Invasive Surgery For Primary Hyperparathyroidism Research Articles

Comparison of intraoperative imaging with a portable gamma camera with extemporaneous histology in minimally invasive surgery for primary hyperparathyroidism

IntroductionThe curative treatment of primary hyperparathyroidism (PPH) is surgical and today it can be performed by minimally invasive surgery (MIS) and also be radioguided (RG) if a radiopharmaceutical with affinity for the parathyroid tissue that can be detected with gamma-detector probes or with a portable gamma camera (PGC) is injected. AimThe objective is to assess whether intraoperative scintigraphy (GGio) with PGC can replace intraoperative pathological anatomy (APio) to determine if the removed specimen is an abnormal parathyroid. Material and method92 patients underwent CMI RG--HPP with PGC after the administration of a dose of 99 mTc-MIBI. The information provided by the PGC in the analysis of the excised specimens is qualitatively compared (capture yes/no) with the result of the intraoperative pathological anatomy (APio). The Gold standard is the definitive histology. Results120 excised pieces are evaluated with GGio and APio. There were 110 agreements (95TP and 15TN) and 10 disagreements (3FP and 7FN). Of the 120 lesions, 102 were parathyroid and 18 were non-parathyroid. There was good agreement between intraoperative scintigraphy imaging (GGio) and PA, 70.1% according to Cohen's Kappa index. The GGio presented the following values ​​of Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, Positive Likelihood Ratio, Negative Likelihood Ratio and Overall Value of the Test (93.1%, 83.3%, 96.9%, 68.2%, 5.59, 0.08 and 0.92 respectively). ConclusionGGio is a rapid and effective surgical aid technique to confirm/rule out the possible parathyroid nature of the lesions removed in PPH surgery, but it cannot replace histological study.

Vitamin D3 Levels in Predicting Transient Hypocalcemia After Parathyroidectomy.

IntroductionHypocalcemia following parathyroidectomy can often be problematic, requiring long-term follow-up. This complication can be permanent or transient. It most commonly occurs following head and neck surgery where there is accidental removal of the parathyroid gland or damage to the blood supply to the gland during dissection. This study aimed to predict transient hypocalcemia and hypoparathyroidism by evaluating preoperative vitamin D.MethodsWe retrospectively reviewed the medical records of 82 patients that had undergone minimally invasive surgery for primary hyperparathyroidism. Data for patient demographics, histopathology, preoperative and postoperative parathyroid hormone (PTH), calcium levels and vitamin D levels were reviewed.ResultsThe female to male ratio was 8.1:1 and the mean age was 56.4 ± 6.2. Preoperative vitamin D was normal in 47.6%, 39% had vitamin D deficiency and 13.4% had vitamin D insufficiency. Postoperatively, 23% has hypocalcemia and 10% had hypoparathyroidism. Postoperative median calcium levels were low in both the vitamin D deficiency and insufficiency groups but failed to show a significant association.ConclusionIn our study, preoperative vitamin D levels failed to show an association between postoperative calcium and PTH levels.

Evaluation of the performance of ultrasonography and 99mTc-sestamibi scintigraphy for primary hyperparathyroidism surgery

IntroductionMinimally invasive surgery has become the standard surgical attitude in primary hyperparathyroidism. It requires precise preoperative lesion localization. The aim of the present study was to evaluate the performance of ultrasonography and 99mTc-sestamibi scintigraphy in minimally invasive surgery for primary hyperparathyroidism. Materials and methodsA retrospective study included all patients managed surgically for primary hyperparathyroidism between January 2008 and November 2017 in the University Hospital of Brest (France). Two hundred and seventy-three patients underwent ultrasonography and 99mTc-sestamibi scintigraphy. Results determined intrinsic (sensitivity and specificity) and extrinsic (positive and negative predictive values) performance on per-patient and per-gland analysis. Demographic, preoperative, interventional and cure data were compared according to ultrasonography and scintigraphy results, distinguishing 3 patient groups: concordant n=156, discordant n=99, negative n=18. ResultsOn per-gland analysis, sensitivity was 70% for ultrasound, 74% for 99mTc-sestamibi scintigraphy and 81% for associated ultrasound-scintigraphy; positive predictive values were 89%, 91% and 96%, respectively. Gland volume and concomitant thyroid pathology rates differed significantly (both p=0.003) between the 3 imaging results groups. ConclusionThe performance of associated ultrasound-99mTc-sestamibi-scintigraphy provided a positive predictive value of 96%. Combining the two techniques reduced surgical morbidity.

