Endoscopic Parathyroid Surgery

Endoscopic Parathyroid Surgery

Danny Yacoub MDGeorge Ferzli MD, FACS

Professor of Surgery, SUNY

SUNY Downstate Medical Center

Lutheran Medical Center

The Legacy of Ivar Sandstrom (1852–1889)

• New Gland, the last major organ to be recognized in man, 1880.

• Discovery met with silence.

• First publication rejected.

• Two national prizes.

I.V. Sandstrom, On new gland in man and several mammals, Bull Inst Hist Med 6 (1938), pp. 192–222.c

“to each gland there are

often one or more small

arteriole branches from the

inferior thyroid artery”





First Parathyroid Surgery

• 1925 by Felix Mandl in Vienna, Austria

• Patient had resolution of severe symptoms

associated with the disease after surgery.

Niederle BE etal, J Am Coll Surg. 2006

Captain Charles Martell

• First to be surgically treated in US, 1932.

• Underwent 6 unsuccessful neck explorations.

O. Cope, The story of hyperparathyroidism at the Massachusetts General Hospital, N Engl J Med 274 (1966), pp. 1174–1182

Edward Churchill (1895-1972)

• He performed his 7th operation

• Median sternotomy

• Successful operation

O. Cope, The story of hyperparathyroidism at the Massachusetts General Hospital, N Engl J Med 274 (1966), pp. 1174–1182

Unfortunately, Martell died soon after due to tetany and complications of nephrolithiasis.

Parathyroid Surgery

New Technology:• IOPTH• Tieless surgery• Intraoperative nerve monitoring• Radioguided surgery• Needle localization• Video assisted surgery• Robotic surgery

Minimally Invasive Parathyroid Surgery

Why MIVAP? …Cosmetic Results

Open surgery scar Minimally invasive / endoscopic scars

Minimally invasive parathyroid surgery:

Endoscopic• Central• Lateral• “Other” (transaxillary,

transpectoral, transoral)

Minimally invasive• MIVAP (min. invasive video

assisted parathyroidectomy)

• Robotic assisted

Inferior parathyroid release in minimally invasive thyroidectomy

MIVAP-Results

• MIVAP yield equivalent endocrine results as open procedure

• Oncologic result is equivalent in selected patients

• Equivalent safety profile as open procedures

• Postop pain is decreased

• Patient satisfaction with procedure and cosmetic result is significantly increased

MIVAP vs Open - Results

Miccoli et al., RCT, Surgery. 2001

1o end points:• pHPT• Hypocalcemia (All patients were cured)

2o end points: MIVAP vs. OMIP• OR time: similar, ave. 42min vs. 49min (p=0.22)• scar length: ave. 17.2mm vs. 30.8mm (p<0.001)• pain intensity: 4hr: 25 vs. 32, 8hr: 26 vs.32

Cosmetic satisfaction: • 1 month: 85% vs. 75% (p=0.006)• 6 months: No difference

Cost: $1,150 vs.1,015 (p<0.001) $$$$

MIVAP vs Open-Results

M. Barczynski et al.,World J Surg 2006

Parathyroid Surgery

• Single parathyroid adenoma (80%-87%)

• Double adenomas (2%-15%)

• Asymmetric 4-gland hyperplasia (10%-15%)

• Carcinoma (<1% of patients)

Preoperative Imaging

Non Invasive Imaging:• Sestamibi Scan• Ultrasound• CT scan• MRI• Positron Emission Tomography (PET) scan PET/CT

Invasive Imaging:• Parathyroid FNA• Arteriography and selective venous sampling for PTH

Parathyroid Locations

Possible locations of enlarged parathyroid glands in the neck and superior mediastinum with the use of an anteroposterior projection (A) and a lateral projection (B)

Udelsman R. Ann Surg 244:471-479, 2006

Aberrant Parathyroid Locations

Anatomic locations of abnormal parathyroid glands found at reoperation by single group. Most common ectopic sites mirror routes of descent of upper parathyroid glands (short migration path) and of lower parathyroid glands (longer migration path in association with thymus)

Wang CA. Parathyroid re-exploration. Ann Surg. 1977;186:140–145

Preoperative Parathyroid Localization

Ultrasonography: • Sensitivity 70-80%(less in MGD)• Specificity 40-100%

(Ammori, Ann R Coll Surg Engl. 1998;80:433–437)

CT and MRI:• Sensitivity 60-80% (80% when done with IV contrast)

(Weber, Radiol Clin North Am. 2000;38:1105–1129)

Scintigraphy ± intraoperative gamma probe:• 99mTc-Sestamibi ± SPECT:

• Sensitivity 85-95% (Originally described by Coakley et al., Nucl Med Commun. 1989;10:791–794)

• 99mTc-Tetrofosmin• provided it is used within a dual-tracer subtraction protoco(Gallowitsch et al., Invest Radiol. 2000;35:453–459)

Sestamibi

EctopicAdenoma

Hyperplasia

Sonogram / Sestamibi

Are additional Localization Studies and Referral indicated for patients with Primary Hyperparathyroidism Who have negative Sestamibi scan results? Elaraj, DM. Sippel, RS. Lindsay S. Sansano I. Duh QY. Clark OH. Kebebew E. Arch Surg Vol 145, No 6, 578-581 June 2010.

