Invasive Parathyroidectomy For Primary Hyperparathyroidism Research Articles

Surgical description and outcome of ultrasound-guided minimally invasive parathyroidectomy in 50 dogs with primary hyperparathyroidism.

To describe the surgical technique and clinical outcome of minimally invasive parathyroidectomy for primary hyperparathyroidism (PHPT) in the dog. Fifty client-owned dogs with PHPT that underwent minimally invasive parathyroidectomy. Retrospective cohort study. An ultrasound-guided mini lateral approach was made via a plane established between the sternocephalicus muscle and sternohyoideus muscles to expose the thyroid gland and enlarged parathyroid gland. Abnormal parathyroid glands were removed en bloc via partial thyroidectomy. The technique for bilateral disease was similar, the skin incision was made on midline and moved laterally to develop the above-mentioned plane of dissection. Age, sex, breed, bodyweight, ultrasound findings, histopathological diagnosis, surgical time, preoperative clinical signs, and clinical outcome were extracted from the records for descriptive statistics. A total of 62 glands were surgically removed, including 17 hyperplastic glands (17/62, 27.4%), 34 adenomas (34/62, 54.8%), and two carcinomas (2/62, 3.2%). Hypercalcemia resolved shortly after surgery in 44 dogs (44/45, 97.8%). One dog had recurrent hypercalcemia (1/45, 2.2%), one dog had persistent hypercalcemia (1/45, 2.2%), two dogs had permanent hypocalcemia requiring life-long calcitriol supplementation (2/45, 4.4%), and one dog died from clinical hypocalcemia (1/45, 2.2%). Minimally invasive parathyroidectomy was associated with a low morbidity and led to favorable outcomes in 44/45 dogs in this series. The results of this study supports the use of minimally invasive parathyroidectomy to treat PHPT in dogs.

Use of Intraoperative Parathyroid Hormone in Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism

Intraoperative parathyroid hormone (ioPTH) is a surgical adjunct that has been increasingly used during minimally invasive parathyroidectomy (MIP). Despite its growing popularity, to our knowledge a meta-analysis comparing MIP with ioPTH vs MIP without ioPTH has not yet been conducted. To evaluate the safety and efficacy of MIP with ioPTH for treatment of primary hyperparathyroidism. A systematic search of the databases PubMed, Embase, Scopus, Web of Science, and Cochrane Collaboration was performed to identify studies that compared MIP with and without ioPTH. Data were analyzed between August and September 2019. Inclusion criteria consisted of randomized clinical trials and observational studies with a retrospective/prospective design, comparing MIP using ioPTH vs MIP not using ioPTH for treatment of primary hyperparathyroidism. Eligible studies had to present odds ratio (OR), risk ratio, or hazard ratio estimates (with 95% CI), standard errors, or number of events necessary to calculate these for the outcome of interest rate. Studies involving patients with secondary or tertiary hyperparathyroidism or those with multiple endocrine neoplasia syndrome were excluded. Two reviewers independently reviewed the literature according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Dichotomous variables were pooled as ORs while continuous variables were compared using weighted mean differences. Quality assessment was performed using the Newcastle-Ottawa Scale. The primary outcome was rate of cure. Secondary outcomes included need for reoperation, need for bilateral neck exploration, morbidity, and length of surgery. A total of 12 studies, involving 2290 patients with primary hyperparathyroidism, were eligible for inclusion. The median (SD) age of participants was 60.1 (11.8) years and 77.3% of participants were women. The median Newcastle-Ottawa score was 7. Patients who underwent MIP with ioPTH had higher cure rates (OR, 3.88; 95% CI, 2.12-7.10; P < .001). There was a greater need for reoperation in the group of patients who had surgery without ioPTH (OR, 0.40; 95% CI, 0.19-0.86; P = .02). There was a trend toward longer operating times/increased duration of surgery in the ioPTH group; however, this did not reach statistical significance (weighted mean difference, 21.62 minutes; 95% CI, -0.93 to 44.17 minutes; P = .06). The use of ioPTH was associated with higher rates of bilateral neck exploration (OR, 3.55; 95% CI, 1.27-9.92; P = .02). Use of ioPTH is associated with higher cure rates for patients with primary hyperparathyroidism undergoing MIP. Minimally invasive parathyroidectomy performed without ioPTH is associated with less conversion to bilateral neck exploration at initial surgery but with lower cure rates and an increased risk for reoperation. PROSPERO identifier: CRD42020148588.

