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Nievera KH, Alba R. Persistent Primary Hyperparathyroidism Secondary to an Ectopic Mediastinal Adenoma in a Young Adult: A Case Report. J ASEAN Fed Endocr Soc 2023; 38:145-148. [PMID: 38045675 PMCID: PMC10692408 DOI: 10.15605/jafes.038.02.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/04/2023] [Indexed: 12/05/2023] Open
Abstract
Primary hyperparathyroidism commonly affects elderly women. When present in the young population, it is usually asymptomatic, most frequently due to a parathyroid adenoma and the definitive management is surgical excision. Uncommonly, 5-10% of patients fail to achieve long-term cure after initial parathyroidectomy and 6-16% of them is due to an ectopic parathyroid adenoma that will require focused diagnostic and surgical approaches. We report a 21-year-old male who had bilateral thigh pain. Work-up revealed bilateral femoral fractures, brown tumors on the arms and multiple lytic lesions on the skull. Serum studies showed hypercalcemia (1.83 mmol/L), elevated parathyroid hormone [(PTH) 2025.10 pg/mL], elevated alkaline phosphatase (830 U/L), normal phosphorus (0.92 mmol/L) and low vitamin D levels (18.50 ng/mL). Bone densitometry showed osteoporotic findings. Sestamibi scan showed uptake on the left superior mediastinal region consistent with an ectopic parathyroid adenoma. Vitamin D supplementation was started pre-operatively. Patient underwent parathyroidectomy with neck exploration; however, the pathologic adenoma was not visualized and PTH levels remained elevated post-operatively. Chest computed tomography with intravenous contrast was performed revealing a mediastinal location of the adenoma. A repeat parathyroidectomy was done, with successful identification of the adenoma resulting in a significant drop in PTH and calcium levels. Patient experienced hungry bone syndrome post-operatively and was managed with calcium and magnesium supplementation. A high index of suspicion for an ectopic adenoma is warranted for patients presenting with hypercalcemia and secondary osteoporosis if there is persistent PTH elevation after initial surgical intervention. Adequate follow-up and monitoring is also needed starting immediately in the post-operative period to manage possible complications such as hungry bone syndrome.
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Affiliation(s)
- Karl Homer Nievera
- Section of Endocrinology, Diabetes and Metabolism, Chinese General Hospital and Medical Center, Manila, Philippines
| | - Rebecca Alba
- Section of Endocrinology, Diabetes and Metabolism, Chinese General Hospital and Medical Center, Manila, Philippines
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Lee WG, Gosnell JE, Shen WT, Duh QY, Suh I, Chen Y. Recovery After Thyroid and Parathyroid Surgery: How Do Our Patients Really Feel? J Surg Res 2023; 283:764-770. [PMID: 36470201 DOI: 10.1016/j.jss.2022.11.028] [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: 08/09/2022] [Revised: 11/10/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Counseling on the immediate postoperative experience for outpatient procedures is largely based on anecdotal experience. We devised a short messaging service (SMS) survey using mobile phone text messages to evaluate real-time patient recovery following outpatient thyroid or parathyroid surgery. MATERIALS AND METHODS Daily automated SMS surveys were sent the evening of the operation until postoperative day 10. Pain, opioid use, voice quality, and energy levels were assessed. Impaired voice and energy was defined as a score < 2/3 of normal. RESULTS One hundred fifty five patients were enrolled with an overall response rate of 81.6%. One hundred thirty three patients had an individual response rate > 50% and were included in the final analysis. Median patient age was 60 y with 102 females (76.7%). Seventy patients (52.6%) underwent parathyroidectomy and 66 (49.6%) thyroidectomy and 10 (7.5%) neck dissection. Forty eight patients (36.1%) did not use any opioids postoperatively. Independent risk factors for higher total pain scores included thyroidectomy and patients with preoperative opioid or tobacco use, while increased opioid use was associated with age < 60 y, body mass index > 30 kg/m2, preoperative opioid or tobacco use, and history of anxiety or depression. Patients with loss of intraoperative recurrent laryngeal nerve signaling had a significantly worse overall voice score (54.65 versus 92.67, P < 0.001). Up to 10% of patients were still using opioids and/or reported impaired voice and energy levels beyond 1 wk postoperatively. CONCLUSIONS Real-time SMS survey is an effective and potentially valuable way to monitor patient recovery following surgery. A subset of patients reported impaired voice and energy and was still using opioids beyond 1 wk after thyroid and parathyroid surgery and these patients may benefit from closer follow-up and earlier intervention.
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Affiliation(s)
- William G Lee
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California
| | - Jessica E Gosnell
- University of San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Wen T Shen
- University of San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Quan-Yang Duh
- University of San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Insoo Suh
- NYU Langone Health, Division of Endocrine Surgery, New York, New York
| | - Yufei Chen
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California.
