Patricia Donovan

One Hundred Consecutive Minimally Invasive Parathyroid Explorations

ObjectiveTo review the outcomes of 100 consecutive minimally invasive parathyroid explorations. Summary Background DataMinimally invasive parathyroidectomy (MIP) has challenged the traditional approach of bilateral neck exploration for patients with primary hyperparathyroidism. Most patients with primary hyperparathyroidism have a single adenoma that when resected results in cure. It therefore appears logical to perform a directed approach to adenoma extirpation. MIP involves high-quality sestamibi images obtained with single photon emission computed tomography to localize enlarged parathyroid glands in three dimensions, limited exploration after surgeon-administered cervical block anesthesia, rapid intraoperative parathyroid hormone assay to confirm the adequacy of resection, and discharge within 1 to 3 hours of surgery. MethodsMIP was offered to 100 selected consecutive patients during an 18-month period beginning in March 1998. ResultsNinety-two cases were accomplished under cervical block anesthesia and 89 of these on an ambulatory basis. The cure rate was 100%, and there were no long-term complications. The mean hospital charge for MIP was less than 40% of that associated with traditional exploration. ConclusionsOutpatient MIP appears to be the procedure of choice for most patients with primary hyperparathyroidism.

The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism.

Objective:To compare the results of minimally invasive parathyroidectomy (MIP) and conventional parathyroid surgery. Background:Primary hyperparathyroidism is a common endocrine disorder often treated by surgical intervention. Outpatient MIP, employing image-directed focused exploration under cervical block anesthesia, has replaced traditional surgical approaches for many patients with primary hyperparathyroidism. This retrospective review of a prospective database compared MIP with conventional parathyroid surgery. Methods:One thousand six hundred fifty consecutive patients underwent surgery for primary hyperparathyroidism by a single surgeon between 1990 and 2009 at 2 tertiary care academic hospitals. Conventional bilateral cervical exploration under general anesthesia was performed in 613 patients and MIP was performed in 1037 cases. Cure rates, complication rates, pathologic findings, length of hospital stay, and total hospital costs were compared. Results:Minimally invasive parathyroidectomy is associated with improvements in the cure rate (99.4%) and the complication rate (1.45%) compared to conventional exploration with a cure rate of 97.1% and a complication rate of 3.10%. In addition, the hospital length of stay and total hospital charges were also improved compared to conventional surgery. Conclusions:Minimally invasive parathyroidectomy is a superior technique and should be adopted for the majority of patients with sporadic primary hyperparathyroidism.

Randomized Prospective Evaluation of Frozen-Section Analysis for Follicular Neoplasms of the Thyroid

ObjectiveTo evaluate the clinical utility of frozen section in patients with follicular neoplasms of the thyroid in a randomized prospective trial. Summary Background DataThe finding of a follicular neoplasm on fine-needle aspiration prompts many surgeons to perform intraoperative frozen section during thyroid lobectomy. However, the focal distribution of key diagnostic features of malignancy contributes to a high rate of noninformative frozen sections. MethodsThe series comprised 68 consecutive patients with a solitary thyroid nodule in whom fine-needle aspiration showed a follicular neoplasm. Patients were excluded for bilateral or nodal disease, extrathyroidal extension, or a definitive fine-needle aspiration diagnosis. Final pathologic findings were compared with frozen sections, and cost analyses were performed. ResultsSixty-one patients met the inclusion criteria. Twenty-nine were randomized to the frozen-section group and 32 to the non-frozen-section group. In the non-frozen-section group, one patient was excluded when gross examination of the specimen was suggestive of malignancy and a directed frozen section was diagnostic of follicular carcinoma. Frozen-section analysis rendered a definitive diagnosis of malignancy in 1 of 29 (3.4%) patients, who then underwent a one-stage total thyroidectomy. In the remaining 28 patients, frozen section showed a “follicular or Hürthle cell neoplasm.” Permanent histology demonstrated well-differentiated thyroid cancer in 6 of these 28 patients (21%). Of the 31 patients in the non-frozen-section group, 3 (10%) showed well-differentiated thyroid carcinoma on permanent histology. Complications were limited to one transient unilateral vocal cord dysfunction. All but one patient had a 1-day hospital stay. There were no significant differences between the groups in surgical time or total hospital charges; however, the charge per informative frozen section was approximately

Remedial parathyroid surgery: changing trends in 130 consecutive cases.

12,470. ConclusionsFor the vast majority of patients (96.4%) with follicular neoplasms of the thyroid, frozen section is neither informative nor cost-effective.

