Conclusion

In contrast to the surgeon performing open surgery, in which surgery alone can be successful in more than 95% of cases, the endoscopic parathyroid surgeon must depend on multiple

TABLE 51-1. Contraindications for Endoscopic Parathyroidectomy in 228 of the 528 Patients Who Underwent Surgery for Primary Hyperparathyroidism

Associated nodular goiter 99

Previous cervical surgery 42

Inconclusive preoperative localization 48

Suspicion of multiglandular disease 25

Acute hyperparathyroidism 4

Lesion too large 4

Local anesthesia 3

Major ectopia 2

Cervical hematoma 1

TABLE 51-2. Reasons for Conversion to Conventional Cervicotomy in 42 of 300 Patients Who Underwent Endoscopic Parathyroidectomy

Adenomas not found 11

Difficult dissections 7

Multiglandular disease 10*

Quick parathormone 3 assessment (QPTH) assay false-negative result

Sestamibi scan false-positive result 10

Ultrasonography false-positive result 1

*QPTH assay true-positive result.

techniques such as preoperative specialized imaging, intraoperative QPTH assessment, and use of special surgical instruments.

The possible advantages of endoscopic parathyroidectomy are a better cosmetic result and more comfort for the patient.

Endoscopic parathyroidectomy should not be opposed to conventional parathyroidectomy. Theses operations will probably turn out to be complementary in the future. Endoscopic parathyroidectomy should be reserved for patients with sporadic PHPT, with a single adenoma clearly localized preoperatively.

Among many minimally invasive techniques applied to parathyroidectomy, the endoscopic technique has the main advantage of offering a magnified view that permits a precise and careful dissection with minimal risks.

The lateral approach is particularly suitable for patients with adenoma located posteriorly in the neck. The central access is reserved for inferior adenomas located anteriorly. As with other minimally invasive techniques, a longer follow-up is needed before one can evaluate the real risk of recurrent PHPT following endoscopic techniques.

REFERENCES

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2. Van Heerden JA, Grant CS. Surgical management of primary hyperparathyroidism: An institutional perspective. World J Surg 1991:15:688.

3. Tibblin SA, Bondeson AG, Ljunberg O. Unilateral parathyroidectomy in hyperparathyroidism due to single adenoma. Ann Surg 1982;195:245.

4. Rüssel CF, Laird JD, Fergusson WR. Scan-directed unilateral cervical exploration for parathyroid adenoma: A legitimate approach? World J Surg 1990;14:406.

5. Chapuis Y, Richard B, Fulla Y, et al. Chirurgie de l'hyperparathyroïdie primaire par abord unilatéral sous anesthésie locale et dosage per opératoire delà PTH 1-84. Chirurgie 1993-1994:119:121.

6. Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery 1997;122:998.

7. Burkey SH, Van Heerden JA, Farley DR, et al. Will directed parathyroidectomy utilizing the gamma probe or intraoperative parathyroid hormone assay replace bilateral cervical exploration as the preferred operation for primary hyperparathyroidism? World J Surg 2002; 26:914.

8. Udelsman R, Donovan PI, Sokoll LJ. One hundred consecutive minimally invasive parathyroid explorations. Ann Surg 2000;232:331.

9. Inabnet WB, Biertho L. Chirurgie parathyroïdienne dirigée: Une série de 100 patients consécutifs. Ann Chir 2002;127:751.

10. Ikeda Y, Takami H, Tajima G, et al. Direct mini-incision parathyroidectomy. Biomed Pharmacother 2002;56(Suppl 1):14S.

11. Gagner M. Endoscopic parathyroidectomy. Br J Surg 1996;83:875.

12. Miccoli P, Bendinelli C, Vignali E, et al. Endoscopic parathyroidectomy: Report of an initial experience. Surgery 1998;124:1077.

13. Henry JF, Defechereux T, Gramatica L, et al. Parathyroïdectomie vidéo-assistée par abord latéro-cervical. Ann Chir 1999;53:302.

