|
|
Ann Surg. 2000 September; 232(3): 331–339. | PMCID: PMC1421147 |
Copyright © 2000 Lippincott Williams & Wilkins, Inc. One Hundred Consecutive Minimally Invasive Parathyroid Explorations Robert Udelsman, MD, MBA, FACS,* Patricia I. Donovan, RN, BSN,* and Lori J. Sokoll, PhD† From the Departments of *Surgery and †Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
Objective To review the outcomes of 100 consecutive minimally invasive parathyroid explorations. Summary Background Data Minimally invasive parathyroidectomy (MIP) has challenged the traditional approach of bilateral neck exploration for patients with primary hyperparathyroidism. Most patients with primary hyperparathyroidism have a single adenoma that when resected results in cure. It therefore appears logical to perform a directed approach to adenoma extirpation. MIP involves high-quality sestamibi images obtained with single photon emission computed tomography to localize enlarged parathyroid glands in three dimensions, limited exploration after surgeon-administered cervical block anesthesia, rapid intraoperative parathyroid hormone assay to confirm the adequacy of resection, and discharge within 1 to 3 hours of surgery. Methods MIP was offered to 100 selected consecutive patients during an 18-month period beginning in March 1998. Results Ninety-two cases were accomplished under cervical block anesthesia and 89 of these on an ambulatory basis. The cure rate was 100%, and there were no long-term complications. The mean hospital charge for MIP was less than 40% of that associated with traditional exploration. Conclusions Outpatient MIP appears to be the procedure of choice for most patients with primary hyperparathyroidism. The first successful parathyroidectomy for primary hyperparathyroidism was performed by Felix Mandl in Vienna in 1925. 1 The procedure was performed under local anesthesia, four parathyroid glands were identified, and an enlarged parathyroid gland was excised. The patient experienced cure with marked resolution of his symptoms and signs of hyperparathyroidism. 2 Thereafter, it became the standard of care in most institutions to perform bilateral neck explorations for primary hyperparathyroidism. The results in large series demonstrate cure rates that exceed 95%, with complication rates in the range of 1% to 2%. 3Despite the admirable results obtained in selected series, a group of surgeons has questioned the need for bilateral neck explorations for all patients with primary hyperparathyroidism. 4,5 This is based on the fact that 85% to 90% of patients with primary hyperparathyroidism have a single parathyroid adenoma that when excised results in cure. Therefore, if one could determine before surgery where the abnormal parathyroid gland was, a directed operation would appear to be logical. Several recent innovations have made this concept increasingly attractive: the exquisitely accurate preoperative diagnosis of primary hyperparathyroidism that can be achieved by measuring intact serum parathyroid hormone (PTH) levels; high-quality sestamibi scans, especially when combined with single photon emission computed tomography (SPECT); the availability and practical use of the intraoperative PTH assay, which can demonstrate resolution of PTH hypersecretion at the time of surgery; a resurgence of interest in local or regional anesthetic techniques; and referring physician and patient interest in minimally invasive techniques. We have adopted and modified the technique described by Dr. George Irvin at the University of Miami. 6,7 Our technique of minimally invasive parathyroidectomy (MIP) requires an accurate preoperative diagnosis of primary hyperparathyroidism, localization with sensitive sestamibi scans, and directed exploration using cervical block anesthesia and the intraoperative PTH assay. We have previously reported on our initial 33 patients who underwent this protocol. 8 The current series updates our experience to 100 consecutive patients and compares them with patients who underwent conventional parathyroid exploration during a concurrent interval. MIP Protocol All patients underwent parathyroid localization by preoperative 99mTc-sestamibi (sestamibi) scans imaged using SPECT. This outpatient procedure results in a three-dimensional reconstruction of the patient and, in the vast majority, demonstrates a single abnormal area of uptake. All scans were interpreted by both the radiology staff and the surgeon. In addition, the planar and SPECT images were available in the surgical suite. Patient with nonlocalizing sestamibi scans were excluded from the MIP protocol and underwent conventional exploration under general anesthesia. The selected patients were taken to the operating room, and a large-bore peripheral intravenous catheter was inserted through which blood could be obtained before and after tumor extirpation. Anesthesia Technique A superficial cervical block was administered by the surgeon on the ipsilateral side of the sestamibi-localized adenoma. 