Localizing methods of primary hyperparathyroidism and those results

The results of several pre-operative localizing methods and pathological findings were compared in 11 patients with primary hyperparathyroidism. 1. The accuracy rate was highest with selective blood sampling from the thyroid vein and MRI, which was 75% with both methods. The 3rd was dual photon scintigraphy, the accuracy rate being 62.5%. The 4th was ultrasonography, 57.1%, and the rate was lowest with CT, 25%. 2. MRI-a new localizing method-has a weak point that it cannot differentiate lymph nodes from parathyroid adenoma/hyperplasia. 3. Not to overlook small lesion of primary hyperplasia, several localizing methods should be performed before initial neck exploration.     

Feasibility of localizing ectopic testes by 131I-labeled luteinizing hormone scintigraphy.

A new method for localizing ectopic testes preoperatively was investigated in rats. Twenty hours after administration of iodine-131 luteinizing hormone the position of normal descended testes was easily identified by scintigraphy. Clinically, this technique may offer a noninvasive and practical means of locating testes undetected by palpation. The complexity and hazards of the surgical intervention to follow would thus be greatly reduced.     

Unilateral parathyroidectomy: the role of thallium-technetium subtraction scans

The rationale for using the thallium-technetium subtraction scan as a preoperative localizing study in previously untreated patients with primary hyperparathyroidism is presented. The concept of unilateral parathyroidectomy is also presented, and the role of preoperative localizing studies in this approach to parathyroid surgery is carefully analyzed.     

Intraoperative doppler and real time sonography in neurosurgery

Summary Ultrasound Doppler sonography with miniaturized probes and high resolution offers new possibilities of intraoperative control of neurovascular procedures. Patency, flow direction stenoses and changes in resistance can be investigated atraumatically, repeatedly and without additional preparation.In bypass and aneurysm surgery, about 10% of the cases were shown by Doppler examinations to be unsatisfactory, with stenoses and occlusions. These could be immediately corrected without loss of time. In normal cases, the information on the local haemodynamics enlarges the knowledge as to the effects of the operation and make it safer.Real time ultrasonography, which can be easily adapted to neurosurgery, is a new atraumatic tool for localizing, in two dimensions, subcortical intrinsic processes, haematomas, ventricles ect. It is useful for guided biopsies and punctures and for the centering of the dura and brain incision over the middle of the lesion, especially in microsurgical procedures.     

A new technique for intraoperative enteroscopy using a 12-mm trocar

Intraoperative enteroscopy is a valuable method for localizing gastrointestinal bleeding of obscure origin. The insertion and manipulation of an endoscope through an enterotomy, however, may result in significant trauma to the intestinal wall, as well as contamination of the abdominal cavity. We have devised a new technique for the introduction of the endoscope that lessens trauma to the bowel wall and allows a complete enteroscopy with minimal contamination. Received: 22 July 1998/Accepted: 17 February 1999     

Trigeminal involvement and peripheral facial paralysis caused by Arnold-Chiari malformation with hydrocephalus

The case of a 26 years old woman who presented with hydrocephalus from an Arnold-Chiari malformation is described. The first signs were a left trigeminal disorder and a left facial paresis as false localizing signs. Symptomatology was secondary to decompensation of the hydrocephalus, and was associated with aqueductal stenosis. Complete and rapid regression of the symptomatology after ventriculo-caval shunt was observed. Type 1 Arnold-Chiari malformation can manifest itself clinically in a number of ways. Cranial nerve abnormalities are uncommon, and may be false localizing signs. Unsuccessful investigations can delay the diagnosis and the treatment.     

