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PubMed1999

New technique of parathyroidectomy to prevent parathyromatosis and hypoparathyroidism.

A 54-year-old woman with end-stage renal disease and on haemodialysis for 4 years developed severe secondary hyperparathyroidism and was operated upon. The two upper and the largest lower parathyroid glands were resected. The right lower gland was dissected from the lower pole of the thyroid and, by gently pulling upwards, the lateral walls were dissected using electrocautery. The lower aspect of the gland maintained the blood supply through small mediastinal and thymic vessels of the neopedicle, which allowed its mobilization to a more superficial plane. Because of the large size of the gland, the part opposite to the neopedicle was resected and the cutting surface was sealed with fibrin adhesive. Pre-thyroidal muscles were reapproximated and the remnant of the parathyroid gland was pulled out through a small hole in the inferior part of the midline and sutured with fine silk to the muscle. The gland was therefore placed in a subcutaneous position in the lowest part of the operative field just above the sternal border. The postoperative course was uneventful and, 8 months after surgery, the patient maintains a normal parathyroid function.

Female↗
PubMed2002

Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk.

OBJECTIVES/HYPOTHESIS: Recurrent laryngeal nerve palsy (RLNP) is a major obstacle in thyroid and parathyroid surgery. Therefore, methods that reduce the number of temporary and, especially, permanent recurrent laryngeal nerve palsies are of great interest. One promising way to ensure the integrity of the recurrent laryngeal nerve (RLN) is to identify the nerve always. The first question raised in the present study was whether RLN preparation reduces the number of recurrent laryngeal nerve palsies or whether it introduces additional risks. Second, from former cases we know that the absence of postoperative hoarseness does not exclude RLNP, nor does postoperative hoarseness exclusively imply RLNP. Besides, misdiagnosis is not uncommon. Therefore, preoperative and postoperative laryngoscopic examination was given attention. STUDY DESIGN: Patients were investigated 1 to 7 days before and 3 to 7 days after surgery. When an RLNP was identified, patients were followed up in a 2-week rhythm the first few times and every 6 to 8 weeks thereafter until RLNP resolved or it was considered permanent after 2 years. METHODS: We prospectively investigated 608 surgical patients with 1080 nerves at risk. Because different diseases might have different rates of postoperative RLNP, we analyzed benign thyroid disease (680 nerves at risk), thyroid malignoma (321 nerves at risk), and hyperparathyroidism (79 nerves at risk) separately. Patients undergoing primary surgery (no prior thyroid surgery) and secondary interventions (there were one or more thyroid operations before this intervention) were evaluated separately. RESULTS: We found 3.4%, 7.2%, and 2.5% of temporary recurrent laryngeal nerve palsies per nerve in the benign thyroid disease, thyroid malignoma, and hyperparathyroidism groups, respectively. The prevalence of recurrent laryngeal nerve palsies in these groups was 0.3%, 1.2%, and 0%, respectively. Conforming with other studies, the total number of recurrent laryngeal nerve palsies (temporary and permanent) was not increased compared with cases with no RLN preparation, whereas the number of permanent recurrent laryngeal nerve palsies was markedly reduced. An RLN was always identifiable. Astonishingly, the restitution of an RLNP was up to 2 years in duration; however, most restitutions occurred within the first 6 months. Thirty cases of hoarseness appeared or were intensified after surgery and were not caused by RLNP. Eleven cases of postoperative RLNP had no detectable hoarseness. CONCLUSIONS: Besides indirect laryngoscopy, videostroboscopy should be performed in all cases with no evident bilateral normal laryngeal function or normal voice. Otherwise, the incidence of false-positive or false-negative diagnosis of RLNP is likely to be increased.

Adolescent↗
PubMed2004

Minimally invasive radioguided parathyroidectomy: an attractive therapeutic option for elderly patients with primary hyperparathyroidism.

BACKGROUND AND AIM: Surgery for primary hyperparathyroidism (PHPT) due to a solitary parathyroid adenoma (PA) is moving from traditional bilateral neck exploration (BNE) towards the use of limited neck exploration. The aim of the present study was to define the efficacy of minimally invasive radioguided surgery (MIRS) in PHPT patients with a high probability of a solitary PA with particular regard to benefits achievable in elderly patients. PATIENTS AND METHODS: The study population included a total of 266 consecutive PHPT patients who had undergone surgery at our centre between September 1999 and February 2003. Preoperative imaging consisted of [Tc]pertechnetate/Tc sestamibi (TcO4/sestamibi) scintigraphy and neck ultrasound obtained in the same session. One hundred and eighty-seven patients from the whole series (75 of whom were older than 65 years) with a high scan/ultrasound probability of a solitary PA, a high PA sestamibi uptake, and a normal thyroid gland were selected for MIRS. The other 79 patients were selected for traditional BNE. The intra-operative technique was based on the injection of a low dose (37 MBq) of sestamibi in the operating theatre a few minutes before the beginning of intervention and on the use of an 11 mm collimated gamma probe. RESULTS: MIRS was successfully performed in 97.8% of all PHPT patients selected for this type of surgery and, in particular, in 100% of the subgroup (n=75) of elderly patients. MIRS required a mean operating time of 35 min and a mean hospital stay of 1.2 days; that is, approximately half of that required for traditional BNE. Moreover, local anaesthesia was successfully performed in 27 patients, 19 of whom were >65 years with concomitant invalidating diseases contraindicating general anaesthesia. No major surgical complications were recorded. Transitory hypocalcaemia was observed in 9% of cases treated with MIRS compared with 27% of patients treated with BNE. CONCLUSION: MIRS can be accurately planned in elderly PHPT patients with a solitary PA on the basis of a TcO4/sestamibi scan and neck ultrasound. MIRS has been proven to be safe and effective in our experience, and allows a significant reduction of operating and recovery time, as well as the possibility of using local anaesthesia, especially in elderly patients with concomitant invalidating diseases.

Adenoma↗