Real-Time Super Selective Venous Sampling in Remedial Parathyroid Surgery.

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.

Paradigm shift in the surgical management of multigland parathyroid hyperplasia: an individualized approach.

IMPORTANCE: Locoregional anesthesia, conscious sedation, and exploration via a limited incision have become a well-accepted approach for the treatment of patients with primary hyperparathyroidism with image-localized, presumed single-gland disease. However, to our knowledge, this minimally invasive technique has never been investigated in patients with multigland disease. OBJECTIVE: To extrapolate the technique of locoregional anesthesia, conscious sedation, and exploration via a limited incision to perform minimally invasive bilateral exploration in patients who have multigland hyperplasia. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis at a tertiary academic referral center of 100 consecutive patients undergoing parathyroidectomy for primary hyperparathyroidism due to parathyroid hyperplasia between January 19, 2010, and July 30, 2013, who were included in a prospective database. INTERVENTIONS: All patients underwent subtotal parathyroidectomy using either conventional treatment (bilateral neck exploration under general anesthesia) or extended minimally invasive parathyroidectomy (ex-MIP; locoregional anesthesia, conscious sedation, and exploration via a limited incision). Patients in the ex-MIP group who required conversion to general anesthesia were analyzed in the ex-MIP group on an intent-to-treat basis. MAIN OUTCOMES AND MEASURES: Patient cure and complication rates, length of stay, and total hospital charges. RESULTS: Of the 100 consecutive patients with parathyroid hyperplasia, 29 received conventional treatment and 71 underwent ex-MIP. In the ex-MIP group, 11 of 71 patients (15.5%) required conversion to general anesthesia. There were no differences between the ex-MIP and conventional treatment groups in age (mean [SD], 62.2 [12.2] vs 57.7 [15.2] years; P = .12), sex (59 [83.1%] vs 23 [79.3%] female; P = .78), preoperative serum calcium level (mean [SD], 11.1 [0.9] vs 10.8 [0.8] mg/dL; to convert to millimoles per liter, multiply by 0.25; P = .15), preoperative serum parathyroid hormone level (mean [SD], 114.5 [56.8] vs 137.8 [83.4] pg/mL; to convert to nanograms per liter, multiply by 1; P = .10), complications (4 vs 0 complications; P = .32), or cure rates (98.6% vs 96.6%; P = .50). Importantly, the ex-MIP group had a significant reduction in length of stay compared with the conventional treatment group (mean [SD], 1.01 [0.02] vs 1.35 [0.24] days; P = .04). They also had lower total hospital charges, but the difference was not statistically significant (mean, $23,199 vs $27,312; P = .17). CONCLUSIONS AND RELEVANCE: Parathyroidectomy with bilateral neck exploration under general anesthesia has been the standard of care for the treatment of parathyroid hyperplasia. We demonstrate that ex-MIP can provide equivalent cure and complication rates with a shorter hospital stay and a mean hospital charge reduction of more than $4000 per case.

Partial median sternotomy: an attractive approach to mediastinal parathyroid disease.

BACKGROUND: Parathyroid 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 DESIGN: We reviewed our experience with the use of partial median sternotomy in the treatment of these patients. RESULTS: Over 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. CONCLUSIONS: Rarely, 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.

Outpatient parathyroidectomy: a new paradigm from a nursing perspective.

PURPOSE OF REVIEW: Nursing assessment and management regarding the care of patients with primary hyperparathyroidism (1 degrees HPTH) has evolved in parallel with the marked changes in diagnosis and surgical approach to the disease. Earlier diagnosis and vast advancements in surgical approach has shifted the paradigm of nursing intervention into the outpatient setting. RECENT FINDINGS: The early detection of 1 degrees HPTH has become more prevalent in the preceding three decades. The clinical profile has shifted to minimally symptomatic or asymptomatic patients who have excess serum PTH levels, along with hypercalcemia. A recent consensus conference proposed diagnostic guidelines relevant to the decision making process regarding the advisability of surgical intervention vs. medical management. With surgical intervention as the only definitive treatment for 1 degrees HPTH, the successful outcomes associated with outpatient minimally invasive parathyroidectomy have shifted the patterns of recommendation for surgery, even within the group of asymptomatic patients. SUMMARY: The endocrine nurse is integral in the successful team management of patients diagnosed with 1 degrees HPTH. From a nursing perspective, the paradigm has shifted from an inpatient focus centered around the progressive clinical signs and symptoms of the disease, to a comprehensive patient care model of assessment, education, and pre, peri and postoperative monitoring of patients who benefit from the demonstrated positive outcomes associated with parathyroid surgery in the outpatient setting.

Open minimally invasive parathyroid surgery.

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.

Rapid parathyroid hormone analysis during venous localization.

OBJECTIVE: To determine the usefulness of the rapid parathyroid hormone (PTH) assay during venous localization for primary hyperparathyroidism (1 degrees HPTH). SUMMARY BACKGROUND DATA: Remedial exploration for persistent 1 degrees 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. METHODS: Between November 1997 and July 2002, 446 patients with 1 degrees 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 degrees HPTH and negative noninvasive studies underwent selective venous sampling employing a rapid PTH assay in the interventional suite. RESULTS: Venous 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. CONCLUSIONS: The rapid PTH assay is a major adjunct for obtaining informative venous localization in patients with persistent 1 degrees 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.