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L W Delbridge

Publications and source records attributed to L W Delbridge.

34 records · Page 2Linked to original sources
PubMed2000

Minimally invasive parathyroidectomy: 50 consecutive cases.

OBJECTIVE: To determine the effectiveness and outcomes of minimally invasive parathyroidectomy. DESIGN: Prospective, non-randomised, non-blinded trial. SETTING: Affiliated university teaching hospitals of the Northern Clinical School, University of Sydney, New South Wales, May 1998 to October 1999. PATIENTS: 50 consecutive patients who underwent minimally invasive parathyroidectomy for primary hyperparathyroidism, and 150 consecutive patients undergoing open parathyroidectomy over the same period. RESULTS: Minimally invasive parathyroidectomy was successfully completed and resulted in cure (normocalcaemia) in 42 of 50 patients (84%). Seven patients (14%) required conversion to an open procedure, all of which also resulted in normocalcaemia, giving an overall cure rate of 98%. One patient had persistent hyperparathyroidism after minimally invasive parathyroidectomy which was cured at subsequent open reoperation. Three patients had a temporary recurrent laryngeal nerve palsy. Open parathyroidectomy was successful in 147 of 150 patients (98%) at initial operation; one patient had a temporary recurrent laryngeal nerve palsy. Intraoperative measurement of parathyroid hormone levels by a quick technique in 23 of the patients (13 having minimally invasive and 10 open procedures) correctly identified the presence of multiple-gland disease. CONCLUSION: Minimally invasive parathyroidectomy is a feasible procedure, although there are concerns about the complication rate.

Adenoma↗
PubMed2000

Minimally invasive surgery for primary hyperparathyroidism: systematic review.

HYPOTHESIS: Use of minimally invasive parathyroidectomy techniques, either unilateral or endoscopic, will result in the same or improved safety and efficacy outcomes as those of the bilateral open neck exploration technique in patients with primary hyperparathyroidism. DATA SOURCES: Studies on minimally invasive parathyroid surgery were identified using MEDLINE (January 1984 to August 1998), EMBASE (January 1974 to August 1998), and Current Contents (week 1 of 1993 to week 34 of 1998). The search terms were as follows: ((endoscop* or (minimal* and invasive) or unilateral) and parathyroid). The Cochrane Library was searched from issue 1 of 1966 to issue 3 of 1998, using the search terms "parathyroidectomy or parathyroid resection." STUDY SELECTION: Human studies of patients with primary hyperparathyroidism using unilateral or endoscopic exploration were included. Animal studies describing minimally invasive technique development were also included. A surgeon (R.F.P.) and researcher (W.J.B.) independently assessed the retrieved articles for their inclusion in the review. DATA EXTRACTION: Studies directly comparing the unilateral method with bilateral open neck exploration were used to analyze outcomes. DATA SYNTHESIS: Analysis of data using odds ratios and 95% confidence intervals indicated a tendency to favor the unilateral technique. However, these individual studies generally had large confidence intervals; therefore, preference to the unilateral procedure cannot be espoused with certainty. There is also a selection bias due to the strict enrollment criteria for unilateral surgery. CONCLUSIONS: The proposed role of minimally invasive parathyroid surgery is for patients with primary hyperparathyroidism who have unilateral parathyroid pathological features. To assess the safety and efficacy of minimally invasive techniques, it is suggested that their introduction be monitored as part of a trial in Australia, from which data should be accrued to a register.

Humans↗
PubMed2000

Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique.

The cornerstone of safe and effective thyroid surgery is thorough training in and understanding of thyroid anatomy and pathology. With appropriate techniques, total thyroid lobectomy and total thyroidectomy (which should be considered simply as a bilateral total thyroid lobectomy performed during the same operation) can be undertaken with minimal risk of damage to the recurrent laryngeal nerves, the external branches of the superior laryngeal nerves, and the parathyroid glands. Safe surgery requires a specific operative plan, progressing in a series of logical, orderly, anatomically based steps. Exposure of the thyroid gland is followed by careful dissection of the superior pole, utilizing the avascular plane between the superior pole and the cricothyroid muscle to identify and preserve the external branch of the superior laryngeal nerve. Medial retraction of the gland then allows dissection of the lateral aspect of the thyroid lobe. Protection of the recurrent laryngeal nerves and preservation of the blood supply to the parathyroid glands is best achieved by "capsular dissection," ligating the tertiary branches of the inferior thyroid artery on the gland surface. If a parathyroid gland cannot be preserved or becomes ischemic after dissection of its vascular pedicle, it should be immediately minced and autotransplanted into the ipsilateral sternocleidomastoid muscle. The current evolution of outpatient or short-stay thyroidectomy emphasizes the need to avoid complications by utilizing meticulous surgical technique. Minimally invasive thyroidectomy utilizing endoscopic techniques may also affect the practice of thyroid surgery. Even so, understanding the surgical anatomy of the thyroid gland and its possible variations is paramount to safe and effective surgery.

