Concomitant Thyroid Surgery Research Articles

Preoperative parathyroid localization. Relevance of MIBI SPECT-CT in adverse scenarios

PurposeSelective parathyroidectomy, the treatment of choice for primary hyperparathyroidism, requires precise preoperative localization. Our purpose was to compare the accuracy and concordance of pre-surgical MIBI parathyroid scintigraphy and ultrasonography, as well as to assess the relevance of hybrid acquisition (SPECT/CT) in compromised circumstances: low-weight or ectopic adenomas, coexisting thyroid disease and re-interventions. MethodsThe study included 223 patients with primary hyperparathyroidism operated in a single Surgical Unit from August 2016 to March 2021. Preoperative ultrasonography and double-phase MIBI were performed with early SPECT/CT acquisition. A minimally invasive surgical approach was initially attempted, except in patients with concomitant thyroid surgery or multiglandular parathyroid disease. ResultsSelective parathyroidectomy was accomplished in 179 patients (80.2%); cervicotomy and/or thoracoscopy in 44. Removal of the parathyroid lesion was achieved in 211 patients (94.6%), corresponding 204 (96.7%) to adenomas (37 ectopic). The cure rate was 94.2%. Preoperative MIBI SPECT/CT showed higher sensitivity and accuracy (84%; 80%) compared to ultrasound (72%; 71%), being more precise in defining the exact anatomical location (75.8% vs 68.7%). These differences reached statistical significance in ectopic glands. The existence of concomitant thyroid pathology did not decrease the sensitivity of SPECT/CT (84.2%). Mean parathyroid weight was 692.2mg (95%CI: 443.5-941) in MIBI-negative cases and 1145.9mg (95%CI: 983.6-1308.3) in MIBI-positive (p=0.001). Re-intervention was successful in the 8 patients with previous surgery. ConclusionMIBI SPECT/CT presents greater sensitivity, accuracy and anatomical precision than ultrasound for preoperative parathyroid localization, even in the case of ectopic glands or coexisting thyroid pathology. The weight of the pathological gland is a significantly limiting factor.

Preoperative parathyroid localization. Relevance of MIBI SPECT-CT in adverse scenarios

PurposeSelective parathyroidectomy, the treatment of choice for primary hyperparathyroidism, requires precise preoperative localization. Our purpose was to compare the accuracy and concordance of pre-surgical MIBI parathyroid scintigraphy and ultrasonography, as well as to assess the relevance of hybrid acquisition (SPECT/CT) in compromised circumstances: low-weight or ectopic adenomas, coexisting thyroid disease and re-interventions. MethodsThe study included 223 patients with primary hyperparathyroidism operated in a single Surgical Unit from August 2016 to March 2021. Preoperative ultrasonography and double-phase MIBI were performed with early SPECT/CT acquisition. A minimally invasive surgical approach was initially attempted, except in patients with concomitant thyroid surgery or multiglandular parathyroid disease. ResultsSelective parathyroidectomy was accomplished in 179 patients (80.2%); cervicotomy and/or thoracoscopy in 44. Removal of the parathyroid lesion was achieved in 211 patients (94.6%), corresponding 204 (96.7%) to adenomas (37 ectopic). The cure rate was 94.2%. Preoperative MIBI SPECT/CT showed higher sensitivity and accuracy (84%; 80%) compared to ultrasound (72%; 71%), being more precise in defining the exact anatomical location (75.8% vs 68.7%). These differences reached statistical significance in ectopic glands. The existence of concomitant thyroid pathology did not decrease the sensitivity of SPECT/CT (84.2%). Mean parathyroid weight was 692.2mg (95%CI: 443.5-941) in MIBI-negative cases and 1145.9mg (95%CI: 983.6-1308.3) in MIBI-positive (p=0.001). Re-intervention was successful in the 8 patients with previous surgery. ConclusionMIBI SPECT/CT presents greater sensitivity, accuracy and anatomical precision than ultrasound for preoperative parathyroid localization, even in the case of ectopic glands or coexisting thyroid pathology. The weight of the pathological gland is a significantly limiting factor.

