Minimally Invasive Radioguided Parathyroidectomy Research Articles

AB084. SOH24AB_270. Perioperative monitoring of calcium levels after minimally invasive radio guided parathyroidectomy (MIRP) for early detection of hypocalcemia and its management: an observational study

AB084. SOH24AB_270. Perioperative monitoring of calcium levels after minimally invasive radio guided parathyroidectomy (MIRP) for early detection of hypocalcemia and its management: an observational study

O62: INTRA-OPERATIVE ADJUNCTS IN MINIMALLY INVASIVE RADIO-GUIDED PARATHYROIDECTOMY AT A SPECIALIST ENDOCRINE SURGERY CENTRE

Abstract Introduction Primary Hyperparathyroidism (PH) is common cause of hypercalcaemia (0.3% of the population). Minimally invasive radio-guided parathyroidectomy (MIRP) has been made possible due to advancements in pre-operative imaging i.e. sestamibi scans allowing localisation of areas of parathyroid hyperactivity. Method Due to the disagreement in the literature regarding which intra operative adjunct is best used in MIRP surgery to decrease recurrence, the rationale for this study is to examine and compare the performance of these adjuncts in consecutive patients i.e. 1. Intra operative PTH assay (IOPTHA) 2. Tc-99m radio-guidance using a gamma probe and the 20% rule 3. Frozen section analysis. Result 45 MIRP procedures were carried out between 01/07/2018 and 30/10/2019. 77.8% were females; mean age was 62 years (range 30 - 79). Final pathology showed that in 43 of the cases parathyroid tissue was correctly removed; thyroid tissue was identified for the other 2 cases. 20% rule was positive in 43 out of the 45 cases and negative in 2 (sensitivity 100%, specificity 100%). A drop in IOPTHA greater than 50% was found in 41 out of the 45 cases but not in 4 (sensitivity 93.9%, specificity 100%). Frozen section was 100% concordant with final pathology (45/45). AUC analysis showed no significant difference in the performance of these tests (p = 0.15) but was around 1 for 20% rule and Frozen section. Conclusion When radio-guidance and frozen sections are added to IOPTHA, the success rate of parathyroidectomy is markedly improved. Using them together will greatly reduce recurrent hyperparathyroidism. Take-home message When radio-guidance and frozen sections are added to Intra-operative PTH assays in Minimally Invasive Radio-Guided Parathyroidectomy, the success rate of parathyroidectomy is markedly improved. Using them together as in our study will greatly reduce the incidence of recurrent hyperparathyroidism and thus recurrent surgery.

Individualised Timing of Radio-Guided Parathyroidectomy Using Multi-Phase SPECT/CT Increases In Vivo Sensitivity and Accuracy and Reduces Operating Time: A Randomised Clinical Trial.

Background: Minimally invasive parathyroidectomy is the preferred treatment for primary hyperparathyroidism. Despite relatively accurate preoperative information, minimally invasive parathyroidectomy can be challenging, especially in the case of small and ectopic adenomas. Radio guidance aids in both in vivo identification and ex vivo confirmation of adenoma. In vivo accuracy is currently not satisfactory. The present study evaluated whether a beneficial effect (increased sensitivity, specificity, accuracy) is obtained with individualised timing of minimally invasive radio-guided parathyroidectomy (MIRGP) using preoperative multi-phase 99mTc-MIBI single photon emission computed tomography (SPECT)/computed tomography (CT). Methods: This randomised clinical trial was conducted from May 2016 to January 2020 in a tertiary referral hospital. Adult patients with primary hyperparathyroidism sent for 99mTc-MIBI SPECT/CT were included consecutively and randomly assigned to conventional (dual-phase) SPECT/CT and conventional MIRGP (group I) or multi-phase SPECT/CT and individualised MIRGP (group II). One hundred of 106 eligible patients were included, and 83 patients underwent complete intervention. Results: A total of 47 patients in group I and 35 patients in group II were analysed. Group II had a shorter operating time (p = 0.003). The in vivo sensitivity and accuracy of radio guidance was 85.1% in group I and 100% in group II (p = 0.046), and 90.4% in group I and 100% in group II (p = 0.021), respectively. We found no difference in the in vivo specificity and ex vivo parameters between groups. Conclusion: Individualised timing increased the in vivo sensitivity and accuracy of radio guidance and reduced operating time, as some parathyroid adenomas rapidly wash out the radionuclide.

