minimally invasive parathyroidectomy in treatment of primary hyperparathyroidism dr. dennis ck ng...
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Minimally Invasive Parathyroidectomy
In treatment of primary hyperparathyroidism
Dr. Dennis CK NgPYNEH
18-9-2004
First Parathyroidectomy
• First successful parathyroidectomy– Vienna in 1925– Felix Mandl– Bilateral exploration under LA, with single
enlarged gland resection– Disease recurred and died of uncontrolled
hypercalcaemia 6 years later
Mandl F., Wien Klin Wochenshr Zebtral 1926; 143: 245-284
Bilateral Neck Exploration
• GA
• Collar incision
• Bilateral neck exploration
• Identify of all 4 glands
• Removal of the diseased glands
→ Cure rate : 70-97%
Feasibility of Minimally Invasive Parathyroid operation
• Base on
– Disease characteristics
– More accurate pre-op localization tools
– Less traumatic surgical approach
Disease Characteristics
• Solitary lesion is more commonRoutine bilateral exploration is not indicated
if accurate pre-op. localization availableExcision of a small 1-2 cm lesion only
Julia AS, Udelsman R, 2003
Pre-operative Localization
Sensitivity
MIBI (Technetium-99m sestamibi scan) 90%
USG (Ultrasound scan) 60 - 90%
CT (Computed tomography) 80%
MRI (Magnetic resonance imaging) 80%
MIBI Scan
Daphne W. Denham MDA and James Norman, 1997
Julia AS, Udelsman R, 2003
Minimally Invasive Parathyroidectomy Surgical Approaches
• Unilateral neck exploration under LA• Under LA / regional block• MIBI scan & USG• Small incision• Most popular
• Radio-guided with focus incision• Gamma probe• Accurate localization
• Videoscopic assisted / Endoscopic• Can have contralateral neck exploration• Learning curve
Endoscopic Approach
• Low insufflation pressure (5-8 mmHg)
• Strap muscle retracted
• Thyroid gland mobilized medially
• Parathyroid gland identified and resected
Systemic Review of Minimally Invasive Parathyroidectomy
• The ASERNIP-S Management Committee• Council of the Royal Australasian College
of Surgeon• June 2001• Meta-analysis
ASERNIP-S, 2001
Source
• All original published studies
• Medline, Current Contents, Embase, The Cochrane Library
• 1966 - 2000
ASERNIP-S, 2001
Author Year Evidence Design Approach Patient No
Smit et al. 2000 III Case Control Scan-directed unilateral exploration 84
Ito 2000 III Case Control Scan-directed unilateral exploration 91
Martin et al. 2000 III Case Control Unilateral exploration, +/- scan 59
Kountakis et al. 1999 III Case Control Scan-directed unilateral exploration 24
Boggs et al. 1999 III Historical Control Scan-directed unilateral exploration 133
Chen et al. 1999 III Historical Control Scan-directed unilateral exploration 33
Gupta et al. 1998 III Case Control Scan-directed unilateral exploration 21
Ammori et al. 1998 III Case Control Scan-directed unilateral exploration 29
Russel et al. 1990 III Case Control Scan-directed unilateral exploration 48
Lucas et al. 1990 III Historical Control Scan-directed unilateral exploration 19
Tibblin et al. 1991 III Case Control Unilateral exploration 50
Westerdahl et al. 2000 IV Case Series Unilateral exploration 86
Dackiw et al. 2000 IV Case Series Scan-directed unilateral exploration 26
Inabnet et al. 1999 IV Case Series Scan-directed unilateral exploration 230
Moore et al. 1999 IV Case Series Unilateral exploration +/- scan 48
Purcell et al. 1999 IV Case Series Scan-directed unilateral exploration 61
Song et al. 1999 IV Case Series Scan-directed unilateral exploration 91
Sofferman et al. 1998 IV Case Series Scan-directed unilateral exploration 16
Robertson et al. 1992 IV Case Series Scan-directed unilateral exploration 10
Uden et al. 1990 IV Case Series Scan-directed unilateral exploration 50
ASERNIP-S, 2001
Author Year Evidence Study Approach Patient No.
Microcoli et al. 1999 II RCT Video-assisted 20
Delbridge et al. 2000 III Case Control Endoscopic-assisted 35
Gauger et al. 1999 III Case Control Endoscopic-assisted 24
Chowbey et al. 1999 IV Case series Video-assisted 3
Dralle et al. 1999 IV Case series Video-assisted 13
Henry et al. 1999 IV Case series Video-assisted 22
Miccoli et al. 1998 IV Case series Video-assisted 20
Goldstein et al. 2000 III Case Control Radio-guided 20
Flynn et al. 2000 III Case Control Radio-guided 39
Norman et al. 2000 IV Case series Radio-guided 17
Norman Denham 1998 IV Case series Radio-guided 21
ASERNIP-S, 2001
Conclusion
• Scan directed Unilateral Neck Exploration– Level III/IV evidence– Local anaesthesia– Lesser morbidity– Shorter operative time– Shorter hospital stay
ASERNIP-S, 2001
• Radio-Guided Parathyroidectomy– Level III/IV evidence– Local anaesthesia– Lesser morbidity– Increased level of radiation– Need accurate timing of radioisotope
administration
ASERNIP-S, 2001
• Video-Endoscopic Parathyroidectomy– Level II/III evidence– Success rate comparable– General anaesthesia– 5% conversion rate– Shorter operative time– Shorter hospital stay
ASERNIP-S, 2001
QMH QEH
Author Lo CY et al. CH Wong et al.
Year 1999 - 2002 2002
Patient No. 66 11
Study design Case series Historical control
Pre-op localization
MIBI + USG MIBI +/- USG
Surgical approach
Endoscopic assisted
Unilateral exploration (lateral approach)
Quick PTH Yes Yes
Cure rate 100% 100%
Conversion 8 2
Hong Kong Experience
Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy
WR Sackett in 2003
• Survey– Members of international association of
endocrine surgeon– 160 surveys completed
Results
• 59% surgeon, on 44% of patient• Approach
– 73% scan directed technique with small incision
– 27% video-assisted / endoscopic
• Geographic difference– 59% surgeon in America– 56% surgeon in Australia– 49% surgeon in Europe or Middle East
Sackett WR et. Al., Arch Surg 2003; 138(9): 1024
Trend
Bilateral exploration
Unilateral exploration (GA)
Minimal InvasiveUnilateral exploration under LA
Radioguided focused approach
Endoscopic / videoscopic assisted
Which is the BestBilateral Unilateral
under LARadioguided Endoscopic
Pre-operative imaging
No Yes Yes Yes
Pathology All Single adenoma
Single adenoma
Single adenoma
LA/GA GA LA LA GA
Cost Cheap Intermediate Intermediate Expensive
Learning curve
Short Short Short Long
Irradiation No Low High Low
Recovery Days Hours Hours Hours
Cure rate No Difference
Complication No Difference
Conclusion
• World trend directed to minimally invasive approach
• Comparable results
• Similar complication rates
• Less operative time
• Shorter hospital stay
Ways to Go
• Need randomization trial
• Cost
• Diversity of methods
• Need further standardization