Open Neck Exploration Research Articles

Comparison Between Open and Ultrasonography Guided Venous Access Ports in Children with Malignancy

Background: Long-term central venous access is used in children for various reasons specially for delivering chemotherapy. Since vessels in children have smaller diameters, they are more prone to injury and complications such as thrombosis. Different methods are used for implantation of port-a-cath in children. We aimed to compare the complications of insertion of central venous access ports between two methods of open and ultrasound (US) guided. Methods: All children who were referred to pediatric surgery department of a children hospital from April 2018 to March 2020 for implantation of port-a-cath were included. Right jugular vein was the target vein and patients were randomly divided between two methods of insertion of open lateral neck exploration and ultrasound real-time guided percutaneous insertion and the reservoir was fixed in subpectoral fascia pouch. All open cases in which jugular vein was ligated proximally were excluded. Patients were followed up for early and late complications two days and one week later by the surgical team, then monthly by a trained nurse and were referred to the surgeon if any complication or malfunction had occurred for at least 6 months. Results: We included 76 patients (21 girls and 55 boys) less than 18 years of age: 24 patients with ultrasound guided method (1-13 years, median 3 years) and 52 patients with open exploration method (4 months-17 years, median 6 years). We observed no statistically significant difference between two groups with respect to sex, underlying disease, and complications. Most patients had hematological malignancies including ALL (52.9%), AML (19.1%) and the rest had solid organ malignancies. Early complications were observed in 2 (3.8%) in the open and 1 (4.2%) in the US- guided group (P=1). Late complications were observed in 9 (17.3%) patients in the open group and 1 (4.2%) in the US guided group. Infection was observed in 9.6% and malfunction in 5.8% of the open group leading to earlier removal of the catheter. There was not any complication indicative of infection in the US-guided group. Conclusion: US-guided method can be suggested for routine use as a safe method of insertion of port venous access in children.

An essential practice summary of the new EANM guidelines for parathyroid imaging.

Parathyroid imaging is essential for the detection and localization of hyperfunctioning parathyroid tissue in patients with primary hyperparathyroidism (pHPT). Surgical treatment of pHPT mainly consists of minimally invasive parathyroidectomy (MIP), as a single adenoma represents the most common cause of this endocrine disorder. Successful surgery requires an experienced surgeon and relies on the correct preoperative detection and localization of hyperfunctioning parathyroid glands. Failure to preoperatively identify the culprit parathyroid gland by imaging may entail a more invasive surgical approach, including bilateral open neck exploration, with higher morbidity compared to minimally invasive parathyroidectomy. Parathyroid imaging may be also useful before surgery in case of secondary hyperparathyroidism (sHPT) or hereditary disorders (MEN 1, 2, 4) as it enables correct localization of typically located parathyroid glands, detection of ectopic as well as supernumerary glands. It is now accepted by most surgeons experienced in parathyroid surgery that preoperative imaging plays a key role in their patients' management. Recently, the European Association of Nuclear Medicine (EANM) issued an updated version of its Guidelines on parathyroid imaging. Its aim is to precise the role and the advantages and drawbacks of the various imaging modalities proposed or well established in the preoperative imaging strategy. It also aims to favor high performance in indicating, performing, and interpreting those examinations. The objective of the present article is to offer a summary of those recent EANM Guidelines and their originality among other Guidelines in this domain issued by societies of nuclear medicine physicians or other disciplines.

Focused parathyroidectomy without intraoperative parathyroid hormone measurement in primary hyperparathyroidism: Still a valid approach?

