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Endoscopic

Parathyroid Surgery

Danny Yacoub MDGeorge Ferzl i MD, FACS

Professor of Surgery, SUNY

SUNY Downstate

Medical Center

Lutheran

Medical Center


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The Legacy of Ivar Sandstrom (18521889)

New Gland, the last majororgan to be recognized inman, 1880.

Discovery met with silence.

First publication rejected.

Two national prizes.

I.V. Sandstrom, On new gland in man and several mammals, Bull Inst Hist Med6 (1938), pp. 192222.c


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to each gland there are

often one or more small

arteriole branches from theinferior thyroid artery




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First Parathyroid Surgery

1925 by Felix Mandl in Vienna, Austria

Patient had resolution of severe symptomsassociated with the disease after surgery.

Niederle BE etal,J Am Coll Surg. 2006


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Captain Charles Martell Firstto be surgically treated in US, 1932.

Underwent 6 unsuccessful neck explorations.

O. Cope, The story of hyperparathyroidism at the Massachusetts General Hospital, N Engl J

Med274 (1966), pp. 11741182


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Edward Churchill (1895-1972)

He performed his 7th operation

Median sternotomy

Successful operation

O. Cope, The story of hyperparathyroidism at the Massachusetts General Hospital,N Engl J Med

274 (1966), pp. 11741182

Unfortunately, Martell died soon

after due to tetany and

complications of nephrolithiasis.


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Parathyroid Surgery

New Technology:

IOPTH

Tieless surgery

Intraoperative nerve monitoring Radioguided surgery

Needle localization

Video assisted surgery

Robotic surgery


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Minimally Invasive Parathyroid Surgery


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Why MIVAP? Cosmetic Results

Open surgery scar Minimally invasive / endoscopic scars
http://azfamily.beloblog.com/catsmeow/scar.html


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Minimally invasive parathyroid surgery:

Endoscopic Central

Lateral

Other (transaxillary,transpectoral, transoral)

Minimally invasive MIVAP (min. invasive video

assistedparathyroidectomy)

Robotic assisted

Inferior parathyroid release inminimally invasive thyroidectomy


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MIVAP-Results


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MIVAP yield equivalent endocrine results as openprocedure

Oncologic result is equivalent in selected patients

Equivalent safety profile as open procedures

Postop pain is decreased

Patient satisfaction with procedure and cosmetic result issignificantly increased

MIVAP vs Open - Results

Miccoli et al., RCT, Surgery. 2001


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1o end points: pHPT Hypocalcemia (All patients were cured)

2o end points: MIVAP vs. OMIP OR time: similar, ave. 42min vs. 49min (p=0.22)

scar length: ave. 17.2mm vs. 30.8mm (p


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Parathyroid Surgery

Single parathyroid adenoma (80%-87%)

Double adenomas (2%-15%)

Asymmetric 4-gland hyperplasia (10%-15%)

Carcinoma (


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Preoperative Imaging

Non Invasive Imaging: Sestamibi Scan

Ultrasound

CT scan

MRI

Positron Emission Tomography (PET) scan PET/CT

Invasive Imaging: Parathyroid FNA

Arteriography and selective venous sampling for PTH


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Parathyroid Locations

Possible locations of enlarged parathyroid glands in the neck and

superior mediastinum with the use of an anteroposterior projection (A)

and a lateral projection (B)

Udelsman R.Ann Surg244:471-479, 2006


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Aberrant Parathyroid Locations

Anatomic locations of abnormal parathyroid glands found at reoperation by single group.

Most common ectopic sites mirror routes of descent of upper parathyroid glands (short

migration path) and of lower parathyroid glands (longer migration path in association with

thymus)

Wang CA. Parathyroid re-exploration.Ann Surg. 1977;186:140

145


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Preoperative Parathyroid Localization

Ultrasonography: Sensitivity 70-80%(less in MGD)

Specificity 40-100%(Ammori, Ann R Coll Surg Engl. 1998;80:433437)

CT and MRI: Sensitivity 60-80% (80% when done with IV contrast)

(Weber, Radiol Clin North Am. 2000;38:11051129)

Scintigraphy intraoperative gamma probe:

99mTc-Sestamibi SPECT: Sensitivity 85-95%(Originally described by Coakley et al., Nucl Med Commun. 1989;10:791794)

99mTc-Tetrofosmin provided it is used within a dual-tracer subtraction protoco(Gallowitsch et al., Invest Radiol. 2000;35:453459)


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Sestamibi

EctopicAdenoma

Hyperplasia


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Sonogram / Sestamibi

Are additional Localization Studies and Referral indicated for patients with Primary Hyperparathyroidism Who

have negative Sestamibi scan results? Elaraj, DM. Sippel, RS. Lindsay S. Sansano I. Duh QY. Clark OH.

Kebebew E.Arch SurgVol 145, No 6, 578-581 June 2010.

May 2005 - May 2007

487 patients underwent 492 neck explorations (88% initial 12% reoperation).

339 underwent focused parathyroid surgery (69%).

447 Sestamibi scans were positive (91%) and 82% were true positive

In patients with negative Sestamibi scan, Sono was positive in 51% (43% true positive).

Patients with positive sestamibi when compared to patients with negative sestamibi:

-Higher rate of single gland disease (87% vs 63%)

-Lower rates of of double adenomas (6% vs 22%) and asymmetric hyperplasia (7% vs 15%).

--No difference in the rate of ectopic glands.

--No difference in the cure rate (97% vs 89%).

-Conclusion: Additional imaging with sonogram is helpful for selecting minimally invasive

Parathyroidectomy in most patients with primary hyperparathyroidism who have negative

Sestamibi scan results.


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Intra operative PTH assay. Prospective 361

consecutive patients undergoing minimally invasiveparathyroidectomy.Hwang RS et al.Ann Surg2010;251:1122-1126.

1- There is no role for IOPTH for Sestamibi positive patients.

2- It will guide the surgeon in Sestamibi negative / positive sonogram

patients: In these cases an inadequate fall in the 10- minute post excision

PTH level was highly predictive of multi glandular disease.A Selective Bayesian approach to Intraoperative PTH monitoring.

A Rising IoPTH Level Immediately after Parathyroid ResectionAre Additional Hyperfunctioning Glands Always Present? Anapplication of the Wisconsin Criteria.Cook MR et alAnn Surg 2010;251 1127-1130.

797 consecutive patients. 108 (14%) had a rising ioPTH 5 min after resection

of a single parathyroid gland, 36 (33%) continued to have elevated levels and

further exploration revealed additional hyperfunctioning glands. In 72 (67%)

the ioPTH started to drop within 20 min of gland resection and in all cases

correctly predicted operative success.

IOPTH / Sonogram


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CT Sestamibi Fusion Scan


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4D-CT Localization

45 patients underwent reoperative parathyroidectomy.

The sensitivity of 4D-CT for localization was 88%compared with 54% for Sestamibi imaging.

4D-CT correctly localized (p=0.0003) and laterlized(p=0.005) hyperfunctional parathyroid tissue thanSestamibi did.

Parathyroid Exploration in the Reoperative Neck:Improved Preoperative Localization with 4D-ComputedTomography.

Mortenson MM et al. JACS May 2008 Volume 206 No 5 pages 888-895.


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CT Guidance


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Ultrasound Guidance


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MIVAT


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Endoscopic ParathyroidectomyPrerequisite Conditions 1

1- The surgeon must be experienced in conventional

parathyroid surgery and trained for endoscopic neck

procedures

2- The patient must be carefully selected

3- The adenoma must be clearly localized


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Patients Eligible for EndoscopicParathyroidectomy

No goiter

No previous neck surgery

Sporadic HPT I


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Evaluation for Concomitant Thyroid Nodules and PHPT inPatients Undergoing Parathyroidectomy or Thyroidectomy

200 patients who underwent a parathyroidectomy

102 (51.1%) were found to have thyroid nodular

disease

Six percent of these 200 patients also had a thyroidmalignancy

Of the 326 patients who were primarily seen for thyroid

disease, the incidence of PHPT was 3.1%

Morita S, etal, Surgery, 2008


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Racial Disparity / Double Adenoma

AA

12%

Non-AA

5%

AfricanAmericans

14

(12.4%)

Non-AfricanAmericans

21

(5.1%)


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Sestamibi and Vitamin D Deficiency

Prevalence of vitamin D deficiency in PHPT

Predictive value of 25 (OH) D levels in having positivesestamibi scans.

428 consecutive patients who underwent preoperative sestamibi

scintigraphy and a targeted parathyroidectomy for PHPT.

Parathyroid sestamibi scanning is more useful for thissubset of patients

Kandil. E. et alArch of Otolaryngology, 2008

Ad Si d


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Adenoma Size andBiochemical Measurements

Preoperative serum calcium and parathormone levels predict

adenoma weight and volume in primary hyperparathyroidism for a

single adenoma.

(Bindlish. Head Neck. 2002 Nov; 24 (11): 1000-3)

More than a 50% decrease in preexcision iPTH levels and

subsequent attainment of the normal range within 15 min is

considered satsifactory.

(Ozimek et al. Surg Endosc. 2010 May 20)

Adenoma weight may relate to the percentage decrease of iPTH

levels at the 10-minute postparathyroidectomy interval.