14. Cougard P, Goudet P, Osmak L, et al. La vidéo-cervicoscopie dans la chirurgie de l'hyperparathyroïdie primitive. Etude préliminaire portant sur 19 patients. Ann Chir 1998;52:885.

15. Gauger PG, Reeve TS, Delbridge LW. Endoscopically assisted minimally invasive parathyroidectomy. Br J Surg 1999:86:1563.

16. Duh QY. Videoscopic parathyroidectomy: Rationales, techniques, indications and contraindications. Acta Chir Aust 1999:31:214.

17. Lorenz K, Nguyen-Thanh P, Dralle H. First experience with minimally invasive video-assisted parathyroidectomy. Acta Chir Aust 1999; 30:218.

18. Yeung GHC. Endoscopic surgery of the neck. A new frontier. Surg Laparosc Endosc 1998;8:227.

19. Okido M, Shimizu S, Kuroki S, et al. Video-assisted parathyroidectomy for primary hyperparathyroidism: An approach involving a skin-lifting method. Surg Endosc 2001;15:1120.

20. Ikeda Y, Takami H, Tajima G, et al. Total endoscopic parathyroidectomy. Biomed Pharmacother 2002;56(Suppl l):22s.

21. Suzuki S, Fukushima T, Ami H, et al. Video-assisted parathyroidectomy. Biomed Pharmacother 2002;56(Suppl l):18s.

22. Prinz RA, Longhyna V, Carnaille B, et al. Thoracoscopic excision of enlarged mediastinal parathyroid glands. Surgery 1994;116:999.

23. Miccoli P, Bendinelli C, Conte M. Endoscopic parathyroidectomy by a gasless approach. J Laparoendosc Adv Surg Tech A 1998;8:189.

24. Henry JF. Endoscopic exploration. In: Van Heerden JA, Farley DR (eds), Udelsman R (guest ed), Operative Technique in General Surgery. Surgical Exploration for Hyperparathyroidism. Philadelphia, WB Saunders, 1999, p 49.

25. Feind CR. Re-exploration for parathyroid adenoma. Am J Surg 1964; 108:543.

26. Miccoli P, Berti P, Conte M, et al. Minimally invasive video-assisted parathyroidectomy: Lesson learned from 137 cases. J Am Coll Surg 2000:191:613.

27. Miccoli P, Bendinelli C, Berti P, et al. Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: A prospective randomized study. Surgery 1999;126:1117.

28. Henry JF, Raffaelli M, Iacobone M, et al. Video-assisted parathyroidectomy via lateral approach versus conventional surgery in the treatment of sporadic primary hyperparathyroidism. Results of a case-control study. Surg Endosc 2001:15:1116.

29. Cougard P, Goudet P, Bilosi M, et al. Exérèse vidéoendoscopique des adénomes parathyroïdiens: Résultats à propos d'une série prospective de 100 patients. Ann Chir 2001;126:314.

30. Henry JF, Iacobone M, Mirallié E, et al. Indications and results of video-assisted parathyroidectomy by a lateral approach in patients with primary hyperparathyroidism. Surgery 2001; 130:999.

31. Irvin GL, Cameiro DM. Rapid parathyroid hormone assay guided exploration. In: Van Heerden JA, Farley DR (eds), Operative Technique in General Surgery. Surgical Exploration for Hyperparathyroidism. Philadelphia, WB Saunders, 1999, p 18.

32. Sebag F, Hubbard JGH, Maweja S. Negative preoperative localization studies are highly predictive of multiglandular disease in sporadic primary hyperparathyroidism. Surgery 2003;134:1038.

33. Lorenz K, Nguyen-Thanh P, Dralle H. Unilateral open and minimally invasive procedures for primary hyperparathyroidism: A review of selective approaches. Langenbecks Arch Surg 2000:385:106.