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The difficult parathyroid: advice to find elusive gland(s) and avoid or navigate reoperation. Curr Probl Surg 2023; 60:101262. [PMID: 36894218 DOI: 10.1016/j.cpsurg.2022.101262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Wang R, Abraham P, Lindeman B, Chen H, Fazendin J. Is preoperative parathyroid localization necessary for tertiary hyperparathyroidism? Am J Surg 2022; 224:918-922. [DOI: 10.1016/j.amjsurg.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 04/28/2022] [Accepted: 05/03/2022] [Indexed: 12/15/2022]
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Quinn AJ, Ryan ÉJ, Garry S, James DL, Boland MR, Young O, Kerin MJ, Lowery AJ. Use of Intraoperative Parathyroid Hormone in Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:135-143. [PMID: 33211086 DOI: 10.1001/jamaoto.2020.4021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Intraoperative parathyroid hormone (ioPTH) is a surgical adjunct that has been increasingly used during minimally invasive parathyroidectomy (MIP). Despite its growing popularity, to our knowledge a meta-analysis comparing MIP with ioPTH vs MIP without ioPTH has not yet been conducted. Objective To evaluate the safety and efficacy of MIP with ioPTH for treatment of primary hyperparathyroidism. Data Sources A systematic search of the databases PubMed, Embase, Scopus, Web of Science, and Cochrane Collaboration was performed to identify studies that compared MIP with and without ioPTH. Data were analyzed between August and September 2019. Study Selection Inclusion criteria consisted of randomized clinical trials and observational studies with a retrospective/prospective design, comparing MIP using ioPTH vs MIP not using ioPTH for treatment of primary hyperparathyroidism. Eligible studies had to present odds ratio (OR), risk ratio, or hazard ratio estimates (with 95% CI), standard errors, or number of events necessary to calculate these for the outcome of interest rate. Studies involving patients with secondary or tertiary hyperparathyroidism or those with multiple endocrine neoplasia syndrome were excluded. Data Extraction Two reviewers independently reviewed the literature according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Dichotomous variables were pooled as ORs while continuous variables were compared using weighted mean differences. Quality assessment was performed using the Newcastle-Ottawa Scale. Main Outcomes and Measures The primary outcome was rate of cure. Secondary outcomes included need for reoperation, need for bilateral neck exploration, morbidity, and length of surgery. Results A total of 12 studies, involving 2290 patients with primary hyperparathyroidism, were eligible for inclusion. The median (SD) age of participants was 60.1 (11.8) years and 77.3% of participants were women. The median Newcastle-Ottawa score was 7. Patients who underwent MIP with ioPTH had higher cure rates (OR, 3.88; 95% CI, 2.12-7.10; P < .001). There was a greater need for reoperation in the group of patients who had surgery without ioPTH (OR, 0.40; 95% CI, 0.19-0.86; P = .02). There was a trend toward longer operating times/increased duration of surgery in the ioPTH group; however, this did not reach statistical significance (weighted mean difference, 21.62 minutes; 95% CI, -0.93 to 44.17 minutes; P = .06). The use of ioPTH was associated with higher rates of bilateral neck exploration (OR, 3.55; 95% CI, 1.27-9.92; P = .02). Conclusions and Relevance Use of ioPTH is associated with higher cure rates for patients with primary hyperparathyroidism undergoing MIP. Minimally invasive parathyroidectomy performed without ioPTH is associated with less conversion to bilateral neck exploration at initial surgery but with lower cure rates and an increased risk for reoperation. Trial Registration PROSPERO identifier: CRD42020148588.
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Affiliation(s)
| | - Éanna J Ryan
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Stephen Garry
- Department of Otorhinolaryngology, Head & Neck Surgery, Galway University Hospitals, Galway, Ireland
| | - Danielle L James
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Michael R Boland
- Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Young
- Department of Otorhinolaryngology, Head & Neck Surgery, Galway University Hospitals, Galway, Ireland
| | - Michael J Kerin
- Department of Surgery, Galway University Hospitals, Galway, Ireland.,The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, Ireland
| | - Aoife J Lowery
- Department of Surgery, Galway University Hospitals, Galway, Ireland.,The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, Ireland
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Broome DT, Naples R, Bailey R, Tekin Z, Hamidi M, Bena JF, Morrison SL, Berber E, Siperstein AE, Scharpf J, Skugor M. Use of Preoperative Imaging in Primary Hyperparathyroidism. J Clin Endocrinol Metab 2021; 106:e328-e337. [PMID: 33119066 DOI: 10.1210/clinem/dgaa779] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Indexed: 12/12/2022]
Abstract
CONTEXT Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. OBJECTIVE Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. DESIGN, SETTING, AND PATIENTS This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. MAIN OUTCOME MEASURES Surgical cure rate, concordance of imaging with operative findings, and imaging performance. RESULTS The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas. CONCLUSIONS Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.
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Affiliation(s)
- David T Broome
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
| | - Robert Naples
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Richard Bailey
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Zehra Tekin
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
| | - Moska Hamidi
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - James F Bena
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Shannon L Morrison
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Allan E Siperstein
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mario Skugor
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
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Wang B, Zhu CR, Liu H, Yao XM, Wu J. The Accuracy of Near Infrared Autofluorescence in Identifying Parathyroid Gland During Thyroid and Parathyroid Surgery: A Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:701253. [PMID: 34234746 PMCID: PMC8255791 DOI: 10.3389/fendo.2021.701253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/07/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE We aim to assess the accuracy of near infrared autofluorescence in identifying parathyroid gland during thyroid and parathyroid surgery. METHOD A systematic literature search was conducted by using PubMed, Embase, and the Cochrane Library electronic databases for studies that were published up to February 2021. The reference lists of the retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the combined variable. Publication bias in these studies was evaluated with the Deeks' funnel plots. RESULT A total of 24 studies involving 2,062 patients and 6,680 specimens were included for the meta-analysis. The overall combined sensitivity and specificity, and the area under curve of near infrared autofluorescence were 0.96, 0.96, and 0.99, respectively. Significant heterogeneities were presented (Sen: I2 = 87.97%, Spe: I2 = 65.38%). In the subgroup of thyroid surgery, the combined sensitivity and specificity, and the area under curve of near infrared autofluorescence was 0.98, 0.99, and 0.99, respectively, and the heterogeneities were moderate (Sen: I2 = 59.71%, Spe: I2 = 67.65%). CONCLUSION Near infrared autofluorescence is an excellent indicator for identifying parathyroid gland during thyroid and parathyroid surgery.
