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Giudici F, Fortuna L, Russo E, Badii B, Coratti F, Staderini F, Morandi A, Sparano C, Petrone L, Cianchi F, Perigli G. Surgery for Sporadic Primary Hyperparathyroidism: Evolution over the Last Twenty Years in a Monocentric Setting. Cancers (Basel) 2023; 15:cancers15092581. [PMID: 37174047 PMCID: PMC10177273 DOI: 10.3390/cancers15092581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
The sporadic parathyroid pathology of surgical interest is primarily limited to lesions that are the cause of hormonal hyperfunction (primary hyperparathyroidism). In recent years, parathyroid surgery has evolved significantly, and numerous minimally invasive parathyroidectomy techniques have been developed. In this study, we describe a single-center and well-documented case series of sporadic primary hyperparathyroidism, surgically treated by a single operator in the Endocrine Surgery Unit of the Surgical Clinic of the University of Florence-Careggi University Hospital, recorded and updated in a dedicated database that embraces the entire evolutionary timeframe of parathyroid surgery. From January 2000 to May 2020, 504 patients with a clinical and instrumental diagnosis of hyperparathyroidism were included in the study. The patients were divided into two groups, based on the application of intraoperative parathyroid hormone (ioPTH). The analysis shows that the use of ioPTH with the rapid method could be ineffective in helping surgeons in primary operations, especially when ultrasound and scintiscan are concordant. The advantages obtained by not using intraoperative PTH are not only economic. In fact, our data shows shorter operating and general anesthesia times and hospital stays, having an important impact on patient biological commitment. Furthermore, the significant reduction in operating time makes it possible to almost triple the volume of activity in the same unit of time available, with an undeniable advantage for the reduction of waiting lists. In recent years, minimally invasive approaches have allowed surgeons to reach the best compromise between invasiveness and aesthetic results.
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Affiliation(s)
- Francesco Giudici
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Laura Fortuna
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Edda Russo
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Benedetta Badii
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Francesco Coratti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Fabio Staderini
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Alessio Morandi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Clotilde Sparano
- Department of Biomedical, Experimental and Clinical Sciences Mario Serio, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Luisa Petrone
- Department of Biomedical, Experimental and Clinical Sciences Mario Serio, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Fabio Cianchi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
| | - Giuliano Perigli
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 6, 50135 Florence, Italy
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Muacevic A, Adler JR, Althaf S, Halkud R. Primary Hyperparathyroidism: Is Image Localization Alone Sufficient to Ensure Long-Term Cure in Unifocal Disease? Cureus 2022; 14:e31244. [PMID: 36514639 PMCID: PMC9733777 DOI: 10.7759/cureus.31244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Advances in imaging have facilitated precise preoperative localization and focused resection of hyperfunctional parathyroids in primary hyperparathyroidism (PHPT). Combining imaging techniques or a "dual" approach, when concordant, improves adenoma-localizing accuracy above individual modalities. This study sought to assess biochemical cure and failure rates (persistence or recurrence) of surgery directed by dual imaging alone in PHPT. METHODOLOGY This observational, single-center analysis comprised 31 patients diagnosed with PHPT and imaged with both ultrasound (USG) of the neck and sestamibi scintigraphy. The extent of surgery was based solely on inter-modality concurrence for adenoma localization; imaging-concordant patients underwent focused parathyroidectomy, whereas discordant patients necessitated neck exploration (with extent altered according to scintigraphic lesion lateralization). No intraoperative localizing adjuncts were used. RESULTS Twenty-three patients had concordant imaging, of which 19 underwent focused exploration, with sensitivity and positive predictive value (PPV) for dual imaging of 100% and 95.7%, respectively. The overall sensitivity and PPV were 92.9% and 89.7% for USG alone and 100% and 93.6% for scintigraphy, respectively. The mean age and prevalence of thyroid disease were significantly higher in the discordant group. All patients achieved postoperative normocalcemia. There were no cases of persistent or recurrent hyperparathyroidism on follow-up. CONCLUSIONS In the imaging-concordant setting, focused surgery may be safely performed with the omission of other adjuncts for localization. Older age and concomitant thyroid pathology predispose to discordant imaging and are risk factors for surgical failure when attempting an image-directed approach. Neck exploration is an alternative in these patients with excellent cure rates and acceptable morbidity.
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Smaxwil C, Aschoff P, Reischl G, Busch M, Wagner J, Altmeier J, Ploner O, Zielke A. [ 18F]fluoro-ethylcholine-PET Plus 4D-CT (FEC-PET-CT): A Break-Through Tool to Localize the "Negative" Parathyroid Adenoma. One Year Follow Up Results Involving 170 Patients. J Clin Med 2021; 10:jcm10081648. [PMID: 33924371 PMCID: PMC8068905 DOI: 10.3390/jcm10081648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/16/2021] [Accepted: 03/25/2021] [Indexed: 12/18/2022] Open
Abstract
Background: The diagnostic performance of [18F]fluoro-ethylcholine-PET-CT&4D-CT (FEC-PET&4D-CT) to identify parathyroid adenomas (PA) was analyzed when ultrasound (US) or MIBI-Scan (MS) failed to localize. Postsurgical one year follow-up data are presented. Methods: Patients in whom US and MS delivered either incongruent or entirely negative findings were subjected to FEC-PET&4D-CT and cases from July 2017 to June 2020 were analyzed, retrospectively. Cervical exploration with intraoperative PTH-monitoring (IO-PTH) was performed. Imaging results were correlated to intraoperative findings, and short term and one year postoperative follow-up data. Results: From July 2017 to June 2020 in 171 FEC-PET&4D-CTs 159 (92.9%) PAs were suggested. 147 patients already had surgery, FEC-PET&4D-CT accurately localized in 141; false neg. 4, false pos. 2, global sensitivity 0.97; accuracy 0.96, PPV 0.99. All of the 117 patients that already have completed their 12-month postoperative follow up had normal biochemical parameter, i.e., no signs of persisting disease. However, two cases may have a potential for recurrent disease, for a cure rate of at least 98.3%. Conclusion: FEC-PET&4D-CT shows unprecedented results regarding the accuracy localizing PAs. The one-year-follow-up data demonstrate a high cure rate. We, therefore, suggest FEC-PET-CT as the relevant diagnostic tool for the localization of PAs when US fails to localize PA, especially after previous surgery to the neck.
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Affiliation(s)
- Constantin Smaxwil
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
- Correspondence: ; Tel.: +49-711-9913301; Fax: +49-711-9913309
| | - Philip Aschoff
- Department of Nuclear Medicine and PET-CT Centre, Institute of Diagnostic and Interventional Radiology, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany;
| | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, Werner Siemens Imaging Center, Eberhard Karls University of Tuebingen, 72076 Tuebingen, Germany;
- Cluster of Excellence iFIT (EXC 2180) Image Guided and Functionally Instructed Tumor Therapies, University of Tuebingen, 72076 Tuebingen, Germany
| | - Mirjam Busch
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
| | - Joachim Wagner
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
| | - Julia Altmeier
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
| | - Oswald Ploner
- Department of Internal Medicine, Endocrinology, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany;
| | - Andreas Zielke
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
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Paspala A, Spartalis E, Nastos C, Tsourouflis G, Dimitroulis D, Pikoulis E, Nikiteas N. Robotic-assisted parathyroidectomy and short-term outcomes: a systematic review of the literature. J Robot Surg 2020; 14:821-827. [PMID: 32661866 DOI: 10.1007/s11701-020-01119-x] [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] [Received: 12/22/2019] [Accepted: 07/09/2020] [Indexed: 11/27/2022]
Abstract
Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these patients.
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Affiliation(s)
- A Paspala
- Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, Athens, Greece.
