Minimally invasive parathyroidectomy using the lateral focused miniincision approach: Is there a learning curve for surgeons experienced in the open procedure?

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

BACKGROUND

Concern 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.

METHODS

Retrospective 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.

RESULTS

A 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).

CONCLUSIONS

In 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.

Radioactive seed localization for breast conservation surgery: Low positive margin rate with no learning curve

BACKGROUND

Radioactive seed localization (RSL) is an alternative to wire localization. We compared the rate of positive margins for evidence of a learning curve in implementing RSL.

METHODS

A retrospective review of RSL by three surgeons at a single institution from 2002 to 2016. Positive margins were defined as ink on tumor.

RESULTS

Surgeon experience with RSL for ranged from 142 to >500 cases. The positive margin rate among the first 100 of each surgeons' experience (n = 300) was 2.3% and the rate during the most recent up to 100 cases after experience with at least 100 RSL procedures (n = 242) was 4.1% (p = 0.32). Individual surgeon's positive margin rates ranged from 2 to 5% in the early experience and 2-7% in the later experience (p = NS).

CONCLUSIONS

RSL for breast conservation surgery has a low rate of positive margins even early in a surgeon's experience. Implementation of RSL can be done with no evidence of a learning curve.

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.

Abandoning unilateral parathyroidectomy: why we reversed our position after 15,000 parathyroid operations

BACKGROUND

Our group championed the techniques and benefits of unilateral parathyroidectomy. As our experience has matured, it seems this limited operation might be appropriate only occasionally.

METHODS

A single surgical group's experience with 15,000 parathyroidectomies examined the ongoing differences between unilateral and bilateral techniques for 10-year failure/recurrence, multigland removal, operative times, and length of stay.

RESULTS

With limited experience, 100% of operations were bilateral, decreasing to 32% by the 500(th) operation (p < 0.001), and long-term failure rates increased to 6%. Failures were 11 times more likely for unilateral explorations (p < 0.001 vs bilateral), causing gradual increases in bilateral explorations to 97% at the 14,000(th) operation (p < 0.001). Ten-year cure rates are unchanged for bilateral operations, and unilateral operations show continued slow recurrence rates of 5% (p < 0.001). Removal of more than one gland occurred 16 times more frequently when 4 glands were analyzed (p < 0.001), increasing cure rates to the current 99.4% (p < 0.001). Of 1,060 reoperations performed for failure at another institution, intraoperative parathyroid hormone levels fell >50% in 22% of patients, yet a second adenoma was subsequently found. Operative times decreased with experience; bilateral operations taking only 5.9 minutes longer on average (22.3 vs 16.4 minutes; p < 0.001), which is 25 minutes less than unilateral at the 500(th) operation (p < 0.001). By the 1,000(th) operation, incision size (2.5 ± 0.2 cm), anesthesia, and hospital stay (1.6 hours) were identical for unilateral and bilateral procedures.

CONCLUSIONS

Regardless of surgical adjuncts (scanning, intraoperative parathyroid hormone), unilateral parathyroidectomy will carry a 1-year failure rate of 3% to 5% and a 10-year recurrence rate of 4% to 6%. Allowing rapid analysis of all 4 glands through the same 1-inch incision has caused us to all but abandon unilateral parathyroidectomy.

Minimally invasive parathyroidectomy

Minimally invasive parathyroidectomy (MIP) is an operative approach for the treatment of primary hyperparathyroidism (pHPT). Currently, routine use of improved preoperative localization studies, cervical block anesthesia in the conscious patient, and intraoperative parathyroid hormone analyses aid in guiding surgical therapy. MIP requires less surgical dissection causing decreased trauma to tissues, can be performed safely in the ambulatory setting, and is at least as effective as standard cervical exploration. This paper reviews advances in preoperative localization, anesthetic techniques, and intraoperative management of patients undergoing MIP for the treatment of pHPT.

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations

PURPOSE

Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration.

MATERIALS AND METHODS

Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence.

RESULTS

Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia.

CONCLUSIONS

Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy.