Article

Primary Hyperparathyroidism Surgical Management Since the Introduction of Minimally Invasive Parathyroidectomy

Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
Archives of Surgery (Impact Factor: 4.93). 06/2005; 140(5):472-8; discussion 478-9. DOI: 10.1001/archsurg.140.5.472
Source: PubMed

ABSTRACT

Minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism (HPT) has equal cure and recurrence rates as standard cervical exploration. Changes in the management of primary HPT have occurred since introducing MIP including localization, anesthesia, intraoperative parathyroid hormone monitoring, and indications for parathyroidectomy.
Cohort analysis of 1361 consecutive patients with primary HPT operated on at the Mayo Clinic, Rochester, Minn, from June 1998 through March 2004. Mean follow-up, 25 months.
Tertiary referral center.
One thousand three hundred sixty-one patients operated on for primary HPT, excluding 160 patients who were reoperated on.
Standard cervical exploration MIP.
Cure, recurrence, localization, anesthesia, hospitalization, intraoperative parathyroid hormone level monitoring, contraindications to MIP, surgical indications, assessment of osteoporosis and osteopenia, postoperative patient assessment of general patient health, and operative satisfaction.
Cure of primary HPT for both conventional exploration and MIP was 97%; only 1 patient who underwent MIP had a potential recurrence. Imaging sensitivity and positive predictive values were as follows: sestamibi scintigraphy, 86% and 93%; ultrasonography, 61% and 87%, respectively. Usage of general vs local anesthesia with intravenous sedation was 46% and 49%, respectively, in patients w ho underwent MIP; 46% were dismissed as outpatients, 49% had single-night stays. The accuracy of intraoperative parathyroid hormone level monitoring was as follows: 98% (8% had true-negative results); the frequency of multiple gland disease was 13%. Accounting for causes precluding MIP, an estimated 60% to 70% of all patients would be eligible for MIP. By preoperative assessment, 79% had osteoporosis-osteopenia; 58% with postoperative bone mineral density measurements were improved. More than 85% were satisfied with the results of their operation.
With high-quality localization and intraoperative parathyroid hormone level monitoring, MIP can be performed with equal cure rates as standard cervical exploration, with no present evidence of delayed recurrence.

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    • "Previous studies have suggested the sensitivities for MIBI and US to range from 54% to 88% and 59% to 89% respectively [1] [7], while others have found variable results. Grant et al. reported the sensitivity of MIBI scans in localizing adenomas in those with primary hyperparathyroidism to be 86% compared to 61% with utilizing US [11]. Chapuis et al. demonstrated a higher sensitivity for detection with US versus MIBI scans (92.5% vs. 80%) [12]. "
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    ABSTRACT: Patients with primary hyperparathyroidism routinely undergo preoperative imaging to localize the abnormal gland to facilitate a guided parathyroidectomy. These techniques include neck ultrasound (US), dual phase planar technetium-99 m (99mTC) sestamibi (MIBI) scans, single photon emission computed tomography (SPECT), combined SPECT/CT, and four dimensional CT scans (4D CT). Despite appropriate preoperative imaging, non-localization of abnormal glands does occur. This study aims to determine whether non-localization is the result of radiologic interpretive error or a representation of a subset of truly non-localizing parathyroid adenomas.Materials and methodsA retrospective study was performed; two senior radiologists reinterpreted the preoperative imaging (US and MIBI scans) of 30 patients with initially non-localizing studies. All patients underwent parathyroidectomy for primary hyperparathyroidism at a tertiary referral center. Both radiologists were blinded to the scores of his colleague. The results were compared for inter-reader reliability using Cohen’s kappa test.ResultsTwenty-nine of thirty nuclear studies were found to be negative on reinterpretation. The readers agreed in 86.67% of their observations, with a kappa (κ) value of 0.706 (SE = ± 0.131, 95% confidence interval for κ = 0.449–0.962). One of eighteen ultrasounds had positive localizations on reexamination, however, the inter-observer agreement was only 55.6%, with a kappa value of 0.351 (SE = ± 0.139, and 95% confidence interval for κ = 0.080–0.623). Overall, no statistically significant difference in preoperative and retrospective interpretation was found.Conclusion This study identifies a subset of parathyroid adenomas that do not localize on preoperative imaging despite sound radiographic evaluation.
    Full-text · Article · Nov 2014 · American Journal of Otolaryngology
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    • "The success rate of bilateral neck exploration is higher than 95% when it is performed by an experienced endocrine surgeon [8] [9]. However, nowadays there is a new trend in surgery methods called minimally invasive parathyroidectomy (MIP) which is a more selective surgical approach [9] [10]. Precise pre-operative localization is an essential prerequisite for this targeted excision method's success. "
    Dataset: 2p

    Full-text · Dataset · Aug 2014
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    • "The success rate of bilateral neck exploration is higher than 95% when it is performed by an experienced endocrine surgeon [8] [9]. However, nowadays there is a new trend in surgery methods called minimally invasive parathyroidectomy (MIP) which is a more selective surgical approach [9] [10]. Precise pre-operative localization is an essential prerequisite for this targeted excision method's success. "
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    ABSTRACT: Hyper-functioning parathyroid glands with autonomous overproduction of PTH is the most frequent cause of hypercalcemia in outpatient populations with primary hyper-parathyroidism. It is generally caused by a solitary adenoma in 80%-90% of patients. Despite the various methodologies that are available for preoperative localization of parathyroid lesions, there is still no certain preoperative imaging algorithm to guide a surgical approach prior to the management of primary hyper-parathyroidism (P-HPT). Minimally invasive surgery has replaced the traditional bilateral neck exploration (BNE) as the initial approach in parathyroidectomy at many referral hospitals worldwide. In our study, we investigated diagnostic contributions of SPECT-CT combined with conventional planar scintigraphy in the detection of hyper-functioning parathyroid gland localization, since planar imaging has limitations. We also evaluated the efficacy of preoperative USG in adding to initial diagnostic imaging algorithms to localize a parathyroid adenoma. Methods: A total of 256 consecutive surgically naive patients with hyper-parathyroidism diagnosis were included in the following preoperative localization study. The study consisted of 256 consecutive patients with HPT, with a selected 154 patients who had neck surgery with definitive histology reports. All patients had 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) double-phase scintigraphy. The SPECT-CT procedure, combined with standard 99mTc-MIBI planar parathyroid scintigraphy with a pinhole and parallel-hole collimator to evaluate whether the SPECT-CT procedure was able to provide additional information in the localization of the pathology, caused hyper-parathyroidism in both P-HPT and S-HPT. Results: In the 154 P-HPT patients, 168 lesions (142 adenomas including 2 intrathyroidal and 2 double adenoma, 2 carcinoma, and 22 hyperplastic glands (four patients had MEN I, each with four hyperplastic glands)), were found at surgery. SPECT-CT detected more lesions than planar imaging in P-HPT (97.8% vs. 87.6%). SPECT-CT detected all adenomas and increased sensitivity, particularly in small lesions. Regardless of their size, the number of detected hyperplastic glands by SPECT-CT was remarkably higher than planar imaging.
    Full-text · Dataset · Aug 2014
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