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Affiliation(s)
- Bin Wang
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Chun-Rong Zhu
- Department of Chemistry, School of Basic Medical Science, North Sichuan Medical College, Nanchong, China
| | - Hong Liu
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Xin-Min Yao
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Jian Wu
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
- *Correspondence: Jian Wu,
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Risk Factors of Redo Surgery After Unilateral Focused Parathyroidectomy: Conclusions From a Comprehensive Nationwide Database of 13,247 Interventions Over 6 Years. Ann Surg 2020; 272:801-806. [PMID: 32833757 DOI: 10.1097/sla.0000000000004269] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgical removal of hyperfunctional parathyroid gland is the definitive treatment for primary hyperparathyroidism (pHPT). Postoperative follow-up shows variability in persistent/recurrent disease rate throughout different centers. OBJECTIVE To evaluate the incidence of redo surgery after targeted parathyroidectomy for pHPT. METHODS We performed a nationwide retrospective cohort study on the "Programme de Medicalisation des Systemes d'Information," the French administrative database that collects information on all healthcare facilities' discharges. We extracted data from 2009 to 2018 for all patients who underwent parathyroidectomy for pHPT between January 2011 to December 2016. The primary outcome was the reoperation rate within 2 years since first surgery. Patients who had a first attempt of surgery within the previous 24 months, familial hyperparathyroidism, multiglandular disease, and renal failure were excluded. Results were adjusted according to sex and the Elixhauser Comorbidity Index. Operative volume thresholds to define high-volume centers were achieved by the Chi-Squared Automatic Interaction Detector method. RESULTS In the study period, 13,247 patients (median age 63, F/M=3.6) had a focused parathyroidectomy by open (88.7%) or endoscopic approach. Need of remedial surgery was 2.8% at 2 years. In multivariate analysis, factors predicting redo surgery were: cardiac history (P=0.008), obesity (P=0.048), endoscopic approach (P=0.005), and low-volume center (P<0.001). We evaluated that an annual caseload of 31 parathyroidectomies was the best threshold to discriminate high-volume centers and carries the lowest morbidity/failure rate. CONCLUSION Although focused parathyroidectomy represents a standardized operation, cure rate is strongly associated with annual hospital caseload, type of procedure (endoscopic), and patients' features (obesity, cardiac history). Patients with risk factors for redo surgery should be considered for an open surgery in a high-volume center.
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Khandelwal AH, Batra S, Jajodia S, Gupta S, Khandelwal R, Kapoor AK, Mishra SK, Baijal SS. Radiofrequency Ablation of Parathyroid Adenomas: Safety and Efficacy in a Study of 10 Patients. Indian J Endocrinol Metab 2020; 24:543-550. [PMID: 33643872 PMCID: PMC7906106 DOI: 10.4103/ijem.ijem_671_20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/18/2020] [Accepted: 12/16/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To evaluate safety and effectiveness of ultrasound-guided percutaneous radiofrequency ablation of parathyroid adenoma in surgically unfit patients with hypercalcemia because of hyperparathyroidism. MATERIALS AND METHODS A retrospective review of hospital records from Jan 2012 to Dec 2018 revealed 10 patients, who had undergone ablation for solitary parathyroid adenoma. All 10 patients suffered from hyperparathyroidism because of parathyroid adenoma, resulting in hypercalcemia. These patients were surgically unfit because of comorbidities. Pre-ablation serum calcium and serum parathormone levels were measured and compared with the levels after the ablation. RESULTS Mean serum calcium level decreased significantly from 2.81 ± 0.17 mmol/L pre-ablation to 2.42 ± 0.17 mmol/L 72 h after ablation and parathyroid hormone levels became normal in all patients within 7 days. Seven patients remained normo-calcaemic at 6 months follow-up with no signs and symptoms of hyperparathyroidism. One patient with pancreatitis died after 15 days because of pre-existing multi-organ failure. Two patients were lost to follow-up before 6 months. CONCLUSION Radiofrequency ablation of parathyroid adenoma is a safe and effective alternate treatment method for symptomatic hypercalcemia in surgically unfit patients suffering from primary hyperparathyroidism because of parathyroid adenoma.
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Affiliation(s)
| | - Smarth Batra
- Department of Interventional Radiology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Surabhi Jajodia
- Department of Interventional Radiology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Saurabh Gupta
- Department of Interventional Radiology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Rohit Khandelwal
- Department of Interventional Radiology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Abhay Kumar Kapoor
- Department of Interventional Radiology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Sunil Kumar Mishra
- Department of Endocrinology and Metabolism, Medanta-The Medicity, Gurugram, Haryana, India
| | - S. S. Baijal
- Department of Interventional Radiology, Medanta-The Medicity, Gurugram, Haryana, India
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Takahashi T, Yamazaki K, Ota H, Shodo R, Ueki Y, Horii A. Near-Infrared Fluorescence Imaging in the Identification of Parathyroid Glands in Thyroidectomy. Laryngoscope 2020; 131:1188-1193. [PMID: 33016342 DOI: 10.1002/lary.29163] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/31/2020] [Accepted: 09/19/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess the ability of near-infrared fluorescence imaging (NIFI) to identify parathyroid glands (PGs) among histologically proven PG/non-PG specimens compared with a surgeon's visual acumen, and to determine NIFI sensitivity in detecting incidentally resected PGs from thyroidectomy specimens, compared to the surgeon's visual inspection. STUDY DESIGN Prospective study. METHODS With mean age of 61 years, 36 patients with various thyroid diseases were enrolled. Possible PGs (n = 28) and lymph nodes (n = 32) were identified by the experienced surgeon's visual inspection. Using NIFI, 15 PGs were further identified from thyroidectomy specimens. For these 75 specimens, the surgeon's judgments (PG vs. non-PG) were recorded. Histological evaluation was performed after examining the NIFI auto-fluorescence of each specimen. RESULTS There were no significant differences in sensitivity, specificity, positive predictive value, and negative predictive value between the surgeon's visual inspection and NIFI in identifying PGs, with values of 100%/97.1%, 85.0%/87.5%, 85.4%/87.2%, and 100%/97.2%, respectively. The sensitivity of NIFI (82.9%) for detection of PGs from thyroidectomy specimens was significantly higher than that of the surgeon's visual inspection (61.0%). False negative specimens contained bleeding/congestion and/or encapsulation by thick tissues, whereas false positive specimens contained electrocoagulated tissues. CONCLUSIONS NIFI showed results comparable to the experienced surgeon's visual inspection in identifying PGs. This could benefit novice surgeons. NIFI may be useful for experienced surgeons to locate incidentally resected PGs within thyroidectomy specimens for auto-transplantation. Prevention of intra-gland bleeding and congestion, careful removal of thick capsules, and bloodless surgeries without electrocoagulation are important for reducing false positive and false negative results. Laryngoscope, 131:1188-1193, 2021.
