A comparison of minimally invasive video-assisted parathyroidectomy and traditional parathyroidectomy for parathyroid adenoma

Open Minimally Invasive Parathyroidectomy Versus Minimally Invasive Video-Assisted Parathyroidectomy: A Systematic Review and Meta-Analysis

Various minimally invasive techniques exist for surgical parathyroidectomy. The aim of this study was to conduct a meta-analysis comparing two popular minimally invasive techniques: minimally invasive video-assisted parathyroidectomy (MIVAP) and open minimally invasive parathyroidectomy (OMIP). An extensive search was conducted of online databases to identify all previous studies that had compared MIVAP and OMIP. The primary outcome measures considered were visual analog scale (VAS) score 24 hours postoperatively, conversion of operation (to open), failure rate and analgesic consumption. The data from these studies was extracted and compiled into a meta-analysis. The literature search yielded 104 studies of which four were included, enrolling 903 patients in this analysis. A significant difference was found regarding rates of conversion to open parathyroidectomy between the two groups, with the OMIP group demonstrating fewer conversions (MD = 3.52, CI = (2.04-6.08), P< 0.00001). No statistically significant differences were found between the two groups when comparing postoperative VAS scores at 24 hours (MD = -1.75, CI = (-9.8-6.3), P = 0.67), consumption of analgesia (OR = 0.49, CI = 0.07-3.54, P = 0.48) or failure rates (OR = 1.81, CI = 0.58-5.72, P = 0.31). OMIP was seen to require less need to convert to open parathyroidectomy with shorter operative times, while similar complication rates and scar lengths to MIVAP. More studies are required to evaluate the superior technique for parathyroidectomy.

A mini-invasive approach is feasible in patients with primary hyperparathyroidism and discordant or negative localisation studies

Preoperative localisation of pathological glands in patients with primary hyperparathyroidism (PHP) is the mainstay for mini-invasive parathyroidectomy. Nevertheless, a not negligible number of patients presents discordant or negative neck ultrasound (US) and ^99mTc-Sestamibi (MIBI) scan. The aim of this study was to assess if a mini-invasive approach is feasible in this kind of patients. In this retrospective study were included patients that underwent parathyroidectomy for PHP. Patients were divided into two groups according to concordance of US and MIBI scan results. 242 patients were included: 183 had concordant preoperative studies, and 59 had discordant or negative studies. A mini-invasive approach was possible in 42 (72.9%) patients with unclear preoperative studies, whereas 12 (20.3%) additional patients required conversion to BNE. The incidence of persistent PHP was higher in patients with unclear preoperative studies (8.5% vs 2.7%), but this difference did not reach a statistical significance (p = 0.121). In patients with unclear preoperative studies, a negative result of intraoperative PTH allowed to avoid a persistent disease in 12 patients, while in 3 cases led to an unnecessary additional exploration. In patients with discordant preoperative studies a mini-invasive approach is feasible; in this setting, the use of intraoperative PTH is mandatory to reduce the incidence of persistent PHP.

The role of Rapid Intraoperative Parathyroid Hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder. In the last few decades, the introduction of Rapid Intraoperative Parathyroid Hormone (ioPTH) monitoring has allowed to ensurance of the excision of all hyperfunctioning parathyroid tissues, reducing the risks of persistent and recurrent PHPT. However, the use of ioPTH is still debated among endocrine surgeons.

MATERIAL AND METHODS

The objective of this systematic review and meta-analysis was to assess if ioPTH monitoring is able to reduce the incidence of persistent or recurrent PHPT. A systematic literature search was performed using PubMed, Scopus, ISI-Web of Science and Cochrane Library Database. Prospective and retrospective studies addressing the efficacy of ioPTH monitoring were included in the systematic review and meta-analysis. The random-effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated.