SAT-394 Concordant Parathyroid Imaging; Frequency and Predictors of Concordance and Its Impacts on Cure

Introduction: Accurate pre-operative imaging of a parathyroid adenoma facilitates minimally invasive surgery for primary hyperparathyroidism, increases cure rate and reduces perioperative complications. The two most commonly deployed preoperative localization studies are ultrasonography (US) and parathyroid scintigraphy using 99m-techentium sestamibi (RN). Patients who have concordant results between the two studies (most studies report concordance rate of 60%) usually undergo minimally invasive surgery whilst those with non-concordance scan results often need bilateral open neck surgery.Objectives: We did a retrospective assessment of the clinical, biochemical and imaging parameters of patients who had parathyroid surgery in our hospital to assess (a) the sensitivity and positive predictive value (PPV) of US and RN scans (b) the frequency of concordance between the two imaging studies (c) the clinical and laboratory predictors of concordance and (d) the impact of concordance on the cure rate.Method: 155 patients who were operated for PHPT between January 2011 and January 2019 were included. All patients underwent preoperative localization with US and RN imaging. The sensitivity and PPV of the 2 imaging procedures in detecting a parathyroid adenoma were determined by correlating the imaging findings of both scans with the composite information obtained from surgical findings and post-operative biochemical results to indicate cure. The patients with concordant and non-concordant imaging findings were compared for surgical cure rate, serum calcium and parathormone level, and the volume and weight of the adenoma.Results: The sensitivity and PPV of US were 80.9% and 82.8% and for RN scan 78.7% and 87.8% respectively. There was no statistically significant difference in the accuracy between the two modalities. 93(60%) patients had concordant and 62(40%) patients had non-concordant scan results, which included true discordance and non-localization by one or both scans. Cure rate in concordant and non-concordant scans were 96.8% and 83.7% respectively (p=0.02, chi-square). In comparison to patients with non-concordant imaging, patients with concordant imaging had higher level of serum calcium (mean 3.02 vs 2.86, p=0.04), the resected adenoma was larger in volume (mean 3109mm3 vs 2083mm3, p=0.05) and was heavier (mean 1.59 vs 1.10 p=ns). However there was no difference in the age or serum PTH level between the 2 groups of patients.Conclusion: Both US and RN imaging have similarly high sensitivity and PPV in identifying a parathyroid adenoma and our figures were comparable to the published literature. When the two studies are concordant a significantly higher surgical success rate is obtained. Patients with higher serum calcium and larger adenomas are more likely to demonstrate concordant imaging.

Successful minimally invasive surgery for primary hyperparathyroidism: influence of preoperative imaging and intraoperative parathyroid hormone levels.

Adenoma is the main parathyroid disorder leading to primary hyperparathyroidism (PHP). Minimally invasive parathyroidectomy (MIP) is recognized as a valid procedure for adenoma-related PHP. It requires precise preoperative localization combining Tc-99m-MIBI (methoxy-isobutyl-isonitrile) scintigraphy and single-photon emission computed tomography (SPECT) with x-ray computed tomography (CT) and intraoperative confirmation of successful excision by change in intact parathormone (iPTH) levels. The study aim was to assess the surgery success in relation to these two parameters. All patients operated on for PHP from 2005 to mid-2014 at our institution were retrospectively reviewed. MIP was performed in case of precise preoperative adenoma localization on scintigraphy, absence of past cervical surgery, and absence of concomitant thyroid resection necessity. In these patients, iPTH levels were monitored intraoperatively. Confirmation criteria for iPTH values were a return to normal level or a decrease >50 % of basal iPTH level. There were 197 PHP operations during the study period: 118 MIP and 79 bilateral neck explorations (BNEs). The MIP success rate was 95 % (112/118) with a preoperative MIBI scan ± CT accurate in 94 % (111/118) of the patients and with correct iPTH in 90 % (106/118) of the cases. Among the 12 iPTH levels that did not meet the confirmation criteria, 10 returned to normal range by postoperative day 2. Treatment failure appeared in three patients (one BNE, two MIPs). Tc-99m-MIBI dual-phase scintigraphy with SPECT/CT is the key examination for functional and morphological parathyroid adenoma localization. If preoperative scintigraphy is obvious and intraoperative assessment is clear, one could possibly safely omit iPTH, as it may lead to unnecessary BNE in primary PHP.

The Final Intraoperative Parathyroid Hormone Level: How Low Should It Go?

