Accuracy of Surgeon-performed Ultrasound in Parathyroid Localization
ABSTRACT Ultrasound is one of the preferred modalities for localization of abnormal parathyroids. Accuracy of ultrasound is technician-dependent. This study was undertaken to determine the accuracy of surgeon-performed ultrasound (SPU) for the localization of parathyroid tumors in comparison to radiology-performed ultrasound (RPU) and nuclear scintigraphy (NS). In this series 74 consecutive patients with untreated primary hyperparathyroidism underwent SPU at the initial clinic visit; 21 of these patients did not undergo surgery and are excluded from the analysis. Of the 53 patients remaining, RPU was obtained in 26, and 52 patients underwent NS. Directed parathyroidectomy was performed with use of the intraoperative parathyroid hormone assay (IOPTH). In all, 46 patients had a single adenoma as indicated by IOPTH and final pathology. Two patients had double gland disease, and 5 patients had multi-gland hyperplasia. The sensitivity of SPU was 82% and the specificity was 90% in detecting the diseased glands on the correct side (right versus left). The sensitivity for RPU was 42% and the specificity was 92% (n = 26). The sensitivity of NS was 44% and the specificity was 98% (n = 52). In only one case did RPU or NS detect a gland not found by SPU. SPU can be done with accuracy comparable to other ultrasound series in the literature, and it may be superior to RPU or NS in some institutions. It is important for surgeons to be aware of local institutional expertise when relying on RPU and NS during preoperative evaluation prior to directed parathyroidectomy.
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ABSTRACT: With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy. Nuclear scanning and ultrasonography done by third parties are costly. We investigated whether ultrasonography performed by the operating surgeon (SUS) could be the initial and only preoperative localization study in patients with sporadic primary hyperparathyroidism. Two hundred twenty-six patients underwent preoperative SUS and Sestamibi scans before limited parathyroidectomy guided by quick intraoperative parathyroid hormone assay. SUS findings were noted before the surgeon had access to the scan results. Charge for localization by nuclear scan was 1,315 dollars and 204 dollars for SUS. Successful localization was determined by operative findings, intraoperative hormone dynamics, and postoperative calcium levels. SUS correctly localized all the offending glands in 173 of 226 (77%) successfully treated patients. In 53 patients, SUS showed no parathyroid gland (n = 32), did not recognize multiglandular disease (n = 5), and showed an incorrect location of the abnormal gland (n = 16). In these patients, the technetium-99m-sestamibi scans successfully identified all abnormal tissue in 30 of 53 (57%). Localization using both methods was correct in 203 of 226 (90%) patients. Accuracy of SUS and scans used separately was equal. With use of quick intraoperative parathyroid hormone assay, successful parathyroidectomy was accomplished in 223 of 226 (99%), unilateral exploration in 88%, and overnight stay avoided in 78% of patients. With equal accuracy, SUS is more convenient, less expensive, and noninvasive when compared with scans. Sestamibi should be used when the SUS is negative or equivocal. SUS should be the initial localizing test in the treatment of sporadic primary hyperparathyroidism.Journal of the American College of Surgeons 02/2006; 202(1):18-24. DOI:10.1016/j.jamcollsurg.2005.08.014 · 4.45 Impact Factor
