Operative failure rate and documentation of family history in young patients undergoing focused parathyroidectomy for primary hyperparathyroidism.

Primary hyperparathyroidism in multiple endocrine neoplasia type I usually affects all parathyroid glands, making focused parathyroidectomy (FP) inappropriate. The risk of previously undiagnosed multiple endocrine neoplasia type I in a younger patient with primary hyperparathyroidism is higher than in an older patient. We hypothesized that FP may lead to a higher failure rate in younger versus older patients. A retrospective review was performed of a single-institution database of patients who underwent parathyroidectomy for primary hyperparathyroidism. Routine statistical analysis was performed, including Fisher's exact test. A total of 635 patients were included. Operative failure occurred in 7/55 (13%) younger patients and 21/580 (4%) older patients (P = 0.007). In conclusion, operative failure occurred in a statistically significantly higher percentage of younger versus older patients undergoing FP. This is partly explained by undiagnosed multiple endocrine neoplasia syndrome type I in the younger patient group. Endocrine surgeons must make every effort to preoperatively identify multiple endocrine neoplasia syndrome type I in the younger patient population.

Outpatient parathyroid surgery: ten-year experience: is it safe?

Outpatient parathyroid surgery is increasing in frequency especially for patients undergoing minimally invasive operations. From January 1, 2000 to December 31, 2009, 585 operations were performed on patients with untreated primary hyperparathyroidism. Outpatient operations were performed on 43 per cent (249/585), whereas 57 per cent (336/585) were admitted. Comorbidities were present in 63 per cent of outpatients and 72 per cent of inpatients, whereas systemic complications occurred in 0.8 per cent of outpatients and 7 per cent of inpatients. Ninety-four per cent of outpatients were minimally invasive although inpatient procedures were evenly divided. Local complications were low (8% and 6%) in both groups. Using zip codes to determine distance from home to hospital, no differences were noted. Readmission rates were low (<0.5%) and the same in each group. Inpatients longer than 23 hours tended to be older with higher local and systemic complication rates. Over a decade, most patients undergoing same day parathyroid surgery had minimally invasive operations with lower comorbidities and lower systemic complications than inpatients. Minimally invasive and less complex nonminimally invasive operations can safely be performed on an outpatient basis with careful patient selection. Patient with more severe comorbidities and multiple comorbidities are less favorable candidates for outpatient surgery because of a higher risk of systemic complications.

Minimally invasive parathyroid surgery, the Norman 20% rule: is it valid?

The 20 per cent rule proposed by Norman established a guideline using radioactivity in the minimally invasive radioguided parathyroidectomy (MIRP) technique to localize and confirm removal of an abnormal parathyroid gland in patients with primary hyperparathyroidism. If radioactivity in the resected gland was at least 20 per cent of excision site/background radioactivity, the 20 per cent rule was satisfied. Patients meeting these criteria underwent unilateral MIRP without intraoperative parathyroid hormone assay or intraoperative frozen section. The study aim was to independently evaluate the 20 per cent rule in MIRP patients with primary hyperparathyroidism. Using the University of Louisville Parathyroid Database from January 1, 1999 to December 31, 2007, 216 MIRP patients with complete radioguided and postoperative management data were identified. The average percentage of ex vivo parathyroid gland radioactivity compared with excision site/background radioactivity was 107 per cent with a range from 14 to 388 per cent. For 99 per cent (196/198) radioactivity recorded from the excised gland was at least 20 per cent of radioactivity recorded from the excision site. Normocalcemia was documented in 98.5 per cent (195/198) at 12 month follow-up. Our data supports the 20 per cent rule in that in 99 per cent of MIRP patients the resected gland radioactivity was at least 20 per cent of excision site radioactivity allowing localization and confirmation of an overactive gland without intraoperative parathyroid hormone monitoring or tissue analysis.

Parathyroidectomy in the elderly population: does age really matter?

OBJECTIVES/HYPOTHESIS: Compare parathyroidectomy patients based on age, including demographics, outcomes, and complications. STUDY DESIGN: Retrospective review. METHODS: Prospective parathyroidectomy database covering 1998 to 2007 was reviewed retrospectively. RESULTS: A total of 687 patients underwent parathyroidectomy, including 247 (36%) >65 years old. Discharge was more often on day of surgery in younger patients (42.5% vs. 29.2%, P = .007) and >23 hours for older patients (24.7% vs. 12.3%, P < .0001). Older patients stayed longer in the recovery room (134 vs. 107 minutes, P = .005). Despite postoperative normocalcemia, older patients tended to have persistently elevated parathyroid hormone (PTH) (10.5% vs. 6.4%, P = .07), whereas younger patients had normal PTH (81.6% vs. 70%, P = .0007). PTH levels were low-abnormal (56-110) in younger patients (47% vs. 29%, P = .046), but high-abnormal (>220) in older patients (16.6% vs. 9.55%, P = .009). Overall complication rates were low (6%-8%), with >93% in either group having no major complications. There was no difference in timing or types of complications, except elderly patients were more likely to have cardiac complications (2.83% vs. 0.45%, P = .022). CONCLUSIONS: Nearly 700 parathyroidectomies were performed at our institution over 10 years. Elderly patients comprised one third of this population. They were likely to have longer hospital and recovery room stays, and postoperative normocalcemia with elevated PTH, which may actually be a normal finding for these patients, but it warrants further study. The rate, timing, and types of complications were similar between age groups, although elderly patients had more cardiac complications. When properly indicated, parathyroidectomy remains a safe and effective option for management of hyperparathyroidism in elderly patients.

