Management of the neck in parotid carcinoma

Parathyroid Surgery Using Monitored Anesthesia Care as an Alternative to General Anesthesia Beth Ann Ditkoff,

MD, John Chabot,

MD, Carl Feind, MD, Paul Lo Gerfo, MD, New York, New York

BACKGROUND: Although there have been several reports in the literature describing a renewed interest in performing thyroid surgery under local anesthesia (LA), there has been little information regarding parathyroid surgery under local anesthesia. METHODS: We retrospectively reviewed our experience of 49 LA parathyroid patients over a g-year period at a single institution. A bilateral cervical block (C2-C3) was administered by a single surgeon using lidocaine and bupivacaine. RESULTS: The study included 39 females and 10 males with an average age of 62 years (range, 35-69 years). Every surgery was curative and the final pathology revealed 46 parathyroid adenomas and 3 cases of parathyroid hyperplasia. Forty-seven percent of the patients were discharged within 6 hours of operation and the remaining patients had a 1.Cday average length of hospital stay. A group of age- and sexmatched controls who underwent parathyroid surgery using general anesthesia (GA) served as a control group with 27% of operations performed as outpatients and an average length of stay of 1.6 days. Return to work averaged 6 days for the LA group versus 6 days for the GA. In the LA group, there was one instance of postoperative hemorrhage requiring reoperation and one instance of conversion to GA secondary to an inability to tolerate LA. There were no instances of recurrent laryngeal nerve injury or permanent hypoparathyroidism in either group. CONCLUSIONS: These data suggest that experienced surgeons can perform parathyroid surgery safely and effectively using LA as an alternative to GA. 01996 by Excerpta Medica, Inc. Am J Surg. 1996;172:698-700.

A

lthough there have been several reports in the literature describing a renewed interest in performing thyroid surgery under local anesthesia (LA), there

From the Department of Surgery, Columbia University College of Physicians & Surgeons, New York, New York. Requests for reprints should be addressed to Beth Ann Ditkoff, MD, Department of Surgery, Columbia-Presbyterian Medical Center, 622 West 168th Street, P.H. 14-131, New York, New York 10032. Presented at the Fourth International Conference on Head and Neck Cancer, Toronto, Ontario, Canada, July 28-August 1, 1996.

698

0 1996 by Excerpta All rights reserved.

Medica,

Inc.

has been little information regarding parathyroid surgery under local anesthesia-” In 1981, Pyrtek et al described three case reports of high-risk patients who had undergone successful unilateral neck exploration under LA after preoperative ultrasonographic localization.i This technique was originally described by Feind in 1964.’ Later, in 1988, Pyrtek described 29 parathyroid explorations using LA, including 25 patients who were being treated for primary hyperparathyroidism, 2 patients undergoing secondary exploration for recurrent tertiary hyperparathyroidism, and 2 patients with secondary hyperparathyroiilism.” Patients were selected for LA based on symptomatic hypercalcemia and positive preoperative localization studies. There were 4 complications described, including 2 patients with sytnptomatic hypocalcemia, I case of transient Horner’s syndrome, and 1 patient who suffered a nonfatal cerebral vascular accident 7 days postoperatively. In addition, Saxe et al published a report in 1988 descrihing thyroid and parathyroid surgery under LA which included 2 patients undergoing neck exploration for parathywere reported. roid disease. ” No complications The success of performing both thyroid and parathyroid surgery under LA has encouraged the use of monitored anesthesia care during parathyroid surgery. The current study is the largest series in the literature reporting the outcome of parathyroid surgery using regional anesthetic techniques.

MATERIALS

AND METHODS

Forty-nine patients undergoing parathyroid surgery from 2187 to 6/96 under LA were included in this retrospective chart review study. Postoperative follow-up and information regarding patient satisfaction was obtained hy office visit and telephone survey. A group of age- and sex-matched patients who had parathyroid surgery performed under general anesthesia (GA) served as controls to compare patient characteristics, operative details, duration of hospital stay, complications, and patient satisfaction. All patients had their surgery performed hy a single senior surgeon (P.L.) at the Columbia-Presbyterian Medical Center. These 49 patients represent approximately 7% of the total number of parathyroid surgeries performed during this time period. In all instances, the indication for LA was patient request. A general surgery resident, usually postgraduate year three or four, served as the first assistant. Local anesthesia was administered by the senior surgeon In all cases. An anesthesia team consisting of a resident supervised by an attending provided perioperative monitoring as well as mild intraoperative sedation. 0002-961 O/96/$1 PII SOOO2-9610(96)00311-O

5.00

1 PARATHYROID TABLE

SURGERY

UNDER

LOCAL

ANESTHESIA/DITKOFF

ET

RESULTS

I Number

of Patients

Undergoing Local Anesthesia

Parathyroidectomy Parathyroidectomy and partial thyroidectomy Parathyroidectomy and unilateral thyroid lobectomy Parathyroidectomy and subtotal thyroidectomy Parathyroidectomy and total thyroidectomy Total

TABLE II Average Duration

All 49 charts were available

Operation General Anesthesia

34

28

5

10

9

8

0

2

1

1

n = 49

n = 49

and Range of Time (In Minutes) of Operative Based on Operation Performed

for review.

