Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: A prospective randomized trial

Management of surgical diseases of Primary Hyperparathyroidism: indications of the United Italian Society of Endocrine Surgery (SIUEC)

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in parathyroid surgery published in 2014, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 12 members of the SIUEC highly trained and experienced in thyroid and parathyroid surgery. The main topics concern diagnostic test and localization studies, mode of admission and waiting time, therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications), hospital discharge and patient information, outpatient care and follow-up, outpatient initial management of patients with pHPT.

Minimally invasive video-assisted parathyroidectomy in dogs: Technique description and feasibility study

OBJECTIVE

To describe a minimally invasive approach to the parathyroid gland for the treatment of primary hyperparathyroidism.

STUDY DESIGN

Surgical technique description and clinical case report.

ANIMALS

Five canine cadavers and 5 client-owned dogs with primary hyperparathyroidism.

METHODS

A surgical technique for minimally invasive video-assisted parathyroidectomy (MIVAP), described for humans, was adapted for dogs. With the dog in dorsal recumbency, a 15 mm incision was made on the midline, 1 finger width caudal to the cricoid cartilage of the larynx. A 5 mm 30° rigid endoscope was inserted into the peritracheal space with the aid of a blunt suction dissector, and fine elevators. The parathyroid was subsequently removed using electrocautery and blunt and sharp dissection. The technique was refined in 5 cadaver dogs to assess feasibility, and was subsequently performed in 5 clinical cases.

RESULTS

A minimally invasive approach to the parathyroid gland was possible and allowed successful removal of a parathyroid mass in 5 dogs without complication. The use of fluid ingress was trialed in 1 cadaver and not found to be helpful. The use of a blunt suction dissector greatly facilitated dissection of the peritracheal space.

CONCLUSION

Minimally invasive video-assisted parathyroidectomy is feasible in dogs and was not associated with complications in 5 clinical cases.

CLINICAL SIGNIFICANCE

Minimally invasive techniques tend to reduce morbidity and are popular with pet owners. This study demonstrates that a minimally invasive technique may be considered for parathyroidectomy in dogs.

The role of Rapid Intraoperative Parathyroid Hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder. In the last few decades, the introduction of Rapid Intraoperative Parathyroid Hormone (ioPTH) monitoring has allowed to ensurance of the excision of all hyperfunctioning parathyroid tissues, reducing the risks of persistent and recurrent PHPT. However, the use of ioPTH is still debated among endocrine surgeons.

MATERIAL AND METHODS

The objective of this systematic review and meta-analysis was to assess if ioPTH monitoring is able to reduce the incidence of persistent or recurrent PHPT. A systematic literature search was performed using PubMed, Scopus, ISI-Web of Science and Cochrane Library Database. Prospective and retrospective studies addressing the efficacy of ioPTH monitoring were included in the systematic review and meta-analysis. The random-effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated.

RESULTS

A total of 28 studies with 13,323 patients were included in the quantitative analysis. The incidence of operative failure was 3.2% in the case group and 5.8% in the control group. After excluding three outlier studies, the quantitative analysis revealed that ioPTH reduced significantly the incidence of postoperative persistent or recurrent PHPT. (Risk Difference = -0.02; CI = -0.03, -0.01; p < 0.001). There was no evidence of heterogeneity among the studies (Q = 19.92, p = 0.70; I² = 0%). The analysis of several continuous moderators revealed that the effectiveness of ioPTH was larger in studies with lower preoperative serum calcium values and higher incidences of multiple gland disease.

CONCLUSION

ioPTH monitoring is effective in reducing the incidence of persistent and recurrent PHPT. Its routine use should be suggested in the next guidelines regarding management of PHPT.

Minimally invasive parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IOPTH) and preoperative imaging versus bilateral neck exploration for primary hyperparathyroidism in adults

BACKGROUND

Bilateral neck exploration (BNE) is the traditional approach to sporadic primary hyperparathyroidism. With the availability of the preoperative imaging techniques and intraoperative parathyroid hormone assays, minimally invasive parathyroidectomy (MIP) is fast becoming the favoured surgical approach.