(Moretz et al. Laryngoscope. 2007 Nov; 117 (11): 1957-60)


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Endoscopic/Conventional Parathyroidectomy

(98-2005 / 970 HPT I)

Endoscopic 538 (55.5%)

Conventional 432 (44.5%)

Jean - Francois Henry Department of Endocrine Suregery, University Hopspital La Timone.Marseilles, France Endoscopic Parathyroidectomy: Why and When ? World Journal of Surgery

Volume 32 Number 11, November 2008


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Clear positive localization:

Posterior: lateral approach

Anterior: anterior approach

Negative or unclear localization:

Conventional approach


Jean - Francois Henry Department of Endocrine Suregery, University Hopspital La Timone.Marseilles, France Endoscopic Parathyroidectomy: Why and When ? World Journal of SurgeryVolume 32 Number 11, November 2008


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Contraindications: 432/970: 44.5 % Associated nodular goiter 174

No preoperative localization 107

Previous neck surgery 71

Suspicion of MGD 45

Acute HPT 8

Large tumor 7

Local anesthesia 9

Major ectopia 9

Spontaneous neck hematoma 2

Jean - Francois Henry Department of Endocrine Suregery, University Hopspital La Timone.Marseilles, France Endoscopic Parathyroidectomy: Why and When ? World Journal of Surgery



E d i P th id t


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Endoscopic Parathyroidectomyin the Previously Radiated Neck

May 2005-May 2007: 491 consecutive

parathyroidectomies for primary hyperparathyroidism. 52(12.6%) with history of neck radiation.

In the radiation exposure group, 40 (76.9%) had a

positive sestamibi scan vs 360 (81%) in the non radiated

group. The radiation group was older at presentation (p=0.001)

and the rate of previous history of thyroid cancer was

higher (p=0.02).

Patients with PHPT, previous RT, positive localizationstudy and a normal thyroid ultrasound would be ideal

candidates for minimally invasive parathyroidectomy.

Prior Head and Neck Radiation Exposure Is not a Contraindication to Minimally Invasive

Parathyroidectomy. Rahbari R. et al JACS Vol210 No 6. 942-948 June 2010.


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MIVAP -Technique


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Bilateral Axillo-Breast (BABA)

Subcutaneous dissection bilaterally from the incision to

the thyroid cartilage and the SCM


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Axillary Approach

First introduced by Ikeda,2000

4-6 cm vertical skin

incision in the axilla forcamera port and two

working ports

0.5 cm incision on themedial side of the

anterior chest wall

T ill A h


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Transaxillary Approach

R b ti A h


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Robotic Approach

Arm 1

Camera

Arm 2Arm 3

This approach was

developed in South Korea

by Dr. Woong Chung atYonsei University College

of Medicine in Seoul. He

reported his experience

with 338 patients


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Confidential


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Confidential


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Confidential


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Fourth arm trocar

External retractor

Connected withcontinuous suction

system


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Maryland dissector

Harmonic curved shears


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Confidential


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The Cervical / Direct Approaches:

- Anterior cervical approach

- Lateral cervical approach

- Video-assisted approach

Pros: Less pain, better cosmesis and shorter hospital stay

Cons: visible scars, not much different than open withsmall incision

The Extra-cervical Approaches:

- Axilla, chest or both.

Pros: scarless (in the neck)

Cons: extensive dissection, paresthesia, musclestiffness,operative time and learning curve

Endoscopic Parathyroidectomy


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Conclusions

Endoscopic parathyroidectomy is feasible and

has good results.

The key to success is patient selection andsurgeon experience.


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Should be proposed in carefully selected patients.

Has the main advantage of offering a magnified view and

a light that permit a safe dissection.

The lateral approach is particularly suitable for

adenomas posteriorly located in the neck


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Small tumors

Benign tumors

No surgical reconstruction

C it t Th id Di


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Concomitant Thyroid Disease

The use of a double-tracer technique (123I/99mTc-sestamibi or99mTc

pertechnetate/99m

Tc-sestamibi) or (99mTc-sestamibi scintigraphy) combinedwith US examination might be useful in planning the type and extent of surgery:

Bilateral neck exploration in the case of any PHPT patient with concomitant

multinodular goiter unilateral neck exploration in the case of a solitary

parathyroid adenoma with concomitant nodular goiter located in the ipsilateral

thyroid lobe

Gamma probe guided minimally invasive parathyroidectomy (GP-MIP) in the

case of a solitary 99mTc-sestamibi-avid parathyroid adenoma with a normal

thyroid gland endoscopic surgery in the infrequent case of a solitary 99mTc-

sestamibi negative (but US positive) parathyroid adenoma with a normal thyroid

gland.

Mariani et al. Journal of Nuclear MedicineVol. 44 No. 9 1443-1458

E d i /C ti l P th id t


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Conversions: 13.2%

Operative time: 48' (16'-130')

Complications-Hematoma in sternocleidomastoid 3

Definitive recurrent nerve palsy 1

Capsular disruption 10

Persistent HPT: 3

Recurrent HPT: 1

Jean - Francois Henry Department of Endocrine Suregery, University Hopspital La Timone.Marseilles, France Endoscopic Parathyroidectomy: Why and When ?World Journal of Surgery



E d i /C ti l P th id t


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CONVERSIONS 71/538: 13.2 %

Missed adenoma 18

Difficulties of dissection 16

QPTH assay true negative *18

QPTH assay false negative 4 Sestamibi false positive 11

Ultrasonography false positive 4

* 18 multiglandular diseases

Jean - Francois Henry Department of Endocrine Suregery, University Hopspital La Timone.Marseilles, France Endoscopic Parathyroidectomy: Why and When ? World Journal of SurgeryV l 32 N b 11 N b 2008


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