Dual-tracer subtraction scintigraphy combined with SPECT/CT in preoperative patients with primary hyperparathyroidism.

Abstract.

Parathyroid carcinoma and atypical parathyroid tumor: analysis of an Italian database.

OBJECTIVE: Atypical parathyroid tumor (aPT) and parathyroid carcinoma (PC) are extremely rare parathyroid neoplasms, accounting together for <2% of all parathyroid tumors. They often present an overlapping clinical phenotype, sharing clinical, biochemical, and some histological features. They are distinguished only by the presence of local invasion, and lymph nodes or distant metastasis, which are all absent in aPTs. To date, only few studies have compared clinical presentation and features between aPTs and PCs. Our purpose was to conduct a retrospective study on a multicenter Italian database of aPT and PC patients. DESIGN AND METHODS: We comparatively analyzed main features of aPT (n = 57) and PC (n = 74) patients collected at 15 major endocrinology and endocrine surgery centers in Italy. RESULTS AND CONCLUSIONS: Atypical parathyroid tumors and PCs showed no significant differences in many clinical features and presented similar values of elevated parathyroid hormone and total serum calcium. Renal complications, namely nephrolithiasis and nephrocalcinosis, appeared to be more common in PC, with a significantly higher rate of renal colic, regardless of total serum calcium levels and 24-h calciuria. Parathyroid carcinomas showed significantly higher postoperative disease persistence and recurrence rates, presumably due to an uncomplete resection of the primary tumor in 23.5% of cases and/or presence of unremoved active metastasis, but they had similar disease-free mean time after surgery than aPT. To deepen the study of malignant parathyroid tumors, the institution of a novel Italian retro-prospective multicenter registry of aPTs and PCs is currently ongoing, and a dedicated PC European registry has been recently activated.

Cohort review of patients with parathyroid cancer in End Stage Renal Disease (ESRD).

BACKGROUND AND HYPOTHESIS: Parathyroid carcinoma (PTTC) is a rare malignant endocrine tumor seen in up to 1-2% of all cases of primary hyperparathyroidism. However, incidence of parathyroid carcinoma in renal hyperparathyroidism is a rare phenomenon. We aimed to evaluate the outcomes of PTTC in renal hyperparathyroidism published in the literature. METHODS: Cohort review of parathyroid cancer cases reported in Medline (via PubMed), COCHRANE and EMBASE between the period 1985 - 2023 in patients with renal hyperparathyroidism. RESULTS: A total of 48 patients (20 M: 28F), with a mean age of 49.8 (± 11.7 SD: range 20-75) years. Dialysis vintage was for a period of 8.9 (± 7.2; range 6 months to 40 years). The mean preoperative values were as follows: serum corrected calcium-2.87 IQR 2.56-3.01), PTH - 221.8 (IQR 86.6 -257.2 pmol/L) and serum phosphate - 2.07 (IQR 1.72-2.28) mmol/L. Preoperative imaging was in the form of ultrasound of the neck in 21 of 48 (44%), MIBI scan in 27/48 (56%), contrast enhanced computerized tomography in 14/48 (29%) and MRI neck in 1/48 (2%). The mean size of the cancer was 2.7 (± 1.35) cm and weight of the gland ranged between 0.9 to 4.98 g. 18/48 (37%) patients underwent a total parathyroidectomy and 30/48 (63%) had subtotal parathyroidectomy. En bloc excision of the tumour along with the thyroid along and central compartment lymph nodes was only performed in 12/48 (25%), of whom 9 (19%) had it performed at index surgery, whereas in the rest was done for persistent or recurrent disease. After a mean follow up of 34 months, 14 (29%) had local recurrence, 1 (2%) had distant metastasis to the skeletal system, and 12 (25%) to the lungs. Cohort mortality was 6 (13%) due to refractory hypercalcemia. CONCLUSIONS: Parathyroid carcinoma in renal hyperparathyroidism is rare but when encountered, en bloc excision with parathyroidectomy provides the best chance of cure. Recurrences can be difficult to treat but may be needed to treat intractable hypercalcaemia.

Impact of perioperative diagnostic tools on clinical outcomes and cost-effectiveness in parathyroid surgery: a decision model-based analysis.