May 2005 - May 2007487 patients underwent 492 neck explorations (88% initial 12% reoperation).

339 underwent focused parathyroid surgery (69%).

447 Sestamibi scans were positive (91%) and 82% were true positive

In patients with negative Sestamibi scan, Sono was positive in 51% (43% true positive).

Patients with positive sestamibi when compared to patients with negative sestamibi:-Higher rate of single gland disease (87% vs 63%)-Lower rates of of double adenomas (6% vs 22%) and asymmetric hyperplasia (7% vs 15%).--No difference in the rate of ectopic glands.--No difference in the cure rate (97% vs 89%).

-Conclusion: Additional imaging with sonogram is helpful for selecting minimally invasive Parathyroidectomy in most patients with primary hyperparathyroidism who have negative Sestamibi scan results.

Intra operative PTH assay. Prospective 361 consecutive patients undergoing minimally invasive parathyroidectomy.Hwang RS et al. Ann Surg 2010;251:1122-1126.1- There is no role for IOPTH for Sestamibi positive patients.2- It will guide the surgeon in Sestamibi negative / positive sonogram patients: In these cases an inadequate fall in the 10- minute post excision PTH level was highly predictive of multi glandular disease.A Selective Bayesian approach to Intraoperative PTH monitoring.

A Rising IoPTH Level Immediately after Parathyroid Resection Are Additional Hyperfunctioning Glands Always Present? An application of the Wisconsin Criteria. Cook MR et al Ann Surg 2010;251 1127-1130.797 consecutive patients. 108 (14%) had a rising ioPTH 5 min after resection of a single parathyroid gland, 36 (33%) continued to have elevated levels and further exploration revealed additional hyperfunctioning glands. In 72 (67%) the ioPTH started to drop within 20 min of gland resection and in all cases correctly predicted operative success.

IOPTH / Sonogram

CT Sestamibi Fusion Scan

4D-CT Localization

• 45 patients underwent reoperative parathyroidectomy.

• The sensitivity of 4D-CT for localization was 88% compared with 54% for Sestamibi imaging.

• 4D-CT correctly localized (p=0.0003) and laterlized (p=0.005) hyperfunctional parathyroid tissue than Sestamibi did.

• Parathyroid Exploration in the Reoperative Neck: Improved Preoperative Localization with 4D-Computed Tomography.

Mortenson MM et al. JACS May 2008 Volume 206 No 5 pages 888-895.

CT Guidance

Ultrasound Guidance

MIVAT

Endoscopic Parathyroidectomy Prerequisite Conditions 1

1- The surgeon must be experienced in conventional parathyroid surgery and trained for endoscopic neck procedures

2- The patient must be carefully selected

3- The adenoma must be clearly localized

Patients Eligible for Endoscopic Parathyroidectomy

• No goiter

• No previous neck surgery

• Sporadic HPT I

Evaluation for Concomitant Thyroid Nodules and PHPT in Patients Undergoing Parathyroidectomy or Thyroidectomy

• 200 patients who underwent a parathyroidectomy

• 102 (51.1%) were found to have thyroid nodular disease

• Six percent of these 200 patients also had a thyroid malignancy

• Of the 326 patients who were primarily seen for thyroid disease, the incidence of PHPT was 3.1%

Morita S, etal, Surgery, 2008

Racial Disparity / Double Adenoma

AA12%

African Americans

14 (12.4%)

Non-African Americans

21(5.1%)

Sestamibi and Vitamin D Deficiency

• Prevalence of vitamin D deficiency in PHPT

• Predictive value of 25 (OH) D levels in having positive sestamibi scans.

428 consecutive patients who underwent preoperative sestamibiscintigraphy and a targeted parathyroidectomy for PHPT.

• Parathyroid sestamibi scanning is more useful for this subset of patients

Kandil. E. et al Arch of Otolaryngology, 2008

Adenoma Size and Biochemical Measurements

• Preoperative serum calcium and parathormone levels predict adenoma weight and volume in primary hyperparathyroidism for a single adenoma.

(Bindlish. Head Neck. 2002 Nov; 24 (11): 1000-3)

• More than a 50% decrease in preexcision iPTH levels and subsequent attainment of the normal range within 15 min is considered satsifactory.

(Ozimek et al. Surg Endosc. 2010 May 20)

• Adenoma weight may relate to the percentage decrease of iPTH levels at the 10-minute postparathyroidectomy interval.

