Surgical results and the location of pathological glands in the treatment of primary sporadic hyperparathyroidism with negative preoperative 99mTc-sestamibi scintigraphy.

INTRODUCTION: The primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative 99mTc-sestamibi scintigraphy. METHODS: Observational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative 99mTc-sestamibi scintigraphy, operated consecutively in an endocrine surgery unit for 18 years. The cure rate, the intraoperatory PTH, the etiology and the pathological glands location were analyzed. RESULTS: In the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. 14.1% presented a multigland disease. 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum. CONCLUSIONS: The absence of uptake in the 99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.

Surgical results and the location of pathological glands in the treatment of primary sporadic hyperparathyroidism with negative preoperative 99mTc-sestamibi scintigraphy. / Resultados quirúrgicos y localización de las glándulas patológicas en el tratamiento del hiperparatiroidismo primario esporádico con gammagrafía 99mTc-sestamibi negativa.

INTRODUCTION: The primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative 99mTc-sestamibi scintigraphy. METHODS: Observational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative 99mTc-sestamibi scintigraphy, operated consecutively in an Endocrine Surgery Unit for 18 years. The cure rate, the intraoperatory parathyroid hormone (PTH), the etiology and the pathological glands location were analyzed. RESULTS: In the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. The 14.1% presented a multigland disease; 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum. CONCLUSIONS: The absence of uptake in the 99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.

Risk factors for open conversion of lateral transperitoneal laparoscopic adrenalectomy: retrospective cohort study of the Spanish Adrenal Surgery Group (SASG).

BACKGROUND: Laparoscopic adrenalectomy has become the standard of care for treating adrenal tumors. Conversion from laparoscopic adrenalectomy to an open approach during surgery may be necessary in some cases. This study aimed to identify the risk factors for open conversion of laparoscopic adrenalectomy. METHODS: Retrospective analysis of all consecutive patients undergoing lateral transperitoneal laparoscopic adrenalectomy in six endocrine surgery units of the Spanish Adrenal Surgery Group (SASG) between January 2005 and December 2017. Demographic, clinical, surgical, and histopathologic characteristics were recorded. Risk factors for conversion were assessed by logistic regression analysis. RESULTS: Of a total of 865 patients included in the study, 58 (6.7%) required conversion to open surgery. In the univariate analysis, factors associated with conversion from laparoscopic to open adrenalectomy were body mass index (BMI) ≥ 30 kg/m2 (P = 0.002), previous abdominal surgery (P = 0.015), tumor size > 5 cm (P = 0.001), and surgery for pheochromocytoma (P = 0.034). In the multivariate analysis, independent risk factors were BMI ≥ 30 kg/m2 [odds ratio (OR) 4.26, 95% confidence interval (CI) 2.81-8.75; P = 0.001], tumor size > 5 cm (OR 10.15, 95% CI 4.24-28.31; P < 0.001), and surgery for pheochromocytoma (OR 2.96, 95% CI 1.89-11.55; P = 0.015). CONCLUSIONS: Obesity, tumor size, and pheochromocytoma as the type of adrenal tumor were predictive factors for intraoperative conversion from laparoscopic to open adrenalectomy. Preoperative assessment of these characteristics should be valuable to clinicians in discussing conversion risk in patients and for surgical planning.

Weight difference between double parathyroid adenomas is the cause of false-positive IOPTH test after resection of the first lesion.

BACKGROUND: Some patients with double parathyroid adenoma show a greater than 50% decline in intraoperative parathyroid hormone (IOPTH) after resection of the first lesion. The present study was designed to test the hypothesis that significant adenoma weight differences may explain this inappropriate decline of IOPTH. METHODS: We reviewed prospective database records at two tertiary institutions. Patients with a histopathologic diagnosis of double adenoma and no familial history of hyperparathyroidism were included. Diagnosis of double adenoma was confirmed either preoperatively (double uptake), intraoperatively (bilateral exploration), or at reintervention. IOPTH was determined following the Miami protocol. The 10-min postexcision sample was considered as the 0-min sample for IOPTH determinations at the time of resection of the second lesion. RESULTS: Thirteen patients met the inclusion criteria. After resection of the first lesion, IOPTH failed to decline in four patients and a second adenoma was removed. They had similar weight (404 vs. 598 mg). In nine patients IOPTH showed a false greater than 50% decline. These patients had the largest adenoma removed first (846 +/- 226 mg), and only two had normal PTH serum concentrations 10 min after resection. The second adenoma was always smaller (284 +/- 177 mg; P = 0.02) and its resection either during the same operation (7 cases) or at reoperation (2 cases) led to normalization of IOPTH at 10 min in all cases. CONCLUSIONS: Two-thirds of patients with double parathyroid adenoma show a false-positive decline of IOPTH after resection of the first adenoma. This appears to be due to the initial removal of the larger lesion.

[Modifications in intact parathyroid hormone, total serum calcium, and ionized calcium levels in the surgery of primary hyperparathyroidism for single adenoma]. / Modificaciones de paratirina intacta, calcio sérico total y calcio ionizado en la cirugía por hiperparatiroidismo primario por adenoma único.

INTRODUCTION: We evaluated total serum calcium (TSC) and ionized calcium (IC) and their correlation with intraoperative intact parathyroid hormone (iPTH) in the surgery of primary hyperparathyroidism in patients with a single adenoma. MATERIAL AND METHOD: We performed a prospective, blind trial with determination of iPHT, TSC and IC in a cohort of surgical patients (n = 279; 244 were valid for the study) who underwent surgery in the Department of Surgery, Hospital de Cruces, between October 1999 and April 2006. Total calcium, ionic calcium and iPTH were measured in the outpatient department, on admission and intraoperatively (at anesthesia induction and every 5 minutes after surgical excision). RESULTS: Levels of calcium and iPTH were corrected in 234 (95.9%) patients. iPTH decreased from abnormal preoperative values of 294.43 +/- 286.38 pg/ml to 97.89 +/- 121.01 mg/dl (minute 5), 58.58 +/- 58.37 pg/ml (minute 10), 44.62 +/- 54.77 pg/ml (minute 15), and 38.42 +/- 51.72 pg/ml (minute 20). TSC decreased from preoperative values of 10.93 +/- 1.04 mg/dl to 10.2 +/- 0.97 mg/dl (minute 5), 10.17 +/- 1.00 mg/dl (minute 10), 10.12 +/- 0.98 mg/ml (minute 15), and 10.09 +/- 1.03 mg/ml (minute 20). The results for ionized calcium were as follows: 4.90 +/- 0.63 mg/dl at induction, 4.84 +/- 0.61 mg/dl (minute 5), 4.84 +/- 0.66 mg/dl (minute 10), 4.82 +/- 0.63 mg/dl (minute 15), and 4.82 +/- 0.63 mg/dl (minute 20). Frozen samples were conclusive for parathyroid tissue (19.56 +/- 15.3 after excision). CONCLUSIONS: Intraoperative total calcium levels may help to predict adequate elimination of parathyroid tissue in primary hyperparathyroidism when intraoperative iPTH is not available. Ionized calcium levels did not show the same decrease.