OBJECTIVES

To assess the effects of minimally invasive parathyroidectomy (MIP) guided by preoperative imaging and intraoperative parathyroid hormone monitoring versus bilateral neck exploration (BNE) for the surgical management of primary hyperparathyroidism.

SEARCH METHODS

We searched CENTRAL, MEDLINE, WHO ICTRP and ClinicalTrials.gov. The date of the last search of all databases was 21 October 2019. There were no language restrictions applied.

SELECTION CRITERIA

We included randomised controlled trials comparing MIP to BNE for the treatment of sporadic primary hyperparathyroidism in persons undergoing surgery for the first time.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Two review authors independently screened for inclusion, extracted data and carried out risk of bias assessment. The content expert senior author resolved conflicts. We assessed studies for overall certainty of the evidence using the GRADE instrument. We conducted meta-analyses using a random-effects model and performed statistical analyses according to the guidelines in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We identified five eligible studies, all conducted in European university hospitals. They included 266 adults, 136 participants were randomised to MIP and 130 participants to BNE. Data were available for all participants post-surgery up to one year, with the exception of missing data for two participants in the MIP group and for one participant in the BNE group at one year. Nine participants in the MIP group and 11 participants in the BNE group had missing data at five years. No study had a low risk of bias in all risk of bias domains. The risk ratio (RR) for success rate (eucalcaemia) at six months in the MIP group compared to the BNE group was 0.98 (95% confidence interval (CI) 0.94 to 1.03; P = 0.43; 5 studies, 266 participants; very low-certainty evidence). A total of 132/136 (97.1%) participants in the MIP group compared with 129/130 (99.2%) participants in the BNE group were judged as operative success. At five years, the RR was 0.94 (95% CI 0.83 to 1.08; P = 0.38; 1 study, 77 participants; very low-certainty evidence). A total of 34/38 (89.5%) participants in the MIP group compared with 37/39 (94.9%) participants in the BNE group were judged as operative success. The RR for the total incidence of perioperative adverse events was 0.50, in favour of MIP (95% CI 0.33 to 0.76; P = 0.001; 5 studies, 236 participants; low-certainty evidence). Perioperative adverse events occurred in 23/136 (16.9%) participants in the MIP group compared with 44/130 (33.9%) participants in the BNE group. The 95% prediction interval ranged between 0.25 and 0.99. These adverse events included symptomatic hypocalcaemia, vocal cord palsy, bleeding, fever and infection. Fifteen of 104 (14.4%) participants experienced symptomatic hypocalcaemia in the MIP group compared with 26/98 (26.5%) participants in the BNE group. The RR for this event comparing MIP with BNE at two days was 0.54 (95% CI 0.32 to 0.92; P = 0.02; 4 studies, 202 participants). Statistical significance was lost in sensitivity analyses, with a 95% prediction interval ranging between 0.17 and 1.74. Five out of 133 (3.8%) participants in the MIP group experienced vocal cord paralysis compared with 2/128 (1.6%) participants in the BNE group. The RR for this event was 1.87 (95% CI 0.47 to 7.51; P = 0.38; 5 studies, 261 participants). The 95% prediction interval ranged between 0.20 and 17.87. The effect on all-cause mortality was not explicitly reported and could not be adequately assessed (very low-certainty evidence). There was no clear difference for health-related quality of life between the treatment groups in two studies, but studies did not report numerical data (very low-certainty evidence). There was a possible treatment benefit for MIP compared to BNE in terms of cosmetic satisfaction (very low-certainty evidence). The mean difference (MD) for duration of surgery comparing BNE with MIP was in favour of the MIP group (-18 minutes, 95% CI -31 to -6; P = 0.004; 3 studies, 171 participants; very low-certainty evidence). The 95% prediction interval ranged between -162 minutes and 126 minutes. The studies did not report length of hospital stay. Four studies reported intraoperative conversion rate from MIP to open procedure information. Out of 115 included participants, there were 24 incidences of conversion, amounting to a conversion rate of 20.8%.

AUTHORS' CONCLUSIONS

The success rates of MIP and BNE at six months were comparable. There were similar results at five years, but these were only based on one study. The incidence of perioperative symptomatic hypocalcaemia was lower in the MIP compared to the BNE group, whereas the incidence of vocal cord paralysis tended to be higher. Our systematic review did not provide clear evidence for the superiority of MIP over BNE. However, it was limited by low-certainty to very low-certainty evidence.