Coexistent papillary thyroid carcinoma diagnosed in surgically treated patients for primary versus secondary hyperparathyroidism: same incidence, different characteristics

BackgroundThe coexistence of hyperparathyroidism and thyroid cancer presents important diagnostic and management challenges. With minimally invasive parathyroid surgery trending, preoperative thyroid imaging becomes more important as concomitant thyroid and parathyroid lesions are reported. The aim of the study was to evaluate the rate of thyroid cancer in patients operated for either primary (PHPT) or secondary hyperparathyroidism (SHPT).MethodsOur retrospective study included PHPT and SHPT patients submitted to parathyroidectomy and, when indicated, concomitant thyroid surgery between 2010 and 2017.ResultsParathyroidectomy was performed in 217 patients: 140 (64.5%) for PHPT and 77 (35.5%) for SHPT. Concomitant thyroid surgery was performed in 75 patients with PHPT (53.6%), and 19 papillary thyroid carcinomas (PTC) were found, accounting for 13.6% from all cases with PHPT and 25.3% from PHPT cases with concomitant thyroid surgery. Thirty-one of operated SHPT patients (40.3%) also underwent thyroid surgery and 9 PTC cases were diagnosed (11.7% of all SHPT patients and 29% of patients with concomitant thyroid surgery).We found differences between PHPT and SHPT patients (p < 0.001) with respect to age (54.6 ± 13y versus 48.8 ± 12y), female-to-male ratio (8:1 versus ~ 1:1), surgical technique (single gland parathyroidectomy in 82.8% PHPT cases; versus subtotal parathyroidectomy in 85.7% SHPT cases) and presurgical PTH (357.51 ± 38.11 pg/ml versus 1020 ± 161.38 pg/ml).Morphopathological particularities, TNM classification and multifocality incidence of PTC were similar in the two groups. All PTC from patients with SHPT were thyroid microcarcinomas (TMC, i.e. tumors with a diameter smaller than 1 cm), whereas seven out of the 19 cases with PTC and PHPT were larger than 1 cm.ConclusionsPTC was frequently and similarly associated with both PHPT and SHPT irrespective of presurgical PTH levels. Thyroid tumors above 1 cm were found only in patients with PHPT. Investigators should focus also on associated thyroid nodular pathology in patients with PHPT.

Is there a role for routine laryngoscopy before and after parathyroid surgery?

IntroductionRecurrent laryngeal nerve (RLN) palsy is a potential complication of parathyroid surgery with significant morbidity and a cause of medico-legal litigation. Peri-operative laryngoscopy to assess RLN function helps identify a vocal cord palsy and guide management. The value of its routine use in asymptomatic patients is however unclear. The low risk of permanent palsy, rarity of true asymptomatic palsy and costs, discomfort and inconvenience to patients are arguments against routine laryngoscopy. This study assessed the results of routine laryngoscopy in patients having parathyroid surgery for primary hyperparathyroidism (PHPT). MethodsAll patients having parathyroid surgery for PHPT (exclusion: re-do surgery and concurrent thyroidectomy) over a 3-year period were included from a tertiary endocrine surgical unit. Data on voice-related outcomes and pre- and post-operative laryngoscopy, including its local cost, were collected and analysed. ResultsOf 189 patients who underwent parathyroid surgery, 66 had a unilateral neck exploration. The incidence of vocal cord palsy was 0.5% (1 in 186 patients) and 1.7% (3 in 179 patients) for pre- and post-operative laryngoscopy respectively. The single patient with pre-operative cord palsy was asymptomatic. Of the three with post-operative cord palsy, two were temporary and symptomatic and one was asymptomatic. In the region, the clinical commissioning group was charged £127.00 per laryngoscopy, amounting to £46,736.00 for the whole cohort. ConclusionsThe rare nature of vocal cord palsy suggests laryngoscopy is not necessary for patients having surgery for PHPT. It may be reserved for patients with voice change and those having re-operative or concomitant thyroid surgery.

