Surgery News - January 2008 - (Page 20) HEAD AND NECK SURGERY NEWS • J A N U A RY 2 0 0 8 Preop Localization Hones Parathyroid Procedure B Y K AT E J O H N S O N Else vier Global Medical Ne ws M O N T R E A L — Preoperative localization techniques can allow less invasive reoperation for hyperparathyroidism, and could potentially improve success rates, according to Dr. Peter Stålberg of University Hospital in Uppsala, Sweden. “Results may be improved by using these sensitive methods. . . . However, our study didn’t have enough statistical power to allow us to make conclusions about improved cure rates,” he said in an interview. His study, which he presented at a meeting sponsored by the International Society of Surgery, compared parathyroid reoperations performed in 144 patients between 1962 and 1999 with 46 reoperations done after 1999, using new preoperative localization techniques such as sestamibi scintigraphy, [11C]-methionine positron emission tomography/computed tomography (PET/CT), surgeon-performed ultrasound, ultrasound-guided fine-needle aspiration biopsy, and selective venous sampling with rapid parathyroid hormone analysis. The cure rate (reversal of hypercalcemia) was not significantly different between the earlier and later groups—91% and 98%, respectively—but the big change was in the surgical approach, as a result of the localization techniques, Dr. Stålberg said. “Now we can do more focused operations, which [would allow us to avoid] doing extensive explorations in the scarred neck tissue, thus minimizing surgical trauma and risks for patients. Also, we now need to perform fewer sternotomies, and the ones we do perform are more likely to have positive findings,” he said. Compared with reoperations done before 1999, which involved bilateral explorations in 71% of cases, the more recent procedures involved mostly focused, unilateral explorations, with only a 21% rate of bilateral procedures, he explained. Additionally, the need for sternotomy decreased, from 22 (15%) during the early period to 3 (7%) in the later period, with a corresponding higher yield of pathologic glands (from 64% to 100%). Dr. Stålberg attributed the improvements to increased use of preoperative localization techniques. In the operations done after 1999, sestamibi scintigraphy was performed in 43 patients with an overall sensitivity of 90% and a positive predictive value of 88%. A total of 27 patients underwent [11C]-methionine PET/CT, which had a sensitivity of 79% and a positive predictive value of 87%. Surgeon-performed ultrasound had a sensitivity and positive predictive value of 72% and 93%, respectively, and selective venous sampling with rapid parathyroid hormone (PTH) analysis provided accurate localization and regionalization in 11 of 11 patients. After 1999, rapid PTH analysis of fineneedle aspirates was used in two patients preoperatively and routinely intraoperatively to verify parathyroid origin of excised specimens, he said. In five cases, an inadequate rapid PTH drop intraoperatively prompted further exploration that revealed additional pathologic parathyroid tissue and one intrathyroidal gland, he said. Reoperations for hyperparathyroidism are known for being less successful and having greater complication rates than primary operations, Dr. Stålberg said. Venous sampling localizes a parathyroid adenoma to the left above the thyroid. However, with the use of these new localization techniques he expects reoperative success rates to become comparable with those of primary procedures. ■ Intracapsular Tonsillectomy Reduces Pain, Bleeding formed at the same institution by the same group of surgeons during 2002-2005. Else vier Global Medical Ne ws The sex distribution (48% girls) and mean pantracapsular tonsillectomy has lower rates of tient age (6 years) were the same in both delayed hemorrhage, severe hemorrhage, and groups. Mean follow-up was 20 months. The rate of hemorrhage within 24 hours was rehospitalization for pain or other complications than does traditional electrodissection 0.1% in both groups. However, the 1.1% rate tonsillectomy, according to a report in Archives of delayed hemorrhage with the intracapsular procedure was significantly lower than the of Otolaryngology–Head and Neck Surgery. The technique, first described in 2002, in- 3.4% rate with the traditional technique. Simvolves using a microdebrider to remove 90% or ilarly, the rate of severe hemorrhage requiring more of the tonsillar tissue while sparing the OR treatment