Endoscopic parathyroidectomy: a retrospective review of 27 cases

BACKGROUND

Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP).

METHODS

Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection.

RESULTS

Eleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104 min and 34 mL in trans-vestibular approach, respectively, while they were 47 min and 68 mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids.

CONCLUSION

Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.

Pursuing the second ipsilateral gland during minimally invasive video-assisted parathyroidectomy

BACKGROUND

In patients with primary hyperparathyroidism (PHPT) and preoperative imaging suggesting a solitary parathyroid adenoma (SPA), focused parathyroidectomy is most often curative. Even so, large studies show up to 3% of patients experience persistent or recurrent PHPT. Unilateral neck exploration (UNE) aiming to identify the SPA and the other ipsilateral parathyroid may reduce this failure rate. We hypothesized that: (i) minimally invasive video-assisted (MIVA) approach would facilitate UNE and (ii) this would be a clinically relevant strategy.

METHODS

Prospective case series of a consecutive cohort of PHPT patients (with preoperative diagnosis of SPA), who underwent MIVA-UNE. A 15 mm collar incision and endoscopic magnification were utilized to both excise the SPA and seek the ipsilateral parathyroid gland.

RESULTS

From 2009 to 2014, 132 patients were offered MIVA-UNE (age: 63.0 (interquartile range: 11.2); females: 94 (71.2%); symptomatic: 89 (67.4%); mean serum corrected calcium: 2.7 (standard deviation: 0.9) mmol/L; mean serum parathyroid hormone: 16.8 (standard deviation: 11.8) pmol/L). Conversion from MIVA-UNE to open UNE was required in 14 (10.6%) patients (excluded from subsequent analysis). MIVA-UNE was concluded in 118 patients. The second ipsilateral parathyroid was identified in 62 (52.5%) patients and in 13 (11.0%) it appeared enlarged and was excised. Histopathology confirmed five (4.2%) of these glands to be hyperplastic.

CONCLUSION

MIVA-UNE allows identification of the second ipsilateral parathyroid in about half the patients. This approach helped to diagnose and treat unexpected multigland disease in almost 5% of patients.

Intraoperative Parathyroid Hormone Monitoring: Optimal Utilization

Intraoperative parathyroid hormone (IOPTH) monitoring is a highly accurate surgical adjunct used to determine the extent of surgery in the setting of primary hyperparathyroidism. It is the successful interpretation of changes in PTH levels that is essential for using this technique in a way to optimize cure. Thus, it is imperative that the surgeon has an understanding of PTH dynamics and carefully chooses the appropriate IOPTH protocol and interpretation criteria that will best predict operative success, minimize unnecessary bilateral exploration, decrease the likelihood of resecting parathyroid glands that are not hypersecreting, and prevent recurrence.

No Need to Abandon Focused Unilateral Exploration for Primary Hyperparathyroidism with Intraoperative Monitoring of Intact Parathyroid Hormone

BACKGROUND

We investigated the rate of persistent and recurrent hyperparathyroidism after focused unilateral exploration (UE) with intraoperative monitoring of intact parathyroid hormone (IOPTH).

STUDY DESIGN

A prospective cohort of 915 patients with primary hyperparathyroidism (PHP) underwent parathyroid surgery by a single surgeon from January 2003 to September 2013. A total of 556 patients with at least a single positive preoperative localization by ultrasound (US) and/or sestamibi scan (STS) underwent UE with IOPTH. The criterion for completion of surgery was an IOPTH fall of 50% from the highest intraoperative level and into the normal range 5 to 10 minutes after resection of the localized gland.

RESULTS

Fifteen patients had either persistent or recurrent PHP, yielding a 2.7% (95% CI 1.6% to 4.4%) overall recurrence rate based on the refined Wilson method with continuity correction. Four patients had persistent PHP. Three of these patients were cured with reoperation, and the fourth patient was followed nonoperatively. Eleven patients had recurrent PHP, with 5 corrected by surgery and 6 patients followed nonoperatively. The mean postoperative serum calcium (Ca) level was 9.4 mg/dL over a mean follow-up interval of 44.0 months. Preoperative localization rates by each localization study were: US 74.3% (n = 413), STS 86.9% (n = 483), and US and STS 71.4% (n = 397). There was no difference in the preoperative study that localized the hyperfunctional parathyroid gland in recurrent vs nonrecurrent patients by the Fisher's exact test (US, p =1.00; STS, p =0.65; US and STS, p =1.00).