- 3rd Department of Surgery, Medical School, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - E Spartalis
- Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, Athens, Greece
| | - C Nastos
- 3rd Department of Surgery, Medical School, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - G Tsourouflis
- Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, Athens, Greece
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Dimitroulis
- Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, Athens, Greece
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - E Pikoulis
- 3rd Department of Surgery, Medical School, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - N Nikiteas
- Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, Athens, Greece
- 2nd Department of Propaedeutic Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Djordjević L, Bojić T, Djordjević M, Marinković M. TUMORS OF PARATHYROID GLANDS. ACTA MEDICA MEDIANAE 2019. [DOI: 10.5633/amm.2019.0315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Christakis I, Khan S, Sadler GP, Gleeson FV, Bradley KM, Mihai R. 18Fluorocholine PET/CT scanning with arterial phase-enhanced CT is useful for persistent/recurrent primary hyperparathyroidism: first UK case series results. Ann R Coll Surg Engl 2019; 101:501-507. [PMID: 31305126 PMCID: PMC6667949 DOI: 10.1308/rcsann.2019.0059] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Redo parathyroidectomy for persistent/recurrent primary hyperparathyroidism is associated with a higher risk of complications and should be planned only with convincing localisation. We assessed whether 18fluorocholine positron emission tomography/computed tomography could identify parathyroid adenoma(s) in patients with persistent/recurrent primary hyperparathyroidism and negative conventional scans. MATERIALS AND METHODS A departmental database was used to identify patients with failed localisation attempts (sestamibi single photon emission computed tomography/computed tomography and/or computed tomography/magnetic resonance imaging and/or selective parathyroid hormone sampling) after previous unsuccessful surgery for primary hyperparathyroidism. 18Fluorocholine positron emission tomography was performed in all patients and redo surgery offered to those with positive findings. RESULTS 18Fluorocholine positron emission tomography incorporating arterial and portal phase enhanced computed tomography was performed in 12 patients with persistent/recurrent primary hyperparathyroidism (four men and eight women). Seven patients (58%) were cured after excision of adenomas located in ectopic positions (n = 3) or in anatomical position (n = 4). Five patients (42%) had persistent hypercalcaemia and repeat 18fluorocholine scan confirmed that the area highlighted on preoperative scans was excised. The arterial phase enhancement of the computed tomography was significantly different between cured and not-cured patients (P = 0.007). All seven cured patients had either a strong or weak enhancing pattern on computed tomography. Standardised uptake value at 60 minutes in patients with successful surgery (range 2.7-15.7, median 4.05) was higher than in patients with failed surgery (range 1.8-5.8, median 3.2) but was not statistically significant (P = 0.300). DISCUSSION 18fluorocholine scanning can identify elusive parathyroid adenomas, including those that are ectopic, and is useful in the management of patients with persistent/recurrent primary hyperparathyroidism when first-line scans are negative. The grading of the arterial phase of computed tomography can help to differentiate between true adenomas and false positive targets (lymph nodes).
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Affiliation(s)
- I Christakis
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Khan
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - GP Sadler
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - FV Gleeson
- Department of Radiology, Churchill Hospital, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - KM Bradley
- Department of Radiology, Churchill Hospital, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - R Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Thomas PR, Beggs AD, Han TS. Utility of surgeon-performed pre-operative ultrasound in the localisation of parathyroid adenomas. JRSM Cardiovasc Dis 2019; 8:2048004019856950. [PMID: 31258895 PMCID: PMC6585239 DOI: 10.1177/2048004019856949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/03/2019] [Accepted: 05/13/2019] [Indexed: 11/17/2022] Open
Abstract
Background Primary hyperparathyroidism arising from parathyroid adenoma is one of the most common endocrine disorders treated by endocrine surgeons. The adenoma is commonly identified by imaging techniques. The present study evaluated the performance of a portable ultrasound machine (Sonosite MicroMaxx) operated by a surgeon, departmental ultrasound and 99mTc-sestamibi-SPECT/CT by a radiologist in the identification of parathyroid adenomas. Methods Patient case notes were retrieved from medical records and imaging from picture archiving and communication system over the period from 2006 to 2012. 99mTc-sestamibi-SPECT/CT and departmental ultrasound images were reported by a nuclear radiologist. The ability of each imaging technique in localising parathyroid adenomas was referenced against the actual adenomas identified from parathyroidectomy. Results With reference to the actual site of the lesion, surgeon-performed ultrasound accurately localised the site of the lesion in 30/33 (90.1%) of cases with a sensitivity of 86.7%, departmental ultrasound accurately localised the site of the lesion in 21/26 (80.1%) of cases with a sensitivity of 79.2%. In 6/75 patients where 99mTc-sestamibi-SPECT/CT did not localise the lesion, departmental ultrasound did not localise any lesions correctly, while surgeon-performed ultrasound successfully located the adenoma in three (50%) of these six patients. Patients whose parathyroid adenomas identified by the surgeon were more likely to have shorter length of stay in hospital: odds ratio = 0.53 (95% confidence interval = 0.30-0.92, p = 0.025). Conclusions Surgeon-performed ultrasound for immediately pre-operative localisation improves identification of parathyroid adenomas and reduces length of stay in hospital, lending support for the use of this technique by endocrine surgeons.
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Affiliation(s)
- Paul Rs Thomas
- Department of Surgery, Epsom & St Helier Hospital NHS Trust, Surrey, UK
| | - Andrew D Beggs
- Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK.,Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Thang S Han
- Department of Endocrinology, Ashford & St Peter's NHS Foundation Trust, Chertsey, UK.,Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
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Abstract
Primary hyperparathyroidism (PHPT) is characterized by excessive, dysregulated production of parathyroid hormone (PTH) by 1 or more abnormal parathyroid glands. Minimally invasive surgical techniques have created a need for more precise localization of the parathyroid lesion by imaging. A variety of imaging protocols and techniques have been used for this purpose, but no one modality is clearly superior. Nuclear medicine scintigraphy and ultrasound imaging are established modalities, although multiphase or 4-dimensional computed tomography is an emerging modality with several advantages. This review provides a background regarding PHPT and key anatomy, and discusses these alternative parathyroid imaging modalities with updates.
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Affiliation(s)
- Samuel J Kuzminski
- Department of Radiological Sciences, University of Oklahoma Health Sciences Center, College of Medicine, PO Box 2690, Garrison Tower, Suite 4G4250, Oklahoma City, OK 73126, USA
| | - Julie A Sosa
- Department of Surgery, Duke University, Duke University Medical Center, Box 2945, Durham, NC 27710, USA
| | - Jenny K Hoang
- Department of Radiology, Duke University, Duke University Medical Center, Box 3808, Erwin Road, Durham, NC 27710, USA.
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Christakis I, Vu T, Chuang HH, Fellman B, Figueroa AM, Williams MD, Busaidy NL, Perrier ND. The diagnostic accuracy of neck ultrasound, 4D-Computed tomographyand sestamibi imaging in parathyroid carcinoma. Eur J Radiol 2017; 95:82-88. [DOI: 10.1016/j.ejrad.2017.07.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 06/17/2017] [Accepted: 07/31/2017] [Indexed: 02/08/2023]
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Sadeghi N, Li NW, Shokri T, Akin E, Joshi AS, Knoll S. Minimally elevated preoperative parathyroid hormone level influences the management of primary hyperparathyroidism. Laryngoscope 2017; 128:1016-1021. [PMID: 28850730 DOI: 10.1002/lary.26699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/05/2017] [Accepted: 04/25/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine the effect of preoperative parathyroid hormone (PTH) level on the extent of surgery and the accuracy of parathyroid imaging in primary hyperparathyroidism. STUDY DESIGN Retrospective cohort. METHODS Final diagnosis of single-gland adenoma and its location versus multigland disease was established in this retrospective cohort study. Positive predictive value, negative predictive value, and accuracy of imaging were analyzed in relation to preoperative PTH levels. RESULTS Eighty-seven percent of the 218 patients enrolled in the study underwent unilateral targeted operation and had a 97.9% (95% confidence interval: 95.8%-100%) success rate. However, in patients with PTH <65 pg/mL, 28.6% had bilateral exploration compared to 10.3% in those with PTH ≥65 pg/mL (P = .042). In patients with PTH <65 pg/mL, 7/21 (33.3%) had inaccurate sestamibi findings compared to 24/174 (13.8%) in patients with PTH ≥65 pg/mL (P = .047). CONCLUSIONS Accuracy of sestamibi drops significantly, by threefold, in patients with mild primary hyperparathyroidism and PTH <65 pg/mL. Patients with PTH < 65 pg/mL have a 2.5-fold higher rate of bilateral operation to identify the hypersecreting gland(s) compared to patients with PTH ≥65 pg/mL. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1016-1021, 2018.
