Parathyroid adenoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

Surgery is the mainstay of treatment for parathyroid adenoma. Symptomatic parathyroid adenoma is an indication for surgery. However, there are guidelines for surgery in asymptomatic parathyroid adenoma. Surgery for parathyroid adenoma is parathyroidectomy which includes bilateral neck exploration and minimally invasive parathyroidectomy. Most commonly done surgery for parathyroid adenoma is minimally invasive parathyroidectomy (MIP). There are various types of MIP. MIP provides excellent postoperative cure rates comparable to bilateral neck exploration (BNE) with less complications than BNE. This is due to precise preoperative localization of hyper-functioning parathyroid gland and use of intraoperative parathyroid hormone (IOPTH) monitoring for predicting post-surgical success (postoperative normocalcemia).

Indications

  • Symptomatic primary hyperparathyroidism due to parathyroid adenoma is an indication for surgery. However, there are guidelines for surgery in asymptomatic primary hyperparathyroidism due to parathyroid adenoma.[1]
Guidelines for Surgery in Asymptomatic PHPT
Factors Criteria
Serum calcium
  • 1.0 mg/dL (0.25 mmol/L) (>upper limit of normal)
Skeletal
Renal
Age
  • <50
  • Note(1): Patients need to meet only one of these criteria to be advised to have parathyroid surgery. They do not have to meet more than one.
  • Note(2): Surgery is also indicated in patients for whom medical surveillance is neither desired nor possible and in patients opting for surgery, in the absence of meeting any guidelines, as long as there are no medical contraindications.
  • Note(3): Consistent with the position established by the International society of clinical densiometry (ISCD), the use of Z-scores instead of T-scores is recommended in evaluating Bone mineral density (BMD) in premenopausal women and men younger than 50 years.
  • Note(4): Most clinicians will first obtain a 24-hour urine for calcium excretion. If marked hypercalciuria is present (>400 mg/d [>10 mmol/d]), further evidence of calcium-containing stone risk should be sought by a urinary biochemical stone risk profile, available through most commercial laboratories. In the presence of abnormal findings indicating increased calcium-containing stone risk and marked hypercalciuria, a guideline for surgery is met.

Surgery

  • Surgery is the mainstay of treatment for parathyroid adenoma.

Minimally invasive parathyroidectomy

  • Most commonly done surgery for parathyroid adenoma is minimally invasive parathyroidectomy (MIP).[2]
  • MIP is may done in loco-regional anesthesia or general anesthesia.
  • Various techniques for MIP includes:[3]
    • Open minimally-invasive parathyroidectomy (OMIP)[4]
    • Minimally-invasive radio-guided parathyroidectomy (MI-RP)
    • Endoscopic parathyroidectomy (EP)[5]
    • Minimally invasive video-assisted parathyroidectomy (MIVAP)[6]
    • Video-assisted parathyroidectomy through a lateral approach (VAP-LA)[7]
    • Minimally-invasive radio-guided parathyroidectomy[8]
  • Open minimally-invasive parathyroidectomy (OMIP) is the most commonly used minimally invasive parathyroidectomy.[9]
  • MIP increases safety and cost-effectiveness in patients with preoperative localization of hyper-functioning parathyroid glands.
  • Hyper-functioning parathyroid glands are excised and operative cure is confirmed by rapid intraoperative PTH assay.[10][11]
  • MIP provides excellent postoperative cure rates comparable to bilateral neck exploration. This is due to precise preoperative localization of hyper-functioning parathyroid gland and use of intraoperative parathyroid hormone (IOPTH) monitoring for predicting post-surgical success (postoperative normocalcemia).[12][13]

Bilateral neck exploration

  • Bilateral neck exploration (BNE) is the traditional surgery for hyperparathyroidism due to parathyroid adenoma.
  • BNE is usually done under general anesthesia.
  • BNE is used less commonly as outcomes is comparable to MIP.