In minimally invasive surgery for primary hyperparathyroidism (HPT), intraoperative parathyroid hormone (IOPTH) monitoring assists in obtaining demonstrably better outcomes, but optimal criteria are controversial. The outcomes of 1,108 initial parathyroid operations for sporadic HPT using IOPTH monitoring from 1997 to 2011 were stratified by final post-resection IOPTH level. All patients had adequate follow-up to verify cure. With mean follow-up of 1.8years (range 0.5-14.3years), parathyroidectomy using IOPTH monitoring failed in 1.2% of cases, with an additional 0.5% incidence of long-term recurrence at a mean of 3.2years (range 0.8-6.8years) postoperatively. Operative success was equally likely with a final IOPTH drop to 41-65pg/mL vs ≤40pg/mL (p=1). In the 76 patients with an elevated baseline IOPTH level that did not drop to ≤65pg/mL, surgical failure was 43 times more likely than with a drop into normal range (13 vs. 0.3%; p<0.001). When the final IOPTH level dropped by >50% but not into the normal range, surgical failure was 19 times more likely (3.8 vs. 0.2%; p=0.015). Long-term recurrence was more likely in patients with a final IOPTH level of 41-65pg/mL than with a level ≤40pg/mL (1.2 vs. 0; p=0.016). Adjunctive intraoperative PTH monitoring facilitates a high cure rate for initial surgery of sporadic primary hyperparathyroidism. A final IOPTH level that is within the normal range and drops by >50% from baseline is a strong predictor of operative success. Patients with a final IOPTH level between 41-65pg/mL should be followed beyond 6months for long-term recurrence.

Ultrasound for Localization in Primary Hyperparathyroidism

Objective: Minimally invasive surgery for primary hyperparathyroidism has gained significant popularity. Preoperative localization is required, with ultrasonography and sestamibi imaging being most commonly utilized. When both are obtained, frequently the same site is localized. It is unclear that 2 localization techniques are required in patients with hyperparathyroidism. Method: Prospectively collected data from the Midwest Head and Neck Cancer Consortium’s parathyroid protocol was retrospectively reviewed. The study included patients that had preoperative localization and subsequently underwent surgery. The localization studies were correlated to surgical findings. Results: Of the 96 patients, preoperative US, sestamibi, or both studies were obtained in 77, 88, and 71, respectively. Preoperative US and sestamibi localized an abnormality in 69% and 80%, respectively. In patients with localizing US, surgical findings were exactly as predicted in 75% and localized to the correct side in 84%. The accuracy of localization was similar for sestamibi imaging. In 8 patients with inaccurate US localization, the sestamibi detected an abnormal gland in only 50%. In patients with a nonlocalizing US, sestamibi was able to detect disease in 75%, with 2 being in the mediastinum. Conclusion: Given the lower cost of ultrasonography, it is an acceptable initial localization study for patients with primary hyperparathyroidism. In patients with nonlocalizing ultrasound, sestamibi imaging should be obtained. Frequently potential sites of disease will be identified, still allowing for a minimally invasive surgical approach.

Minimally invasive surgery for primary hyperparathyroidism with or without intraoperative parathyroid hormone monitoring

We analyzed the utility of intraoperative parathyroid hormone (IOPTH) monitoring in minimally invasive surgery for primary hyperparathyroidism (pHPT). The subjects were the 167 consecutive patients with pHPT performed initial operation with or without IOPTH between January 2000 and December 2006. Patients were divided into 2 groups. A group who underwent surgery without IOPTH monitoring (Group 1; n=87), and a group who underwent surgery with IOPTH monitoring (Group 2; n=80), in which IOPTH was measured at 5, 10, 15 minutes after excision of the abnormal parathyroid gland. Criterion for evaluation as a cure was a drop in intact PTH level of 50% or more from the preoperative baseline value. The overall cure rate in Group 1 was 93.1%. An enlarged parathyroid gland that was consistent with the results of a preoperative imaging study was found in 84 patients (96.6%). The overall cure rate in Group 2 was 97.5%. In 7 of the patients, there was no drop of 50% or more at any of the 3 points in time measured. Two of these patients were found to have had double adenomas, one on each side, during the initial surgery. Three others were eucalcemic and had normal intact PTH values after surgery, and the remaining 2 patients had persistent disease. Although preoperative localization studies are accurate and essential, IOPTH monitoring improves the cure rate of minimally invasive parathyroidectomy. IOPTH monitoring is a valuable adjunct to achieve adequate intraoperative decision-making, recognizing and resecting additional image-negative hyperfunctioning lesions.

Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy.

