Scan-directed mini-incision focused parathyroidectomy: how accurate is accurate enough?
INTRODUCTION Mini-incision focused parathyroidectomy (MI-FP) is advocated as an alternative to bilateral neck exploration (BNE), owing to its reduced morbidity. The site and side of the affected gland is identified preoperatively using a combination of ultrasound and sestamibi scans. However, the acceptable degree of inter-scan concordance required to prompt MI-FP without compromising accuracy is undetermined. METHODS Accuracy of preoperative imaging was determined both individually and in combination for all parathyroidectomies (2007-2014). A grading system (excellent, good, poor) was devised to describe the interscan concordance, which was validated by the operative and histological findings. RESULTS Eighty-nine patients (17 male, 68 female) underwent parathyroidectomy (MI-FP 44, BNE 45). The accuracy of scans interpreted individually was 53% for ultrasound and 60% for sestamibi, with no difference according to surgical technique (P = 0.43, P = 1, respectively). The proportion of interscan concordance was: excellent - 35%, good - 40%, poor 25%. Combined accuracy was 100% for both excellent and good grades but only 13% for those graded poor. Similar rates of normocalcaemia were observed for MI-FP and BNE, while postoperative hypocalcaemia was five times higher in those undergoing BNE. CONCLUSIONS Reduction in the inter-scan concordance from excellent to good does not compromise accuracy. MI-FP could be successfully performed in up to 75% of patients - 25% higher than recommended in national guidelines. Focused parathyroidectomy does not compromise surgical and endocrinological outcomes but boasts a far superior complication rate.
Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK.
I M
IM
Shapey
Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK.
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S
Jabbar
Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK.
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Z
Khan
Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK.
J E
JE
Nicholson
Department of General Surgery, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital , Blackburn , UK.
R J
RJ
Watson
D005260:Female; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D010279:Parathyroid Diseases / Q000601:surgery; D010280:Parathyroid Glands / Q000601:surgery; D016105:Parathyroidectomy / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome
Focused parathyroidectomy; Primary hyperparathyroidism; Sestamibi; Ultrasound