9 In most patients, a total volume of 20 mL 1% lidocaine containing 1:100,000 epinephrine was used. Supplementation of local anesthesia was used when required. In addition, intravenous sedation with propofol was administered by the anesthesiologist. The propofol was discontinued at least 5 minutes before PTH sampling because it can interfere with the PTH assay. The goal of sedation was to minimize patient anxiety while maintaining an awake, conscious patient who could phonate during the procedure and cooperate with the surgeon’s request to maintain hyperextension of the neck. To avoid a fire hazard, supplemental oxygen was not used unless necessary because the electrocautery was used in the surgical field. Intraoperative PTH Assay The rapid PTH assay is a commercially available modified immunochemiluminometric assay with a 7-minute incubation time (QuiCk-IntraOperative Intact PTH assay, Nichols Institute Diagnostics, San Juan Capistrano, CA). We have previously confirmed the validity of this assay by demonstrating an intraassay precision of 12.4% at 28 pg/mL and 10.6% at 278 pg/mL. In addition, the correlation coefficient between this rapid assay and our standard immunoradiometric assay is 0.94. 10 The assay uses two polyclonal antibodies directed against intact PTH, one coated on a polystyrene bead and another labeled with an acridinium ester. The entire assay cart is portable and is transported into the operating room, thereby eliminating specimen transit time. A baseline blood sample is obtained from a peripheral intravenous catheter after an adequate volume of saline-diluted blood has been removed. The sample is transferred into an EDTA vacutainer tube, mixed, and centrifuged, and 200 μL plasma is incubated with the acridinium-labeled signal antibody, to which the capture antibody-coated polystyrene bead is added. After incubation at 45°C with vibratory shaking, the bead is washed and the light output is measured in a luminometer after initiation of the chemiluminescent reaction. The elapsed time from blood sample to hormone value is 12 to 14 minutes. Intact PTH has a half-life of less than 5 minutes. In addition, because a parathyroid adenoma suppresses PTH secretion from normal parathyroid glands, plasma PTH levels decline rapidly after all hypersecreting parathyroid tissue has been removed. 11 Accordingly, a postresection plasma PTH level is measured 5 minutes after tumor extirpation. A 50% fall from the baseline level indicates an adequate resection. Surgical Exploration An abbreviated Kocher incision 1.25″ to 1.5″ long is made approximately one fingerbreadth above the sternal notch in most patients. For superior retroesophageal parathyroid adenomas, a higher incision is made along the anterior border of the ipsilateral sternocleidomastoid muscle. The goal is to identify the single parathyroid abnormality and remove it. No attempt is made to perform a conventional bilateral exploration. The ipsilateral recurrent laryngeal nerve is identified in most cases. The abnormal parathyroid gland is removed and the incision is closed while waiting 5 minutes before obtaining the postresection specimen. If there appears to be an unusual amount of manipulation of an enlarged parathyroid gland, a second baseline sample is obtained immediately after tumor extraction, because this sample is likely to be higher than the nonstimulated baseline. Under these circumstances, the higher of the two baseline values is used as the comparison baseline level. Frozen sections of the resected specimen are not routinely obtained. 12 However, the surgeon bivalves the resected specimen with instruments that are excluded from the surgical field. The gross intraoperative identification of a parathyroid gland is readily apparent in almost all cases. A postresection PTH level is obtained 5 minutes after tumor extraction, and if there is a 50% fall from baseline, the procedure is terminated. If there is an inadequate response, additional PTH samples are obtained, and if an inadequate response persists, the exploration is continued either on the ipsilateral or contralateral side of the neck. If the patient cannot tolerate additional exploration, conversion to general anesthesia is performed under controlled conditions and a standard, bilateral exploration is performed. Patients undergoing MIP are discharged to home after a 1- to 3-hour stay in the recovery room. They are instructed to recognize and notify the surgical staff if they encounter symptoms or signs of hypocalcemia, neck swelling, or infection. Outcome