AB024. Intra-operative adjuncts in minimally invasive radio-guided parathyroidectomy at a specialist endocrine surgery centre

Background: Primary hyperparathyroidism (PH) is a common cause of hypercalcaemia (0.3% of the population) and is characterized by high concentrations of calcium and parathyroid hormone (PTH). Minimally invasive radio-guided parathyroidectomy (MIRP) has been made possible due to advancements in pre-operative imaging i.e., sestamibi scans that allows localization of areas of parathyroid hyperactivity.

Feasibility and safety of minimally invasive radioguided parathyroidectomy using very low intraoperative dose of Tc-99m MIBI

BackgroundSurgical resection of the abnormal parathyroid glands is the only curative treatment for primary hyperparathyroidism (PHPT). Radioguided parathyroidectomy with technetium-99m (TC-99m) sestamibi has been successfully used in patients with PHPT.This study was designed to evaluate the results of a series of patients with PHPT who underwent minimally invasive radioguided parathyroidectomy (MIRP) using very low dose (1 mCi) of TC-99m sestamibi (MIBI) without application of intraoperative parathyroid hormone (PTH) assay or frozen section analysis. MethodsEighty-seven patients with PHPT were prospectively studied from November 2012 to January 2015. Following neck ultrasound (US) and MIBI scan concordant for single gland disease, patients underwent MIRP using a handheld gamma probe. The technique involved injecting of 1 mCi MIBI in the operative room before the beginning of the intervention. All patients were followed up for a minimum of 6 months postoperatively. ResultsMIRP was successfully performed in 86 out of 87 patients (98.85%). The Gamma probe was particularly useful in detection of ectopic parathyroid adenomas in upper mediastinum. Mean operative time was 23.95 ± 7.982 min and mean hospital stay was 1.44 ± 0.604 days. No major surgical complications were recorded. ConclusionsThe MIRP technique using very low dose (1 mCi) of Tc-99m MIBI without intraoperative PTH assay and frozen section analysis resulted in excellent cure rate for PHPT. This technique involves a radiation exposure to patients and surgical staffs 20 times lower than conventional MIRP using 20 mCi Tc-99m MIBI. Besides, patients with PHPT due to ectopic parathyroid adenoma may especially benefit from MIRP.

Republication: Minimally invasive radioguided parathyroidectomy: A patient satisfaction survey

Introduction: Minimally invasive radioguided parathyroidectomy (MIRP) combines technetium sestamibi scan, intraoperative gamma probe, methylene blue dye, and measurement of circulating parathyroid hormone levels. While MIRP is a well-established approach to neck exploration for hyperparathyroidism, there are little published data about patient satisfaction following this type of surgery. Methods: All patients in this study underwent either unilateral MIRP or bilateral neck exploration for primary or recurrent hyperparathyroidism. Postoperative prospective patient satisfaction surveys were collected and analyzed with regard to preoperative education, surgical outcomes, extent of procedure, and patient age and gender. Statistical analysis was performed to examine patient satisfaction trends for significance. Results: Of 68 study patients 34 completed the survey at the 1-week follow-up appointment, 4/68 mailed in the survey, 10/68 were contacted by phone, with the remaining surveys either returned incomplete or not filled out. Among the 48 completed surveys, most patients (85–100%) were satisfied with both operative and postoperative care aspects. Although patient dissatisfaction was higher among patients discharged on the same day and those hospitalized for Conclusions: The survey used in this study appears to be an effective instrument in assessing the level of patient satisfaction with regard to the surgical efficacy of MIRP, perioperative and postoperative patient care, and quality of preoperative education. The following core competencies are addressed in this article: Interpersonal skills and communication, patient care, practice-based learning and improvement, professionalism, and systems-based practice. Republished with permission from: Stawicki SP, Schill KM, Flynn MB. Minimally invasive radioguided parathyroidectomy: Postoperative patient satisfaction survey. OPUS 12 Scientist 2007;1(2):31-35.

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.

Minimally Invasive Parathyroid Surgery, The Norman 20% Rule: Is It Valid?

