Six hundred fifty-six consecutive explorations for primary hyperparathyroidism

Abstract

Objective: To review the outcomes of 656 consecutive parathyroid explorations performed by a single surgeon and to compare the results of conventional and minimally invasive parathyroidectomy (MIP) techniques.

Summary background data: Traditional surgery for primary hyperparathyroidism (HPTH) involves bilateral cervical exploration, which is usually accomplished under general endotracheal anesthesia. The MIP technique involves preoperative localization with sestamibi scans, surgeon-administered cervical block anesthesia, directed exploration through a small incision, intraoperative rapid parathyroid hormone assay, and discharge within 2 to 3 hours of surgery.

Methods: Six hundred fifty-six consecutive patients with primary HPTH underwent exploration between January 1990 and March 2001.

Results: MIP was used with ever-increasing frequency beginning in March 1998. Four hundred one procedures (61%) were performed using the standard technique and 255 patients (39%) were selected for MIP. The success rate for the entire series was 98%, with no significant differences comparing traditional and MIP techniques. The overall complication rate of 2.3% reflects 3.0% and 1.2% rates in the standard and MIP groups, respectively. MIP was associated with approximately a 50% reduction in operating time, a sevenfold reduction in length of hospital stay, and a mean cost savings of $2,693 per procedure, which represents nearly a 50% reduction in total hospital charges.

Conclusions: A dramatic and sustained shift has occurred in the surgical treatment of primary HPTH: MIP has replaced traditional exploration for most patients.

Figure 1. Flow diagram showing stratification and distribution of procedures.

Figure 2. Sequential distribution comparing frequency of standard and minimally invasive parathyroidectomy (MIP) procedures.

Figure 3. Results of preoperative sestamibi scans in patients who underwent standard or minimally invasive parathyroidectomy (MIP) exploration.

Figure 4. Cure rates comparing standard and minimally invasive parathyroidectomy (MIP) procedures, including all procedures as well as the subsets of new and redo procedures.

Figure 5. Length of surgery and anesthesia in hours as recorded on the anesthesia data sheet. *P < .001. MIP, minimally invasive para-thyroidectomy.

Figure 6. Length of hospital stay comparing standard and minimally invasive parathyroidectomy (MIP) procedures, including all procedures as well as the subsets of new and redo procedures. *P < .0001, **P < .005.

Figure 7. Total hospital charges comparing standard and minimally invasive parathyroidectomy (MIP) procedures, including all procedures as well as the subsets of new and redo procedures. *P < .0001, **P < .05.

Figure 8. Serum intact parathyroid hormone levels comparing patients undergoing standard and minimally invasive parathyroidectomy (MIP) before surgery, 7 to 10 days after surgery, and after long-term follow-up. The gray area indicates the normal range for serum intact parathyroid hormone (10–72 pg/mL). The preoperative levels for both groups were substantially elevated compared with the postoperative and long-term values. However, there were no differences comparing the standard and MIP groups.

Figure 9. Serum calcium levels obtained before surgery, after surgery, and in long-term follow-up. The gray area indicates the normal range for serum calcium (8.4–10.5 mg/dL). The preoperative levels for both groups were substantially elevated compared with the postoperative and long-term values. However, there were no differences comparing the standard and minimally invasive parathyroidectomy (MIP) groups.