Total endoscopic parathyroidectomy

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Endoscopic parathyroidectomy in primary hyperparathyroidism

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

Video-assisted submandibular resection: two-step technique

BACKGROUND

The relative delay in the development of endoscopic neck surgery has been attributed to the relatively narrow operative field and to the presence of many vital structures in it. For endoscopic neck surgery to be feasible, it is essential to create a comfortable working space. A method of creating a working space is the gasless skin-lifting technique. To date, there have been only few reports on the transcervical endoscopic approach to the submandibular gland.

AIM

Assessment of a new modification in the technique of video-assisted submandibular sialadenectomy aiming at improving the visibility and safety of the operation.

METHODS

The study included 12 adult patients indicated for sialadenectomy. Patients having large, hard or fixed submandibular gland were excluded. Laboratory work-up and ultrasound of the neck were obtained in all patients. All patients had video-assisted submandibular sialadenectomy, using a "two-step resection" technique: A 15-20-m skin incision was performed. The superficial part of the submandibular gland down to the plane of the mylohyoid muscle was dissected free and excised, leaving behind a roomy working space and a clearer view to the deeper part (step 1). The remaining deep part of the gland was then dissected and removed (step 2). A gasless skin lifting was adopted using Army-Navy retractors. Dissection was performed using ultrasonic sealing device.

RESULTS

Mean operative time was 89.67 ± 37.97 min. Mean blood loss was 45 ± 19.78 ml. There was no permanent nerve injury.

CONCLUSION

The two-step submandibular sialadenectomy using skin-lifting gasless technique offers good visibility and good working space that allow safer dissection.

Minimally invasive neck surgery. Surgical feasibility and physiological effects of carbon dioxide insufflation in a unilateral subplatysmal approach

Endoscopically assisted, minimally invasive techniques to regions without a natural cavity require insufflation with carbon dioxide (CO2). In the neck region this may impair hemodynamics, blood gas homoeostasis, cerebral blood circulation and increase the intracranial pressure. An exclusively endoscopic unilateral subplatysmal approach to the submandibular region was investigated in nine mini-pigs randomized to three groups. On both neck sides, within a 14 day interval, the subplatysmal space was inflated with CO2 at 10 mmHg, 20 mmHg (1.33/2.66 x 10 (3)Pa) or 20 mmHg (2.66 x 10 (3)Pa) combined with mechanical suspension. Data for hemodynamic and blood gas parameters, gas volumes, and intracranial pressure were obtained preoperatively, 30 min after onset and 10 min postopeatively. In a pocket created by insufflation of 20 mmHg (2.66 x 10 (3)Pa), exposition and resection of the submandibular gland were accomplished easily. The elevation procedure had technical disadvantages. The mean operation time was 48.9 min. Unilateral subplatysmal carbon dioxide insufflation of the submandibular neck region up to 20 mmHg (2.66 x 10 (3)Pa) did not affect physiological parameters. As an exclusive endoscopical approach for unilateral surgery of the submandibular region, the use of inflation pressures of up to 20 mmHg (2.66 x 10 (3)Pa) might be considered.

Feasibility of an endoscopic approach to the submandibular neck region—Experimental and clinical results

We have investigated the feasibility of an exclusively endoscopic approach to the submandibular region in four pigs, four cadavers and two women. We inflated the subplatysmal space with carbon dioxide at low pressure. The submandibular gland and the jugulodigastric region were easy to identify once the correct anatomical space had been dissected and inflated. Four endoscopic resections of the submandibular gland were done successfully.

Treatment of Secondary Hyperparathyroidism With Ultrasonographically Guided Percutaneous Radiofrequency Thermoablation

We present a case of a 63-year-old woman with a recurrent secondary hyperparathyroidism hyperplasia with absolute contraindication for surgery, treated in 2 sessions with percutaneous ultrasonographically guided radiofrequency tissue ablation. The complete pathologic tissue ablation was confirmed by contrast-enhanced ultrasonography performed before and after the treatment and by clinical and laboratory follow-up. Furthermore in work progress, the percutaneous ultrasonographically guided radiofrequency tissue ablation can be considered a feasible and effective nonsurgical alternative treatment for symptomatic secondary hyperparathyroidism in high-risk patients.

Enhanced ALA-induced fluorescence in hyperparathyroidism

INTRODUCTION

Intraoperative localization of parathyroid glands can be challenging especially in minimally invasive surgery. Fluorescence diagnosis using the photosensitizer aminolevulinic acid (ALA) has been described to identify normal parathyroid glands during experimental bilateral neck exploration. The present study evaluated fluorescence differences between hyperplastic and normal parathyroid glands as a precondition for a clinical application of the technique.