Humans↗
PubMed2000

Minimally invasive surgery for primary hyperparathyroidism: a systematic review.

BACKGROUND: The aim of the present paper was to systematically review the literature regarding the safety and efficacy of minimally invasive parathyroidectomy techniques in patients with primary hyperparathyroidism. Studies using unilateral or endoscopic exploration following imaging were compared with bilateral open neck exploration. METHODS: Studies on minimally invasive parathyroid surgery were identified using MEDLINE (1984 to August 1998), EMBASE (1974 to August 1998) and Current Contents (1993 to week 34, 1998). The search terms were ((endoscop* or (minimal* and invasive) or unilateral) and parathyroid). The Cochrane Library was searched from 1966 to issue 3 1998, using the search terms 'parathyroidectomy or parathyroid resection'. Human studies of patients with primary hyperparathyroidism using unilateral or endoscopic exploration were included. Animal studies describing minimally invasive technique development were also included. A surgeon and researcher independently assessed the retrieved articles for their inclusion in the review. Studies directly comparing the unilateral method with bilateral open neck exploration were used to analyse outcomes. RESULTS: Analysis of data using odds ratios and 95% confidence intervals (CI) indicated a tendency to favour the unilateral technique. These individual studies generally had large CI, however; therefore preference to the unilateral procedure cannot be espoused with certainty. There is also a selection bias due to the strict enrollment criteria for unilateral surgery. CONCLUSIONS: The proposed role of minimally invasive parathyroid surgery is for patients with primary hyperparathyroidism who have unilateral parathyroid pathology. To assess the safety and efficacy of minimally invasive techniques it is suggested that their introduction be monitored as part of a trial in Australia, from which data should be accrued to a register.

Endoscopy↗
PubMed2000

Routine parathyroid autotransplantation during total thyroidectomy: the influence of technique.

OBJECTIVE: To find out whether injecting a suspension of finely minced parathyroid tissue into the muscle bed had any adverse outcomes as it is simpler and potentially safer than implanting parathyroid tissue into muscle pockets. DESIGN: Prospective, randomised, controlled clinical trial. SETTING: University hospital, Australia. PATIENTS: 50 patients who were to have total thyroidectomy and routine parathyroid autotransplantation. INTERVENTIONS: Patients were randomised to either the injection technique or the implantation technique. MAIN OUTCOME MEASURES: Clinical assessment; corrected serum calcium and intact parathyroid hormone concentrations (PTH) measured immediately before, and at 1 day, 2 weeks, and 3 months after operation. RESULTS: Calcium was reduced significantly in both groups immediately after thyroidectomy. Although mean PTH concentrations decreased immediately after thyroidectomy and parathyroid autotransplantation in both groups, these changes were significant only in the implantation group. By 2 weeks and again by 3 months, calcium and intact parathyroid hormone concentrations had returned to baseline in both groups. At 3 months, 2 patients in each group still required some form of calcium supplement. At 6 months, no patients in the injection group required supplement. CONCLUSIONS: Injection of a suspension of parathyroid tissue is a simple, safe, and rapid technique for parathyroid autotransplantation during total thyroidectomy and is not associated with any more adverse outcome than is the standard technique.

Adolescent↗
PubMed1999

The spectrum of emergency admissions for thyroidectomy.

Emergency physicians frequently encounter patients with thyroid disease. However, it is unusual for these thyroid disorders to create acute, life-threatening situations. Critical airway compression attributable to benign or malignant thyroid enlargement may occur suddenly. Similarly, venous obstruction from thyroid tumors or severe physiological compromise from thyrotoxicosis may require urgent treatment. We reviewed a group of patients who were evaluated by emergency physicians for acute thyroid pathology and subsequently admitted for urgent thyroidectomy. Over a 7-year period, 13 patients had acute airway compressive symptoms, and 1 had acute venous compressive symptoms. Six patients had thyrotoxicosis with physiological compromise. Common airway management techniques were successfully used. Nineteen patients underwent thyroidectomy. One patient suffered a cardiopulmonary arrest before thyroidectomy could be performed. Surgical morbidity may be increased for patients undergoing thyroidectomy for urgent indications.

Adult↗
PubMed1999

Intraoperative decision making in follicular lesions of the thyroid: is tumor size important?