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Affiliation(s)
- Takeshi Takahashi
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Keisuke Yamazaki
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hisayuki Ota
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ryusuke Shodo
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yushi Ueki
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Arata Horii
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Mainali B, Lindeman B, Chen H. Re-operative Parathyroidectomy in Patients With Mild Primary Hyperparathyroidism. J Surg Res 2020; 255:130-134. [PMID: 32543378 DOI: 10.1016/j.jss.2020.05.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/23/2020] [Accepted: 05/03/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgery is the definitive management of primary hyperparathyroidism and the only curative therapy. However, many surgeons are hesitant to operate on individuals with mild primary hyperparathyroidism, with an even greater reluctance to operate on those who underwent a previous parathyroidectomy. We hypothesize that patients with mild primary hyperparathyroidism who undergo a re-operation have equivalent outcomes compared with those who undergo a first-time (FT) operation. METHODS We reviewed a prospective database of 459 patients with mild primary hyperparathyroidism who underwent surgery by one endocrine surgeon. Of these patients, 59 had a re-operative (RE-OP) parathyroid surgery. We compared these patients to those with mild primary hyperparathyroidism who had FT surgery (n = 400) using either the Pearson chi-square, Fisher's exact test, or Student's t-test where appropriate. RESULTS The mean age of our cohort was 60 ± 14 y, with 86% females. Patients in the RE-OP group had similar preoperative calcium and parathyroid hormone levels compared with those in the FT group. Most patients who underwent a RE-OP surgery had four gland hyperplasia on pathology (49.2%). Patients in the RE-OP and FT groups both had high and similar cure rates (100% versus 99.8%, P = 0.70). RE-OP patients had a higher rate of recurrent hyperparathyroidism (10.3% versus 3.3%, P = 0.025). CONCLUSIONS In patients with mild primary hyperparathyroidism, those who undergo RE-OP parathyroidectomy have a high cure rate that is similar to FT surgery. Therefore, we recommend that these patients with recurrence of mild hyperparathyroid disease be considered for parathyroidectomy.
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Affiliation(s)
- Bigyan Mainali
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
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Iacobone M, Scerrino G, Palazzo FF. Parathyroid surgery: an evidence-based volume-outcomes analysis : European Society of Endocrine Surgeons (ESES) positional statement. Langenbecks Arch Surg 2019; 404:919-927. [PMID: 31595330 DOI: 10.1007/s00423-019-01823-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The interest in correlation between hospital and surgeon practice volume and postoperative outcomes has grown considerably over the last decades; it has been suggested that surgery is likely to be associated with higher cure rates, lower morbidity and more favourable results in cost-effectiveness when performed in a high-volume setting. The aim of this paper is to undertake an evidence-based literature review of the relationship between surgical volume and clinical outcomes in parathyroidectomy for primary hyperparathyroidism. We used accepted quality markers to identify the relationship between volume and outcome with a view to defining a reproducible minimal surgical volume-related standard of care in parathyroid surgery. METHODS A peer review literature analysis of volume and outcomes in parathyroid surgery was carried out and assessed from an evidence-based perspective. Results were discussed at the 2019 Conference of the European Society of Endocrine Surgeons devoted to "Volumes, Outcomes and Quality Standards in Endocrine Surgery". RESULTS Literature reports no prospective randomised studies; thus, a low level of evidence may be achieved. CONCLUSIONS Parathyroid surgery is at increased risk of failures, morbidity and need for reoperations and cost when performed in low-volume settings; thus, it should be concentrated in dedicated settings, with adequate annual volume and expertise. Acceptable results may be achieved moving parathyroid surgery cases away from low-volume settings (< 15 parathyroidectomies/year). Challenging procedures (primary hyperparathyroidism without unequivocal preoperative localization, hereditary variants, paediatric patients, reoperations) should be confined to high-volume settings (> 40 parathyroidectomies/year).
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Affiliation(s)
- Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Gregorio Scerrino
- General and Emergency Surgery Unit, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - F Fausto Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, London, UK
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Abstract
BACKGROUND Since its first description, several studies have highlighted the role of the surgeon's experience in the outcome of parathyroid surgery, however, no uniform consensus exists regarding the minimum operative experience required for good surgical outcomes. This work aims to summarize the current data regarding the surgeon volume-outcome relationship for parathyroidectomy. METHODS An electronic literature review identified 85 publications, and after study selection 11 were included. An additional nine publications were added based on reference review and inclusion of publications not initially captured. CONCLUSIONS There are insufficient data to dogmatically conclude a minimum number of cases required to achieve optimal surgical results. However, extrapolation from the inclusive studies support the conclusions that higher operative volumes improve cure rates and decrease the rates of complications, recurrent disease, and perioperative costs. Endocrine Surgery fellowships or mentorships may help prepare the less experienced surgeon for successful outcomes. Although reticent to offer firm minimal volume requirements, we have made suggestions in this manuscript.