Minimally Invasive Video-Assisted Parathyroidectomy; A Detailed Illustration and Highlighting an Additional Potential Advantage Over Other Targeted Parathyroid Surgeries

Targeted parathyroid surgery also referred to as minimally invasive parathyroidectomy has replaced full neck exploration as the preferred surgical approach to primary hyperparathyroidism. This is attributed to the ability to accurately localize enlarged parathyroid glands preoperatively and obtain objective evidence of adequate resection intraoperatively. The two most widely used minimally invasive parathyroid surgeries are the non-endoscopic miniincision parathyroidectomy and the minimally invasive video-assisted parathyroidectomy. The aim of this article is to provide a detailed illustration of the latter supplemented with an animated video of the procedure, and to highlight a potential advantage it offers over other targeted parathyroid procedures; the ability to perform a full neck exploration and/or a concomitant thyroid surgery without the need to convert to a standard cervicotomy.

Incidental Finding of Papillary Thyroid Carcinoma in the Patients with Primary Hyperparathyroidism.

The relationship between primary hyperparathyroidism (pHPT) and papillary thyroid cancer (PTC) still remains unclear. We aimed to investigate the incidence of the co-existence of pHPT and PTC. Between 2010 and 2013, all patients with pHPT were retrospectively reviewed and those undergoing concomitant thyroid surgery were recorded. Of these, patients with a pathological result showing papillary or micro-papillary thyroid cancer were included into the study. A chart review of 228 patients who underwent surgery for pHPT revealed 86 (37.7%) patients with concurrent thyroid disease requiring surgical treatment. Thyroid cancer was noted in six female patients (6.9%) undergoing thyroid resection, and 2.6% of all patients with pHPT. Four patients underwent total thyroidectomy while lobectomy was applied in the remaining two. None of the cases with lobectomy required a completion thyroidectomy. We demonstrated the concurrence of PTC and pHPT at a rate of 2.6% which appeared as a coincidental pathology; however, thyroid disorders, seen in one of three patients with pHPT, were not uncommon. Further research is still needed to develop a reliable explanation for relationship between pHPT and non-medullary thyroid cancer.

Morbidity Associated with Concomitant Thyroid Surgery in Patients with Primary Hyperparathyroidism.

Recurrent laryngeal nerve (RLN) palsy and hypoparathyroidism are serious complications in thyroid and parathyroid surgery. The extent to which incidentally detected thyroid nodules should be treated concomitantly is a matter of debate. This analysis was based on 1,065 patients who underwent consecutive surgery for primary hyperparathyroidism at a single institution. Together with the surgical strategy, histologic and follow-up examinations were documented prospectively and analyzed retrospectively regarding the occurrence and course of RLN palsy, hypoparathyroidism, and thyroid carcinoma. Altogether, RLN palsy occurred for 38 patients (3.6%) and proved to be permanent for 1 patient (0.1%). Postoperative calcium substitution was necessary for 191 patients (17.9%), with 3 patients showing permanent hypoparathyroidism (0.3%). Procedures other than open minimally invasive exploration were accompanied by a significantly increased risk for temporary RLN paresis (odds ratio [OR], 6.136) and temporary hypoparathyroidism (OR 3.306). Concomitant thyroid surgery was performed for 502 patients (47.1%). Compared with open minimally invasive parathyroid exploration, patients undergoing unilateral exploration and hemithyroidectomy (OR 5.827) or bilateral neck exploration (BNE) and thyroidectomy (OR 8.047) had a significantly increased risk for RLN paresis. Patients administered BNE with hemithyroidectomy (OR 2.380) or thyroidectomy (OR 7.233) had a significantly increased risk for hypoparathyroidism. Thyroid malignancy was incidentally detected in 86 patients (8.1%). Patients undergoing concomitant thyroid procedures have a significantly higher risk for temporary RLN palsy and hypoparathyroidism. However, the high rate of incidentally detected thyroid carcinoma in an iodine-replete endemic goiter area indicates hemithyroidectomy in the presence of thyroid nodules incidentally identified in preoperative ultrasounds.

