Direct, minimally invasive adenomectomy for primary hyperparathyroidism - An alternative to conventional neck exploration?

Objective To evaluate the feasibility and efficacy of a direct, minimally invasive ad enomectomy (MIA) as an alternative to conventional neck exploration (CNE) i n patients with primary hyperparathyroidism. Summary Background Data Because primary hyperparathyroidism is caused by a solitary adenoma in 85% to 90% of patients, a direct adenomectomy through a mini-incision would the oretically suffice whenever an adenoma is correctly localized on preoperati ve imaging. If effective, a less invasive method could spare the patient an unnecessary bilateral neck exploration, thus saving time and rendering fut ure surgical procedures in the neck less problematic. Methods Between October 1994 and October 1998, 110 consecutive patients with bioche mically proven primary hyperparathyroidism who were to undergo surgery were enrolled in this study. Ultrasound and spiral CT were routinely performed as standard preoperative imaging modalities in the first series of 65 patie nts. In the second series of 45 patients, ultrasound was performed as the s ole initial modality; it was supplemented by CT only in case of inconclusiv e test results. if test results were unequivocal tone adenoma), the patient was offered MIA. CNE was performed if the results were equivocal or if mul tiglandular disease was suspected. Results Overall, 84 patients were selected for MIA and 26 for CNE. In the first ser ies, 2 MIA procedures (2/51) were converted to CNE because of negative peri operative findings, All 65 procedures resulted in normocalcemia. In the sec ond series, all but five (4/33 MIAs, 1/12 CNEs) resulted in normocalcemia, A reexploration (CNE) was performed in three patients, resulting in normoca lcemia after resection of a second or third adenoma, Two patients are still awaiting reexploration. In both series together, 78 of the 110 patients we re successfully treated with MIA and spared CNE, Conclusion MIA is a safe and effective alternative to CNE that may replace CNE in appr oximately two thirds of all patients.