Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience

Comparative Analysis of Transoral Endoscopic Parathyroidectomy Vestibular Approach and Focused Open Surgery for Primary Hyperparathyroidism Treatment: A Single Center Experience

BACKGROUND Primary hyperparathyroidism is one of the most common endocrine disorders, for which the definitive treatment is surgical parathyroidectomy. Generally, surgical exploration is performed as open focused neck surgery. The vestibular route is a new approach to minimally invasive endoscopic parathyroidectomy. This retrospective study from a single center in Turkey aimed to compare surgical outcomes from the transoral endoscopic vestibular approach (TOEPVA) vs direct open parathyroidectomy in 57 patients. MATERIAL AND METHODS Our study included data from 57 patients. TOEPVA was performed in 20 of these patients who did not want a cervical scar, and focused surgery was performed in the remaining 37 patients. The variables we analyzed were size, volume, and localization of the adenoma, operative time, presence of bleeding, presence of the recurrent laryngeal nerve damage, preoperative, short-term, and long-term postoperative PTH levels, use of drain, presence of postoperative hypocalcemia, and short-term and long-term calcium levels. RESULTS No laryngeal nerve and mental nerve damage was observed in either group. The mean operative time in focused open surgery was 80.54±33.1 min, while the mean operative time in TOEPVA was 128.21±30.88 (p: 0.794) min. The mean hospitalization period of patients who underwent open surgery was 3.29±1.9 days, while the mean discharge days of patients who underwent endoscopic surgery was 2.40±1.2. (p>0.05). CONCLUSIONS TOEPVA is a safe method in patients who underwent parthyroid surgery to avoid cervical scarring.

Surgery for Sporadic Primary Hyperparathyroidism: Evolution over the Last Twenty Years in a Monocentric Setting

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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.

Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) for primary hyperparathyroidism: Turkey's experience

AIM

Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey.

MATERIALS AND METHODS

Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020.

RESULTS

Of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20 min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1 day. No persistence was documented on follow up.

CONCLUSION

TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery.

Transoral endoscopic parathyroidectomy vestibular approach: A systematic review

BACKGROUND

Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) is a novel surgical approach that has gained increasing traction as a remote access approach for parathyroid surgery. The primary aim of this systematic review is to assess the feasibility and safety of this approach.

METHODS

Several databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system.

RESULTS

Nine articles containing 78 cases of TOEPVA met the inclusion criteria. Overall, there was a 96% success rate. There were three cases (3.8%) that had complications, including one case of transient recurrent laryngeal nerve palsy. The average MINORS score of the studies suggested a moderate amount of bias.

CONCLUSIONS

Based on limited quality evidence, this review suggests that TOEPVA is safe and feasible, with reasonable success rates and low complication rates in a very carefully selected patient population. Further large-scale studies are warranted.

Imaging and choosing the right patients for transoral endoscopic parathyroidectomy vestibular approach

Advances in imaging for preoperative localization have propelled the widespread adoption of minimally invasive/focused parathyroidectomy in primary hyperparathyroidism. Though it is performed through a relatively small incision, studies have shown that the presence of a neck scar increases attentional bias towards the neck resulting in compromised quality of life. Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) eliminates a neck scar. While indications for TOEPVA are the same as that of minimally invasive open parathyroidectomy, confident preoperative localization of the parathyroid with a surgeon performed ultrasound along with concordant localization with SPECT CT is an essential prerequisite before offering patients this approach for parathyroidectomy. Early data has demonstrated the feasibility and safety of this approach.

Robotic transoral vestibular parathyroidectomy: Two case reports and review of literature

Advances in preoperative localization studies and demands for scarless surgery have promoted the investigation for remote techniques in parathyroid surgery. Transoral vestibular approach seems to provide the most comfortable and safest access to the neck. In this paper, we report our initial experience with robotic transoral vestibular parathyroidectomy (RTVP) in four patients with primary hyperparathyroidism. The surgery was performed with the Da Vinci system through three trocars introduced from the lower lip vestibule. The procedure was converted to open in two patients due to inappropriate preoperative localization. The mean operative time was 169 min. No postoperative complications were seen. Patients were discharged on postoperative day 1. RTVP is a feasible and safe technique, which allows better surgical exposure and manipulation of the instruments. The advantages of transoral vestibular approach can be enhanced by robotics. Further studies are needed to analyze complications and costs.