Remedial Parathyroid Surgery: Changing Trends in 130 Consecutive Cases
Robert Udelsman, MD, Patricia I. Donovan, RN*
Yale University School of Medicine, New Haven, CT
OBJECTIVE(S): Remedial surgery for primary hyperparathyroidism (10 HPTH) is challenging. These patients traditionaly undergo extensive preoperative imaging and reexploration under general anesthesia. This prospective series of 130 consecutive remedial operations for 10 HPTH selectively employed minimally invasive techniques and tested the hypothesis that these techniques can improve outcomes.
METHODS: Between January 1990 and June 2005, 1090 patients were evaluated and explored for 10 HPTH. Of these, 130 (12%) had been referred for remedial explorations. Preoperative imaging was obtained in all remedial patients who then underwent either conventual exploration under general anesthesia (N=106) or minimally invasive parathyroidectomy (N=24) employing cervical block anesthesia, directed exploration, and curative confirmation with the intraoperative rapid parathyroid hormone assay.
RESULTS: The imaging data in these remedial patients were positive as follows: Sestamibi scans [88/115 (77 %)], Ultrasound [30/41 (73 %)], CT [9/19 (47 %)], MRI [17/35 (48 %)], Ultrasound/FNA [7/9 (78%)] and Venous Localization [15/16 (94 %)]. The cure rate in the conventional remedial group (N=106) was 93 % and was associated with a mean length of stay (LOS) of 1.6 + 0.2 days with complications occurring in 3 patients. Remedial exploration employing minimally invasive techniques (N=24) resulted in a cure rate of 96 %, a mean LOS of 0.4 + 0.1 days and 1 complication. These results were almost identical to those achieved in 960 unexplored patients where the cure rate was 98% and the LOS was 0.71 + 0.1 days.
CONCLUSIONS: Remedial parathyroid surgery can be accomplished with acceptable cure and complication rates. Minimally invasive techniques can be applied to this challenging group of patients and can achieve outcomes that are similar to those obtained in unexplored patients.
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