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Section 1. Parathyroid
Biomed Pharmacother 56 (2002) 22s–25s www.elsevier.com/locate/biopha
Mini review
Section 1. Parathyroid Total endoscopic parathyroidectomy Y. Ikeda *, H. Takami, G. Tajima, Y. Sasaki, J. Takayama, H. Kurihara, M. Niimi Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
Abstract During the last five years, minimally invasive procedures have been adopted for the surgical treatment of hyperparathyroidism, because preoperative localization studies such as high-resolution ultrasonography and sestamibi scintigraphy, guidance by intraoperative scans, and the use of quick, intraoperative parathyroid hormone assay have improved. Endoscopic parathyroidectomy was performed by Gagner in 1996, and surgical procedures using endoscopy have been devised. The endoscopic procedures range from the “pure” endoscopic approach characterized by constant gas insufflation to video-assisted gasless techniques. We adopted the “pure” endoscopic approach, because a small incision can be made far from the neck and the cosmetic result is excellent. We report our technique with no scars in the neck region for endoscopic unilateral neck exploration with primary hyperparathyroidism and for endoscopic bilateral neck exploration with renal hyperparathyroidism. © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Primary hyperparathyroidism; Renal hyperparathyroidism; Minimally invasive surgery; Parathyroid; Parathyroidectomy
1. Introduction Minimally invasive surgery of the neck has recently been reported for the treatment of parathyroid diseases. Purely endoscopic parathyroidectomy was performed by Gagner in 1996 [1], and some surgeons have followed this technique strictly. However, this approach involves three ports in the neck region, and an unwillingness to shift to a purely endoscopic procedure in a small, enclosed space with no dedicated instruments and general concern about the effects of constant CO2 insufflation into an extraperitoneal cavity have led other surgeons to attempt a different approach. Some of them devised video-assisted gasless techniques [2,3] and radio-guided minimally open surgery [4,5]. We adopted minimally invasive neck surgery in 1999 [6,7] and found that the problems of purely endoscopic surgery were avoided by making an incision far from the neck region and the working space under the platysma. In the large working space, some of the ordinary instruments and forceps used in
* Corresponding author. Tel.: +81-3-3964-1228; fax: +81-3-3962-2128. E-mail address: [email protected] (Y. Ikeda). © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. PII: S 0 7 5 3 - 3 3 2 2 ( 0 2 ) 0 0 2 6 1 - 5
laparoscopic surgery can be used, and no complication occurs due to CO2 insufflation at a pressure of less than 4 mmHg, which is sufficient for lifting only the platysma [8,9]. In addition, the cosmetic result is excellent, because a small incision can be made far from the neck region, and the wounds under the clavicles are completely hidden even by clothes with a wide neck. The operative field is clearly identified with a high-magnification video monitor, and the whole field can also be visualized from a distant position. Here, we report our original, purely endoscopic parathyroidectomy by an anterior chest approach for the treatment of hyperparathyroidism.