MINIMALLY INVASIVE PARATHYROIDECTOMY FOR PRIMARY HYPERPARATHYROIDISM.

Primary hyperparathyroidism (PHPT), characterized by the inappropriate secretion of parathyroid hormone (PTH) with respect to the extracellular calcium concentration. Curative treatment of PHPT is surgery and bilateral neck exploration has been replaced by minimally invasive parathyroidectomy (MIP), with the advanced imaging technologies combined with radio-guided occult lesion localization (ROLL). The present study analyzes the MIP data from 45 patients who underwent surgery for parathyroid adenoma and debates if MIP is a feasible technique for the treatment of PHPT. The study presents the MIP excision data of 45 hyperparathyroidism patients with a 58-month follow up period. Forty-five operations were performed for 48 parathyroid adenomas. The mean duration of operation was 22.7 (12-55) minutes. Mean follow-up was 14.2 (6-26) months. All patients had normal postoperative calcium levels and PTH levels were normal in the follow-up period, except for one persistent hyperparathyroidism. ROLL-guided MIP is a feasible technique for parathyroid surgery and reduces surgeon based failure. It also provides the widespread application of parathyroid surgery by decreasing the need for specific experience.

Open minimally invasive versus video-assisted minimally invasive parathyroidectomy for primary hyperparathyroidism

Open minimally invasive versus video-assisted minimally invasive parathyroidectomy for primary hyperparathyroidism

Open minimally invasive versus video-assisted minimally invasive parathyroidectomy for primary hyperparathyroidism

Open minimally invasive versus video-assisted minimally invasive parathyroidectomy for primary hyperparathyroidism

Does levothyroxine administration impact parathyroid localization?

BackgroundProper localization is crucial in performing minimally invasive parathyroidectomy for primary hyperparathyroidism. Ultrasonography (US) and Tc-99m sestamibi (MIBI) scintigraphy are common methods used for localization. As the appearance and activity of the thyroid gland may impact parathyroid localization, the purpose of this study was to determine how exogenous use of the thyroid hormone, levothyroxine (LT), affects parathyroid localization. MethodsAdult patients with non–familial primary hyperparathyroidism who underwent initial parathyroidectomy from 2000–2014 were retrospectively identified. LT (+LT) and non-LT (−LT) patients were matched 1:3 based on age, gender, goiter status, and preoperative parathyroid hormone levels. Subgroup analysis was performed on patients previously treated with radioactive iodine and patients undergoing single adenoma resection. ResultsOf the 1737 patients that met inclusion criteria, 286 were on LT at the time of their parathyroid localization scan. Use of LT did not impact the percentage of correct MIBI localization scans when compared with −LT patients (P = 0.83). Interestingly, use of LT significantly hindered localization by US in comparison with the −LT group (48.4 versus 62.2%, P < 0.01). When examining only patients where a single upper gland was removed, the +LT group was less likely to have a correct US compared with the −LT group (50 versus 72.8%, P < 0.01). However, there was no difference in US accuracy for patients who only had a single lower gland removed (P = 0.51). ConclusionsExogenous LT is associated with impaired parathyroid localization with US but not MIBI. Surgeons should be aware of localization efficiency for this subset of patients in the era of personalized medicine and cost effectiveness.