CONCLUSIONS

The low rate of recurrent PHP after focused unilateral exploration with IOPTH suggests that this procedure should not be abandoned.

Radioguided Parathyroidectomy with Portable Mini Gamma-Camera for the Treatment of Primary Hyperparathyroidism

Background. A proper localisation of pathological parathyroid glands is essential for a minimally invasive approach in the surgical treatment of primary hyperparathyroidism (PHP). The recent introduction of portable mini gamma-cameras (pMGCs) enabled intraoperative scintigraphic scanning. The aim of our study is to evaluate the efficacy of this new method and compare it with the preoperative localisation surveys. Methods. 20 patients were studied; they were evaluated preoperatively by neck ultrasound and (99mm)Tc-sestaMIBI-scintigraphy and intraoperatively with the pMGC IP Guardian 2. The results obtained from the three evaluations were compared. Results. The pMGC presented a sensitivity of 95%, a specificity of 98.89%, and a diagnostic accuracy of 98.18%, which were higher than those of preoperative ultrasound (sensitivity 55%; specificity 95%; diagnostic accuracy 87%) and scintigraphy with (99mm)Tc-sestaMIBI (sensitivity 73.68%; specificity 96.05%; diagnostic accuracy 91.58%). Conclusions. The pMGC can be used effectively as an intraoperative method to find the correct location of the pathological parathyroid glands. The pMGC is more reliable than the currently used preoperative and intraoperative localisation techniques.

Diagnosis and management of primary hyperparathyroidism--a scientific statement from the Department of Bone Metabolism, the Brazilian Society for Endocrinology and Metabolism

OBJECTIVE

To conduct a literature review on the diagnosis and management of primary hyperparathyroidism including the classical hipercalcemic form as well as the normocalcemic variant.

MATERIALS AND METHODS

This scientific statement was generated by a request from the Brazilian Medical Association (AMB) to the Brazilian Society for Endocrinology as part of its Clinical Practice Guidelines program. Articles were identified by searching in PubMed and Cochrane databases as well as abstracts presented at the Endocrine Society, Brazilian Society for Endocrinology Annual Meetings and the American Society for Bone and Mineral Research Annual Meeting during the last 5 years. Grading quality of evidence and strength of recommendation were adapted from the first report of the Oxford Centre for Evidence-based Medicine. All grades of recommendation, including "D", are based on scientific evidence. The differences between A, B, C and D, are due exclusively to the methods employed in generating evidence.

CONCLUSION

We present a scientific statement on primary hyperparathyroidism providing the level of evidence and the degree of recommendation regarding causes, clinical presentation as well as surgical and medical treatment.

A retrospective case-controlled study of video-assisted versus open minimally invasive parathyroidectomy

INTRODUCTION

Minimally invasive parathyroidectomy (MIP) with intraoperative parathyroid hormone assay (IOPTH) has successfully replaced conventional neck exploration in most patients with primary hyperparathyroidism (pHPT) and preoperatively localized parathyroid adenoma.

AIM

To compare outcomes of video-assisted MIP (MIVAP) to open MIP (OMIP).

MATERIAL AND METHODS

A retrospective case-controlled study of 455 patients with sporadic pHPT undergoing MIP with IOPTH at our institution in 2003-2012 was undertaken. The primary outcome measure was postoperative pain. Secondary outcome measures were: duration of surgery, recurrent laryngeal nerve (RLN) identification rate, conversion rate, length of hospital stay, cure rate, patients' satisfaction with cosmetic outcome, morbidity, costs, and diagnostic accuracy of IOPTH.