The 20 per cent rule proposed by Norman established a guideline using radioactivity in the minimally invasive radioguided parathyroidectomy (MIRP) technique to localize and confirm removal of an abnormal parathyroid gland in patients with primary hyperparathyroidism. If radioactivity in the resected gland was at least 20 per cent of excision site/background radioactivity, the 20 per cent rule was satisfied. Patients meeting these criteria underwent unilateral MIRP without intraoperative parathyroid hormone assay or intraoperative frozen section. The study aim was to independently evaluate the 20 per cent rule in MIRP patients with primary hyperparathyroidism. Using the University of Louisville Parathyroid Database from January 1, 1999 to December 31, 2007, 216 MIRP patients with complete radioguided and postoperative management data were identified. The average percentage of ex vivo parathyroid gland radioactivity compared with excision site/background radioactivity was 107 per cent with a range from 14 to 388 per cent. For 99 per cent (196/198) radioactivity recorded from the excised gland was at least 20 per cent of radioactivity recorded from the excision site. Normocalcemia was documented in 98.5 per cent (195/198) at 12 month follow-up. Our data supports the 20 per cent rule in that in 99 per cent of MIRP patients the resected gland radioactivity was at least 20 per cent of excision site radioactivity allowing localization and confirmation of an overactive gland without intraoperative parathyroid hormone monitoring or tissue analysis.

CT-MIBI-SPECT Fusion Imaging Combined with Gamma Probe for Minimally Invasive Radioguided Parathyroidectomy (MIRP)

CT-MIBI-SPECT Fusion Imaging Combined with Gamma Probe for Minimally Invasive Radioguided Parathyroidectomy (MIRP)

The Benefits of an Interactive, Individualized Online Patient Pathway for Patients Undergoing Minimally Invasive Radioguided Parathyroidectomy: A Prospective, Double-Blinded, Randomized Clinical Trial

This study determined the usefulness of an interactive, individualized online patient pathway to patients undergoing elective operation for nonmalignant disease. An exploratory double-blind, prospective randomized controlled trial was established involving consecutive patients undergoing minimally invasive radioguided parathyroidectomy (MIRP). A total of 64 patients were randomly assigned to either a standard or an enhanced Web site (interactive with detailed, personalized timeline). Each patient completed validated Hospital Anxiety and Depression Scale questionnaires preoperatively and pain assessments and questionnaires concerning Web site usefulness postoperatively. All patients found their Web site useful, although patient satisfaction was significantly higher with the enhanced Web site in regard to overall impression as well as ease, organization, usefulness, and specificity of information. There were no significant differences in mean anxiety or pain scores, in analgesia requirements, or adequacy of informed consent. Providing education and information through a tailored Web server is viewed positively by patients.

Radioguided surgery of primary hyperparathyroidism in a population with a high prevalence of thyroid pathology

Patients with concomitant thyroid pathology are usually excluded from minimally invasive radioguided parathyroidectomy (MIRP). We assessed the value in these patients of the gamma probe, alone or in combination with other techniques, in MIRP and unilateral or bilateral approaches. We evaluated its performance in association with intraoperative determination of intact parathyroid hormone (ioPTHi) and preoperative (99m)Tc-MIBI dual phase scintigraphy. Included in the study were 87 patients with a diagnosis of primary hyperparathyroidism who underwent radioguided surgery. They were divided into two groups depending on the presence of concomitant thyroid pathology (TP group, 33 patients) or absence of concomitant thyroid pathology (NTP group, 54 patients). In the TP group, ioPTHi achieved the highest accuracy (90.9%), followed by the gamma probe (81.8%) and scintigraphy (69.7%). In the NTP group, the probe (94.4%) performed better than ioPTH and scintigraphy (both 85.2%). In the TP group, scintigraphy in combination with the gamma probe had a success rate of 90.9%, and 94% in combination with ioPTHi. The three techniques are applied together had a success rate of 97%. For all patients undergoing MIRP, the probe alone worked well, irrespective of the presence or absence of concomitant thyroid pathology. Patients with concomitant thyroid pathology should not be a priori excluded from a MIRP, as long as other adjuvant techniques (scintigraphy or ioPTHi) are used in conjunction with the gamma probe. In these patients, the probe can also be helpful in unilateral or bilateral surgery.

Success of Minimally Invasive Single-Gland Exploration Using the Quick Intraoperative Parathyroid Assay