Surgical and calcium outcomes in 427 patients treated prospectively in an image-guided and intraoperative PTH (IOPTH) supplemented protocol for primary hyperparathyroidism: outcomes and opportunities.

UNLABELLED: Unilateral exploration based upon preoperative imaging has become increasingly applied in the management of patients with primary hyperparathyroidism. Unilateral surgical exploration purportedly has high rates of disease control, limited morbidity, and shortened operative time. Unfortunately, significant cohorts of patients with primary hyperparathyroidism are unable to have abnormal glands localized on preoperative imaging evaluation. AIM: The aim of our study was to evaluate the efficacy of Tc(99m) sestamibi preoperative imaging, intraoperative Tc(99m) sestamibi with gamma probe, and intraoperative parathyroid hormone (IOPTH) assessment in a large cohort of patients with primary hyperparathyroidism. RESULTS: A total of 427 patients were prospectively evaluated who were deemed surgical candidates for the treatment of primary hyperparathyroidism. Of these patients, 240 (56%) presented with positive Tc(99m) sestamibi imaging. Another 105 (25%) presented with equivocal Tc(99m) sestamibi imaging. Finally, 82 (19%) presented with negative Tc(99m) sestamibi imaging. Intraoperative rapid assessment of parathyroid hormone was performed at the time of surgical exploration in all patients with negative and equivocal preoperative imaging. All 240 patients with positive preoperative imaging underwent unilateral surgical exploration utilizing intraoperative Tc(99m) sestamibi with gamma probe. The most common finding in the positive Tc(99m) sestamibi scan group was single adenoma in 235 (98%). Normocalcemia was achieved in 233 (97%) of these patients, although in 25 (10%) this was normocalcemia with a persistent elevation in parathyroid hormone (PTH). The most common surgical finding in the equivocal Tc(99m) sestamibi scan group was single adenoma in 85 (81%). Additionally 85 (81%) of these equivocal patients were able to undergo unilateral exploration limited by IOPTH assessment. Normocalcemia was achieved in 101/105 (96%) of patients; although, 10 patients were normocalcemic with persistently elevated PTH and 2 patients had normocalcemia with low PTH. All patients with negative Tc(99m) sestamibi scan underwent bilateral cervical exploration plus IOPTH; 52/82 (63%) were found to have a single adenoma which was the most common surgical finding. Normocalcemia was achieved in 77/82 (94%) of the negative Tc(99m) sestamibi cohort; although 5 patients had normocalcemia with persistently elevated PTH and 2 had normocalcemia with low PTH. Only 3 (0.7%) overall recurrent laryngeal nerve injuries were encountered, and only 1 (0.2%) was permanent. Wound complication rates are reported in detail and were low and comparable for all three Tc(99m) sestamibi imaging based cohorts. CONCLUSIONS: Tc(99m) sestamibi preoperative imaging, intraoperative Tc(99m) sestamibi with gamma probe, IOPTH, and combinations of these strategies allow for excellent opportunities for targeted excision of pathologic parathyroid tissue with the least dissection necessary while achieving excellent long-term calcium control and low rates of complication.

Intra-operative parathyroid identification using methylene blue in parathyroid surgery.

The objective of this study was to determine the value of intra-operative methylene blue (MB) during parathyroid surgery. We did a retrospective study of 473 patients after initial exploration for previously untreated symptomatic primary hyperparathyroidism. Procedural and post procedural data were collected on four groups of patients: minimally invasive parathyroidectomy with MB (n = 147), and without MB (n = 205), bilateral parathyroid exploration with intra-operative parathormone assay with MB (n = 56), and without MB (n = 65). Length of surgery was shorter for patients explored with MB (P = 0.026). For the minimally invasive parathyroidectomy group, the difference between the MB and non-MB groups was seven minutes. Twelve minutes was the difference between the MB and non-MB intra-operative parathormone assay groups. Length of stay, local complications, and correction of hypercalcemia after parathyroidectomy were not significantly affected by the use of MB. Systemic complications were lower in the MB groups. Aside from a statistically significant, but quantitatively minimal decrease in the length of surgery, no consistent benefit was identified with the use of MB for intra-operative parathyroid identification.