Open Minimally Invasive Parathyroid Surgery

Objective:To review the outcomes in 130 consecutive remedial explorations for primary hyperparathyroidism. Summary Background Data:Remedial surgery for primary hyperparathyroidism is challenging and requires meticulous preoperative evaluation and imaging to expedite a focused surgical exploration that has traditionally been performed under general anesthesia. This prospective series of 130 consecutive remedial operations for primary hyperparathyroidism selectively used minimally invasive techniques and tested the hypothesis that these techniques could improve outcomes. Methods:Between 1990 and 2005, 1090 patients were evaluated and explored for primary hyperparathyroidism. Of these, 130 remedial explorations were performed in 128 patients who underwent either conventional exploration under general anesthesia (n = 107) or minimally invasive parathyroidectomy (n = 23) employing cervical block anesthesia, directed exploration, and curative confirmation with the rapid intraoperative parathyroid hormone assay. Results:The sensitivity of preoperative imaging were: Sestamibi (79%), ultrasound (74%), MRI (47%), CT (50%), venous localization (93%), and ultrasound guided parathyroid fine needle aspiration (78%). The cure rate in the conventional remedial group (n = 107) was 94% and was associated with a mean length of stay of 1.6 ± 0.2 days. Remedial exploration employing minimally invasive techniques (n = 23) resulted in a cure rate of 96% and a mean length of stay of 0.4 ± 0.1 days. Complications were rare in both remedial groups. These results were almost identical to those achieved in 960 unexplored patients. Conclusions:Remedial parathyroid surgery can be accomplished with acceptable cure and complication rates. Minimally invasive techniques can achieve outcomes that are similar to those obtained in unexplored patients.

Rapid Parathyroid Hormone Analysis During Venous Localization

Outpatient minimally invasive parathyroidectomy (MIP) employs (1) preoperative parathyroid localization with high quality sestamibi scans, (2) cervical block anesthesia, (3) limited exploration, and (4) the rapid intraoperative parathyroid hormone assay to confirm an adequate resection. The technical aspects of this procedure are described, and the results obtained in 255 patients who underwent MIP are compared with those of 401 patients who underwent conventional bilateral cervical exploration under general anesthesia. MIP and standard exploration were indistinguishable with regard to high cure and low complication rates. MIP, however, was superior with regard to operating time, length of hospital stay, patient comfort, and costs.

Real-Time Super Selective Venous Sampling in Remedial Parathyroid Surgery

ObjectiveTo determine the usefulness of the rapid parathyroid hormone (PTH) assay during venous localization for primary hyperparathyroidism (1° HPTH). Summary Background DataRemedial exploration for persistent 1° HPTH poses a significant challenge when noninvasive preoperative localization studies are negative. Based on experience with the intraoperative rapid PTH assay, this technique was extrapolated to the interventional radiology suite and generated near real-time data for the interventional radiologist employing on-site hormone analysis, with a 12-minute turnaround time from blood sampling to assay result. MethodsBetween November 1997 and July 2002, 446 patients with 1° HPTH were referred for treatment. Of these, 56 (12.5%) represented remedial patients who had each undergone one or more previous cervical explorations. Noninvasive imaging studies were positive for or suggestive of localized disease in 49/56 (87.5%) of these patients, who therefore proceeded directly to surgical exploration. Seven patients with persistent 1° HPTH and negative noninvasive studies underwent selective venous sampling employing a rapid PTH assay in the interventional suite. ResultsVenous localization demonstrated an apparent PTH gradient in six of the seven patients. In three, a subtle gradient demonstrated in near real-time prompted additional sampling, which confirmed an unequivocal hormone gradient. In an additional case, the absence of a gradient on initial sampling prompted further sampling, which was positive. All of the patients were explored, and in five of the six patients with a positive PTH gradient, a parathyroid adenoma (mean weight 636 ± 196 mg) was resected from a location predicted by venous localization. In the sixth patient with a positive gradient, parathyroid tissue was not identified; however, there was a significant fall in the intraoperative PTH values, and immediate postoperative and follow-up laboratory data at 1 month are indicative of a cure. In the one patient with negative localization, abnormal parathyroid tissue could not be located during surgical exploration. ConclusionsThe rapid PTH assay is a major adjunct for obtaining informative venous localization in patients with persistent 1° HPTH. This information is extremely helpful to the surgeon in this challenging group of patients and resulted in a 100% cure rate when a venous gradient was demonstrated. The authors now employ this technique routinely in remedial patients with negative noninvasive imaging studies.