The Biochemical Severity of Primary Hyperparathyroidism Correlates with the Localization Accuracy of Sestamibi and Surgeon-Performed Ultrasound

Minimally invasive parathyroidectomy for primary hyperparathyroidism is dependent on preoperative localization, commonly with ultrasound and sestamibi imaging. This study sought to determine if preoperative serum calcium and parathyroid hormone (PTH) levels correlate with localization sensitivity and positive predictive value (PPV). This is a retrospective analysis of a prospective database of 1,910 patients with primary hyperparathyroidism from 2002 to 2013, who had surgeon-performed ultrasound and/or sestamibi for preoperative localization. The sensitivity and PPV of ultrasound and sestamibi were analyzed by degree of preoperative serum calcium and parathyroid hormone level perturbation. In 1,910 parathyroidectomy patients, ultrasound was localizing in 1,411 of 1,644 (86%) and sestamibi in 802 of 1,165 (69%) (p < 0.01). The PPV of ultrasound was 1,135 of 1,411 (80%) and sestamibi was 705 of 802 (88%) (p < 0.01). Using logistic regression analysis, there was statistically significant positive correlation between localization and preoperative serum calcium for both sestamibi (odds ratio [OR] 1.21 [95% CI 1.00 to 1.47; p<0.05]) and ultrasound (OR 1.29 [95% CI 1.03 to 1.60; p < 0.05]). There was a weak, but statistically significant positive correlation of PTH with sestamibi localization (OR 1.00 [95% CI 1.00 to 1.01; p < 0.05]). There was no statistically significant correlation between the PPV and serum calcium or PTH for either study. When patients were divided into quartiles of preoperative serum calcium and PTH levels, localization rates and PPV of both ultrasound and sestamibi increased with higher calcium and PTH levels. Surgeon-performed ultrasound had higher localization rates than sestamibi, with lower calcium and PTH values. Sestamibi demonstrated higher PPV values across all quartiles. Surgeon-performed ultrasound and sestamibi have higher localization rates and PPV, with increasing preoperative serum calcium and PTH levels. Surgeon-performed ultrasound may be a better initial test for patients with lower calcium (<10.5 mg/dL) and PTH (<90 pg/mL) values due to significantly higher localization rates; however, a localizing sestamibi has higher PPV.

Role of cervical ultrasound in detecting thyroid pathology in primary hyperparathyroidism

BackgroundMinimally invasive parathyroidectomy for primary hyperparathyroidism is made possible with accurate preoperative imaging. In addition to the detection of parathyroid adenomas, cervical ultrasound also provides concomitant assessment of the thyroid gland, and many surgeons believe that it is essential. However, the incidental identification of thyroid nodules may then subject patients to further workup and potentially invasive thyroid procedures. We sought to determine the long-term consequence of omitting preoperative ultrasound on the development of thyroid pathology and cancer. MethodsAt our institution, 222 patients with primary hyperparathyroidism underwent parathyroidectomy without preoperative cervical ultrasound from 1990–2001. Thyroid pathology discovered by follow-up after parathyroidectomy, subsequent biopsy, and surgical interventions were analyzed. ResultsOf the 222 patients who underwent parathyroidectomy, the mean age was 55 ± 1 y and 149 were female (67%). In the course of their follow-up after parathyroidectomy, 13 patients (6%) received a cervical ultrasound, and seven of 13 (3%) underwent fine needle aspiration of a thyroid nodule. Only one of seven (0.4% of all patients) was ultimately diagnosed with thyroid cancer. Four additional patients were discovered to have thyroid malignancies as a result of intraoperative decision making. All five patients are currently alive with an average follow-up time of 14.9 ± 1.6 y. No patients in this series had an unnecessary thyroid intervention. ConclusionsIn patients who underwent parathyroidectomy without a preoperative ultrasound, only a small number (0.4%) were subsequently diagnosed with thyroid cancer. Furthermore, omission of ultrasound during the localization of parathyroid glands does not have a negative impact on the diagnosis of thyroid pathology as all patients who had thyroid cancer had good outcomes, and in fact, may prevent unnecessary thyroid interventions. Therefore, the use of cervical ultrasound for parathyroid localization should be considered optional rather than essential.