OBJECTIVES: Preoperative and intraoperative diagnostic tools influence the surgical management of primary hyperparathyroidism (PHPT), whereby their performance of classification varies considerably for the two common causes of PHPT: solitary adenomas and multiglandular disease. A consensus on the use of such diagnostic tools for optimal perioperative management of all PHPT patients has not been reached. DESIGN: A decision tree model was constructed to estimate and compare the clinical outcomes and the cost-effectiveness of preoperative imaging modalities and intraoperative parathyroid hormone (ioPTH) monitoring criteria in a 21-year time horizon with a 3% discount rate. The robustness of the model was assessed by conducting a one-way sensitivity analysis and probabilistic uncertainty analysis. SETTING: The US healthcare system. POPULATION: A hypothetical population consisting of 5000 patients with sporadic, symptomatic or asymptomatic PHPT. INTERVENTIONS: Preoperative and intraoperative diagnostic modalities for parathyroidectomy. MAIN OUTCOME MEASURES: Costs, quality-adjusted life-years (QALYs), net monetary benefits (NMBs) and clinical outcomes. RESULTS: In the base-case analysis, four-dimensional (4D) CT was the least expensive strategy with US$10 276 and 15.333 QALYs. Ultrasound and 99mTc-Sestamibi single-photon-emission CT/CT were both dominated strategies while 18F-fluorocholine positron emission tomography was cost-effective with an NMB of US$416 considering a willingness to pay a threshold of US$95 958. The application of ioPTH monitoring with the Vienna criterion decreased the rate of reoperations from 10.50 to 0.58 per 1000 patients compared to not using ioPTH monitoring. Due to an increased rate of bilateral neck explorations from 257.45 to 347.45 per 1000 patients, it was not cost-effective. CONCLUSIONS: 4D-CT is the most cost-effective modality for the preoperative localisation of solitary parathyroid adenomas and multiglandular disease. The use of ioPTH monitoring is not cost-effective, but to minimise clinical complications, the Miami criterion should be applied for suspected solitary adenomas and the Vienna criterion for multiglandular disease.

Primary hyperparathyroidism-induced acute pancreatitis in pregnancy: A systematic review with a diagnostic-treatment algorithm.

BACKGROUND: Primary hyperparathyroidism (PHPT)-induced acute pancreatitis (AP) during pregnancy has rarely been described. Due to this rarity, there are no diagnostic or treatment algorithms for pregnant patients. AIM: To determine appropriate diagnostic methods, therapeutic options, and factors related to maternal and fetal outcomes for PHPT-induced AP in pregnancy. METHODS: A literature search of articles in English, Japanese, German, Spanish, and Italian was performed using PubMed (1946-2023), PubMed Central (1900-2023), and Google Scholar. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) protocol was followed. The search terms included "pancreatite acuta," "iperparatiroidismo primario," "gravidanza," "travaglio," "puerperio," "postpartum," "akute pankreatitis," "primärer hyperparathyreoidismus," "Schwangerschaft," "Wehen," "Wochenbett," "pancreatitis aguda," "hiperparatiroidismo primario," "embarazo," "parto," "puerperio," "posparto," "acute pancreatitis," "primary hyperparathyroidism," "pregnancy," "labor," "puerperium," and "postpartum." Additional studies were identified by reviewing the reference lists of retrieved studies. Demographic, imaging, surgical, obstetric, and outcome data were obtained. RESULTS: Fifty-four cases were collected from the 51 studies. The median maternal age was 29 years. PHPT-induced AP starts at the 20th gestational week; higher gestational weeks were seen in mothers who died (mean gestational week 28). Median values of amylase (1399, Q1-Q3 = 519-2072), lipase (2072, Q1-Q3 = 893-2804), serum calcium (3.5, Q1-Q3 = 3.1-3.9), and parathormone (PTH) (384, Q1-Q3 = 123-910) were reported. In 46 cases, adenoma was the cause of PHPT, followed by 2 cases of carcinoma and 1 case of hyperplasia. In the remaining 5 cases, the diagnosis was not reported. Neck ultrasound was positive in 34 cases, whereas sestamibi was performed in 3 cases, and neck computed tomography or magnetic resonance imaging was performed in 9 cases (the enlarged parathyroid gland was not localized in 3 cases). Surgery was the preferred treatment during pregnancy in 33 cases (median week of gestation 25, Q1-Q3 = 20-30) and postpartum in 12 cases. The timing was not reported in the remaining 9 cases, or surgery was not performed. AP was managed surgically in 11 cases and conservatively in 43 (79.6%) cases. Maternal and fetal mortality was 9.3% (5 cases). Surgery was more common in deceased mothers (60.0% vs 16.3%; P = 0.052), and PTH values tended to be higher in this group (910 pg/mL vs 302 pg/mL; P = 0.059). Maternal mortality was higher with higher serum lipase levels and earlier delivery week. Higher calcium (4.1 mmol/L vs 3.3 mmol/L; P = 0.009) and PTH (1914 pg/mL vs 302 pg/mL; P = 0.003) values increased fetal/child mortality, as well as abortions (40.0% vs 0.0%; P = 0.007) and complex deliveries (60.0% vs 8.2%; P = 0.01). CONCLUSION: If serum calcium is not tested during admission, definitive diagnosis of PHPT-induced AP in pregnancy is delayed, while early diagnosis and immediate intervention lead to excellent maternal and fetal outcomes.