Patient Characteristics The study included 39 females and 10 males with an average age of 62 years and an age range trom 35 to 89 years. Body habitus, determined by height and weight, was divided into three categories: thin, average, and obese, based on the Presbyterian Hospital diet manual developed from the Fogarty International Conference on Ohcsity and the Table of the Metropolitan Life Insurance Company.” Twentyfour of 49 patients (51%) were considered to be in the average body hahitus range, while 5 ( 10%) patients were thin, and 19 patients (39(X,) were considered bhese. Control patients (age and sex matched) who underwent parathyroid surgery under GA during the same time period were considered to he of ,lverage body hahitus (33%), thin (4%), and obese (63%). Procedures

Preoperative Studies We do not routmely obtain preoperaAverage Time (Range) tive localization studies on primary neck Local Anesthesia General Anesthesia WLfhdtiOll for hyperl7arathyroidism. Sixteen preoperative localization studies Single gland parathyroidectomy 59 (30- 130) 56 (18-100) were obtained m 11 LA patients. These Single gland parathyroidectomy and thyroidectomy 74 (35-l 40) 90 (45-l 35) included 7 sestamibi scans, 2 CT scans, Multiple gland parathyroidectomy 66 (45-l 05) 65 (45-85) 1 MRI, and 6 ultras<>und tests. The maMultiple gland parathyroidectomy jority of tests were ordered hy the referand thyroidectomy 63 (55-80) 69 (55-85) ring physician. Preoperative localization was successful in 9 of 11 patients. A total of 21 preoperative localization studies were ordered for 17 GA control patients, In all cases, Xylocaine (lidocaine hydrochloride 0.5% including 9 sestamibi scans, 6 CT scums, 0 MRI, and 6 ulwithout epinephrine; Astra Pharmaceutical, Westboro, trasound tests. Prcoperdtive localization was successful in MA) was mixed with in a 1:l solution with Marcaine 12 of 17 patients. (hupivacaine hydrochloride 0.25% without epinephrine; Winthrop Pharmaceuticals, New York, NY). The dose of Surgery lidocaine was near the maximal recommended dosage acForty-eight patients underwent primary neck exploration for parathyroid disease; there was 1 instance of secondary cording to the manufacturer’s instructions, usually about 300 mg per patient, hut never exceeded 4.5 mg/kg. The neck exploration m both the LA and GA groups. The type dose of hupivacaine was approximately 40 mg. of operations performed for both the LA and the GA groups A deep cervical plexus block and field block were adare outlined in Table I. In the LA group, 46 patients were ministered as previously descrihed.6,‘1,‘2 We have modioperated on for a pamthyroid adenoma and the remaining fied the technique as follows. The patient is placed with 3 patients had a diagnosis of parathyrold hyperplasia. In the their head turned to the side. Using a 25-gauge needle, GA group, the pathology included 48 parathyroid adenomas, 1 pamthyroid cancer, and 0 hyperplastic glands. Opapproximately 5-10 cc of a 1:l mixture of lidocaine and hupivacaine is injected in the superior lateral border of era&e strategy aimed to successfully Identify all four parathe sternocleidomastoid muscle at the level of the tnanthyroid glands, even m instances where a parathyroid dible approximately 2-3 cm below the mastoid process. adenoma and normal parathyroid gland were identified on After repeating the cervical block on the contralateral the side of initial exploration. Table II details the duration side, a field block is then accomplished by injecting apof operative procedure based on the operation performed proximately 15 cc of the same solution in the anterior for both the LA and GA groups. neck bilaterally. At operation, an additional 5-10 cc of anesthetic agent is infiltrated directly into the thyroid Perioperative Anesthesia isthmus and superior poles bilaterally. Physical status was assessed using the American Society Complications of the cervical plexus block include intraof Anesthesiologists’ classification. For the local anesthesia arterial injection into the vertebral artery and Infiltration group, 5 patients were characterized as Class I (lo%), 33 of the phrenic nerve with resulting respiratory embarrass(67%) Class II, 10 (21%) Class III, and 1 (2%) Class IV. ment. The first complication can be avoided by aspirating The general anesthesia group had the following distributhe syringe before injecting, and the second complication tion: 4 (So/), 32 (65%), 13 (27%), and 0 (0%). Intracan he prevented by injecting superiorly at the CZC3 level operative sedation was provided for the LA group by a cornand not attempting to block C4 or lower. bination of inrrwvenous medications, usually midazolam, THE AMERICAN

