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PubMed1999

Unintentional parathyroidectomy during thyroidectomy.

OBJECTIVES: In the United States thyroidectomy is a frequently performed surgery by both general and head and neck surgeons. Even the most experienced thyroid surgeon, however, has probably received a pathology report stating that an incidental parathyroid gland or parathyroid tissue was found in the submitted thyroidectomy specimen. The aim of this report is to explore some of the pathologic and clinical characteristics of unintentional parathyroidectomy during thyroidectomy. STUDY DESIGN: A retrospective review was performed of thyroidectomies performed at the University of California, Los Angeles, Center for the Health Sciences between 1989 and June 1998 which had pathology reports showing parathyroid tissue contained within the thyroidectomy specimen. This excluded any tissue submitted separately to be evaluated for parathyroid tissue and parathyroid tissue removed unintentionally during a thyroidectomy for a different procedure such as a laryngectomy or surgery for parathyroid disease. METHODS: The pathology slides were reviewed to determine the incidence of unintentional parathyroid tissue removal, the size of the parathyroid tissue found within the thyroid specimen, the location of the parathyroid tissue (extracapsular, intracapsular, intrathyroidal), and whether this unintentional parathyroidectomy during thyroidectomy caused clinical consequences. RESULTS: Four hundred fourteen applicable thyroidectomies were performed during this time with 45 (11%) discovered cases of unintentional parathyroidectomy during thyroidectomy. Twenty-five (56%) cases were discovered during thyroidectomy for benign disease, and 20 (44%) during thyroidectomy for malignant thyroid disease. All the parathyroid tissue was normal and was found in extracapsular (58%), intracapsular (20%), or intrathyroidal (22%) locations. Of these 45 cases, recurrent laryngeal nerve paralysis was found only in two patients who had the nerve resected intentionally during the thyroidectomy, and none of the patients developed permanent hypocalcemia. CONCLUSIONS: Incidental parathyroid gland tissue was reported in 11% of the thyroidectomies performed in our series, without the clinical consequence of hypocalcemia. The majority (78%) of this parathyroid tissue was found in the extracapsular and intracapsular locations; therefore it is possible that these parathyroid glands may be identified and preserved with more meticulous inspection of the thyroid capsule during and after thyroidectomy to decrease the incidence of unintentional parathyroidectomy during thyroidectomy in the future.

Carcinoma↗
PubMed1983

Changes in blood pressure and renal function after parathyroidectomy in primary hyperparathyroidism.

Changes in blood pressure and renal function were investigated in 62 patients with primary hyperparathyroidism treated surgically, in an attempt to assess whether or not hypertension and renal impairment should be regarded as important indications for parathyroidectomy. 29% were hypertensive pre-operatively and the blood pressure remained elevated after parathyroidectomy in all of these patients. Hypertension developed for the first time after parathyroidectomy in 45% of those patients who were normotensive before surgery. Renal function was normal initially in 73% and mild renal impairment developed after surgery in 9% of these patients. At the end of the follow-up period, the prevalence of hypertension was higher in patients with renal impairment pre-operatively (88%) than in those with normal renal function (51%). We conclude that hypertension alone should not be regarded as an indication for parathyroidectomy in asymptomatic hyperparathyroidism. No firm conclusions can be reached about the importance of mild renal failure as an indication for surgery and the question is unlikely to be resolved without conducting a prospective controlled trial.

Blood Pressure↗
PubMed1985

Modification of experimental gentamicin nephrotoxicity by selective parathyroidectomy.