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Affiliation(s)
- Neeta J Erinjeri
- Endocrine Neoplasia Institute, Miami Cancer Institute, Miami, FL, USA.
| | - Robert Udelsman
- Endocrine Neoplasia Institute, Miami Cancer Institute, Miami, FL, USA; Florida International University, Miami, FL, USA; Yale University School of Medicine, New Haven, CT, USA.
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McWade MA, Thomas G, Nguyen JQ, Sanders ME, Solórzano CC, Mahadevan-Jansen A. Enhancing Parathyroid Gland Visualization Using a Near Infrared Fluorescence-Based Overlay Imaging System. J Am Coll Surg 2019; 228:730-743. [PMID: 30769112 PMCID: PMC6487208 DOI: 10.1016/j.jamcollsurg.2019.01.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Misidentifying parathyroid glands (PGs) during thyroidectomies or parathyroidectomies could significantly increase postoperative morbidity. Imaging systems based on near infrared autofluorescence (NIRAF) detection can localize PGs with high accuracy. These devices, however, depict NIRAF images on remote display monitors, where images lack spatial context and comparability with actual surgical field of view. In this study, we designed an overlay tissue imaging system (OTIS) that detects tissue NIRAF and back-projects the collected signal as a visible image directly onto the surgical field of view instead of a display monitor, and tested its ability for enhancing parathyroid visualization. STUDY DESIGN The OTIS was first calibrated with a fluorescent ink grid and initially tested with parathyroid, thyroid, and lymph node tissues ex vivo. For in vivo measurements, the surgeon's opinion on tissue of interest was first ascertained. After the surgeon looked away, the OTIS back-projected visible green light directly onto the tissue of interest, only if the device detected relatively high NIRAF as observed in PGs. System accuracy was determined by correlating NIRAF projection with surgeon's visual confirmation for in situ PGs or histopathology report for excised PGs. RESULTS The OTIS yielded 100% accuracy when tested ex vivo with parathyroid, thyroid, and lymph node specimens. Subsequently, the device was evaluated in 30 patients who underwent thyroidectomy and/or parathyroidectomy. Ninety-seven percent of exposed tissue of interest was visualized correctly as PGs by the OTIS, without requiring display monitors or contrast agents. CONCLUSIONS Although OTIS holds novel potential for enhancing label-free parathyroid visualization directly within the surgical field of view, additional device optimization is required for eventual clinical use.
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Affiliation(s)
- Melanie A McWade
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - John Q Nguyen
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Melinda E Sanders
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN.
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Thomas G, McWade MA, Paras C, Mannoh EA, Sanders ME, White LM, Broome JT, Phay JE, Baregamian N, Solórzano CC, Mahadevan-Jansen A. Developing a Clinical Prototype to Guide Surgeons for Intraoperative Label-Free Identification of Parathyroid Glands in Real Time. Thyroid 2018; 28:1517-1531. [PMID: 30084742 PMCID: PMC6247985 DOI: 10.1089/thy.2017.0716] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Patients undergoing thyroidectomy may have inadvertent damage or removal of the parathyroid gland(s) due to difficulty in real-time parathyroid identification. Near-infrared autofluorescence (NIRAF) has been demonstrated as a label-free modality for intraoperative parathyroid identification with high accuracy. This study presents the translation of that approach into a user-friendly clinical prototype for rapid intraoperative guidance in parathyroid identification. METHODS A laboratory (lab)-built spectroscopy system that measures NIRAF in tissue was evaluated for identifying parathyroid glands in vivo across 162 patients undergoing thyroidectomy and/or parathyroidectomy. Based on these results, a clinical prototype called PTeye was designed with a user-friendly interface and subsequently investigated in 35 patients. The performance of the lab-built system and the clinical prototype were concurrently compared side by side by a single user with 20 patients in each group. The influence of (i) intrapatient and interpatient variability of NIRAF in thyroid and parathyroid glands and (ii) thyroid and parathyroid pathology on intraoperative parathyroid identification were investigated. The effect of blood on NIRAF intensity of parathyroid and thyroid was tested ex vivo with the PTeye system to assess if a hemorrhagic surgical field would affect parathyroid identification. Accuracy of both systems were determined by correlating the acquired data with either visual confirmation by a surgeon for unexcised parathyroid glands or histology reports for excised parathyroid glands. RESULTS The overall accuracy of the lab-built system in guiding parathyroid identification was 92.5%, while the PTeye system achieved an accuracy of 96.1%. Unlike the lab-built system, the PTeye could guide parathyroid identification even as the operating room lights remained on and required only 25% of the laser power used by the lab-built setup. Parathyroid glands had elevated NIRAF intensity compared to thyroid and other neck tissues, regardless of thyroid or parathyroid pathology. Blood did not seem to affect tissue NIRAF measurements obtained with both systems. CONCLUSION In this study, the clinical prototype PTeye demonstrated high accuracy for label-free intraoperative parathyroid identification. The intuitive interface of the PTeye that can guide in identifying parathyroid tissue in the presence of ambient room lights suggests that it is a reliable and easy-to-use tool for surgical personnel.