RESULTS

Of 455 patients with pHPT and a solitary parathyroid adenoma on preoperative imaging, 151 underwent MIVAP and 304 had OMIP. The following outcomes were favourable for MIVAP vs. OMIP: lower pain intensity during 24 h postoperatively (p < 0.001), lower analgesia request rate (p < 0.001), lower analgesics consumption (p < 0.001), higher recurrent laryngeal nerve identification rate (p < 0.001), shorter scar length (p < 0.001), and better cosmetic satisfaction at 1 month (p = 0.013) and at 6 months (p = 0.024) after surgery. However, MIVAP vs. OMIP had longer duration of surgery (p < 0.001), and was more expensive (p < 0.001). No differences were noted in the conversion rate, length of hospital stay, and morbidity.

CONCLUSIONS

Both MIVAP and OMIP approaches were equally safe and effective. However, the outcomes of MIVAP operations were superior to OMIP in terms of lesser postoperative pain, lower analgesics consumption, and better cosmetic satisfaction resulting from a smaller scar.

Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery: II Consensus Conference of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB)

AIM

To update the Diagnostic-Therapeutic-Healthcare Protocol (Protocollo Diagnostico-Terapeutico-Assistenziale, PDTA) created by the U.E.C. CLUB (Association of the Italian Endocrine Surgery Units) during the I Consensus Conference in 2008.

METHODS

In the preliminary phase, the II Consensus involved a selected group of experts; the elaboration phase was conducted via e-mail among all members; the conclusion phase took place during the X National Congress of the U.E.C. CLUB. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up.

CONCLUSIONS

The PDTA for parathyroid surgery approved by the II Consensus Conference (June 2013) is the official PDTA of the U.E.C. CLUB.

A comparison of minimally invasive video-assisted parathyroidectomy and traditional parathyroidectomy for parathyroid adenoma

Background: Pre-operative imaging techniques for sporadic primary hyperparathyroidism (SPHPT) and intraoperative parathyroid hormone (ioPTH) have led to the wide spread use of minimally invasive surgical approaches.

Study Design: In our prospectively collected database, 157 subjects with SPHPT and a preoperative diagnosis of parathyroid adenoma were treated with parathyroidectomy between January 2003 and November 2011. Subjects in group A were enrolled between January 2003 to September 2006, and underwent traditional parathyroidectomy with intraoperative frozen section and bilateral neck exploration. Subjects in group B were enrolled between September 2006 to November 2011, and underwent minimally invasive video-assisted parathyroidectomy (MIVAP) with ioPTH. Operative times and post-operative pain levels were compared between groups. Subjects were followed for a minimum of 6 months post-operatively and recurrence rates and complication rates were measured between groups.

Results: 81 subjects were enrolled in group A, and 76 subjects were enrolled in group B. Pre-operative evaluation demonstrated that the groups were statistically similar. Significantly decreased operative times (28min vs. 62min) and post-operative pain levels were noted in group B. Recurrence rates were similar between group A (3.7%) and group B (2.6%).

Conclusions: MIVAP with ioPTH demonstrated significantly improved operative times and post-operative pain levels, while maintaining equivalent recurrence rates.

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

Background

Gestational 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 presentation

A 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.

Conclusion

Video-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.

Feasibility of video-assisted bilateral neck exploration for patients with primary hyperparathyroidism and failed or discordant localization studies

PURPOSE

Minimally invasive video-assisted parathyroidectomy (MIVAP) is generally adopted for patients affected by primary hyperparathyroidism (pHPT) with clear preoperative localization. Standard bilateral neck exploration (BNE) is considered the obligate surgery for patients with unlocalized glands. We reviewed our experience of minimally invasive video-assisted BNE in patients with pHPT and negative or discordant localization studies.

METHODS

From a prospective series of 576 MIVAP for pHPT, 107 patients (19 males, 88 females; mean age 58 years) with failed localization studies underwent BNE using the video-assisted technique. Operative time, complications, conversions to standard cervical exploration, and cure rate were analyzed.

RESULTS

MIVAP with BNE was successfully completed in 99 (93 %) patients with 8 conversions. Mean operative time was 57 ± 37 min (range 20-180 min). Permanent recurrent laryngeal nerve palsy occurred in one patient. Biochemical cure was achieved in 104 patients (97 %). Five patients required a reoperation in the immediate postoperative period, which achieved cure in four. Two patients remained with persistent disease; one developed recurrence disease 3 years after the first exploration.