Dietary calcium loading reduces gentamicin nephrotoxicity in rats. Since parathyroid hormone increases renal brush border membrane anionic phospholipids, the putative gentamicin receptors, the effects of selective parathyroidectomy on gentamicin nephrotoxicity were examined. Male Fisher 344 rats underwent parathyroidectomy or sham surgery. All animals were fed a diet containing 0.5% calcium for 2 wk prior to gentamicin, 20 mg/kg twice daily for 6 and 10 days. Other parathyroidectomized rats were fed a 4% calcium diet for 2 wk and treated similarly with gentamicin On day 6, serum creatinine (mg/100 ml) was 2.0 +/- 0.9 in the sham-operated animals, 1.7 +/- 1.6 in the parathyroidectomized animals on the 0.5% diet, and 0.8 +/- 0.1 in the parathyroidectomized animals on the 4% diet. By 10 days, the sham-operated animals had creatinine values of 6.3 +/- 1.6 (mg/100 ml) compared with 1.7 +/- .9 in the parathyroidectomized animals on the same diet and 0.8 +/- 0.2 in the 4% diet animals. More severe tubular necrosis was present in the sham-operated compared with the parathyroidectomized animals. High calcium diet in the parathyroidectomized animals produced structural and functional protection from gentamicin nephrotoxicity. Human parathyroid hormone (1-34) 20 IU twice daily given subcutaneously to a separate group of parathyroidectomized rats, eliminated the protective effect of parathyroidectomy on renal structure and function. Parathyroidectomy modifies experimental gentamicin nephrotoxicity. The additional protective effect of dietary calcium loading may be independent of parathyroid ablation.

Animals↗
PubMed1984

Familial hypocalciuric hypercalcaemia: evidence for continued enhanced renal tubular reabsorption of calcium following total parathyroidectomy.

A patient with familial hypocalciuric hypercalcaemia (FHH) is reported. Seven years after total parathyroidectomy he remained hypocalcaemic, with biochemical evidence of hypoparathyroidism (enhanced renal tubular reabsorption of phosphate, low nephrogenic cyclic AMP excretion, and reduced serum concentration of 1,25-dihydroxycholecalciferol in the presence of normal renal function and normal serum 25-hydroxyvitamin D levels). Iv infusions of calcium were given before and 6 years after total parathyroidectomy. The renal tubular reabsorption of calcium was compared in these two situations. No difference was found. Before and after parathyroidectomy there was enhanced renal tubular reabsorption of calcium. It is concluded that the enhanced renal tubular reabsorption of calcium in FHH is independent of parathyroid hormone. Total parathyroidectomy corrects the hypercalcaemia in FHH by a reduction in the input of calcium into the extra-cellular fluid from gut and or bone perhaps as a result of reduced renal synthesis of 1,25-dihydroxycholecalciferol.

Adolescent↗
PubMed1984

Arterial calcifications in uraemic rats treated with 1-alpha-hydroxycholecalciferol and parathyroidectomy.

The effect of 1-alpha-hydroxycholecalciferol (1-alpha-OH-D3) on the incidence of arterial calcifications, and the influence of parathyroidectomy on the effect of this vitamin D treatment, were studied in uraemic rats. Uraemia was induced by 3/4 kidney resection, and parathyroidectomy was achieved by electrocoagulation. 1-alpha-OH-D3 in a dose of 3, 10 or 125 ng/100 g body weight (b.w.) was given in the drinking water. The animals were killed after 12 or 16 weeks. Aorta and small arteries in the heart and in anterior tibial muscle were studied by light microscopy. Arterial lesions were frequently found in uraemic rats and were characterized by medial necrosis and calcifications. Following a 1-alpha-OH-D3 dose of 125 ng/100 g b.w. in uraemic rats both serum calcium and serum phosphate were increased and there was a high incidence of arterial calcifications both in the aorta and the small arteries. In uraemic rats receiving 10 ng/100 g b.w. of 1-alpha-OH-D3 serum calcium was only slightly elevated although the incidence of arterial calcifications (mainly in the aorta) was such higher than in uraemic rats without vitamin-D treatment. A dose of 3 ng/100 g b.w. of 1-alpha-OH-D3 given to uraemic rats did not result in any serum calcium increase, nor did it alter the incidence of arterial calcifications. Parathyroidectomy prevented arterial calcifications. Parathyroidectomy prevented arterial calcification in uraemic rats, but this effect was abolished by 1-alpha-OH-D3 in a dose of 10 ng/100 g b.w. which only raised the serum calcium to a subnormal value. In uraemia, treatment with 1-alpha-OH-D3 may increase the serum calcium X phosphate product, but this cannot fully explain the increased incidence of arterial calcifications. It is therefore suggested that vitamin D causes changes in the arterial wall which increase its susceptibility to the development of calcifications.