Postoperative pancytopenia in a patient with giant parathyroid adenoma and brown tumor: a case report.

BACKGROUND: Parathyroid adenoma is the primary cause of primary hyperparathyroidism, commonly presenting with elevated parathyroid hormone (PTH) and blood calcium levels. Chronic primary hyperparathyroidism often results in bone destruction, resulting in the formation of brown tumors. The preferred clinical treatment for parathyroid adenoma is parathyroidectomy. Postoperative pancytopenia, although rare, is a critical complication that warrants further investigation into its mechanisms and management strategies. CASE PRESENTATION: We present a case of a 59-year-old female patient who was admitted due to nausea and vomiting. Positron emission tomography-computed tomography (PET-CT) revealed a mass posterior to the left thyroid lobe and multiple areas of fibrocystic osteitis throughout the body. Hematological tests showed elevated serum calcium and parathyroid hormone (PTH) levels. The patient subsequently underwent parathyroidectomy, and pathological examination confirmed the presence of a parathyroid adenoma. Postoperatively, the patient developed pancytopenia and received symptomatic treatment such as correction of anemia and elevation of white blood. At the two-month follow-up, all indicators had returned to normal. CONCLUSIONS: Pancytopenia is commonly seen in bone marrow diseases, infections and immune-related disorders, nutritional deficiencies, and metabolic diseases. This case confirms that pancytopenia can also occur postoperatively in patients with parathyroid adenoma. Therefore, Clinicians should be aware of the potential for postoperative pancytopenia following parathyroidectomy and the need for prompt management.

A new approach for perioperative parathyroid hormone (PTH) measurement to establish cure in patients with primary hyperparathyroidism.

PURPOSE: In this study, we analyse the possibility to omit pre-incision PTH measurement since we routinely measure it at the time of pre-surgery ambulatory admission. METHODS: A total of 435 patients were enrolled. All patients with pHPT included underwent pre-surgical PTH level assessment as part of the pre-admission preparation to surgery. Intraoperative PTH was routinely assessed after induction of the anaesthesia (pre-incision PTH) and 15 min after resection of the enlarged gland(s) (post-excision PTH). Moreover, calcium and PTH levels were routinely assessed on the first postoperative day. Cure was defined as an intraoperative drop of > 50% or into normal range on first post-operative day. RESULTS: The median value of the preoperative and pre-incision PTH were both 127 pg/ml (p = ns). Thirty-two patients (7.3%) exhibited a not appropriate drop of post-excision PTH level. Nevertheless, nineteen of them (59.3%) showed a satisfying PTH drop on 1st POD. Ten patients (2.3%) experienced a persistent disease with six achieving cure through reoperation. Additionally, three patients (0.6%) showed normalization of calcium and PTH values during the follow-up. Three patients, apparently deemed cured after an adequate PTH-drop on the day of surgery, showed persistence. Cure rate at primary surgery was 98.4%. Accuracy of our simplified protocol is 99.3%. CONCLUSION: Pre-incision PTH is not superior to preoperative PTH blood test and can be omitted without compromising the sensitivity of cure prediction. One blood sample 15 min after resection, along with the postoperative PTH value on the day after surgery, is sufficient to predict the surgical outcome bearing the cost of a very low reoperation rate.

