Article information
Resumen
La prevalencia y la incidencia del hiperparatiroidismo primario han aumentado más de lo que previamente se había estimado, y su diagnóstico se ha simplificado mucho con el desarrollo del inmunoanálisis para la paratirina. La paratiroidectomía sigue siendo el único tratamiento definitivo de esta enfermedad.
El mayor avance en los últimos años ha sido la mejora de las técnicas de localización con la aparición de la gammagrafía con 99mTc-sestamibi, lo que ha propiciado el desarrollo de una serie de tácticas quirúrgicas que se basan en el acceso limitado a la enfermedad puesta de manifiesto por esta exploración, como la paratiroidectomía mínimamente invasiva, la paratiroidectomía mínimamente invasiva videoasistida y la paratiroidectomía mínimamente invasiva radioguiada; todas con o sin la ayuda de la determinación intraoperatoria de paratirina. La introducción de estos avances en el diagnóstico hace que se cuestione la necesidad de la práctica del acceso clásico con la visualización de las cuatro glándulas paratiroideas.
Los resultados obtenidos por las citadas técnicas son prometedores, pero en la actualidad no se ha demostrado de manera concluyente que sean superiores al acceso clásico, debido a la incompleta o escasa evidencia existente, por lo que es necesaria la realización de estudios diseñados de forma adecuada para su confirmación.
Palabras clave:
Hiperparatiroidismo primario
Tratamiento quirúrgico
Revisión
The incidence and prevalence of primary hyperparathyroidism has increased more than was previously expected and the diagnosis of this disorder has been greatly simplified by the development of the parathyroid hormone (PTH) immunoassay. Parathyroidectomy is still the only definitive treatment.
The greatest advance in the last few years has been improvement in localization techniques with the development of 99mtc—sestamibi scintigraphy, which has favored limited access surgical techniques, such as minimally-invasive parathyroidectomy, video-assisted minimally-invasive parathyroidectomy and radio-guided minimally-invasive parathyroidectomy. all of these techniques can be performed with or without intraoperative pth determination, casting doubt on the need for classical access with visualization of the four parathyroid glands.
The results obtained by these techniques are promising. However, to date there is insufficient evidence to conclusively demonstrate the superiority of these techniques over the classical approach and further, well-designed studies are required.
Key words:
Primary hyperparathyroidism
Surgical treatment
Review
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Bibliografía
[1.]
Consensus Development Conference Panel NIH Conference. Diagnosismanagement of asymptomatic primary hyperparathyroidism:development conference statement..
Ann Intern Med, 114 (1991), pp. 593-597
[2.]
T.J. Van Vroonhoven, A. van Dalen.
Successful minimally invasive surgery in primary hyperparathyroidism after combined preoperative ultrasound and computed tomography imaging.
J Intern Med, 243 (1998), pp. 581-587
[3.]
D.W. Denham, J. Norman.
Cost-effectiveness of preoperative sestamibi scan for primary hyperparathyroidism is dependent solely upon the surgeon’s choice of operative procedure.
J Am Coll Surg, 186 (1998), pp. 293-305
[4.]
W. Shen, U. Sabanci, E.T. Morita, A.E. Siperstein, Q.Y. Duh, O.H. Clark.
Sestamibi scanning is inadequate for directing unilateral neck exploration for first-time parathyroidectomy.
Arch Surg, 132 (1997), pp. 969-974
[5.]
S. Mazzeo, D. Caramella, R. Lencioni, N. Molea, A. De Liperi, C. Marcocci, et al.
Comparison among sonography, double-tracer substraction scintigraphy, and double-phase scintigraphy in the detection of parathyroid lesions.
Am J Roentgenol, 166 (1996), pp. 1465-1470
[6.]
E. Hindié, D. Melliere, D. Simon, L. Perlemuter, P. Galle.
Primary hyperparathyroidism: is technetium-99m-sestamibi/iodine-123 substraction scanning the best procedure to locate enlarged glands before surgery?.
J Clin Endocrinol Metab, 80 (1995), pp. 302-307
[7.]
E. Larrañaga, E. Martin, P. Cardeñoso, F. Martinez de Paz, B. Doblado, L. Domínguez, et al.
Tratamiento ambulatorio del adenoma único de paratiroides mediante abordaje unilateral.