Measurements All patients were seen 1 week after surgery, at which time intact serum PTH, ionized calcium, and total calcium levels were obtained. In addition, long-term serum calcium levels were obtained. The following data were collected prospectively in all patients: surgical time, length of stay, total hospital charges, perioperative complications, and conversion rates to general anesthesia. Statistical analyses were performed by the Student t test or repeated measures analysis of variance, when appropriate. Statistical significance was defined as P < .05. Data are presented as mean ± SEM, unless otherwise indicated. Between March 1998 and October 1999, 150 patients were evaluated for hyperparathyroidism. Twelve patients had secondary hyperparathyroidism and one had mutiple endocrine neoplasia type 1 syndrome. Therefore, 138 patients were potential candidates for MIP. Thirty-eight of these patients were excluded for one or more of the following reasons: anticipation of a complicated remedial parathyroid exploration (n = 17), need for simultaneous thyroidectomy (n = 13) or simultaneous thyroidectomy and adrenalectomy (n = 1), two areas of sestamibi uptake on both sides of the neck (n = 8), negative sestamibi scan (n = 5), no sestamibi scan (n = 3), or an ectopic mediastinal parathyroid (n = 1). Therefore, of 138 potential candidates, 100 (72%) were offered MIP (). Ninety-five of these 100 MIP patients had not undergone previous cervical exploration. Five patients offered MIP had undergone previous cervical explorations, which included failed parathyroid exploration with thyroid lobectomy (n = 2), thyroid lobectomy (n = 2), or tracheostomy ( n = 1). All patients had biochemical evidence of primary hyperparathyroidism, as evidenced by an elevated total or ionized serum calcium level in conjunction with an elevated (>65 pg/mL) or inappropriate intact serum PTH level. The mean age of these patients was 57.3 ± 1.4 years, and 70% were women. The symptoms and signs of primary hyperparathyroidism in these 100 patients are shown in . Forty-four percent had demonstrable bone disease or nephrolithiasis; only 6% were “asymptomatic.” Sestamibi Findings The results of the sestamibi findings in the 100 MIP patients are compared with the surgical findings in Table 1. Because all patients had biochemically proven primary hyperparathyroidism and required a positive scan to be included in the study, by definition there were no true-negative scans. Most of these patients (89%) had true-positive scans: a single parathyroid adenoma was resected from the location predicted by the scan. In one of these patients, the surgeon interpreted a negative scan as positive and resected a parathyroid adenoma from the imaged location; this scan is reported as a true-positive finding. | Table 1. SESTAMIBI RESULTS |
Five patients had a single adenoma resected from an anatomically distant location relative to the sestamibi interpretation. Three patients had double adenomas, and in all cases the sestamibi scan demonstrated only a single area of uptake. Two patients suspected of having a single adenoma proved to have multigland hyperplasia. In all of the patients with double adenomas and multigland hyperplasia, the intraoperative PTH assay did not demonstrate an adequate decrement until all abnormal parathyroid tissue was resected. One patient with two areas of uptake proved to have only one parathyroid adenoma. MIP Of the 100 patients offered MIP, the procedure was accomplished under cervical blockade in 92. In eight patients, the procedure was converted to general anesthesia ( Table 2). Conversion indications were a relatively difficult exploration, the need for concomitant thyroidectomy, patient comfort, lack of an adequate PTH decrement after parathyroid resection, or an intraoperative seizure. Some patients had more than one indication. | Table 2. CONVERSION TO GENERAL ANESTHESIA |
The results of the intraoperative PTH assay in the 100 MIP patients are shown in . Ninety-nine percent of the patients demonstrated a decrease of PTH levels of greater than 50% after tumor excision. This reduction occurred within 5 minutes of parathyroid adenoma resection in 65 patients. Thirty-four patients demonstrated a delayed intraoperative drop of PTH levels. In five patients, more than one enlarged parathyroid gland was identified and the PTH did not demonstrate an adequate response until 2 (double adenomas, n = 3) or 3.5 (multigland hyperplasia, n = 2) enlarged parathyroid glands were resected. One patient did not satisfy the 50% reduction criteria. Her preoperative evaluation had demonstrated osteopenia, a serum calcium level of 10.8 mg/dL, and an intact serum PTH level of 62 pg/mL. She had a relatively low baseline intraoperative PTH level (43 pg/mL), which fell to 26 pg/mL (40% reduction) 5 minutes after resection of a 160-mg parathyroid adenoma. Frozen-section analysis of resected specimens was rarely performed. 