Objective: Using accurate localization techniques and the quick intra-operative parathyroid assay (QPTH), surgery for primary hyperparathyroidism due to a solitary adenoma has moved from the traditional wide bilateral neck exploration to more limited approaches such as minimally invasive single-gland exploration (MISGE) and minimally invasive radio-guided parathyroidectomy (MIRP). This study investigated whether the MISGE could take the place of MIRP with the help of the QPTH.Design: From 2007 to 2009, 56 patients with primary hyperparathyroidism were studied. All patients were pre-opera-tively investigated by imaging techniques to improve the pre-operative determination of adenomas. Twenty-five patients were in the MIRP group and 31 in the MISGE group. QPTH was routinely measured; a 50% reduction in the QPTH level indicated complete excision.Results: There were no differences in the complication rates, surgical time, anaesthesia time or mean length of hospital stay between the groups. However, total hospital charges were more favourable in the MISGE group with a mean saving of $400 per case.Conclusion: This study demonstrates that with the additon of the QPTH, MISGE can be performed as a quick and reliable procedure in correct adenoma removal instead of MIRP. Moreover MISGE achieves the optimal time interval between injection and exploration, reduces the radiation exposure of both patient and surgeon, decreases the cost, and decreases usage of pre-operative imaging and intra-operative equipment.

Minimally invasive radioguided parathyroidectomy performed for primary hyperparathyroidism

Objective Parathyroid surgery is often challenging due to considerable variability in anatomy. Minimally invasive radioguided parathyroidectomy (MIRP) is a directed surgical approach that has been made possible by the advent of new imaging techniques, specifically sestamibi scanning. In this study, we review our experience and outcomes with MIRP in one of the largest case series reported in the literature. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Subjects were 305 patients who underwent MIRP in our institution between 1997 and 2007. Data including symptoms, preoperative and postoperative calcium levels, and PTH levels were collected. Analyses were performed using Excel AnalysisPak. Results MIRP in this series had a 100 percent rate of success in removing a hyperfunctional parathyroid gland. The mean preoperative calcium was 10.9 whereas the mean postoperative level was 9.8. There was a significant difference between preoperative and postoperative calcium levels (both ionized and total) ( P < 0.01). Mean preoperative and postoperative serum PTH levels were 138 and 50, respectively. PTH levels were therefore significantly lower postoperatively ( P < 0.01). Rapid PTH testing showed a similar pattern. There were no cases of recurrent laryngeal nerve palsy. Conclusion MIRP is an effective method for removal of image-localized hyperfunctional parathyroid glands.

Minimally invasive radioguided parathyroidectomy

Minimally invasive radioguided parathyroidectomy (MIRP) is a small incision, outpatient procedure which is directed to identifying and excising the offending parathyroid gland(s) which result in hyperparathyroidism. The technique can be replicated by well-trained surgeons and can result in consistent achievement of biochemical cures of hyperparathyroidism. The procedure is safe, efficient, and results in a high degree of patient satisfaction. This article will outline the indications for and application of the MIRP procedure. Minimally invasive radioguided parathyroidectomy (MIRP) is a small incision, outpatient procedure which is directed to identifying and excising the offending parathyroid gland(s) which result in hyperparathyroidism. The technique can be replicated by well-trained surgeons and can result in consistent achievement of biochemical cures of hyperparathyroidism. The procedure is safe, efficient, and results in a high degree of patient satisfaction. This article will outline the indications for and application of the MIRP procedure.

Optimization of Minimally Invasive Radio-Guided Parathyroidectomy: The Importance of Neck Ultrasonography and Intraoperative Parathyroid Hormone Assay

To determine whether close collaboration between a neck ultrasound-certified endocrinologist and a skilled endocrine surgeon can optimize minimally invasive radio-guided parathyroidectomy (MIRP) surgical outcomes. Outcome data were collected on patients with primary hyperparathyroidism whom we intended to treat with MIRP at the induction of anesthesia between October 1, 2005, and December 31, 2007. Patients underwent preoperative gamma camera sestamibi scanning (GCSS), intraoperative gamma probe sestamibi scanning (IOSS), and preoperative neck ultrasonography. Intraoperative parathyroid hormone (PTH) monitoring was performed. Postoperative surgical success was defined as a serum calcium concentration between 8.0 and 10.4 mg/dL within 4 weeks of surgery. During the study period, MIRP was planned for 46 patients. Of the 46 patients, 39 had preoperative neck ultrasonography; 7 underwent evaluation by an endocrinologist or internist who was not ultrasound certified and they therefore did not undergo preoperative ultrasonography. IOSS correctly identified 1 adenomatous gland in 38 of 46 patients (83%), while GCSS correctly localized 1 adenomatous gland in 30 of 46 patients (65%). In 11 GCSS-negative patients, IOSS identified the abnormal gland in 7 (64%), while ultrasonography identified the abnormal gland in 8 (73%). The surgical approach was converted to traditional parathyroidectomy in 3 patients. Every patient exhibited at least a 51% drop in intraoperative PTH levels with resection of the final adenoma; average decrement for the entire group was 79 +/- 8% from the highest baseline level. Forty-five patients (98%) demonstrated sustained normalization of serum calcium within several days of surgery. A collaborative endocrinology and surgical endocrine oncology practice arrangement, emphasizing careful preoperative physician-supervised neck ultrasonography and the use of intraoperative PTH measurement, optimizes MIRP outcomes.