Contrast-enhanced ultrasonography for localization of pathologic glands in patients with primary hyperparathyroidism

The localization of enlarged parathyroid glands might, depending on size, histology, and concomitant goiter, be difficult in some patients. In the presented study, contrast-enhanced ultrasonography (CEUS) was applied as a new diagnostic tool to detect the site of parathyroid lesions. Thirty patients underwent operation for primary hyperparathyroidism (pHPT) between 8/2009 and 6/2010. Contrast-enhanced ultrasonography (CEUS) using a linear probe (6-9 MHz, LOGIQE9/GE), fundamental B scan, and Doppler ultrasonography, (99m)Technetium-sestamibi scintigraphy and magnetic resonance imaging (MRI) were performed in all patients preoperatively. The diagnostic sensitivity of the procedures, time requirements, and overall costs were analyzed. Using CEUS, all 31 pathologic glands could be detected, compared with 23 using conventional ultrasonography, 25 using (99m)Technetium-sestamibi scintigraphy and 22 using MRI (P = .015). Costs and time requirement were less using CEUS as compared with (99m)Technetium-scintigraphy and MRI examinations (P = .002). Minimally invasive, video-assisted parathyroidectomy could be performed successfully based on CEUS findings in all but 7 patients who required concomitant thyroid surgery or had underwent previous thyroid operations. All patients showed normal serum levels of calcium and parathyroid hormone serum levels 3 months after parathyroidectomy. CEUS represents a highly sensitive and cost-efficient method for localization of pathologic parathyroid glands in patients with pHPT. Future studies should confirm these findings in order to establish CEUS as a standard diagnostic procedure.

Predicting the Success of Limited Exploration for Primary Hyperparathyroidism Using Ultrasound, Sestamibi, and Intraoperative Parathyroid Hormone

The aim of this study was to determine the success of limited neck exploration (LE) for primary hyperparathyroidism (1 degrees HPT). Between 1999 and 2007, 1407 patients with hyperparathyroidism underwent bilateral neck exploration (BE). Of these, 1158 patients with first-time sporadic 1 degrees HPT were analyzed prospectively. Based on surgeon-performed ultrasound (US) and sestamibi scan (MIBI), LE was initially performed. Regardless of results, BE followed to identify the presence of additional parathyroid pathology. Of 1158 patients, 242 (21%) were found to require concomitant thyroid surgery thus excluding LE. Of the remaining 916 patients, a single abnormal gland was identified on MIBI in 682 (74%), US in 731 (80%), and concordance of both in 588 (64%). Unsuspected multiglandular disease (MGD) was identified at BE in 22%, 22%, and 20% of patients, respectively. Adding intraoperative parathyroid hormone sampling (IOPTH) further reduced the rate of unsuspected MGD to 16%, 17%, and 16%. Overall, IOPTH correctly predicted MGD in only 22%. Neither concomitant nonsurgical thyroid disease nor more stringent selection criteria (preop Ca>11 mg/dL and PTH>120 pg/dL) altered success rates. In patients with MGD, a subsequent gland identified was larger than the index gland in 23%. Ninety-eight percent of BE patients were cured of 1 degrees HPT. This is the largest study to evaluate the prevalence of additional parathyroid pathology in patients who are candidates for LE. Limitations in localizing studies and IOPTH fail to identify MGD in at least 16% of patients, risking future recurrence.

