Surgical Approach to Primary Hyperparathyroidism in Patients with Concomitant Thyroid Diseases: A Retrospective Single Center Study

Background. Primary hyperparathyroidism (PHPT) and thyroid diseases are a frequent concomitant occurrence, but the surgical approach to associated disease is still debated. Methods. We retrospectively evaluated a series of PHPT patients focusing on thyroid disease and surgery. Results. Among 238 PHPT patients undergoing parathyroidectomy (PTX) between 2002 and 2017, 128 were affected also by a benign thyroid disease, namely, goiter in 118 (76 multinodular (MNG) and 42 uninodular (UNG)), autoimmune thyroiditis in 10, and hyperthyroidism in 21. Surgical approach was unilateral neck exploration (UNE) in 59 patients and bilateral neck exploration (BNE) in 69. The PHPT cure rate was 94%. On comparing patients submitted to PTX only and PTX plus thyroidectomy (TX), in the latter MNG and hyperthyroidism were more frequent, and surgical time and length of stay were longer. No difference in surgical complications was found between patients undergoing UNE and BNE. Conclusion. PHPT patients with a concomitant thyroid disease underwent double surgery in almost two-thirds of the cases, mostly by BNE. The main factors driving the decision to perform concomitant PTX and TX were the presence of thyroid nodular disease with the nodule site ipsilateral to the presurgically localized parathyroid adenoma.

A 20-Year Study on 190 Patients With Primary Hyperparathyroidism in a Developing Country: Turkey Experience

The aim of this study was to present our 20-year experience regarding primary hyperparathyroidism (PHPT). PHPT patients who underwent parathyroidectomy in our clinic were reviewed retrospectively. There were 190 PHPT patients, of whom 137 were asymptomatic (72%). The mean serum calcium at the time of diagnosis was 11.9 ± 2.2 mg/dL. The mean parathyroid hormone (PTH) level was 467 ± 78 pg/mL. Ultrasonography (USG) identified all abnormal glands accurately (82.6%) and Technetium-99m sestamibi scintigraphy (MIBI) was used in 89.4% of the patients and magnetic resonance imaging (MRI) in 61%. The common use of USG and MIBI detected 92% of the lesions. Bilateral neck exploration (BNE) was performed in 12.2% of the patients and focused unilateral neck exploration (FUNE) in the remaining 87.8%. Surgical intervention was unsuccessful in 1 patient (0.5%). The conversion ratio from FUNE to BNE was 5.2%. The mean operation time and mean hospital stay decreased significantly in patients with FUNE. Pathologic examination revealed single adenoma in 93% of the patients. New imaging techniques result in the conversion of surgical treatments of PHPT. FUNE in parathyroidectomy performed by an experienced surgeon may provide successful treatment rates.

Primary hyperparathyroidism with water clear cell content: the impact of histological diagnosis on clinical management and outcome

Water clear cell hyperplasia (WCCH) and water clear cell adenomas (WCCA) of the parathyroid glands are rare causes of primary hyperparathyroidism. We report in this series one case of WCCH and two cases of WCCA representing 0.3% of patients with primary hyperparathyroidism presenting to our institution. Increased parathyroid cellular water content was responsible for relatively larger parathyroid gland sizes. However, this was not associated with higher biochemical markers or more severe clinical presentations. Histological distinction between WCCH and WCCA is difficult but important since patients with WCCH who have had a parathyroidectomy via a unilateral neck exploration may carry an increased risk of future disease recurrence.

Vitamin D: Implications for Thyroid Surgery

Thyroid and parathyroid surgeries are performed each year on more than 140,000 adults in the United States. Hypocalcemia is one of the most frequent complications of total thyroidectomy—a procedure used for both benign and malignant pathologies of the thyroid gland. In most situations, disruption of calcium homeostasis is felt to be related to disturbance of the parathyroid glands during exploration. Because the parathyroid glands control the amount of calcium in the blood, postoperative supplementation of oral calcium is routine in these cases. When only one side of the neck is explored, the contralateral parathyroid glands are expected to sustain calcium balance; therefore, routine supplementation has not been the standard. The author and colleagues found unexpected symptomatic hypocalcemia in three patients undergoing unilateral neck exploration of the thyroid gland over a 4-month period. This report addresses how the interprofessional team identified the unexpected problem, examined potential causes and contributing factors, and have changed their approach to care for thyroid and parathyroid surgery patients. One of the initial case examples will be described in detail to illustrate the problem.

Surgeon-performed Ultrasound in Preoperative Parathyroid Localization: The Cutting Edge of Endocrine Surgeon

ABSTRACT Background Over the years surgery for primary hyperparathyroidism has evolved from bilateral neck exploration to focus unilateral approach. This has been made possible by the advancement in localization technique and availability of the preoperative imaging. This study aimed to determine the feasibility and accuracy of focus unilateral neck approach for primary hyperparathyroidism with surgeon- performed ultrasound as the main decisive preoperative localization imaging technique. Method The decision of focus unilateral approach was stipulated if an enlarged parathyroid adenoma was confidently seen in the preoperative localization by surgeon-performed ultrasound. The focus unilateral exploration was terminated if the diseased gland was found. Nonetheless if in doubt, the exploration was extended to include the opposite side of the neck. More importantly any negative preoperative ultrasound will be considered for bilateral neck exploration. Results 118 consecutive patients were accrued in this study, 76 females and 42 males with mean age of 50 years. Focus unilateral neck exploration was performed on 86 (72.9%) patients and 96.5% of them were successfully explored and cured. 13 (13.1%) patients had exploration of both sides of the neck although the initial decision was only to explore one side. The overall cure rate was 93.2% with the sensitivity and specificity of ultrasound were 78.3% and 95.1% respectively. Conclusion Surgeon-performed ultrasound in parathyroid localization in coupled with focus unilateral approach in primary HPT can be performed 73% of patients with a success rate of more than 96%.

Can parathyroidectomy for primary hyperparathyroidism be carried out as a day-case procedure?

Introduction: Surgery for primary hyperparathyroidism has traditionally involved a bilateral neck exploration performed as an in-patient procedure. We present a feasibility study to demonstrate whether, with a focused surgical exploration, the procedure can be carried out as a day case.Method: Eighty-seven patients had pre-operative sestamibi and ultrasound scans of the neck. When the results of these scans agreed, a unilateral neck exploration was carried out.Results: Sixty-seven patients received a focused approach parathyroidectomy. Ninety-seven per cent of these patients were normocalcaemic after the first operation. All patients who fitted the day-case criteria left hospital the following morning.Discussion: When pre-operative imaging results agree, a parathyroidectomy can be carried out using a unilateral neck exploration, avoiding the increased risks associated with a bilateral exploration.Conclusion: Parathyroidectomy can be safely carried out as a day-case procedure in selected patients.