Temporal research trends in parathyroid surgery.

BACKGROUND: Progress has been observed in the pathophysiology of calcium homeostasis, localization studies, and intraoperative adjuncts in parathyroid surgery. The aim of this study is to gain a comprehensive perspective on the research landscape of parathyroid surgery over time. METHODS: A search of the Web of Science Core Collection was conducted to identify publications on parathyroid surgery from 1985 to 2024. Keywords were manually curated, and their frequencies were calculated based on the publication year. RESULTS: Publications on secondary hyperparathyroidism have decreased in recent years, but those on calcimimetics, tertiary hyperparathyroidism, and parathyroid cancer have increased. Publications related to sestamibi scans have decreased, while research on four-dimensional computed tomography and positron emission tomography has increased. Research on fluorescence and ablation treatment has recently been on the rise. The citation count per publication was positively correlated with the number of contributing institutions. CONCLUSION: We provide an overview of contemporary research themes and emerging topics related to parathyroid surgery. The endocrine surgery community could benefit from more inter-institutional partnerships to foster scientific progress.

Parathyroidectomy reduces the costs of medication in patients with secondary hyperparathyroidism.

INTRODUCTION: Subtotal Parathyroidectomy (S-PTx) and total Parathyroidectomy with immediate Autograft (PTx-AG) are well-established techniques for the treatment of refractory Secondary Hyperparathyroidism (SHPT), with comparable improvements in patients' quality of life and survival. However, the long-term costs after these operations may impact the choice of surgical technique. The objective of the study is to analyze the impact of surgical treatment on medication costs and whether there is any difference between medication use after each procedure, considering impacts on the health system. MATERIAL AND METHODS: Prospective and randomized study in patients with severe SHPT undergoing S-PTx and PTx-AG. Analysis of prescribed medication costs in the month before the postoperative period at 1-, 3-, 6-, 12-, and 18 months. Costs were estimated according to government payment system values. The medications of 65 patients after PTx-AG were compared with those of 24 patients after S-PTx. A comparison of the total costs of the period between 38 men and 51 women was also made. RESULTS: There were 89 evaluable cases. Surgery reduced medication costs after 12 months. The median of total drug costs in the analyzed period was R$ 8,375.00 per patient. There was no difference in costs per patient in the S-PTx group compared to the PTx-AG group. The median total costs were R$ 11,063.0 for men and R$ 7,651.0 for women (p = 0.0078). CONCLUSIONS: The type of parathyroidectomy did not impact costs after surgery. In the first year after surgery, the use of calcium and calcitriol was more significant than the use of other medications. In the following months, the use of sevelamer is responsible for the highest costs. Men have higher costs in outpatient follow-up after surgery.

Postoperative hungry bone syndrome in primary hyperparathyroidism: A case report.

RATIONALE: Hungry bone syndrome (HBS) is a forgotten and underdiagnosed cause. Postoperative HBS refers to patients with high bone turnover before surgery, but after surgery, the inhibition of osteoclast resorption by intact parathyroid hormone suddenly decreases, resulting in a sudden increase in the amount of calcium resorbed by the bone, and a rapid, severe and persistent hypocalcemia, which may be accompanied by hypophosphatemia and hypomagnesemia. We present a case with information about HBS and related complications after parathyroidectomy (PTX). PATIENT CONCERNS: The patient was a 57-year-old woman who presented to the hospital with "pain in both ankles for more than 3 years and in both knees for more than 2 years." DIAGNOSES: A parathyroid mass was found preoperative. Unilateral resection of the lesion was performed under general anesthesia. On gross examination, the mass was reddish brown in color, about 2.9 × 2.5 × 2.3 cm, with abundant blood supply. Postoperative pathology diagnosed parathyroid adenoma. INTERVENTIONS: The patient was diagnosed with HBS on day 3 post-PTX, which lasted for 9 days. OUTCOMES: After active calcium supplementation and other pharmacological interventions, her test parameters gradually returned to normal and she was discharged on the 13th day after surgery. LESSONS: Using the case of a patient with primary hyperparathyroidism with HBS lasting 9 days after PTX for diagnosis and management, we aimed to summarize possible predictors and perioperative management strategies to reduce the incidence, severity, and duration of postoperative HBS.