Risk Assessment for Severe Postoperative Hypocalcaemia after Neck Exploration for Primary Hyperparathyroidism

A further development of the risk profile for severe postoperative hypocalcaemia after surgery for primary hyperparathyroidism (pHPT) was made with the aim of expanding the group of patients who can be discharged safely after 23 hours. Prospective study with 156 consecutive pHPT patients (158 operations) during 2001 and 2002. Risk factors for postoperative severe hypocalcaemia (ionised calcium < 1 mmol/L), were (1) preoperative concentration of parathyroid hormone (PTH) > 35 pmol/L (five times the upper reference value, reference range 1.1 to 6.9), (2) history of previous neck surgery, (3) biopsy/excision of > 2 parathyroid glands or (4) concomitant thyroid surgery. The risk factors showed a sensitivity of 100 % (9/9). In 110 of the operations (70%) no risk factors were identified. Postoperative calcium levels were significantly lower after 48 operations with risk factor(s) identified, as compared to the group without risk factors (p < 0.01). Seven of 17 patients (41%) with PTH > 35 pmol/L developed severe postoperative hypocalcaemia. Two of 31 patients (6%) with PTH < 35 pmol/L in the presence of other risk factor(s) developed severe postoperative hypocalcaemia. Patients with no risk factor can safely been discharged from hospital on the first postoperative day. Patients with preoperative concentration of PTH > 35 pmol/ L (five times the upper reference value) should stay in hospital until nadir level of calcium is reached. Patients with concentration of parathyroid hormone less than 35 pmol/ L in the presence of other risk factor(s) may have an early discharge from hospital (second postoperative day) combined with outpatient measurements of calcium levels.

The Impact of Office Neck Ultrasonography on Reducing Unnecessary Thyroid Surgery in Patients Undergoing Parathyroidectomy

Some have suggested that thyroid disease is even more prevalent among patients with hyperparathyroidism (HPT) than in the general population. We sought to define the incidence and optimal management strategies of thyroid disease in patients undergoing surgery for HPT. Clinical characteristics were reviewed for 1200 consecutive HPT patients treated at two endocrine surgery referral centers from 1992-2003. Both centers practice bilateral neck exploration, and one routinely obtains preoperative neck ultrasound (US) performed by surgeons. Forty percent (477/1195) of HPT patients had coexisting thyroid disease, whether identified at parathyroidectomy (39%; 327/845) or by US (43%; 150/350). Colloid nodules/goiters accounted for nearly half of thyroid pathology, followed by follicular adenomas, papillary cancer, thyroiditis, and intrathyroidal parathyroids. Thyroid malignancy was found in 4.6% of HPT patients versus less than 1% in autopsy reports. Thyroid pathology was similar among single adenomas, multigland, and renal HPT. Unexpected thyroid disease first encountered at parathyroidectomy required partial or total thyroidectomy in 30% (257/845). US-detected thyroid nodules prompted fine-needle biopsy in 20%, which was cost effective in limiting concomitant thyroid surgery to fewer patients (6%; 21/350). Overall low incidence (<0.5%) of persistent/recurrent HPT, nerve injury, and neck hematoma was unaffected by thyroid abnormalities. The high prevalence of thyroid disease, especially malignancies, among HPT patients mandates vigilant diagnosis and preparation for possible simultaneous parathyroid-thyroid surgery. Without appropriate preoperative screening, focal explorations for HPT may be prone to delayed diagnosis of thyroid tumors. Ultrasound performed by surgeons or endocrinologists preoperatively is an excellent diagnostic tool and minimizes unnecessary thyroidectomy in patients with subclinical thyroid disease.