CONCLUSION

In experienced hands, video-assisted BNE for pHPT is feasible and safe and provides results equivalent to the conventional open technique.

Use of minimally invasive parathyroidectomy techniques in sporadic primary hyperparathyroidism: systematic review

The past two decades have seen rapidly changing attitudes towards the surgical management of primary hyperparathyroidism. Advances in localisation techniques and confidence with endoscopy have led to the development of numerous minimally invasive parathyroidectomy approaches, including open minimal incision and endoscopic and video-assisted parathyroidectomy. This paper systematically reviews the evidence for these methods to determine: (1) whether these new, minimally invasive techniques are comparable to conventional bilateral neck exploration methods in terms of success and complication rate; and (2) if they are comparable, which technique is likely to be best for cosmesis, patient safety and patient satisfaction. A search of the Medline, Cochrane Reviews and Scopus databases was conducted, using a defined list of search parameters. Abstracts were compared against inclusion and exclusion criteria, before the full text was sought and analysed for data. The evidence from each study was then assessed, based on study quality, and a recommendation made based on the level of evidence available. There is level 1b evidence that minimally invasive surgery is comparable to bilateral neck exploration in terms of efficacy and complication rates. This paper recommends that the treatment of choice for solitary adenoma (in most healthcare centres) should be open minimal incision parathyroidectomy, due to advantages in operative duration, learning curve and cost-effectiveness.

Contemporary and practical uses of intraoperative parathyroid hormone monitoring

OBJECTIVE

To describe the evolution and current applications of intraoperative parathyroid hormone (PTH) monitoring along with a detailed description of intraoperative protocol and assay methodology.

METHODS

Review of the literature regarding the role of intraoperative PTH monitoring in parathyroidectomy, controversies associated with its use in the treatment of hyperparathyroidism, and outcomes using this operative approach. The technologies currently available for "quick" PTH measurement are summarized.

RESULTS

Since its inception, intraoperative PTH monitoring has become an essential tool in the endocrine surgeon's armamentarium for treatment of sporadic primary hyperparathyroidism. Intraoperative PTH monitoring changed the operative approach to this disease from bilateral neck exploration with identification of all parathyroid glands and excision based on size, to a highly successful procedure achieved with a limited dissection and gland excision guided by hormone hypersecretion instead of morphologic characteristics. Intraoperative PTH monitoring accuracy is directly associated with the intraoperative criteria used. Although controversy exists regarding the best intraoperative PTH monitoring criteria to be used, most specialized centers have shown excellent results with this intraoperative guidance. Currently, most parathyroid surgeons use intraoperative PTH monitoring, selectively or routinely, during parathyroidectomy.

CONCLUSION

Parathyroidectomy guided by intraoperative PTH monitoring to treat sporadic primary hyperparathyroidism is a highly successful and less-invasive approach associated with lower risks than bilateral neck exploration, and it has become the surgical treatment of choice for this disease.

Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update

Thyroid surgery during the last century was characterized by a development of Kocher's concepts: through a relentless work of surgeons from all over the world thyroidectomy reached a standard of quality in terms of overall results which was unimaginable in the first half of the XX century. The flattering data collected in the literature until the 90's were all concordant in assuming that there would be little space for a real improvement in the quality standard of thyroid surgery. The introduction of laparoscopic surgery, though, changed very quickly the attitude of surgeons towards their operative behavior and countless new mini-invasive techniques were soon proposed for almost any field of surgery. In 1994, Gagner published the first series of laparoscopic adrenalectomies. Soon after, parathyroid adenomas seemed to offer an ideal field of application of these new surgical concepts. The first report of an endoscopic parathyroidectomy was in 1996. One year later other videoscopic procedures were described whose results seemed quite encouraging so as to push surgeons to try the same access and the same technique also for operations on thyroid. During the following decade several endoscopic or video-assisted approaches were proposed for the removal of thyroid gland. This paper aims to evaluate the results of minimally invasive thyroid and parathyroid surgery through an extensive review of the literature, in particular as far as minimally invasive video-assisted thyroidectomy is concerned.

