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

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Primary hyperparathyroidism (PHPT) is cured in more than 90% of patients by removal of a solitary parathyroid adenoma (SPA), the exact location of which can be predicted using a combination of functional and anatomical imaging including Technetium Sestamibi subtraction single‐photon emission computed tomography (Sestamibi), dedicated ultrasound (US), and contrast‐enhanced multi‐sequential computed tomography.1 Once localized, the SPA can be excised with a variety of ‘focused’ procedures which usually take the name of minimally invasive parathyroidectomy (MIP) and do not involve exploration of any other parathyroid.1 A recent multicentre retrospective study on a consecutive series of 2531 MIP (without intraoperative adjuncts) in patients with sporadic PHPT and preoperative diagnosis of SPA showed a 97% initial cure rate. In this series, among the 118 patients who did require reoperation for persistent PHPT, ipsilateral double adenoma or hyperplasia were diagnosed in 16 and 18% of patients, respectively. Essentially 34% of patients with persistent PHPT following MIP would have been correctly diagnosed with multigland disease, if the second ipsilateral gland was sought for at the time of the initial surgery.1 As a matter of facts, identification of both the preoperative localized SPA and the ipsilateral parathyroid gland, that is performing a two‐glands unilateral neck exploration (UNE), is a well‐validated strategy that may represent a reasonable compromise between the ‘invasiveness’ of surgery and the risk of missing unexpected multigland disease.6
The aim of this study was to investigate the findings of UNE performed using a minimally invasive video‐assisted (MIVA) technique in patients with PHPT and preoperative diagnosis of SPA. We hypothesized that MIVA‐UNE would be feasible and clinically relevant. Our primary outcome was the percentage of procedures in which the second ipsilateral parathyroid was identified. Our secondary outcome was the incidence of unexpected cases of multigland disease discovered by means of MIVA‐UNE.
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