BACKGROUND: Intraoperative decision making in treating follicular lesions of the thyroid remains controversial because there are no reliable preoperative or intraoperative factors predictive of malignancy. This study was undertaken to determine whether lesion size is a reliable factor that can be used to predict a final pathologic diagnosis of follicular carcinoma. STUDY DESIGN: This was a retrospective, case-matched control study. One hundred consecutive patients with follicular carcinoma were matched by gender, age, and date of operation with 100 patients with follicular adenomas. Seventy-nine matched pairs had pure follicular lesions and 21 matched pairs had oxyphilic variants of follicular lesions. After confirming adequate matching, lesion size was compared between groups. RESULTS: Regardless of whether all follicular lesions were analyzed or whether only pure follicular or oxyphilic variant lesions were compared, there was no significant difference in lesion size between the carcinoma and adenoma groups. The mean size of all follicular carcinomas was 31.5 +/- 1.7 mm and the mean size of all follicular adenomas was 30.8 +/- 1.5 mm (p = NS). When the proportions of the carcinoma and adenoma groups were indexed by five different size intervals and compared, there was again no significant difference in any category. CONCLUSIONS: On the basis of this case-matched control study, the size of a follicular lesion cannot be used to predict a final diagnosis of follicular carcinoma and is of no value when making intraoperative decisions about the extent of thyroid resection.

Adenocarcinoma, Follicular↗
PubMed1999

Endoscopically assisted, minimally invasive parathyroidectomy.

BACKGROUND: Despite the success of open parathyroid exploration, minimally invasive alternatives have been emerging. This study reports an experience with endoscopically assisted, minimally invasive parathyroidectomy and evaluates its current role in patients undergoing surgery for hyperparathyroidism. METHODS: One hundred consecutive patients requiring surgery for hyperparathyroidism were evaluated. Endoscopic parathyroidectomy was offered based on the absence of coexisting nodular thyroid disease, previous neck surgery or irradiation, suspicion of parathyroid hyperplasia, or other anatomical or medical contraindications. Some 24 of 100 patients fulfilled the criteria and underwent endoscopic parathyroidectomy. Unequivocal localization to a single site by a technetium-99m-radiolabelled sestamibi scan allowed removal of the adenoma through a 25-mm suprasternal incision while being guided by a surgical telescope. RESULTS: There were no statistically significant differences in operating time or the mean size of resected adenomas between patients undergoing endoscopic and open parathyroidectomy. Four patients required conversion to an open procedure. Two patients developed temporary recurrent laryngeal nerve paresis and one had persistent hyperparathyroidism. CONCLUSION: Although endoscopic parathyroidectomy is technically feasible, its applicability is limited to a minority of patients undergoing operation for hyperparathyroidism. The potential for higher complication and failure rates makes optimism for the procedure appropriately guarded.

Adenoma↗
PubMed1998

Surgery for primary hyperparathyroidism 1962-1996: indications and outcomes.

OBJECTIVE: To examine changes over the past three decades in the indications for, and outcomes of, surgery for primary hyperparathyroidism. DESIGN: Survey of a prospective hospital database. SETTING: Royal North Shore Hospital (a tertiary referral and university teaching hospital), Sydney, New South Wales, January 1962 to December 1996. PATIENTS: All 733 patients who underwent neck exploration for primary hyperparathyroidism. RESULTS: The annual number of parathyroidectomies increased virtually exponentially, from a mean of two in 1962-1969 to 73 in 1996. In the 1960s and 1970s, the most common indication for surgery was the presence of renal calculi (58% and 43%, respectively), but in the 1980s there was a marked increase in presentation of asymptomatic disease after biochemical screening (19%). In the 1990s, low bone mineral density detected by osteodensitometry has become the most common indication for surgery (31%). After initial operation, 11 patients (2%) had persistent hypercalcaemia, with five of these cured by reoperation--an overall failure rate of 1%. CONCLUSIONS: Surgery for primary hyperparathyroidism has become increasingly common, with low bone mineral density replacing renal calculi as the most common indication for surgery. Neck exploration in experienced hands results in an overall cure rate of 99%.

Adolescent↗
PubMed1998

RET/PTC and RET tyrosine kinase expression in adult papillary thyroid carcinomas.

The prevalence of RET/PTC rearrangements in papillary thyroid carcinomas (PTCs) varies widely in different studies, and an association of RET/PTC presence with tumor behavior remains to be clarified. A prospective study of 50 adult PTCs examined, using RT-PCR, the prevalence of the 3 main RET rearrangements and also of RET tyrosine kinase (TK) domain sequence expression. The genetic findings were correlated with the MACIS clinical prognostic score and with individual clinical parameters. Three of the patients had been exposed to radiation in childhood or adolescence. Four of the PTCs contained RET/PTC1, confirmed by sequencing, and none contained RET/PTC2 or RET/PTC3. The prevalence of RET rearrangements overall was 8%, but in the subgroup of 3 radiation-exposed patients it was 66.6%. Interestingly, RET tyrosine kinase domain messenger ribonucleic acid was detectable in 70% of PTCs using RET exon 12/13 primers and was detectable in 24% of PTCs using RET exon 15/17 primers. RT-PCR for calcitonin and RET extracellular domain, however, was negative. There was no association between the presence or absence of RET/PTC in the patient's tumor and clinical parameters. We conclude that RET/PTC1 is the predominant rearrangement in PTCs from adults with a history of external irradiation in childhood. RET TK messenger ribonucleic acid expression is common in PTCs, using RT-PCR, and cannot be used to infer the presence of specific RET rearrangements or of RET activation.