Toxic metabolic encephalopathy after parathyroidectomy with methylene blue localization.

OBJECTIVE: To determine the correlation between methylene blue use and toxic metabolic encephalopathy in patients undergoing surgery for primary hyperparathyroidism. STUDY DESIGN AND SETTING: A retrospective study of 193 patients was performed to collect demographic, perioperative, and postoperative data. Patients were divided into two groups: Group A (postoperative neurological sequelae) and Group B (no neurological sequelae). All data points were compared between the groups. RESULTS: Twelve of 193 patients were placed in Group A; 181 patients were placed in Group B. Ten patients in Group A were female, and 10 patients were older than 60 years. Of the patients in Group A, 100% were taking a serotonin reuptake inhibitor (SRI). In Group B, 8.8% of patients were taking an SRI. CONCLUSION: All the patients who experienced transient neurological events were taking an SRI. A correlation can be made between methylene blue infusion and SRI usage. SIGNIFICANCE: Patients taking SRIs may represent a high-risk group for postoperative neurological events when methylene blue is utilized.

Advantages of a targeted approach in minimally invasive radioguided parathyroidectomy surgery for primary hyperparathyroidism.

OBJECTIVE: In a large series of patients, we associated the need for preoperative parathyroid hormone (PTH) and calcium levels as a vital component in our approach to the radioguided minimally invasive parathyroidectomy (MIRP) procedure. Our objective was to determine whether these preoperative levels indeed complemented the procedure. Our study also included a postoperative assessment of excised gland volume and length of operation. STUDY DESIGN: This was a prospective cohort study. METHODS: : One hundred seventy-three patients with primary hyperparathyroidism enrolled in our radioguided MIRP protocol. Patients were divided into groups based on the results of sestamibi scans. Comparisons were made between these results and the assessed preoperative PTH and calcium levels and the postoperative excised gland volume and length of operation. RESULTS: PTH and calcium levels did not statistically relate with the likelihood of having a "positive," "equivocal," or "negative" sestamibi scan, but the volume of excised gland was significantly different among the three groups (P < .01). There was no significant difference between positive and equivocal scans (P = .40). Operative time was significantly different between positive and equivocal scans (P < .01), positive and negative scans (P < .01), and equivocal and negative scans (P < .01). CONCLUSIONS: Routine preoperative PTH and calcium levels are necessary for the biologic diagnosis of hyperparathyroidism, but they do not appear to relate to the outcome of a sestamibi scan and therefore do not complement the radioguided MIRP procedure. Because the size of the affected gland, however, did correlate with a positive sestamibi scan, we conclude that as the volume of the gland increases, so does the likelihood of a successfully chosen minimally invasive surgical approach.

Hypocalcemia after neck exploration for untreated primary hyperparathyroidism.

Hypocalcemia after neck exploration for hyperparathyroidism is an important postoperative management issue. With increasing acceptance of less invasive surgical approaches, hypocalcemia is less frequent. This study was conducted to evaluate postoperative hypocalcemia after current surgical exploration techniques in patients with untreated primary hyperparathyroidism. From the University of Louisville parathyroid database, charts of patients undergoing surgery for untreated primary hyperparathyroidism from May 1, 1998 to May 30, 2004 were reviewed. Data was analyzed based on age, sex, preoperative calcium and parathyroid hormone levels, preexisting diseases, and extent of neck exploration. One hundred sixty-nine patients were identified with adequate data for analysis. Transient postoperative hypocalcemia occurred in 21 per cent (36/169) for the total group, in 18 per cent (22/125) after minimally invasive radio-guided parathyroidectomy, and in 32 per cent (14/44) after bilateral neck exploration. Patients with postoperative hypocalcemia had a statistically significant association with older age and pre-existing hypertension. Patients with postoperative hypocalcemia were more likely to have undergone longer surgical procedures and were more likely to have had pre-existing diabetes and mental disorders. These findings were not statistically significant and were considered trends. The frequency of osteoporosis in the hypocalcemia group was increased but was not significant. Transient hypocalcemia occurred in 21 per cent of patients after parathyroid surgery. It was more likely after bilateral neck exploration, a longer duration of surgery, and with hypertension, diabetes, and mental disorders.

Diagnostic accuracy of palpation-guided and image-guided fine-needle aspiration biopsy of the thyroid.

