Incidence of hypoparathyroidism after radical surgery for thyroid carcinoma and autotransplantation of parathyroid glands

Ninety-seven consecutive patients had radical surgery for thyroid carcinoma. Eighty-six of these had one or more parathyroids implanted into muscle tissue. At follow-up, ninety-one patients were normocalcemic without substitution, fifteen of those with only implanted glands. The results show that radical surgery can be performed with a low incidence of hypoparathyroidism, provided the parathyroids are carefully searched for and liberally implanted.     

甲状腺外科手术中甲状旁腺识别技术研究进展

甲状腺癌是内分泌系统发病率最高的恶性肿瘤,全球发病率呈逐年上升趋势,手术全切是目前该疾病常用的治疗手段。甲状旁腺位于左右两叶甲状腺背面中部和下部（或埋在其中）,是调节人体钙、磷代谢的关键腺体,其功能减退会导致血钙浓度降低,手足抽搐等症状,严重时可导致死亡。由于甲状旁腺体积较小且分布位置因人而异,使得甲状腺外科手术中对甲状旁腺的定位识别和功能保护极具难度,极易造成甲状旁腺损伤,导致其功能减退,引起人体血钙浓度降低等术后并发症。因此,为降低甲状腺外科手术中甲状旁腺的损伤概率,避免术后并发症的出现,笔者对甲状旁腺术中定位识别的几种主流方法进行了综述分析,主要包括基于染色法的甲状旁腺术中定位识别技术、基于光学方法的甲状旁腺术中定位识别技术和基于甲状旁腺素监测的甲状旁腺术中定位识别技术等,分析对比了各项方法的技术特点及优势,详细介绍了各方法的适用场景及其技术局限,以期推进甲状腺外科手术中甲状旁腺识别技术进一步发展,为甲状旁腺的术中快速精准识别及功能保护奠定相关技术基础。     

The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients

BACKGROUND: Limited information exists about risk factors for postoperative hypoparathyroidism after bilateral thyroid surgery. METHODS: Between January 1 and December 31, 1998, bilateral thyroid surgery was performed on 5846 patients for benign and malignant thyroid disease. Data were prospectively collected by questionnaires from 45 hospitals. A logistic regression model was used to determine independent risk factors. RESULTS: The overall incidence of transient and permanent hypoparathyroidism was 7.3% and 1.5%, respectively. On logistic regression analysis, total thyroidectomy (odds ratio [OR], 4.7), female gender (OR, 1.9), Graves' disease (OR, 1.9), recurrent goiter (OR, 1.7), and bilateral central ligation of the inferior thyroid artery (OR, 1.7) constituted independent risk factors for transient hypoparathyroidism. When the multivariate analysis was confined to permanent hypoparathyroidism, total thyroidectomy (OR, 11.4), bilateral central (OR, 5.0) and peripheral (OR, 2.0) ligation of the inferior thyroid artery, identification and preservation of no or only a single parathyroid gland (OR, 4.1), and Graves' disease (OR, 2.4) emerged as independent risk factors. CONCLUSIONS: Extent of resection and surgical technique had a greater impact on the rates of permanent postoperative hypoparathyroidism than thyroid pathologic condition. In bilateral thyroid surgery, peripheral ligation of the inferior thyroid artery at the thyroid capsule should be favored over central ligation, and at least 2 parathyroid glands should be identified and preserved. High-risk procedures, such as total thyroidectomy and Graves' disease, require special surgical training and expertise.     

Routine autotransplantation of at least one parathyroid gland during total thyroidectomy may reduce permanent hypoparathyroidism to zero.

BACKGROUND: Permanent hypoparathyroidism, although a recognized complication of total thyroidectomy, is an outcome that all endocrine surgeons try to avoid. METHODS: To minimize the risk of postoperative hypoparathyroidism a strategy was developed of routine autotransplantation of at least one parathyroid gland into the ipsilateral sternomastoid muscle during every total thyroidectomy. One hundred consecutive patients undergoing total thyroidectomy were included in the study. Serum calcium and albumin levels were measured pre-operatively, on the first 2 postoperative days, and after 2 weeks, or until return to normal serum calcium levels without calcium supplementation. If patients developed biochemical evidence or symptoms of hypocalcaemia postoperatively, a calcium replacement was administered according to defined protocol. RESULTS: In 74 cases one parathyroid gland was autotransplanted: 44 for inadvertent removal or anatomical reasons, 19 because of devascularization (assessed by a cut through the gland's capsule and evaluation of the capillary bleeding pattern), and 11 by protocol. In 25 cases, two or more glands were autotransplanted. Fourteen patients developed symptoms of hypocalcaemia and received calcium supplementation, as did another 13 asymptomatic patients with only biochemical evidence of hypocalcaemia. At follow-up 3 months postoperatively the incidence of permanent hypoparathyroidism was zero, with all patients being normocalcaemic without calcium supplementation. CONCLUSIONS: This strategy, easily adopted by any experienced surgeon, has the potential to eliminate permanent hypoparathyroidism following total thyroidectomy.     