BackgroundConcern regarding suboptimal cure rates has led to some endocrine surgery units abandoning focused parathyroidectomy for primary hyperparathyroidism in favor of open bilateral neck exploration or making intraoperative parathyroid hormone estimation mandatory in focused parathyroidectomy. This study explores whether focused parathyroidectomy for radiologically localized primary hyperparathyroidism without intraoperative parathyroid hormone is still a valid approach. MethodsRetrospective review of a tertiary referral endocrine surgery unit database. All parathyroidectomies for primary hyperparathyroidism over 6 years (2013–2019) were included. Lithium-induced hyperparathyroidism, reoperations, familial disease, and concurrent thyroid surgery were excluded. Characteristics and outcomes for focused parathyroidectomy and open bilateral neck exploration were compared by intention-to-treat and treatment delivered. Persistence and recurrence, conversions and complications were analyzed as endpoints. ResultsA total of 2,828 parathyroidectomies were performed and 2,421 analyzed. By intention to treat there were 1,409 focused parathyroidectomies and 1,012 open bilateral neck explorations. Focused parathyroidectomy patients were younger: 63 vs 66 years (P < .01); however, gender (77%, 79% female), preoperative peak serum calcium (2.72, 2.70 mmol/L [P = .23]), and serum parathyroid hormone (11.5, 11.0 pmol/L [P = .52]) did not differ. In total, 229 (16.3%) focused parathyroidectomies were converted to open bilateral neck exploration. Multiple gland disease was confirmed in 54.5% of converted patients. Median follow-up was 41 months (3–60 months). Persistence or recurrence requiring reoperation totaled 2.2% and did not differ between focused parathyroidectomy and open bilateral neck exploration in either intention to treat or final treatment analyses. Complications occurred in 1.2% of focused parathyroidectomy and 3.2% open bilateral neck exploration (P < .01). ConclusionsIn experienced hands and with a ready-selective approach to conversion, focused parathyroidectomy based on concordant imaging and without intraoperative parathyroid hormone may deliver equivalent cure rates to open bilateral neck exploration with significantly fewer complications. Focused parathyroidectomy without intraoperative parathyroid hormone should therefore be maintained in the endocrine surgeon’s armamentarium.

Suspension Microesophagoscopy for Foreign Body Removal in Children.

View Video S1 Laryngoscope, 131:E2066–E2068, 2021

SAT-232 Is There a Role for Genetic Testing in Guiding the Management of Primary Hyperparathyroidism in Pregnancy?

Introduction Primary hyperparathyroidism (PHPT) in pregnancy is rare, with a reported incidence of <1%. It is associated with serious maternal and foetal complications, and is genetically determined in ~10% of cases. Confirming a genetic diagnosis can guide management of inherited PHPT, and enables screening for syndrome-related diseases. This case series highlights the role of genetic testing in the tailored management of patients with PHPT in pregnancy. Clinical cases Case 1 is a 20 year old female who was diagnosed with PHPT at 5 weeks gestation after presentation with nausea. She was hypercalcaemic (2.78 mmol/L at diagnosis; 2.98 mmol/L pre-parathyroidectomy), had negative neck ultrasonography and a MEN1 mutation (exon 2, c.236_237del, p.(Pro79fs)) on genetic testing in pregnancy. After initial management with oral and IV rehydration, her severe symptomatic hypercalcaemia required treatment with open neck exploration and a 3 gland parathyroidectomy in the 2nd trimester. The standard surgical approach of a 3.5 gland parathyroidectomy was avoided due to the risk of inducing hypoparathyroidism. Intra-operative PTH dropped 53.8% post 3 gland parathyroidectomy. Parathyroid hyperplasia on histology was consistent with the diagnosis of MEN1 syndrome. The patient’s symptoms resolved post-operatively and foetal investigations are normal at 28 weeks gestation. She is receiving close obstetric follow-up including 3-weekly foetal growth scans due to the increased risk of IUGR. She was counseled on her increased risk of pancreatic and pituitary tumours and her 1st degree relatives are undergoing genetic screening. Case 2 is a 40 year old female with a known diagnosis of PHPT who was awaiting parathyroidectomy prior to pregnancy. She was hypercalcaemic (2.78 mmol/L at 7 weeks; 2.99 mmol/L pre-parathyroidectomy), and had a lower left parathyroid adenoma on ultrasound and pre-pregnancy SPECT-CT. Genetic testing was not performed as she was 40 at diagnosis and had no contributory family history. After failure of conservative management, parathyroidectomy of the left superior parathyroid gland was performed in the 2nd trimester. Histology results confirmed a left inferior parathyroid adenoma, concordant with the radiological findings. Her symptoms improved post-operatively; she is receiving close obstetric follow-up. Clinical lessons Genetic testing enables the management of PHPT to be tailored appropriately. It can better inform the surgical approach; including the need for subtotal parathyroidectomy and bilateral neck exploration in those cases at risk of multiple parathyroid gland disease, as demonstrated in our case with MEN1. Finally this case series demonstrates that surgical management of PHPT should be considered for select cases in pregnancy and thus far no maternal or foetal complications have arisen in these featured cases following surgical intervention.