2. Methods 2.1. Patients Between April 2000 and March 2001, 20 patients with hyperparathyroidism were treated by our newly devised procedures. Endoscopic unilateral neck exploration by an anterior chest approach was performed in 15 patients with primary hyperparathyroidism. They consisted of two men
Y. Ikeda et al. / Biomed Pharmacother 56 (2002) 22s–25s
23s
and 13 women, and their mean age was 60 years. Endoscopic total parathyroidectomy bilateral neck exploration by an anterior chest approach was carried out in five patients with renal hyperparathyroidism. They consisted of two men and three women, and their mean age was 50 years. The preoperative localization studies consisted of highresolution ultrasonography and sestamibi-99mTc subtraction scintigraphy with SPECT. All patients had hypercalcemia and elevated parathyroid hormone (PTH) levels. All the procedures were performed by the same surgeon (Y.I.). 2.2. Operative technique: endoscopic parathyroidectomy by an anterior chest approach Under general anesthesia, the patient is placed in the supine position with the neck extended. A 5-mm skin incision is made about 3.0 cm below the inferior border of the clavicle on both sides of the chest, and the lower layer of the platysma is extracted manually. A 5-mm trocar is inserted through each of the incisions, and a purse-string suture is placed at both sites to prevent gas leakage and trocar slippage out of the wounds. CO2 is then insufflated up to 4 mmHg, and a 30° 5-mm endoscope is inserted through the trocar of a side to operate on. Two additional 5-mm trocars are then inserted under endoscopic guidance, one inferior to the sternal notch and the other below the ipsilateral clavicle (Fig. 1). The thyroid gland is exposed by splitting the sternothyroid muscle, and it is then rotated forward with the retractor through the opposite 5-mm trocar to reveal the parathyroid glands. The perithyroid fascia is cut carefully to avoid injuring the recurrent laryngeal nerve, so that the parathyroid adenoma protrudes, and the adenoma is then dissected with endoscopic scissors or the Harmonic Scalpel (Johnson-Johnson Medical, Cincinnati, OH, USA) (Fig. 2). The specimen is placed in a finger of a plastic glove and extracted through the 5-mm skin incision. The other ipsilateral parathyroid gland is also explored. If the parathyroid gland appears normal, it is biopsied. If it appears enlarged, however, it is dissected and removed. Quick intraoperative intact PTH assay (Nichols Institute Diagnostics, San Juan Capistrano, CA) is performed. The completeness of the surgical resection of all hyperfunctioning parathyroid tissue is confirmed when the intact PTH levels return to within their normal range 15 min after removal of the adenoma. In the treatment of renal hyperparathyroidism, the other ipsilateral parathyroid adenoma is also resected. Next, the endoscope is inserted through the opposite 5-mm trocar, and one more 5-mm trocar is inserted below the opposite clavicle under endoscopic guidance (Fig. 3). Endoscopic total parathyroidectomy is performed by the same procedure. The transplants are preferably excised from the
Fig. 1. The schema of the anterior neck area from the anterior chest wall. The excoriated layer under platysma from the anterior chest is indicated by oblique lines. Three 5-mm trocars were inserted about 3.0 cm below the inferior border of the clavicle for primary hyperparathyroidism.
smallest gland in each case, avoiding macroscopically visible nodules. A parathyroid autoimplantation is performed in the pectoralis major muscle through a 5-mm incision at the anterior chest. The wound is closed by suturing the adipose tissue with 3-0 absorbable thread, tightly suturing the subcutis with 4-0 absorbable monofilament thread with an atraumatic needle, and then approximating the skin with nonabsorbable thread.
Fig. 2. The parathyroid adenoma is dissected to avoid injuring the recurrent laryngeal nerve.
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Y. Ikeda et al. / Biomed Pharmacother 56 (2002) 22s–25s Table 2 Patient characteristics and operation details of renal hyperparathyroidism (n = 5) Mean ± SEM Age (years) Gender: men/women Duration of operation Blood loss (g) Weight of the adenomas (mg) Postoperative stay (d)
50.2 ± 3.2 2/3 236 ± 30 11 ± 1 1917 ± 411 6.0 ± 0.6
Range 40–58 190–337 10–16 1000–3211 4–7
4. Discussion
Fig. 3. The schema of the anterior neck area from the anterior chest wall. The excoriated layer under platysma from the anterior chest is indicated by oblique lines. Five 5-mm trocars were inserted about 3.0 cm below the inferior border of the clavicle for renal hyperparathyroidism.