was significantly lower with capsule (Laryngoscope 2002;112:8[pt. 2 suppl. intracapsular tonsillectomy (0.5%) than with 100];17-9). Suction cautery is used to fulgurate electrodissection (2.1%). The rate of readmission to either the emerremaining tonsillar tissue and achieve hemostasis, said Dr. Richard Schmidt, who is an ACS gency department or the hospital for pain, with Fellow, and his associates at the Alfred I. duPont or without dehydration, also was significantly lower with the new technique (3.0%) than Hospital for Children, Wilmington, Del. The investigators conducted a retrospective with traditional tonsillectomy (5.4%). Similar study comparing the outcomes of 1,731 intra- trends were found when the data were broken capsular tonsillectomies with those of 1,212 down according to the indication for the traditional tonsillectomies using monopolar surgery—whether tonsillectomy was ordered electrodissection. The procedures were per- for hypertrophy, recurrent infection, or both. “Patients in the intracapsular tonsillectomy group appeared to be less likely to require a return Results of Tonsillectomies trip to the OR for any reason (bleeding, drainage of peritonIntracapsular tonsillectomy sillar abscess, or revision tonsil(n = 1,731) 5.4% lectomy) than those in the traTraditional tonsillectomy ditional tonsillectomy group,” (n = 1,212) but this difference did not reach 3.0% significance, the investigators 3.4% said (Arch. Otolaryngol. Head Neck Surg. 2007;133:925-8). 2.1% The main drawback with in1.1% tracapsular tonsillectomy was a 0.5% greater need for revision tonsillectomy in a few patients. Eleven Delayed severe Delayed Readmission hemorrhage hemorrhage for pain patients (0.6%) in that group required reoperation, compared Note: Based on a mean 20-month follow-up. with none in the traditional Source: Archives of Otolaryngology–Head and Neck Surgery surgery group. ■ B Y M A RY A N N M O O N Ultrasound by Surgeon Aids Parathyroidectomy For single-gland parathyroid disease, Dr. Soon found that the sensitivity of SUS was comparable to M O N T R E A L — Compared with that of RUS (90% and 89%, respecradiologist-performed ultrasound, tively) for localizing adenomas. However, for multiglandular dissurgeon-performed ultrasound is equally accurate for localizing a sin- ease, the results showed that none of gle parathyroid adenoma after ses- the SUS were correct, and RUS had tamibi scan, and has advantages that a sensitivity of 38%. And for parafacilitate minimally invasive parathy- thyroid hyperplasia, the sensitivity of SUS was 17%, roidectomy, recompared with ported Dr. Patsy 11% for RUS. Soon at a meeting SURGEONS CAN USE The causes of sponsored by the PREOPERATIVE incorrect interpreInternational SociULTRASOUND tation of ultraety of Surgery. sound imaging in“We have a dediAS AN EXTENSION OF cluded cystic cated paraTHEIR PHYSICAL EXAM, degeneration in thyroid radiologist, thyroid nodules, and the accuracy of AND TO OPTIMIZE the presence of r adiolog ist-perINCISION PLACEMENT. lymph nodes, formed ultrasound retroesophageal in our institution is location of adeno88%,” said Dr. mas, and ectopic and small parathySoon of the University of Sydney. “Recognizing that not all institu- roid glands, said Dr. Soon. SUS have several advantages over tions will have a dedicated parathyroid radiologist, the next logical op- RUS, she noted. Surgeons can use preoperative ultion would be surgeon-performed trasound as an extension of their ultrasound.” Dr. Soon’s prospective study physical examination. SUS are also less expensive and compared 148 preoperative radiologist-performed ultrasounds (RUS) more convenient for patients bewith 87 preoperative surgeon-per- cause they do not require a separate formed ultrasounds (SUS) in 235 pa- visit. And SUS allow preoperative evaltients who had positive sestamibi scans and were scheduled for mini- uation of incidentally detected thyroid nodules with fine-needle aspimally invasive parathyroidectomy. The patients were mostly female ration biopsy, she said. Finally, SUS also “optimize place(90%), with a median age of 63 years. RUS were performed preop- ment of the neck incision, thereby eratively at a separate office visit, increasing the ease of the operation whereas SUS were performed on and allowing a small, 2-cm incision to remain.” the operating table. ■ B Y K AT E J O H N S O N Else vier Global Medical Ne ws I ELSEVIER GLOBAL MEDICAL NEWS COURTESY DR. PETER STÅLBERG
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