Is minimally invasive parathyroid surgery an option for patients with gestational primary hyperparathyroidism?

BackgroundGestational primary hyperparathyroidism is associated with serious maternal and neonatal complications, which require prompt surgical treatment. Minimally invasive parathyroidectomy reduces pain, improves cosmesis and may achieve cure rates comparable to traditional open bilateral neck exploration. We report the clinical course of a woman with newly diagnosed gestational primary hyperparathyroidism and discuss the decision making behind the choice of video-assisted minimally invasive parathyroidectomy, amongst the other minimally invasive parathyroidectomy techniques available.Case presentationA 38-years-old pregnant woman at 9 weeks of gestation, with severe hyperemesis and hypercalcaemia secondary to gestational primary hyperparathyroidism (ionised calcium 1.28 mmol/l) was referred for surgery. Ultrasound examination of her neck identified 2 suspicious parathyroid enlargements. In view of pregnancy, a radioisotope Sestamibi parathyroid scan was not performed. Bilateral four-gland exploration was therefore deemed necessary to guarantee cure. This was performed with video-assisted minimally invasive parathyroidectomy, which relies on a single 15 mm central incision with external retraction and endoscopic magnification, allowing bilateral neck exploration.Surgery was performed at 23 weeks of gestation. Four glands were identified in orthotopic positions of which three had normal appearance. The fourth was a right superior parathyroid adenoma of 756 mg. Ionized calcium (1.12 mmol/l) and PTH (0.9 pmol/l) normalised postoperatively. Patient was discharged on the second postoperative day, needing no pain relief. Cosmetic result was excellent. Her pregnancy progressed normally and she delivered a healthy baby.ConclusionVideo-assisted minimally invasive parathyroidectomy allows bilateral four-gland exploration, and is an optimal technique to treat gestational primary hyperparathyroidism. This procedure removes the need for radiation exposure, reduces pain, improves cosmesis and may achieve cure rates comparable to traditional open bilateral neck exploration.

Video‐Assisted Bilateral Neck Exploration in Patients with Primary Hyperparathyroidism and Failed Localization Studies

In primary hyperparathyroidism (pHPT) positive preoperative localization studies are accepted as a precondition for applying minimally invasive surgical techniques. Without localization, open bilateral neck exploration (BNE) is considered the standard option. The present study analyzes the feasibility and effectiveness of minimally invasive video-assisted BNE in patients with pHPT and negative or discordant localization studies. From a prospective series of 380 minimally invasive video-assisted parathyroidectomies (MIVAP) performed in 367 patients for pHPT (1999-2009), 68 patients (10 male, 58 female; mean age: 58 years) were selected. These patients had failed localization studies and underwent BNE with the MIVAP technique. Operative time, complications, conversions to open technique, and cure rate were determined. Mean operative time was 52 +/- 26 min (range: 20-180 min). MIVAP with BNE was successfully completed in 66 (97%) patients with two conversions to open technique. Recurrent laryngeal nerve palsy occurred in one patient. Biochemical cure was achieved in 67 patients (98.5%), in 65 patients (95.5%) after the first operation and in two more patients by video-assisted re-exploration on the first postoperative day. One patient remained with persistent disease even after repeated open BNE. In experienced hands, video-assisted BNE with the MIVAP technique, for pHPT and failed localization studies, is feasible, safe, and gives results equivalent to the conventional open technique.

Degenerative Thyroid Cartilage Cysts as a Cause of Hoarseness

Cysts located in the thyroid cartilage proper are rare. A literature review identified only 4 cases. 1-4 Three of the cysts were lined by respiratory epithelium 2-4 and were thought 4cases. 1-4 Three of the cysts were lined by respiratory epithelium 2-4 and were thought to be the result of mucosal herniation through a congenital foramen. Burgess and Yim 1 reported a case of a true degenerative thyroid cartilage cyst. We describe 2 patients with degenerative thyroid cartilage cysts who presented with hoarseness and a history of neck trauma. In both cases, findings of an endoscopic biopsy were consistent with benign degenerative cartilage. We compare our surgical management in these cases-an open neck exploration with extirpation of the cyst in the first case, and an endoscopic marsupialization of the cyst in the second case-and discuss why we would favor the latter approach in a future case. We also briefly discuss the potential pathogenesis of these degenerative cysts.