Real-Time Intraoperative Sestamibi Imaging as an Adjunct to Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism

Real-Time Intraoperative Sestamibi Imaging as an Adjunct to Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism

Accurate Preoperative Localization of Parathyroid Adenomas With C-11 Methionine PET/CT

Focused unilateral or minimally invasive parathyroidectomy for primary hyperparathyroidism (pHPT) depends on the successful preoperative localization of parathyroid adenomas. The aim of this prospective study was to determine the accuracy of C-11 methionine positron emission tomography/computed tomography (Met-PET/CT), a novel localization procedure for hyperfunctional parathyroid tissue. Preoperative Met-PET/CT scans of the neck and mediastinum of 102 patients undergoing parathyroidectomy for pHPT were preoperatively evaluated by a radiologist and a nuclear medicine physician and prospectively documented. The results of Met-PET/CT were compared with intraoperative and histopathological findings. pHPT was caused by a single-gland adenoma in 97 patients, whereas 5 patients had multiglandular disease. Met-PET/CT correctly located a single-gland adenoma in 83 of 97 (86%) patients with pHPT (sensitivity 91%). The positive predictive value of Met-PET/CT in localizing a single-gland adenoma was 93%. Of the 5 patients with multiglandular disease, Met-PET/CT identified 2 hyperfunctioning parathyroid glands in 1 patient, 1 gland in 3 individuals, and was negative in the fifth patient (sensitivity 80%). A highly significant correlation was observed between true-positive findings and the size (mean = 1.81 ± 0.84 cm) and weight (mean = 1.50 ± 2.56 g) of parathyroid adenoma, whereas patients with false-negative findings had significantly smaller (mean = 1.09 ± 0.41 cm) and lighter (mean = 0.37 ± 0.29 g) glands (P < 0.001 and P = 0.001, respectively). This study demonstrates the high accuracy of Met-PET/CT in the preoperative localization of parathyroid adenomas in a large series of patients with pHPT.

Hormone, Relationships of Parathyroid Gamma Counts, and Adenoma Mass in Minimally Invasive Parathyroidectomy

To better understand relationships of parathyroid hormone (PTH) production, adenoma gamma counts, and adenoma mass in patients undergoing minimally radioguided invasive parathyroidectomy for primary hyperparathyroidism from single-gland disease. A prospective review of 104 patients operated on by a single surgeon. University tertiary hospital. Adults who have primary hyperparathyroidism due to a single gland. There were 23 men and 81 women with an average age of 63 years. The mean (SD) adenoma mass was 0.78 (0.69) g (median, 0.57 g). The mean (SD) percent of background for the adenoma was 120.2 (90.5). Preoperative PTH and percent of background gamma count of the adenoma showed a likely correlation with a Spearman ρ value of 0.2039 and a P value of .037. There were significant correlations between both percent of background of the adenoma and adenoma mass (Spearman ρ = 0.4991 and P < .0001). Preoperative PTH and adenoma mass also showed a significant positive correlation (Spearman ρ = 0.308 and P = .002). There exist correlations between gland mass, radioactivity, and PTH level. Adenoma radiation counts do not appear to be a proxy for changes in PTH levels measured during surgery as has been reported. Intraoperative PTH has been shown by others not to be necessary when doing radioguided parathyroid surgery if the Norman rule is observed. However, a radioguided technique and intraoperative PTH can provide complementary information in making an assessment of completion of parathyroid procedures.

Dual Localization with Ultrasound and Iodine 123 and Technetium (99mTc) Sestamibi Scintigraphy is Superior to Single Imaging Modalities in Facilitating Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism

ABSTRACT Primary hyperparathyroidism is caused by a single parathyroid adenoma in the majority of patients. Localization of parathyroid adenomas prior to surgery has the benefit of allowing a minimally invasive approach. Over the years, multiple imaging modalities have been employed in an attempt to identify the site preoperatively, with varying degrees of success. In this study, we explore the accuracy of a combination of ultrasound and nuclear medicine planar scintigraphy with iodine-123 and technetium (99mTc) sestamibi. A retrospective study of consecutive series of 117 patients undergoing minimally invasive parathyroidectomy was carried out. Inclusion criteria incorporated clinical and biochemical evidence of primary hyperparathyroidism. All patients had at least one form of imaging: Ultrasound or nuclear medicine scintigraphy or both. The accuracy was compared with surgical findings. Gland weight was also related to imaging accuracy. A total of 101 patients underwent surgery for primary hyperparathyroidism. There was no significant difference between ultrasound and scintigraphy ability to localize a parathyroid adenoma (p = 0.738). The combination of ultrasound and scintigraphy was superior at preoperative localization compared to ultrasound (p = 0.039) or scintigraphy alone (p = 0.0078). Gland weight had no significant bearing on the accuracy of the scan (ultrasound, p = 0.89; scintigraphy, p = 0.16). Dual localization with ultrasound and scintigraphy in primary hyperparathyroidism is superior to a single imaging technique. Dual localization facilitates minimally invasive parathyroidectomy. How to cite this article Lyon A, Komolafe OO, Wilson CR, Doughty JC. Dual Localization with Ultrasound and Iodine 123 and Technetium (99mTc) Sestamibi Scintigraphy is Superior to Single Imaging Modalities in Facilitating Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism. World J Endoc Surg 2012;4(3):93-98.

Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism

Minimally invasive parathyroidectomy for primary hyperparathyroidism depends on accurate preoperative localization. This study examines the cost-utility of sestamibi in combination with single photon emission computed tomography (sestamibi-SPECT); ultrasound; and 4-dimensional computed tomography (4D-CT). A decision tree was constructed for patients undergoing initial parathyroidectomy. Patients were randomized to 1 of 5 preoperative localization protocols: (1) ultrasound; (2) sestamibi-SPECT; (3) 4D-CT; (4) sestamibi-SPECT and ultrasound; and (5) sestamibi-SPECT and ultrasound and 4D-CT, if discordant (sestamibi-SPECT and ultrasound ± 4D-CT). From a societal perspective, all relevant costs were included. Input data were obtained from literature and Medicare. The incremental cost-utility ratio was determined in dollars per quality-adjusted life years ($/QALY). Sensitivity analyses were performed. In the base-case, ultrasound was least expensive, with a cost of $6666, compared to $6773 (4-D CT); $7214 (sestamibi-SPECT and ultrasound ± 4D-CT); $7330 (sestamibi-SPECT); and $7371(sestamibi-SPECT and ultrasound). Sestamibi-SPECT and ultrasound ± 4D-CT were most cost-effective because improved localization resulted in fewer bilateral explorations. QALY were comparable across modalities. Compared to sestamibi-SPECT, ultrasound, 4D- CT, and sestamibi-SPECT and ultrasound ± 4D-CT resulted a win-win situation-costing less and accruing more utility. Sensitivity analyses demonstrated that the model was sensitive to surgery cost and diagnostic accuracy of imaging. In our model, sestamibi-SPECT and ultrasound ± 4D-CT were the most cost-effective methods, followed by 4D-CT and ultrasound. Sestamibi-SPECT alone was least cost-effective. Cost-utilities were dependent on the sensitivities of ultrasound and 4D-CT and may vary by institution.

PTH Level, Gland Radioactivity, and Gland Weight in MIRP

Objective: Better understand the relationships of parathyroid hormone production (PTH), adenoma gamma counts, and adenoma weight in patients undergoing minimally invasive parathyroidectomy for primary hyperparathyroidism due to single gland disease. Method: A retrospective review of 68 patients that had minimally invasive parathyroid surgery for single gland disease. All patients underwent intraoperative PTH monitoring as well as radioguided parathyroid surgery. All glands were weighed and examined by a pathologist. Results: Adenoma weight was 0.58 gms ± 0.44 gms. Day of surgery preoperative PTH was 132 ± 68 pg/mL. Intraoperative PTH level dropped to 35 ± 22 pg/mL. The drop in PTH was 72.1 ± 17.2 %. Ex-vivo gamma counts of the adenomas were 2233 counts per second ± 2058. Percentage of background for the adenoma was 107.2 ± 86.8%. Correlations between the preoperative PTH and percentage of background gamma counts showed a likely correlation. There were significant correlations between both percentage of background and preoperative PTH levels with adenoma weight and preoperative PTH and adenoma weight. Conclusion: Correlation exists between gland weight, radioactivity, and PTH. Radiation counts are not a proxy for changes in PTH levels as claimed by some authors. A radioguided parathyroid surgery technique and intraoperative parathyroid hormone measurements can provide complementary information in making an assessment of completion of focused/minimally invasive parathyroid procedures.

Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism

Background The aim of this study was to determine whether minimally invasive radioguided parathyroidectomy (MIRP) and intraoperative parathyroid hormone–guided parathyroidectomy (ioPTH) have equivalent intermediate-term outcomes in primary hyperparathyroidism (PHPT). Methods A retrospective study of 244 patients who underwent parathyroidectomy for PHPT in a 25-month time period was conducted. Patients who either underwent MIRP- or ioPTH-guided parathyroidectomies were included. The primary outcome was persistent disease. Conversion to bilateral exploration, complications, and multigland disease (MGD) were secondary outcomes. Results There was 1 MIRP patient and no ioPTH patients who had persistent disease. The ioPTH group had more conversions to a bilateral exploration (bilateral neck exploration [BNE]) (3.7% vs 13%, P = .024). In the MIRP group, no patients were found to have MGD. In the ioPTH group, 7 patients with double adenomas and 6 patients with MGD were found (0 vs 13, P = .0028). Conclusions ioPTH facilitates successful minimally invasive parathyroidectomy (MIP) when compared with MIRP and provides cure rates similar to BNE.

What is the Added Benefit of Cervical Ultrasound to 99mTc-Sestamibi Scanning in Primary Hyperparathyroidism?

Minimally invasive parathyroidectomy for primary hyperparathyroidism depends on accurate preoperative imaging, which is traditionally accomplished by (99m)Tc-sestamibi scanning. Cervical ultrasound is gaining in use, but it is unclear how much information it adds to the routine use of (99m)Tc-sestamibi scans. A prospectively maintained database of patients undergoing parathyroidectomy for primary hyperparathyroidism was queried, and the utility of cervical ultrasound in preoperative planning was analyzed. Between July 2002 and November 2009, 310 patients with primary hyperparathyroidism underwent both (99m)Tc-sestamibi and ultrasound imaging. Ultrasound added new information to (99m)Tc-sestamibi in 43 patients (14%) by finding either the correct enlarged gland (n = 40, 88%) or additional enlarged glands (n = 5, 12%). Ultrasound correctly localized glands in 38 of 85 (45%) patients with a negative (99m)Tc-sestamibi, allowing for a minimally invasive parathyroidectomy in those patients. However, in the 206 patients (66%) who had a 1-gland positive (99m)Tc-sestamibi, ultrasound only added information for 8 patients (4%). When compared with radiology-performed ultrasound, surgeon-performed ultrasound was successful in localizing additional glands in 27 (15%) versus 17 patients (10%) (P < 0.001). Ultrasound led to additional localization information in 14% of patients, although this benefit was less in patients with a clearly positive 1-gland (99m)Tc-sestamibi scan. Cervical ultrasound provides added benefit to (99m)Tc-sestamibi scanning in patients with primary hyperparathyroidism, but its greatest utility is when performed by a surgeon in patients with a negative (99m)Tc-sestamibi scan.

Dual localisation with ultrasound and technetium (99MTC) sestamibi spect in minimally invasive parathyroidectomy for primary hyperparathyroidism

Dual localisation with ultrasound and technetium (99MTC) sestamibi spect in minimally invasive parathyroidectomy for primary hyperparathyroidism

Does Routine Use of Ultrasound Result in Additional Thyroid Procedures in Patients with Primary Hyperparathyroidism?