12 Permanent histologic analysis confirmed enlarged parathyroid glands in every case. The mean surgical time recorded by the anesthesiologist (time of surgical positioning until time of wound closure) for the 100 patients was 81 ± 4 minutes (range 35–322, median 71). The surgical times for the 92 patients who underwent MIP under regional anesthesia (73 ± 2 minutes) are compared with those of the 8 patients who underwent conversion to general anesthesia (178 ± 32 minutes) in . The mean surgical time for the conventional exploration group was 140 ± 12 minutes (median 126). There were no deaths. Complications were limited to one unilateral transient recurrent laryngeal nerve injury, which resolved spontaneously 4 months after surgery, and one intraoperative seizure resulting from retrograde intraarterial injection of lidocaine. This was treated with supplemental oxygen and conversion to general anesthesia without sequelae. The mean length of stay for the 100 MIP patients was 0.15 ± 0 days (). Eighty-nine patients were discharged 1 to 3 hours after surgery. Ten patients were admitted for overnight observation, and one patient in hypercalcemic crisis required a 5-day admission to stabilize her serum calcium levels. The most common indication for admission was conversion to general anesthesia (n = 8). The mean length of stay for the conventional exploration patients was 1.4 ± 0.2 days. The preoperative, early postoperative (7 days), and long-term postoperative calcium levels are shown in . All patients had normal serum calcium levels at their 7-day follow-up. Eucalcemia persisted at a median follow-up of 8 months, with the exception of one patient. This patient had a serum calcium level of 10.8 mg/dL with a serum intact PTH level of 29 pg/mL (reference range, 10–65 pg/mL). This finding is inconsistent with recurrent hyperparathyroidism but is suggestive of exogenous calcium supplementation. The preoperative and 7-day postoperative serum PTH levels demonstrated normal PTH levels in 94 patients (). Six patients developed mild postoperative secondary hyperparathyroidism, manifested by a relatively low serum calcium level accompanied by an elevated PTH level. This phenomenon has been described, and the PTH level returns to normal as the residual parathyroid glands achieve a eucalcemic state. 13 The hospital charges of the 100 MIP patients are shown in . These data reflect the total hospital charges but not professional fees or the cost of outpatient evaluation. The mean hospital charge for the entire MIP group was $2,598 ± 168. There was a marked difference between the MIP patients who were admitted to the hospital and those who were not admitted ($5,737 ± 601 vs. $2,153 ± 106, P < .01). A comparison between the total hospital charges of the entire MIP group versus the 38 patients who were preselected for conventional exploration is presented in . The mean charge for the patients who underwent conventional exploration ($6,646 ± 722) was 2.5 times the mean charge incurred by the MIP patients ($2,598 ± 168). Minimally invasive parathyroidectomy is a safe, cost-effective technique that permits successful treatment of primary hyperparathyroidism on an ambulatory basis. The procedure is well tolerated and is associated with cure rates that are at least as good as those attained through traditional bilateral exploration. The complication rate is exceedingly low. The avoidance of both general anesthesia and an overnight hospital stay results in a cost savings of more than 50% compared with conventional treatment. This procedure appears appropriate for most (72% in this series) patients with primary hyperparathyroidism. Initially, we were reluctant to apply this technique in the setting of remedial parathyroid surgery for patients with persistent or recurrent hyperparathyroidism. However, as our experience and confidence increased, we expanded our pool of candidates and now routinely perform this procedure in patients who have had previous explorations. We estimate that approximately 90% of all patients referred with primary hyperparathyroidism will be appropriate candidates for MIP. The technique requires sophisticated technical adjuncts, including high-quality sestamibi scans with three-dimensional reconstruction. Patients referred to us often have had suboptimal scans that are likely to demonstrate only large parathyroid adenomas. In addition, we believe that the intraoperative PTH assay is essential. The sestamibi scan directs the surgeon where to start the exploration, and an adequate decrement in intraoperative PTH confirms the adequacy of resection. We