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Affiliation(s)
- Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University Nashville, Tennessee
| | - Melanie A. McWade
- Vanderbilt Biophotonics Center, Vanderbilt University Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University Nashville, Tennessee
| | - Constantine Paras
- Vanderbilt Biophotonics Center, Vanderbilt University Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University Nashville, Tennessee
| | - Emmanuel A. Mannoh
- Vanderbilt Biophotonics Center, Vanderbilt University Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University Nashville, Tennessee
| | | | - Lisa M. White
- Murfreesboro Surgical Center, Murfreesboro, Tennessee
| | | | - John E. Phay
- Division of Surgical Oncology, The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Naira Baregamian
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Nashville, Tennessee
| | - Carmen C. Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Nashville, Tennessee
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Vanderbilt University Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University Nashville, Tennessee
- Address correspondence to: Anita Mahadevan-Jansen, PhD, Department of Biomedical Engineering, Vanderbilt University, Station B, Box 351631, Nashville, TN 37235
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Stack BC, Tolley NS, Bartel TB, Bilezikian JP, Bodenner D, Camacho P, Cox JPDT, Dralle H, Jackson JE, Morris JC, Orloff LA, Palazzo F, Ridge JA, Scott-Coombes D, Steward DL, Terris DJ, Thompson G, Randolph GW. AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons. Head Neck 2018; 40:1617-1629. [PMID: 30070413 DOI: 10.1002/hed.25023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/13/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present. METHODS A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness. RESULTS Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed. CONCLUSION Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.
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Affiliation(s)
- Brendan C Stack
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Neil S Tolley
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | | | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Donald Bodenner
- Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Pauline Camacho
- Department of Medicine, Division of Endocrinology, Loyola University, Chicago, Illinois
| | - Jeremy P D T Cox
- Department of Metabolic Medicine, Imperial College Hospital, NHS Healthcare Trust, London, UK
| | - Henning Dralle
- Sektion Endokrine Chirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinisches Zentrum, Germany
| | - James E Jackson
- Department of Imaging, Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John C Morris
- Department of Medicine, Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Lisa Ann Orloff
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Fausto Palazzo
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | | | - David L Steward
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - David J Terris
- Department of Otolaryngology - Head and Neck Surgery, Augusta University, Augusta, Georgia
| | | | - Gregory W Randolph
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts
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Parnell KE, Oltmann SC. The surgical management of primary hyperparathyroidism: an updated review. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2018. [DOI: 10.2217/ije-2017-0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Patients with primary hyperparathyroidism often present clinically asymptomatic with various biochemical compositions of serum calcium, parathyroid hormone, vitamin D and urinary calcium. Understanding the subtle differences in clinical and biochemical presentations is key for timely diagnosis and referral to an experienced parathyroid surgeon. Surgery remains the only option for cure of primary hyperparathyroidism, which now favors a directed parathyroidectomy with intra-operative adjuncts. However it is important to understand and revise the surgical approach for patients with hereditary conditions or nonlocalizing studies. Revised guidelines from the Fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism in 2013 and the American Association of Endocrine Surgeons in 2016 are reviewed in this paper for an updated review of this condition.
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Affiliation(s)
- Kaela E Parnell
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, E6.104B, Dallas, TX 75390–9092, USA
| | - Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, E6.104B, Dallas, TX 75390–9092, USA
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Al-Qurayshi Z, Hauch A, Srivastav S, Kandil E. Ethnic and economic disparities effect on management of hyperparathyroidism. Am J Surg 2017; 213:1134-1142. [DOI: 10.1016/j.amjsurg.2016.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/06/2016] [Accepted: 07/06/2016] [Indexed: 10/21/2022]
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Shinden Y, Nakajo A, Arima H, Tanoue K, Hirata M, Kijima Y, Maemura K, Natsugoe S. Intraoperative Identification of the Parathyroid Gland with a Fluorescence Detection System. World J Surg 2017; 41:1506-1512. [DOI: 10.1007/s00268-017-3903-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hanba C, Bobian M, Svider PF, Sheyn A, Siegel B, Lin HS, Raza SN. Perioperative considerations and complications in pediatric parathyroidectomy. Int J Pediatr Otorhinolaryngol 2016; 91:94-99. [PMID: 27863650 DOI: 10.1016/j.ijporl.2016.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/10/2016] [Accepted: 10/13/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate perioperative considerations and post-operative complications associated with parathyroidectomy in the pediatric population. METHODS The Kids' Inpatient Database 21 (KID) was searched for patients who underwent parathyroidectomy in 2009 and 2012. Patient demographics, hospital stay, associated charges, and post-operative adverse sequelae were evaluated in all patients and included patient comorbidity and additional procedure requirement analysis. RESULTS There were 182 patients extrapolating to 262 parathyroidectomies over the two years analyzed. Although a minority of patients were male (45.4%), these patients had greater rates of complications, length of stay, and hospital charges. Importantly, minorities and younger patients (≤15y) also had more complicated post-operative courses. The lengths of stay for patients experiencing post-operative altered mental status (18.7d), post-operative infection (15.5d), respiratory complications (19d), and cardiac complications (13d) were significantly increased compared to individuals without major complications (3.4d) (p < 0.001). Patients with pre-existing chronic kidney disease, dialysis-dependence, and bone sequelae (most commonly from hungry bone syndrome) also had significantly lengthier stays and greater associated costs. CONCLUSION Findings from this analysis can be included in a comprehensive pre-operative informed consent process between physicians and patients discussing perioperative considerations and potential complications of parathyroidectomy. Males, younger children, and patients with preexisting renal conditions experienced lengthier and more complicated hospital stays, suggesting the need for closer monitoring of these cohorts.
