Parathyroid autotransplantation during thyroidectomy

Permanent hypoparathyroidism is a debilitating morbidity following thyroidectomy, with a reported incidence of up to 43%. Apart from meticulous dissection to preserve parathyroid glands and their blood supply, parathyroid autotransplantation (PA) has been increasingly employed to preserve parathyroid function. The adoption of PA during thyroidectomy has been reported to be associated with a low incidence of permanent hypoparathyroidism. Biochemical function of parathyroid autografts can be demonstrated objectively by forearm reimplantation or during long-term follow up. The clearest indication for PA is for inadvertently removed or devascularized parathyroid glands during thyroid surgery. Other strategies, including routine autotransplantation of at least one parathyroid gland, can be considered, but is associated with a high incidence of transient hypocalcaemia. Apart from refinement in technique to facilitate graft success, a reliable way to assess overall parathyroid function or viability of individual parathyroid gland may assist in monitoring parathyroid function and selecting patients requiring this procedure to prevent permanent hypoparathyroidism.     

甲状腺全切术中甲状旁腺自体移植的现状和思考

甲状旁腺功能减退是甲状腺术后最常见的并发症之一,不仅增加患者的住院时间、费用,而且导致患者术后生活质量下降.外科医生及患者希望尽可能避免永久性甲状旁腺功能减退的发生,因此甲状旁腺自体移植作为一种简单、易行的防治策略,在甲状腺手术中广泛应用.但是移植旁腺功能的有效性尚未明确,术中甲状旁腺是否移植?还存在争议.通过文献复习...     

Parathyroid autotransplantation in patients with parathyroid disease and total thyroidectomy: Indications in 117 cases

Parathyroid autotransplantation is a known and increasingly utilized procedure. It is indicated in patients with primary parathyroid hyperplasia, in patients with primary hypercalcemia who have normal parathyroid tissue devascularized during surgery, in patients with secondary and tertiary parathyroid hyperplasia, and in patients with total thyroidectomy when normal parathyroid tissue is accidentally or unavoidably removed or completely devascularized. No normal viable parathyroid tissue should be autotransplanted.This procedure was performed in 13 dialysis patients, 27 primary hypercalcemic patients and 77 patients with thyroidectomy. The hypercalcemic patients had autotransplantations into muscle pockets in the volar surface of the forearm, while the thyroidectomy patients had autotransplantation into the sternocleidomastoid muscles. The application of parathyroid autotransplantation is a major technical and physiologic breakthrough in the field of thyroid and parathyroid surgery. It should greatly reduce the morbidity associated with permanent hypocalcemia in this type of extensive surgery.     

Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up.

SUMMARY BACKGROUND DATA: Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy. METHODS: An analysis of 194 patients having thyroidectomy and simultaneous parathyroid autotransplantation at Barnes Hospital from 1990 to 1994 was performed. Data were collected regarding patient demographics, indication for thyroidectomy, operative procedure, pathologic diagnoses, and postoperative course, including biochemical assessment of parathyroid autograft function. RESULTS: Of 194 patients having either total, subtotal, or completion thyroidectomy, 104 (54%) experienced a [Ca(+2)]nadir less than or equal to 8.0 mg/dL and had symptoms and signs of hypocalcemia. Parathyroid autotransplantation was successful in 103 (99%) of these 104 cases and resulted in a 1.0% incidence of hypoparathyroidism in this series. CONCLUSIONS: Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.     

Parathyroid autotransplantation with total thyroidectomy for thyroid carcinoma: long-term follow-up of grafted parathyroid function.