3. Results Endoscopic parathyroidectomy was successfully carried out in all patients. The patient characteristics and operation details of primary hyperparathyroidism and renal hyperparathyroidism are presented in Tables 1 and 2, respectively. The mean operation time for unilateral neck exploration and total parathyroidectomy was 95 and 236 min, respectively. Histologic examination of the specimen confirmed the diagnosis of parathyroid adenoma in primary hyperparathyroidism and of hyperplasia in renal hyperparathyroidism. At follow-up, the serum calcium and PTH levels had returned to within the normal range in all patients. Blood loss is minimized. Hypercapnia, respiratory acidosis, and air embolism were minimized. The subcutaneous emphysema did not extend to the patient’s face, and it resolved during the postoperative period. There was no pain and no evidence of injury to the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve. The postoperative cosmetic status was excellent, with minimal hypesthesia and paresthesia. Table 1 Patient characteristics and operation details of primary hyperparathyroidism (n = 15) Mean ± SEM Age (years) Gender: men/women Duration of operation Blood loss (g) Weight of the adenomas (mg) Postoperative stay (d)
60.5 ± 13.5 2/13 95 ± 25 7±5 1586 ± 1534 4.0 ± 1.0
Range 32–68 44–115 5–26 400–6000 3–5
Endoscopic procedures for minimally invasive surgery have been applied in various surgical specialties, and to cervical exploration by Gagner in 1996 [1]. The scar from the neck incision is small and inconspicuous in comparison with that of conventional open surgery. With this in mind, we have adopted a “pure” endoscopic approach featuring constant gas insufflation, because this technique allows the incision to be made far from the neck region [10-14]. We have now developed unilateral neck exploration by an anterior chest approach. In our new approach, three trocars are inserted in the anterior chest, allowing neck incisions to be completely avoided. The small scars left in the anterior are completely hidden even by clothes with a wide neck. In addition, there are several noteworthy theoretical advantages of endoscopic parathyroidectomy by an anterior chest approach. The thyroid gland can be visualized laterally by our method, and the perithyroid fascia can be carefully cut, providing an operative field of view equivalent to that of open surgery. This allows the recurrent laryngeal nerve and the parathyroid glands to be identified, and it creates a sufficiently large working space from the anterior border of the sternocleidomastoid muscle to the ipsilateral sternohyoid muscle. CO2 insufflation at a pressure of less than 4 mmHg is adequate, because only the platysma needs to be lifted. This method is significantly different from those described by other authors, who create a working space by lifting both the platysma and the sternohyoid muscle by a neck approach. Because of the small working space and CO2 insufflation pressure of less than 4 mmHg, hypercapnia, respiratory acidosis, subcutaneous emphysema, and air embolism are minimized [7,8]. The disadvantages of the endoscopic technique described herein include the time required for surgery, invasion, because of the extensive exploration from the anterior chest to the neck, and difficulty in identifying infraclavicular ectopic parathyroid glands. We believe the operation time will decrease with further experience. The operation time for primary hyperparathyroidism was over 150 min in the first two cases, and after this early phase of the learning curve, it quickly dropped to less than 100 min. Furthermore, the operation time for renal hyperparathyroidism was nearly
Y. Ikeda et al. / Biomed Pharmacother 56 (2002) 22s–25s
300 min in the first two cases, and after this early phase of the learning curve, it quickly dropped to less than 200 min. The area of dissection from the anterior chest to the neck caused pain and discomfort in some patients, but the pain passed away by the next day, and the discomfort disappeared after about 3 months. In the inquiry of ambulatory treatment, nearly all the patients felt that the cosmetic advantages outweighed the transient discomfort. However, infraclavicular ectopic parathyroid glands are extremely difficult to resect, because the clavicle interferes with insertion of the forceps into that position. Thus, preoperative localization diagnosis is mandatory. Patients with hyperparathyroidism could be treated by endoscopic parathyroidectomy by an anterior chest approach when functional parathyroid adenomas have been identified above the clavicle in the neck by preoperative localization studies. Nowadays, the use of a quick, intraoperative PTH assay in patients with primary hyperparathyroidism has improved the success rate of parathyroidectomy [3], and we are in the process of introducing intraoperative hormone assays to confirm successful excision of all hyperfunctioning glands. In conclusion, endoscopic parathyroidectomy by an anterior chest approach is the procedure of choice in wellselected patients with hyperparathyroidism.
