Paradigm shift in the surgical management of multigland parathyroid hyperplasia: an individualized approach

JAMA Surg. 2014 Nov;149(11):1133-7. doi: 10.1001/jamasurg.2014.1296.

Abstract

Importance: Locoregional anesthesia, conscious sedation, and exploration via a limited incision have become a well-accepted approach for the treatment of patients with primary hyperparathyroidism with image-localized, presumed single-gland disease. However, to our knowledge, this minimally invasive technique has never been investigated in patients with multigland disease.

Objective: To extrapolate the technique of locoregional anesthesia, conscious sedation, and exploration via a limited incision to perform minimally invasive bilateral exploration in patients who have multigland hyperplasia.

Design, setting, and participants: Retrospective analysis at a tertiary academic referral center of 100 consecutive patients undergoing parathyroidectomy for primary hyperparathyroidism due to parathyroid hyperplasia between January 19, 2010, and July 30, 2013, who were included in a prospective database.

Interventions: All patients underwent subtotal parathyroidectomy using either conventional treatment (bilateral neck exploration under general anesthesia) or extended minimally invasive parathyroidectomy (ex-MIP; locoregional anesthesia, conscious sedation, and exploration via a limited incision). Patients in the ex-MIP group who required conversion to general anesthesia were analyzed in the ex-MIP group on an intent-to-treat basis.

Main outcomes and measures: Patient cure and complication rates, length of stay, and total hospital charges.

Results: Of the 100 consecutive patients with parathyroid hyperplasia, 29 received conventional treatment and 71 underwent ex-MIP. In the ex-MIP group, 11 of 71 patients (15.5%) required conversion to general anesthesia. There were no differences between the ex-MIP and conventional treatment groups in age (mean [SD], 62.2 [12.2] vs 57.7 [15.2] years; P = .12), sex (59 [83.1%] vs 23 [79.3%] female; P = .78), preoperative serum calcium level (mean [SD], 11.1 [0.9] vs 10.8 [0.8] mg/dL; to convert to millimoles per liter, multiply by 0.25; P = .15), preoperative serum parathyroid hormone level (mean [SD], 114.5 [56.8] vs 137.8 [83.4] pg/mL; to convert to nanograms per liter, multiply by 1; P = .10), complications (4 vs 0 complications; P = .32), or cure rates (98.6% vs 96.6%; P = .50). Importantly, the ex-MIP group had a significant reduction in length of stay compared with the conventional treatment group (mean [SD], 1.01 [0.02] vs 1.35 [0.24] days; P = .04). They also had lower total hospital charges, but the difference was not statistically significant (mean, $23,199 vs $27,312; P = .17).

Conclusions and relevance: Parathyroidectomy with bilateral neck exploration under general anesthesia has been the standard of care for the treatment of parathyroid hyperplasia. We demonstrate that ex-MIP can provide equivalent cure and complication rates with a shorter hospital stay and a mean hospital charge reduction of more than $4000 per case.

Publication types

  • Evaluation Study

MeSH terms

  • Adult
  • Age Distribution
  • Aged
  • Aged, 80 and over
  • Female
  • Hospital Costs / statistics & numerical data
  • Humans
  • Hyperparathyroidism / pathology
  • Hyperparathyroidism / surgery*
  • Hyperplasia / pathology
  • Hyperplasia / surgery
  • Length of Stay / economics
  • Male
  • Middle Aged
  • Minimally Invasive Surgical Procedures*
  • Parathyroid Neoplasms / pathology
  • Parathyroid Neoplasms / surgery
  • Parathyroidectomy / methods*
  • Precision Medicine / methods
  • Retrospective Studies
  • Sex Distribution
  • Thyroid Gland / pathology