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fentanyl, and propofol. In all instances, patients were cooperative and able to respond to questions and directions appropriately. The surgeons’ goal was to produce conscious sedation. Duration of Hospital Stay For the LA group, 23 patients (47%) were operated on as outpatients versus 27% for the GA. The remaining LA patients had an average length of stay of 1.4 days versus 1.6 days for the GA group. One LA patient and 4 GA patients were excluded from the analysis because multiple medical problems unrelated to their parathyroid disease or surgery required them to have a length of stay ranging from 11 to 38 days. Complications No patients in either the LA or GA groups experienced complications from wound infection or recurrent laryngeal nerve injury. There was 1 instance in the LA group of postoperative hemorrhage, which was treated with immediate reoperation. One additional LA patient had his operation temporarily halted for transient hypertension, which was medically managed by the anesthesiologists. Only 1 patient was converted from LA to GA secondary to an inability to tolerate the LA. It is difficult to determine if any patients experienced mild symptomatic hypocalcemia postoperatively because we routinely instruct our postoperative parathyroid patients to take 2 g of calcium daily. No patients required vitamin D postoperatively to control their calcium. All patients were rendered eucalcemic postoperatively; no patients required reoperation for a missed adenoma. Patient Satisfaction Sixty-seven percent of patients who had pararhyroid surgery performed under LA and 71% of the GA group were able to be contacted by telephone for a patient satisfaction survey. Patients who had both parathyroid and thyroid surgery were excluded from this analysis in order to compare similar operations. Eighty-two percent of the LA patients stated that the surgery was equal to or less painful than a routine trip to the dentist to have a cavity filled. Average length of time before returning to work was 6 days for the LA group versus 8 days for the GA group. Ninety-five percent of the LA patients stated that they would choose LA again if the situation arose.

DISCUSSION LA provides a simple and safe alternative to patients who need to undergo parathyroid surgery, but do not desire GA. In our series, there was no difference in patient characteristics or length of surgery. More operations were able to be performed on an outpatient basis for the LA group versus the GA group (47% versus 27%). In addition, the LA group

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returned to work an average of 2 days before the patient operated on under GA (6 days versus 8 days). Other series have focused on performing parathyroid SUI gery under LA for patients who have severe medical prol: lems and thus are at risk for GA. The current study als supports using LA in these instances, with approximate1 one-fifth of the patients assigned a Class III or 1V anesthesi category. We have also shown that preoperative localize tion studies are unnecessary in primary neck exploration duration of surgery was generally about 1 hour in both th LA and GA groups. Our study IS the largest series in the literature describin patient characteristics, techniques, and perioperative tour:: of patients undergoing parathyroid surgery using LA. Th two most important predictors of success for parathyroi surgery under LA is a well-informed patient and a surge0 who is skilled at administering a cervical block. By carefull screening patients preoperatively and competently perforrr ing a regional block, LA for parathyroid surgery can be err ployed successfully in a broad range of patients. These L1 patients appear to benefit by having their surgery performe more often on an outpatient basis and returning to work normal activity more quickly than GA patients.

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3. Vanevcskii VL, Kaiumova IK. Ane\theslolo#ic provisions for SUI gery of the thyroici. Vest Khir. 1972;108:86-89. 4. Lo Gerfo roid surgery.

P, Gates R, Gazetas P. Outpatients Head Neck Surg. 1991;13:97~1@1.

and short-stay

thl

5. Hochrnan M, Fee W. Thyroidcctomy under local anesthesi; Head Neck Su,g 1991; 117:405-407. 6. Lo Gerfo P, Dirkoff BA, Chahot 1, Feind C. Thyroid surgery usin

Arch Otohyngol

monitored anesthesia care: an alternative to general anesthesi: Thyroid. 1994;4:437-439. 7. Pyrtek LJ, McClelland ,411. Primary surgery for hyperparathl

roidism: the lateral approach after pre<>pemtive ultrasunographic I( calization. 41nJ Surg. 1983;145:5@3~507. 8. Feind C. Re-exploration for parathyroid 1964;108:543-546.

adenoma.

Am J Surf

9. Pyrtek LJ, Belkin M, Bartus S, Schweizer R. Parathyroid glan exploration with local anesthesia in elderly high-risk patients. Arc Surg. 1988;123:614-617. 10. Sax ,4W, Brown

E, Hamburger SW. Thyr& and parathyrol surgery performed urith patlenr u&r reg:lonal anesthesia. Surger: 1988;103:415-420. 11. Prithvi Raj P, Pal U, Rnwdl N. Techniques of regional ane: thesia in adults. In: Prithvi Raj P, ed. Clinicul Practice of Regionc Anesthesin. New 12. Marshall M. Raj P, ed. Clintcal chill Livingstone, 13. Presbyterian the City of New

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York: Church111 Llxwngstone, 1991. Preopemfwe evaluation of the patient. In: Prlrh\ Pmctxe of Regional Anesthesia. New York: Chu: 1991. Hospltsl Diet Manual, Presbyterian Hospiral i York, New York, 1988.