Minimally Invasive Radioguided Parathyroidectomy

Objective Parathyroid surgery is often challenging due to considerable variability in anatomy. Minimally invasive radioguided parathyroidectomy (MIRP) is a surgical option that has been made possible by the advent of new imaging techniques, specifically Sestamibi scanning. In this study, we review our experience, methods, and outcomes with MIRP in one of the largest case series reported in the literature. Methods A retrospective chart review was performed on 365 patients who underwent MIRP between 1997 and 2007. Data including symptoms, pre- and postoperative calcium levels, and PTH levels were collected. Analyses were performed using Excel AnaylsisPak. Results Intraoperatively, an average of 20mCi Tc-99m was injected for Sestamibi scanning. The mean pre-op calcium was 10.9, whereas the mean post-op level was 9.8. There was a significant difference between pre-op and post-op calcium levels (both ionized and total) (p&lt;.01). Mean pre- and post-op PTH levels were 277 and 46 respectively. Rapid PTH levels were therefore significantly lower post-operatively (p&lt;.01). Conclusions MIRP is an effective method for removal of parathyroid adenomas. The benefits of MIRP include more accurate localization, shorter operative and recovery time, a shorter hospital stay, and better cosmetic results.

Surgeon-Performed Ultrasonography as an Adjunct to Minimally Invasive Radio-Guided Parathyroidectomy in 100 Consecutive Patients with Primary Hyperparathyroidism

To examine whether surgeon-performed ultrasonography (SPU) in patients with primary hyperparathyroidism and negative preoperative sestamibi scans improves adenoma localization, increases the directed unilateral exploration rate, and reduces operative time and length of hospital stay. We retrospectively analyzed 100 consecutive patients with primary hyperparathyroidism encountered between January 1, 2005, and March 31, 2007. Patients underwent preoperative sestamibi scanning and SPU. Minimally invasive radio-guided parathyroidectomy (MIRP) was performed on patients with positive sestamibi scans. In sestamibi scan-negative patients, unilateral exploration was performed with removal of the adenoma, which was submitted for frozen section. Accuracy, operative time, hospital length of stay, mortality, and morbidity were assessed. Of 100 patients, 79 had positive sestamibi scans and underwent MIRP. Twenty-one had negative sestamibi scans, 18 of whom underwent SPU. Parathyroid adenoma was localized in 17 (94%) of the 18 patients. Operative time and length of hospital stay were not significantly different between sestamibi scan-negative patients who underwent SPU with directed unilateral exploration and sestamibi scan-positive patients who underwent MIRP (operative time: 46 minutes vs 38 minutes, respectively; length of hospital stay: 17.8 hours vs 16.1 hours, respectively). Operative time and length of hospital stay were significantly shorter in sestamibi scan-negative patients who underwent SPU with directed unilateral exploration and in patients who underwent MIRP than in historical controls who underwent 4-gland exploration (P<.01 for both outcomes). No morbidity or mortality was documented. SPU localizes 94% of adenomas in sestamibi scan-negative patients, which allows for directed unilateral exploration and results in operative time and length of hospital stay not significantly different from patients undergoing MIRP.

Diminished Dose Minimally Invasive Radioguided Parathyroidectomy: A Case for Radioguidance