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Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Michael Bobian
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Peter F Svider
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Anthony Sheyn
- Department of Otolaryngology - University of Tennessee Health Science Center, Memphis, TN, USA; LeBonheur Children's Hospital, Department of Pediatric Otolaryngology, Memphis, TN, USA
| | - Bianca Siegel
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA; Children's Hospital of Michigan, Detroit Medical Center, Detroit, MI, USA
| | - Ho-Sheng Lin
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA; Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA
| | - S Naweed Raza
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI, USA; Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA
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Parathyroid surgery can be safely performed in a community hospital by experienced parathyroid surgeons: A retrospective cohort study. Int J Surg 2016; 27:72-76. [DOI: 10.1016/j.ijsu.2015.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/11/2015] [Indexed: 11/20/2022]
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Persistent Primary Hyperparathyroidism, Severe Vitamin D Deficiency, and Multiple Pathological Fractures. Case Rep Endocrinol 2016; 2016:3016201. [PMID: 27525132 PMCID: PMC4976193 DOI: 10.1155/2016/3016201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/23/2016] [Indexed: 11/18/2022] Open
Abstract
Persistent primary hyperparathyroidism (PHPT) refers to the sustained hypercalcemia state detected within the first six months following parathyroidectomy. When it coexists with severe vitamin D deficiency, the effects on bone can be devastating. We report the case of a 56-year-old woman who was sent to this center because of persistent hyperparathyroidism. Her disease had over 3 years of evolution with nephrolithiasis and hip fracture. Parathyroidectomy was performed in her local unit; however, she continued with hypercalcemia, bone pain, and pathological fractures. On admission, the patient was bedridden with multiple deformations by fractures in thoracic and pelvic members. Blood pressure was 100/80, heart rate was 86 per minute, and body mass index was 19 kg/m2. Calcium was 14 mg/dL, parathormone 1648 pg/mL, phosphorus 2.3 mg/dL, creatinine 2.4 mg/dL, urea 59 mg/dL, alkaline phosphatase 1580 U/L, and vitamin D 4 ng/mL. She received parenteral treatment of hypercalcemia and replenishment of vitamin D. The second surgical exploration was radioguided by gamma probe. A retroesophageal adenoma of 4 cm was resected. Conclusion. Persistent hyperparathyroidism with severe vitamin D deficiency can cause catastrophic skeletal bone softening and fractures.
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Magnabosco FF, Tavares MR, Montenegro FLDM. [Surgical treatment of secondary hyperparathyroidism: a systematic review of the literature]. ACTA ACUST UNITED AC 2015; 58:562-71. [PMID: 25166048 DOI: 10.1590/0004-2730000003372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022]
Abstract
Secondary hyperparathyroidism (HPT) has a high prevalence in renal patients. Secondary HPT results from disturbances in mineral homeostasis, particularly calcium, which stimulates the parathyroid glands, increasing the secretion of parathyroid hormone (PTH). Prolonged stimulation can lead to autonomy in parathyroid function. Initial treatment is clinical, but parathyroidectomy (PTx) may be required. PTx can be subtotal or total followed or not followed by parathyroid tissue autograft. We compared the indications and results of these strategies as shown in the literature through a systematic literature review on surgical treatment of secondary HPT presented in MedLine and LILACS from January 2008 to March 2014. The search terms were: hyperparathyroidism; secondary hyperparathyroidism; parathyroidectomy and parathyroid glands, restricted to research only in humans, articles available in electronic media, published in Portuguese, Spanish, English or French. We selected 49 articles. Subtotal and total PTx followed by parathyroid tissue autograft were the most used techniques, without consensus on the most effective surgical procedure, although there was a preference for the latter. The choice depends on surgeon's experience. There was consensus on the need to identify all parathyroid glands and cryopreservation of parathyroid tissue whenever possible to graft if hypoparathyroidism arise. Imaging studies may be useful, especially in recurrences. Alternative treatments of secondary HPT, both interventional and conservative, require further study.
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Affiliation(s)
| | - Marcos Roberto Tavares
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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Oltmann SC, Sippel RS. Surgical management of the patient with primary hyperparathyroidism. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.14.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract: The successful surgical management of primary hyperparathyroidism requires a surgeon with a clear understanding of both the embryology and anatomy of the parathyroid glands. While the majority of patients may only have a single diseased gland, there is no 100% confirmation that can be attained in the preoperative period. For this reason, even when imaging is suggestive of a single diseased gland, additional intraoperative adjuncts should be used. Intraoperative parathyroid hormone monitoring is the most commonly used adjunct. When preoperative localization is not possible, or intraoperative parathyroid hormone levels fail to meet criteria for successful resection, the patient requires a four gland exploration. Cure is not confirmed until normocalcemia is documented for at least 6 months after surgery.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9092, USA
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, 600 Highland Ave, K3/704, Madison, WI, 53792-7375, USA
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McWade MA, Paras C, White LM, Phay JE, Solórzano CC, Broome JT, Mahadevan-Jansen A. Label-free intraoperative parathyroid localization with near-infrared autofluorescence imaging. J Clin Endocrinol Metab 2014; 99:4574-80. [PMID: 25148235 PMCID: PMC4255111 DOI: 10.1210/jc.2014-2503] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The inability to accurately localize the parathyroid glands during parathyroidectomy and thyroidectomy procedures can prevent patients from achieving postoperative normocalcemia. There is a critical need for an improved intraoperative method for real-time parathyroid identification. OBJECTIVE The objective of the study was to test the accuracy of a real-time, label-free technique that uses near-infrared (NIR) autofluorescence imaging to localize the parathyroid. SETTING The study was conducted at the Vanderbilt University endocrine surgery center. SUBJECTS AND METHODS Patients undergoing parathyroidectomy and/or thyroidectomy were included in this study. To validate the intrinsic fluorescence signal in parathyroid, point measurements from 110 patients were collected using NIR fluorescence spectroscopy. Fluorescence imaging was performed on 6 patients. Imaging contrast is based on a previously unreported intrinsic NIR fluorophore in the parathyroid gland. The accuracy of fluorescence imaging was analyzed in comparison with visual assessment and histological findings. MAIN OUTCOME MEASURE The detection rate of parathyroid glands was measured. RESULTS The parathyroid glands in 100% of patients measured with fluorescence imaging were successfully detected in real time. Fluorescence images consistently showed 2.4 to 8.5 times higher emission intensity from the parathyroid than surrounding tissue. Histological validation confirmed that the high intrinsic fluorescence signal in the parathyroid gland can be used to localize the parathyroid gland regardless of disease state. CONCLUSION NIR fluorescence imaging represents a highly sensitive, real-time, label-free tool for parathyroid localization during surgery. The elegance and effectiveness of NIR autofluorescence imaging of the parathyroid gland makes it highly attractive for clinical application in endocrine surgery.