Animals↗
PubMed2003

Radioguided parathyroidectomy for renal hyperparathyroidism.

BACKGROUND: The usefulness of radioguided parathyroidectomy for primary hyperparathyroidism has been demonstrated in recent years, however, its applicability to renal hyperparathyroidism is uncertain. We report a case in which radioguided parathyroidectomy was used to treat renal hyperparathyroidism and was found to be helpful in preventing persistent and recurrent hyperparathyroidism. CASE REPORT: The patient was a 55-year-old Japanese woman who had received hemodialysis for 67 months. Three enlarged parathyroid glands were identified preoperatively by ultrasonography. Two hours before the operation, the patient received an intravenous injection of 600 MBq 99mTc-sestamibi and radioguided parathyroidectomy was performed. The three enlarged parathyroid glands were resected easily by the use of radioguided surgery. However, the localization of the residual parathyroid gland was uncertain. The operative field was analyzed using an intraoperative gamma probe, and the upper mediastinum was found to have higher radioactivity than the other regions. The upper mediastinum was dissected and the enlarged parathyroid gland was identified in the anterosuperior mediastinum in front of the trachea. The target parathyroid gland was then removed. The pathological diagnosis was hyperplasia of the parathyroid. No complications were observed and a follow-up examination 30 months later did not show any recurrence. CONCLUSIONS: An intraoperative gamma probe can be used to locate supernumerary and ectopic parathyroid glands. Radioguided parathyroidectomy for renal hyperparathyroidism can theoretically decrease the risk of persistent and recurrent hyperparathyroidism that is due to remaining parathyroid tissue.

Female↗
PubMed1988

Acute pseudogout following parathyroidectomy.

Four patients developed acute arthritis following parathyroidectomy over a 3 year period in two general surgical practices. The diagnosis of pseudogout was made by clinical presentation, radiologic findings and demonstration of synovial fluid crystals exhibiting weakly positive birefringence. Rapid resolution of clinical arthritis followed joint aspiration and administration of anti-inflammatory agents in all four patients. Patients with hypercalcemia have a high incidence of calcium pyrophosphate dihydrate crystal deposition into joints. Rapid drops in serum calcium levels can cause shedding of these crystals into synovial fluid which may precipitate acute attacks of pseudogout. Because the relative hypocalcemia following parathyroidectomy provides a good stimulus for crystal shedding, it follows that hypercalcemic patients undergoing parathyroidectomy should experience a high incidence of acute pseudogout. Although this entity has been described before, its occurrence is not widely recognized in clinical practice. It is proposed that these four cases observed over a 3 year period indicate that pseudogout following parathyroidectomy occurs more commonly than previously recognized.

Calcium Pyrophosphate↗
PubMed1987

Calcium homeostasis after parathyroidectomy in normal and shocked states.

The natural history of parathyroidectomy was studied for 75 weeks in two dogs. After parathyroidectomy, the dogs required intravenous and intramuscular calcium supplementation for 1 week. Despite calcium supplementation, in 2 weeks the ionized calcium (Ca++) level fell from 4.67 mg/dl to 2.39 mg/dl. The Ca++ level rose to 4.25 mg/dl by 7 weeks after which the intramuscular calcium supplement was gradually weaned so that no calcium was given after 20 weeks. The Ca++ level stabilized at 3.15 to 3.25 mg/dl after 20 weeks. Postoperative parathormone (PTH) levels remained low. The response to hemorrhagic shock in these two calcium-independent dogs was compared with that seen in two calcium-dependent dogs 4 weeks after parathyroidectomy and to that seen in two euparathyroid dogs. Shock caused a sharp decrease in Ca++ in all animals that had parathyroid ectomy. Prostaglandin E2 (PGE2) was elevated preoperatively in these dogs and fell markedly during shock. Ca++ remained normal and PGE2 increased slightly after shock in the euparathyroid dogs. Cardiac output rose with resuscitation in the euparathyroid dogs but remained constant in the calcium-dependent dogs and increased slightly in the calcium independent parathyroidectomized animals. PTH levels were low in the parathyroidectomy groups and did not react to shock. PTH increased markedly after resuscitation in the euparathyroid dogs, suggesting its role as an acute-phase hormone. All levels returned to baseline levels within 3 days after shock. Adaptation to hypocalcemia occurs in parathyroidectomized dogs and involves PGE2 as well as other factors. Hemorrhagic shock exceeds this compensatory response which in euparathyroid dogs involves active PTH release in response to hypocalcemia.