Modern parathyroid surgery: a cost-benefit analysis of localizing strategies

HYPOTHESIS: Preoperative and intraoperative localizing techniques are more cost-effective than a nondirected bilateral neck exploration in the initial treatment of primary hyperparathyroidism (HPT). DESIGN: A clinical outcome model was developed to simulate the surgical management of primary HPT. Clinical scenarios modeled included a nondirected bilateral neck exploration and surgery using the following localizing strategies: preoperative technetium Tc 99m sestamibi scanning, intraoperative "quick" intact parathyroid hormone assay, or intraoperative radioguidance. Average total charges based on intent to treat were estimated from our practice and from the literature. MAIN OUTCOME MEASURES: Average total charges per patient (for the primary operation and for reexploration for persistent HPT, if needed), incidence of surgical failure (ie, persistent HPT), and risk of recurrent laryngeal nerve injury (cumulative risk of the primary procedure and a subsequent operation for persistent HPT). RESULTS: The use of any localizing strategy reduced total charges, risk of persistent HPT, and cumulative risk of recurrent laryngeal nerve injury compared with a nondirected bilateral neck exploration. The greatest cost savings and the lowest risk of recurrent laryngeal nerve injury were achieved when technetium Tc 99m sestamibi scanning was combined with intraoperative radioguidance. The lowest rate of persistent HPT was found when technetium Tc 99m sestamibi scanning was combined with an intraoperative parathyroid hormone assay. CONCLUSIONS: Limited parathyroid surgery using any localizing strategy is cost-effective, safe, and efficacious in the management of primary HPT. The cost benefit was primarily achieved by reduced operative charges and immediate hospital discharge rather than a lower need for reexploration for persistent HPT.     

New means of foreign body localization and extraction using the Sadowsky Breast Marking System

A thorough and concise review of the literature has revealed innumerous techniques available for localizing and retrieving foreign bodies within the foot. A new method of isolating and removing foreign bodies using the Sadowsky Breast Marking System (SBS) is presented. The SBS, in association with fluoroscopy, permits simple surgical implementation with accurate localization and extraction of foreign bodies, with the elimination of awkward, unpredictable, and time consuming retrieval techniques.     

Cavernosography using digital luminescence radiography (DLR) in the diagnosis of venous induced erectile function and of diseases of the corpus cavernosum

Dynamic cavernosography is the most important technique for identifying and localizing venous leakage in erectile dysfunction. The use of digital radiography with a greater degree of tolerance in the exposure, a more dynamic signal, and a shorter exposure time can enhance the diagnostic value of conventional cavernosography. A further advantage of the method is the lower dosage required, which means that the gonads are exposed to less radiation. For 30 patients with erectile dysfunction and 7 other cases, conventional cavernosography images were compared with those obtained by this new method. The advantages of digital radiography are discussed.     

Unilateral fixed dilation of the pupil as a false-localizing sign with intracranial hemorrhage: case report and literature review

OBJECTIVE AND IMPORTANCE: Although other focal signs may prove "false localizing," it is a neurosurgical axiom that unilateral fixed dilation of the pupil occurs ipsilateral to a supratentorial mass. CLINICAL PRESENTATION: A 25-year-old man collapsed with a dense right hemiplegia and a Glasgow Coma Scale score of 6 (eye opening, 1; motor, 4; verbal, 1) after rupture of a left middle cerebral artery aneurysm associated with an intrasylvian hematoma. Initially, both pupils had remained equal-sized and reactive: however, within hours, the right (contralateral) pupil became fixed and dilated (i.e., false localizing). For some time, the left (ipsilateral) pupil remained small and reactive; at emergency craniotomy, this also became fixed and equally dilated. INTERVENTION: After evacuation of the clot and wrapping of the aneurysm, both pupils rapidly became equal-sized and reactive. Twenty-four hours later, concurrent with massive left hemispheric swelling and a midline shift, the left (ipsilateral) pupil became unilaterally fixed and dilated (i.e., false localizing). Eventually, the right (contralateral) pupil also became fixed and dilated, concurrent with cardiovascular collapse. Death occurred within 10 hours. CONCLUSION: Unilateral fixed dilation of the pupil in patients with hemispheric mass lesions may be false localizing. Furthermore, disparate "herniating mechanisms" can arise despite mass effect emanating from the same side. Because such mechanisms cannot be witnessed, their nature remains speculative. An extensive review is contained in this article.     

Tumour-surgery within the central motor strip: Surgical results with the aid of electrical motor cortex stimulation

Summary Surgery of tumours within or close to the central motor area always carries the risk of a new or increased postoperative motor deficit. One reason may be the difficulty of localizing the sensorimotor region, when it is displaced or distorted by the tumour and the perifocal oedema. Recently anatomical data of the craniocerebral topography of the central sulcus^{6, 9, 15} became available. We safely used under general anaesthesia the intraoperative mapping of the motor cortex by direct cortical electrical stimulation. In 21 patients tumours adjacent to or within the motor area were microsurgically resected. As a result of intraoperative localization the surgical approach had to be modified in contrast to the preoperative localization of the lesion in 5 patients. No new or increased motor deficit occurred and in some cases the preoperative weakness was reduced remarkably.     

