Scan-directed mini-incision focused parathyroidectomy: how accurate is accurate enough?

Abstract

INTRODUCTION Mini-incision focused parathyroidectomy (MI-FP) is advocated as an alternative to bilateral neck exploration (BNE), owing to its reduced morbidity. The site and side of the affected gland is identified preoperatively using a combination of ultrasound and sestamibi scans. However, the acceptable degree of inter-scan concordance required to prompt MI-FP without compromising accuracy is undetermined. METHODS Accuracy of preoperative imaging was determined both individually and in combination for all parathyroidectomies (2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014). A grading system (excellent, good, poor) was devised to describe the interscan concordance, which was validated by the operative and histological findings. RESULTS Eighty-nine patients (17 male, 68 female) underwent parathyroidectomy (MI-FP 44, BNE 45). The accuracy of scans interpreted individually was 53% for ultrasound and 60% for sestamibi, with no difference according to surgical technique (P = 0.43, P = 1, respectively). The proportion of interscan concordance was: excellent -35%, good -40%, poor 25%. Combined accuracy was 100% for both excellent and good grades but only 13% for those graded poor. Similar rates of normocalcaemia were observed for MI-FP and BNE, while postoperative hypocalcaemia was five times higher in those undergoing BNE. CONCLUSIONS Reduction in the inter-scan concordance from excellent to good does not compromise accuracy. MI-FP could be successfully performed in up to 75% of patients -25% higher than recommended in national guidelines. Focused parathyroidectomy does not compromise surgical and endocrinological outcomes but boasts a far superior complication rate.

Effectiveness of Intraoperative Parathyroid Monitoring (IoPTH) During Minimally - Invasive Parathyroidectomy: A Decade Experience in a Single Center

“…Since that year this technique has been widely used to guide parathyroid surgery, helping -in association with the improvement in pre-operatory imaging techniques to perform a less invasive surgery [28,29]. Intraoperative PTH Assay during minimally invasive parathyroidectomy is considered helpful in the detection of double adenomas and may minimize the risk of recurrent surgery.…”

Setting up a parathyroid multidisciplinary team meeting: one year's experience, outcomes and learning points

“…This in turn means that more procedures can be performed as a day case. The risk of complications will be reduced (including vocal fold palsy, post-operative bleeding and pain), as the procedure is one-sided and less invasive 8 . This can reduce the duration of patient hospitalisation and determine the number of day-case procedures that it is possible to perform.…”

Selection of parathyroidectomy methods for primary hyperparathyroidism according to concordance between ultrasonography and MIBI scan results

“…Before the advent of the MIBI scan in the late 1990s, bilateral neck exploration (BNE) was the preferred method for PHPT (6)(7)(8)(9). However, over the past two decades, the operative management of PHPT has changed from BNE to FP because most cases of PHPT are caused by a single adenoma (80-85%) (10)(11)(12)(13)(14).…”