Intraoperative adjuncts for parathyroid surgery

In recent years, parathyroid surgery has evolved from traditional bilateral neck exploration to minimal invasive parathyroidectomy. This trend became possible due to preoperative localization imaging that guides the surgeon in the search for a parathyroid adenoma. Intraoperative adjuncts are complementary to preoperative localization and assist in localizing parathyroid glands, confirming parathyroid tissue and establishing a cure. Institutions and surgeons utilize different intraoperative adjuncts in different protocols with varying results. The purpose of this article is to review the available intraoperative adjuncts to parathyroid surgery and critically evaluate their utility, accuracy and their added value to the surgeon.

Current concepts in the management of primary hyperparathyroidism

Primary hyperparathyroidism is the commonest cause of hypercalcemia in the ambulatory setting. Widespread use of routine laboratory screening has resulted in a large number of patients presenting with subclinical disease. In truly asymptomatic patients, consensus guidelines have been developed to determine which patients need definitive treatment. The most common pathologic finding is parathyroid adenoma, followed by hyperplasia, double adenomas and parathyroid carcinoma. The mainstay of treatment is surgery. While there is still an important role for four gland exploration and evaluation, there is now considerable interest in a more focused surgical approach. This paradigm shift is based on localizing studies that combine sestamibi scanning with anatomic imaging, most commonly ultrasound scanning. A range of minimally invasive approaches have been developed to treat parathyroid adenomas, including unilateral and single gland explorations as well as a number of different endoscopic techniques. Intra-operative rapid parathormone assay has replaced histologic examination as a more effective method to confirm the adequacy of surgery in most cases. Functional localization and exploration using a gamma probe has also been described. The management of patients with persistent or recurrent hyperparathyroidism is difficult and requires a multidisciplinary approach.

Intraoperative adjuncts in surgery for primary hyperparathyroidism

PURPOSE

This paper is a review of the evidence base to produce recommendations for the use of intraoperative parathyroid hormone (PTH), radioguided parathyroidectomy (RGP), methylene blue (MB), frozen section, and intraoperative neuromonitoring during surgery for primary hyperparathyroidism (PHPT).

MATERIALS AND METHODS

A Medline keyword search of English-language articles led to the production of a draft document, subsequently revised by committee, containing levels of evidence and the grading of recommendations as proposed by the Agency for Healthcare Research and Quality.

RESULTS

Literature review provides the basis for clear recommendations on the use of intraoperative PTH at surgery for PHPT. There is little evidence to support the use of RGP, MB, routine frozen section, and intraoperative neuromonitoring.

Is minimally invasive parathyroidectomy without QPTH monitoring justified?

BACKGROUND

It is matter of discussion if quick parathyroid hormone (QPTH) monitoring is helpful in patients with primary hyperparathyroidism (PHPT) and "localized single-gland disease" (SGD; concordant sestamibi and ultrasound results) to further increase the rate of success (permanent normocalcemia) of performing selective parathyroidectomy by minimally invasive parathyroid exploration (MIP). The aim of this study was to evaluate if a randomized controlled trial was justified in order to clarify this discussion.

MATERIALS AND METHODS

The prospective database of patients with sporadic PHPT, SGD, MIP, and QPTH monitoring (1999-2005) was evaluated regarding the "conversion rate" to bilateral exploration and permanent normocalcemia ("QPTH" group). Retrospectively, the patients were analyzed a second time "without" applying QPTH monitoring ("non-QPTH" group). Statistical differences between both groups were calculated (McNemar's test).

RESULTS

By definition, 338 patients with "localized SGD" underwent MIP. MIP was finished in 308 (91.1%) patients. Five of 308 patients (1.6%) showed persisting (n = 1) or recurrent disease (n = 4). In 30 of 338 patients (8.9%), a conversion to bilateral exploration was necessary (false preoperative localization 15 patients--one patient not cured; multiple-gland disease correctly indicated by QPTH monitoring 15 patients--one patient not cured). Analyzing the "non-QPTH" group, 14 additional patients showed persisting disease. Thus, without using QPTH monitoring, the rate of persisting PHPT would increase from 0.9% (three patients) to 5.0% (17 patients; p = 0.0005).

CONCLUSION

Intraoperative QPTH assay seems necessary even in patients with "localized SGD" by two techniques in an endemic goiter region. Abandoning QPTH monitoring would more than double the rate of persisting disease. A randomized trial seems not to be justified.

