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intraoperative iPTH assay ; primary hyperparathyroidism ; bilateral neck exploration ; minimally invasive parathyroidectomy ; Miami criterion
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Aims: 1). To evaluate diagnostic accuracy of intraoperative iPTH assay during minimally invasive parathyroidectomy with respect to few prognostic criteria most commonly used. 2). To compare outcomes of video-assisted minimally invasive parathyroidectomy (MIVAP) to open minimally invasive parathyroidectomy (OMIP). 3). To assess indications for bilateral neck exploration in the era of minimally invasive parathyroidectomy, including short-term outcomes of surgery with intraoperative iPTH monitoring added-value.Material and methods: Ad.1). A retrospective study of 455 patients with sporadic primary hyperparathyroidism undergoing minimally invasive parathyroidectomy with intraoperative iPTH assay at our institution between 2003 and 2012 was undertaken. Diagnostic accuracy of few prognostic criteria most commonly used was done including Halle, Miami, Rome and Vienna criteria. Results of intraoperative iPTH assay were compared to outcomes of minimally invasive parathyroidectomy in 6-months follow-up after surgery (serum calcium and iPTH levels). Both ROC (Receiver Operating, Characteristics) curve and error matrix analysis were used for accuracy assessment of intraoperative iPTH assay prognostic criteria. Based on this method the following accuracy parameters were calculated for each intraoperative iPTH assay criterion separately: sensitivity, specificity, positive predictive value (P ; PV), negative predictive value (NPV) and overall accuracy. Ad.2). A retrospective case-controlled study of 455 patients with sporadic pHPT undergoing minimally invasive parathyroidectomy with intraoperative iPTH assay at our institution in 2003-2012 was undertaken. The primary outcome measure was postoperative pain. Secondary outcome measures were: duration of surgery, recurrent laryngeal nerve identification rate, conversion rate, length of hospital stay, cure rate, patients’ satisfaction with cosmetic outcome, morbidity, costs, and diagnostic accuracy of intraoperative iPTH assay. Ad.3). Data of 155 patients with pHPT qualified for bilateral neck exploration with intraoperative iPTH monitoring and treated in 2003 – 2012 were retrospectively analysed. All patients underwent biochemical and imaging testing in the preoperative work-up. The following endpoints were analysed in this study: indications for bilateral neck exploration, short-term outcomes of surgery, and intraoperative iPTH monitoring added-value. Results: Ad.1). The following diagnostic accuracy parameters of intraoperative iPTH assay were found for each of the tested criteria (sensitivity, specificity, PPV, NPV, accuracy), respectively: for Halle criterion 63.2%, 100.0%, 100.0%, 12.6%, 65.1%; for Miami criterion 97.7%, 96.4%, 99.8%, 73.0%, 97.6%; for Rome criterion 84.4%, 100.0%, 100.0%, 27.2%, 85.3%; for Vienna cr ; iterion 93.7%, 92.3%, 99.5%, 47.1%, 93.6%. Ad.2). Of 455 patients with primary hyperparathyroidism and a solitary parathyroid adenoma on preoperative imaging, 151 underwent MIVAP and 304 had OMIP. The following outcomes were favourable for MIVAP vs. OMIP: lower pain intensity during 24 hours postoperatively (p<0.001), lower analgesia request rate (p<0.001), lower analgesics consumption (p<0.001), higher recurrent laryngeal nerve identification rate (p < 0.001), shorter scar length (p<0.001), better cosmetic satisfaction at 1 month (p=0.013) and at 6 months (p=0.024) after surgery. However, MIVAP vs. OMIP had longer duration of surgery (p<0.001), and was more expensive (p<0.001). No differences were noted in the conversion rate, length of hospital stay, and morbidity. Ad.3). Indications for bilateral neck exploration were: negative preoperative imaging in 65 (41.9%) patients, concomitant goitre necessitating surgical removal in 51 (32.9%) patients, MEN 1 syndrome in 17 (11.0%) patients, lithium treatment in 12 (7.7%) patients, lacking consent for minimally invasive parathyroidectomy in 5 (3.2%) patients, and MEN 2A syndrome in 5 (3.2%) patients. The extent of parathyroidectomy was a solitary parathyroid adenoma removal in 97 (62,6%) patients, subtotal parathyroidectomy in 41 (26.4%) patients, and double-parathyroid adenoma removal in 17 (11,0%) patients. Use of intraoperative iP ; TH monitoring influenced on the extent of parathyroid tissue resection in 16 (10.3%) patients. Normalized total serum calcium values were observed in 154 (99.4%) patients during a 6-month follow-up. Conclusions: Ad.1). Miami criterion of intraoperative iPTH assay is the most accurate in prognostication of postoperative serum calcium levels after minimally invasive parathyroidectomy. Use of other, criteria may involve a higher risk of false negative results and unnecessary conversion to more extensive neck dissection in search for non-existent hyperfunctioning parathyroid tissue. Ad.2). Both MIVAP and OMIP approaches were equally safe and effective. However, the outcomes of MIVAP operations were superior to OMIP in terms of lesser postoperative pain, lower analgesics consumption, and better cosmetic satisfaction resulting from a smaller scar. Ad.3). Bilateral neck exploration in patients with primary hyperparathyroidism is the preferred surgical technique in the following circumstances: a suspicion of multiglandular parathyroid disease (MEN 1 or 2A syndrome, familial hyperparathyroidism, lithium therapy), a negative preoperative imaging, in patients not consenting for minimally invasive parathyroidectomy, and in cases with concomitant goitre necessitating surgical treatment. Use of intraoperative iPTH monitoring influences on the extent of parathyroid tissue resection in one of ; ten patients, hence assuring the highest quality of surgical treatment.
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Barczyński, Marcin ; Kenig, Jakub