the past decade, and this change has largely been a technology-driven phenomenon. Acquisition of familiarity and skill with these new technologies will be necessary for the endocrine head and neck surgeon wishing to stay abreast of modern surgical techniques and provide quality care.

A prospective evaluation of preoperative localization by technetium-99m sestamibi scintigraphy and ultrasonography in primary hyperparathyroidism

BACKGROUND

Ultrasonography (USG) and technetium-99m sestamibi (MIBI) scintigraphy are commonly used imaging modalities in the era of minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism (pHPT). However, their relative importance and actual contribution to MIP have not been prospectively assessed.

METHODS

A total of 100 consecutive pHPT patients planning for MIP were recruited. Both USG and MIBI findings were correlated with intraoperative findings and postoperative outcome. Clinicopathologic factors were examined for potential association with a correct localizing result.

RESULTS

Thirty men and 70 women (age range 13 to 93 years [median 55.5]) were included in the study. The final pathology included 98 patients with solitary adenoma and 2 patients with multiglandular disease. The sensitivities, accuracies, and positive predicted values for USG and MIBI alone were 57% vs 89%, 56% vs 85%, and 97% vs 94%, respectively. Correctly localized adenomas were significantly heavier than incorrectly localized ones.

CONCLUSIONS

MIBI is preferred over USG in pHPT patients planning for MIP. Weight of adenoma appeared to be the only clinicopathologic factor determining localization accuracy.

Best practice no 183. Examination of parathyroid gland specimens

The pathological examination of parathyroid glands is an essential component of the evaluation of hyperparathyroidism. Traditionally, this has involved intraoperative frozen sections during bilateral surgical exploration of the neck, to confirm removal of parathyroid tissue. With recent developments in imaging, some diseased glands can be localised preoperatively, enabling removal by minimally invasive, targetted surgery, with or without additional non-histological intraoperative procedures to confirm the removal of all hyperfunctioning parathyroid tissue. This article reviews these developments and describes the ideal approach to reporting parathyroid specimens.

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.