Animals↗
PubMed1979

Effect of parathyroidectomy on crystallization of calcium salts in urine of patients with primary hyperparathyroidism.

The effect of parathyroidectomy on the crystallization of calcium salts in urine was examined in seven stone-forming patients with primary hyperparathyroidism. After parathyroidectomy, urinary calcium decreased significantly from 205 +/- 30 to 67 +/- 11 mg per day (P less than 0.01); there were no significant changes in urinary phosphorus, oxalate, magnesium, sodium, potassium, uric acid, pH, or total volume. The urinary activity product ratio (state of saturation) of brushite (CaHPO4.2H2O) and calcium oxalate decreased significantly from 1.34 +/- 0.14 to 0.75 +/- 0.18 and from 3.20 +/- 0.56 to 1.53 +/- 0.21 respectively (P less than 0.05), owing principally to the decline in urinary calcium. Moreover, the urinary formation product ratio of calcium oxalate, which reflects the minimum supersaturation required for spontaneous nucleation, increased significantly after parathyroidectomy, from 7.19 +/- 1.19 to 12.99 +/- 1.69 (P less than 0.001). The results indicate that parathyroidectomy restores the normal urinary environment with respect to saturation and inhibitor and/or promoter activity.

Calcium↗
PubMed1979

Results of subtotal parathyroidectomy for primary chief cell hyperplasia.

Analysis of the long-term results of subtotal parathyroidectomy in patients with primary chief cell hyperplasia provides evidence that refutes the recent assertion that such treatment is often ineffective. With the use of rigid criteria, 55 patients with unequivocal chief cell hyperplasia were culled from 1,576 patients who had been operated on for primary hyperparathyroidism at the Mayo Clinic between July, 1959, and July, 1976. Follow-up information, including serum levels of calcium, was obtained for all patients up to at least July, 1977. Follow-up for surviving patients ranged from 1 year to 17 years (average, 3.9 years). Seven patients (13%) were not cured by subtotal parathyroidectomy and were left with persistent hyperparathyroidism after operation, presumably because a supernumerary gland was overlooked. However, not a single patient experienced recurrent hyperparathyroidism during the 213 patient-years of follow-up. In only three patients (5%) did permanent hypoparathyroidism develop following operation. These results reaffirm the efficacy of subtotal parathyroidectomy for primary chief cell hyperplasia and call into serious question the recent advocacy of total parathyroidectomy and autotransplantation of parathyroid tissue in these cases.

Female↗
PubMed1982

Serum calcium, parathyroid hormone, and urinary cyclic adenosine monophosphate after parathyroidectomy.

In specific cases of primary hyperparathyroidism (HPT), an intraoperative measure of parathyroid function might aid the surgeon. Ideally this would permit the surgeons to recognize that sufficient parathyroid tissue had been removed to cure the patient, but that viable glandular tissue remains. This study was designed to evaluate the efficacy of urinary cyclic adenosine monophosphate (cAMP) concentrations as such a determinant. We studied serum calcium and parathyroid hormone concentrations and urinary cAMP levels in 11 control patients undergoing thyroid and non-neck operations and in 22 persons undergoing parathyroidectomy for primary HPT. The serum calcium and parathyroid hormone concentrations were normal in control patients and elevated in each person with primary HPT. Changes of these parameters after successful parathyroidectomy took too long either to occur or to be measured to be clinically useful intraoperatively. Basal urinary cAMP concentrations were normal in 10 of 11 control patients and remained so during their operations. Elevations of basal urinary cAMP levels were found in 78% of those with primary HPT. At 30 minutes after removal of all abnormal parathyroid tissue, urinary cAMP levels remained high in 41% of those in whom it as elevated in the basal state. However, by 60 minutes all urinary cAMP values were normal or low. Plasma cAMP values were normal in three of four patients with primary HPT and did not change within 90 minutes after operation despite the performance of a successful parathyroidectomy. As expected, urinary cAMP levels returned to normal in each of these individuals. Intraoperative changes of urinary cAMP levels do reflect changes in parathyroid status. However, because of the delay of 40 to 60 minutes before urinary cAMP normalizes after parathyroidectomy and because of the sophisticated technology necessary for rapid determination of this cyclic nucleotide, its present clinical applicability is limited.

