Original Article
Surgery in Primary Hyperparathyroidism: Extensive Personal Experience

https://doi.org/10.1016/j.jocd.2012.11.007Get rights and content

Abstract

Parathyroidectomy is the optimal treatment for primary hyperparathyroidism (PHPT) and provides a cure in the vast majority of cases. Over the last 2 decades, improvements in preoperative localization and the development of intraoperative parathyroid hormone monitoring have opened the door for new surgical approaches to parathyroidectomy. Minimally invasive parathyroidectomy is performed under regional or local anesthesia. It requires less surgical dissection resulting in decreased trauma to tissues and is more effective and less costly than traditional bilateral cervical exploration. This article reviews our approach reflecting advances in preoperative localization, anesthetic techniques, and intraoperative management of patients undergoing parathyroidectomy for the treatment of PHPT.

Introduction

Mandl (1) performed the first successful parathyroidectomy in 1925. Under local anesthesia and without the aid of preoperative imaging, he identified 3 normal parathyroid glands and removed a single enlarged parathyroid gland, resulting in a dramatic cure. Although in the ensuing decades, standard surgical management came to involve bilateral cervical exploration under general anesthesia, the surgery continued to require identification of all 4 parathyroid glands. However, the realization that the etiology of approx 85% of cases of primary hyperparathyroidism (PHPT) is a single adenoma along with advances in preoperative imaging, regional anesthetic techniques, and the availability of intraoperative parathyroid hormone (PTH) monitoring has opened the door for less invasive techniques. As opposed to bilateral cervical exploration, minimally invasive parathyroidectomy (MIP) uses unilateral neck exploration under regional and/or local anesthesia. Unilateral focused cervical exploration for PHPT was first introduced in 1975 with the side to be explored determined by palpation, esophageal imaging, venography, or arteriography 2, 3, 4. The technique was advocated as a means of reducing the cost and morbidity of surgery while maintaining cure rates (5). Today, MIP is performed after preoperative parathyroid localization, including sestamibi scans with single-photon emission computed tomography (SPECT), ultrasonography, and more recently high-quality 4-dimensional computed tomography (4DCT) scans. An intraoperative PTH (IOPTH) assay is used to confirm decreased PTH to ensure the adequacy of the resection. Of note, other nonconventional approaches have also been used including video-assisted, radioguided, and endoscopic parathyroidectomy.

Section snippets

Indications for MIP and Conventional Parathyroidectomy

Indications for parathyroidectomy whether by traditional bilateral cervical exploration or by MIP are symptomatic disease or asymptomatic PHPT with features in accordance with published guidelines 6, 7. Symptoms may include subtle neurocognitive dysfunction with fatigue, mood swings, anxiety, and depression 8, 9, 10. Multiple studies have shown improvement in neurocognitive function especially in relation to mood and anxiety in patients who undergo successful parathyroidectomy 11, 12, 13, 14.

A

Preoperative Imaging

Over the past 2 decades, the development and refinement of parathyroid imaging (sestamibi-technetium 99m scintigraphy, ultrasonography, and 4DCT) have ushered in an evolution in the surgical approach to PHPT. The most established modality is sestamibi-SPECT, which generates 3-dimensional images 19, 20, 21. Initially developed for cardiac scintigraphy, technetium 99m methoxyisobutylisonitrile (sestamibi) was incidentally found to concentrate in enlarged parathyroid glands (22). As a monovalent

Anesthesia

Conventional bilateral cervical parathyroid exploration is performed under general anesthesia with placement of either an endotracheal tube or a laryngeal mask airway. However, at high-volume centers, an increasing number of cases are being performed under monitored anesthesia care with local or regional anesthesia (41). At our institution, the surgeon performs the regional block by injecting 20 mL of 1% lidocaine containing 1:100,000 epinephrine unilaterally at Erb's point (located on the

Intraoperative PTH Monitoring

Intraoperative PTH monitoring was first introduced in 1990 and allowed for a biochemical alternative to 4-gland visualization. Previously, direct visualization of all 4 parathyroid glands was necessary to rule out multiglandular disease. The feasibility of intraoperative PTH monitoring is because of the relatively short half-life of PTH (3–5 min).

In the preoperative holding area, an intravenous catheter is inserted in the antecubital fossa to obtain a baseline PTH level. In the operating room,

Complications

The complications of parathyroidectomy whether by MIP or by traditional bilateral cervical exploration are principally hematomas, recurrently laryngeal nerve injury, and hypocalcemia (4). However, because of the use of regional anesthesia, patients undergoing MIP are spared the complications of endotracheal intubation, which is associated with vocal cord changes and damage (42). In a prospectively collected and retrospectively reviewed series of 1650 consecutive parathyroidectomies performed

Recurrent or Persistent PHPT

Despite the high success rate of both MIP and conventional bilateral cervical exploration, a small percentage of patients present with either persistent or recurrent PHPT. Persistent PHPT occurs when hypercalcemia develops within 6 mo of initial parathyroid surgery. When hypercalcemia develops after 6 mo of normocalcemia, this represents recurrent disease (52). In general, persistent PHPT implies inadequate resection, whereas recurrent PHPT indicates development of new disease. Several causes

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    Copyright © 2013 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.