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Affiliation(s)
- Nader Sadeghi
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Ning-Wei Li
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Tom Shokri
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Esma Akin
- Division of General Surgery, Department of Surgery, George Washington University, Washington, DC, U.S.A
| | - Arjun S Joshi
- Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC, U.S.A
| | - Stanley Knoll
- Department of Radiology, George Washington University, Washington, DC, U.S.A
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Sessa L, Lombardi CP, De Crea C, Raffaelli M, Bellantone R. Video-assisted endocrine neck surgery: state of the art. Updates Surg 2017. [DOI: 10.1007/s13304-017-0467-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Shapey IM, Jabbar S, Khan Z, Nicholson JE, Watson RJ. Scan-directed mini-incision focused parathyroidectomy: how accurate is accurate enough? Ann R Coll Surg Engl 2017; 99:123-128. [PMID: 28145779 PMCID: PMC5392823 DOI: 10.1308/rcsann.2016.0271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Mini-incision focused parathyroidectomy (MI-FP) is advocated as an alternative to bilateral neck exploration (BNE), owing to its reduced morbidity. The site and side of the affected gland is identified preoperatively using a combination of ultrasound and sestamibi scans. However, the acceptable degree of inter-scan concordance required to prompt MI-FP without compromising accuracy is undetermined. METHODS Accuracy of preoperative imaging was determined both individually and in combination for all parathyroidectomies (2007-2014). A grading system (excellent, good, poor) was devised to describe the interscan concordance, which was validated by the operative and histological findings. RESULTS Eighty-nine patients (17 male, 68 female) underwent parathyroidectomy (MI-FP 44, BNE 45). The accuracy of scans interpreted individually was 53% for ultrasound and 60% for sestamibi, with no difference according to surgical technique (P = 0.43, P = 1, respectively). The proportion of interscan concordance was: excellent - 35%, good - 40%, poor 25%. Combined accuracy was 100% for both excellent and good grades but only 13% for those graded poor. Similar rates of normocalcaemia were observed for MI-FP and BNE, while postoperative hypocalcaemia was five times higher in those undergoing BNE. CONCLUSIONS Reduction in the inter-scan concordance from excellent to good does not compromise accuracy. MI-FP could be successfully performed in up to 75% of patients - 25% higher than recommended in national guidelines. Focused parathyroidectomy does not compromise surgical and endocrinological outcomes but boasts a far superior complication rate.
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Affiliation(s)
- I M Shapey
- Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK
| | - S Jabbar
- Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK
| | - Z Khan
- Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK
| | - J E Nicholson
- Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK
| | - R J Watson
- Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK
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Alhefdhi A, Ahmad K, Sippel R, Chen H, Schneider DF. Intraoperative Parathyroid Hormone Levels at 5 min Can Identify Multigland Disease. Ann Surg Oncol 2016; 24:733-738. [PMID: 27743228 DOI: 10.1245/s10434-016-5617-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraoperative parathyroid hormone (IOPTH) monitoring is crucial in the treatment of primary hyperparathyroidism (PHPT). Often, the 5 min IOPTH levels fall, but not by the requisite 50 %. In such cases, the surgeon must decide whether to wait for additional levels or to continue exploration. This study aimed to evaluate the 5 min drop in IOPTH for distinguishing single adenomas (SA) from multigland disease. METHODS A retrospective analysis of a prospectively collected database was performed on PHPT patients who underwent initial curative parathyroidectomy between 2001 and 2013. Those with familial disease and those taking lithium or undergoing concomitant thyroidectomy were excluded from the analysis. For cases of double adenomas (DA) or hyperplasia (HA), the IOPTH values indicating additional glands were analyzed. RESULTS The inclusion criteria were met by 1021 patients: 817 patients with SA (82.2 %), 99 patients with DA (10 %), and 78 with HA (7.9 %). The SA patients exhibited a 56.6 ± 4.9 % decline in IOPTH at 5 min compared with 21.3 ± 4.5 % of the DA patients and 22.5 ± 4.3 % of the HA patients (p < 0.01). Post hoc comparisons showed that the 5 min decrease in the SA group was significantly greater than in either the DA group or the HA group (p < 0.01). A 5 min percentage decline of 35 % best distinguished SA from multiglandular disease (85.3 vs. 24.9 %). CONCLUSION The data suggest that when IOPTH level does not drop by at least 35 % at 5 min after excision, the surgeon should consider further exploration rather than wait for additional levels.
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Affiliation(s)
- Amal Alhefdhi
- Section of Endocrine Surgery, Department of Surgery, K4/738 Clinical Science Center, University of Wisconsin, Madison, WI, USA
| | - Kamal Ahmad
- Section of Endocrine Surgery, Department of Surgery, K4/738 Clinical Science Center, University of Wisconsin, Madison, WI, USA
| | - Rebecca Sippel
- Section of Endocrine Surgery, Department of Surgery, K4/738 Clinical Science Center, University of Wisconsin, Madison, WI, USA
| | - Herbert Chen
- Section of Endocrine Surgery, Department of Surgery, K4/738 Clinical Science Center, University of Wisconsin, Madison, WI, USA
| | - David F Schneider
- Section of Endocrine Surgery, Department of Surgery, K4/738 Clinical Science Center, University of Wisconsin, Madison, WI, USA.
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Raj R, Lotwala V, Anajwala P. Minimally invasive supraomohyoid neck dissection by total endoscopic technique for oral squamous carcinoma. Surg Endosc 2015; 30:2315-20. [PMID: 26715016 DOI: 10.1007/s00464-015-4427-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/07/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE To study the feasibility of a total endoscopic technique for selective neck dissection in oral cancers and to compare the technique with conventional open technique with a long cervical scar. METHODS We included patients with early intraorally resectable squamous carcinomas and excluded patients whose primary lesion required reconstruction with microvascular flaps. We compared the following intraoperative parameters: cumulative length of the incision(s), duration of surgery, estimated blood loss, and intraoperative complications. The postoperative parameters included hospital stay, shoulder function, duration of analgesic use, and early postoperative complications. We used Shoulder Pain And Disability Index scores to assess shoulder function and assessed the oncologic outcome histopathologically by the number of nodes dissected. RESULTS The mean operative time for minimally invasive supraomohyoid neck dissection (MISOND) was 53.7 ± 29.8 min, which was significantly longer than 39.4 ± 5.0 min for the open technique. The estimated blood loss in the MISOND group was significantly lower compared with the open technique (p < 0.001), and there were no major intraoperative complications in either group. Postoperative recovery assessed by hospital stay and time to resume routine work was slightly shorter in the MISOND group but not statistically significant. There were no reported early postoperative complications such as haemorrhage, wound dehiscence, or chyle leakage in either group. The mean Shoulder Pain And Disability Index score assessed 2 weeks postoperatively for the MISOND group was 14.35 ± 0.71 %, which was significantly better than 44.14 ± 1.18 % for the open technique (p < 0.001). The number of nodes dissected showed no significant difference between groups. CONCLUSIONS MISOND is a feasible and safe procedure with immediate oncologic outcomes comparable with those of conventional open SOND and provides better cosmetic and functional outcomes.