have encountered patients in whom resection of the sestamibi-identified parathyroid adenoma did not result in a sufficient reduction in intraoperative PTH. In these cases, we continued our exploration and found additional parathyroid abnormalities that when resected resulted in an adequate PTH response. The limited incision is perceived by the patients and their referring physicians as advantageous. However, limited exposure should not be equated with inadequate exposure. If the case is difficult, the surgeon should not hesitate to extend the incision or convert to general anesthesia. This study has potential limitations. The patients were referred to a large endocrine surgical center containing a team of health practitioners interested in hyperparathyroidism. Therefore, the patient population may not reflect the larger population with primary hyperparathyroidism. In addition, because patients with negative sestamibi scans are not candidates for this technique, a preselection bias may have occurred. Although the median follow-up was 8 months, longer-term follow-up is unknown. One patient had a slight elevation in her serum calcium levels at long-term follow-up. However, this occurred in conjunction with a low PTH level, which is inconsistent with recurrent primary hyperparathyroidism. We suspect that she was taking exogenous calcium, which would account for this finding. The patients selected for conventional exploration contained a high percentage of remedial cervical explorations (45%) and simultaneous procedures (37%). Their outcome data are, therefore, likely to be less favorable than the group preselected for MIP. The surgical time recorded by the anesthesia staff appears to be substantially longer than the interval between incision and closure. A review of our last 22 consecutive MIP patients revealed that our mean incision-to-closure time was 36.5 minutes (range 16–65). Despite these limitations, the MIP technique has radically altered our management of patients with primary hyperparathyroidism. We offer this procedure to 90% of patients with primary hyperparathyroidism (20% of whom are referred for remedial cervical exploration) and have shifted the procedure to our ambulatory surgery center. It is likely that this or other MIP techniques will become the standard of care for patients with primary hyperparathyroidism. The authors thank Rae Moore for her assistance with the preparation of the manuscript and Stephanie Poe, RN, for her statistical support. Discussion Dr. George L. Irvin III (Miami, Florida): Surgeons who perform parathyroidectomies in their practice are well aware of the changing operative approach to this disease, as presented by Dr. Udelsman and his group from Baltimore. With the minimally invasive exploration available using the surgical adjuncts of preoperative localization and a quick hormone assay to ensure a successful operation, the indications for parathyroidectomy are changing, especially in elderly, symptomatic patients who have been denied definitive treatment because of the risks of general anesthesia and extensive bilateral neck exploration. One criticism of Dr. Udelsman’s presentation is the short follow-up in the series. Operative success or failure is usually defined in terms of normocalcemia at 6 months after parathyroidectomy. To support his work, we looked at our series of 196 consecutive patients who were followed for 6 months or longer using the same surgical adjuncts: 74% of our patients were eligible for same-day discharge without an overnight hospital stay, but 19% of the eligible patients were kept overnight due to prolonged procedures, anesthesia complications, urinary retention, and one hematoma. Of these 196 patients, there were six operative failures, two virgin and four in reoperative cases, with an overall success rate of 97%. Dr. Udelsman showed us a picture of Dr. Mandl, whose patient was named Albert Jahne, a streetcar conductor. What he didn’t tell you is that this patient developed recurrent hypercalcemia and went on to die 6 years after surgery. Dr. Udelsman, a question: Do you think patients treated with this minimally invasive technique without a search for other enlarged parathyroid glands, which may be present in the unexplored neck, will lead to a higher recurrence rate? Presenter Dr. Robert Udelsman (Baltimore, Maryland): Will there be a high recurrence rate? The answer is, we are really not sure. This is a new technique, and Dr. Irvin has the longest follow-up. It is possible that they will, but I doubt it because most patients with single adenomas are cured when you remove that single gland. Dr. Richard A. Prinz (Chicago, Illinois): Surgical therapy is a dynamic process that adapts to growth in knowledge and changes in technology. The