Construction and validation of a risk prediction model for early hungry bone syndrome in maintenance hemodialysis patients post-parathyroidectomy. / ç»´æŒæ€§è¡€æ¶²é€æžæ‚£è€ ç”²çŠ¶æ—è ºåˆ‡é™¤æœ¯åŽæ—©æœŸéª¨é¥¥é¥¿ç»¼åˆå¾é£Žé™©é¢„æµ‹æ¨¡åž‹çš„æž„å»ºä¸ŽéªŒè¯.

OBJECTIVES: Parathyroidectomy (PTX) is an effective treatment for refractory secondary hyperparathyroidism (SHPT), but it can lead to hungry bone syndrome (HBS), significantly threatening the health of maintenance haemodialysis (MHD) patients. While previous studies have analyzed the risk factors for HBS post-PTX, the predictive performance and clinical applicability of these risk models need further validation. This study aims to construct and validate a risk prediction model for HBS in MHD patients with SHPT post-PTX. METHODS: A retrospective analysis was conducted on 368 MHD patients with SHPT who underwent PTX at Changsha Jieao Nephrology Hospital from January 2020 to December 2021. Patients were divided into a HBS group and a non-HBS group based on the occurrence of HBS. General data, surgical information, and biochemical indicators were compared between the 2 groups. Multivariate logistic regression was used to identify factors influencing HBS, and a risk prediction model was established. The model's performance was evaluated using receiver operator characteristic (ROC) curves, decision curves, and calibration curves. External validation was performed on 170 MHD patients with SHPT who underwent PTX at the Third Xiangya Hospital of Central South University from January to December 2022. RESULTS: The incidence of HBS post-PTX in MHD patients with SHPT was 60.60%. Logistic regression analysis identified preoperative bone involvement (OR=3.908, 95% CI 2.179 to 7.171), preoperative serum calcium (OR=7.174, 95% CI 2.291 to 24.015), preoperative intact parathyroid hormone (iPTH) (OR=1.001, 95% CI 1.001 to 1.001), preoperative alkaline phosphatase (ALP) (OR=1.001, 95% CI 1.000 to 1.001), and serum calcium on the first postoperative day (OR=0.006, 95% CI 0.001 to 0.038) as independent risk factors for HBS (all P<0.01). The constructed risk prediction model demonstrated good predictive performance in both internal and external validation cohorts. The internal validation cohort showed an accuracy of 0.821, sensitivity of 0.890, specificity of 0.776, Youden index of 0.666, and area under the curve (AUC) of 0.882 (95% CI 0.845 to 0.919). The external validation cohort showed an accuracy of 0.800, sensitivity of 0.806, specificity of 0.799, Youden index of 0.605, and AUC of 0.863 (95% CI 0.795 to 0.932). CONCLUSIONS: Preoperative bone involvement, serum calcium, iPTH, ALP, and serum calcium on the first postoperative day are influencing factors for HBS in MHD patients with SHPT post-PTX. The constructed risk prediction model based on these factors is reliable.

Initial Experience With Ultra-High-Definition 3D Exoscope in Thyroid and Parathyroid Surgery.

