Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery: II Consensus Conference of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB) (original) (raw)
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Kocaeli tıp dergisi, 2023
Bu çalışmada kliniğimize başvuran paratiroid hastalarının sosyo-epidemiyolojik verileri, preoperatif ve postoperatif laboratuvar değerleri, görüntüleme özellikleri ile kliniğimizin paratiroid hastalıklarını tedavi ederken uyguladığı yaklaşımların ve sonuçlarının retrospektif olarak incelenmesi amaçlandı. YÖNTEM ve GEREÇLER: Bu çalışmaya 2013-2018 yılları arasında paratiroid hastalıkları nedeniyle Dicle Üniversitesi Tıp Fakültesi Genel Cerrahi Ana Bilim Dalı'nda tedavi edilen 200 hasta dahil edildi. Bu hastalara ait klinik ve laboratuvar verileri hasta dosyalarından retrospekt if olarak değerlendirildi. Çalışmaya paratiroid hastalığı tanısı almış ve tedavi seçeneği olarak cerrahi planlanan olgular dahil edildi. BULGULAR: Çalışmadaki 200 hastadan 33'ünün (%16.5) erkek, 167'sinin (%83.5) kadın olduğu gözlendi. Ortalama yaş 51.76 (18-93) idi. Ek tiroid hastalığı bulunmayan 128 (%64) hastaya unilateral cerrahi yaklaşım ve lokal eksplorasyon ile sadece paratiroid adenom eksizyonu uygulandı. Ek tiroid hastalığı olan 45 (%22.5) hastanın 41'ine bilateral total tiroidektomi, 4'üne sol tamamlayıcı tiroidektomi uygulandı. Hastaların 182 (%91)'sind e patolojik tanı paratiroid adenomu olarak raporlandı. Patolojik tanı ile preoperatif USG bulguları arasında 129 (%75.6) hastada, sintigrafi ile ise 110 (% 73.3) hastada uyum saptandı. Preoperatif yüksek olan serum PTH değerine oranla, intraoperatif, postoperatif 1. gün ve 1. ay çalışılan PTH değerinde anlamlı düşme olduğu görüldü (p<0.001). Preoperatif yüksek olan serum kalsiyum değerindeki postoperatif 1. gün ve 1. ay sonundaki düşmenin istatistiksel olarak anlamlı olduğu te spit edildi (p<0.001). Ameliyat sonrası dönemde bakılan serum fosfor değerlerindeki artışın istatistiksel olarak anlamlı olduğu gözlendi (p<0.05). Postoperatif dönemde 9 (% 4.5) hastada komplikasyon görüldü. TARTIŞMA ve SONUÇ: Çalışmamızda paratiroid bozuklukları tedavisinde, cerrahinin uygun preoperatif değerlendirme ile deneyimli ellerde, dikkatli eksplorasyon yaparak, çok düşük komplikasyon oranı ile gerçekleşmesinin mümkün olacağı gösterildi. Kılavuzlara uygun olarak b u hastalıklarda öncelikle tercih edilmesi gereken tedavi yöntemi de cerrahi yaklaşım olmalıdır. Anahtar Kelimeler: cerrahi, primer hiperparatiroidi, paratiroid adenomu INTRODUCTION: This study aimed to retrospectively evaluate the socio-epidemiological data, preoperative and postoperative laboratory values, and imaging characteristics of patients with parathyroid disorders, as well as our clinic's approaches to treat parathyroid diseases and their out comes. METHODS: This study included 200 patients who were treated for parathyroid diseases at Dicle University Faculty of Medicine, Department of General Surgery between 2013 and 2018. The clinical and laboratory data of these patients were retrospectively obtained from their me dical records. The study included patients who were diagnosed with parathyroid disease and intended for surgical treatment. RESULTS: Out of 200 patients enrolled by the study, 33 (16.5%) were male and 167 (83.5%) were female. The mean patient age was 51.76 (18-93) years. Parathyroid adenoma excision with unilateral surgical approach plus local exploration alone was performed for 128 (64%) patients without accompanying thyroid disease, bilateral total thyroidectomy for 41 of 45 (22.5%) patients with accompanying thyroid disease, and left completion thyroidectomy for the remainder 4 patients with accompanying thyroid disease. The pathological diagnosis was reported as parathyroid adenoma in 182 (91%) patients. The pathological diagnosis was in agreement with preoperative USG in 129 (75.6%) patients and scintigraphy in 110 (73.3%) patients. There occurred a significant decrease in the PTH levels measured intraoperatively, on the first postoperative day, and at the first postoperative month compared with the preoperatively elevated serum PTH level (p<0.001). The decrease in preoperatively elevated serum calcium level on the first postoperative day and at the first postoperative month were statistically significant (p<0.001). The increase in serum phosphorus level at the postoperati ve period was statistically significant (p<0.05). Postoperative complications occurred in 9 (4.5%) patients. DISCUSSION AND CONCLUSION: Our study showed that it is possible to perform surgery for parathyroid diseases with a very low complication rate, provided that an appropriate preoperative evaluation is performed and a careful exploration is carried out by experienced hands. In accordance with the current guidelines, surgical approach should become the preferred treatment method for the treatment of these disorders.