Cir Esp, 70 (2001), pp. 222-226
[8.]
E. Martín Pérez, E. Larrañaga, P.A. Serrano.
Utilidad de las diferentes técnicas de localización preoperatoria en el hiperparatiroidismo.
Cir Esp, 66 (1999), pp. 61-68
[9.]
J.M. Rodríguez González, S. Ortiz Sebastián, A. Hernández, M.A. Claver, T. Soria Cogollos, A. Ramírez Romero, et al.
Utilidad y limitaciones del sestamibi-99mTc como diagnóstico de localización en el hiperparatiroidismo.
Cir Esp, 60 (1996), pp. 400-403
[10.]
A.E. Kearns, G.B. Thompson.
Medical and surgical management of hyperparathyroidism.
Mayo Clin Proc, 77 (2002), pp. 87-91
[11.]
J. Bilezikian, J. Potts, G. El-Hajj Fuleihan, M. Kleerekoper, R. Neer, et al.
Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st Century.
J Clin Endocrinol Metab, 87 (2002), pp. 5353-5361
[12.]
O.H. Clark.
Surgical treatment of primary hyperparathyroidism.
Adv Endocrinol Metab, 6 (1995), pp. 1-6
[13.]
L.W. Delbridge, N.A. Younes, A.I. Guinea, T.S. Reeve, P. Clifton-Bligh, B.G.A. Robinson.
Surgery for primary hyperparathyroidism 1962- 1996: indications and outcome.
Med J Aust, 168 (1998), pp. 153-156
[14.]
R.A. Low, A.D. Katz.
Parathyroidectomy via bilateral cervical exploration: a retrospective review of 866 cases.
Head Neck, 20 (1998), pp. 583-587
[15.]
K.E. Levin, O.H. Clark.
The reasons for failure in parathyroidism operations.
Arch Surg, 124 (1989), pp. 911-915
[16.]
J.A. Sosa, N.R. Powe, M.A. Levine, R. Udelsman, M.A. Zeigler.
Profile of a clinical practice: threshold for surgery and surgical outcomes for patients with primary hyperparathyroidism: a national survey of endocrine surgeons.
J Clin Endocrinol Metab, 83 (1998), pp. 2658-2665
[17.]
H. Chen, L.J. Sokoll, R. Udelsman.
Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localisation, cervical block anesthesia, and intraoperative parathyroid hormone assay.
Surgery, 126 (1999), pp. 1016-1021
[18.]
P.L. Gerfo.
Bilateral neck exploration for parathyroidectomy under local anesthesia: a viable technique for patients with coexisting thyroid disease with or without sestamibi scanning. ; :..
Surgery, 126 (1999), pp. 1011-1015
[19.]
T.S. Reeve, W.J. Babidge, R.F. Parkyn, A.J. Edis, L.W. Delbridge, P.G. Devitt, et al.
Minimally invasive surgery for primary hyperparathyroidism: systematic review.
Arch Surg, 135 (2000), pp. 481-487
[20.]
J.L. Doppman, D.L. Miller.
Localisation of parathyroid tumours in patients with asymptomatic hyperparathyroidism and no previous surgery.
J Bone Miner Res, 6 (1991), pp. 153-158
[21.]
S. Tibblin, A.G. Bondeson, O. Ljungberg.
Unilateral parathyroidectomy in hyperparathyroidism due to a single adenoma.
Ann Surg, 195 (1982), pp. 245-251
[22.]
C.A. Wang.
Unilateral neck exploration for primary hyperparathyroidism.
Arch Surg, 125 (1990), pp. 982-1050
[23.]
M. Davies, W.D. Fraser, D.J. Hosking.
The management of primary hyperparathyroidism.
Clin Endocrinol, 57 (2002), pp. 145-155
[24.]
S. Kountakis, A. Maillard.
Parathyroid adenomas: is bilateral neck exploration necessary.
Am J Otolaryngol, 20 (1999), pp. 396-399
[25.]
P.C. Smit, I.H. Rinkes, A. Van Dalen, T.J. Van Vroonhoven.