BACKGROUND: Operation with a 3D exoscope has recently been introduced in clinical practice. The exoscope consists of two cameras placed in front of the operative field. Images are shown on a large 3D screen with high resolution. The system can be used to enhance precise dissection and provides new possibilities for improved ergonomics, fluorescence, and other optical-guided modalities. METHODS: Initial experience with the ultra-high-definition (4K) 3D exoscope in thyroid and parathyroid operations. The exoscope (OrbEyeTM) was mounted on a holding system (Olympus). RESULTS: We used the exoscope in parathyroidectomy (N = 6) and thyroidectomy (N = 6). Immediate advantages and disadvantages were discussed and recorded. The learning curve for use of the exoscope may be shorter for surgeons with training in endoscopic or robotic procedures. There may be improved ergonomics compared with normal open-neck operations. Further, the optical guided operations can be used with fluorescence and have potential for different on-lay techniques in the future. The 4 K 3D image quality is state-of-art and is highly appreciated during fine surgical dissection and eliminates the need for loupes. CONCLUSION: In several ways, using the ORBEYE™ in thyroid and parathyroid surgery provides the surgical team with a new and enhanced experience. This includes improved possibility for teaching, surgical ergonomics, and a 4K 3D camera with a powerful magnification system. However, it is not clear if utilization of these features would improve surgical outcomes. Furthermore, the ORBEYE™ lacks incorporation of parathyroid autofluorescence, and the current costs for the system do not facilitate general access to exoscope assisted operations.

Comparison of intraoperative imaging with a portable gamma camera with extemporaneous histology in minimally invasive surgery for primary hyperparathyroidism.

INTRODUCTION: The curative treatment of primary hyperparathyroidism (PPH) is surgical and today it can be performed by minimally invasive surgery (MIS) and also be radioguided (RG) if a radiopharmaceutical with affinity for the parathyroid tissue that can be detected with gamma-detector probes or with a portable gamma camera (PGC) is injected. AIM: The objective is to assess whether intraoperative scintigraphy (GGio) with PGC can replace intraoperative pathological anatomy (APio) to determine if the removed specimen is an abnormal parathyroid. MATERIAL AND METHOD: 92 patients underwent CMI RG--HPP with PGC after the administration of a dose of 99 mTc-MIBI. The information provided by the PGC in the analysis of the excised specimens is qualitatively compared (capture yes/no) with the result of the intraoperative pathological anatomy (APio). The Gold standard is the definitive histology. RESULTS: 120 excised pieces are evaluated with GGio and APio. There were 110 agreements (95TP and 15TN) and 10 disagreements (3FP and 7FN). Of the 120 lesions, 102 were parathyroid and 18 were non-parathyroid. There was good agreement between intraoperative scintigraphy imaging (GGio) and PA, 70.1% according to Cohen's Kappa index. The GGio presented the following values ​​of Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value, Positive Likelihood Ratio, Negative Likelihood Ratio and Overall Value of the Test (93.1%, 83.3%, 96.9%, 68.2%, 5.59, 0.08 and 0.92 respectively). CONCLUSION: GGio is a rapid and effective surgical aid technique to confirm/rule out the possible parathyroid nature of the lesions removed in PPH surgery, but it cannot replace histological study.

No effect of surgery on kidney and cardiovascular risk factors in mild primary hyperparathyroidism: secondary analyses from a 10-year randomized controlled trial.

OBJECTIVE: Renal function and the skeleton are classic target organs in primary hyperparathyroidism (PHPT), affected by the chronic course of the disease. Most patients diagnosed today exhibit mild PHPT, characterized by slight hypercalcemia and no or unspecific symptoms. Concerns have been raised that PHPT could promote deteriorating kidney function and increase cardiovascular risk directly. To examine the effect of parathyroidectomy (PTX) on mild PHPT on renal function and markers for bone turnover, cardiovascular disease (CVD), and vascular inflammation. DESIGN: Prospective randomized controlled trial. ClinicalTrials.gov: NCT00522028. SETTING: Eight Scandinavian referral centers. PARTICIPANTS: From 1998 to 2005, 191 patients with mild PHPT were included in Sweden, Norway, and Denmark. Of these 150 were included in the present analyses. INTERVENTION: Seventy patients were randomized to PTX and 80 to observation without intervention (OBS). MEASURES: e-GFR was calculated based on creatinine and cystatin C. Markers of CVD and systemic inflammation: osteoprotegerin, vascular cell adhesion molecule 1, soluble CD40 ligand, interleukin-1 receptor antagonist, von Willebrand factor. Bone turnover markers: C-terminal telopeptide of type 1 collagen (CTX-1) and serum Procollagen type 1 N-terminal propeptide. RESULTS: No differences in the development of renal function or vascular and systemic inflammation were detected. CTX-1 was lower in PTX after 10 years. LIMITATIONS: Secondary analyses of a randomized controlled trial. CONCLUSION: PTX does not appear to affect renal function or markers of CVD and vascular inflammation in mild PHPT in a ten-year perspective.