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.
Is Intraoperative Parathyroid Hormone Assay Mandatory for the Success of Targeted Parathyroidectomy
Journal of The American College of Surgeons, 2007
BACKGROUND: Minimally invasive parathyroidectomy has become the first surgical option for patients with primary hyperparathyroidism (HPT) in many places. Preoperative localization studies are mandatory, and the use of a quick parathyroid hormone (PTH) assay is highly recommended. The aim of this study was to analyze our initial series of targeted parathyroidectomies. STUDY DESIGN: In a 2-year period, 50 patients underwent unilateral neck exploration for HPT under local anesthesia and light sedation. After biochemical diagnosis, a technetium 99m sestamibi scan was performed on all patients, and cervical ultrasonography was obtained in some patients. Frozen section analysis was used to confirm parathyroid tissue in all patients. There was no biochemical intraoperative evaluation of PTH. Demographics, surgical details, results, and complications were analyzed.
International Journal of Surgery, 2016
Intraoperative parathyroid hormone (PTH) monitoring in the setting of the operating room represents a valuable example of the rationale use of the laboratory diagnostic in a patient-oriented approach. Rapid intraoperative PTH (ioPTH) assay is a valid tool for an accurate evaluation of the success of parathyroid surgery. The reliability of the user-friendly portable systems as well as the collaboration between operators and surgical staff allow the one-site monitoring of the ioPTH decrements on the course of the surgical management of hyperparathyroidism. The rapid answer provided by an effective decrement of PTH during parathyroidectomy contributes dramatically to the efficacy of parathyroid surgery and the reduction of the number of re-operations. Therefore the dose of ioPTH is a valid and reliable support for the success of the intervention of parathyroidectomy at controlled costs.
Parathyroid Surgery Outcome at King Salman Armed Forces Hospital
Surgical Science, 2022
Introduction: The aim of this study is to review the surgical outcome of parathyroidectomy at one institution over nine years in form of methods of diagnosis, type of surgery, postoperative complications and histopathology findings. Methods: This is a retrospective study from a single institution (King Salman North West Armed Forced Hospital (KSAFH), Tabuk, Saudi Arabia). All cases underwent parathyroidectomy from 1/1/2010 until 31/12/2018 were retrieved from the archives of the department of surgery. Data were extracted from the patients' charts. They included demographical data, presence of comorbidities, laboratory and radiological investigations, type of surgery, postoperative complications and histopathology findings. Inclusion criteria include patients older than 13 years old. Exclusion criteria include patients younger than 13 years old, hyperparathyroidism cured with medication, patients unwilling to give informed consent and patients with serious underlying medical conditions that restrict diagnostic testing or therapy such as congestive cardiac failure. Results: A total of 30 patients underwent parathyroidectomy at KSAFH. 20 out of 30 patients were female (66.7%). The mean age was 35-45 years old. Diabetes mellitus was found in 5 patients (16.7%), while hypertension was seen in 10 patients (33.3%). 6 patients (20%) had end stage renal disease (ESRD). The data showed 24 patients with primary hyperparathyroidism (80%), 5 patients with secondary hyperparathyroisim (16.7%) and one patient with tertiary hyperparathyroidism (3.3%). Our study demonstrated that 23 patients underwent partial parathyroidectomy (76.6%), while 7 patients underwent total parathyroidectomy (23.3%). According to the method used for diagnosis of hyperparathyroidism, blood tests were used in 27 patients (90%), Sestamibi parathyroid scan in 26 patients (86.6%), ultrasound scanning in 28 patients (93.3%) and bone scan in 9 patients (30%). Sensitivity of Sestamibi scan in primary hyperparathyroidism (91.7%) and (66%) for secondary hyperparathyroidism. Mean operative time was 79 minutes. Mean hospital stay was 4
Head & neck, 2018
Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present. A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness. Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed. Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that t...
Hyperparathyroid crisis: The timing of surgery
Asian Journal of Surgery, 2011
Background: Hyperparathyroid crisis is a rare, critical, and potentially fatal disease. The aim of this study was to classify different clinical courses of this disease, according to their preoperative medical responses and suggest the proper timing for surgery. Methods: Patients who had undergone parathyroidectomies for hyperparathyroid crisis, were enrolled between January 1, 1994 and January 31, 2009. Preoperative medical treatment and responses in terms of predisposing factors, preoperative localization, operative and pathological findings, postoperative outcome, and intervals from medicine to surgery, were retrospectively reviewed. Results: A total of 11 patients, receiving more than 72 hours of medical treatment, were divided into three types by preoperative medical responses. These included: Type I (three patients were resistant to medicine with persistent serum Ca > 14 mg/mL and were eventually treated with emergency surgery; two died of postoperative respiratory and hepatic failure), Type II (six patients with abnormal serum Ca < 14 mg/mL) and Type III (two patients in whom serum calcium returned to normal preoperatively. One patient was successfully treated with emergency surgery 18 hours post-hospitalization). We found no method for predicting the medical response, but all Type I patients exhibited high serum Ca >14 mg/mL after 48 hours of medical treatment. All abnormal parathyroid glands were >1.8 cm in length and easily detectable using preoperative ultrasonography.
Intraoperative parathyroid hormone level in parathyroidectomy: which patients benefit from it?
Journal of Otolaryngology - Head & Neck Surgery, 2013
Background: Intraoperative parathyroid hormone level (IOPTH) is withdrawn during parathyroidectomy to confirm the success of the procedure. Recently, the importance of IOPTH has been put to question. The purpose of this study is to determine whether IOPTH is necessary for all patients undergoing parathyroidectomy in the presence of frozen section. Materials and methods: A cohort study of parathyroidectomies was performed in three university affiliated hospitals during 2007-2012. The patients were divided into two groups. Group 1: Patients with two preoperative concordant imaging localizing a hyperactive gland. Group 2: Patients without two concordant imaging. A comparison of benefit of IOPTH was carried out. Frozen section results were also analyzed to determine sensitivity and predictability of a parathyroid adenoma. Results: The study considered 221 patients having parathyroidectomies for primary hyperparathyroidism (PHPT). Of them, 10 were excluded due to incomplete data. Among the remaining, 186 had 2 concordant imaging preoperatively localizing an adenoma. 93.5% of whom were found intraoperatively in that location. IOPTH was not found to be of importance in 98.92% of the preoperative localized adenomas in the presence of frozen section. IOPTH added an estimate of 30.9 minutes on average to the surgery time. Conclusion: This study demonstrates that the added operating time associated with IOPTH may not be justified for patients undergoing parathyroidectomy who have 2 concordant imaging preoperatively in the presence of frozen section. This study suggests a simple algorithm, The McGill Parathyroid Protocol (MPP), to help in approaching PHPT patients undergoing parathyroidectomy.
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.
Primary hyperparathyroidism: Referral patterns and outcomes of surgery
ANZ Journal of Surgery, 2002
Primary hyperparathyroidism (HPT) is a disease characterized by persistently elevated serum calcium and parathyroid hormone (PTH) levels. In 1925 the Viennese surgeon Felix Mendl performed the first successful parathyroidectomy for this condition. Since then surgical management has evolved into a procedure with 95-98% cure rate and low morbidity. Current trends aim at simplifying surgical practice into minimally invasive procedures, and are currently being evaluated by the Australian Safety and Efficacy Register for New Interventional Procedures-Surgical (ASERNIP-S). 1 The aim of the present study was to ascertain the nature of primary HPT and the referral trends at North Shore Hospital, Auckland, as well as evaluating the outcome of parathyroidectomies performed at the institution. METHODS North Shore Hospital is an urban-based, 400-bed hospital serving a catchment population of 400 000 people. A retrospective audit was performed of those who had parathyroidectomies for primary HPT at North Shore Hospital from 1985 to 1999 inclusive. Data were obtained from the hospital's Otago Surgical Audit System, theatre logbook and patient notes. We examined patient demographics, referral patterns, preoperative symptoms, laboratory values, operative procedure, postoperative complications and pathology. RESULTS Demographics There were 22 females and 11 males, whose ages ranged from 18 to 77 years (median 63 years) at surgery. All patients had primary HPT. No patients were identified as having familial primary HPT. Referral trends The referral source was identified for 31 patients. All were referred by a physician: 55% by general physicians, 33% by endocrinologists and 6% by geriatricians. Original diagnosis was made by general practitioners in 16 of the 22 cases identified (72%). Delay between diagnosis and surgery ranged from 8 days to