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ABSTRACT: A variety of minimally invasive parathyroidectomy (MIP) techniques have been currently introduced to surgical management of primary hyperparathyroidism (pHPT) caused by a solitary parathyroid adenoma. This study aimed at comparing the video-assisted MIP (MIVAP) and open MIP (OMIP) in a prospective, randomized, blinded trial. Among 84 consecutive pHPT patients referred for surgery, 60 individuals with concordant localization of parathyroid adenoma on ultrasound and subtraction Tc99m-MIBI scintigraphy were found eligible for MIP under general anesthesia and were randomized to two groups (n = 30 each): MIVAP and OMIP. An intraoperative intact parathyroid hormone (iPTH) assay was routinely used in both groups to determine the cure. Primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. Secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within 7 postoperative days (SF-36), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. All patients were cured. In 2 patients, an intraoperative iPTH assay revealed a need for further exploration: in one MIVAP patient, subtotal parathyroidectomy for parathyroid hyperplasia was performed with the video-assisted approach, and in an OMIP patient, the approach was converted to unilateral neck exploration with the final diagnosis of double adenoma. MIVAP versus OMIP patients were characterized by similar operative time (44.2 +/- 18.9 vs. 49.7 +/- 15.9 minutes; P = 0.22), transient hypocalcemia rate (3 vs. 3 individuals; P = 1.0), lower pain intensity at 4, 8, 12, and 24 hours after surgery (24.9 +/- 6.1 vs. 32.2 +/- 4.6; 26.4 +/- 4.5 vs. 32.0 +/- 4.0; 19.6 +/- 4.9 vs. 25.4 +/- 3.8; 15.5 +/- 5.5 vs. 20.4 +/- 4.7 points, respectively; P < 0.001), lower analgesia request rate (63.3% vs. 90%; P = 0.01), lower analgesic consumption (51.6 +/- 46.4 mg vs. 121.6 +/- 50.3 mg of ketoprofen; P < 0.001), better physical functioning aspect and bodily pain aspect of the quality of life on early recovery (88.4 +/- 6.9 vs. 84.6 +/- 4.7 and 90.3 +/- 4.7 vs. 87.5 +/- 5.8; P = 0.02 and P = 0.003, respectively), shorter scar length (17.2 +/- 2.2 mm vs. 30.8 +/- 4.0 mm; P < 0.001), and higher cosmetic satisfaction rate at 1 month after surgery (85.4 +/- 12.4% vs. 77.4 +/- 9.7%; P = 0.006). Cosmetic satisfaction was increasing with time, and there were no significant differences at 6 months postoperatively. MIVAP was more expensive (US$1,150 +/- 63.4 vs. 1,015 +/- 61.8; P < 0.001) while the mean hospital stay was similar (28 +/- 10.1 vs. 31.1 +/- 9.7 hours; P = 0.22). Differences in serum calcium values and iPTH during 6 months of follow-up were nonsignificant. Transient laryngeal nerve palsy appeared in one OMIP patient (P = 0.31). There was no other morbidity or mortality. Both MIVAP and OMIP offer a valuable approach for solitary parathyroid adenoma with a similar excellent success rate and a minimal morbidity rate. Routine use of the intraoperative iPTH assay is essential in both approaches to avoid surgical failures of overlooked multiglandular disease. The advantages of MIVAP include easier recognition of recurrent laryngeal nerve (RLN), lower pain intensity within 24 hours following surgery, lower analgesia request rate, lower analgesic consumption, shorter scar length, better physical functioning and bodily pain aspects of the quality of life on early recovery, and higher early cosmetic satisfaction rate. However, these advantages are achieved at higher costs because of endoscopic tool involvement.World Journal of Surgery 05/2006; 30(5):721-31. DOI:10.1007/s00268-005-0312-6 · 2.35 Impact Factor
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ABSTRACT: Compare surgeon-performed ultrasound versus sestamibi for preoperative parathyroid adenoma localization. Single-institutional cohort. One hundred six consecutive patients undergoing parathyroidectomy at an academic institution between 2004 to 2005 were included. Of those, 103 underwent both surgeon-performed ultrasound and sestamibi-Tc99m localization preoperatively. Primary outcome is sensitivity for adenoma localization to correct quadrant (right vs. left, superior vs. inferior). Hypercalcemia resolved in 97% of patients. Sensitivities for correct quadrant localization for ultrasound versus sestamibi were 87% versus 58% (P < .001). Specificities were 95%. Positive and negative predictive values were 85% versus 78% and 96% versus 87%, respectively. Combined sensitivity was 93%. Sensitivities for correct side localization were 91% and 74% (P = .002). Ultrasound appears more sensitive than sestamibi for localization to correct quadrant or side when performed in-office by the author in this cohort.The Laryngoscope 08/2006; 116(8):1380-4. DOI:10.1097/01.mlg.0000227957.06529.22 · 2.03 Impact Factor