MATERIALS AND METHODS

Polycystic kidney disease (PKD) rats with hyperparathyroidism due to hyperplastic parathyroid glands and Wistar rats with normal parathyroid glands were photosensitized by peritoneal lavage with ALA solution. After surgical exposure of thyroid and parathyroid glands the operative site was observed under blue light conditions using the d-light system to assess fluorescence characteristics of each tissue. Fluorescence intensities of parathyroid glands and surrounding thyroid tissue were measured by spectrometry. Parathyroid hormone in serum of the rats was determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Observation of the exposed thyroid site showed a subjectively stronger red fluorescence of the parathyroid glands in the PKD rats in comparison to the Wistar rats, whereas thyroid tissue appeared equally fluorescent. In the PKD animals, spectrometric fluorescence intensity was 10 times higher in the parathyroid glands than in the thyroid gland, whereas in the Wistar rats the ratio was 3.2:1. Fluorescence intensity in the parathyroid glands was more than twice in the PKD rats than in the Wistar rats, however slightly lower in the thyroid tissue. ELISA confirmed the pathophysiological change of a hyperparathyroidism with significantly increased serum levels of parathyroid hormone in the PKD rats.

DISCUSSION

Hyperparathyroidism enhances ALA-induced fluorescence of the parathyroid glands. A combined surgical fluorescence strategy may justify a unilateral, minimally invasive approach in selected patients and serve to improve the capability of the surgeon to safely and efficiently manage parathyroid diseases.

Endoscopic parathyroid surgery: results of 365 consecutive procedures

In recent years, several series have documented the feasibility of endoscopic approaches for parathyroid diseases. We performed a retrospective study to evaluate the results of endoscopic parathyroidectomy (EP) in the management of our patients with primary hyperparathyroidism (PHPT). During a 5.5 year period (1998-2003), we operated on 644 patients with PHPT. EP was proposed for patients with sporadic PHPT, without associated goiter, and without previous neck surgery in whom a single adenoma was localized by means of sonography and sestamibi scanning. EP was performed by the lateral approach with insufflation for patients with an adenoma located deep in the neck and by a gasless midline approach for patients whose adenoma was located anteriorly. A quick parathyroid (QPTH) assay was used during the surgical procedures. Among 644 patients with PHPT, 279 (43.3%) were not eligible for EP for the following reasons: associated nodular goiter (116 cases), previous neck surgery (52 cases), suspicion of multiglandular disease (31 cases), lack of preoperative localization (61 cases), and miscellaneous causes (19 cases). EP was performed in 365 patients with sporadic PHPT: 339 lateral access, 25 midline access, and one thoracoscopy. The median operating time was 49 minutes (16-130 minutes). Conversion to conventional parathyroidectomy was required in 49 patients (13.4%) for these reasons: missed adenomas (14 cases), difficulty with the dissection (8 cases), multiglandular disease correctly predicted by QPTH (11 cases), false-negative QPTH assay results (4 cases), false-positive sestamibi scan results (11 cases), and 1 false-positive sonography result. One patient presented with definitive recurrent nerve palsy. Three patients remained hypercalcemic, and one other patient had recurrent hypercalcemia. In conclusion, EP can be proposed for more than half of the patients with PHPT. Immediate results of EP are similar to those obtained with conventional parathyroidectomy, but no conclusions can be drawn in terms of the influence of EP on the outcome of the patients operated on for PHPT.

[Video-assisted parathyroidectomy in the management of patients with primary hyperparathyroidism]

INTRODUCTION

In recent years, different minimally invasive techniques of parathyroidectomy have been described. We performed a retrospective study to evaluate the indications and results of video-assisted parathyroidectomy (Vap) in the management of our patients with primary hyperparathyroidism (PHPT).

MATERIALS AND METHODS

During the last 5 years (1998-2002), we operated on 528 patients with PHPT. Vap was proposed for patients with sporadic PHPT, without associated goiter and without previous neck surgery, in whom a single adenoma was localized by means of sonography and/or sestamibi scanning. Vap was performed by lateral approach with insufflation for patients with adenoma located deeply in the neck and by gasless midline approach for patients with adenoma located anteriorly. A quick parathyroid (qPTH) assay was used during the surgical procedures. Calcemia, phosphoremia and PTH were systematically evaluated in patients on days 1 and 8, 1 month and 1 year after surgery. All patients underwent pre-operative and postoperative investigations of vocal cord movements.

RESULTS

Among 528 patients with PHPT, 228 (43%) were not eligible for Vap: associated nodular goiter (99 cases), previous neck surgery (42 cases), suspicion of multiglandular disease (25 cases), lack of pre-operative localization (48 cases), and miscellaneous causes (14 cases). Vap was performed in 300 patients with sporadic PHPT: 282 lateral access, 17 midline access and 1 thoracoscopy. Median operative time was 50 min (20-130 min). Conversion to conventional parathyroidectomy was required in 42 patients (14%): missed adenomas (11 cases), difficulties of dissection (7 cases), multiglandular disease correctly predicted by qPTH (10 cases); qPTH assay false negative results (3 cases), sestamibi scan false positive results (10 cases) and 1 sonography false positive result. One patient presented definitive recurrent nerve palsy. One patient had a persistent PHPT and one other patient had a recurrent PHPT.

CONCLUSION

Vap can be proposed for more than half of patients with PHPT. In our experience Vap and conventional parathyroidectomy are complementary. Immediate results of Vap are similar to those obtained with conventional parathyroidectomy but no conclusions can be drawn in terms of influence of Vap on the outcome of the patients operated for PHPT.