Operation for Primary Hyperparathyroidism: The New versus the Old Order (original) (raw)
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The European Journal of Surgery, 2001
Objective: To nd out whether preoperative parathyroid localisation studies are cost-effective in patients with persistent hyperparathyroidism (HPT). Design: Retrospective study. Setting: University hospital, Sweden. Patients: 29 consecutive patients with persistent HPT who were reoperated on with or without localisation studies. 15 other patients had initial operations for HPT without localisation studies. Interventions: Initial or repeat operation for HPT, localisation studies with 99m Tc sestamibi scintigraphy, and catheterisation of large cervical and mediastinal veins with measurements of serum concentrations of parathyroid hormone. Main outcome measures: Operative time. Cost of operations, frozen section biopsy and localisation studies. Results: The mean durations of reoperation with localisation studies and for the initial operation without them, were 124 and 135 minutes, respectively, while it was 269 minutes for reoperation without studies. For patients who had localisation studies the mean total cost of the investigations, operating time, and frozen section biopsy was 28% less than for patients who were reoperated on without such studies. Conclusion: Preoperative localisation studies before repeat operations for HPT were cost-effective. Even if it has not been shown in this series, the reduction in operating time and the extent of dissection by localisation studies has the potential to decrease morbidity.
American journal of surgery, 2009
Successful preoperative localization plays an important role in patient selection for focused parathyroidectomy. The case records of 499 consecutive patients with presumed hyperparathyroidism who underwent neck exploration were reviewed. Positive imaging patients (n = 373) had a localizing study that clearly showed a single abnormal parathyroid gland whereas negative imaging patients (n = 44) failed to localize or had discordant imaging results. Positive imaging patients were more likely to have a single adenoma (93.0% vs 72.1%; P < .001), and were less likely to require a bilateral exploration (8.1% vs 70.4%; P < .001). Negative imaging patients required more frozen sections (.9 +/- 1.3 vs .2 +/- .7; P < .001), and longer surgical time (77.3 +/- 52.5 min vs 48.4 +/- 34.6 min; P < .001). The cure rate was significantly higher in the positive imaging group (96.0% vs 87.1%; P < .03), with no difference in the incidence of complications (3.2% vs 2.3%; P value was not sig...
European Journal of Nuclear Medicine and Molecular Imaging, 2007
Introduction Primary hyperparathyroidism (PHPT) is an increasingly diagnosed disease worldwide. In most cases, PHPT is related to the presence of a solitary parathyroid adenoma (PA). Fifty percent or more of newly diagnosed PHPT patients are asymptomatic, and there is debate among endocrinologists and endocrine surgeons about whether or not such patients should be treated. Localization Usually, in a PHPT patient with a solitary PA that is well localised pre-operatively, a parathyroidectomy with limited or minimally invasive neck exploration is offered. The diffusion of minimally invasive neck exploration procedures is a consequence of the significant improvement in the accuracy of pre-operative imaging (mainly scintigraphic) techniques; these techniques have changed the surgical strategy to PHPT, from the wide traditional bilateral neck exploration to limited neck exploration.
Langenbecks Archives of Surgery, 2000
The currently established procedure for surgical treatment of primary hyperparathyroidism is bilateral exploration and visualization of all four glands to identify an adenoma and exclude multiglandular disease. With the development of improved preoperative localization imaging of the parathyroids using high-resolution ultrasonography and sestamibi scintigraphy, on the one hand, and perioperative control of surgical success with a rapid parathyroid hormone assay on the other, unilateral and minimally invasive techniques have become feasible. For patients with unequivocal localization in preoperative sestamibi scintigraphy and high-resolution ultrasonography of the parathyroid adenoma in probable single-gland disease, the unilateral and minimally invasive parathyroidectomy present a therapeutic option. Perioperative rapid parathyroid hormone assays, although costly, offer immediate supervision of adenoma extirpation and differentiation of single- and multiglandular disease. These methods demonstrate advantages with favorable cosmetic results and lower reported rate of postoperative hypoparathyroidism. These methods are already being practiced in some places under local anesthesia and in an ambulatory setting. This contribution provides an introduction and overview of the currently practiced unilateral and minimally invasive techniques of parathyroidectomy for primary hyperparathyroidism, discussing indications, advantages and disadvantages, and technical differences in the practiced methods.
Challenges in the Perioperative Localization in Secondary Hyperparathyroidism, a Case Report
Haj Hamad M, Suhaimi S, Latar N, Aini A, Rohaizak M. 2015. Challenges in the Perioperative Localization in Secondary Hyperparathyroidism, a Case Report. International Journal of Science Basic and Applied Research (IJSBAR). Vol 19, No 2 (2015)
To detect hyperfunctioning glands, noninvasive procedures such as ultrasound, sestamibi scan, and magnetic resonance imaging (MRI) are widely available. Preoperative localization studies give important information and enable unilateral exploration or minimal invasive parathyroidectomy. Localization studies and parathyroid hormone assays have not clearly modified the conventional surgical approach of the disease. Controversy regarding the surgery to be favored, between subtotal parathyroidectomy and total parathyroidectomy with autotransplantation, continues against the background of relevant recurrence rates, persistent SHPT, and markedly increased complication rates in reoperation. We are presenting a case of 54-year-old male, on regular hemodialysis (HD) referred by his nephrologist for symptomatic hyperphosphatemia and osteoporosis. Phosphate binders and vitamin D failed to control the disease. Patient underwent neck exploration aiming for total parathyroidectomy, but during surgery we were able to find only the left inferior parathyroid gland. For the few months after the surgery, patient phosphate, iPTH and alkaline phosphatase still deranged. So, the decision was made to do preoperative localization study to confirm the presence and location of the remaining 3 parathyroid gland before re-exploration of the neck. Ultrasonography, computerized tomography of the neck and thorax as well as sestamibi scan done. The results were inconclusive. Re-exploration was performed only right and left superior parathyroid glands. Still unable to localize right inferior gland. Postoperatively, biochemical derangement started to improve slowly. In conclusion; we can say that Noninvasive methods, such as ultrasound, sestamibi scan or MRI, are not always successful in localizing the hyperfunctioning parathyroid gland. Selective venous sampling (SVS) of PTH is an invasive method of localization that is used only rarely in comparison to noninvasive methods. Ultrasonography is an important, cost-effective diagnostic tool that is frequently used in combination with a sestamibi scan.