We conducted a retrospective study to compare the sensitivity and specificity of traditional palpation-guided fine-needle aspiration biopsy (FNAB) performed by clinicians and pathologists with that of image-guided FNAB performed by radiologists for the evaluation of thyroid nodules. We reviewed the medical records of 89 patients who had undergone thyroid FNAB and subsequent surgical excision and pathology. Of this group, 58 patients had undergone palpation-guided FNAB performed by a clinician, 20 had undergone palpation-guided FNAB performed by a pathologist, and 11 had undergone image-guided FNAB performed by a radiologist. The sensitivity of the three techniques was 86, 100, and 100%, respectively, and the specificity was 78, 94, and 44%; there were no statistically significant differences in sensitivity or specificity among the three groups. Our data indicate that FNAB of the thyroid can be performed with equal reliability by clinicians, pathologists, and radiologists.

The operative note as billing documentation: a preliminary report.

Certified professional coders from a multispecialty academic surgical practice used operative notes to identify 10 of the most common deficiencies for reimbursement of services. These 10 deficiencies were then used as evaluation criteria to audit the operative notes used as billing documentation. Twenty-four per cent of operative notes contained no deficiencies, whereas the remaining 76 per cent contained one or more audit criteria deficiencies. The three most common deficiencies identified included an incomplete description of all surgical procedures performed (56%), an inadequate description of the indications for procedures (49%), and only 45 per cent of the operative notes were dictated within 24 hours of the procedure. Thirty-nine per cent were dictated by faculty surgeons, whereas 61 per cent were dictated by surgical residents. Twenty-nine per cent of the operative notes that were dictated by faculty surgeons contained no deficiencies as compared with 20 per cent of the operative notes that were dictated by surgical residents. For a multispecialty academic surgical practice, the operative note is the document of justification for 75 per cent of revenue generated. We conclude that 1) the operative note represents the most important document for justification of reimbursement for surgical services, 2) surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement, 3) surgical residents should be instructed in the details of an operative report as a billing document, and 4) most of the information needed in the operative note for billing purposes is simple and straightforward data that is important not only for reimbursement but also from a medico-legal and medical records standpoint.

Three-year financial analysis of minimally invasive radio-guided parathyroidectomy.

Minimally invasive radio-guided parathyroidectomy (MIRP) has had a high success rate in correcting hypercalcemia, along with a low morbidity rate and high patient satisfaction. Our study was conducted in an attempt to analyze the cost-effectiveness of MIRP in patients treated for primary hyperparathyroidism. We conducted a retrospective study of the total charges of three groups of patients undergoing surgery for previously untreated hyperparathyroidism in a single health care system. The three study groups included patients undergoing traditional bilateral neck exploration, MIRP, and neck exploration guided by intraoperative parathormone (PTH) assay. Charges were stratified into preoperative, intraoperative, and postoperative categories. The average total charge was $8,512 for MIRP, $12,723 for traditional neck exploration, and $13,011 for bilateral neck exploration with PTH assay. The decreased charge for MIRP was due to reduced operating room time, anesthesia costs, length of hospitalization, and an avoidance of the use of intraoperative tissue analysis and PTH assay. There was a greater than $4,000 savings with MIRP as compared with the more extensive neck exploration. These savings more than compensate for the cost of technology (preoperative sestamibi scan and intraoperative gamma probe) necessary to perform radio-guided parathyroidectomy.

Parathyroid cancer, a continued diagnostic and therapeutic dilemma: report of four cases and review of the literature.

Parathyroid cancer presents a diagnostic challenge as a rare endocrine malignancy usually not recognized preoperatively and often not conclusively identified intraoperatively. We examined a cluster of parathyroid cancers treated at University of Louisville-affiliated hospitals during a 5-year interval. Clinical and histologic data from patient records at University Surgical Associates, the University of Louisville Hospital, Norton Hospital, and the Louisville Veterans Administration Medical Center in Louisville, KY were retrospectively reviewed. During the study interval surgical exploration of the neck was undertaken on 175 patients with primary hyperparathyroidism; four parathyroid malignancies (2%) were identified. Three of the four patients exhibited symptomatic hyperparathyroidism with very high diagnostic calcium and parathormone levels. All patients had multiple coexisting diseases and two had undergone previous parathyroid surgery. Sestamibi scan localized the lesion in two patients, ultrasound was used in one patient, and a positron emission tomography scan was needed to identify the lesion in the fourth. Intraoperative findings varied from multiple nodules involving the thyroid and paratracheal nodules to otherwise normal-appearing enlarged parathyroid gland. External pathologic review was needed to conclusively establish the diagnosis in all cases, even though initial histologic analysis was suggestive of malignancy. All patients are alive, well, and free of disease. This rarely occurring malignancy may be suggested by very high preoperative calcium parathormone levels. Intraoperative and histologic findings are often inconclusive resulting in therapeutic decisions made by the operating surgeon on the basis of limited or incomplete information.