RESULTS

A total of 28 studies with 13,323 patients were included in the quantitative analysis. The incidence of operative failure was 3.2% in the case group and 5.8% in the control group. After excluding three outlier studies, the quantitative analysis revealed that ioPTH reduced significantly the incidence of postoperative persistent or recurrent PHPT. (Risk Difference = -0.02; CI = -0.03, -0.01; p < 0.001). There was no evidence of heterogeneity among the studies (Q = 19.92, p = 0.70; I² = 0%). The analysis of several continuous moderators revealed that the effectiveness of ioPTH was larger in studies with lower preoperative serum calcium values and higher incidences of multiple gland disease.

CONCLUSION

ioPTH monitoring is effective in reducing the incidence of persistent and recurrent PHPT. Its routine use should be suggested in the next guidelines regarding management of PHPT.

A peculiar manifestation and clinical course of occult primary hyperparathyroidism: a case report

We present the clinical case of a patient who developed acute hypercalcemia diagnosed after presenting acute pancreatitis.Male patient, age 67, arrived at the Emergency Department of the University Hospital of Parma for upper abdominal pain, radiated to the back, and associated with nausea. Laboratory tests showed elevation of lipase, serum calcium levels, PTH levels and serum creatinine.  Due to the persistence on hypercalcemia an ultrasound scan of the cervical region was performed and showed a hyperechoic nodule of about 25x26x30 mm at the level of the lower pole of the left thyroid lobe, compatible with hyperplastic parathyroid. In the light of clinical-radiological examinations, acute edematous pancreatitis due to hypercalcemia was diagnosed. Hypercalcemia was attributable to primary hyperparathyroidism, so surgical indication to parathyroidectomy was gave.After medical treatment there was a progressive improvement of the clinical conditions and a few days later the patient underwent surgical operation of lower left parathyroidectomy with progressive normalization of the serum calcium levels. If hypercalcemia persists ​​after the beginning of a specific therapy there is an indication to perform an emergency parathyroidectomy; in our case the surgical procedure was performed some days after the diagnosis because the calcium serum levels ​​had returned to normal values with significant improvement of the clinical conditions, despite persistence of high PTH values.

Minimally invasive parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IOPTH) and preoperative imaging versus bilateral neck exploration for primary hyperparathyroidism in adults

BACKGROUND

Bilateral neck exploration (BNE) is the traditional approach to sporadic primary hyperparathyroidism. With the availability of the preoperative imaging techniques and intraoperative parathyroid hormone assays, minimally invasive parathyroidectomy (MIP) is fast becoming the favoured surgical approach.

OBJECTIVES

To assess the effects of minimally invasive parathyroidectomy (MIP) guided by preoperative imaging and intraoperative parathyroid hormone monitoring versus bilateral neck exploration (BNE) for the surgical management of primary hyperparathyroidism.

SEARCH METHODS

We searched CENTRAL, MEDLINE, WHO ICTRP and ClinicalTrials.gov. The date of the last search of all databases was 21 October 2019. There were no language restrictions applied.

