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Ann Thorac Surg 2000;69:221-223
© 2000 The Society of Thoracic Surgeons

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Original Articles

Thoracoscopic resection of ectopic parathyroid glands

^a Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA
^b Division of Cardiothoracic Surgery, Allegheny University of the Health Sciences, Pittsburgh, Pennsylvania, USA

Address reprint requests to Dr Hazelrigg, Division of Cardiothoracic Surgery, SIU School of Medicine, 701 N 1st St, Room D314, Box 19638, Springfield, IL 62794-9638
e-mail: shazelrigg{at}siumed.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The vast majority of parathyroid glands in hyperparathyroidism can be resected through a cervical approach. In approximately 2% of the cases, the ectopic gland is in the mediastinum in a location that requires a thoracic approach.

Methods. We report 7 such cases that were resected using video-assisted thoracic surgery to avoid the need for an open surgical procedure.

Results. All glands were successfully identified preoperatively and subsequently resected. Hospital stay averaged less than 3 days with only one minor complication.

Conclusions. Ectopic mediastinal parathyroid glands may be safely and accurately resected using video-assisted thoracic surgery to avoid open approaches.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The need to remove a parathyroid gland in the mediastinum is a relatively infrequent occurrence. The most common pathologic process in which an ectopic gland needs to be excised is primary or secondary hyperparathyroidism. Although estimates of mediastinal parathyroid glands in primary hyperparathyroidism have been as high as 20% [1], only about 2% cannot be extracted through a cervical incision [2, 3]. It is in this small subset of patients that the use of video-assisted thoracic surgery (VATS) may be used to avoid the need for open incisions. We report our experience in 7 cases of ectopic parathyroid glands resected successfully by VATS.

	Material and methods

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Seven patients presented between January 1990 and January 1999 at one of the two institutions with biochemical evidence of hyperparathyroidism. In 6 patients this was primary hyperparathyroidism, and in 1 patient it was secondary hyperparathyroidism. The patients ranged in age from 22 to 57 years (mean = 39.0 years). There were 5 men and 2 women. Preoperative evaluation revealed a mean serum calcium of 12.8 and phosphate of 2.1 (Table 1). Methods of preoperative localization included computed tomographic scans in all patients (Fig 1), thallium pertechnate scan in 5, and technetium 99m-sestamibi parathyroid imaging in 2 (Fig 2). Magnetic resonance imaging scans were also performed in 2 patients.

View larger version (95K): [in this window] [in a new window]   Fig 1. Computed tomographic scan demonstrating an ectopic parathyroid adenoma anterior to the ascending aorta.

View larger version (164K): [in this window] [in a new window]   Fig 2. Nuclear scan revealing a mediastinal parathyroid adenoma.

	Results

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All 7 patients had their adenomas identified preoperatively by one of the scanning techniques, and all had at least one prior cervical exploration. The average operating time was 65 minutes (range, 40 to 92 minutes), and all patients were extubated in the operating room. No patients required an intensive care unit bed. Two patients were managed without a chest tube, and the mean overall chest tube duration was 0.85 days (range, 0 to 2 days). Average hospital stay was 2.7 days (range, 2 to 3 days), and there were no postoperative occurrences of bleeding, pneumonia, wound infection, or arrhythmia. One patient experienced postoperative pain related to intercostal nerve irritation that resolved 2 weeks postoperatively. During this study period, no open approaches were performed for resection of ectopic thoracic parathyroid glands.

Six patients had parathyroid adenomas, and 1 patient had hyperplasia. The mean size of the glands resected was 2.3 cm, and all were larger than 1.5 cm in size (range, 1.5 to 2.9 cm). Postoperative calcium concentrations returned to normal in all instances and remained normal at a mean follow-up of 36 months (range, 15 to 42 months).

	Comment

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In reports of large series of primary hyperparathyroidism, the incidence of mediastinal location outside the reach of cervical exploration is approximately 2% [2, 3]. Given this low incidence of occurrence, most surgeons do not routinely perform localizing scans before cervical exploration. After a failed cervical exploration, localizing scans are recommended.

Parathyroid glands larger than 1.5 cm are typically seen in computed tomographic scans, but smaller sized glands may be difficult to identify. The most common additional scans now used are the thallium-technetium scintiscan, the ^99mTc sestamibi scan, and magnetic resonance imaging. It appears that the ^99mTc sestamibi scan may offer the highest success rate. When the tumor is greater than 1 g, the success is 86%, and it is 100% when the tumor is more than 2 g. Indeed, one study described successful localization of ectopic tissue weighing less than 500 mg [2]. Compared with computed tomography, the sensitivity of magnetic resonance imaging was greater for detecting mediastinal lesions, but not as good as ^99mTc sestamibi alone [5].

Most ectopic glands are found in close approximation to the thymus gland. The inferior parathyroid glands originate from the third bronchial pouch with the thymus and hence are usually in close approximation to this gland. In a large review by Wang and colleagues [6] of 30 mediastinal glands, 24 were intrathymic and six were parathymic. Edis and associates [7] and Clark [8] reviewed 92 mediastinal parathyroids and found 85% were adjacent to the thymus. Our results support this, with four being intrathymic and the remaining three, parathymic in location.

Without preoperative localization, reports have noted 33% to 40% rates of inability to identify the glands by sternotomy, with complication rates as high as 21% [6, 8, 9]. Given this experience, we would recommend the preoperative localization of the ectopic gland before recommending a surgical exploration.

The options for treatment of an ectopic gland include the use of angiographic ablation. This technique occludes the blood supply to the gland. The drawbacks include a 40% rate of inability to localize the gland and an early failure rate of 40%. This technique has rarely reported neurologic complications and does not provide tissue should autotransplantation be required [10–12].

The VATS approach would seem to offer significant advantages over other open approaches (ie, sternotomy or thoracotomy). The operating room time in our series was short, and all patients were discharged by day 3. Only 1 of 7 patients (14%) had a minor complication, that being intercostal neuralgia that resolved within 2 weeks. This stands in contrast to a report by Russell and co-workers [13] for sternotomy that included 21% incidence of pulmonary complications, 8% wound complications, as well as some atrial fibrillation and deep venous thrombosis. Conn and associates [9] reported a complication rate of 19% (4 of 21 patients) after sternotomy for resection of ectopic parathyroids. Given the small size and mediastinal location, VATS would seem an ideal approach for the rare mediastinal ectopic parathyroid glands and would be our preferred approach. Previous VATS resections have been reported, including three single case reports and a combined experience of 5 cases. In all of these cases, the glands were excised successfully [3, 14, 15].

Other minimally invasive surgical routes are potentially useful for resection of mediastinal masses. These would include a cervical incision similar to that used for thymectomy or a subxiphoid approach. Neither approach has been reported for resection of ectopic parathyroid glands, and we believe thoracoscopy allows better visualization than the cervical approach. The subxiphoid approach may be suitable for biopsy procedures; however, it still requires placement of additional ports if instruments are used for resection and hence would not seem to offer any significant advantages over the approaches used in our series of patients [16].

In summary, we have demonstrated the successful resection of seven ectopic intrathoracic parathyroid glands using VATS. This approach is associated with few complications and a short hospital stay. We recommend that the glands be preoperatively localized, that the diagnosis of hyperparathyroidism be unequivocal, and that the symptoms from this disorder be sufficiently severe to justify the procedure.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stephen R. Hazelrigg Rodney J. Landreneau Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Medrano, C. Articles by Grasch, A. Search for Related Content PubMed PubMed Citation Articles by Medrano, C. Articles by Grasch, A.