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