(Moretz et al. Laryngoscope. 2007 Nov; 117 (11): 1957-60)

Endoscopic/Conventional Parathyroidectomy

(98-2005 / 970 HPT I)

• Endoscopic 538 (55.5%)

• Conventional 432 (44.5%)

Jean - Francois Henry Department of Endocrine Suregery, University Hopspital La Timone. Marseilles, France Endoscopic Parathyroidectomy: Why and When ? World Journal of Surgery Volume 32 Number 11, November 2008

Clear positive localization:• Posterior: lateral approach• Anterior: anterior approach

Negative or unclear localization:• Conventional approach



Contraindications: 432/970: 44.5 %

• Associated nodular goiter 174• No preoperative localization 107• Previous neck surgery 71• Suspicion of MGD 45• Acute HPT 8• Large tumor 7• Local anesthesia 9• Major ectopia 9• Spontaneous neck hematoma 2Jean - Francois Henry Department of Endocrine Suregery, University Hopspital La Timone. Marseilles, France Endoscopic Parathyroidectomy: Why and When ? World Journal of Surgery Volume 32 Number 11, November 2008


Endoscopic Parathyroidectomyin the Previously Radiated Neck

• May 2005-May 2007: 491 consecutive parathyroidectomies for primary hyperparathyroidism. 52 (12.6%) with history of neck radiation.

• In the radiation exposure group, 40 (76.9%) had a positive sestamibi scan vs 360 (81%) in the non radiated group.

• The radiation group was older at presentation (p=0.001) and the rate of previous history of thyroid cancer was higher (p=0.02).

• Patients with PHPT, previous RT, positive localization study and a normal thyroid ultrasound would be ideal candidates for minimally invasive parathyroidectomy.

Prior Head and Neck Radiation Exposure Is not a Contraindication to Minimally Invasive Parathyroidectomy. Rahbari R. et al JACS Vol210 No 6. 942-948 June 2010.

MIVAP -Technique

Bilateral Axillo-Breast (BABA)

Subcutaneous dissection bilaterally from the incision to the thyroid cartilage and the SCM

Axillary Approach

• First introduced by Ikeda, 2000

• 4-6 cm vertical skin incision in the axilla for camera port and two working ports

• 0.5 cm incision on the medial side of the anterior chest wall

Transaxillary Approach

Robotic Approach

Arm 1

Camera

Arm 2Arm 3

This approach was developed in South Korea by Dr. Woong Chung at Yonsei University College of Medicine in Seoul. He reported his experience with 338 patients

Confidential

Confidential

Confidential

Fourth arm trocar

External retractor

Connected with continuous suction

system

Maryland dissector

Harmonic curved shears

Confidential

The Cervical / Direct Approaches: - Anterior cervical approach - Lateral cervical approach - Video-assisted approach• Pros: Less pain, better cosmesis and shorter hospital stay• Cons: visible scars, not much different than open with

small incision

The Extra-cervical Approaches: - Axilla, chest or both.• Pros: scarless (in the neck)• Cons: extensive dissection, paresthesia, muscle

stiffness,operative time and learning curve

Endoscopic Parathyroidectomy

Conclusions

• Endoscopic parathyroidectomy is feasible and has good results.

• The key to success is patient selection and surgeon experience.


• Should be proposed in carefully selected patients.

• Has the main advantage of offering a magnified view and a light that permit a safe dissection.

• The lateral approach is particularly suitable for adenomas posteriorly located in the neck


• Small tumors

• Benign tumors

• No surgical reconstruction

Concomitant Thyroid Disease

The use of a double-tracer technique (123I/99mTc-sestamibi or 99mTcpertechnetate/99mTc-sestamibi) or (99mTc-sestamibi scintigraphy) combined with US examination might be useful in planning the type and extent of surgery:

• Bilateral neck exploration in the case of any PHPT patient with concomitantmultinodular goiter unilateral neck exploration in the case of a solitary parathyroid adenoma with concomitant nodular goiter located in the ipsilateral thyroid lobe

• Gamma probe guided minimally invasive parathyroidectomy (GP-MIP) in thecase of a solitary 99mTc-sestamibi-avid parathyroid adenoma with a normalthyroid gland endoscopic surgery in the infrequent case of a solitary 99mTc-sestamibi negative (but US positive) parathyroid adenoma with a normal thyroid gland.

Mariani et al. Journal of Nuclear Medicine Vol. 44 No. 9 1443-1458

• Conversions: 13.2%

• Operative time: 48' (16'-130')

• Complications-

Hematoma in sternocleidomastoid 3Definitive recurrent nerve palsy 1Capsular disruption 10Persistent HPT: 3Recurrent HPT: 1



CONVERSIONS 71/538: 13.2 % • Missed adenoma 18• Difficulties of dissection 16• QPTH assay true negative *18• QPTH assay false negative 4• Sestamibi false positive 11• Ultrasonography false positive 4

* 18 multiglandular diseases



Documents

Endoscopic Parathyroid Surgery