Hyperparathyroidie primaire évolution des techniques durant trois décennies intérêt et innocuité des opérations précoces

Recent progresses in the ability to obtain a secure diagnosis and preoperative localisation have resulted in a lower threshold for surgery of primary hyperparathyroidism. We questioned whether these trends have been accompanied by an improvement in surgical results, or changes in the profile of the disease among operated patients. From a total of 511 operations (499 patients), we retrospectively investigated the data from three successive periods of 10 years each: (1973-1982: 73 operations; (1983-1992): 155 operations; (1993-2002): 283 operations. Rates of surgical failure, defined as persistent hypercalcaemia at six months, have progressively declined: 6.8%, 1.3% and 0.7% respectively. There also has been a decline in the rates of permanent hypoparathyroidism or laryngeal nerve injury. However, these complications were highly influenced by the underlying pathology (surgery for single adenoma versus surgery for multiple gland disease) and by the need for concomitant thyroid surgery. Considering signs and symptoms, the frequency of kidney stones has declined from 50% to 29.7%, while the rate of patients diagnosed at routine screening has increased from 19% to 39%. The prevalence of parathyroid cancer among operated patients has successively declined from 6.8% to 1.3%, then 0% during the last period. Our data suggest that present improvement in the success rate of parathyroid surgery be partly due to improvement in preoperative localisation. Among imaging techniques, subtraction scintigraphy, based on the simultaneous recording of technetium-99m-sestamibi and iodine-123, provided the highest rate of accurate location (92.6%). Because this imaging technique depicted a majority of cases of multiple parathyroid gland disease at prospective evaluation (14 out of 15), we now use it to select appropriate cases for a focussed surgery under local anaesthesia, without the additional need for intraoperative PTH monitoring. The present good surgical results would justify surgery even for elderly or asymptomatic patients. Surgery carried out before appearance of symptoms seems beneficial. Only asymptomatic patients with a short life expectancy may be denied surgery.

The Impact of Sestamibi Scanning on the Outcome of Parathyroid Surgery

Although sestamibi scanning has been shown to have greater sensitivity and specificity than other preoperative localization techniques for parathyroid adenoma, it is unclear whether preoperative scanning improves outcomes for parathyroid surgery. Data from 528 consecutive patients who underwent neck exploration for primary hyperparathyroidism by one surgeon were collected prospectively over a 5-yr period. Patients were classified by preoperative scanning status (no scan, positive scan, and negative scan), and outcomes were compared in terms of operative time, length of hospital stay, and cure rate. Patients who had undergone a previous parathyroid operation and patients who received alternate preoperative localization techniques (ultrasound, magnetic resonance imaging, and computed tomography) were excluded from the study. All scans were ordered by the referring physician-the surgeon made no recommendations for preoperative scanning. All groups were similar in terms of gender, age, anesthesia class, body habitus, and complication rate. There was no significant difference in cure rate between patients who had preoperative scanning (97.5%) vs. those who did not (99.3%); however, there was a significant difference in cure rate between the negative-scan group (92.7%) and the positive and no-scan groups (99.3%, P < 0.01). In patients without concomitant thyroid surgery, there was no significant difference in operative time between the no scan (42.4 +/- 14.9 min) vs. the all-scan group (40.2 +/- 15.2 min); however, there was a significant difference between the negative scan group (44.5 +/- 21.9 min) and the positive scan group (38.5 +/- 12.6 min, P < 0.01). There was no significant difference in length of hospital stay among the three groups. These results suggest that, although preoperative sestamibi scanning does not alter the outcome of parathyroid surgery, it does identify those patients who are less likely to be cured.

Intraoperative parathyroid hormone testing: what have we learned?

The development of rapid, sensitive assays for measuring the intact parathyroid hormone (iPTH) molecule has the potential to allow the surgeon to determine the success of parathyroid surgery intraoperatively. The purpose of the study was to review our results in the context of currently held beliefs regarding the ability of the intraoperative iPTH to predict resolution of hyperparathyroidism. Retrospective review. The study series is a retrospective review of 107 consecutive parathyroidectomies performed by a single surgeon. Patients with primary, secondary, and tertiary hyperparathyroidism were included. The intraoperative assay allowed an overall success rate of 93.4% across all patient categories. The success rate in patients with primary hyperparathyroidism was 95.7%. Measuring the iPTH level at 10 versus 15 minutes after the removal of tissue did not significantly affect the predictive value of the test. A decrease of 50% in the iPTH level after the resection of hyperfunctioning tissue was prognostic of successful treatment of the hyperparathyroid state. By contrast, a postexcision iPTH level that was within the normal range was not always predictive of cure. The intraoperative iPTH assay is particularly useful in the treatment of primary hyperparathyroidism. The assay eliminates the need for intraoperative frozen-section analysis in most cases and allows the surgeon to perform limited resections with confidence. This is especially true in complicated parathyroid surgeries, such as revision surgeries or those requiring concomitant thyroid surgery. The assay is also useful in secondary hyperparathyroidism, although it appears that the inability to identify small nonfunctional or hypofunctional supernumerary parathyroid glands means that long-term normocalcemia may not be assured.