Direct, minimally invasive adenomectomy for primary hyperparathyroidism: an alternative to conventional neck exploration.
Ann Surg, 231 (2000), pp. 559-565
[26.]
R.E. Goldstein, L. Blevins, D. Delbeke, W.H. Martin.
Effect of minimally invasive radioguided parathyroidectomy on efficacy, length of stay, and costs in the management of primary hyperparathyroidism.
Ann Surg, 231 (2000), pp. 732-742
[27.]
J. Goss, R.A. Landerholm.
Changing experience with primary hyperparathyroidism at group health cooperative, Seattle.
Am J Surg, 181 (2001), pp. 445-448
[28.]
L.M. Vogel, R. Lucas, P. Czako.
Unilateral parathyroid exploration.
Am Surg, 64 (1998), pp. 693-696
[29.]
P.G. Gauger, T.S. Reeves, L.W. Delbridge.
Endoscopically assisted, minimally invasive parathyroidectomy.
Br J Surg, 86 (1999), pp. 1563-1566
[30.]
W.B. Inabnet, Y. Fulla, B. Richard, P. Bonnichon, P. Icard, Y. Chapuis.
Unilateral neck exploration under local anesthesia: the approach choice for asymptomatic primary hyperparathyroidism.
Surgery, 126 (1999;), pp. 1004-1009
[31.]
L.W. Delbridge, S.J. Dolan, T.T. Hop, B.G. Robinson, M.R. Wilkinson, T.S. Reeve.
Minimally invasive parathyroidectomy: 50 cases.
Med J Aust, 172 (2000), pp. 418-422
[32.]
P. Miller, A. Kindred, D. Kosoy, D. Davidson, H. Lang, K. Waxman, et al.
Preoperative sestamibi localization combined with intraoperative parathyroid hormone assay predicts successful focused unilateral neck exploration during surgery for primary hyperparathyroidism.
Am Surg, 69 (2003), pp. 82-85
[33.]
S.C. Katz, G.J. Wang, E.L. Kramer, D.F. Roses.
Limitations of technetium 99m sestamibi scintigraphic localization for primary hyperparathyroidism associated with multiglandular disease.
Am Surg, 69 (2003), pp. 170-175
[34.]
H. Dralle, K. Lorenz, P. Nguyen-Thanh.
Minimally invasive video-assisted parathyroidectomy. Selective approach to localised single gland adenoma.
Langenbecks Arch Surg, 384 (1999), pp. 556-562
[35.]
P. Miccoli, C. Bendinelli, E. Vignali, S. Mazzeo, G.M. Cecchini, A. Pinchera, et al.
Endoscopic parathyroidectomy: report of an initial experience.
Surgery, 124 (1998), pp. 1077-1079
[36.]
P. Miccoli, P. Berti, G. Materazzi, G. Donatini.
Minimally invasive video assisted parathyroidectomy (MIVAP.
Eur J Surg Oncol, 29 (2003), pp. 188-190
[37.]
J. Kuriansky, L. Fernandez-Cruz.
Preliminary experiences with endoscopic parathyroidectomy.
Harefuah, 138 (2000), pp. 94-96
[38.]
A. Gottlieb, J. Sprung, X.M. Zheng, M. Gagner.
Massive subcutaneous emphysema and severe hypercarbia in a patient during endoscopic transcervical parathyroidectomy using carbon dioxide insufflation.
Anesth Analg, 84 (1997), pp. 1154-1156
[39.]
T. Naitoh, M. Gagner, A. Garciaruiz, B.T. Heniford.
Endoscopic endocrine surgery in the neck: an initial report of endoscopic subtotal parathyroidectomy.
Surg Endosc, 12 (1998), pp. 202-205
[40.]
J. Norman, H. Chheda.
Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping.
Surgery, 122 (1997), pp. 998-1004
[41.]
A.K. Greene, P. Mowschenson, R.A. Hodin.
Is sestamibi-guided parathyroidectomy really cost-effective?.
Surgery, 126 (1999), pp. 1036-1040
[42.]
M.B. Flynn, J.M. Bumpous, K. Schill, K.M. McMasters.
Minimally invasive radioguided parathyroidectomy.
J Am Coll Surg, 191 (2000), pp. 24-31
[43.]