SELECTION CRITERIA

We included randomised controlled trials comparing MIP to BNE for the treatment of sporadic primary hyperparathyroidism in persons undergoing surgery for the first time.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Two review authors independently screened for inclusion, extracted data and carried out risk of bias assessment. The content expert senior author resolved conflicts. We assessed studies for overall certainty of the evidence using the GRADE instrument. We conducted meta-analyses using a random-effects model and performed statistical analyses according to the guidelines in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We identified five eligible studies, all conducted in European university hospitals. They included 266 adults, 136 participants were randomised to MIP and 130 participants to BNE. Data were available for all participants post-surgery up to one year, with the exception of missing data for two participants in the MIP group and for one participant in the BNE group at one year. Nine participants in the MIP group and 11 participants in the BNE group had missing data at five years. No study had a low risk of bias in all risk of bias domains. The risk ratio (RR) for success rate (eucalcaemia) at six months in the MIP group compared to the BNE group was 0.98 (95% confidence interval (CI) 0.94 to 1.03; P = 0.43; 5 studies, 266 participants; very low-certainty evidence). A total of 132/136 (97.1%) participants in the MIP group compared with 129/130 (99.2%) participants in the BNE group were judged as operative success. At five years, the RR was 0.94 (95% CI 0.83 to 1.08; P = 0.38; 1 study, 77 participants; very low-certainty evidence). A total of 34/38 (89.5%) participants in the MIP group compared with 37/39 (94.9%) participants in the BNE group were judged as operative success. The RR for the total incidence of perioperative adverse events was 0.50, in favour of MIP (95% CI 0.33 to 0.76; P = 0.001; 5 studies, 236 participants; low-certainty evidence). Perioperative adverse events occurred in 23/136 (16.9%) participants in the MIP group compared with 44/130 (33.9%) participants in the BNE group. The 95% prediction interval ranged between 0.25 and 0.99. These adverse events included symptomatic hypocalcaemia, vocal cord palsy, bleeding, fever and infection. Fifteen of 104 (14.4%) participants experienced symptomatic hypocalcaemia in the MIP group compared with 26/98 (26.5%) participants in the BNE group. The RR for this event comparing MIP with BNE at two days was 0.54 (95% CI 0.32 to 0.92; P = 0.02; 4 studies, 202 participants). Statistical significance was lost in sensitivity analyses, with a 95% prediction interval ranging between 0.17 and 1.74. Five out of 133 (3.8%) participants in the MIP group experienced vocal cord paralysis compared with 2/128 (1.6%) participants in the BNE group. The RR for this event was 1.87 (95% CI 0.47 to 7.51; P = 0.38; 5 studies, 261 participants). The 95% prediction interval ranged between 0.20 and 17.87. The effect on all-cause mortality was not explicitly reported and could not be adequately assessed (very low-certainty evidence). There was no clear difference for health-related quality of life between the treatment groups in two studies, but studies did not report numerical data (very low-certainty evidence). There was a possible treatment benefit for MIP compared to BNE in terms of cosmetic satisfaction (very low-certainty evidence). The mean difference (MD) for duration of surgery comparing BNE with MIP was in favour of the MIP group (-18 minutes, 95% CI -31 to -6; P = 0.004; 3 studies, 171 participants; very low-certainty evidence). The 95% prediction interval ranged between -162 minutes and 126 minutes. The studies did not report length of hospital stay. Four studies reported intraoperative conversion rate from MIP to open procedure information. Out of 115 included participants, there were 24 incidences of conversion, amounting to a conversion rate of 20.8%.

AUTHORS' CONCLUSIONS

The success rates of MIP and BNE at six months were comparable. There were similar results at five years, but these were only based on one study. The incidence of perioperative symptomatic hypocalcaemia was lower in the MIP compared to the BNE group, whereas the incidence of vocal cord paralysis tended to be higher. Our systematic review did not provide clear evidence for the superiority of MIP over BNE. However, it was limited by low-certainty to very low-certainty evidence.

Day case parathyroidectomy: is this the right way for the patients?

Background

Minimally-invasive video-assisted parathyroidectomy (MIVAP) can be considered as the primary treatment of choice for single parathyroid adenoma. Often, this technique is performed in a day surgery setting and is associated with regional anaesthesia (RA). Many studies have already reported the feasibility and safety of MIVAP in day surgery. Here our focus has been on the patient's personal experience with these procedures through an assessment of their recovery at home.

Methods

We conducted a prospective observational study in the University Hospital of Pisa Day Surgery Unit. Forty-eight patients were enrolled and divided by personal choice of anaesthesia technique: a regional anaesthesia group (RAg) and general anaesthesia group (GAg). Data were extracted from the medical records and three questionnaires: the first was self-compiled at discharge (Q1), while the second (Q2) and the third (Q3) were administered as telephone surveys.

Results

None of the patients in RAg reported pain longer than 1 day after discharge, whereas 15% of patients in GAg reported pain relief the third day after discharge (P=0.0065). Discharge in RAg was within 3 hours in 12.5% of patients, within 4 hours in 78.1%, and within 5 hours in 9.4%. Discharge in GAg was within 5 hours in 53.8% and in more than 5 hours in 46.1% (P=0.0027).