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Affiliation(s)
- Ravindrasinh Raj
- Department of Surgical Oncology, Bharat Cancer Hospital and Research Institute, Saroli, Kadodara Road, Surat, 395010, Gujarat, India.
| | - Vikram Lotwala
- Department of Minimal Access Surgery, Bharat Cancer Hospital and Research Institute, Surat, India
| | - Piyush Anajwala
- Department of Minimal Access Surgery, Bharat Cancer Hospital and Research Institute, Surat, India
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Yazici P, Mihmanli M, Bozdag E, Aygun N, Uludag M. Incidental Finding of Papillary Thyroid Carcinoma in the Patients with Primary Hyperparathyroidism. Eurasian J Med 2015; 47:194-8. [PMID: 26644769 DOI: 10.5152/eurasianjmed.2015.119] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The relationship between primary hyperparathyroidism (pHPT) and papillary thyroid cancer (PTC) still remains unclear. We aimed to investigate the incidence of the co-existence of pHPT and PTC. MATERIALS AND METHODS Between 2010 and 2013, all patients with pHPT were retrospectively reviewed and those undergoing concomitant thyroid surgery were recorded. Of these, patients with a pathological result showing papillary or micro-papillary thyroid cancer were included into the study. A chart review of 228 patients who underwent surgery for pHPT revealed 86 (37.7%) patients with concurrent thyroid disease requiring surgical treatment. RESULTS Thyroid cancer was noted in six female patients (6.9%) undergoing thyroid resection, and 2.6% of all patients with pHPT. Four patients underwent total thyroidectomy while lobectomy was applied in the remaining two. None of the cases with lobectomy required a completion thyroidectomy. CONCLUSION We demonstrated the concurrence of PTC and pHPT at a rate of 2.6% which appeared as a coincidental pathology; however, thyroid disorders, seen in one of three patients with pHPT, were not uncommon. Further research is still needed to develop a reliable explanation for relationship between pHPT and non-medullary thyroid cancer.
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Affiliation(s)
- Pinar Yazici
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Mihmanli
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Emre Bozdag
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Nurcihan Aygun
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Uludag
- Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
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What's in a name?: Providing clarity in the definition of minimally invasive parathyroidectomy. World J Surg 2015; 39:975-80. [PMID: 25446489 DOI: 10.1007/s00268-014-2902-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND In recent years minimally invasive parathyroidectomy has become the procedure of choice for many surgeons, but the meaning of the term is unclear. This is confusing for both the medical community and patients. We hypothesize that because the definition of minimally invasive parathyriodectomy in the literature is so variable this term has little meaning. METHODS We performed a Pubmed search using the terms: parathyroidectomy, minimally invasive, localized, focused, unilateral, radio-guided, video-assisted, and endoscopic. Data were collected for: author, journal title, year published, and all described aspects of parathyroidectomy. RESULTS We analyzed 443 (44%) articles after applying the exclusion criteria. Eighteen words were used in 75 different combinations to describe minimally invasive parathyroidectomy. We established four categories that encompassed all 75 definitions: 1. operative approach (incision size, describing as open; endoscopic; robotic; or video-assisted), 2. number of glands explored, 3. operative adjuncts, and 4. anesthesia type. Operative approach was the most commonly described attribute and was mentioned in 47% (n = 207) of the articles (mean incision size was found to be 2.2 cm), followed by number of glands explored, operative adjuncts, and anesthesia type. CONCLUSIONS The finding that there are 75 different definitions for minimally invasive parathyroidectomy confirms that this term is too generic to be useful. We propose a new taxonomic format to describe minimally invasive parathyroidectomy based on the four descriptive categories identified: (operative approach), (# of glands explored), parathyroidectomy using (operative adjuncts) under (anesthesia type). For example, "2 cm, single gland parathyroidectomy using intraoperative parathyroid hormone measurement, under general anesthesia".
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Tolley N, Garas G, Palazzo F, Prichard A, Chaidas K, Cox J, Darzi A, Arora A. Long-term prospective evaluation comparing robotic parathyroidectomy with minimally invasive open parathyroidectomy for primary hyperparathyroidism. Head Neck 2015; 38 Suppl 1:E300-6. [PMID: 25545792 DOI: 10.1002/hed.23990] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Targeted parathyroidectomy is a popular technique for localized pathology. No single technique is established as superior. The purpose of this study was to compare robotic-assisted parathyroidectomy (RAP) with the most common approach. METHODS This was a prospective, nonrandomized study. Fifteen consecutive patients who underwent RAP were compared to 15 matched controls undergoing focused lateral parathyroidectomy (FLP). RESULTS Biochemical cure occurred in 29 of 30 patients (97%). No major complications occurred, although there was 1 robotic conversion. RAP demonstrated a significant time reduction (R(2) = 0.436; p = .01) but took much longer to perform than FLP (119 minutes vs 34 minutes; p = .001). RAP was associated with less initial postoperative pain (p = .036) and higher satisfaction with scar cosmesis (p = .002) until 6 months. Quality of life (QOL) improved in both groups (p = .007). CONCLUSION RAP provides superior early cosmesis with equivalent global health improvement compared to FLP. The high cost and learning curve may preclude widespread adoption. Further evaluation is necessary to establish its clinical efficacy regarding scar cosmesis. © 2015 Wiley Periodicals, Inc. Head Neck 38: E300-E7, 2016.
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Affiliation(s)
- Neil Tolley
- Department of Otorhinolaryngology and Head & Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - George Garas
- Department of Otorhinolaryngology and Head & Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fausto Palazzo
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alexa Prichard
- Department of Otorhinolaryngology and Head & Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Konstantinos Chaidas
- Department of Otorhinolaryngology and Head & Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jeremy Cox
- Department of Endocrinology, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital Campus, London, United Kingdom
| | - Asit Arora
- Department of Otorhinolaryngology and Head & Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Özcan HM, Sezgintürk MK. Detection of parathyroid hormone using an electrochemical impedance biosensor based on PAMAM dendrimers. Biotechnol Prog 2015; 31:815-22. [DOI: 10.1002/btpr.2060] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 12/19/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Hakkı Mevlüt Özcan
- Chemistry Dept., Faculty of Science, University of Trakya; Edirne Turkey
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20
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Reilly DJ, Chew GL, Eckhaus J, Smoll NR, Farrell SG. Outcomes for minimally invasive parathyroidectomy: widening inclusion criteria based on preoperative imaging results. ANZ J Surg 2014; 86:701-5. [PMID: 25345711 DOI: 10.1111/ans.12885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary hyperparathyroidism is caused by a single adenoma in at least 80% of cases. Minimally invasive parathyroidectomy (MIP) has overtaken bilateral neck exploration as the gold standard for treatment in cases with adequate preoperative localization. There is evidence that, following careful review of preoperative imaging by the surgeon, increasing numbers of patients can successfully undergo MIP. METHODS We conducted a retrospective review of 225 consecutive cases performed by a single surgeon. Outcomes for patients with disease reported as localized by radiologists and nuclear medicine physicians using sestamibi and ultrasound were compared with patients with negative or indeterminate localization studies, in which the surgeon reviewed the sestamibi, performed an ultrasound study and identified likely single adenomas and planned MIP. RESULTS One hundred and sixty patients with radiologist-localized disease and an additional 29 patients with surgeon-localized disease underwent MIP. The surgeon-localized group had higher rates of conversion to bilateral neck exploration (21% compared with 4%, P = 0.004), but rates of failure to cure were comparable between the two groups (4.3% compared with 2.8%). CONCLUSION Careful review of preoperative sestamibi and ultrasound studies by an experienced surgeon can increase the number of patients that can successfully undergo MIP for the treatment of primary hyperparathyroidism. Offering MIP to these patients does not result in increased rates of failure or recurrence.