Calcium↗
PubMed1983

Secondary hyperparathyroidism in patients on maintenance hemodialysis: study of optimal hemopurification and parathyroidectomy.

We have found that hemofiltration and direct hemoperfusion combined with hemodialysis removed significant amounts of parathyroid hormone. Hemofiltration and direct hemoperfusion combined with hemodialysis seemed to have better effects on secondary hyperparathyroidism. Surgical parathyroidectomy is indicated when medical parathyroidectomy has failed to prevent progressive bone disease. We had ten patients with refractory secondary hyperparathyroidism. In these patients, subtotal parathyroidectomy was attempted. The results obtained were: 1) Subtotal parathyroidectomy was successful in all patients. 2) Preoperative serum parathyroid hormone values were useful for diagnosis of secondary hyperparathyroidism. 3) The average serum N and C-terminal parathyroid hormone values measured preoperatively were 4,491.00 +/- 892.13 pg/ml and 4,580.00 +/- 474.48 pg/ml, respectively. 4) The average N and C-terminal parathyroid hormone values measured postoperatively were 298.60 +/- 128.68 pg/ml and 2,631.00 +/- 719.51 pg/ml, respectively.

Adult↗
PubMed1980

[Parathyroidectomy and calcium exchange in cardiovascular tissue in the SHR rat].

Previous work has shown that parathyroidectomy lessens hypertension if performed on young SHR (5-6 weeks of age). In this work, ionic changes (Na+, K+, Ca2+, Mg2+) were studied in heart and aorta during a chronic experimentation. In the heart, atria and ventricle, Ca2+ content was significantly diminished, 15 days after parathyroidectomy. Nevertheless after 8 months, this difference did not remain. A correlation between Ca2+ content and heart rate (lessened immediately after parathyroidectomy) is suggested. In the aorta, parathyroidectomy did not change Na+, K+, Ca2+ and Mg2+ content after 15 days. At the opposite Mg2+ content was significantly lessened after 8 months (-33 p. 100, p less than 0,001). Calcium content in the Lanthanum Resistant Fraction was also depressed significantly at this time. Variations in heart and aorta ionic contents are discussed in relation with hypertensive development.

Animals↗
PubMed2003

Directed parathyroidectomy: feasibility and performance in 100 consecutive patients with primary hyperparathyroidism.

HYPOTHESIS: Directed parathyroidectomy (DP) can be successfully completed in most patients with primary hyperparathyroidism. DESIGN AND SETTING: Retrospective review at a tertiary referral center. PATIENTS: One hundred consecutive patients with untreated, sporadic primary hyperparathyroidism operated on by a single surgeon from April 1, 1999, through December 31, 2001. INTERVENTIONS: Following preoperative imaging with sestamibi scintigraphy and ultrasonography, patients underwent parathyroidectomy with intraoperative parathyroid hormone monitoring using a focused approach through a limited neck incision (DP) or bilateral neck exploration (BNE) through a standard collar incision. MAIN OUTCOME MEASURES: Extent of exploration, operative time, length of stay, morbidity, and cure. RESULTS: Directed parathyroidectomy was completed in 70 patients and BNE in 30. Bilateral neck exploration was performed as the initial procedure in 13 patients and following intraoperative conversion from attempted DP in 17. Indications for predetermined BNE were failed preoperative localization (n = 8) and concomitant thyroid disease that required operative treatment (n = 5). The need for predetermined BNE decreased as preoperative localization improved. Intraoperative factors that necessitated conversion to BNE included persistently elevated intraoperative parathyroid hormone levels that accurately predicted multiglandular disease (n = 6), incorrect localization (n = 5), and inadequate exposure (n = 6). Operative time and length of stay were less for DP compared with BNE patients (66 vs 165 minutes and 0.5 vs 1.6 days, respectively). One patient had a temporary vocal cord paresis. All patients were eucalcemic in follow-up (4 months to 3 years). CONCLUSIONS: With accurate preoperative localization and intraoperative parathyroid hormone monitoring, DP can be successfully completed in most patients with sporadic primary hyperparathyroidism. Patients benefit from DP, which reduces operative time and length of stay and facilitates rapid convalescence.

