Impact of intraoperative parathyroid hormone monitoring on the management of patients with primary hyperparathyroidism.

BACKGROUND/OBJECTIVE: Intraoperative parathyroid hormone (IOPTH) monitoring during surgery for primary hyperparathyroidism (PHPT) could improve cure rate and simplify current care pathways. This study assesses the performance of US, MIBI and IOPTH monitoring and their impact on outcomes and perioperative strategy. DESIGN: This is a retrospective study of a prospectively maintained database of patients who underwent parathyroidectomy guided by preoperative US, MIBI and IOPTH monitoring. Test performance (sensitivity, specificity, PPV, NPV, accuracy) and IOPTH added value (percentage of patients in whom test contributed to achieving cure) were calculated. RESULTS: A total of 617 patients (median age 59 years, 75% females), 603 (97.7%) of them cured, were included in analysis. Sensitivity of US was higher than MIBI (78.2% vs 70%, P < 0.05), but both were inferior to IOPTH (98.6%, P < 0.05). US and MIBI were more sensitive at detecting single gland disease (SGD) than multigland disease (MGD) (85% vs 55% and 77.5% vs 45.5%, respectively, P < 0.05), while IOPTH performed well in both situations (98.8% vs 96.7%, P > 0.05). In 41 patients with incorrect US predictions, MIBI gave correct result only in 12 (29.3%) cases, while IOPTH gave correct predictions in all but one patient (97.6%). Minimally invasive parathyroidectomy (MIP) was completed in 409 patients, with a similar completion rate regardless whether both or one scan was positive. IOPTH added value was significant in whole cohort (14%) and in subgroups of patients with concordant vs discordant scans, minimally invasive vs conventional surgery, and initial vs reoperative surgery. CONCLUSIONS: Intraoperative parathyroid hormone monitoring is more accurate at predicting cure than US and MIBI are at identifying abnormal glands in patients undergoing parathyroidectomy for PHPT and significantly contributes to cure rate in range of clinical scenarios. This implies that its routine use could facilitate successful surgery in patients with single positive imaging and increase number of MIPs while maintaining high cure rate.

Routine underwater seal drains are not required after transthoracic oesophagectomy: a pilot study.

OBJECTIVE: Underwater seal drainage of the pleural cavity has been standard practice after transthoracic oesophagectomy. However these chest tubes cause pain and hamper mobility, thereby causing significant morbidity and delaying recovery. We postulated that if complete lung expansion and optimum pulmonary function could be achieved and maintained following a transthoracic oesophagectomy using simple gravity aided transabdominal tube drainage of the pleural cavity, then these may be a simpler alternative to the conventional underwater seal chest drains. METHODS: A total of 50 patients had transthoracic oesophagectomy for oesophageal cancer. Of the cohort, 44 patients were fitted with the transabdominal drain described and hence had 'modified pleural drainage' following the oesophagectomy. All patients had a posterior mediastinal drain placed in either the right or the left pleural cavity during the oesophagectomy. The tube drain was inserted into the pleural cavity from the abdomen and placed into the desired position across the diaphragmatic hiatus. The drain was managed in the conventional manner and patients were monitored postoperatively for any developing pleural collections through serial chest X-rays. Respiratory function was closely monitored. RESULTS: The drains were removed without any significant respiratory complications by the 8th postoperative day in 86% of the patients. Only three patients (7%) developed clinically significant recurrent pleural effusions, causing respiratory compromise meriting further drainage. This was easily and safely managed using fine bore pigtail drains inserted under ultrasound guidance. CONCLUSION: Transabdominal gravity aided tube drainage of the mediastinum and the pleural cavity is an effective and safe means of draining the chest, following uncomplicated transthoracic oesophagectomy.