Hyperparathyroidism after thyroid surgery and autotransplantation of histologically normal parathyroid glands

BACKGROUND: Parathyroid autotransplantation is a well-established method to prevent hypoparathyroidism during parathyroid and thyroid operations. The reported success rate of parathyroid autotransplantation ranges from 75% to 100%. Recurrent hyperparathyroidism may develop after parathyroid autotransplantation, especially after the transplantation of hyperplastic or adenomatous parathyroid tissue. Hyperparathyroidism recurs most frequently after subtotal parathyroidectomy or total parathyroidectomy and autotransplantation, in patients with renal failure and secondary hyperparathyroidism, and in patients with familial primary hyperparathyroidism or MEN I or MEN II syndrome. We report three patients who experienced primary hyperparathyroidism after autotransplantation of normal parathyroid tissue during thyroid operations (two patients) or after a long period of hypoparathyroidism. STUDY DESIGN: We reviewed our records from 1983 to May 1998 and identified three patients in whom hyperparathyroidism developed after thyroid operations. RESULTS: One patient had a thyroidectomy with left modified radical neck dissection for papillary thyroid cancer, followed by radioiodine ablative therapy. Two patients had thyroid operations for benign thyroid disease. One of these patients had a history of radiation exposure for acne, and in the other one secondary hyperparathyroidism arose 6 years after a thyroidectomy for hyperthyroidism. CONCLUSIONS: Our study documents that hyperparathyroidism may develop after autotransplantation of histologically normal parathyroid tissue and after a period of hypoparathyroidism after thyroid operations. For this reason, it is important to mark the site of the parathyroid transplantation.     

Intraoperative parathyroid hormone levels in thyroid surgery are predictive of postoperative hypoparathyroidism and need for vitamin D supplementation

BACKGROUND: Intraoperative parathyroid hormone (ioPTH) levels are not monitored routinely in thyroid surgery, although they are used widely during parathyroidectomy as an indicator of parathyroid gland function. This prospective study evaluated the occurrence of hypoparathyroidism after thyroid surgery and the use of ioPTH levels to predict the need for postoperative vitamin D supplementation. METHODS: Seventy-two patients underwent thyroidectomy or neck dissection by 1 surgeon. Forty-five patients had a total thyroidectomy, 16 patients had a hemithyroidectomy, 9 patients had a completion thyroidectomy, and 2 patients had a neck dissection alone for recurrent thyroid cancer. ioPTH and serum calcium (SCa) levels were obtained during the course of surgery and 1 month after surgery. Levels from these time points were compared, and correlated with the need for vitamin D supplementation at the 1-month follow-up evaluation using the Fisher exact test. RESULTS: Of the 72 patients, 14 had an ioPTH level less than 10 pg/mL at closure. At the 1-month evaluation, 11 of these 14 patients required vitamin D supplementation because of persistent hypoparathyroidism or hypocalcemia (P <.001). The remaining 3 of the 14 patients with ioPTH levels less than 10 pg/mL at closure did not require vitamin D supplementation at the 1-month evaluation because they were asymptomatic and their PTH and SCa levels had normalized. None of the 58 patients with an ioPTH level greater than 10 pg/mL at closure needed vitamin D supplementation at the 1-month follow-up evaluation. CONCLUSIONS: An ioPTH level less than 10 pg/mL at closure is a strong predictor of hypoparathyroidism after thyroid surgery. Patients with ioPTH levels less than 10 pg/mL at closure should be placed on vitamin D supplementation after surgery to anticipate decreased parathyroid gland function and to avoid symptomatic hypocalcemia.     

甲状腺手术中甲状旁腺辨识方法进展

目的总结甲状腺手术中甲状旁腺辨识方法的最新进展,以期为提高临床疗效提供一定的参考。方法复习国内外有关甲状腺手术中甲状旁腺辨识方法的文献,并且作一综述。结果甲状腺手术中辨识甲状旁腺的方法良多,如肉眼识别法、术中快速病理检查、术中染色识别法、术中光学识别法、术中甲状旁腺激素监测、γ-探测仪、组织学鉴定等,每种方法均存在着自身的优点与不足。结论对甲状旁腺的辨识不可单纯依赖于某种方法,还需要外科医师增强自身辨别甲状旁腺的能力。     

甲状腺手术中甲状旁腺试纸鉴别甲状旁腺的应用

目的:研究免疫胶体金试纸法(PTH试纸法)与在注射纳米碳后依据医师经验判断法在甲状腺癌行甲状腺切除手术中快速鉴别甲状旁腺的诊断效能比较。方法:选取2020年3月—7月于首都医科大学附属友谊医院行甲状腺手术的90例患者参与试验研究,对获取的155例标本行经验判断、甲状旁腺试纸检测及病理检测。所有手术均由高年资专科医师操作...     