[Clinical practice guideline for robotic surgical system-assisted thyroid and parathyroid surgery (2024 edition)].

The use of robotic operating systems is an advancement of intelligent precision, minimally invasive surgery. It has been used in the field of thyroid surgery with satisfactory results. Robotic surgery system assisted thyroid and parathyroid surgical expert consensus(2016) as played an important role in the standardization and clinical popularization of robotic surgical system-assisted thyroid and parathyroid surgery. With the deepening of clinical practice, updates in minimally invasive concept, the replacement of robotic platforms and the continuous improvement of technology, robotic thyroid and parathyroid surgery has been further developed. Notably, it has made substantial progress in expanding indications and the training of robotic surgeons and teams. Based on the 2016 Chinese expert consensus, combined with recent related articles and clinical studies, the Clinical Practice Guideline for Robotic Surgical System-Assisted Thyroid and Parathyroid Surgery (2024 edition) was formed. The surgical team training, indications, preoperative evaluation, patient position and space establishment, thyroidectomy procedures, neck lymph node dissection skills were summarized and recommended. Furthermore, reasonable suggestions on reoperation, parathyroid surgery and management of postoperative complications were also put forward, aiming to better guide clinical practice.

Ectopic parathyroid adenoma proved by diagnostic CT.

Primary hyperparathyroidism (PHPT) is the most prevalent cause of hypercalcaemia, affecting 0.3% of the population. The only curative procedure is parathyroidectomy. Ectopic adenomas are challenging to localize and frequently result in persistent PHPT. This is a case report of a 29-year-old male patient who was diagnosed with PHPT prior to neck surgery and reoperated with bilateral neck exploration. However, the PHPT was not cured, until diagnostic CT with contrast had helped localizing a 1 cm ectopic parathyroid adenoma in the right horn of the thymus gland. The adenoma was then removed successfully.

[Endoscopic assisted parathyroid surgery via a subclavian approach].

Objective:To explore the safety and efficacy of airless endoscopic surgery in the treatment of parathyroid diseases. Methods:By retrospective comparison, clinical treatment of 26 patients with primary hyperparathyroidism admitted to the Department of Otolaryngology and Head and Neck Surgery of the Hospital, Sun Yat-sen University from January 2018 to January 2023 were collected. They were divided into traditional group（13 cases） and endoscopic group（13 cases） according to the surgical method. The traditional group underwent traditional open parathyroid surgery, and the endoscopic group underwent airless endoscopic surgery through the subclavian approach. The efficacy, postoperative incision pain, incidence of adverse events, and aesthetic effects of the two groups were evaluated. Results:A total of 26 patients were included, including 13 patients in the traditional group and 13 patients in the endoscopic group. There was no significant difference in the incidence of hypocalcemia and transient hypoparathyroidism on the first day after surgery between the two groups（P>0.05）. No patients with incision pain（>3 points） or swallowing pain were found in both groups after the operation, and they were afraid or unwilling to cough and expel phlegm. There were no significant differences in the amount of blood loss, duration of operation, incidence of temporary recurrent laryngeal nerve palsy and transient hypocalcemia, and postoperative pain score between the two groups. The endoscopic group's scar evaluation score and aesthetic effect satisfaction score at 6 months after surgery were higher than those of the traditional group（P<0.01）. Conclusion:Airless Endoscopic parathyroid surgery via the subclavian approach has good effectiveness and safety, which did not significantly increase the risk of surgery. It can safely remove the lesion and leave no surgical scar on the anterior neck, which has the advantage of a good cosmetic effect. It is a safe and feasible endoscopic parathyroid surgery and can be used as a new choice for patients undergoing parathyroid surgery.

Is intraoperative parathyroid monitoring during minimally invasive parathyroidectomy still justified?