References [1] [2]
Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 1996;83:875. Cougard P, Goudet P, Osmak L, Ferrand L, Letourneau B, Brun JM. Videocervicoscopy in surgery of primary hyperparathyroidism. Preliminary study of 19 patients. Ann Chirurg 1998;52:885–9.
25s
[3]
Miccoli P, Bendinelli C, Vignali E, Mazzeo S, Cecchini GM, Pinchera A, et al. Endoscopic parathyroidectomy: report of an initial experience. Surgery 1998;124:1077–80.
[4]
Gauger PG, Reeve TS, Delbridge LW. Endoscopically assisted, minimally invasive parathyroidectomy. Br J Surg 1999;86:1563–6.
[5]
Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery 1997;122: 998–1004.
[6]
Prager G, Czerny C, Kurtaran A, Passler C, Scheuba C, Niederle B. The value of preoperative localization studies in primary hyperparathyroidism. Chirurg 1999;70:1082–8.
[7]
Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT. Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy. Surg Endosc 1998;12:202–6.
[8]
Huscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877.
[9]
Takami H, Oshima M, Sugawara I, Satake S, Ikeda Y, Nakamura K, et al. Pre-operative localization and tissue uptake study in parathyroid imaging with technetium-99m-sestamibi. Aust N Z J Surg 1999;69:629–31.
[10] Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336–40. [11]
Ikeda Y, Takami H. Endoscopic parathyroidectomy. Biomed Pharmacother 2000;54:52–6.
[12] Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic thyroidectomy by the axillary approach. Surg Endosc 2002; 15:1362–4. [13] Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic thyroidectomy and parathyroidectomy by the axillary approach: a preliminary report. Surg Endosc 2002;16:92–5. [14] Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic total thyroidectomy by the anterior chest approach for renal hyperparathyroidism. Surg Endosc 2002;16:320–2.
Mini review
Section 1. Parathyroid Total endoscopic parathyroidectomy Y. Ikeda *, H. Takami, G. Tajima, Y. Sasaki, J. Takayama, H. Kurihara, M. Niimi Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
Abstract During the last five years, minimally invasive procedures have been adopted for the surgical treatment of hyperparathyroidism, because preoperative localization studies such as high-resolution ultrasonography and sestamibi scintigraphy, guidance by intraoperative scans, and the use of quick, intraoperative parathyroid hormone assay have improved. Endoscopic parathyroidectomy was performed by Gagner in 1996, and surgical procedures using endoscopy have been devised. The endoscopic procedures range from the “pure” endoscopic approach characterized by constant gas insufflation to video-assisted gasless techniques. We adopted the “pure” endoscopic approach, because a small incision can be made far from the neck and the cosmetic result is excellent. We report our technique with no scars in the neck region for endoscopic unilateral neck exploration with primary hyperparathyroidism and for endoscopic bilateral neck exploration with renal hyperparathyroidism. © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Primary hyperparathyroidism; Renal hyperparathyroidism; Minimally invasive surgery; Parathyroid; Parathyroidectomy
1. Introduction Minimally invasive surgery of the neck has recently been reported for the treatment of parathyroid diseases. Purely endoscopic parathyroidectomy was performed by Gagner in 1996 [1], and some surgeons have followed this technique strictly. However, this approach involves three ports in the neck region, and an unwillingness to shift to a purely endoscopic procedure in a small, enclosed space with no dedicated instruments and general concern about the effects of constant CO2 insufflation into an extraperitoneal cavity have led other surgeons to attempt a different approach. Some of them devised video-assisted gasless techniques [2,3] and radio-guided minimally open surgery [4,5]. We adopted minimally invasive neck surgery in 1999 [6,7] and found that the problems of purely endoscopic surgery were avoided by making an incision far from the neck region and the working space under the platysma. In the large working space, some of the ordinary instruments and forceps used in
* Corresponding author. Tel.: +81-3-3964-1228; fax: +81-3-3962-2128. E-mail address: [email protected] (Y. Ikeda). © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. PII: S 0 7 5 3 - 3 3 2 2 ( 0 2 ) 0 0 2 6 1 - 5
laparoscopic surgery can be used, and no complication occurs due to CO2 insufflation at a pressure of less than 4 mmHg, which is sufficient for lifting only the platysma [8,9]. In addition, the cosmetic result is excellent, because a small incision can be made far from the neck region, and the wounds under the clavicles are completely hidden even by clothes with a wide neck. The operative field is clearly identified with a high-magnification video monitor, and the whole field can also be visualized from a distant position. Here, we report our original, purely endoscopic parathyroidectomy by an anterior chest approach for the treatment of hyperparathyroidism.