Adolescent↗
PubMed2004

Tertiary hyperparathyroidism: histologic patterns of disease and results of parathyroidectomy.

HYPOTHESIS: Patients with tertiary hyperparathyroidism (THPT) commonly have parathyroid hyperplasia and should have a bilateral neck exploration with subtotal or total parathyroidectomy with autotransplantation to obtain long-term cure. DESIGN: A retrospective cohort study. SETTING: Tertiary referral medical center. PATIENTS: Thirty-four consecutive patients (21 women and 13 men; mean age, 48 years) who underwent neck exploration for THPT. MAIN OUTCOME MEASURES: Sites and histologic pattern of parathyroid disease, and postoperative normalization of serum calcium and parathyroid hormone levels. RESULTS: Twenty-seven patients underwent initial bilateral neck exploration and 7 patients underwent repeat neck exploration for persistent or recurrent THPT. The mean serum total calcium level was 11.2 mg/dL (2.8 mmol/L) (range, 10.3-13.5 mg/dL [2.6-3.4 mmol/L]) and the mean intact parathyroid hormone level was 355 ng/L (range, 95-1236 ng/L). The THPT was due to 4-gland hyperplasia in 33 patients and a single adenoma in only 1 patient. The parathyroid glands were in the normal position in 23 patients and in ectopic locations in 11 patients (8 intrathymic, 1 carotid sheath, 1 tracheoesophageal groove, and 1 intramuscular). Preoperative localizing studies did not identify ectopic or supernumerary glands in any of the patients (ultrasonography, 14 patients; technetium Tc 99m sestamibi, 15; and magnetic resonance imaging, 7). Persistent (n = 5) and recurrent (n = 2) THPT was more common in patients who had an initial 1- or 2-gland excision instead of subtotal or total parathyroidectomy with autotransplantation (P<.001). Four patients had transient hypocalcemia (<8.0 mg/dL [<2.0 mmol/L]), and no other permanent complications or deaths occurred. Biochemical cure was achieved in 94% of patients with a mean follow-up of 4.8 years. CONCLUSIONS: Tertiary hyperparathyroidism is usually due to multiple hyperplastic parathyroid glands, and patients who have initial limited parathyroidectomy have a higher risk of persistent or recurrent THPT.

Adolescent↗
PubMed1991

Calciphylaxis in secondary hyperparathyroidism. Diagnosis and parathyroidectomy.

Calciphylaxis is a rare, severe complication of secondary hyperparathyroidism. Patients present with painful, violaceous, mottled skin lesions of the upper and lower extremities, which become necrotic and produce nonhealing ulcers. Gangrene of fingers and toes frequently requires amputation, produces nonhealing wounds, and can lead to sepsis and death. We reviewed the clinical course of five patients with calciphylaxis treated in our institution. The three men and two women (aged 47 to 72 years) had secondary hyperparathyroidism from chronic renal failure. All patients had severe pruritus, painful ulcers, and severe hyperphosphatemia with elevated serum calcium-phosphate product (greater than 12 mmol2/L2), but the serum parathyroid hormone levels were only moderately elevated. Most patients had medical calcification of medium and small blood vessels, and some had soft-tissue calcification visible on roentgenography. Treatment consisted of local wound care, antibiotics, phosphate-binding agents, and parathyroidectomy. Two patients died of uncontrollable sepsis. The three survivors had dramatic improvement of pain and ulcers after parathyroidectomy. Calciphylaxis is a limb- and life-threatening complication of secondary hyperparathyroidism. Diagnosis can be made by recognizing the characteristic painful skin lesions, ulcers, and gangrene of the digits, and patients should be treated with subtotal parathyroidectomy.