Ulnar neuropathy in the distal ulnar tunnel

A brief anatomical review of the ulnar nerve and areas of ulnar nerve entrapment is discussed. The importance of the dorsal cutaneous nerve is presented with regard to localizing a lesion to the ulnar nerve in the forearm. A classification system is described for ulnar entrapment that occurs distal to the wrist. The case of a nine-year-old girl with a fibrous entrapment of the ulnar nerve in the distal ulnar tunnel is presented. The clinical and diagnostic procedures required for localizing the level of the ulnar nerve entrapment are described, along with the operative findings of this case report. J Orthop Sports Phys Ther 1991;13(1):6-10.     

Radioimmunoscintigraphy of squamous carcinomas of the head and neck

A pilot study was carried out to assess the value of a radiolabeled antibody against epidermal growth factor receptor (EGFR1) in localizing tumors in patients with squamous carcinomas of the head and neck. Positive images of large tumours (greater than 3 cm diameter) were obtained in 8 of 11 patients after intravenous administration of 111indium-labeled EGFR1. Two patients gave equivocal results, while negative scans were obtained from the patient with the smallest tumor (1 cm diameter). There were no false-positive images. The success of this study in localizing relatively large squamous carcinomas indicates that the antibody should be evaluated in patients with smaller tumors to establish the limits of detection of the technique.     

Zollinger-Ellison syndrome (gastrinoma). Current diagnosis and treatment

Zollinger-Ellison syndrome is being detected at an earlier stage through liberal use of serum gastrin testing and application of secretin provocative tests if needed. The peptic ulcer disease of patients with Zollinger-Ellison syndrome can usually be controlled by large doses of one of the new potent gastric acid inhibitors. A battery of preoperative localizing tests can then be applied to guide exploratory laparotomy in non-MEN I patients. The tumor should be resected if possible, and continued low gastrin levels after operation provide evidence of a complete resection. It is reasonable to perform a parietal cell vagotomy at celiotomy because it will facilitate control of acid secretion if tumor resection is not successful. The only need for total gastrectomy is in a few patients whose acid secretion cannot be controlled with H2 receptor antagonists or who cannot comply with medical therapy. When no tumor is found at celiotomy, the prognosis for long-term tumor-free survival is excellent. Unfortunately, if unresectable hepatic metastases are present at operation, the patient is likely to die from metastatic tumor.     

Contralateral trigeminal nerve dysfunction as a false localizing sign in acoustic neuroma: a clinical and electrophysiological study

A 49-year-old woman presented with right facial sensory impairment due to trigeminal nerve dysfunction caused by a contralateral acoustic neuroma. The mechanism of the falsely localizing trigeminal involvement is probably displacement and distortion of the brain stem by the large mass lesion and not increased intracranial pressure. A preoperative orbicularis oculi reflex study was abnormal and indicative of right trigeminal nerve dysfunction; after surgical removal of the tumor, the orbicularis oculi reflex study was normal. We conclude that a false localizing sign of trigeminal nerve dysfunction can occur rarely on the contralateral side in patients with large posterior fossa tumors, especially tumors arising from the cerebellopontine angle, and should be considered in the differential diagnosis of hemifacial sensory disturbance.     