Minimally invasive radioguided parathyroidectomy (MIRP) has been established as an alternative to bilateral neck exploration (BNE) for primary hyperparathyroidism. We investigate whether a diminished dose of technetium-99m sestamibi gives similar results to the standard dose. One hundred one patients were offered MIRP or diminished-dose MIRP (ddMIRP). Patients received intravenous Tc-99m sestamibi at a dose of either 25 mCi 1.5 hours or 5 mCi 1 hour preoperatively. The procedure was terminated when the 20 per cent rule was satisfied. All tissue was confirmed to be parathyroid tissue by frozen section analysis. In addition, intraoperative parathyroid hormone levels were measured in a majority of patients. Patients who failed IOM underwent BNE. Frozen section analysis and intraoperative parathyroid hormone monitoring were also performed in the BNEs. Postoperatively, serum calcium levels were measured at 1 week and 6 months. Fifteen per cent of patients were male and 85 per cent were female. The median age was 63 years (range, 25-89 years). The first 58 patients had the standard dose of 25 mCi, whereas 43 patients had ddMIRP. Six patients (10%) failed intraoperative mapping in the MIRP group and were found to have single-gland disease. Five patients (12%) failed intraoperative mapping in the ddMIRP group. However, two patients were identified to have multigland disease making the true failure rate of intraoperative mapping 7 per cent (three patients). Median operative times for MIRP, ddMIRP, and BNE were 40 minutes, 46 minutes, and 105 minutes, respectively. The 20 per cent rule was satisfied in 96 per cent of patients undergoing MIRP and 98 per cent of patients undergoing ddMIRP. Frozen section analysis and intraoperative parathyroid hormone monitoring did not result in a change in management. Median follow up was 193 days and serum calcium levels at 6 months were normal. Diminished-dose MIRP is a feasible alternative to standard-dose MIRP without compromising surgical outcomes.

Minimally invasive radio-guided parathyroidectomy on a group of 452 primary hyperparathyroid patients

of this study was to investigate the efficacy of minimally invasive radio-guided parathyroidectomy (MIRP) in primary hyperparathyroid (PHPT) patients. 452 consecutive PHPT patients were evaluated. Inclusion criteria for MIRP were (a) evidence at scintigraphy of a solitary parathyroid adenoma (PA); (b) a clear sestamibi uptake in the PA; (c) the absence of concomitant thyroid nodules; (d) no history of familial HPT or MEN; (e) no history of previous neck irradiation. Intra-operative protocol consisted of the injection of a low 37 MBq sestamibi dose in the operating suite 10 min before surgery. A hand held 11-mm collimated gamma probe was used. Quick PTH (QPTH) was routinely measured. 344 out of the 452 patients met the inclusion criteria, and MIRP was successfully performed in 321 of them (93.3%). No major intra-operative complication was recorded. MIRP required a mean operative time of 32 min, and a mean hospital stay of 1.2 d. The parathyroid to background ratio (P/B) calculated by the probe was well correlated with the P/B calculated by sestamibi SPECT (r = 0.91; p < 0.01), while no significant correlation was found between the probe-calculated P/B and the P/B calculated at planar sestamibi scan. In our experience: a) an accurate preoperative localising imaging protocol based on planar and SPECT sestamibi scan, and neck US is effective in selecting PHPT patients for MIRP, b) the P/B calculated by sestamibi SPECT seems able to predict the probe-calculated P/B more accurately than the P/B calculated at planar scan, c) the low 37 MBq sestamibi dose protocol proved to be a safe and effective approach to perform MIRP.

Minimally Invasive Radio-Guided Parathyroidectomy in 152 Consecutive Patients with Primary Hyperparathyroidism

To examine the results of minimally invasive radio-guided parathyroidectomy (MIRP) in the treatment of patients with primary hyperparathyroidism, including factors associated with negative technetium-labeled sestamibi scanning. We retrospectively analyzed the findings in a group of 152 consecutive patients encountered during the period 2001 through 2004. The overall accuracy of preoperative sestamibi scanning was assessed, and the success of MIRP was determined on the basis of operative time, duration of hospital stay, and rate of complications. All 152 patients underwent preoperative sestamibi scanning; 118 (78%) had positive scans and were treated with MIRP, whereas 34 (22%) had negative scans and underwent traditional neck explorations. Patients with negative sestamibi scans had 5 times the incidence of concomitant thyroid disease in comparison with those who had positive sestamibi scans (P<0.01), and they had higher rates of parathyroid hyperplasia (26% versus 0%; P<0.01). In comparison with traditional neck dissection, MIRP-treated patients had shorter operative times (38 minutes versus 86 minutes; P<0.01) and shorter hospital stays (0.67 day versus 1.09 days; P<0.01). Among the MIRP-treated patients, 67% were discharged the same day as performance of the outpatient surgical procedure. Correction of hypercalcemia was accomplished in 116 of 118 patients (98%) who underwent MIRP. Complications in the MIRP group were low, including 1 postoperative hemorrhage. No cases of recurrent laryngeal nerve injury occurred. There were 2 false-positive sestamibi scans (1.3%). Parathyroid hyperplasia and concomitant thyroid pathologic conditions are associated with negative preoperative sestamibi scans. MIRP is applicable in 78% of patients with primary hyperparathyroidism and is a safe, effective operation that results in shorter surgical time, reduced hospital stay, and minimal complications.