BACKGROUND: Permanent hypoparathyroidism is a major complication of thyroidectomy. Autotransplantation of parathyroid glands has been attempted to prevent this complication. However, no direct data have been available to assess grafted parathyroid function after long-term follow-up in terms of the serum intact parathyroid hormone (PTH) concentration. METHODS: Eighty-four consecutive patients with differentiated thyroid carcinoma who underwent total thyroidectomy and bilateral modified neck dissection from 1992 to 1996 were enrolled. They concomitantly underwent total parathyroidectomy and autotransplantation of all parathyroid glands to the pectoralis major muscle. The serum intact PTH concentration was periodically measured as an index of grafted parathyroid function. RESULTS: The mean follow-up was 34 months. In all autotransplanted patients serum intact PTH concentrations fell below detectable limits immediately after surgery. They were restored to the normal range within 1 month postoperatively and were maintained during observation in 80 (95%) of 84 patients. Seventy-eight of 80 patients with normal intact PTH values were normocalcemic without any treatment and the remainder were normocalcemic with 1 microgram of 1 alpha-vitamin D3. Four hypoparathyroid patients were normocalcemic with 2 micrograms of 1 alpha-vitamin D3. The postoperative average serum intact PTH concentration of patients having more than 2 autotransplanted parathyroid glands was almost equal to that of patients with preservation of the parathyroid glands in situ. The incidence of permanent hypoparathyroidism was inversely correlated with the number of autotransplanted parathyroid glands. CONCLUSIONS: The recovery patterns of the intact PTH concentration indicate that the glands were grafted successfully and functioned for a long period. This feasible method of parathyroid autotransplantation bears comparison with the previous reports in terms of the incidence of permanent postoperative hypoparathyroidism, and it can be performed simply and is reproducible.     

Parathyroid autotransplantation during thyroidectomy: documentation of graft function.

HYPOTHESIS: Biochemical function of normal parathyroid tissue grafted during thyroidectomy can be documented. DESIGN: An intervention study in which devascularized or inadvertently removed parathyroid glands are reimplanted in forearm muscle pockets during thyroidectomy. Postoperative serum parathyroid hormone levels were evaluated by venous sampling from both forearms on postoperative days 1, 3, 14, 28, 56, and 84. SETTING: Tertiary care teaching hospital. PATIENTS: Seven patients undergoing thyroidectomy at risk for postoperative hypocalcemia. RESULTS: A 1.5-fold gradient of parathyroid hormone measurements between grafted and nongrafted arms was demonstrated in all patients on postoperative day 28. A maximal parathyroid hormone gradient was reached on day 56, and biochemical function persisted in 6 patients on day 84. CONCLUSIONS: Biochemical function of parathyroid glands reimplanted during thyroidectomy can be demonstrated objectively. The application of parathyroid autotransplantation may preserve parathyroid function for inadvertently removed or devascularized parathyroid glands during thyroid surgery.     

Parathyroid autotransplantation

7 patients with diffuse parathyroid hyperplasia underwent total parathyroidectomy and microsurgical autotransplantation for diffuse parathyroid hyperplasia. 5 of 7 patients showed good function of the grafted parathyroid tissue, as checked by the separate PTH assay from the grafted versus not grafted forearm. In 1 patient parathyroid stimulation test with EDTA infusion and suppression test with calcium infusion were also performed.     

Parathyroid autotransplantation

This paper reviews the technique, indications and results of parathyroid autotransplantation. Autotransplantation is most commonly indicated following parathyroidectomy for renal osteodystrophy, but can also be used in primary hyperplastic hyperparathyroidism, re-exploration of the neck and radical neck surgery. The success of the technique ranges from 75 to 100 per cent.     

Parathyroid hormone assay predicts hypocalcaemia after total thyroidectomy

BACKGROUND: Postoperative parathyroid gland function after total thyroidectomy (TT) has traditionally been monitored by the measurement of serum calcium concentrations. The purpose of this study is to determine whether measurement of parathyroid hormone (PTH) concentrations in the early postoperative period accurately predicts patients at risk of developing hypocalcaemia. METHODS: A prospective cohort study of patients undergoing TT was carried out. PTH concentrations were measured preoperatively and at 4 and 23 h postoperatively. Serum calcium concentration was measured preoperatively and twice daily for 48 h after surgery. RESULTS: One hundred patients undergoing TT were recruited into the study in the period June 2004 to July 2005. Benign multinodular goitre was the most common indication for surgery (77%). The incidence of temporary hypocalcaemia (Ca < 2.0 mmol/L) was 18%. The mean PTH concentration at 4 h after surgery was 22.3 ng/L and was not significantly different from the 23-h concentration of 23.2 ng/L (P = 0.18). A PTH concentration of < or = 3 ng/L measured at 4 h after surgery had a sensitivity, specificity and likelihood ratio of 0.71, 0.94 and 11.3, respectively, for predicting postoperative hypocalcaemia. The accuracy of a single PTH concentration at 4 h was good for predicting hypocalcaemia (area under receiver-operator characteristic curve 0.90; confidence interval 0.81-0.96). There was no significant difference in accuracy between the 4- and 24-h PTH concentrations (P = 0.14). CONCLUSIONS: A single measurement of PTH concentration in the early postoperative period after TT reliably predicts patients who are likely to develop hypocalcaemia. This approach facilitates early discharge and may decrease the need for multiple postoperative blood tests.     

