Scan‐directed unilateral cervical exploration for parathyroid adenoma: A legitimate approach?

Abstract

Thallium-Technetium isotope subtraction scanning was used routinely as a preoperative localization investigation in 90 patients with primary hyperparathyroidism who were submitted to "first-time" cervical exploration from 1985 to 1988. When the scintigram demonstrated a single focus of activity suggesting the site of a solitary parathyroid adenoma, a scan-directed exploration was carried out. If the tumor was found at the location suggested by the scan, it was then removed and the ipsilateral normal parathyroid was biopsied. The contralateral side of the neck was not explored in these patients. A total of 48 patients underwent unilateral cervical exploration while the remaining 42 individuals had a standard bilateral neck operation performed. The difference in operating times for patients who had a solitary adenoma and who underwent unilateral and bilateral neck exploration, respectively, was statistically highly significant (71 minutes versus 97 minutes, p less than 0.001). At mean follow-up of 16.8 months, no patient who had a unilateral neck exploration performed for solitary parathyroid adenoma demonstrated persistent or recurrent hypercalcemia.

Use of color and power Doppler sonography to identify feeding arteries associated with parathyroid adenomas.

“…Many surgeonsforego imaging entirely and advocate routine bilateral neck exploration as the initial treatmentfor this condition.In experienced hands,such surgery has a cure rate of greater than 95% [11.In contrast,other surgeonsadvo cate unilateral neck exploration, citing de creased operating room time and potential decreased risk of injury to the recurrent laryn geal nervesand normal parathyroidglands [1â€" 4]. When unilateral surgery is planned, accurate preoperative localization is critical.…”

“…When unilateral surgery is planned, accurate preoperative localization is critical. Although 99mTc sestamibi imaging has achieved sensi tivities of greater than 80% [5â€"I 11' recent re ports have suggested that sestamibi imaging alone is inadequate for directing unilateral neck exploration [1,3,4].…”

Randomized clinical trial comparing scan-directed unilateral versus bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma

“…Historically, bilateral cervical exploration has been the standard surgical treatment for patients with HPT, with attempted identification of all four parathyroids and removal of grossly enlarged glands. However, taken that a high proportion of patients have single-gland disease, the authors have questioned the need for routine bilateral neck exploration in all patients with HPT and have suggested that, if the site of the solitary tumour could be identified before operation, a focused unilateral operation with removal of the adenoma would be adequate 4 .…”

The Safety and Efficacy of Surgery for Primary Hyperparathyroidism without Intraoperative Parathyroid Hormone Measurement in Japan

“…With the wide use of sensitive preoperative localization studies, some veteran general surgeons have advocated the use of a unilateral approach [1][2][3], or even minimally invasive [4], or image-guided parathyroid surgery [5,6], and the potential benefits of these procedures are decreased risks of postoperative hypocalcemia and recurrent nerve injury, and a shorter operating time [7][8][9]. Therefore, can IOPM rule out the patients with multiple adenomas and make the surgery more successful and safer?…”