Intraoperative Parathyroid Hormone Measurement During Minimally Invasive Parathyroidectomy: Does it “Value-Add” to Decision-Making?

Routine use of intraoperative parathyroid hormone levels (IOPTH) during minimally invasive parathyroidectomy (MIP) has been challenged simply because the test works best when needed least, ie, once a solitary adenoma has been resected, and is less accurate with multiple gland disease. It has also been shown not to be cost-effective. The aim of this study was to determine if IOPTH "value-added" to decision-making during MIP. The study group comprised 100 consecutive patients with sporadic hyperparathyroidism and an unequivocally positive sestamibi scan who were undergoing MIP in our unit from June 2004 until October 2005, from whom blood was collected for parathyroid hormone measurement preoperatively, preexcision, and at 10 and 30 minutes postremoval. No action was taken on the results of the test. Ninety-eight patients were cured by MIP alone. Two patients had persistent hyperparathyroidism, one of whom was cured with subsequent open reexploration and removal of a second adenoma, and the other remains hypercalcemic despite additional open neck exploration. IOPTH in both patients failed to fall in retrospect, only the first would have been cured by conversion at the time of operation. The value-added accuracy of IOPTH was really only 1%. In an additional nine patients, IOPTH at 10 minutes had failed to fall by > 50% from the highest level, those patients (9%) would have been subjected to an unnecessary conversion on the basis of a false-negative result. IOPTH does not substantially value-add to decision-making during MIP. Most patients will be cured with appropriate selection for MIP based on preoperative localization studies.

Minimal incision parathyroidectomy: cure, cosmesis, and cost.

The goals of operative treatment of primary hyperparathyroidism are (1) cure; (2) minimal invasion; and (3) cost-effectiveness. The optimal strategy is controversial. Retrospective review of was undertaken 66 previously unoperated patients having minimal-incision, full-neck exploration by one surgeon over 29 months. A group of 51 women and 15 men had open full neck exploration under general anesthesia through a small (25-40 mm) incision using specifically selected instruments; patients remained hospitalized overnight. Preoperative sestamibi scans were obtained before referral for 17 patients: 11 had localized disease, and 6 did not (65% sensitivity). Four parathyroid glands were identified in 98% of patients; intraoperative frozen section was used selectively on a median of one gland per patient. About 76% of patients had single-gland disease, 6% had two-gland disease, and 18% had four-gland hyperplasia. One patient had four normal cervical parathyroid glands and an aortopulmonary window parathyroid adenoma resected at thoracotomy 1 week later; preoperative sestamibi scans failed to localize his disease. There were no nerve injuries and a 98% cure rate after initial cervical exploration. Excluding the cost of the sestamibi scans, there was no difference between those who had preoperative localization and those who did not; 60% of hospital costs were operating room time-related. Minimal-incision parathyroidectomy is effective for curing hyperparathyroidism and has excellent cosmetic results with negligible scar. Preoperative sestamibi scanning had no impact on cure or treatment costs. Strategies to improve cost-effectiveness must address the substantial costs of anesthesia and operating room services.

Complications of foreign bodies in the esophagus

Major complications of foreign bodies in the esophagus carry significant morbidity and mortality risks. A retrospective case control study was performed to assess the factors associated with major complications. In total, 273 patients seen within a 7-year period were divided into 2 groups; 253 had no or minor complications, and 20 had major complications. Age, sex, duration of the foreign body, total white cell count (TWC), and nature and site of the foreign body were analyzed in the 2 groups. The major complication rate was 7.3%. Duration of the foreign body and TWC were the only statistically significant factors associated with major complications. Six patients required open neck exploration, 1 had an open thoracotomy, and 13 were treated by endoscopic removal. There were 2 deaths. Given the significant morbidity and mortality risks, we conclude that patients with a prolonged history of a foreign body in the esophagus and a raised TWC should be treated urgently. (Otolaryngol Head Neck Surg 2000;123:613-6.)

