How to avoid a failed Edward D. Churchill, 1931 parathyroidectomy - - PowerPoint PPT Presentation

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How to avoid a failed Edward D. Churchill, 1931 parathyroidectomy - - PowerPoint PPT Presentation

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5/18/2013 Avoiding failed parathyroidectomy the success of parathyroid surgery must lie in the ability of the surgeon to know a parathyroid gland when he sees it, to know the distribution of the knowledge glands,

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5/18/2013 1

How to avoid a failed parathyroidectomy

Postgraduate Course in General Surgery

Jessica E. Gosnell MD

May 18, 2013 2

  • “

“ “ “ the success of parathyroid surgery must lie in the ability of the surgeon to know a parathyroid gland when he sees it, to know the distribution of the glands, where they hide, and also to be delicate enough in technique to be able to make use of this knowledge” ” ” ”

– Edward D. Churchill, 1931

Avoiding failed parathyroidectomy

How to avoid a failed parathyroidectomy

  • 1. right patient
  • 2. right operation
  • 3. right anatomy
  • 4. right tools

Case: primary hyperparathyroidism

  • 63 yo woman with osteopenia on Fosamax,

noted to have hypercalcemia, 11.3-11.7mg/dL

  • PTH inappropriately elevated at 156pg/mL
  • She denied kidney stones, bone pain, poor

memory or concentration, abdominal pain, constipation, fatigue

  • No family history of hypercalcemia, neck
  • perations
  • No history of ionizing radiation to the head,

neck or chest

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5/18/2013 2 Case: primary hyperparathyroidism

  • Sestamibi: persistent

uptake L lower

  • Ultrasound:1.8cm

hypoechoic structure

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Case: primary hyperparathyroidism

  • Plan for focused left parathyroidectomy
  • Intraoperative ultrasound confirmed hypoechoic

structure on the left, just inferior to the lower pole of the left thyroid gland

  • 2.5cm incision, to right of midline, strap

muscles retracted laterally, area around left thyroid lobe explored

  • NO PARATHYROID GLAND
  • RLN identified, thyrothymic ligament explored,

tracheoesophageal groove explored

  • NOTHING

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Case: primary hyperparathyroidism

  • Based on the imaging studies, “blind” FNA of

left thyroid lobe, inferior pole, send for PTH assay

  • While waiting, ligated upper pole vessels,

identified normal left upper parathyroid gland, marked with clip

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Case: primary hyperparathyroidism

  • PTH assay of left

thyroid lobe 7,000 pg/mL

  • Left lobectomy

completed

  • IOPTH

– Pre 1 234 – Pre 2 189 – Post 1 40 – Post 2 23

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Right Patient. Does the patient have the disease?

First things first: establish a biochemical diagnosis

  • Serum Ca >10.1 mg/dL
  • Serum intact PTH >65 ng/L
  • Urinary Ca excretion > 400 mg
  • Serum phosphorous low or low-normal
  • Serum chloride/phos ratio >33
  • Elevated serum alkaline phosphatase, uric acid
  • Serum Creatinine

Avoiding failed parathyroidectomy

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Right Patient. Does the patient have the disease?

First things first: establish a biochemical diagnosis

  • Exclude familial BFHH (benign familial hypocalciuric

hypercalcemia) urinary Ca<100mg/24hrs

  • Consider familial hyperparathyroidism (higher recurrence

rate)

  • Check Vit D 25-OH
  • Consider secondary hyperparathyroidism- check serum

creatinine, glomerular filtration rate

Avoiding failed parathyroidectomy

Right patient. Does the patient need an operation?

  • 2002 NIH guidelines for parathyroid surgery in

asymptomatic primary hyperparathyroidism

– Serum Ca (above upper limit normal) 1.0 mg/d – 24-h urinary Ca >400 mg – Creatinine clearance by 30% – BMD t-score <-2.5 – Age <50 yrs

Avoiding failed parathyroidectomy

(Bilezikian et al, JCEM 2002;87:5353)

Right operation

  • Bilateral exploration (4 gland)
  • Unilateral exploration (2 gland)
  • Focused exploration (1 gland)

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Avoiding failed parathyroidectomy

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What is the best operation?

  • Bilateral approach

– Explores all 4 glands – “gold standard” – No localization studies, no IOPTH – Indicated for pts at high risk for multi-gland disease

  • Familial syndromes
  • Negative localization

studies

– Over 95% successful

Avoiding failed parathyroidectomy

(Paloyan E and Lawrence A, Endocrine Surgery: Operative Surgery, 1976)

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What is the best operation?

  • Unilateral approach

– Explores 2 glands – Only one RLN, 2 PTH glands at risk – Useful for patients w/ US or Mibi suggesting disease on one side – Over 90% success rate

Avoiding failed parathyroidectomy

(Randomized trial : Westerdahl et al, Ann Surg 2007;246:976 Mibi and IOPTH guided surgery)

(Gosnell et al ANZ J Surg 2004;74:330)

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What is the best operation?

  • Focused

(1 gland)

– Explores 1 gland – Only one RLN at risk – Indicated in patients with high probability of single-gland disease

  • US & MIBI concordant

– 95% success rate

Avoiding failed parathyroidectomy

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Right operation. What are the critical technical aspects?