2. Methods 2.1. Patients Between April 2000 and March 2001, 20 patients with hyperparathyroidism were treated by our newly devised procedures. Endoscopic unilateral neck exploration by an anterior chest approach was performed in 15 patients with primary hyperparathyroidism. They consisted of two men
Y. Ikeda et al. / Biomed Pharmacother 56 (2002) 22s–25s
23s
and 13 women, and their mean age was 60 years. Endoscopic total parathyroidectomy bilateral neck exploration by an anterior chest approach was carried out in five patients with renal hyperparathyroidism. They consisted of two men and three women, and their mean age was 50 years. The preoperative localization studies consisted of highresolution ultrasonography and sestamibi-99mTc subtraction scintigraphy with SPECT. All patients had hypercalcemia and elevated parathyroid hormone (PTH) levels. All the procedures were performed by the same surgeon (Y.I.). 2.2. Operative technique: endoscopic parathyroidectomy by an anterior chest approach Under general anesthesia, the patient is placed in the supine position with the neck extended. A 5-mm skin incision is made about 3.0 cm below the inferior border of the clavicle on both sides of the chest, and the lower layer of the platysma is extracted manually. A 5-mm trocar is inserted through each of the incisions, and a purse-string suture is placed at both sites to prevent gas leakage and trocar slippage out of the wounds. CO2 is then insufflated up to 4 mmHg, and a 30° 5-mm endoscope is inserted through the trocar of a side to operate on. Two additional 5-mm trocars are then inserted under endoscopic guidance, one inferior to the sternal notch and the other below the ipsilateral clavicle (Fig. 1). The thyroid gland is exposed by splitting the sternothyroid muscle, and it is then rotated forward with the retractor through the opposite 5-mm trocar to reveal the parathyroid glands. The perithyroid fascia is cut carefully to avoid injuring the recurrent laryngeal nerve, so that the parathyroid adenoma protrudes, and the adenoma is then dissected with endoscopic scissors or the Harmonic Scalpel (Johnson-Johnson Medical, Cincinnati, OH, USA) (Fig. 2). The specimen is placed in a finger of a plastic glove and extracted through the 5-mm skin incision. The other ipsilateral parathyroid gland is also explored. If the parathyroid gland appears normal, it is biopsied. If it appears enlarged, however, it is dissected and removed. Quick intraoperative intact PTH assay (Nichols Institute Diagnostics, San Juan Capistrano, CA) is performed. The completeness of the surgical resection of all hyperfunctioning parathyroid tissue is confirmed when the intact PTH levels return to within their normal range 15 min after removal of the adenoma. In the treatment of renal hyperparathyroidism, the other ipsilateral parathyroid adenoma is also resected. Next, the endoscope is inserted through the opposite 5-mm trocar, and one more 5-mm trocar is inserted below the opposite clavicle under endoscopic guidance (Fig. 3). Endoscopic total parathyroidectomy is performed by the same procedure. The transplants are preferably excised from the
Fig. 1. The schema of the anterior neck area from the anterior chest wall. The excoriated layer under platysma from the anterior chest is indicated by oblique lines. Three 5-mm trocars were inserted about 3.0 cm below the inferior border of the clavicle for primary hyperparathyroidism.
