Focused, minimally invasive radio-guided parathyroidectomy: a feasible and safe option for elderly patients with primary hyperparathyroidism.
BACKGROUND
Primary hyperparathyroidism in elderly patients is usually associated with additional co-morbidity that increases operative risk, and thus many geriatric patients are denied the benefit of surgery for a single parathyroid adenoma.


OBJECTIVE
To evaluate the safety and efficacy of accurate single photon emission computed tomography sestamibi scintigraphy, enabling precise localization of a single adenoma, in the geriatric population.


METHODS
Twenty-two patients aged 70 years and over with biochemically proven PHPT and with a single parathyroid adenoma identified by localization studies (sestamibi SPECT scan and ultrasonography) underwent 23 operations over 29 months (out of a total of 140 patients operated upon during the same period). Immediate preoperative sestamibi scintigraphy and marking of focal adenoma uptake followed by intraoperative hand-held gamma probe were used for the removal of the parathyroid adenoma by unilateral minimal access surgery. Associated major co-morbid conditions and pre- and postoperative calcium, phosphorus and parathormone levels were recorded. Indications for surgery were listed and operative and postoperative complications were noted. The patients were followed for a mean period of 17.7 months using the same parameters.


RESULTS
The 22 patients with PHPT had a mean age of 76.3 +/- 5.9 years (range 70-88 years) and a female to male ratio of 13:9. Associated co-morbidity included ischemic heart disease (n = 15), hypertension (n = 22), non-insulin-dependent diabetes mellitus (n = 9), chronic obstructive pulmonary disease (n = 3), and previous neck surgery (n = 3). Mean preoperative serum calcium, phosphorous and PTH were 11.7 +/- 1.3 mg/dl, 2.5 +/- 0.5 mg/dl and 160.9 +/- 75.4 pg/ml respectively. In 20 of the 22 patients, surgery was successful in curing PHPT (91%). One patient had persistent hypercalcemia due to a missed adenoma, and repeat operation (by focused minimal accesss surgery) was successfully performed 2 weeks later. There were no complications and no morbidity postoperatively. Mean postoperative serum calcium, phosphorous and PTH were 9.6 +/- 1.2 mg/dl, 3.0 +/- 0.5 mg/dl and 35.2 +/- 24 pg/ml respectively. In all patients, serum calcium levels remained normal (9.7 +/- 1.3 mg/ml) after long-term follow-up (mean 17.7 +/- 9.6 months).


CONCLUSIONS
Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is a safe and effective method to cure hyperparathyroidism in the elderly. Success of surgery is directly related to the surgeon's experience and to the precise localization marking provided by sestamibi scintigraphic SPECT localization and concurrent sonographic findings.
Ben Haim
Menahem
M
Department of Surgery, Endocrine Surgery Service, Sheba Medical Center, Tel Hashomer, Israel.
Zwas
S T
ST
Munz
Yaron
Y
Rosin
Dan
D
Shabtai
Esther L
EL
Kuriansky
Joseph
J
Olchovsky
David
D
Zmora
Oded
O
Scarlat
Alexander
A
Ayalon
Amram
A
Shabtai
Moshe
M
D000236:Adenoma / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006961:Hyperparathyroidism / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery*; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D017063:Outcome Assessment, Health Care; D010282:Parathyroid Neoplasms / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D016105:Parathyroidectomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications; D025321:Surgery, Computer-Assisted / Q000379:methods*; D015899:Tomography, Emission-Computed, Single-Photon / Q000009:adverse effects / Q000379:methods*