Minimally invasive radioguided parathyroidectomy in the reoperative neck

doi:10.1067/msy.1998.92007

Surgery

Volume 124, Issue 6, December 1998, Pages 1088-1093

Presented at the 19th Annual Meeting of the American Association of Endocrine Surgeons, Orlando, Fla, Apr 26-28, 1998.

https://doi.org/10.1067/msy.1998.92007 Get rights and content

Abstract

Background: Operations for hyperparathyroidism (HPT) in a previously operated neck present a significant challenge and carry much higher morbidity rates than first-time operations. Our extensive experience with minimally invasive radioguided parathyroidectomy (MIRP) for first-time surgery for HPT has shown this method to be a directed approach to the offending adenoma, suggesting that the technique could be used to minimize reoperative neck surgery as well. Methods: Over an 11-month period 24 consecutive patients with primary HPT who had undergone at least one previous neck operation were referred for re-exploration. All patients underwent preoperative sestamibi scanning; 21 localized sufficiently to undergo MIRP. Results: All patients were cured after reoperation. Eighteen patients underwent MIRP under local anesthesia as outpatients; 3 MIRPs were done under general anesthesia. Average total operative time was 44 minutes, average incision length was 3.0 cm ± 0.2 cm. Nineteen of the procedures were completed without any frozen sections. There were no complications. Conclusion: MIRP is extremely effective in patients with HPT who have undergone previous neck exploration for parathyroid or thyroid disease. The technique allows for such a directed dissection that smaller incisions and local anesthesia in an outpatient setting are routine. (Surgery 1998;124:1088-93.)

Section snippets

Patients

Over an 11-month period between May 1997 and March 1998, 24 patients in whom previous neck exploration had been carried out were referred to the University of South Florida Department of Surgery for sporadic nonfamilial primary HPT. To be included in this group a patient had to have previously undergone either a complete bilateral neck exploration for primary HPT or an ipsilateral thyroid lobectomy with or without lymph node dissection (Table I).

. Demographics of 21 consecutive MIRPs

Patient	Age	Empty Cell

Results

The preoperative and postoperative calcium levels for the 21 patients undergoing MIRP are shown in Fig 2.

. Preoperative and postoperative serum calcium levels for 21 patients undergoing MIRP. Calcium levels are shown after at least 1 previous neck exploration and then 1 to 11 months after MIRP. Average postoperative length of follow-up is 5.6 months.

All serum calcium levels reflect true postoperative levels obtained at 1 week and then at 3 and 6 months after the procedure. No patient had serum

Discussion

The recent development of radioguided parathyroidectomy at our institution has permitted us to develop an algorithm that allows this procedure to be performed rapidly through a significantly less invasive dissection. A miniature handheld gamma-detection probe in the operating room allows the surgeon's every move to be guided toward the radioactive adenoma without exploration of unnecessary areas. The smaller incision and dramatically decreased size of the operative field allow this procedure to

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Minimally invasive parathyroidectomy for primary hyperparathyroidism: decreasing operative time and potential complications while improving cosmetic results
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There are more references available in the full text version of this article.

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A 43-year-old man was referred with primary hyperparathyroidism. Sestamibi demonstrated uptake of equivocal suspicion posterior to the right hemithyroid; ultrasound of this area was negative. Initial exploration failed to find an adenoma or left inferior parathyroid. Repeat sestamibi, 4D-CT and selective venous sampling localised the adenoma to the left upper neck. An intravagal parathyroid adenoma was identified intraoperatively with gamma probe and completely excised. The patient was biochemically cured and had normal vocal cord function at follow up.
Awareness of the possibility of intravagal parathyroid adenoma is important, especially in cases where preoperative localisation is uncertain. Intraoperative localisation with gamma probe can be a useful adjunct to achieve cure in such cases.
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The minimally invasive approach to parathyroid glands represents an important field of application of radioguided surgery. As always happens, in all cases pertaining to hyper-specialized skills, scientific production has long been the prerogative of a few Authors, but the ever increasing technological diffusion, combined with excellent results often achieved, increases the interest in this technique. This is particularly true in the era of minimally invasive surgery. The Authors realize a review of the existing literature to allow an overall view of current knowledge on this particular topic and to guide future research.
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Radioguided parathyroidectomy for tertiary hyperparathyroidism
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Tertiary hyperparathyroidism (3HPT) is defined as the persistent hyperproduction of parathyroid hormone and resulting hypercalcemia after renal transplantation. Here, we examine the utility of radioguided parathyroidectomy (RGP) in patients with 3HPT.
We reviewed a prospective surgery database containing 80 3HPT patients who underwent RGP from January 2001–July 2014 at our institution. We evaluated patient demographics, operative management, radioguided neoprobe utilization, and operative outcomes. Data are reported as mean ± standard error of the mean.
The mean age of the patients was 52 ± 1 y, and 46% were male. A total of 69 patients had hyperplasia and received subtotal parathyroidectomy, whereas 5 patients had double adenomas and 6 patients had single adenomas. The average calcium level among 3HPT patients was 10.8 ± 0.1 mg/dL preoperatively and 8.7 ± 0.1 mg/dL postoperatively. In vivo radioguided counts normalized to background counts averaged 145 ± 4%, whereas ex vivo counts normalized to background counts averaged 69 ± 5%. All but one ex vivo count was >20%. Ectopically located glands were successfully localized in 38 patients using the gamma probe. Ex vivo percentage did not correlate with parathyroid gland weight, preoperative parathyroid hormone, or preoperative calcium. Our radioguided approach achieved normocalcemia in 96% of 3HPT patients undergoing RGP; two patients developed recurrent disease.
In this series, all enlarged parathyroid glands were localized and resected using the gamma probe. Thus, RGP reliably localizes adenomatous, hyperplastic, and ectopically located glands in patients with 3HPT, resulting in high cure rate after resection.

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^☆: Reprint requests: James Norman, MD, University of South Florida, Department of Surgery, Tampa General Hospital Box 1289, Tampa, FL 33601.

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American Association of Endocrine SurgeonsMinimally invasive radioguided parathyroidectomy in the reoperative neck☆

Abstract

Section snippets

Patients

Results

Discussion

Curr Probl Surg

Surgery

Mangement of recurrent or persistent hyperparathyroidism

Probl Gen Surg

Reoperation for persistent or recurrent primary hyperparathyroidism

Arch Surg

Minimally invasive parathyroidectomy for primary hyperparathyroidism: decreasing operative time and potential complications while improving cosmetic results

Am Surg

American Association of Endocrine Surgeons
Minimally invasive radioguided parathyroidectomy in the reoperative neck☆