Radioguided tumorectomy in the management of parathyroid adenomas

HYPOTHESIS: A clearly localizing sestamibi scan predicts a successful minimally invasive radioguided parathyroidectomy that can be performed with a shorter operative time, low morbidity, and decreased duration of hospital stay. DESIGN: Review of prospectively gathered data and patient medical records. SETTING: Hospitalized care.Patients and METHODS: Parathyroidectomy was performed on 55 patients with a secure biochemical diagnosis of hyperparathyroidism and a sestamibi scan performed at the University of Connecticut Health Center. Of the 40 patients with a clearly positive sestamibi scan result, 31 underwent radioguided parathyroidectomy. The results of radioguided parathyroidectomy are compared with those of the standard bilateral exploration performed in the remaining 24 patients. MAIN OUTCOME MEASURES: Ionized calcium concentration, postoperative complications, and operative time. RESULTS: All patients were cured of hyperparathyroidism, and no patients experienced recurrent laryngeal nerve damage. Parathyroid adenomas were found at the predicted site in all 40 patients with a clearly localizing sestamibi scan. Of the 31 patients who underwent radioguided parathyroidectomy, a single parathyroid adenoma was identified in 30 patients, and a double adenoma was found in 1 patient. Conversion to a standard procedure was necessary in 1 patient with a large adenoma. The average operating room time was 128 minutes for the radioguided procedure and 224 minutes for the standard exploration. The average incision length for radioguided parathyroidectomy was 3.3 +/- 0.7 cm. CONCLUSIONS: A clearly localizing sestamibi scan predicts that 97% of patients can undergo a successful and safe minimally invasive radioguided parathyroidectomy that requires less operative time than the standard exploration.     

Surgery of the adrenal glands in Cushing's syndrome

Our surgical experience for the Cushing syndrome, reviewed in 23 patients. The accuracy of localizing adrenal lesions increased recently. The present study shows that, adrenal surgery, after accurate diagnosis and localisation, can be performed with low morbidity and mortality.     

Ultrasound facilitates minimally invasive parathyroidectomy in patients lacking definitive localization from preoperative sestamibi scan

BACKGROUND: Sestamibi scanning is commonly used for preoperative localization in patients with hyperparathyroidism. However, 12% to 15% of these studies are equivocal or negative. Ultrasound may also be used to identify patients suitable for a minimally invasive parathyroidectomy. METHODS: Data from patients treated for hyperparathyroidism between January 2000 and April 2006 were reviewed retrospectively. Sestamibi and ultrasound results were scored as definitive, suggestive, or negative. Patients with suggestive or negative sestamibi scans were included in the analysis. RESULTS: A total of 261 patients underwent operation without a definitively localizing sestamibi scan. Preoperative neck ultrasound was performed in 80 of these patients. Overall, ultrasound was either conclusive or suggestive in 45 of 80 patients (56%) without a definitively localizing sestamibi scan and correctly correlated with the surgical findings in 38 of 45 (84%) of these patients. CONCLUSION: In patients with nonlocalizing sestamibi scans, neck ultrasound increases the number of patients suitable for minimally invasive parathyroidectomy.     

The potential value of mammographically guided fine-needle aspiration biopsy of nonpalpable breast lesions

Nonpalpable breast lesions in 20 female patients were prospectively evaluated with a new technique of fine-needle aspiration biopsy (FNAB) under mammographic guidance. The patient age range was 37-82 years (mean: 60 years), and the mammographic indications for biopsy were microcalcifications (30%), mass (30%), mass with calcifications (25%), and asymmetric density (15%). Seven (35%) patients had significant risk factors for breast cancer. Prototype coaxial 19-gauge/22-gauge and 18-gauge/20-gauge needle systems (Cook, Inc., Bloomington, IN) were used for localization and biopsy. The technique involved needle localization of the target lesion with FNAB performed through the localizing needle after radiologic confirmation of position. A localizing wire then was inserted to allow each patient to proceed directly to the operating room for a standard needle localization open biopsy. Successful localization and aspiration was possible in 18 (90%) patients. Surgical excision was performed in all 20 patients and confirmed by specimen radiography in 17 (85%). A significant concordance of 94 per cent was found between the histologic results of the open biopsy specimens and the cytologic findings of aspirated specimens. These findings suggest that mammographically guided FNAB may offer a safe, reliable, and cost-effective alternative to open biopsy of nonpalpable breast lesions. Further study of this procedure is warranted to confirm its potential in this area.     

Limitations of Tc99m-MIBI-SPECT Imaging Scans in Persistent Primary Hyperparathyroidism

Background  

In primary hyperparathyroidism (PHPT) the predictive value of technetium 99m sestamibi single emission computed tomography (Tc99m-MIBI-SPECT) for localizing pathological parathyroid glands before a first parathyroidectomy (PTx) is 83–100%. Data are scarce in patients undergoing reoperative parathyroidectomy for persistent hyperparathyroidism. The aim of the present study was to determine the value of Tc99m-MIBI-SPECT in localizing residual hyperactive parathyroid tissue in patients with persistent primary hyperparathyroidism (PHPT) after initial excision of one or more pathological glands.