R.E. Goldstein, L. Blevins, D. Delbeke, W.H. Martin.
Effect of minimally invasive radioguided parathyroidectomy on efficacy, length of stay, and costs in the management of primary hyperparathyroidism.
Ann Surg, 231 (2000), pp. 732-742
[44.]
J.G. Norman, C.E. Jaffray, H. Chheda.
The false-positive parathyroid sestamibi: a real or perceived problem and a case for radioguided parathyroidectomy.
Ann Surg, 231 (2000), pp. 31-37
[45.]
Vicente A García, Castrejón A Soriano, Marina S Rodado, J. Martín, J. Hernández.
Cirugía paratiroidea mínimamente invasiva con gammagrafía con 99mTc-sestamibi y cirugía radioguiada con sonda: resultados preliminares.
Rev Esp Med Nuclear, 19 (2000), pp. 403-408
[46.]
S.H. Burkey, J.A. Van Heerden, D.R. Farley, G.B. Thompson, C.S. Grant, K.J. Curlee.
Will directed parathyroidectomy utilizing the gamma probe or intraoperative parathyroid hormone assay replace bilateral cervical exploration as the preferred operation for primary hyperparathyroidism?.
World J Surg, 26 (2002), pp. 914-920
[47.]
G. Irvin, D. Prudhorme, G. Deriso, G. Sfakianakis, G. Chandarlapaty.
A new approach to parathyroidectomy.
Ann Surg, 219 (1994), pp. 574-581
[48.]
G.L. Irvin, A.S. Molinari, C. Figueroa, D.M. Carneiro.
Improved success rate in reoperative parathyroidectomy with intraoperative PTH assay.
Ann Surg, 229 (1999), pp. 874-878
[49.]
S.C. Garner, G.S. Leight Jr.
Initial experience with intraoperative PTH determinations in the surgical management of 130 cases of primary hyperparathyroidism.
Surgery, 126 (1999), pp. 1132-1137
[50.]
F.D. Jr. Moore, F. Mannting, M. Tanasijevic.
Intrinsic limitations to unilateral parathyroid exploration.
Ann Surg, 230 (1999), pp. 382-388
[51.]
J. Deus, I. Gil, A. Urieta, A. Marsella, M.A. Alonso, M.J. Moreno, et al.
Cirugía selectiva bajo anestesia local para el tratamiento de los adenomas paratiroideos.
Cir Esp, 47 (2000), pp. 3-7
[52.]
P Miller, A Kindred, D Kosoy, D Davidson, H Lang, K Waxman, et al.
Preoperative sestamibi localization combined with intraoperative parathyroid hormone assay predicts successful focused unilateral neck exploration during surgery for primary hyperparathyroidism.
Am Surg, 69 (2003), pp. 82-85
[53.]
C.R. Harman, C.S. Grant, I.D. Hay, D.L. Hurley, J.A. Van Heerden, G.B. Thompson, et al.
Indications, technique and efficacy of alcohol injection of enlarged parathyroid glands in patients with primary hyperparathyroidism.
Surgery, 124 (1998), pp. 1011-1019
[54.]
T. Kakuta, M. Fukagawa, T. Fujisaki, M. Hida, H. Suzuki, H. Sakai, et al.
Prognosis of parathyroid function after successful percutaneous ethanol injection therapy guided by color Doppler flow mapping in chronic dialysis patients.
Am J Kidney Dis, 33 (1999), pp. 1091-1099
[55.]
P.C. Chaffanjon, P.Y. Brichon, R. Sarrazin.
Bilateral oblique approach to parathyroid glands.
Ann Surg, 231 (2000), pp. 25-30
[56.]
J. Norman, D. Denham.
Minimally invasive radioguided parathyroidectomy in the reoperative neck.
Surgery, 124 (1998), pp. 1088-1092
[57.]
A. Bergenfelz, P. Lindblom, S. Tibblin, J. Westerdahl.
Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial.
Ann Surg, 236 (2002), pp. 543-551
[58.]
W.R. Sackett, B. Barraclough, T.S. Reeve, L.W. Delbridge.
Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy.
Arch Surg, 137 (2002), pp. 1055-1059
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