Focused parathyroidectomy for single parathyroid adenoma
A clinical account of 20 patients
Keywords:
Parathyroidectomy, Focused parathyroidectomy, Single adenoma hyperparathyroidism, Parathyroid hormoneAbstract
Background: Single parathyroid adenoma is the commonest cause of primary hyperparathyroidism. Localization of the affected gland preoperatively is a critical step in management. Surgery is considered as the main line of treatment for single parathyroid adenoma. Focused technique for parathyroid excision was found by many researchers to have a good success rate even without intraoperative parathyroid hormone measurement.
Objective: The aim of this study was to assess the feasibility, safety, and adequacy of focused parathyroidectomy via an open lateral approach using preoperative positive Sestamibi (MIBI) scan and/or ultrasound without utilizing any intraoperative aiding tools.
Methods: A case-series prospective analysis of focused open parathyroidectomy for 20 patients presented to the department of surgery or referred from the orthopedic department between October 2012 and January 2015 at the Faculty of Medicine, Al-Azhar University, Cairo, Egypt, diagnosed as sporadic hyperparathyroidism with either positive MIBI scan or ultrasound were done. Normalization of the postoperative levels of serum calcium and PTH was considered as a marker of success. Data entry and analysis were done using the IBM-SPSS version 22.
Results: In this study, focused minimal access parathyroidectomy was successful in 95% with no major surgical complications, i.e., recurrent laryngeal nerve palsy or permanent hypoparathyroidism. The patient's mean age was 46.5±12 years. The preoperative serum calcium level ranged from 8.8 to 15.2 mg/dL. The parathyroid hormone level was elevated ranging from 123-2000 pg/mL. In 90% of the cases, serum levels of alkaline phosphatase were elevated, while serum phosphorus was low with range 1.5-4.7 mg/dL. The left inferior parathyroid gland was the most commonly involved gland (40%). Using ultrasound and Sestamibi scan for preoperative localization was accurate in 75% and 90%, respectively. When both techniques were combined localization accuracy increased to 95%.
Conclusion: Our study has shown that focused parathyroidectomy is considered as a good option for single gland disease even if there are no available intraoperative helping aids, provided that good patient selection is undertaken.
References
Pyram R, Mahajan G, Gliwa A. Primary hyperparathyroidism: skeletal and non-skeletal effects, diagnosis
and management. Maturitas. 2011; 70(3): 246-55. doi: 10.1016/j.maturitas.2011.07.021. PMID: 21943558.
Miller PD, Bilezikian JP. Bone densitometry in asymptomatic primary hyperparathyroidism. J Bone Miner
Res. 2002; 17 Suppl 2: N98-102. PMID: 12412785.
Khan A, Hanley D, Rizzoli R, Bollerslev J, Young J, Rejnmark L, et al. Primary hyperparathyroidism:
review and recommendations on evaluation, diagnosis, and management. A Canadian and international
consensus. Osteoporos Int. 2017; 28(1): 1-19. doi: 10.1007/s00198-016-3716-2. PMID: 27613721,
PMCID: PMC5206263.
Hocevar M, Lezaic L, Rep S, Zaletel K, Kocjan T, Sever MJ, et al. Focused parathyroidectomy without
intraoperative parathormone testing is safe after pre-operative localization with 18 F-Fluorocholine
PET/CT. Eur J Surg Oncol. 2017; 43(1): 133-7. doi: 10.1016/j.ejso.2016.09.016. PMID: 27776943.
Seeliger B, Alesina PF, Koch JA, Hinrichs J, Meier B, Walz MK. Diagnostic value and clinical impact of
complementary CT scan prior to surgery for non-localized primary hyperparathyroidism. Langenbecks
Arch Surg. 2015; 400(3): 307-12. doi: 10.1007/s00423-015-1282-2. PMID: 25702138.
Usta A, Alhan E, Cinel A, Türkyılmaz S, Erem C. A 20-year study on 190 patients with primary
hyperparathyroidism in a developing country: Turkey experience. Int Surg. 2015; 100(4): 648-55. doi:
9738/INTSURG-D-14-00094.1. PMID: 25875546, PMCID: PMC4400933.
Calò PG, Medas F, Loi G, Erdas E, Pisano G, Nicolosi A. Feasibility of unilateral parathyroidectomy in
patients with primary hyperparathyroidism and negative or discordant localization studies. Updates Surg.
; 68(2): 155-61. doi: 10.1007/s13304-015-0342-z. PMID: 26826082.