Aged↗
PubMed2003

Image-directed parathyroidectomy under local anaesthesia in the elderly.

BACKGROUND: Surgical morbidity and mortality rates are increased in elderly patients. The aim of this study was to evaluate the outcome of targeted parathyroid operations in patients over the age of 70 years. METHODS: Forty patients aged over 70 years underwent targeted parathyroidectomy for primary hyperparathyroidism (HPT). Data were collected prospectively and reviewed retrospectively. RESULTS: : There were 33 women and seven men with a mean age of 78 (range 70-92) years, all of whom had symptoms attributable to HPT. A solitary parathyroid adenoma was detected by ultrasonography and/or sestamibi scintigraphy before operation in all patients. Six patients had a history of neck surgery, including two with persistent or recurrent HPT. Thirty-three patients underwent neck exploration under local anaesthesia with intravenous sedation. Following parathyroidectomy, intraoperative parathyroid hormone levels normalized in 39 of 40 patients and accurately predicted postoperative eucalcaemia. Intraoperative findings included 37 solitary adenomas, one double adenoma and two carcinomas. One patient with persistent HPT developed severe hypoparathyroidism following targeted parathyroid exploration with autotransplantation. Twenty-nine patients were discharged from hospital on the day of surgery. Nineteen of 21 patients for whom data were available reported an improvement in symptoms. CONCLUSION: A focused neck exploration provides a safe and effective alternative to bilateral neck exploration in elderly patients in whom a solitary parathyroid adenoma has been localized before operation. Targeted parathyroidectomy under local anaesthesia is recommended in most elderly patients with HPT.

Adenoma↗
PubMed2001

Minimally invasive video-assisted parathyroidectomy: multiinstitutional study.

Unilateral and minimally invasive parathyroidectomies with endoscopic and video-assisted technique have been introduced. Most of these procedures utilize preoperative localization and intraoperative monitoring of parathyroid hormone. There are only a few reports on these procedures. The objective of this study was to evaluate video-assisted parathyroidectomy (MIVAP) for surgery in patients with primary hyperparathyroidism (pHPT). From February 1997 to June 1999 a series of 123 consecutive patients with pHPT at four surgical centers were evaluated. The patients' ages ranged from 18 to 77 years (median 50 years). Preoperatively, sestamibi scintigraphy and ultrasonography for localization were performed for all patients. Selection criteria for a MIVAP procedure excluded patients with negative localization, suspicion of multiglandular disease (MGD) or thyroid malignancy, a large thyroid mass, and prior surgery or irradiation to the neck. MIVAP was performed with a 1.5 cm suprasternal incision; the operation was then done through this incision with a 30 degree 5 mm endoscope and microsurgical instruments with brief CO2 insufflation for adenoma identification. We then proceeded with an open technique through the small incision under video-assistance. Intraoperative monitoring of intact parathyroid hormone (iPTH) assays was used in all patients. Among the 123 patients in whom MIVAP was attempted, the procedure was accomplished in 109 (89%). Conversion to conventional cervicotomy was required in 14 (11%) patients because of failed localization, failure of the iPTH level to fall appropriately, or technical problems. There was no persistent or recurrent HPT during the 3 to 12-month follow-up. Oral calcium replacement for symptomatic hypocalcemia postoperatively was given in 7 (6%) cases. A unilateral transient laryngeal nerve palsy, resolving within 6 months postoperatively, occurred in two (2%) patients. The median hospital stay was 1.5 days (range 0.5-5.0 days). This study showed the feasibility of MIVAP as an alternative surgical treatment for pHPT in a selected group of patients. Further studies are necessary to evaluate the efficacy and rationale of MIVAP compared to other techniques for parathyroidectomy in pHPT patients.

Adenoma↗