AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons (original) (raw)
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National Trends in Parathyroid Surgery from 1998 to 2008: A Decade of Change
Journal of the American College of Surgeons, 2009
BACKGROUND: The introduction of limited explorations (LE) for parathyroidectomy broadened the management possibilities for hyperparathyroidism. We sought to document this evolution of change in parathyroid surgery. STUDY DESIGN: Members of the American Association of Endocrine Surgeons and the American College of Surgeons were sent a 49-question survey, and 256 surgeons, accounting for 46% of parathyroid operations nationwide, responded. Associations derived from questionnaire data were tested for significance using chi-square and Kruskal-Wallis methods.
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.
Radioguided parathyroidectomy for hyperparathyroidism in the reoperative neck
Surgery, 2009
Background-The purpose of this study was to determine if radioguided parathyroidectomy (RGP) is effective for hyperparathyroidism (HPT) in the reoperative neck. Methods-We retrospectively reviewed all patients with HPT and a history of neck surgery who underwent RGP over a 7-year period. Data are reported as mean ± SEM. Results-We identified 110 patients with primary (n=94), secondary (n=7), or tertiary (n=9) HPT who underwent 138 previous neck operations. The average hospital stay was 0.6 ± 0.1 days. The in and ex vivo counts obtained with the gamma probe were 310 ± 26 and 130 ± 13, respectively. The ex vivo percentage of background was 69 ± 9%, and virtually all resected parathyroids had ex vivo counts ≥ 20%. Following RGP, 96% of patients were cured, and 4.5% experienced complications (all transient). Cure rates after RGP significantly decreased as the number of previous neck surgeries increased (P=0.002). Additionally, reoperative neck patients with single adenomas were more likely to experience cure than patients with hyperplasia (P=0.02). Conclusions-These results illustrate that RGP is valuable adjunct in the reoperative neck. In addition, RGP allows similar lengths of stay, efficacy, and complication rates as those reported for patients undergoing initial parathyroidectomy. Hyperparathyroidism (HPT) results from the excess secretion of parathyroid hormone (PTH) by at least one hyperfunctioning parathyroid gland usually leading to hypercalcemia. In patients with HPT who meet the indications for parathyroidectomy, initial surgery is associated with high cure rates and minimal morbidity for primary, secondary, and tertiary HPT (1-3). Nonetheless, persistent or recurrent disease develops in a subset of these patients and requires re-exploration. Failure of initial surgery is frequently due to an incomplete or inadequate resection because the diseased parathyroid gland(s) was not identified or a supernumerary gland was present (4, 5). These missed glands are often in an ectopic location or in the normal anatomic position. Failure to identify multiple abnormal glands in patients with a presumed adenoma also occurs and leads to persistent HPT. In addition, patients may present for an initial parathyroidectomy with a history of prior neck surgery related to thyroid, carotid, spine, malignant, or tracheal disease.
Central neck dissection is an independent risk factor for incidental parathyroidectomy
Acta Chirurgica Belgica, 2020
Objective: This study aims to determine the frequency of incidental parathyroidectomy (IP), to reveal the risk factors and to present the clinical importance of IP through the experiences of our clinic. Materials and Methods: Patients undergoing thyroid surgery between June 2016 and May 2019 were reviewed retrospectively. Along with demographic data, surgery reports, pathology results and postoperative follow-up data were examined. Factors assumed to be associated with IP and postoperative hypocalcemia were compared between the IP group and the non-IP group. Results: A total of 633 patients with a mean age of 48 ± 13 years were included in this study. IP was detected in 138 (21.8%) patients and parathyroid glands were localized 29.72% intrathyroidal. Postoperative hypocalcemia in the IP group was approximately 2-fold higher than the no-IP group (%15.94 to %7.27), (p < .001). Gender (p ¼ .014), body mass index (p ¼ .021), both preoperative and postoperative diagnosis of malignancy (p < .001) and performing central neck dissection (CND) (p < .001) were significantly associated with IP in univariate analysis. However, multivariate analysis demonstrated that CND was independently associated with IP (OR ¼ 0.301, 95% Cl: 0.161-0.562, p < .001). Conclusion: This study reveals that IP increases the frequency of postoperative temporary and permanent hypocalcemia in patients undergoing thyroid surgery, and CND is the only independent risk factor for IP. HIGHLIGHTS OF THE STUDY This study reveals that central neck dissection is the most important and only independent risk factor for incidental parathyroidectomy in patients undergoing thyroid surgery. According to our analysis, both temporary and permanent hypocalcemia, which occurs in the postoperative period, are associated with incidental parathyroidectomy.
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.
Re-explorative Parathyroid Surgery for Persistent and Recurrent Primary Hyperparathyroidism
World Journal of Endocrine Surgery, 2011
Primary hyperparathyroidism (HPT) is treated by parathyroidectomy. Excision of abnormal parathyroid tissue is curative in the majority of cases. Postoperative persistent or recurrent HPT has been reported up to 30%. The purpose of this study was to evaluate the role of imaging techniques and determine the efficacy of reexplorative surgery. A total of 306 patients underwent parathyroidectomy between 2000 and 2009. Twelve patients (3.9%) were not cured. Two patients declined further treatment, the other 10 patients underwent further investigation and surgery. Imaging and results of redo surgery together with associated complications were evaluated. All 10 patients were investigated with sestamibi, which accurately localized aberrant parathyroid tissue in three cases and ultrasound scans which also localized three cases. CT was useful in one of the three cases for which it was used. PET and MRI were not helpful. Twelve glands were resected, six adenomas, five hyperplastic and one normal gland. Nine of the 10 reoperated patients became normocalcemic. Complications included a bilateral recurrent laryngeal paresis. In total, 317 operations were performed and 303 of 306 (99%) patients were cured. Redo surgery for HPT is challenging and carries higher risks than primary surgery. Sestamibi and ultrasound scans are the most helpful imaging modalities. When there is concordance a targeted approach may be considered, otherwise a more extensive dissection is required. Redo parathyroid surgery should be considered, even if scans are unhelpful, for patients who are symptomatic or young or have a persistently high calcium level.