High Success Rate of Parathyroid Reoperation may be Achieved with Improved Localization Diagnosis
World Journal of Surgery, 2008
Introduction Because of the difficulty of reoperative parathyroid surgery, preoperative imaging studies have been increasingly adopted. We report the use of consistently applied localization diagnosis to yield high success rates in parathyroid reoperations. Methods Parathyroid reoperation was performed after previous parathyroid surgery in 144 patients with nonmalignant hyperparathyroidism (HPT) between 1962 and 2007. From the year 2000, 46 patients who underwent parathyroid reoperation and 14 patients who were subjected to thyroid surgery before primary parathyroid operation were investigated with sestamibi scintigraphy (MIBI), 11 Cmethionine PET/CT (met-PET), surgeon-performed ultrasound (US), US-guided fine-needle aspiration biopsy (US-FNA), and selective venous sampling (SVS) with rapid PTH (Q-PTH) analyses. When imaging was considered adequate, additional studies were generally not obtained. Results Reversal of hypercalcemia was achieved by reoperation in 134 of 144 (93%) of all patients with previous parathyroid surgery. In patients operated from year 2000, MIBI had 90% sensitivity and 88% predictive value, met-PET 79% sensitivity and 87% predictive value, and US 72% sensitivity and 93% predictive value. SVS with Q-PTH analyses provided accurate localization or regionalization in 11 of 11 recently selected patients. Q-PTH analyses in fine-needle aspirations verified parathyroid origin of excised specimens, and intraoperative Q-PTH helped decide when operations could be terminated. In patients subjected to the algorithm of imaging procedures, reversal of hypercalcemia and apparent cure was obtained after the reoperation in 45 of 46 patients with previous parathyroid surgery, implying a success rate of 98%, and in all patients with previous thyroid surgery. Conclusions Reoperative parathyroid surgery is challenging. Results can be improved by consistently applied sensitive methods of preoperative imaging, and reoperative procedures may then achieve nearly the same success rates as primary operations.
Parathyroid Surgery: Separating Promise from Reality
The Journal of Clinical Endocrinology & Metabolism, 2002
We set out to determine the accuracy in predicting the success of biochemical and localizing studies for use in a minimally invasive parathyroidectomy. Preoperative sestamibi scans, intraoperative ␥-probe examinations, and intraoperative PTH (IOPTH) monitoring were performed on a prospective cohort of patients. Seventy-one patients were included in the study. Of the 59 patients (83%) with primary HPT, adenoma localization by sestamibi scanning was correct in 95% with solitary adenomas, but was correct in only 25% of the 14 patients with multiple adenomas. In patients with secondary and tertiary disease, sestamibi scanning incorrectly identified a single hot spot in 64% of cases. In no case of hyperplasia was the probe useful in locating other glands after a single gland was removed. IOPTH was accurate in 78% of patients with primary disease and in only 45% of patients with nonprimary disease. A minimal approach can be considered in a select group of patients that does not have familial primary HPT, secondary or tertiary disease, coexisting thyroid pathology, or an equivocal sestamibi scan. Only patients with a positive single hot spot on sestamibi scan can be considered candidates. Using this criteria only 64% of all patients with hyperparathyroidism are candidates for a minimally invasive approach. The combination of a solitary hot spot on sestamibi scan and a fall in IOPTH allows the surgeon to make the correct decision regarding the need to convert to a bilateral approach in 93% of these selected patients.
Medical Principles and Practice, 2005
Objective: This study was planned to investigate the efficacy of either 99mTc-sestamibi scan or ultrasonography in predicting the operative treatment in patients with primary hyperparathyroidism (PHPT). Subjects and Method: Thirty patients (25 female, 5 male; mean age: 53 years) being operated for symptomatic primary PHPT were included in this study. Ultrasonography was used in 29 patients while 99mTc-sestamibi scintigraphy was done in 28 patients to localize the hyperfunctioning gland(s). Standard bilateral neck exploration was done in 6 patients. Although unilateral intervention had been planned for 24 patients, bilateral intervention was performed in 9 of them. Results: Sensitivity of 99mTc-sestamibi was 81%, while that of ultrasonography was 42%. 99mTc-sestamibi localization method led to misleading results in 10/28 (35.7%) patients. False-positive localization and accompanying thyroid pathologies played an important role in determining transition from unilateral to bilateral in...