Autotransplantation of at least one parathyroid gland during thyroidectomy in benign thyroid disease minimizes the risk of permanent hypoparathyroidism

OBJECTIVE:Permanent hypoparathyroidism is a distressing complication of thyroid surgery. The reported incidence varies between 0.4 and 13.8 % and is directly correlated to the extent of thyroidectomy. The aim of this retrospective study was to analyze whether simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease could reduce the risk of permanent hypoparathyroidism. METHODS: Since 01/1999 all thyroid operations are prospectively recorded. Beside daily postoperative measurement of serum calcium level, iPTH is routinely determined on the third post op day. Patients with complications are followed closely. Postoperative hypoparathyroidism persisting for more than 6 months is defined permanent. RESULTS: Between 01/1999 and 02/2001 146 total thyroidectomies for benign thyroid disease have been performed (81 pat. with Graves disease, 62 with nodular goiter, 3 with thyroiditis de Quervain/Hashimoto). In 37 pat. (25 %) at least one parathyroid gland was simultaneously autotransplanted into the ipsilateral sternocleidomastoid muscle. Group I (no parathyroid autotransplantation, n = 109) and group II (parathyroid autotransplantation, n = 37) were comparable concerning patient age, thyroid disease and lowest post op calcium level (2.07 versus 2.05 mmol/l). The incidence of postoperative symptomatic hypocalcemia (14.7 % versus 21.6 %) and temporary hypoparathyroidism (15.6 % versus 18.9 %) was higher in group II patients (n. s.). Conversely, permanent hypoparathyroidism occurred exclusively in group I patients (2.75 %), patients with parathyroid autotransplantation (group II) did not develop this complication. CONCLUSIONS: Simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease seems to minimize the risk of permanent hypoparathyroidism. The potential of routine autotransplantation in this setting has to be evaluated. The incidence of postoperative temporary hypocalcemia may be elevated with this policy.     

甲状旁腺鉴定系统在甲状腺手术中快速鉴定甲状旁腺的临床价值

目的:探讨甲状旁腺鉴定(PGI)系统在甲状腺手术中快速鉴定甲状旁腺的临床价值。方法:收集2016年3月—2018年5月于江苏省原子医学研究所附属江原医院进行甲状腺手术的251例患者临床资料,所有患者术中用细针对可疑甲状旁腺组织进行穿刺,使用PGI系统通过检测穿刺组织液的甲状旁腺激素(PTH)浓度来鉴别是否为甲状旁腺,同时将穿刺的组织切少许送冷冻病理检查,以冷冻病理检测结果为对照标准,统计分析该鉴定系统鉴别甲状旁腺的准确性。结果:PGI系统共检测434份组织,其中无效检测16份,有效检测418份。在有效检测的组织中,PGI系统鉴定为甲状旁腺组织311份,非甲状旁腺组织组织107份;冷冻病理检查诊断为甲状旁腺组织314份,非甲状旁腺组织104份。两种检测方法有明显的一致性(к=0.969,P0.001)。使用PGI系统识别甲状旁腺的敏感度99.0%(309/312),特异度98.1%(104/106),阳性预测值99.4%(309/311),阴性预测值97.2%(104/107),误诊率1.9%(2/104),漏诊率1.0%(3/312),准确率98.8%(413/418)。所有患者术后均无出血或感染,均未出现永久性的甲状旁腺功能减退及喉返神经麻痹。结论:PGI系统可用于甲状腺手术中鉴别甲状旁腺组织,具有速度快、准确率高、操作简便、组织损伤小等特点。     

A multicenter evaluation of near-infrared autofluorescence imaging of parathyroid glands in thyroid and parathyroid surgery

BackgroundThe usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology.MethodsThis was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons.ResultsOverall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively.ConclusionThis survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.     

The hyperfunctioning intrathyroidal parathyroid gland: A potential pitfall in parathyroid surgery

The details of 7 patients with hyperparathyroidism in whom 8 intrathyroid hyperfunctioning parathyroid glands were located are presented. Seven of the 8 glands were inferior parathyroids and this observation is discussed in the light of current embryological teaching. The intrathyroidal hyperfunctioning parathyroid is considered to be a potential cause of failed parathyroid surgery and, therefore, when an inferior parathyroid gland is missing, it is recommended that the lower pole of the thyroid be incised and, if necessary, a thyroid lobectomy performed.