  • Bloodless field
  • Meticulous dissection
  • Lighting, exposure, judgement

Avoiding failed parathyroidectomy

1-gland 2-gland 4-gland

  • midline (lower)
  • r lateral (upper)
  • resection of

adenoma

  • +/- IOPTH,

frozen section

  • ID/preserve RLN
  • midline or lateral
  • resection of

adenoma

  • ID of normal PTH
  • +/- IOPTH,

frozen section

  • ID/preserve RLN
  • midline cervical
  • ligate/divide middle

thyroid veins

  • ID of 4 PTH glands
  • resection of enlarged

PTH gland (s)

  • +/- IOPTH,

frozen section

  • ID/preserve RLN
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Causes of primary HPT

Avoiding failed parathyroidectomy

Incidence of multiglandular disease: *15-20% in earlier series (bilateral exploration) * 5% in newer series (unilateral, focused exploration)

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Right operation? Guided by imaging studies

  • Ultrasound
  • Tc-sestamibi
  • CT/MRI
  • FNA (intrathyroidal PTH adenoma, thyroid nodules)
  • Selective venous sampling

Avoiding failed parathyroidectomy

  • Review the images yourself!
  • Suspicious thyroid nodules should be biopsied first

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Is it single-gland disease?

Avoiding failed parathyroidectomy

CaPTHUS (Kebebew) scoring model for predicting single-gland disease *Serum Ca >12 mg/dL *Serum int PTH > 2x normal upper limit *US+ for single enlarged gland *Sestamibi scan + for single enlarged gland *Concordant US and sestambibi

(Kebebew et al, Arch Surg 2006;141:777)

Score >3 100% PPV for single-gland disease

(Arici et al, Surgery 2001;129:720)

In patients with primary hyperparathyroidism, "when both the ultrasonography and sestamibi scans identified the same, solitary parathyroid tumor in patients with sporadic primary hyperparathyroidism, this was the only abnormal parathyroid gland in 96% of the patients. A focused parathyroidectomy could therefore be performed in such patients with an acceptable ( 95%) success rate"

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Anatomy 101. Where do I find the diseased glands?

  • Superior parathyroids

– 4th brachial pouch – Associated with lateral thyroid, C-cells – most are located in the cricothyroid area – 2cm area, intersection of the inferior thyroid artery and the RLN – Usually posterior to the recurrent laryngeal nerve

Avoiding failed parathyroidectomy

(Paloyan E and Lawrence A, Endocrine Surgery: Operative Surgery, 1976)

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Anatomy 101. Where do I find the diseased glands?

  • Inferior parathyroids

– 3rd brachial pouch – Associated with thymus – Lower pole of thyroid, below and anterior to the intersection of inferior thyroid artery and the RLN, thyrothymic ligament – Can have a wider distribution – Usually anterior to the recurrent laryngeal nerve

Avoiding failed parathyroidectomy

(Paloyan E and Lawrence A, Endocrine Surgery: Operative Surgery, 1976)

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Anantomy 101. Where do I find the diseased glands?

  • Enlarged parathyroids

– Tend to become displaced into pathways of least resistance

  • Superior PTH

– “PLUG” posteriorly located upper gland (Harari A. Annals Surg Oncol 2011) – Trachesophageal groove – retroesophageal – Superior posterior mediastinum

  • Inferior PTH

– Ant/Post mediastinum

Avoiding failed parathyroidectomy

Superior Inferior (Paloyan E and Lawrence A, Endocrine Surgery: Operative Surgery, 1976)

Avoiding failed parathyroidectomy

Sites of 104 missing parathyroid tumors (From Wang CA, Ann Surg 1977;186:142)

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Develop intra-operative sequence

1. Usual locations 2. Tracheoesophageal groove 3. Retroesophageal 4. Retropharyngeal 5. Thyrothymic ligament 6. Bilateral exploration 7. Carotid sheath 8. Supernumerary glands

  • 15-25% of failed cases (Henry JF World J Surg 1990;14:303)

9. Intrathyroidal

  • 10. Mediastinal
  • 5-11% of failed cases (Conn JM Am Surgeon 1991;57:62)

Avoiding failed parathyroidectomy

Have a low threshold for converting to 4-gland exploration!

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Develop intra-operative sequence

1. Consider FNA any suspicious thyroid nodules for PTH assay 2. Explore other side, use symmetry 3. Irrigate, lighting, exposure 4. Call a friend 5. STOP.

Avoiding failed parathyroidectomy

Have a low threshold for converting to 4-gland exploration!

Right tools. What surgical adjuncts should I use?

  • Intra operative PTH

– “works best when its needed least” (QY Duh) – Excellent results in 85% pts with solitary adenoma – Only helpful in 50% of pts with double adenomas – >50% drop associated with successful resection (vs return to normal PTH levels)

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Avoiding failed parathyroidectomy

(Gauger et al Surgery 2001;130:1005) (Haciyanli et al JACS 2003;197:739)

Right tools. What surgical adjuncts should I use?

  • Biopsy/Frozen section

– Use sparingly, esp for normal glands – Can confirm PTH tissue – Cannot distinguish b/ adenoma and hyperplasia – Cannot distinguish b/ PTH and Hurthle cell – Useful as confirmation in pts with concordant imaging but no IOPTH

  • Aspiration

– Can be used to distinguish between thyroid and parathyroid tissue.

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(Guerrero et al. Am J Surg 2010 Dec;200(6):701)

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Avoiding failed parathyroidectomy

Take a break, don’t despair