title: Paradigm shift in the surgical management of multigland parathyroid hyperplasia: an individualized approach.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Amir H
authors.initials: AH
authors.lastname: Lebastchi
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Patricia I
authors.initials: PI
authors.lastname: Donovan
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Robert
authors.initials: R
authors.lastname: Udelsman
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data; D006801:Humans; D006961:Hyperparathyroidism / Q000473:pathology / Q000601:surgery*; D006965:Hyperplasia / Q000473:pathology / Q000601:surgery; D007902:Length of Stay / Q000191:economics; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D010282:Parathyroid Neoplasms / Q000473:pathology / Q000601:surgery; D016105:Parathyroidectomy / Q000379:methods*; D057285:Precision Medicine / Q000379:methods; D012189:Retrospective Studies; D017678:Sex Distribution; D013961:Thyroid Gland / Q000473:pathology