smallest gland in each case, avoiding macroscopically visible nodules. A parathyroid autoimplantation is performed in the pectoralis major muscle through a 5-mm incision at the anterior chest. The wound is closed by suturing the adipose tissue with 3-0 absorbable thread, tightly suturing the subcutis with 4-0 absorbable monofilament thread with an atraumatic needle, and then approximating the skin with nonabsorbable thread.
Fig. 2. The parathyroid adenoma is dissected to avoid injuring the recurrent laryngeal nerve.
24s
Y. Ikeda et al. / Biomed Pharmacother 56 (2002) 22s–25s Table 2 Patient characteristics and operation details of renal hyperparathyroidism (n = 5) Mean ± SEM Age (years) Gender: men/women Duration of operation Blood loss (g) Weight of the adenomas (mg) Postoperative stay (d)
50.2 ± 3.2 2/3 236 ± 30 11 ± 1 1917 ± 411 6.0 ± 0.6
Range 40–58 190–337 10–16 1000–3211 4–7
4. Discussion
Fig. 3. The schema of the anterior neck area from the anterior chest wall. The excoriated layer under platysma from the anterior chest is indicated by oblique lines. Five 5-mm trocars were inserted about 3.0 cm below the inferior border of the clavicle for renal hyperparathyroidism.
3. Results Endoscopic parathyroidectomy was successfully carried out in all patients. The patient characteristics and operation details of primary hyperparathyroidism and renal hyperparathyroidism are presented in Tables 1 and 2, respectively. The mean operation time for unilateral neck exploration and total parathyroidectomy was 95 and 236 min, respectively. Histologic examination of the specimen confirmed the diagnosis of parathyroid adenoma in primary hyperparathyroidism and of hyperplasia in renal hyperparathyroidism. At follow-up, the serum calcium and PTH levels had returned to within the normal range in all patients. Blood loss is minimized. Hypercapnia, respiratory acidosis, and air embolism were minimized. The subcutaneous emphysema did not extend to the patient’s face, and it resolved during the postoperative period. There was no pain and no evidence of injury to the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve. The postoperative cosmetic status was excellent, with minimal hypesthesia and paresthesia. Table 1 Patient characteristics and operation details of primary hyperparathyroidism (n = 15) Mean ± SEM Age (years) Gender: men/women Duration of operation Blood loss (g) Weight of the adenomas (mg) Postoperative stay (d)
60.5 ± 13.5 2/13 95 ± 25 7±5 1586 ± 1534 4.0 ± 1.0
Range 32–68 44–115 5–26 400–6000 3–5
Endoscopic procedures for minimally invasive surgery have been applied in various surgical specialties, and to cervical exploration by Gagner in 1996 [1]. The scar from the neck incision is small and inconspicuous in comparison with that of conventional open surgery. With this in mind, we have adopted a “pure” endoscopic approach featuring constant gas insufflation, because this technique allows the incision to be made far from the neck region [10-14]. We have now developed unilateral neck exploration by an anterior chest approach. In our new approach, three trocars are inserted in the anterior chest, allowing neck incisions to be completely avoided. The small scars left in the anterior are completely hidden even by clothes with a wide neck. In addition, there are several noteworthy theoretical advantages of endoscopic parathyroidectomy by an anterior chest approach. The thyroid gland can be visualized laterally by our method, and the perithyroid fascia can be carefully cut, providing an operative field of view equivalent to that of open surgery. This allows the recurrent laryngeal nerve and the parathyroid glands to be identified, and it creates a sufficiently large working space from the anterior border of the sternocleidomastoid muscle to the ipsilateral sternohyoid muscle. CO2 insufflation at a pressure of less than 4 mmHg is adequate, because only the platysma needs to be lifted. This method is significantly different from those described by other authors, who create a working space by lifting both the platysma and the sternohyoid