1. Minimally Invasive Parathyroidectomy In treatment of primary hyperparathyroidism Dr. Dennis CK Ng PYNEH 18-9-2004

2. First Parathyroidectomy First successful parathyroidectomy –Vienna in 1925 –Felix Mandl –Bilateral exploration under LA, with single enlarged gland resection –Disease recurred and died of uncontrolled hypercalcaemia 6 years later Mandl F., Wien Klin Wochenshr Zebtral 1926; 143: 245-284

3. Bilateral Neck Exploration GA Collar incision Bilateral neck exploration Identify of all 4 glands Removal of the diseased glands → Cure rate : 70-97%

4. Feasibility of Minimally Invasive Parathyroid operation Base on –Disease characteristics –More accurate pre-op localization tools –Less traumatic surgical approach

5. Disease Characteristics Solitary lesion is more common  Routine bilateral exploration is not indicated if accurate pre-op. localization available  Excision of a small 1-2 cm lesion only Julia AS, Udelsman R, 2003

6. Pre-operative Localization Sensitivity MIBI (Technetium-99m sestamibi scan)90% USG (Ultrasound scan)60 - 90% CT (Computed tomography)80% MRI (Magnetic resonance imaging)80%

7. MIBI Scan Daphne W. Denham MDA and James Norman, 1997 Julia AS, Udelsman R, 2003

8. Minimally Invasive Parathyroidectomy Surgical Approaches Unilateral neck exploration under LA Under LA / regional block MIBI scan & USG Small incision Most popular Radio-guided with focus incision Gamma probe Accurate localization Videoscopic assisted / Endoscopic Can have contralateral neck exploration Learning curve

9. Endoscopic Approach Low insufflation pressure (5-8 mmHg) Strap muscle retracted Thyroid gland mobilized medially Parathyroid gland identified and resected

10. Systemic Review of Minimally Invasive Parathyroidectomy The ASERNIP-S Management Committee Council of the Royal Australasian College of Surgeon June 2001 Meta-analysis ASERNIP-S, 2001

11. Source All original published studies Medline, Current Contents, Embase, The Cochrane Library 1966 - 2000 ASERNIP-S, 2001

12. AuthorYearEvidenceDesignApproachPatient No Smit et al.2000IIICase ControlScan-directed unilateral exploration84 Ito2000IIICase ControlScan-directed unilateral exploration91 Martin et al.2000IIICase ControlUnilateral exploration, +/- scan59 Kountakis et al.1999IIICase ControlScan-directed unilateral exploration24 Boggs et al.1999IIIHistorical ControlScan-directed unilateral exploration133 Chen et al.1999IIIHistorical ControlScan-directed unilateral exploration33 Gupta et al.1998IIICase ControlScan-directed unilateral exploration21 Ammori et al.1998IIICase ControlScan-directed unilateral exploration29 Russel et al.1990IIICase ControlScan-directed unilateral exploration48 Lucas et al.1990IIIHistorical ControlScan-directed unilateral exploration19 Tibblin et al.1991IIICase ControlUnilateral exploration50 Westerdahl et al.2000IVCase SeriesUnilateral exploration86 Dackiw et al.2000IVCase SeriesScan-directed unilateral exploration26 Inabnet et al.1999IVCase SeriesScan-directed unilateral exploration230 Moore et al.1999IVCase SeriesUnilateral exploration +/- scan48 Purcell et al.1999IVCase SeriesScan-directed unilateral exploration61 Song et al.1999IVCase SeriesScan-directed unilateral exploration91 Sofferman et al.1998IVCase SeriesScan-directed unilateral exploration16 Robertson et al.1992IVCase SeriesScan-directed unilateral exploration10 Uden et al.1990IVCase SeriesScan-directed unilateral exploration50 ASERNIP-S, 2001

13. AuthorYearEvidenceStudyApproachPatient No. Microcoli et al.1999IIRCTVideo-assisted20 Delbridge et al.2000IIICase ControlEndoscopic-assisted35 Gauger et al.1999IIICase ControlEndoscopic-assisted24 Chowbey et al.1999IVCase seriesVideo-assisted3 Dralle et al.1999IVCase seriesVideo-assisted13 Henry et al.1999IVCase seriesVideo-assisted22 Miccoli et al.1998IVCase seriesVideo-assisted20 Goldstein et al.2000IIICase ControlRadio-guided20 Flynn et al.2000IIICase ControlRadio-guided39 Norman et al.2000IVCase seriesRadio-guided17 Norman Denham1998IVCase seriesRadio-guided21 ASERNIP-S, 2001

14. Conclusion Scan directed Unilateral Neck Exploration –Level III/IV evidence –Local anaesthesia –Lesser morbidity –Shorter operative time –Shorter hospital stay ASERNIP-S, 2001

15. Radio-Guided Parathyroidectomy –Level III/IV evidence –Local anaesthesia –Lesser morbidity –Increased level of radiation –Need accurate timing of radioisotope administration ASERNIP-S, 2001

16. Video-Endoscopic Parathyroidectomy –Level II/III evidence –Success rate comparable –General anaesthesia –5% conversion rate –Shorter operative time –Shorter hospital stay ASERNIP-S, 2001

17. QMHQEH AuthorLo CY et al.CH Wong et al. Year1999 - 20022002 Patient No.6611 Study designCase seriesHistorical control Pre-op localization MIBI + USGMIBI +/- USG Surgical approach Endoscopic assisted Unilateral exploration (lateral approach) Quick PTHYes Cure rate100% Conversion82 Hong Kong Experience

18. Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy WR Sackett in 2003 Survey –Members of international association of endocrine surgeon –160 surveys completed

19. Results 59% surgeon, on 44% of patient Approach –73% scan directed technique with small incision –27% video-assisted / endoscopic Geographic difference –59% surgeon in America –56% surgeon in Australia –49% surgeon in Europe or Middle East Sackett WR et. Al., Arch Surg 2003; 138(9): 1024

20. Trend Bilateral exploration Unilateral exploration (GA) Minimal Invasive Unilateral exploration under LA Radioguided focused approach Endoscopic / videoscopic assisted

21. Which is the Best BilateralUnilateral under LA RadioguidedEndoscopic Pre-operative imaging NoYes PathologyAllSingle adenoma LA/GAGALA GA CostCheapIntermediate Expensive Learning curve Short Long IrradiationNoLowHighLow RecoveryDaysHours Cure rateNo Difference ComplicationNo Difference

22. Conclusion World trend directed to minimally invasive approach Comparable results Similar complication rates Less operative time Shorter hospital stay

23. Ways to Go Need randomization trial Cost Diversity of methods Need further standardization