Preoperative localization modalities in primary hyperparathyroidism: Correlation with postoperative cure

BACKGROUND

Accurate preoperative localization is critical to the success of minimally invasive parathyroidectomy. This investigation aimed to assess the correlation among preoperative imaging results, intraoperative findings, and postoperative cure rates in patients undergoing operation for primary hyperparathyroidism.

METHODS

A retrospective review of all patients who underwent operation for primary hyperparathyroidism between June 2010 and March 2016 was performed.

RESULTS

During the study period, 398 patients underwent parathyroidectomy. The overall cure rate was 97.5%. The ultrasonography performed by the surgeon was superior to the ultrasonography performed by the radiologist and to the sestamibi scan in lateralizing the adenoma correctly (80% vs 62% vs 70%, P < .001, respectively), and had the greatest sensitivity (93%) and accuracy (80%) among all tests (P < .001). Age ≥65 was found to be associated with lesser cure rates (94% vs 99.2%, P = .003). The number of positive preoperative studies correlated with cure rate, ranging from 80% for patients with 0 positive studies, to 100% in those with 4 positive studies (P = .0004). In patients with a negative sestamibi and an ultrasonography performed by the radiologist, there was no significant difference in the cure rates among those with no preoperative computed tomography, a positive preoperative computed tomography, or a negative preoperative computed tomography.

CONCLUSION

An ultrasonography performed by an experienced surgeon is an extremely valuable preoperative localization modality. The cure rate obtained is proportional to the number of positive imaging studies. In patients with negative ultrasonography performed by a nonexperienced radiologist and a negative sestamibi scan, the performance of computed tomography does not seem to increase cure rate. Patients with no positive preoperative scans represent a challenging subgroup, with cure rates of approximately 80%.

[SHOULD PATIENTS WITH PRIMARY HYPERPARATHYROIDISM AND NEGATIVE IMAGING STUDIES BE REFERRED TO SURGERY?]

INTRODUCTION

Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (PHPT). In cases where imaging fails to demonstrate an adenoma, a bilateral neck exploration (BNE) is performed. Negative imaging is thought to predict surgical failure, and patients with negative imaging are often not referred for surgery. These patients are at risk for disease progression.

AIMS

Evaluate the effect of negative imaging on surgical findings and the cure rate in patients with PHPT.

METHODS

A total of 133 patients underwent parathyroidectomy for PHPT. Data were retrospectively retrieved including preoperative imaging, surgical findings and results. A comparison was conducted between patients with negative and positive imaging. The main outcome measure was cure.

RESULTS

A negative MIBI (methoxy-isobutyl-isonitrile) scan was seen in 30 (22%) patients and a negative US in 46 (34.5%). Patients with negative MIBI scan more commonly underwent BNE compared with patients with a positive scan (53% vs. 25%, respectively, p=0.0046). Patients with negative imaging had a significantly higher rate of multigland disease compared with patients with positive imaging (35% vs. 12%, p=0.004, for the MIBI scan; 27% vs. 12%, p=0.024, for the US, respectively). Overall cure rate was 96%. Highest cure rates were seen in patients with both positive MIBI and US (99% cure rate) and lowest cure rates of 67% in patients with triple negative imaging (MIBI scan, US and 4DCT (Dual computed tomography)) (p=0.003).

CONCLUSIONS

Localization of an adenoma in preoperative imaging predicts very high cure rates in patients with PHPT. Negative imaging increases the risk for multigland disease and is associated with lower cure rates.

Establishing a definitive airway in the trauma patient by novice intubators: A randomised crossover simulation study

BACKGROUND

Establishing a definitive airway, defined as a tube placed in the trachea with cuff inflated below the vocal cords, is standard of care in pre-hospital airway management of the trauma patient. However, in this setting, and using manual in-line stabilisation of the neck, success rate of intubation by inexperience providers is suboptimal. The use of supraglottic airway devices that allow blind tracheal intubation has been suggested as an alternative method by the Advanced Trauma Life Support (ATLS) programme of the American College of Surgeons. We aimed to compare intubation with the standard intubation technique (direct laryngoscopy [DL]) with blind intubation through an intubating-laryngeal mask airway (I-LMA) during manual in-line stabilisation of the neck.

MATERIALS AND METHODS

A randomised, crossover manikin study was performed with 29 emergency medical technicians undergoing training for paramedic status. Outcome measures were success rate in one intubation attempt, duration of intubation, and assessment of ease-of-use.

RESULTS

Study subjects had a higher success rate of tracheal intubation with I-LMA than with DL (27/29 vs. 18/29, p<0.025), and I-LMA was assessed as easier to use (4 vs. 3, p<0.0001). Longer duration of intubation was found with I-LMA compared to DL (54.2 vs. 42.8s, p<0.002). Success rate of correct placement of I-LMA within the airway was 28/29 (96.5%). Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL (26.9 vs. 42.8s, p<0.0001).

CONCLUSIONS

Novice intubators had a higher success rate of intubation with I-LMA than with DL, but duration of intubation was longer with I-LMA. Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL. Findings of this simulation study suggest that in the presence of manual in-line stabilisation of the neck, I-LMA-guided intubation is the preferred technique for novice intubators.