Introduction: Primary hyperparathyroidism (PHPT) is the third most common endocrine disease. With parathyroidectomy, a cure rate of over 95% at initial surgery is reported. Localization of the abnormal parathyroid gland is critical for the operation to be successful. The aim of this study is to analyze data of patients with single gland disease (SGD) and positive concordant localization imaging undergoing minimally invasive parathyroidectomy (MIP) and intraoperative parathyroid hormone monitoring (IOPTH) to evaluate if IOPTH is still justified in patients with localized SGD. Methods: A retrospective database analysis of all minimally invasive operations with IOPTH for PHPT and positive concordant localization in ultrasound (US) and 99mTc-sestamibi scintigraphy (MIBI) between 2016-2021. When both US and MIBI were negative, patients underwent either choline or methionine PET-CT. The patients were also analyzed a second time without applying IOPTH. Results: In total, 198 patients were included in the study. The sensitivity of US, MIBI and PET-CT was 96%, 94% and 100%, respectively. Positive predictive value was 88%, 89% and 94% with US, MIBI and PET-CT, respectively. IOPTH was true positive in 185 (93.4%) patients. In 13 (6.6%) patients, no adequate IOPTH decline was observed after localizing and extirpating the assumed enlarged parathyroid gland. Without IOPTH, the cure rate decreased from 195 (98.5%) to 182 (92%) patients and the rate of persisting disease increased from 2 (1.0%) to 15 (7.5%) patients. Conclusion: Discontinuing IOPTH significantly increases the persistence rate by a factor of 7.5 in patients with concordantly localized adenoma. Therefore, IOPTH appears to remain necessary even for this group of patients.

Early detection of multiple endocrine neoplasia type 1: A case report.

BACKGROUND: Multiple endocrine neoplasias (MENs) are a group of hereditary diseases involving multiple endocrine glands, and their prevalence is low. MEN type 1 (MEN1) has diverse clinical manifestations, mainly involving the parathyroid glands, gastrointestinal tract, pancreas and pituitary gland, making it easy to miss the clinical diagnosis. CASE SUMMARY: We present the case of a patient in whom MEN1 was detected early. A middle-aged male with recurrent abdominal pain and diarrhea was admitted to the hospital. Blood tests at admission revealed hypercalcemia and hypophosphatemia, and emission computed tomography of the parathyroid glands revealed a hyperfunctioning parathyroid lesion. Gastroscopy findings suggested a duodenal bulge and ulceration. Ultrasound endoscopy revealed a hypoechoic lesion in the duodenal bulb. Further blood tests revealed elevated levels of serum gastrin. Surgery was performed, and pathological analysis of the surgical specimens revealed a parathyroid adenoma after parathyroidectomy and a neuroendocrine tumor after duodenal bulbectomy. The time from onset to the definitive diagnosis of MEN1 was only approximately 1 year. CONCLUSION: For patients who present with gastrointestinal symptoms accompanied by hypercalcemia and hypophosphatemia, clinicians need to be alert to the possibility of MEN1.

Challenging treatment of severe hypotension following tracheal intubation in a patient with primary hyperparathyroidism: A case report.

RATIONALE: Primary hyperparathyroidism (PHPT), which is characterized by increased parathyroid hormone secretion, typically manifests as hypercalcemia and hypertension. Here, we report a case of severe hypotension following tracheal intubation during anesthesia induction in a patient with PHPT, in contrast to the expected hypertensive response. PATIENT CONCERNS: A 52-year-old man presented with nausea after eating, leg pain when walking, and headaches. DIAGNOSIS: Based on the blood test and computed tomography results, he was diagnosed with PHPT. INTERVENTIONS: The patient underwent parathyroidectomy under general anesthesia. After induction anesthesia and tracheal intubation, severe acute hypotension and tachycardia suddenly developed. To treat hypotensive shock, we immediately administered ephedrine and phenylephrine and infused Ringer solution. OUTCOMES: The symptoms of hypotensive shock were alleviated by this intervention. LESSONS: We speculate that the cause of his severe hypotension was vasodilation due to the transient release of parathyroid hormone from mechanical stimulation by anesthetic procedures, such as tracheal intubation, combined with hypercalcemia-induced severe dehydration. Moreover, we speculate that fluid resuscitation stabilized his condition and helped achieve a successful surgical outcome. The possibility of severe hypotension after anesthesia induction should be anticipated, and management of cases with severe dehydration should be optimized during the anesthetic management of patients with PHPT.