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Affiliation(s)
- Daniel J Reilly
- Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Grace L Chew
- Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Jazmin Eckhaus
- Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Nicolas R Smoll
- Gippsland Medical School, Monash University, Churchill, Victoria, Australia
| | - Stephen G Farrell
- Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
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Li X, Massasati SA, Kandil E. Single incision robotic transaxillary approach to perform parathyroidectomy. Gland Surg 2014; 1:169-70. [PMID: 25083444 DOI: 10.3978/j.issn.2227-684x.2012.09.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Accepted: 09/27/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Xinying Li
- 1 Department of Surgery, Division of Endocrine and Oncological Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA ; 2 Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Saleh A Massasati
- 1 Department of Surgery, Division of Endocrine and Oncological Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA ; 2 Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Emad Kandil
- 1 Department of Surgery, Division of Endocrine and Oncological Surgery, Tulane University School of Medicine, New Orleans, LA, 70112, USA ; 2 Department of General Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
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22
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Brown SJ, Lee JC, Christie J, Maher R, Sidhu SB, Sywak MS, Delbridge LW. Four-dimensional computed tomography for parathyroid localization: a new imaging modality. ANZ J Surg 2014; 85:483-7. [DOI: 10.1111/ans.12571] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Sebastian J. Brown
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - James C. Lee
- Endocrine Surgery Unit; Monash University; Melbourne Victoria Australia
| | - James Christie
- North Shore Radiology; North Shore Private Hospital; Sydney New South Wales Australia
| | - Richard Maher
- North Shore Radiology; North Shore Private Hospital; Sydney New South Wales Australia
| | - Stanley B. Sidhu
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Leigh W. Delbridge
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
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23
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Noureldine SI, Lewing N, Tufano RP, Kandil E. The role of the robotic-assisted transaxillary gasless approach for the removal of parathyroid adenomas. ORL J Otorhinolaryngol Relat Spec 2014; 76:19-24. [PMID: 24662482 DOI: 10.1159/000353629] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 08/20/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND We sought to describe a robotic technique of transaxillary gasless parathyroidectomy for the management of primary hyperparathyroidism (PHPT) due to a parathyroid adenoma. METHODS All consecutive patients who underwent robotic parathyroidectomy for a parathyroid adenoma by a single surgeon were included. Data was obtained by a retrospective review of patients' medical charts. RESULTS Nine patients with confirmed PHPT underwent robotic parathyroidectomy. Curative resection was established in all patients with the aid of intraoperative parathyroid hormone monitoring. One patient required bilateral cervical exploration of multiglandular disease. There were no complications. Patients were followed up for a period exceeding 6 months without any evidence of persistent or recurrent hyperparathyroidism. CONCLUSIONS Our initial experience demonstrates that this technique is safe and effective for the treatment of PHPT. We believe that the use of robotic technology for endoscopic parathyroid surgeries could overcome the limitations of conventional techniques in the management of parathyroid lesions.
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Affiliation(s)
- Salem I Noureldine
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Md., USA
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24
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Tee MC, Chan SK, Nguyen V, Strugnell SS, Yang J, Jones S, Tiwari P, Levine DS, Wiseman SM. Incremental value and clinical impact of neck sonography for primary hyperparathyroidism: a risk-adjusted analysis. Can J Surg 2013; 56:325-31. [PMID: 24067517 DOI: 10.1503/cjs.015612] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite the different preoperative imaging modalities available for parathyroid adenoma localization, there is currently no uniform consensus on the most appropriate preoperative imaging algorithm that should be routinely followed prior to the surgical management of primary hyperparathyroidism (PHPT). We sought to determine the incremental value of adding neck ultrasonography to scintigraphy-based imaging tests. METHODS In a single institution, surgically naive patients with PHPT underwent the following localization studies before parathyroidectomy: 1) Tc-99m sestamibi imaging with single photon emission computed tomography/computed tomography (SPECT/CT) or Tc-99m sestamibi imaging with SPECT alone, or 2) ultrasonography in addition to those tests. We retrospectively collected data and performed a multivariate analysis comparing group I (single study) to group II (addition of ultrasonography) and risk of bilateral (BNE) compared with unilateral (UNE) neck exploration. RESULTS Our study included 208 patients. Group II had 0.45 times the odds of BNE versus UNE compared with group I (unadjusted odds ratio [OR] 0.45, 95% confidence interval [CI] 0.25-0.81, p = 0.008). When adjusting for patient age, sex, preoperative calcium level, use of intraoperative PTH monitoring, preoperative PTH level, adenoma size, and number of abnormal parathyroid glands, Group II had 0.48 times the odds of BNE versus UNE compared with group I (adjusted OR 0.48, 95% CI 0.23-1.03, p = 0.06). In a subgroup analysis, only the addition of ultrasonography to SPECT decreased the risk of undergoing BNE compared with SPECT alone (unadjusted OR 0.40, 95% CI 0.19-0.84, p = 0.015; adjusted OR 0.38, 95% CI 0.15-0.96, p = 0.043). CONCLUSION The addition of ultrasonography to SPECT, but not to SPECT/CT, has incremental value in decreasing the extent of surgery during parathyroidectomy, even after adjusting for multiple confounding factors.
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Affiliation(s)
- May C Tee
- From St. Paul's Hospital, Department of Surgery and University of British Columbia, Vancouver, BC
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25
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Robotic Surgery in Otolaryngology: Endocrine. CURRENT OTORHINOLARYNGOLOGY REPORTS 2013. [DOI: 10.1007/s40136-013-0024-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ahmed K, Alhefdhi A, Schneider DF, Ojomo KA, Sippel RS, Chen H, Mazeh H. Minimal benefit to subsequent intraoperative parathyroid hormone testing after all four glands have been identified. Ann Surg Oncol 2013; 20:4200-4. [PMID: 23943032 DOI: 10.1245/s10434-013-3188-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Modern tools, such as intraoperative parathyroid hormone (IoPTH) assay, reduce operative time and extent of parathyroidectomy. However, the utility of a subsequent final set of IoPTH after all four glands are visualized remains questionable. This study was designed to determine the added value of IoPTH assay following parathyroidectomy with four-gland visualization in patients with primary hyperparathyroidism (PHPT). METHODS A retrospective review of patients who underwent parathyroidectomy for PHPT between July 2001 and February 2012 by two experienced endocrine surgeons was performed. Included were patients with operative reports indicating that all four parathyroid glands were identified. Following four-gland visualization a subsequent final set of IoPTH was measured to confirm cure. Cure was defined as at least 50 % fall by 5, 10, or 15 min postexcision compared with preincision levels. RESULTS Of 1,838 patients that underwent parathyroidectomy, four glands were visualized in 238 cases (13 %). Of those patients meeting inclusion criteria with four glands visualized, the final set of IoPTH fell to cure criteria in 235 patients (98 %). An inadequate drop was documented in three (2 %) patients all of which were found to have multigland disease. Only in one patient (0.4 %) was a fifth parathyroid gland identified and resected. In all three cases, the subsequent final IoPTH did not affect the ultimate outcome or cure rate. CONCLUSIONS When experienced surgeons visualize all four parathyroid glands, drawing a subsequent final set of IoPTH rarely changes the operative course and therefore serves a limited role.
