Parathyroid gland exploration with local anesthesia in elderly and high-risk patients.

The management of symptomatic hyperparathyroidism in elderly and medically compromised patients, who are at risk under general anesthesia, may be safely and effectively accomplished using local anesthesia. Positive localization with ultrasound, thallium 201-technetium Tc 99m subtraction, and computed tomography permit surgical exploration with local anesthesia in one or two stages, or bilaterally in one stage, in selected cases, by employing the surgical lateral approach to parathyroid surgery. Our study of 29 patients selected for this technique affirms the value and the safety of this method, especially as surgical experience has grown and localization studies have improved. During the latter 24 months of our study, 11 (30%) of 36 operations were performed using local anesthesia by one of us. A success rate in ten of 11 cases was achieved, with one patient requiring a second exploration for adenomatous hyperplasia while under local anesthesia.

Primary surgery for hyperparathyroidism: the lateral approach after preoperative ultrasonographic localization.

Increasing experience and improving equipment has made ultrasonography the localizing test of choice before neck exploration for hyperparathyroidism is carried out. A study of 16 patients who were examined with ultrasonography before exploration showed that the sensitivity for finding enlarged parathyroid glands was 80 percent, the specificity 95 percent, and the diagnostic accuracy 91 percent. Our operative technique was altered from the classic midline exploration, with bilateral division of the strap muscles, to a lateral approach on the basis of our experience with a high-risk patient who had undergone unilateral exploration under local anesthesia after successful ultrasonographic localization. We found the results with the lateral approach to be equivalent to the results using the midline approach. The lateral approach appeared to be more direct, efficient, and less traumatic than the classic midline approach. This technique is well suited for parathyroid exploration with local anesthesia in high-risk patients who have multiple system failure.

Hyperparathyroidism in the elderly.

Primary hyperparathyroidism seems to be increasing in incidence in elderly patients. Their symptoms are somewhat different from those encountered in younger patients, the most striking difference being the increase in the number of patients with mental changes. Twenty-nine patients, 23 women and 6 men, were treated at two community hospitals. Surgery was successful in all instances with no postoperative mortality and a low rate of complications. When properly evaluated, elderly patients tolerate parathyroid exploration very satisfactorily.

Parathyroid cysts.

Fourteen new cases of parathyroid cyst are presented. Two distinct groups were identified: functioning and nonfunctioning. Patients with functioning cysts presented with hypercalcemia, tended to be men and were older. Patients with nonfunctioning cysts were all women, had normocalcemia and all presented with neck masses. Ultrasonography proved useful while radionuclide thyroid scans were often misleading. In the functioning group removal of parathyroid cysts resulted in postoperative normocalcemia in all cases. In the nonfunctioning cysts thyroid lobectomy was performed in five of six instances. Parathyroid cysts usually contain clear or serous fluid and are surrounded by a well-delineated plane of dissection. We believe that preoperative aspiration of cystic neck masses and consideration of the diagnosis of parathyroid cysts may avoid needless thyroid lobectomy.

Choledochal cyst diagnosed in pregnancy.

A primigravid patient with a type 1 choledochal cyst is reported. Conservative management allowed completion of the pregnancy and vaginal delivery of a term infant. Postpartum, the choledochal cyst was excised and biliary tree drained. A review of the literature and discussion of management alternatives of choledochal cysts discovered during pregnancy is presented.

Benign villous adenomas of the ampulla of Vater.

One of the most unusual sites of isolated villous adenomas is the ampulla of Vater. Six patients with this neoplasm have recently been identified. The mean age was 68 years, and four were female. Four of the six were evaluated on several occasions before definitive diagnosis. Preoperative endoscopy correctly identified the lesions in two of three patients. Five patients underwent local resection and one a radical pancreaticoduodenectomy. Six benign neoplasms of the ampulla were found. In discussing this entity, of which there have been 38 reported cases in the literature, the role of local excision that can be combined with more complex procedures such as sphincteroplasty and duct implantation should be emphasized.