Minimally invasive parathyroid surgery in 103 patients with local/regional anesthesia, without exclusion criteria

Background. Parathyroid surgery for sporadic primary hyperparathyroidism (pHPT) can be accomplished with local/regional anesthesia and intraoperative monitoring of intact parathyroid hormone without exclusion criteria through a 1.0- to 1.25-inch (2.5- to 3.2-cm) incision (MIPL) in a high proportion of patients. Methods. One hundred thirty-one consecutive patients with pHPT were offered MIPL. One hundred three patients elected to have this procedure. Patients were not excluded because of inadequate localization, previous parathyroid surgery, or need for concomitant thyroid surgery. Preoperative localization with ultrasound and/or sestamibi-single photon emission computed tomography scan was done in all patients. Almost all patients had intraoperative monitoring of intact parathyroid hormone (IMPTH). Results. MIPL was accomplished in 89 of these 103 patients (86.4%), but 14 required conversion to general anesthesia. The main reasons for conversion were concomitant thyroid surgery, no positive preoperative localization, and previous parathyroid surgery. This procedure was accomplished in 13 patients requiring a bilateral procedure, 5 patients requiring thyroid surgery, 4 patients with no positive preoperative localization, and in 3 patients with previous parathyroid surgery. The complications of MIPL were comparable to the traditional bilateral exploration with general anesthesia. No patient experienced permanent hypoparathyroidism or postoperative bleeding. Two patients had transient recurrent laryngeal nerve paresis, and surgery failed to correct hypercalcemia in 5 (4.9%) of the patients. There appears to be less need for antiemetic medication in the MIPL patients compared with patients who had general anesthesia. Conclusions. Parathyroid surgery for sporadic pHPT can be accomplished through a 1.0- to 1.25-inch (2.5- to 3.2-cm) incision with local/regional anesthesia, without exclusion criteria. Accurate preoperative localization, particularly localization to the same site by both ultrasound and 99mTc-sestamibi scan, and IMPTH can limit the surgery to a unilateral approach. One should be cautious in proceeding with MIPL in patients with need for concomitant thyroid surgery, no preoperative localization, or previous parathyroid surgery. (Surgery 2002;131:502-8.)

Autotransplantation of fresh diseased parathyroid tissue in primary and radiation-induced hyperparathyroidism

Thirty-five patients with primary or radiationinduced hyperparathyroidism underwent autotransplantation with fresh diseased parathyroid tissue. Due to previous neck surgery (34 percent), concomitant thyroid surgery (66 percent), and a high proportion of multiglandular parathyroid disease (43 percent), all patients ran a high risk of becoming hypoparathyroid. At follow-up, a mean of 28 months after operation, 32 patients had normal parathyroid function, 2 had hyper- and 1 had hypoparathyroid function. The amount of tissue used for transplantation was individually chosen by relating the serum calcium level to the total parathyroid mass. In patients with water-clear cell hyperplasia and thus low endocrine activity on a weight basis, large grafts were needed, whereas less than 120 mg was used in most other cases. In two of our three failures we did not follow these tactics. Our results show that autografting fresh diseased parathyroid tissue can minimize the occurrence of postoperative hypoparathyroidism in patients at high risk of this complication. In no case has recurrent or progressive hypercalcemia developed.