Minimally invasive parathyroidectomy for primary hyperparathyroidism depends on accurate preoperative imaging. Cervical ultrasound is commonly used to localize parathyroid adenomas, but can lead to discovery of concomitant thyroid gland pathology requiring modification of the operative approach. How the identification of incidental thyroid lesions affects patient management is unclear. A prospective database of patients undergoing parathyroidectomy was analyzed for thyroid pathology discovered by ultrasound. Lesions were biopsied if indicated, and operative management was adjusted accordingly. Clinical data were correlated with operative decision-making. Between July 2002 and November 2009, 310 patients with primary hyperparathyroidism underwent ultrasound. Concomitant thyroid pathology was noted in 89 (29%) patients. Thirty-seven patients (42% of pathology) underwent fine-needle aspiration of a thyroid nodule. Thirteen patients (4% of all patients) underwent a thyroid operation not related to parathyroid disease: 9 thyroid lobectomies for presumably benign nodules and 4 total thyroidectomies for malignancy. Two were for confirmed papillary thyroid cancer, and the other 2 were for an indeterminate biopsy that later proved to be papillary thyroid cancer. One lobectomy discovered microscopic papillary thyroid cancer independent of the biopsied nodule. In total, 5 (2% of all patients) malignancies were discovered. Twenty-nine percent of patients with primary hyperparathyroidism had concomitant thyroid pathology on ultrasound. Forty-two percent of these patients underwent biopsy, and 2% had malignant pathology. Routine use of ultrasound in patients with primary hyperparathyroidism leads to discovery of unrecognized thyroid pathology and cancer.

Randomized clinical trial comparing open with video-assisted minimally invasive parathyroid surgery for primary hyperparathyroidism

: Previous studies of video-assisted techniques for parathyroidectomy in patients with primary hyperparathyroidism have found similar or better results compared with bilateral neck exploration. The aim of the present study was to compare open minimally invasive parathyroidectomy with the video-assisted technique for primary hyperparathyroidism in a multicentre randomized trial. : Some 143 patients were randomized to open (n = 75) or video-assisted (n = 68) parathyroidectomy after positive sestamibi scintigraphy. There were no differences in preoperative data. The open operation was performed through a 15-mm incision. The video-assisted techniques used were minimally invasive video-assisted parathyroidectomy (MIVAP) or video-assisted parathyroidectomy using the lateral approach (VAPLA). Data were collected prospectively including postoperative pain scoring. : The procedure was significantly quicker for the open compared to the video assisted operations: mean(s.d.) 60(35) versus 84(47) min (P = 0.001). Both groups of patients had similar conversion rates and the same outcome, with comparable incision lengths, low scores for postoperative neck discomfort, high cosmetic satisfaction and low complication rates. : Open minimally invasive parathyroidectomy for primary hyperparathyroidism was quicker than either video-assisted technique. NCT00877981 (http://www.clinicaltrials.gov)

Successful minimally invasive parathyroidectomy for primary hyperparathyroidism without using intraoperative parathyroid hormone assays

Background The need for intraoperative parathyroid hormone (iPTH) assays in minimally invasive parathyroidectomy (MIP) remains controversial. We report the results of MIP performed without the use of iPTH assays. Methods This was a single-institution retrospective review of patients with primary hyperparathyroidism treated with MIP between October 1, 1998, and December 31, 2002. Results Seventy-seven patients were studied. The mean preoperative calcium level was 11.4 mg/dL. All patients had a normal calcium level postoperatively (range, 7.4–10.2 mg/dL, mean, 9.1 mg/dL). Three patients (4%) required re-exploration for various reasons including the development of a second adenoma, secondary hyperparathyroidism, and discordant pathology. All 3 patients initially were eucalcemic. Conclusions Our success rate of 96% using a combination of preoperative sestamibi scans, intraoperative gamma probe localization, and selective frozen pathology is consistent with the published success rates using iPTH assays of 95% to 100%. We conclude that MIP can be performed successfully without using iPTH assays.