Pursuing the second ipsilateral gland during minimally invasive video-assisted parathyroidectomy

BACKGROUND: In patients with primary hyperparathyroidism (PHPT) and preoperative imaging suggesting a solitary parathyroid adenoma (SPA), focused parathyroidectomy is most often curative. Even so, large studies show up to 3% of patients experience persistent or recurrent PHPT. Unilateral neck exploration (UNE) aiming to identify the SPA and the other ipsilateral parathyroid may reduce this failure rate. We hypothesized that: (i) minimally invasive video-assisted (MIVA) approach would facilitate UNE and (ii) this would be a clinically relevant strategy.

METHODS: Prospective case series of a consecutive cohort of PHPT patients (with preoperative diagnosis of SPA), who underwent MIVA-UNE. A 15 mm collar incision and endoscopic magnification were utilized to both excise the SPA and seek the ipsilateral parathyroid gland.

RESULTS: From 2009 to 2014, 132 patients were offered MIVA-UNE (age: 63.0 (interquartile range: 11.2); females: 94 (71.2%); symptomatic: 89 (67.4%); mean serum corrected calcium: 2.7 (standard deviation: 0.9) mmol/L; mean serum parathyroid hormone: 16.8 (standard deviation: 11.8) pmol/L). Conversion from MIVA-UNE to open UNE was required in 14 (10.6%) patients (excluded from subsequent analysis). MIVA-UNE was concluded in 118 patients. The second ipsilateral parathyroid was identified in 62 (52.5%) patients and in 13 (11.0%) it appeared enlarged and was excised. Histopathology confirmed five (4.2%) of these glands to be hyperplastic.

CONCLUSION: MIVA-UNE allows identification of the second ipsilateral parathyroid in about half the patients. This approach helped to diagnose and treat unexpected multigland disease in almost 5% of patients.