Partial Median Sternotomy: An Attractive Approach to Mediastinal Parathyroid Disease

BACKGROUND Remedial cervical exploration for persistent or recurrent primary hyperparathyroidism can be technically difficult, but is expedited by accurate preoperative localization. We investigated the use of real-time super selective venous sampling (sSVS) in the setting of negative noninvasive imaging modalities. STUDY DESIGN We performed a retrospective analysis of a prospective database incorporating real-time sSVS in a tertiary academic medical center. Between September 2001 and April 2014, 3,643 patients were referred for surgical treatment of primary hyperparathyroidism. Of these, 31 represented remedial patients who had undergone one (n=28) or more (n=3) earlier cervical explorations and had noninformative, noninvasive preoperative localization studies. RESULTS We extended the use of the rapid parathyroid hormone assay in the interventional radiology suite, generating near real-time data facilitating onsite venous localization by a dedicated interventional radiologist. The predictive value of real-time sSVS localization was investigated. Overall, sSVS correctly predicted the localization of the affected gland in 89% of cases. Of 31 patients who underwent sSVS, a significant rapid parathyroid hormone gradient was identified in 28 (90%), localizing specific venous drainage of a culprit gland. All patients underwent subsequent surgery and were biochemically cured, with the exception of one who had metastatic parathyroid carcinoma. Three patients with negative sSVS were also explored and cured. CONCLUSIONS Preoperative parathyroid localization is of paramount importance in remedial cervical explorations. Real-time sSVS is a sensitive localization technique for patients with persistent or recurrent primary hyperparathyroidism, when traditional noninvasive imaging studies fail. These results validate the utility and benefit of real-time sSVS in guiding remedial parathyroid surgery.

Trans-oral Vestibular Endocrine Surgery: A New Technique in the United States.

BackgroundParathyroid exploration through a standard cervical approach is adequate for the resection of most mediastinal parathyroid glands. A subset of mediastinal parathyroid glands causing hyperparathyroidism, however, cannot be removed in this manner.Study DesignWe reviewed our experience with the use of partial median sternotomy in the treatment of these patients.ResultsOver a 14-year period, all but 10 of 937 (1.1%) consecutive patients explored for hyperparathyroidism by a single endocrine surgeon were treated by a cervical approach. Partial median sternotomy was performed in 10 cases and was successful in seven cases (70%), with conversion to a complete sternotomy being required in three cases. Six of these seven patients had failed a previous parathyroid exploration (86%), including one patient who had a previous complete sternotomy. Cure of hyperparathyroidism was achieved in all seven patients undergoing partial median sternotomy. In five patients a mediastinal parathyroid gland was removed (71%), and in one patient a parathyroid adenoma in the carotid sheath was eventually found, and the location of the hyperfunctioning parathyroid gland in one patient was never determined although the patient was cured. The mean length of hospital stay after a partial median sternotomy was 2.6 days. One patient sustained a recurrent laryngeal nerve injury at the time of a repeat cervical exploration and partial median sternotomy.ConclusionsRarely, mediastinal parathyroid glands cannot be resected through a cervical approach. In these cases the use of partial median sternotomy is an attractive technique in achieving cure of hyperparathyroidism and is associated with minimal morbidity and a short length of hospital stay.

Effect of patient Age on surgical outcomes for Graves’ disease: a case–control study of 100 consecutive patients at a high volume thyroid surgical center

To the Editor: T he standard approach to thyroid and parathyroid surgery is by a transverse cervical Kocher incision. Although safe and the standard of care in Western countries, in Asia it is considered cosmetically disfiguring. In response, surgeons in Korea, China, Japan, and Thailand developed trans-axillary, trans-areolar (breast), and retro-auricular approaches to resect thyroid and parathyroid lesions. Each is associated with unique morbidities that have limited widespread adoption. Natural orifice transluminal endoscopic surgery was described employing a trans-oral approach for thyroid surgery in porcine models and cadaver dissections. Recently, Anuwong demonstrated outstanding results in 60 patients undergoing trans-oral vestibular thyroidectomy in Thailand. We traveled to Bangkok to learn the technique, obtained procedural credentialing, developed FDAcompliant instruments and Dr Anuwong joined us in the United States. We report the first seven consecutive cases performed outside of Asia. This study was performed after credentialing committee review and approval of a limited series. All cases were performed at Yale-New Haven Hospital between March 29, 2016 and April 1, 2016 by 2 experienced endocrine surgeons. Written consent and IRB approval were obtained to perform a retrospective chart review of a prospective data base. Adult patients who required thyroid or parathyroid surgery were candidates, 7 were selected, 5 had thyroid, and 2 had parathyroid surgery. The patient characteristics, cases, and results are listed in Table 1. All cases were performed by a dedicated nursing, anesthesia, and surgical team. The patient’s mouth was cleansed with