Conclusions

Patients highly appreciated day-case parathyroidectomy. Furthermore, the association of RA with MIVAP leads to better results than those of general anaesthesia (GA) and MIVAP. Finally, we point out that it is fundamental that the physicians pay attention to what the patients consider important for them; that is, the personal meaning of the hospitalization.

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

BACKGROUND

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

LIMITATIONS

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

CONCLUSION

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

[Endoscopic lateral parathyroidectomy as surgical treatment for patients with primary hyperparathyroidism]

BACKGROUND

Most surgeons have rapidly accepted the use of minimally invasive surgical approaches for the treatment of primary hyperparathyroidism. The role of the endoscope in neck surgery is still being discussed due to its technical difficulty and complex patient selection criteria.

MATERIALS AND METHODS

A prospective study was conducted between April 2010 and April 2013. It included patients diagnosed with sporadic primary hyperparathyroidism (sPHPT) by locating a single adenoma using ultrasound and sestamibi scintigraphy imaging. All patients agreed to be included in the study. Experienced endocrine surgeons that had been trained in endocrine minimally invasive surgery performed the procedure. The same surgical technique was used in all of the cases. The demographic and clinical variables were evaluated. A descriptive analysis was performed on the data measuring mean, standard deviation, and range.

RESULTS

A total of 28 endoscopic lateral parathyroidectomies were performed. All patients were diagnosed with sporadic hyperparathyroidism sPHPT. The mean age was 68 years (59-89). No intraoperative complications were registered. Postoperative morbidity was comparable to that reported in the classical approach. A favourable outcome was observed in 27 of the 28 patients (96%) after a mean follow-up time of 22 (9 - 53) months.

CONCLUSIONS

An endoscopic approach for hyperparathyroidism sPHPT is feasible and reproducible, and it obtains comparable results to the classical open surgery. Several factors make this technique suitable for highly specialised hospitals with a high patient volume and specialised endocrine surgery units.

Comparison of minimally invasive parathyroidectomy under local anaesthesia and minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism: a cost analysis

BACKGROUND

Primary hyperparathyroidism (PHPT) origins from a solitary adenoma in 70- 95% of cases. Moreover, the advances in methods for localizing an abnormal parathyroid gland made minimally invasive techniques more prominent. This study presents a micro-cost analysis of two parathyroidectomy techniques.

PATIENTS AND METHODS

72 consecutive patients who underwent minimally invasive parathyroidectomy, video-assisted (MIVAP, group A, 52 patients) or "open" under local anaesthesia (OMIP, group B, 20 patients) for PHPT were reviewed. Operating room, consumable, anaesthesia, maintenance costs, equipment depreciation and surgeons/anaesthesiologists fees were evaluated. The patient's satisfaction and the rate of conversion to conventional parathyroidectomy were investigated. T-Student's, Kolmogorov-Smirnov tests and Odds Ratio were used for statistical analysis.

RESULTS

1 patient of the group A and 2 of the group B were excluded from the cost analysis because of the conversion to the conventional technique. Concerning the remnant patients, the overall average costs were: for Operative Room, 1186,69 € for the MIVAP group (51 patients) and 836,11 € for the OMIP group (p<0,001); for the Team, 122,93 € (group A) and 90,02 € (group B) (p<0,001); the other operative costs were 1388,32 € (group A) and 928,23 € (group B) (p<0,001). The patient's satisfaction was very strongly in favour of the group B (Odds Ratio 20,5 with a 95% confidence interval).

CONCLUSIONS

MIVAP is more expensive compared to the "open" parathyroidectomy under local anaesthesia due to the costs of general anaesthesia and the longer operative time. Moreover, the patients generally prefer the local anaesthesia. Nevertheless, the rate of conversion to the conventional parathyroidectomy was relevant in the group of the local anaesthesia compared to the MIVAP, since the latter allows a four-gland exploration.