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Affiliation(s)
- Kamal Ahmed
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
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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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Nagar S, Reid D, Czako P, Long G, Shanley C. Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism. Am J Surg 2012; 203:177-81. [DOI: 10.1016/j.amjsurg.2010.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 10/12/2010] [Accepted: 10/25/2010] [Indexed: 11/25/2022]
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Prichard RS, O’Neill CJ, Oucharek JJ, Sippel RS, Delbridge LW, Sidhu SB, Chen H. Is Focused Minimally Invasive Parathyroidectomy Appropriate for Patients With Familial Primary Hyperparathyroidism? Ann Surg Oncol 2011; 19:1264-8. [DOI: 10.1245/s10434-011-2092-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Indexed: 11/18/2022]
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Chowbey PK, Soni V, Khullar R, Sharma A, Baijal M. Endoscopic neck surgery. J Minim Access Surg 2011; 3:3-7. [PMID: 20668611 PMCID: PMC2910378 DOI: 10.4103/0972-9941.30679] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 11/30/2006] [Indexed: 11/04/2022] Open
Abstract
Endoscopic surgery in the neck was attempted in 1996 for performing parathyroidectomy. A similar surgical technique was used for performing thyroidectomy the following year. Most commonly reported endoscopic neck surgery studies in literature have been on thyroid and parathyroid glands. The approaches are divided into two types i.e., the total endoscopic approach using CO(2) insufflation and the video-assisted approach without CO(2) insufflation. The latter approach has been reported more often. The surgical access (port placements) may vary-the common sites are the neck, anterior chest wall, axilla, and periareolar region. The limiting factors are the size of the gland and malignancy. Few reports are available on endoscopic resection for early thyroid malignancy and cervical lymph node dissection. Endoscopic neck surgery has primarily evolved due to its cosmetic benefits and it has proved to be safe and feasible in suitable patients with thyroid and parathyroid pathologies. Application of this technique for approaching other cervical organs such as the submandibular gland and carotid artery are still in the early experimental phase.
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Affiliation(s)
- P K Chowbey
- Department of Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi, India
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Abstract
AIM Hyperparathyroidism (HPT) is a condition that occurs due to exacerbated activity of the parathyroid glands. According to the etiology it may be primary, secondary or tertiary hyperparathyroidism (pHPT, sHPT, tHPT). This is a study done to document and evaluate the presentations of primary and secondary HPT, with the associated complications and the approach to management in these patients, at our hospital. MATERIALS AND METHODS Twenty-one patients with HPT were encountered at Sri Ramachandra Medical College and Research Institute between January 2000 and January 2010. Operative notes, histopathology files, and medical records were used for the retrospective analysis of the patients with HPT. Parathormone, calcium, and phosphate levels were estimated on all the patients, to determine the primary or secondary etiology of this endocrine abnormality. Furthermore, these patients were subjected to ultrasonography (USG) of the neck and Technetium (99 mTc) scan of the neck to identify the parathyroid gland. RESULTS This study revealed that about 76, 19, and 5% of the patients suffered from pHPT, sHPT, and tHPT, respectively, with a female preponderance (62%).The neoplasm in all patients with pHPT was parathyroid adenoma. The patients presented with renal, bony, and menstrual abnormalities. Cases with sHPT had a 15 - 20 year history of chronic kidney disease and they subsequently developed bony abnormalities. Even as all the patients with pHPT were managed with parathyroidectomy, individuals with sHPT were treated conservatively. Postoperative features of hypocalcemia were noted in only one patient. CONCLUSION This study re-emphasizes that pHPT is more common and is often due to an adenoma. Recent advances in parathormone sampling operatively and minimal access surgery, along with accurate and prompt clinical diagnosis, is necessary for the cure of these patients presenting with obscure abdominal, bony, and renal ailments.
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Affiliation(s)
- Rekha Arcot
- Department of General Surgery, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India
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Tolley N, Arora A, Palazzo F, Garas G, Dhawan R, Cox J, Darzi A. Robotic-Assisted Parathyroidectomy. Otolaryngol Head Neck Surg 2011; 144:859-66. [DOI: 10.1177/0194599811402152] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Objective. Targeted parathyroidectomy is the gold standard for localized parathyroid disease. A robotic-assisted approach has not been investigated. The aim was to assess the feasibility of a robotic technique that avoids a neck scar. Study Design. Feasibility study. Setting. Tertiary referral center. Subjects and Methods. Eleven patients with primary hyperparathyroidism were prospectively evaluated. Triple modality concordant localization was a prerequisite. All patients underwent robotic-assisted parathyroidectomy (RAP). Outcome variables assessed were operative time, voice change, biochemical cure, and histopathological confirmation. Patient-reported outcome measures (PROMs) included subjective assessment of pain and scar cosmesis, Voice Handicap Index 2, and EQ-5D quality-of-life assessment. Mean follow-up was 6 months (range, 3-12 months). Results. The parathyroid adenoma was successfully excised in all cases with negligible blood loss (<5 mL). There was 1 conversion. There was no voice change in any case. Robot docking time plateaued to 10 minutes after 8 cases. Mean exposure and console times (31 and 51 minutes, respectively) were affected by body habitus. The mean visual analog scale for scar cosmesis was 75% on the first postoperative day, improving to 92% at 6 months and 95% at 1 year. Pain scores decreased to 8% at 2 weeks. All 5 EQ-5D quality-of-life parameters significantly improved following surgery. Conclusion. The robotic approach is feasible for performing targeted parathyroidectomy that avoids a neck scar. The clinical efficacy and cost-effectiveness of the robotic approach compared with conventional targeted parathyroidectomy warrant further evaluation to establish if this represents a viable alternative to the existing targeted techniques.
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Affiliation(s)
- Neil Tolley
- Department of Otorhinolaryngology and Head & Neck Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Asit Arora
- Department of Otorhinolaryngology and Head & Neck Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Fausto Palazzo
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - George Garas
- Department of Otorhinolaryngology and Head & Neck Surgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Ranju Dhawan
- Department of Radiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy Cox
- Department of Endocrinology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Ara Darzi
- Department of Biosurgery and Surgical Technology, St Mary’s Hospital, Imperial College London, London, UK
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Alesina PF, Singaporewalla RM, Walz MK. Video-assisted bilateral neck exploration in patients with primary hyperparathyroidism and failed localization studies. World J Surg 2011; 34:2344-9. [PMID: 20596707 DOI: 10.1007/s00268-010-0700-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Pier F Alesina
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Duisburg-Essen, Henricistrasse 92, 45136, Essen, Germany.
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Fraker DL, Harsono H, Lewis R. Minimally invasive parathyroidectomy: benefits and requirements of localization, diagnosis, and intraoperative PTH monitoring. long-term results. World J Surg 2010; 33:2256-65. [PMID: 19763685 DOI: 10.1007/s00268-009-0166-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgery is the only curative treatment for primary hyperparathyroidism. Initial parathyroidectomy procedures fail due to ectopic gland location and unappreciated multigland disease. METHODS An evidence-based literature review was performed,which surveyed all human studies in PubMed, searching for parathyroidectomy in humans between 1990 and 2009. Between 10 and 30% of patients have multigland disease caused by double adenomas or hyperplasia. Use of preoperative imaging studies and intraoperative PTH monitoring helps parathyroid surgeons overcome these obstacles. RESULTS Sestamibi nuclear scan and neck ultrasound identify 70-80% of abnormal glands in patients with single adenomas. The sensitivity of ultrasound or sestamibi to identify all abnormal glands in patients with multigland disease is extremely low. Intraoperative PTH monitoring should be utilized in all patients who undergo neck exploration for primary hyperparathyroidism to reduce failures due to multigland disease. Blood samples should be drawn from peripheral veins only and a postresection level 10-15 min after gland removal should have a >50%decrease from baseline preoperative levels, and also must go to the normal range for the PTH assay being used. CONCLUSIONS Contemporary prospective studies (level of evidence III/IV) show that by combining preoperative imaging and IOPTH it is possible to maximize performance of successful outpatient minimally invasive parathyroidectomy.
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Affiliation(s)
- Douglas L Fraker
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA.