traditional standard bilateral exploration of the neck for hyperparathyroidism has achieved superb results, but this does not mean we should stop looking for ways to do it better. The limited approach for minimally invasive parathyroidectomy that you described depends on accurate localization of a single adenoma. Do you think that the high rate of positive sestamibi localization you have achieved can be replicated in centers that do not have the same level of interest or the high volume of patients with hyperparathyroidism that you are seeing? Do you think that ultrasound or intraoperative sestamibi scanning might be useful adjuncts for your approach? Can you elaborate on the problems of the false-positive localization study and the operative difficulties it brought you? You do rely on intraoperative PTH levels for determining adequacy of your resection. We have found that a >50% drop in intraoperative PTH levels will have an elevated postoperative PTH level associated with borderline or mildly elevated calcium levels in about 5% of our patients. Have you encountered this difficulty? This brings up your definition of cured, that is, removal of abnormal parathyroid tissue and early normalization of your serum calcium. Is this a rigid-enough definition, especially in light of your short follow-up? You have had a less than 10% rate of conversion with your approach. Are there any clinical features in that small number of patients that would have predicted the need for conversion preoperatively so that the more appropriate extended procedure could have been done primarily? Finally, your results in terms of disease control and minimal morbidity can stand up to any report available. Do you think surgeons seeing only an occasional patient with hyperparathyroidism can equal your stellar results both in terms of curing the disease and minimal morbidity? Dr. Udelsman: The quality of imaging is dependent upon the institution and the interest of those doing it. A simple planar view does not give you as much information as the single photon emission computed tomography (SPECT) view that I showed you today. It is our job to get our nuclear physician colleagues to obtain the high-quality images that we need to do these operations. Ultrasounds can be useful, but we do not use them routinely. Intraoperative sestamibi has been popularized by some surgeons using a gamma probe, where sestamibi is administered 2 hours before surgery and then a gamma probe is employed for intraoperative localization. We have not employed this technique because high-quality sestamibi scans obviate the gamma probe. Nonetheless, it appears to be a valid technique. False-positive localization will occur with sestamibi scans. There is nothing specific about sestamibi. Its uptake is related to mitochondria. There can be amounts of mitochondria in thyroid nodules. Therefore, a false-positive can be caused by a thyroid adenoma, and the surgeon needs to know that and deal with it appropriately at the time of surgery. I believe PTH monitoring in the operating room is important, and we use it in all of our patients. We too see elevation in postoperative PTH levels in a subset of our patients, in this case 6%. In our patients, it is associated with low calcium levels. So we do believe those patients are cured. The definition for cure in most series requires the demonstration of a normal serum calcium level 6 months postoperatively. Our mean follow-up is 8 months, so we need to get longer follow-up in our patients. Our conversion rate was 8%. It may actually go up in the future because we are more confident with this technique and are liberalizing our indications. We don’t view conversion as a failure, but as part of a therapeutic modality. If we can’t find the parathyroid adenoma or it is difficult, we don’t hesitate to convert. It only takes us 8 to 10 minutes to convert under controlled conditions, and our anesthesiologists are prepared to do that. Finally, can you select patients who are unlikely to be converted? Well, if you want to have 100% nonconversion rate, then you only operate on patients with perfect sestamibi scans who have never had surgical exploration. We are more liberal and offer MIP for remedial parathyroid surgery if we have excellent localization. Dr. Andrea Frilling (Essen, Germany): We have adopted a unilateral neck exploration in local anesthesia in our patients. Now we have experience in 30 patients with this technique. However, due to a high prevalence of goiter in our country, we would always perform sestamibi scintigraphy in combination with ultrasound to detect concomitant thyroid disease and to avoid false-positive scanning results based on the tracer uptake in the thyroid module. I would like to ask you two questions. First, in how many of your patients with primary or secondary hyperparathyroidism did the preoperative sestamibi scanning detect more than one positive gland? And where was the positive gland?