Adult↗
PubMed1997

Technetium-99m-sestamibi scanning in recurrent medullary thyroid carcinoma.

UNLABELLED: The presence of recurrent medullary thyroid carcinoma (MTC) can be detected early by measurement of serum calcitonin levels, but the localization of recurrent tumors is often difficult. METHODS: We compared 99mTc-sestamibi scans with computed tomographic (CT) scans in 10 patients with recurrent MTC, who had basal serum calcitonin values ranging from 220-61800 ng/liter. Two patients additionally had bone scans performed because of the clinical suspicion of bone metastases. RESULTS: Seven of the 10 patients had at least one site of abnormal 99mTc-sestamibi uptake, and all of these patients had basal serum calcitonin values > 6000 ng/liter. Only five of the 10 patients had abnormal CT scans. Technetium-99m-sestamibi scans detected 22 abnormal sites in the soft tissues of the neck and chest, while CT scans detected only 11 lesions in the neck and chest. Five of these sestamibi positive sites (in the neck and mediastinum of one patient) were confirmed histologically to represent MTC. When imaging the liver, CT scans detected 47 lesions in three patients while 99mTc-sestamibi scans detected none. One of these liver lesions was confirmed as MTC histologically. When imaging bone in two of the patients, the bone scans detected 17 abnormal sites, while 99mTc-sestamibi scans detected six abnormal sites. CONCLUSION: Technetium-99m-sestamibi scans complement CT and bone scans in the localization of recurrent MTC in patients with extremely high calcitonin levels. Technetium-99m-sestamibi scans are more sensitive than CT scans in the assessment of the soft tissues of the neck and chest, but CT is more appropriate for imaging hepatic lesions and bone scans are better for imaging bone lesions. Technetium-99m-sestamibi scans are unlikely to be abnormal in patients with only mild elevation of calcitonin.

Adult↗
PubMed1988

Neuromuscular symptoms in elderly patients with hyperparathyroidism: improvement with parathyroid surgery.

In a consecutive series of 100 neck explorations for primary hyperparathyroidism, 42 patients were 60 years of age or older; in this group of elderly patients the surgical cure rate was 100%. These patients were reviewed retrospectively by means of a structure interview. Twenty-one patients had had preoperative neuromuscular symptoms that ranged from coma to subjective muscular weakness. These patients had significantly-higher preoperative serum calcium and parathyroid hormone levels than did 21 patients without neuromuscular symptoms (P = 0.003 and P = 0.046, respectively). Most of the neuromuscular symptoms improved in the postoperative period. In particular, 15 of 17 patients with muscle weakness reported a significant improvement, while 14 of 15 patients who suffered from fatigue and lethargy reported an improvement. An improvement also occurred in the level of day-to-day function in eight patients. While surgery for primary hyperparathyroidism generally is undertaken for a specific indication, such as severe hypercalcaemia or renal stones, it appears from this study that neuromuscular symptoms also may improve, particularly in elderly patients.

Adolescent↗
PubMed1986

Epidermal growth factor causes hypocalcemia in sheep.

During iv infusions of epidermal growth factor into sheep, serum calcium concentrations fell, whereas serum magnesium and serum immunoreactive PTH levels increased. Urinary calcium and magnesium decreased significantly. The role of epidermal growth factor in calcium homeostasis is discussed.

Animals↗
PubMed1982

Pancreatitis following parathyroid surgery.

While pancreatitis may provide the clue to the diagnosis of hyperparathyroidism preoperatively, the occurrence of pancreatitis following parathyroidectomy is not generally recognized. In this study preoperative and postoperative serum amylase estimations, together with a clinical assessment, were performed on 86 patients undergoing neck exploration for hyperparathyroidism. It was found that postoperative hyperamylasaemia occurred in 35% of the total group, while clinically significant pancreatitis was found in 9% of cases. Pancreatitis was significantly more common when thyroidectomy was performed at the time of parathyroidectomy, occurring in 23% of this group of patients, and may be due to the blunted C-cell response of calcitonin secretion to the induced hypercalcaemia associated with operative manipulation. Careful attention should be paid to postoperative abdominal symptoms, for they may indicate pancreatitis.

Acute Disease↗