muscle by a neck approach. Because of the small working space and CO2 insufflation pressure of less than 4 mmHg, hypercapnia, respiratory acidosis, subcutaneous emphysema, and air embolism are minimized [7,8]. The disadvantages of the endoscopic technique described herein include the time required for surgery, invasion, because of the extensive exploration from the anterior chest to the neck, and difficulty in identifying infraclavicular ectopic parathyroid glands. We believe the operation time will decrease with further experience. The operation time for primary hyperparathyroidism was over 150 min in the first two cases, and after this early phase of the learning curve, it quickly dropped to less than 100 min. Furthermore, the operation time for renal hyperparathyroidism was nearly
Y. Ikeda et al. / Biomed Pharmacother 56 (2002) 22s–25s
300 min in the first two cases, and after this early phase of the learning curve, it quickly dropped to less than 200 min. The area of dissection from the anterior chest to the neck caused pain and discomfort in some patients, but the pain passed away by the next day, and the discomfort disappeared after about 3 months. In the inquiry of ambulatory treatment, nearly all the patients felt that the cosmetic advantages outweighed the transient discomfort. However, infraclavicular ectopic parathyroid glands are extremely difficult to resect, because the clavicle interferes with insertion of the forceps into that position. Thus, preoperative localization diagnosis is mandatory. Patients with hyperparathyroidism could be treated by endoscopic parathyroidectomy by an anterior chest approach when functional parathyroid adenomas have been identified above the clavicle in the neck by preoperative localization studies. Nowadays, the use of a quick, intraoperative PTH assay in patients with primary hyperparathyroidism has improved the success rate of parathyroidectomy [3], and we are in the process of introducing intraoperative hormone assays to confirm successful excision of all hyperfunctioning glands. In conclusion, endoscopic parathyroidectomy by an anterior chest approach is the procedure of choice in wellselected patients with hyperparathyroidism.
References [1] [2]
Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 1996;83:875. Cougard P, Goudet P, Osmak L, Ferrand L, Letourneau B, Brun JM. Videocervicoscopy in surgery of primary hyperparathyroidism. Preliminary study of 19 patients. Ann Chirurg 1998;52:885–9.
25s
[3]
Miccoli P, Bendinelli C, Vignali E, Mazzeo S, Cecchini GM, Pinchera A, et al. Endoscopic parathyroidectomy: report of an initial experience. Surgery 1998;124:1077–80.
[4]
Gauger PG, Reeve TS, Delbridge LW. Endoscopically assisted, minimally invasive parathyroidectomy. Br J Surg 1999;86:1563–6.
[5]
Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery 1997;122: 998–1004.
[6]
Prager G, Czerny C, Kurtaran A, Passler C, Scheuba C, Niederle B. The value of preoperative localization studies in primary hyperparathyroidism. Chirurg 1999;70:1082–8.
[7]
Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT. Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy. Surg Endosc 1998;12:202–6.
[8]
Huscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877.
[9]
Takami H, Oshima M, Sugawara I, Satake S, Ikeda Y, Nakamura K, et al. Pre-operative localization and tissue uptake study in parathyroid imaging with technetium-99m-sestamibi. Aust N Z J Surg 1999;69:629–31.
[10] Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336–40. [11]
Ikeda Y, Takami H. Endoscopic parathyroidectomy. Biomed Pharmacother 2000;54:52–6.
[12] Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic thyroidectomy by the axillary approach. Surg Endosc 2002; 15:1362–4. [13] Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic thyroidectomy and parathyroidectomy by the axillary approach: a preliminary report. Surg Endosc 2002;16:92–5. [14] Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J. Endoscopic total thyroidectomy by the anterior chest approach for renal hyperparathyroidism. Surg Endosc 2002;16:320–2.