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Oucharek JJ, O’Neill CJ, Suliburk JW, Sywak MS, Delbridge LW, Sidhu SB. Durability of Focused Minimally Invasive Parathyroidectomy in Young Patients with Sporadic Primary Hyperparathyroidism. Ann Surg Oncol 2010; 18:1290-2. [DOI: 10.1245/s10434-010-1417-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Indexed: 11/18/2022]
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Suliburk JW, Sywak MS, Sidhu SB, Delbridge LW. 1000 minimally invasive parathyroidectomies without intra-operative parathyroid hormone measurement: lessons learned. ANZ J Surg 2010; 81:362-5. [PMID: 21518187 DOI: 10.1111/j.1445-2197.2010.05488.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Minimally invasive parathyroidectomy (MIP) has become the procedure of choice in the treatment of primary hyperparathyroidism where a single adenoma can be localized preoperatively. The role for intra-operative parathyroid hormone measurement (IOPTH) is controversial. Some experts recommend that IOPTH is a mandatory requirement for successful MIP while others state that the technique is not needed. We reviewed 10 years of MIP in a single unit without the use of IOPTH in order to examine causes of failure. METHODS This study is a retrospective review of the University of Sydney Endocrine Surgery Database from May of 1998 to August of 2008. The database was queried for MIPs performed as well as for failed operations. Patient record analysis was completed to determine the reason for failure of the operation. RESULTS In the period January 1998 to August 2008, a total of 2343 parathyroidectomy procedures were performed. Of these, 1020 were MIPs with 23 (2.2%) failures. One patient was found to have benign familial hypercalcemia, whereas five were lost to follow-up. Reasons for failure in the remaining 17 patients were: 10 patients (59%) were found to have double adenomas, 3 (17%) patients with hyperplasia and 4 (24%) patients with single gland disease were missed at initial operation. All 17 were cured on repeat exploration. CONCLUSION MIP can be performed safely and with 98% success without the need for IOPTH. The most common cause of failure after MIP is an occult double adenoma. Given that repeat sestamibi scan correctly identifies persistent disease in most cases, consideration can be given to MIP as a choice of procedure for repeat operation.
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Affiliation(s)
- James W Suliburk
- Baylor College of Medicine, Department of Surgery, Houston, Texas, USA
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McLean T, Delbridge L. Comparison of consumer information on the internet to the current evidence base for minimally invasive parathyroidectomy. World J Surg 2010; 34:1304-11. [PMID: 20012291 DOI: 10.1007/s00268-009-0306-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Internet is increasingly used as a source of health information by patients. Under these circumstances, the opportunity exists for Internet sites ostensibly providing patient information to act to promote surgical referrals based on exaggerated claims. This study aims to assess quantitatively and qualitatively the Internet-based consumer health information for minimally invasive parathyroidectomy (MIP) techniques. METHODS This is a prospective analysis of Internet web sites. Descriptive information about specific published claims on each of the web sites was documented and compared to the published evidence base. Web sites were then rated using a validated composite score (CS) tool and an MIP score tool developed specifically for the study. RESULTS The search yielded 308 web sites, which, after assessment by the inclusion criteria left 44 unique web sites suitable for analysis. "Exaggerated," "misleading," or "false" claims were present in 27.3% of the web sites analyzed. The false claims category had a high negative item-total correlation with the overall score, and accuracy was found to have a statistically significant (p < 0.05) negative correlation with quality. However, analysis performed for country of origin and the organization responsible for the web site found no significant difference. CONCLUSIONS Web sites offering information in relation to MIP have a surprisingly high rate of claims that are not in accord with the evidence. Such claims may be posted to attract surgical referrals. It is difficult for consumers to differentiate quality consumer health web sites from poor ones as there are no hard and fast rules to differentiate them.
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Affiliation(s)
- Timothy McLean
- Endocrine Surgical Unit, University of Sydney, Sydney, Australia
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Rahbari R, Sansano IG, Elaraj DM, Duh QY, Clark OH, Kebebew E. Prior head and neck radiation exposure is not a contraindication to minimally invasive parathyroidectomy. J Am Coll Surg 2010; 210:942-8. [PMID: 20510803 DOI: 10.1016/j.jamcollsurg.2010.02.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 02/13/2010] [Accepted: 02/15/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Most patients with primary hyperparathyroidism can have a minimally invasive parathyroidectomy based on localization studies showing single-gland disease. In patients with a history of head and neck irradiation, due to the increased risk of multigland disease and risk of concurrent thyroid cancer, minimally invasive parathyroidectomy is considered by some to be a contraindication. We postulated that previous history of head and neck irradiation should not be a contraindication for minimally invasive parathyroidectomy and tested this hypothesis in a prospective cohort of patients undergoing parathyroidectomy for primary hyperparathyroidism. STUDY DESIGN We performed a retrospective analysis of a prospective database of 491 consecutive parathyroidectomies performed between May 2005 and May 2007 at a tertiary referral medical center. RESULTS Fifty-two (12.6%) patients had a history of head and neck irradiation and 360 (87.4%) had no exposure to radiation. The 2 groups had no significant difference in terms of gender or ethnicity. The radiation group was older, with an average age of 65.1 years versus 58.1 years (p < 0.0009). There was no significant difference in concurrent benign thyroid neoplasm, thyroid cancer, and type of parathyroid disease (single vs multigland) in the 2 groups. There was no significant difference in the operative approach used between the 2 groups (focused vs unilateral or bilateral). CONCLUSIONS Head and neck irradiation should not be a contraindication for minimally invasive parathyroidectomy in patients with primary hyperparathyroidism in the setting of preoperative localization studies showing single-gland disease and no concurrent thyroid neoplasm. Furthermore, history of head and neck irradiation is associated with a later age of presentation for parathyroidectomy.
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Affiliation(s)
- Reza Rahbari
- Surgery Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
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Ypsilantis E, Charfare H, Wassif WS. Intraoperative PTH Assay during Minimally Invasive Parathyroidectomy May Be Helpful in the Detection of Double Adenomas and May Minimise the Risk of Recurrent Surgery. Int J Endocrinol 2010; 2010:178671. [PMID: 21197437 PMCID: PMC3010640 DOI: 10.1155/2010/178671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2010] [Revised: 10/12/2010] [Accepted: 11/10/2010] [Indexed: 11/18/2022] Open
Abstract
Background. Minimally invasive parathyroidectomy (MIP) is increasingly replacing the traditional bilateral neck exploration in the treatment of primary hyperparathyroidism (PHP). Intraoperative PTH (IOPTH) measurement has recently been introduced as a useful adjunct in confirming successful excision of abnormal parathyroid gland. Aims. We evaluate the safety, efficacy, and clinical usefulness of IOPTH measurement during MIP in a district general hospital. Methods. Retrospective review of eleven consecutive patients with PHP who underwent MIP with IOPTH, following preoperative assessment with ultrasound and sestamibi scans. Results. All patients had successful removal of the abnormal parathyroid gland. The concordance rate between ultrasound and sestamibi scan in localising the parathyroid adenoma was 82%. IOPTH measurement confirmed the removal of adenoma in all cases and, in one case, led to identification of a second adenoma, not localised preoperatively. The median hospital stay was 2 days (range 1-7 days). All patients remained normocalcaemic after a median of 6 months (range 1-10 months). Conclusions. Minimally invasive parathyroidectomy is a feasible, safe, and effective method for treatment of PHP. The use of IOPTH monitoring potentially offers increased sensitivity in detecting multiglandular disease, can minimise the need and risk associated with recurrent operations, and may facilitate cost-effective minimally invasive surgery.