Minimally invasive parathyroidectomy (MIP) is preferred over BNE due to following reasons:[14][15][13]

  • MIP has similar success rate as BNE.
  • Rate of complications is low in MIP compared to BNE.
  • Operating time is reduced to almost half in MIP compared to BNE.
  • Hospital stay is reduced by seven folds after MIP compared to BNE.
  • MIP results in a mean cost savings of $2,693 per procedure compared to BNE accounting to approximately 50% reduction in total hospital charges.
  • MIP has lower incidence of post-operative severe symptomatic hypocalcemia compared to BNE.

References

  1. ↑ Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C; et al. (2014). "Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop". J Clin Endocrinol Metab. 99 (10): 3561–9. doi:10.1210/jc.2014-1413. PMC 5393490. PMID 25162665.
  2. ↑ Miccoli, P.; Monchik, J. M. (2000). "Minimally invasive parathyroid surgery" (PDF). Surgical Endoscopy. 14 (11): 987–990. doi:10.1007/s004640000192. ISSN 0930-2794.
  3. ↑ Bellantone R, Raffaelli M, DE Crea C, Traini E, Lombardi CP (2011). "Minimally-invasive parathyroid surgery". Acta Otorhinolaryngol Ital. 31 (4): 207–15. PMC 3203720. PMID 22065831.
  4. ↑ Agarwal G, Barraclough BH, Reeve TS, Delbridge LW (2002). "Minimally invasive parathyroidectomy using the 'focused' lateral approach. II. Surgical technique". ANZ J Surg. 72 (2): 147–51. PMID 12074068.
  5. ↑ Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT (1998). "Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy". Surg Endosc. 12 (3): 202–5, discussion 206. PMID 9502695.
  6. ↑ Miccoli P, Berti P, Conte M, Raffaelli M, Materazzi G (2000). "Minimally invasive video-assisted parathyroidectomy: lesson learned from 137 cases". J Am Coll Surg. 191 (6): 613–8. PMID 11129809.
  7. ↑ Henry JF, Defechereux T, Gramatica L, de Boissezon C (1999). "Minimally invasive videoscopic parathyroidectomy by lateral approach". Langenbecks Arch Surg. 384 (3): 298–301. PMID 10437620.
  8. ↑ Norman J, Chheda H, Farrell C (1998). "Minimally invasive parathyroidectomy for primary hyperparathyroidism: decreasing operative time and potential complications while improving cosmetic results". Am Surg. 64 (5): 391–5, discussion 395-6. PMID 9585770.
  9. ↑ Sackett WR, Barraclough B, Reeve TS, Delbridge LW (2002). "Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy". Arch Surg. 137 (9): 1055–9. PMID 12215160.
  10. ↑ Udelsman R, Pasieka JL, Sturgeon C, Young JE, Clark OH (2009). "Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop". J Clin Endocrinol Metab. 94 (2): 366–72. doi:10.1210/jc.2008-1761. PMID 19193911.
  11. ↑ Fraker DL, Harsono H, Lewis R (2009). "Minimally invasive parathyroidectomy: benefits and requirements of localization, diagnosis, and intraoperative PTH monitoring. long-term results". World J Surg. 33 (11): 2256–65. doi:10.1007/s00268-009-0166-4. PMID 19763685.
  12. ↑ Carneiro DM, Irvin GL (2000). "Late parathyroid function after successful parathyroidectomy guided by intraoperative hormone assay (QPTH) compared with the standard bilateral neck exploration". Surgery. 128 (6): 925–9, discussion 935-6. doi:10.1067/msy.2000.109964. PMID 11114625.
  13. ↑ 13.0 13.1 Irvin GL, Prudhomme DL, Deriso GT, Sfakianakis G, Chandarlapaty SK (1994). "A new approach to parathyroidectomy". Ann Surg. 219 (5): 574–9, discussion 579-81. PMC 1243192. PMID 8185406.
  14. ↑ Udelsman R (2002). "Six hundred fifty-six consecutive explorations for primary hyperparathyroidism". Ann Surg. 235 (5): 665–70, discussion 670-2. PMC 1422492. PMID 11981212.
  15. ↑ Chen H (2002). "Surgery for primary hyperparathyroidism: what is the best approach?". Ann. Surg. 236 (5): 552–3. doi:10.1097/01.SLA.0000032950.78031.E6. PMC 1422610. PMID 12409658.

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