Recent findings in the use of intraoperative parathyroid hormone monitoring in parathyroid disease

PURPOSE OF REVIEW

To discuss recent findings and controversies regarding intraoperative parathyroid hormone monitoring (IPM) in guiding parathyroidectomy.

RECENT FINDINGS

IPM is being frequently used in guiding surgeons to complete excision of abnormal glands during parathyroidectomy for sporadic primary hyperparathyroidism (SPHPT). This adjunct is now being used in many centers around the world and has become a standard of care in the treatment of SPHPT. As the use of this technique developed, the understanding of what was necessary to return patients with hyperparathyroidism to a eucalcemic state, namely, excision of all parathyroid tissue secreting high amount of parathyroid hormone, was recognized. Two major controversies have developed during the evolution of IPM guided parathyroidectomy. One is that gland excision based on this modality may not recognize all abnormal glands, which, if not excised, will result in operative failure or recurrent hyperparathyroidism. The second disagreement is a technical one and concerns the best intraoperative protocol to be used.

SUMMARY

Parathyroidectomy for SPHPT is highly successful regardless of the operative approach used. Despite the controversies summarized in the present review, IPM has been shown to be accurate as an adjunct to guide parathyroidectomy and has changed the operative management of SPHPT.

Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop

CONTEXT

An international workshop on primary hyperparathyroidism (PHPT) was convened on May 13, 2008, to review and update the previous summary statement on the management of asymptomatic PHPT published in 2002.

EVIDENCE ACQUISITION

Electronic literature sources were systematically reviewed, addressing critical aspects of the surgical issues pertaining to the indications, imaging, surgical treatment, and cost-effective management of patients with PHPT.

EVIDENCE SYNTHESIS

The surgical group concluded that many patients with "asymptomatic" PHPT have neurocognitive symptoms that may be unmasked after successful parathyroidectomy. Furthermore, reduced bone density and increased fracture risk can be improved with parathyroidectomy. When PHPT is symptomatic, it may be associated with nephrolithiasis, increased cardiovascular disease, and decreased survival. Preoperative imaging studies should only be performed to help plan the operation, and negative imaging should never preclude surgical referral. Noninvasive localization studies including ultrasound and sestamibi scans are often employed, especially in anticipation of focused explorations. Invasive localization studies should be reserved for remedial explorations where noninvasive imaging has been unsuccessful.

CONCLUSIONS

When performed by expert parathyroid surgeons, parathyroid surgery is safe, cost-effective, and associated with very low perioperative morbidity. Minimally invasive approaches to parathyroid surgery appear to be as effective as the classic bilateral cervical exploration approach.

Safe incorporation of new technologies in thyroid surgery

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between the years of 1873 and 1910. In general the essential objectives for thyroidectomy are: sparing the parathyroid glands, avoidance of injury to the laryngeal nerves, an accurate hemostasis and an excellent cosmesis. In the last 10 years, major improvements and new technologies have been proposed and applied in thyroid surgery. These include mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia, intraoperative neuromonitoring, parathyroid hormone assay technology and genetic screening. This paper reviews the relevant medical literature published on the influence of these new technologies on the quality of thyroid surgery, as well as prevention of postoperative morbidity and mortality. Searches were last updated in April 2008.

Nuclear imaging and minimally invasive surgery in the management of hyperparathyroidism

Primary hyperparathyroidism is the most common cause of hypercalcemia, and the treatment is primarily surgical. Because of biochemical screening, more patients now present with asymptomatic primary hyperparathyroidism, and consensus guidelines have been developed for the treatment of these patients. There is now considerable interest in minimally invasive approaches to the treatment of hyperparathyroidism. Sestamibi scanning as a localizing study, used in combination with anatomic imaging and intraoperative rapid parathyroid hormone assays, has enabled focused surgical approaches. Patients with localizing studies that indicate a single parathyroid adenoma are candidates for such approaches, including unilateral neck exploration, minimally invasive single-gland exploration, or endoscopic exploration instead of the traditional approach of bilateral neck exploration. Nuclear imaging is also critical to the successful management of patients with persistent or recurrent hyperparathyroidism.