—in the neck or in the mediastinum? Second, concerning intraoperative PTH measurement, some groups require not only a >50% fall from a higher baseline, but also PTH level below the starting point before operation since intraoperative PTH levels may be influenced by the fluid administration to the patient during the operation. Could you please comment on these questions? Dr. Udelsman: We do not routinely employ ultrasound examination. But we do encounter thyroid nodules, and we will occasionally do a thyroidectomy during this procedure. We never get sestamibi scans in patients with secondary hyperparathyroidism unless it is a redo case, because in secondary hyperparathyroidism we anticipate that all of the parathyroid glands will be enlarged and we see no reason to obtain sestamibi in that subset of patients. You asked how many times does a sestamibi show two areas of uptake. In this series, of the 100 patients, there were five patients where we saw two areas of uptake. In general, if they are both in the same side, we still offer the procedure. I remember one of those, however, was a professional opera singer, one was in the right upper, one was in the left lower position, and I elected to do her case under general anesthesia because I thought it would be safer to protect all of her nerves, including the external branch of the superior laryngeal nerve. Dr. Paul Lo Gerfo (New York, New York): I have just one question. When you look at your data, almost 40% of your patients were excluded from having local anesthesia for a number of reasons—multiple gland disease, conversion to general anesthesia, negative scans, multiple thyroid modules. In our own experience, that number comes out to exactly the same number, around 40% to 45%. This led us a number of years ago to just go ahead and do bilateral neck explorations under local as outpatients. I have been looking at your data and I am looking at your incisions, and they are identical to what we usually routinely use for bilateral explorations, and certainly the operative time is almost exactly identical. I am just curious why you don’t just progress to that stage rather than stop and convert everybody to general anesthesia. Dr. Udelsman: I think surgeon experience is a natural progression. It was you, Dr. Lo Gerfo, who convinced me to convert to using cervical block technique, and I adopted your technique. I have been a little reticent to do bilateral blocks because theoretically one can block both vagus nerves and therefore both recurrent nerves. But I know you have been doing this for some time. I think what you do is very reasonable. I just haven’t been as brave as you are thus far. But we are heading in that direction. 1. Mandl F. Therapeutisher versuch bein einem falls von ostitis fibrosa generalisata mittles. Extirpation eines epithelkörperchen tumors. Wien Klin Wochenshr Zentral 1926; 143: 245–284. 2. Carney JA. The glandulae parathyroideae of Ivar Sandström. Am J Surg Pathol 1996; 20: 1123–1144. [PubMed] 3. Chen H, Zeiger MA, Gordon TA, Udelsman R. Parathyroidectomy in Maryland: effects of an endocrine center. Surgery 1996; 120: 948–953. [PubMed] 4. Tibblin S, Bondeson A, Ljungberg O. Unilateral parathyroidectomy in hyperparathyroidism due to a single adenoma. Ann Surg 1982; 195: 245–252. [PubMed] 5. Wang CA. Surgical management of primary hyperparathyroidism. Curr Probl Surg 1985; 22: 1–50. 6. Irvin GL III, Deserio III. A new, practical intraoperative parathyroid hormone assay. Am J Surgery 1994; 168: 466–468. 7. Irvin GL III, Sfakianakis G, Yeung, et al. Ambulatory parathyroidectomy for primary hyperparathyroidism. Arch Surg 1996; 31: 1074–1078. 8. Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery 1999; 126: 1016–1022. [PubMed] 9. Lo Gerfo PL, Kim LJ. Technique for regional anesthesia: thyroidectomy and parathyroidectomy. Oper Tech Gen Surg 1999; 1: 95–102. 10. Sokoll LJ, Udelsman R, Chan DW. Intraoperative parathyroid hormone measurement. Diag Endocrinol Metab 1999; 17: 295–302. 11. Brasier AR, Wang CA, Nussbaum SR. Recovery of parathyroid hormone secretion after parathyroid adenomectomy. J Clin Endocrinol Metab 1988; 66: 495–500. [PubMed] 12. Westra WH, Prichett DD, Udelsman R. Intraoperative confirmation of parathyroid tissue during parathyroid exploration: a retrospective evaluation of the frozen section. Am J Surg Pathol 1998; 22: 538–544. [PubMed] 13. Mandal AK, Udelsman R. Secondary hyperparathyroidism is an expected consequence of parathyroidectomy for primary hyperparathyroidism: a prospective study. Surgery 1998; 124: 1021–1027. [PubMed]
|
This article has been 