34. Henry JF, Sebag F, Maweja S, et al. Video-assisted parathyroidectomy in the management of patients with primary hyperparathyroidism. Ann Chir 2003:128:379.

chapter 52

Intraoperative Parathyroid Hormone Assay as a Surgical Adjunct in Patients with Sporadic Primary Hyperparathyroidism

Many techniques have been tried during parathyroidectomy to differentiate between normal and abnormal parathyroid glands and to predict operative success. At present, none is superior to the intraoperative measurement of parathyroid hormone (PTH) by a quick assay (QPTH) in predicting operative outcome during parathyroidectomy. This surgical adjunct allows the surgeon to quantitatively determine intra-operatively when all hyperfunctioning parathyroid tissue has been excised. Furthermore, in the case of multiglandular disease (MGD), QPTH accurately identifies the presence of additional hypersecreting gland(s), guiding the surgeon to further exploration.

Since first suggested in 1988 by Nussbaum and coworkers, the intraoperative monitoring of intact parathyroid hormone (PTH) levels has been adopted as a quantitative predictor of postoperative serum calcium levels in the treatment of sporadic primary hyperparathyroidism (SPHPT) in many institutions.1"14 This surgical adjunct became a real intraoperative tool in 1991 with an immunoradiometric assay and was later changed to a more stable, practical, sensitive, and nonradionuclear two-site antibody immunochemilumines-cent assay (ICMA) in 1993.1516 This rapid PTH assay became commercially available as a point of care system in 1996 and is the most widely used intraoperative method for hormone measurement in the United States.

The operative results, using this surgical adjunct to guide the resection during parathyroidectomy, are reported with success rates ranging from 94% to 100%.1'2-5"9111317 25 However, the accuracy of QPTH in guiding the surgeon intraoperatively to a successful outcome is directly related to the protocol and criteria used to interpret the measured hormone levels. The intraoperative hormone assay only provides PTH levels at specific times during the operation; therefore, the surgeon's knowledge of the timing of sample collection and interpretation of changes in the hormone values are necessary to ensure a high rate of success. At the University of Miami, this assay is used to (1) determine the complete excision of all hyperfunctioning parathyroid tissue before the operative procedure is finished; (2) guide the surgeon to further cervical exploration when the PTH levels do not drop sufficiently; (3) differentiate parathyroid from nonparathyroid tissues biopsied using measurement of PTH levels in fine-needle aspiration (FNA) samples;

(4) localize the side of the neck harboring the hypersecreting parathyroid(s) through differential jugular venous sampling when the preoperative localization study is equivocal; and

(5) safely allow limited parathyroidectomy with resection of only hypersecreting gland(s) along with preservation of the normally functioning parathyroids in patients with SPHPT.

The traditional parathyroidectomy, associated with a bilateral neck exploration, is intended to excise all abnormal glands while preserving all macroscopically normal parathyroids. A "limited parathyroidectomy" is guided by QPTH and helped by preoperative localization studies in an attempt to achieve operative success with rapid, minimal dissection. This quantitative operative approach allows the excision of only the hypersecreting parathyroids with preservation of the remaining normally secreting glands, despite their macroscopic appearance, without disturbing or visualizing them. When a secure diagnosis of SPHPT is obtained (hypercalcemia, elevated PTH levels, normal or high 24-hour urinary calcium levels, and normal renal function) and the patient has defined indications for parathyroidectomy, a preoperative localization study is performed in an attempt to guide the surgeon to the side of the neck harboring the hypersecreting parathyroid gland. The localization study should not be used to diagnose, indicate, or contraindícate parathyroidectomy. It is used only for guidance of a targeted neck or mediastinal exploration when positive. Even when localization studies are negative, patients with definitive surgical indications are entitled to limited parathyroidectomy guided by QPTH.26

This chapter describes in detail the authors' 9-year experience in developing, improving, and testing the most accurate intraoperative QPTH criterion for predicting operative outcome in patients with SPHPT.

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