Karakas E, Kann S, Höffken H, Bartsch DK, Celik I, Görg C, et al. Does contrast-enhanced cervical
ultrasonography improve preoperative localization results in patients with sporadic primary
hyperparathyroidism? J Clin Imaging Sci. 2012; 2: 64. doi: 10.4103/2156-7514.103054. PMID: 23230546,
PMCID: PMC3515932.
Guerin C, Lowery A, Gabriel S, Castinetti F, Philippon M, Vaillant-Lombard J, et al. Preoperative imaging
for focused parathyroidectomy: making a good strategy even better. Eur J Endocrinol. 2015; 172(5): 519- 26. doi: 10.1530/EJE-14-0964. PMID: 25637075.
Kandil E, Malazai AJ, Alrasheedi S, Tufano RP. Minimally invasive/focused parathyroidectomy in patients
with negative sestamibi scan results. Arch Otolaryngol Head Neck Surg. 2012; 138(3): 223-5. doi:
1001/archoto.2011.1419. PMID: 22351855.
Kandil E, Malazai AJ, Alrasheedi S, Tufano RP. Minimally invasive/focused parathyroidectomy in patients
with negative sestamibi scan results. Arch Otolaryngol Head Neck Surg. 2012; 138(3): 223-5. doi:
1001/archoto.2011.1419. PMID: 22351855.
Calò PG, Pisano G, Loi G, Medas F, Barca L, Atzeni M, et al. Intraoperative parathyroid hormone assay
during focused parathyroidectomy: the importance of 20 minutes measurement. BMC Surg. 2013; 13(1):
doi: 10.1186/1471-2482-13-36. PMID: 24044556, PMCID: PMC3848580.
Minisola S, Cipriani C, Diacinti D, Tartaglia F, Scillitani A, Pepe J, et al. Imaging of the parathyroid glands
in primary hyperparathyroidism. Eur J Endocrinol. 2016; 174(1): D1-8. doi: 10.1530/EJE-15-0565. PMID:
Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg.
; 235(5): 665. doi: 10.1097/00000658-200205000-00008. PMID: 11981212, PMCID: PMC1422492.
Al-Lami A, Riffat F, Alamgir F, Dwivedi R, Berman L, Fish B, et al. Utility of an intraoperative ultrasound
in lateral approach mini-parathyroidectomy with discordant pre-operative imaging. Eur Arch
Otorhinolaryngol. 2013; 270(6): 1903-8. doi: 10.1007/s00405-012-2284-0. PMID: 23183852.
Afzal A, Gauhar TM, Butt WT, Khawaja AA, Azim KM. Management of hyperparathyroidism: a five year
surgical experience. J Pak Med Assoc. 2011; 61(12): 1194-8. PMID: 22355965.
Haber RS, Kim CK, Inabnet WB. Ultrasonography for preoperative localization of enlarged parathyroid
glands in primary hyperparathyroidism: comparison with 99 mtechnetium sestamibi scintigraphy. Clin
Endocrinol (Oxf). 2002; 57(2): 241-9. doi: 10.1046/j.1365-2265.2002.01583.x.
Wong W, Foo FJ, Lau MI, Sarin A, Kiruparan P. Simplified minimally invasive parathyroidectomy: a
series of 100 cases and review of the literature. Ann R Coll Surg Engl. 2011; 93(4): 290-3. doi:
1308/003588411X571836. PMID: 21944794, PMCID: PMC3363078.
Badii B, Staderini F, Foppa C, Tofani L, Skalamera I, Fiorenza G, et al. Cost–benefit analysis of the
intraoperative parathyroid hormone assay in primary hyperparathyroidism. Head Neck. 2017; 39(2): 241-6.
doi: 10.1002/hed.24567. PMID: 27557453.
Suliburk JW, Sywak MS, Sidhu SB, Delbridge LW. 1000 minimally invasive parathyroidectomies without
intra‐operative parathyroid hormone measurement: lessons learned. ANZ J Surg. 2011; 81(5): 362-5. doi:
1111/j.1445-2197.2010.05488.x. PMID: 21518187.
Chow TL, Choi CY, Lam SH. Focused parathyroidectomy without intra-operative parathyroid hormone
monitoring for primary hyperparathyroidism: results in a low-volume hospital. J Laryngol Otol. 2015;
(8): 788-94. doi: 10.1017/S0022215115000651. PMID: 26072937.
Pang T, Stalberg P, Sidhu S, Sywak M, Wilkinson M, Reeve T, et al. Minimally invasive
parathyroidectomy using the lateral focused mini‐incision technique without intraoperative parathyroid
hormone monitoring. Br J Surg. 2007; 94(3): 315-9. doi: 10.1002/bjs.5608. PMID: 17205496.
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