Minimally invasive surgery for primary hyperparathyroidism has become an accepted part of endocrine surgical practice worldwide. Survey of members of the International Association of Endocrine Surgeons. Clinical practice of endocrine surgeons worldwide. Numbers of parathyroid procedures performed, types of minimally invasive procedures undertaken, and techniques used to ensure completeness of removal of hyperfunctioning parathyroid tissue as reported by the survey respondents. Of 160 surveys completed, 95 (59%) indicate that the surgeons currently perform minimally invasive parathyroidectomy and use this technique on average for 44% of patients with primary hyperparathyroidism. The most common approach is the focused technique with a small incision, either central or lateral (92% [87 respondents]), followed by a video-assisted technique (22% [21 respondents]), and a true endoscopic technique with gas insufflation (12% [11 respondents]). Techniques used to ensure completeness of resection include the quick intraoperative intact parathyroid hormone assay (68% [65 respondents]), a same-day intact parathyroid hormone assay (17% [16 respondents]), and the nuclear probe (14% [13 respondents]). The number of parathyroidectomies performed worldwide increased from 1727 in 1980 to 6977 in 2000 with the average number per surgeon increasing from 23 in 1980 to 45 in 2000. Geographically, 20 (59%) of 34 surveys from the Americas report the use of minimally invasive parathyroidectomy, 23 (56%) of 41 from the Australasian region, and 34 (49%) of 69 from Europe or the Middle East. The number of parathyroidectomies performed for primary hyperparathyroidism has increased worldwide over the past 20 years. More than half of the surgeons responding to the survey perform minimally invasive parathyroidectomy, with the most using the focused small-incision technique.

Minimally invasive surgery for primary hyperparathyroidism: A systematic review: Reply

Australian and New Zealand Journal of SurgeryVolume 70, Issue 10 p. 745-745 Minimally invasive surgery for primary hyperparathyroidism: A systematic review: Reply Guy Maddern, Guy Maddern ASERNIP-S North Adelaide, SASearch for more papers by this author Guy Maddern, Guy Maddern ASERNIP-S North Adelaide, SASearch for more papers by this author First published: 24 December 2001 https://doi.org/10.1046/j.1440-1622.2000.01945.xAbout ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume70, Issue10October 2000Pages 745-745 RelatedInformation

Minimally invasive surgery for primary hyperparathyroidism: a systematic review.

The aim of the present paper was to systematically review the literature regarding the safety and efficacy of minimally invasive parathyroidectomy techniques in patients with primary hyperparathyroidism. Studies using unilateral or endoscopic exploration following imaging were compared with bilateral open neck exploration. Studies on minimally invasive parathyroid surgery were identified using MEDLINE (1984 to August 1998), EMBASE (1974 to August 1998) and Current Contents (1993 to week 34, 1998). The search terms were ((endoscop* or (minimal* and invasive) or unilateral) and parathyroid). The Cochrane Library was searched from 1966 to issue 3 1998, using the search terms 'parathyroidectomy or parathyroid resection'. Human studies of patients with primary hyperparathyroidism using unilateral or endoscopic exploration were included. Animal studies describing minimally invasive technique development were also included. A surgeon and researcher independently assessed the retrieved articles for their inclusion in the review. Studies directly comparing the unilateral method with bilateral open neck exploration were used to analyse outcomes. Analysis of data using odds ratios and 95% confidence intervals (CI) indicated a tendency to favour the unilateral technique. These individual studies generally had large CI, however; therefore preference to the unilateral procedure cannot be espoused with certainty. There is also a selection bias due to the strict enrollment criteria for unilateral surgery. The proposed role of minimally invasive parathyroid surgery is for patients with primary hyperparathyroidism who have unilateral parathyroid pathology. To assess the safety and efficacy of minimally invasive techniques it is suggested that their introduction be monitored as part of a trial in Australia, from which data should be accrued to a register.

Minimally invasive surgery for primary hyperparathyroidism: systematic review.

Use of minimally invasive parathyroidectomy techniques, either unilateral or endoscopic, will result in the same or improved safety and efficacy outcomes as those of the bilateral open neck exploration technique in patients with primary hyperparathyroidism. Studies on minimally invasive parathyroid surgery were identified using MEDLINE (January 1984 to August 1998), EMBASE (January 1974 to August 1998), and Current Contents (week 1 of 1993 to week 34 of 1998). The search terms were as follows: ((endoscop* or (minimal* and invasive) or unilateral) and parathyroid). The Cochrane Library was searched from issue 1 of 1966 to issue 3 of 1998, using the search terms "parathyroidectomy or parathyroid resection." Human studies of patients with primary hyperparathyroidism using unilateral or endoscopic exploration were included. Animal studies describing minimally invasive technique development were also included. A surgeon (R.F.P.) and researcher (W.J.B.) independently assessed the retrieved articles for their inclusion in the review. Studies directly comparing the unilateral method with bilateral open neck exploration were used to analyze outcomes. Analysis of data using odds ratios and 95% confidence intervals indicated a tendency to favor the unilateral technique. However, these individual studies generally had large confidence intervals; therefore, preference to the unilateral procedure cannot be espoused with certainty. There is also a selection bias due to the strict enrollment criteria for unilateral surgery. The proposed role of minimally invasive parathyroid surgery is for patients with primary hyperparathyroidism who have unilateral parathyroid pathological features. To assess the safety and efficacy of minimally invasive techniques, it is suggested that their introduction be monitored as part of a trial in Australia, from which data should be accrued to a register.