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Affiliation(s)
- Melanie A McWade
- Biomedical Photonics Laboratory (M.A.W., C.P., A.M.-J.), Department of Biomedical Engineering Vanderbilt University, Nashville, Tennessee 37235; Murfreesboro Surgical Center (L.M.W.), Murfreesboro, Tennessee 37129; Division of Surgical Oncology (J.E.P.), Ohio State University, Columbus, Ohio 43210; Division of Surgical Oncology and Endocrine Surgery (C.C.S.), Vanderbilt University, Nashville, Tennessee 37232; and Division of Surgical Endocrinology (J.T.B.), St Thomas Midtown Hospital, Nashville, Tennessee 37203
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Fewer adverse events after reoperative parathyroidectomy associated with initial minimally invasive parathyroidectomy. Am J Surg 2014; 208:850-855. [PMID: 25152254 DOI: 10.1016/j.amjsurg.2014.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/22/2014] [Accepted: 05/19/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND This study compared reoperative complication rates after initial minimally invasive parathyroidectomy and standard cervical exploration. METHODS Records from patients who underwent 1 reoperative parathyroidectomy at a single institution (1998 to 2012) were retrospectively reviewed. RESULTS Seventy-seven patients were included; 74% underwent initial standard cervical exploration. Preoperative and operative characteristics were similar between groups; 74% underwent focused, unilateral reoperation. A significantly higher rate of postoperative complications occurred in the initial standard cervical exploration group (42% vs 15%, P = .03) that could not be explained by differences in the rates of symptomatic hypocalcemia (P = .5). The type of prior parathyroidectomy was significantly associated with postoperative complications (odds ratio 4.1, 95% confidence interval 1.1 to 15.7, P = .04). In a multivariable logistic regression model that included body mass index, type of operation (for initial and reoperation), and initial operation performed prereferral as covariates, type of prior parathyroidectomy remained a significant predictor of postoperative complications. CONCLUSION Higher rates of postoperative sequelae after initial standard cervical exploration should be considered before performing routine 4-gland exploration.
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McCoy KL, Chen NH, Armstrong MJ, Howell GM, Stang MT, Yip L, Carty SE. The Small Abnormal Parathyroid Gland is Increasingly Common and Heralds Operative Complexity. World J Surg 2014; 38:1274-81. [DOI: 10.1007/s00268-014-2450-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ali M, Kumpe DA. Embolization of Bronchial Artery–supplied Ectopic Parathyroid Adenomas Located in the Aortopulmonary Window. J Vasc Interv Radiol 2014; 25:138-43. [DOI: 10.1016/j.jvir.2013.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/02/2013] [Accepted: 10/03/2013] [Indexed: 10/25/2022] Open
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Zia S, Sippel RS, Chen H. Sestamibi imaging for primary hyperparathyroidism: the impact of surgeon interpretation and radiologist volume. Ann Surg Oncol 2012; 19:3827-31. [PMID: 22868920 DOI: 10.1245/s10434-012-2581-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Preoperative localization is the first step towards minimally invasive targeted parathyroidectomy. While there are data emphasizing that surgeon experience optimizes operative outcomes, the role of the radiologist's experience in successful preoperative imaging is unclear. We hypothesized that the accuracy of sestamibi scanning for primary hyperparathyroidism is dependent upon surgeon interpretation and radiologist volume. METHODS Between January 2000 to August 2009, 1,255 patients underwent parathyroidectomy for hyperparathyroidism at our institution. Of these, 763 had sestamibi scans for primary hyperparathyroidism. All scans were reviewed by surgeons and radiologists blinded, and were correlated with the operative findings and pathological reports. Radiologists were grouped into high volume (>50 cases/year, HV-RAD) or low volume (<50 cases/year, LV-RAD) based upon a database of >6,000 parathyroid cases reported by 89 regional hospitals. RESULTS Of the 763 patients, 77 % were female and the mean age was 60 years. Mean baseline calcium and parathyroid hormone levels were 11.2 ± 0.03 mg/dl and 133 ± 3.27 pg/ml, respectively. The sensitivity of the surgeon (93 %) was higher than both HV (83 %) and LV (72 %) radiologists. Importantly, the positive predictive values were similar: 96 % for surgeon, 93 % for HV-RAD, and 98 % for LV-RAD. As a result, out of 99 scans which were correctly read by the surgeon but not by radiologist, 84 were read as negative by radiologist, 11 on the wrong side of the neck, and 4 on the same side but the wrong gland. CONCLUSIONS Surgeon interpretation and radiologist volume increase the likelihood of successful preoperative sestamibi parathyroid localization for primary hyperparathyroidism. We recommend that imaging be reviewed by experienced parathyroid surgeons rather than relying on radiological interpretation alone.
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Affiliation(s)
- Saqib Zia
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
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