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The outcome of surgical treatment of primary hyperparathyreoidism (PHP) is largely dependent on the radicality of the operation. This is sometimes difficult due to abnormal location of the glands. The use of intraoperative parathormone assay (IOPTH) and a handheld gamma-ray detector (HGRD) might influence the outcome of treatment.The aim of the study was to assess the feasibility of intraoperative parathormone assay and handheld gamma ray detector in surgical treatment of primary hyperparathyroidism.Material and methods. Prospective analysis of the treatment outcomes of patients with PHP undergoing surgery at the Dept. of General and Endocrine Surgery was accomplished. The patients were divided into two groups: G1 - patients in whom HGRD was used to intraoperatively locate the parathyroid glands; G2 - patients in whom both the HGRD and IOPTH were utilized. In all of the patients preoperative serum calcium and PTH measurements were taken. Thirty minutes before the scheduled start of the operation, patients from both groups received an 800 MBq dose of the Tc-MIBI radiomarker. Gamma radiation measurements were performed with the use of a Gamma Finder handheld device. In patients from the G2 group, serum PTH was assessed 10 minutes after the removal of the last gland. In the G1 group, bilateral neck exploration was performed. In the G2 group, the operation was brought to a close after the Miami criterion was met; in most cases, the surgery was limited to unilateral neck exploration.Results. Between 2007 and 2009 25 patients underwent surgery for PHP (group G1 - 12, group G2 - 13). There was one case of persistent hyperparathyroidism in group G1. All of the parathyroidectomies in group G2 were successful. No difference in the length of hospital stay were noted between the groups. The duration of surgery was longer in group G2.Conclusions. Surgical treatment of PHP with the combined use of a handheld gamma radiation detector and an intraoperative parathormone assay yields satisfactory results despite limited tissue preparation.
The aim of the study was to present the experience of the authors in employing minimally invasive radio-guided parathyroid reoperative surgery (MIRP) combined with intraoperative iPTH assay (IOPTH) in persistent and recurrent primary hyperparathyroidism (PHP) and in patients with a history of thyroidectomy.Material and methods. A prospective analysis included the results of 12 reoperations performed employing the minimally invasive method using an intraoperative hand-held gamma camera (Gamma Finder II) following IV administration of 10 mCi 99mTc-MIBI, combined with IOPTH (Future Diagnostics) in six patients with persistent PHP, one patient with recurrent PHP and five patients after subtotal strumectomies without planned parathyroidectomies (F: M = 10 : 2; mean age 54±10.7 years; mean preoperative iPTH concentration 233.3±80.6 ng/L). Prior to surgery, all the patients had been subjected to diagnostic imaging studies (parathyroid scintiscans, USG of the neck, in selected cases, SPECT and CT of the neck and mediastinum). The validity of MIRP and IOPTH in minimizing the extent of intraoperative neck exploration was assessed. Therapeutic results were evaluated in six-month postoperative follow-up.Results. All the patients were cured. The mean incision length was 3.5±0.5 cm. The mean operative time was 49±10 min. All the patients had a single parathyroid adenoma (in five cases - in the tracheoesophageal groove, in 3 - in the retroesophageal region in the neck, in one - in the retroesophageal region in the superior posterior mediastinum, in one - in the thyrothymic ligament and in two - in the thymus). The mean ratio of adenoma to background neck radioactivity was 25.7±5.4%. The mean iPTH concentration 10 min after adenoma resection was 38.5±17.4 ng/L. No postoperative complications were noted. In six-month postoperative follow-up, all the patients demonstrated normal serum calcium values.Conclusions. MIRP has proven to be highly successful in reoperations in patients with PHP. The procedure performed using a hand-held gamma camera allows for a safe execution of a minimally invasive procedure focused on resection of a single parathyroid adenoma, eliminating the need for bilateral neck exploration, which is extensive, time-consuming and associated with a higher risk of damaging the recurrent laryngeal nerve and normal parathyroids.
At present, the majority of patients with sporadic primary hyperparathyroidism (pHPT) qualify to minimally invasive parathyroidectomy (MIP). Nevertheless, in some patients, especially those with multiglandular parathyroid disease, achieving normocalcemia necessitates bilateral neck exploration (BNE).The aim of the study was evaluation of current indications for BNE and results obtained employing this method in an endocrine surgery referral center.Material and methods. A prospective analysis included 385 patients with pHPT qualified to parathyroidectomy (300 to MIP and 85 to BNE procedures) in the period between 12/2002 and 05/2008. Prior to the procedure, all the patients underwent preoperative imaging diagnostic studies (scintiscans of the parathyroids and ultrasound of the neck). Intraoperative parathormone assay was carried out in the course of all the operations. Indications for BNE and therapeutic results were evaluated.Results. The most common indication for BNE was lack of preoperative location of a parathyroid adenoma in imaging studies aiming either at lateralization or regionalization (49.4%), followed by concomitant thyroid pathology that required surgical treatment (23.5%), MEN 1 syndrome (12.9%), long-term lithium therapy (5.9%), refusal of the patient to grant informed consent to a minimally invasive parathyroidectomy (5.9%) and MEN 2A syndrome (2.4%). In the discussed group, 31 subtotal parathyroidectomies were performed, along with ten resections of two parathyroid adenomas and 44 resections of single parathyroid adenomas. Intraoperative iPTH assay affected the extent of parathyroid tissues resection in eight (9.4%) cases. One case of persistent and one case of recurrent hyperparathyroidism were noted in the follow-up of mean 37.4 ± 19.4 months postoperatively.Conclusions. In an endocrine surgery referral center, BNE is a procedure of choice in patients suspected of multiglandular parathyroid disease (MEN 1 and 2A, familial pHPT, long-term lithium therapy), in cases when a pathological parathyroid has not been located preoperatively and in patients which refuse their consent to MIP. Supplementing BNE with intraoperative iPTH assay allows for maintaining the highest quality of surgical treatment.
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