Meta-analysis of video-assisted versus open parathyroidectomy for primary hyperparathyroidism

The gold standard treatment of primary hyperparathyroidism was bilateral neck exploration. Video-assisted parathyroidectomy (VAP) facilitated less invasive surgery, however there is lack of evidence comparing it to open parathyroidectomy (OP). A meta-analysis was conducted according to the PRISMA guidelines to compare them. In three eligible randomized controlled trials (241 patients), VAP operative time (61.7 ± 12 min) was comparable to OP (59.9 ± 6 min), less early postoperative pain, higher cosmetic satisfaction (statistically not significant) and 4% failure rate (none in OP). 25% of VAP converted to OP. Hypocalcaemia was six-times less in VAP (RR 6.4). Careful patient selection and unequivocally positive preoperative localization are critical to the success of this procedure. To our knowledge, this is the first meta-analysis comparing the two techniques.

Incidentalomas during imaging for primary hyperparathyroidism--incidence and clinical outcomes

Background

Imaging for pre-operative localisation of parathyroid glands in primary hyperparathyroidism is now routine. This has led to the detection of incidental lesions (incidentalomas) in other organs, the nature of which is not well characterised.

The aim of this study was to determine the incidence, characteristics and outcomes in patients who had incidental findings on parathyroid imaging.

Methods

Records of patients who underwent imaging for primary hyperparathyroidism over 2 years were reviewed to identify incidental lesions detected on parathyroid imaging. Patients with persistent or renal hyperparathyroidism were excluded. Details on the management of detected incidentalomas were obtained from patient records.

Results

Incidentalomas were identified in 17 of 170 patients (10 %) undergoing parathyroid imaging. Incidentalomas included thyroid (n = 11), breast (n = 3), lateral compartment of the neck (n = 1), lung (n = 1) and clavicle (n = 1). However, no disease of clinical significance needing treatment was detected on further investigation.

Conclusions

Although a significant proportion of patients undergoing parathyroid imaging had incidental lesions detected, these seem to be of little clinical significance. The morbidity and cost of further interventions on these incidentalomas need to be weighed against the benefits of routine imaging in improving outcomes of first-time surgery in patients with primary hyperparathyroidism.

Minimally invasive video-assisted parathyroidectomy without intraoperative parathyroid hormone monitoring

INTRODUCTION AND OBJECTIVES

surgical treatment of primary hyperparathyroidism has evolved from the classical bilateral neck exploration to minimally invasive techniques due to recent advances in preoperative localisation methods. The additional value of intraoperative parathyroid hormone (PTH) monitoring is questioned. The aim of this study was to analyse the results of minimally invasive video-assisted parathyroidectomy (MIVAP) without intraoperative PTH monitoring.

METHODS

the patients who underwent MIVAP without PTH monitoring for primary hyperparathyroidism between 2007 and 2013 were evaluated. In all cases the suspected enlarged gland was identified preoperatively by 99Tc-sestamibi scintigraphy, ultrasound or computed tomography.

RESULTS

71 patients were studied (56 females and 15 males), with a mean age of 60 years. In 3 cases (4%) the technique was converted to open parathyroidectomy. Calcium and PTH levels were normalised after first surgery in 69 cases (97%), and after a second surgery in the remaining 2 cases (a second contralateral and a second intrathyroid adenoma). One patient developed a postoperative wound infection, 1 postoperative hypocalcaemia, and 4 transient vocal fold paralysis. No permanent vocal fold paralysis or other complications were observed.

CONCLUSIONS

MIVAP is a safe, effective surgical technique to cure primary hyperparathyroidism. Intraoperative PTH monitoring may not be routinely necessary in patients treated with this technique.

Sporadic primary hyperparathyroidism: medical and surgical updates

This review discusses recent findings on the clinical presentation, evaluation, medical and surgical management of primary hyperparathyroidism. Medical management includes the use of cinacalcet and bisphosphonates for bone loss and correction of vitamin D deficiency. Surgical updates reviewed recent studies on the preoperative localization of the disease, specifically, sestamibi scans, 4DCT and MRI. Focused parathyroidectomy continues to be the preferred surgical approach for a select group of patients, guided by intraoperative use of PTH and new technology, such as endoscopic and robotic platforms; however, there appears to be no difference in long-term success compared to the traditional approach.