Surgery for primary hyperparathyroidism

Abstract Background Routine open bilateral neck exploration without preoperative localization or intraoperative parathyroid hormone assay has been repeatedly challenged over recent years as the optimal surgical strategy for the treatment of idiopathic primary hyperparathyroidism (HPT). This has prompted a review of the Oxford experience with adherence to traditional practice, questioning whether results could have been improved upon or cost justified by targeting unilateral exploration and immediate hormonal assay. Methods The records of all patients undergoing first-time surgery for idiopathic primary HPT over a 32-year period have been reviewed. In every patient bilateral neck exploration was performed and an attempt made to identify all four parathyroid glands. All macroscopically enlarged glands were removed and the operating time recorded. A successful outcome was defined as normocalcaemia without any therapy at 3-month review after surgery, with good cosmesis. Results Between 1968 and 2000, 688 patients were operated upon; a total of 2520 parathyroids were identified, of which 968 were abnormal. A single adenoma was found in 542 patients (79 per cent) (eight in a fifth gland), multiple gland disease in 120 (17 per cent) and parathyroid carcinoma in ten (1 per cent). Mean operating time for all patients was 65 min, including those requiring thyroid lobectomy and cervical thymectomy. When a single adenoma was found in a normal anatomical site the mean operating time was 35 min. Some 672 patients (98 per cent) were treated successfully. Conclusion Open bilateral neck exploration and removal of all macroscopically enlarged parathyroid glands resulted in a high level of success in this series. No evidence has been found in a worldwide literature search to suggest that expensive high technology would have provided greater benefit for the group as a whole.

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.

The value of computed tomography scan versus an explorative surgical approach for removal of squamous cell carcinoma of the posterior pharyngeal wall

The prevertebral fascia plays a key role in surgery of posterior pharyngeal wall tumors. Invasion of the prevertebral muscles determines the irresectability of the tumor and accurate diagnosis of invasion posteriorly is a prerequisite for major ablative surgery. A retrospective study was performed to define the value of CT scanning versus open neck exploration with regard to the resectability of posterior pharyngeal wall carcinoma. The predictive value of preoperative CT scans was assessed and compared with the outcome of open neck exploration and resectability of the primary tumor, using the final histopathology report as a gold standard. Nineteen patients with 20 tumors were included in this study. Overall the CT scan was correct concerning prevertebral muscle status in 4 out of 20 (20%), whereas open neck exploration was correct in 18 tumors (90%). The predictive value of a suspicious CT scan in determining prevertebral muscle invasion is extremely low in this study. Open neck exploration seems to be superior for determining resectability of posterior wall carcinoma.

Evaluation of Prevertebral Muscle Invasion by Squamous Cell Carcinoma: Can Computed Tomography Replace Open Neck Exploration?

To compare computed tomography (CT) with open neck exploration in determining prevertebral invasion by squamous cell carcinoma of the oropharynx or hypopharynx. Retrospective analysis using the findings at open neck exploration and results of histopathologic studies as the criterion standards. Tertiary care referral center. Twenty-nine of 40 patients with advanced squamous cell carcinoma of the oropharynx or hypopharynx treated between January 1, 1986, and December 31, 1994, were selected for analysis based on CT findings of posterolateral extension of the primary tumor placing the prevertebral muscle (PVM) at risk. All study patients had no previous therapy and underwent neck exploration to determine resectability. Overall accuracy of CT in predicting PVM status was 55.2%. The sensitivity of preoperative CT for PVM invasion was 50%; the specificity was 61%. Using an estimate of 21% for the prevalence of PVM invasion, the predictive value of a positive CT scan was 0.254 and the predictive value of a negative CT scan was 0.821. Open neck exploration correctly predicted PVM status in all cases. Open neck exploration is superior to CT to evaluate possible PVM invasion by squamous cell carcinoma of the oropharynx or hypopharynx. The predictive value of a negative CT scan for PVM invasion is high, so it may be useful in treatment planning. Patients with advanced squamous cell carcinoma of the oropharynx or hypopharynx at risk for PVM invasion who are otherwise surgical candidates should be considered for open neck exploration to determine resectability most accurately.

Focal Myositis: A New Cause for the Pediatric Neck Mass

Focal myositis is an inflammatory pseudotumor of skeletal muscle that may involve the head and neck. It can closely mimic either a neoplastic or infectious process. We present the case of a 7-year-old boy with a 2-week history of a painful, unilateral neck swelling, fever, and torticollis. He failed to respond to antibiotic therapy and required an open neck exploration. An incisional biopsy of the indurated, inflammatory tissue adherent to his sternocleidomastoid muscle showed focal myositis. Focal myositis is an unusual, but important possibility in the differential diagnosis of any neck mass and especially one in a child. Although its cause is unknown, it is a self-limited disease and neither excisional biopsy nor radical resection is justified.