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Affiliation(s)
- E. Ypsilantis
- Princess Royal University Hospital, Farnborough Common, London BR6 8ND, UK
- *E. Ypsilantis:
| | - H. Charfare
- Bedford Hospital South Wing, Kempston Road, Bedford MK42 9DJ, UK
| | - W. S. Wassif
- Bedford Hospital South Wing, Kempston Road, Bedford MK42 9DJ, UK
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Thakur A, Sebag F, Slotema E, Ippolito G, Taïeb D, Henry JF. Significance of biochemical parameters in differentiating uniglandular from multiglandular disease and limiting use of intraoperative parathormone assay. World J Surg 2009; 33:1219-23. [PMID: 19363691 DOI: 10.1007/s00268-009-0029-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND We studied whether serum calcium and parathormone (PTH) levels are significantly different for uniglandular disease (UGD) and multiglandular disease (MGD) and whether intraoperative rapid intact parathormone (IOPTH) monitoring can be avoided in some cases of minimally invasive parathyroidectomy (MIP) without affecting cure rates, substantiating various previous published studies. METHOD This is a single-referral-center retrospective review of prospectively collected data for 281 patients with sporadic primary hyperparathyroidism (sPHPT) from January 1999 to February 2005. The calcium and PTH values were categorized using the following parameters: calcium > or = 3 mmol/l = 1, < 3 mmol/l = 0, PTH > or = 100 pg/ml = 1, PTH < 100 = 1. RESULTS P values for serum calcium and PTH by ANOVA were 0.0547 and 0.3936, respectively, and by the Mann-Whitney test were 0.1606 and 0.6208, respectively. We had 118 patients with concordant technetium 99 m sestamibi scintigraphy (MIBI) and neck ultrasonography (US) and UGD was confirmed in 118 (100%) cases. CONCLUSIONS No significant difference between serum calcium and PTH for UGD and MGD was found. IOPTH monitoring could be avoided when there is concordant positive MIBI and neck US for single, unilateral, hyperfunctioning gland without affecting cure rates.
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Affiliation(s)
- Abhijit Thakur
- Department of Endocrine Surgery, University Hospital La Timone, 264, Rue Saint-Pierre, 13385, Marseille, France
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Tratamiento quirúrgico y técnicas de localización en el hiperparatiroidismo primario. ACTA ACUST UNITED AC 2009; 56 Suppl 1:20-8. [DOI: 10.1016/s1575-0922(09)70852-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lombardi CP, Raffaelli M, Traini E, De Crea C, Corsello SM, Bellantone R. Video-Assisted Minimally Invasive Parathyroidectomy: Benefits and Long-Term Results. World J Surg 2009; 33:2266-81. [DOI: 10.1007/s00268-009-9931-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gannagé-Yared MH, Abboud B, Amm-Azar M, Saab A, Khalife S, Halaby G, Atallah C, Medlej R, Jambart S. Predictors of intra-operative parathyroid hormone decline in subjects operated for primary hyperparathyroidism by minimally invasive parathyroidectomy. J Endocrinol Invest 2009; 32:160-4. [PMID: 19411816 DOI: 10.1007/bf03345707] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The predictors of intra-operative PTH (IOPTH) decline during minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism have been but poorly studied. MATERIALS AND METHODS This retrospective study included 108 patients who underwent MIP for a single adenoma. Serum calcium and phosphorus were measured before surgery and 1 day post-operatively. IOPTH was measured before (intra-operative preincision or PTHt0) and 10 min after removal of the adenoma (PTHt10). The Modification of Diet in Renal Disease (MDRD) equation was used to estimate the glomerular filtration rate. The weight of the adenoma was assessed in all the subjects. RESULTS The sex ratio female/male was 5.37 with a mean age of 57.3 yr. The mean pre- and postoperative values were for calcium 2.80 and 2.19 mmol/l, respectively (p<0.0001) and for phosphorus 0.90 and 1.16 mmol/l, respectively (p<0.0001). The PTH dropped from a mean value of 184.8 to 50.8 pg/ml 10 min after adenoma resection with a mean drop of 69.7%. Thirteen patients (12%) did not achieve a PTH fall of more than 50%. In a bivariate analysis, age, an MDRD<60 ml/min and weight of adenoma were inversely associated with IOPTH fall (p=0.009, p=0.004, and p<0.001, respectively) while gender, body mass index, hypertension, diabetes, pre-operative phosphorus and calcium had no significant effects. In the multivariate analysis, age, weight of adenoma, and MDRD were still independent negative predictors of the IOPTH fall (p=0.01, p=0.018, and p<0.001, respectively). CONCLUSION Our results suggest that during MIP the presence of a parathyroid adenoma with a high weight, in an elderly subject or in a subject with altered renal function, will result in a lesser degree of IOPTH fall.
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Affiliation(s)
- M-H Gannagé-Yared
- Department of Endocrinology, Saint-Joseph University, Beirut, Lebanon.
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Comparison of pinhole and SPECT 99mTc-MIBI imaging in primary hyperparathyroidism. Nucl Med Commun 2008; 29:949-55. [DOI: 10.1097/mnm.0b013e328309789e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Moure D, Larrañaga E, Domínguez-Gadea L, Luque-Ramírez M, Nattero L, Gómez-Pan A, Marazuela M. 99MTc-sestamibi as sole technique in selection of primary hyperparathyroidism patients for unilateral neck exploration. Surgery 2008; 144:454-9. [PMID: 18707045 DOI: 10.1016/j.surg.2008.05.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Accepted: 05/20/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unilateral neck exploration (UNE) is becoming the procedure of choice for treatment of primary hyperparathyroidism (PHPT). The aim of this study was to evaluate the role of (99m)Tc-sestamibi (MIBI) parathyroid scintigraphy as the sole technique in selecting patients for UNE. METHOD We selected 136 consecutive PHPT patients who had only 1 solitary uptake at a MIBI were for UNE. The technique was a single dual-phase using MIBI and a subtraction technique with (99m)Tc-pertechnetate. Imaging data were correlated with surgical results. RESULTS In 3 cases, the sestamibi scan was falsely positive, 1 had a contralateral location relative to the uptake, and 2 had multiglandular hyperplasia. Overall, the positive predictive value (PPV) of MIBI for detecting a solitary parathyroid adenoma in patients with 1 solitary uptake was 97.8. Sixteen patients (12%) had evidence of multinodular goiter. Overall, the PPV of MIBI was 98.4% (2 false positive among 120 cases) in patients with no multinodular thyroid disease (MNG) and 93.7% (1 false negative among 16 cases) in patients with MNG. The mean duration of the surgical procedure was 34.17 minutes. Mean hospitalization was 0.6 days. Conversion to bilateral neck exploration was performed in 5 patients. After a period of follow-up of 40 months (range, 6-72 months), the cure rate was 98%. CONCLUSION Patients with PHPT and unequivocally positive preoperative (99m)Tc-sestamibi can safely be managed with UNE without additional localizing techniques.
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Affiliation(s)
- Dolores Moure
- Department of Endocrinology, Hospital de la Princesa, Universidad Autónoma, Madrid, Spain.
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Focused versus conventional parathyroidectomy for primary hyperparathyroidism: a prospective, randomized, blinded trial. Langenbecks Arch Surg 2008; 393:659-66. [DOI: 10.1007/s00423-008-0408-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Accepted: 07/29/2008] [Indexed: 10/21/2022]
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Bonnichon P. [Treatment of primary hyperparathyroidism at Cochin hospital (Paris). Changes in procedures during the last thirty years]. ANNALES D'ENDOCRINOLOGIE 2008; 69:169-73. [PMID: 18683287 DOI: 10.1016/j.ando.2007.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The association of high performance techniques and low morbidity has enabled the development of preventive surgery for hyperparathyroidism. Over the last 30 years, 2500 patients have undergone this type of procedure at the Visceral Surgery Unit of the Cochin Hospital in Paris. This experience has enabled us to achieve the current concept of surgical treatment for primary hyperparathyroidism, particularly with the development of minimally invasive techniques performed under local anesthesia. The promotional role played by our institution over the last 30 years in this area has enabled sturdy evidence-based reflection. The report of the work accomplished would not be complete without the story of the rich adventure which began in the 19th century. We propose here a review of the major advance achieved in order to better apprehend the principles currently regulation our approach to surgery of the parathyroid glands.
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Affiliation(s)
- P Bonnichon
- Service de chirurgie, hôpital Cochin, Paris, France.
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