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Resumen La glándula paratiroides de ubicación anormal es una bien reconocida causa de fracaso en cirugía paratiroidea. Una de las anomalías más interesantes y provocadoras es la paratiroides hiperfuncionante intratiroidea. Se define la paratiroides intratiroidea como la glándula paratiroides, normal o anormal, que se encuentra totalmente ubicada en el interior de la tiroides y rodeada por parenquima tiroideo. Se presentan las características clínicas, quirúrgicas, y patológicas de 7 pacientes con hiperparatiroidismo, en quienes 8 glándulas paratiroides intratiroideas fueron halladas. Estos 7 casos representan 3.5% de 200 pacientes sometidos a exploración cervical por hiperparatiroidismo entre 1978 y 1984. Siete de las 8 glándulas fueron paratiroides inferiores, hallazgo que es discutido a la luz de conocimientos embriológicos actuales. La paratiroides hiperfuncionante intratiroidea no es una anomalía rara y es considerada como una potencial causa de fracaso en cirugía de paratiroides; por consiguiente, cuando en el curso de la exploración no se encuentre una de las paratiroides inferiores se debe incidir el polo inferior de la tiroides y, si necesario, realizar lobectomía.

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Résumé Une série de 7 malades hyperparathyroïdiens qui présentaient des glandes parathyroïdiennes hyperfonctionnelles situées au sein de la thyroïde est présentée par les auteurs. Dans 7 cas sur 8, elles répondaient aux glandes parathyroïdiennes inférieures et ce fait est discuté en fonction de nos connaissances actuelles de l'embryologie. La présence d'une glande parathyroïdienne hyperfonctionnelle au sein de la thyroïde doit être envisagée en cas d'échec de la chirurgie parathyroïdienne. En fait quand une glande parathyroïde inférieure n'est pas retrouvée en cours d'intervention les auteurs recommandent d'inciser le pôle inférieur de la thyroïde et de pratiquer, si nécessaire, une lobectomie thyroïdienne.

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Based on a communication to the British Association of Endocrine Surgeons, Newcastle, May, 1985.     

Penile prosthesis cultures during revision surgery: a multicenter study

PURPOSE: Initial implantation of inflatable penile prosthesis has a 3% risk of infection. Reoperation of penile implants has a higher rate of infection, estimated between 10% and 18%. To explain the higher risk in revision surgery in this prospective study we cultured clinically uninfected prostheses requiring revision. Prosthesis pain was also investigated as a predictor of positive culture. MATERIALS AND METHODS: At 3 institutions cultures were prospectively obtained from 77 clinically uninfected penile prostheses at revision surgery. Immediately upon surgical exposure of the pump cultures were obtained. If a bacterial biofilm was noted on any component it was additionally cultured. All culture isolates positive for a staphylococcus species were tested for sensitivity to rifampin and tetracycline (minocycline). An implant is now available that is coated with these antibiotics. Patient history of chronic prosthesis pain was ascertained. RESULTS: Culture positive bacteria were found in 54 of 77 (70%) patients with clinically uninfected penile prostheses. In some patients more than 1 organism grew and, occasionally, the pump culture was negative but the biofilm was positive. Of 54 patients 49 had positive (90%) culture for staphylococcus genus with 10 different species. All staphylococcal species were sensitive to rifampin and/or tetracycline. We did not find a significant association between prosthesis related pain and culture laboratory results. CONCLUSIONS: The majority of clinically uninfected penile prostheses have organisms growing in the implant spaces at reoperation. Most of these organisms are staphylococcal species that are sensitive to rifampin/minocycline.     

Autotransplantation of parathyroid glands in thyroid carcinoma surgery and their postoperative function

Total removal and subsequent autotransplantation of parathyroid glands were carried out in operations for thyroid carcinoma in 25 cases. For the purpose of fine dissection of paratracheal lymph nodes, before thyroidectomy more than 2 parathyroid glands were found and transplanted into greater pectoralis muscle. The patients who underwent surgery were studied for more than one year following operation to determine the short term and long term outcomes of the procedure. None of the patients received prophylactic calcium supplement therapy except for hypocalcemic symptoms. In thirteen patients, the parathyroid function was almost completely restored within 3 weeks without any postoperative substitution therapy, with an obvious surge in the plasma PTH level on 5P.O.D. The serum Ca level started to elevate on 7P.O.D. and recovered to 97.4% of the preoperative value 3 weeks after transplantation. As for the 12 patients who exhibited hypocalcemic symptoms, Ca lactate and hydroxycholecalciferol were administered for only 24.7 and 17.0 days, respectively. Serum levels of Ca and P, as well as the index of bone mineral content, were all within the extremely excellent range even one year after operation. None of the patients was on a substitution regimen. These results suggest that autotransplantation is a valuable alternative for the preservation of the parathyroid function in operations for thyroid carcinoma.