Parathyroid gland transplantation after total thyroidectomy with pharyngolaryngoesophagectomy

Surgical treatment of extensive hypopharyngeal carcinoma often includes total thyroidectomy together with resection of the primary disease. The risk of removing or damaging the parathyroid glands is considerable; this may render the patient permanently hypoparathyroid with all the problems of management. These patients must be on lifelong supplementation and at times, due to failure to take the medication, hypocalcemic crises are precipitated. To avoid this problem, we have been identifying the parathyroid glands intraoperatively and, after pathological confirmation, have transplanted them to the forearm. Three patients who underwent this procedure are presented. All are normocalcemic without supplementation and parathyroid hormone assays on serum from the transplanted forearm show significantly elevated levels.     

Parathyroid autotransplantation.

Although rare following initial cervical exploration, reoperative parathyroid surgery may cause permanent hypoparathyroidism in 15% to 30% of patients. Immediate fresh or delayed cryopreserved parathyroid autotransplantation is the principal surgical option to resolve this complication. Between 1980 and 1990, 18 and 12 patients underwent immediate and cryopreserved autotransplantation, respectively. With a mean follow-up of nearly 5 years, 61% of the immediate and 42% of the cryopreserved tissue showed evidence of function. However, only 10 (55%) and two (17%) of the respective patients had completely discontinued treatment with calcium supplementation. Graft-dependent hypercalcemia can occur with either technique. We conclude that until cryopreserved tissue can be transplanted with more reliable success and if the excised abnormal parathyroid likely represents the only remaining gland, we would advise immediate autotransplantation. In the reoperative setting, unless a residual normal parathyroid gland is confirmed, a portion of the excised parathyroid tissue should be cryopreserved for possible autotransplantation in case hypoparathyroidism develops subsequently.     

Parathyroid hormone: A sensitive predictor of hypocalcemia following total thyroidectomy

OBJECTIVE: To investigate whether monitoring parathyroid hormone (PTH) could predict hypocalcemia following total thyroidectomy or other bilateral thyroid manipulations. STUDY DESIGN AND SETTING: Forty patients undergoing total thyroidectomy as well as other bilateral thyroid procedures were prospectively enrolled. PTH levels were measured preoperatively and 30 minutes postoperatively. Calcium levels were measured preoperatively and every 8-12 hours for the first 72 postoperative hours. Changes in PTH levels as well as symptoms of hypocalcemia were correlated with postoperative hypocalcemia. RESULTS: Hypocalcemia developed in 13/40 patients (32.5%), mainly those patients undergoing total thyroidectomy in conjunction with paratracheal neck dissections. The respective sensitivity and specificity of a drop in PTH for detecting hypocalcemia was 92% and 66% (50% drop), 23% and 75% (75% drop), and 46% and 100% (drop below normal range). CONCLUSIONS: A 50% drop in PTH levels 30 minutes following bilateral thyroid procedures is a sensitive predictor of hypocalcemia. A drop of 75% is a highly specific indicator of postoperative hypocalcemia, though not highly sensitive. EBM RATING: C-4.     

Assessment of parathyroid autotransplantation for preservation of parathyroid function after total thyroidectomy

BACKGROUND: Hypoparathyroidism with permanent hypocalcemia is a well-recognized complication after thyroid surgery. AIM: This study was conducted to assess the role of immediate parathyroid autotransplantation in the preservation of parathyroid function after total thyroidectomy. PATIENTS AND METHODS: Twenty-eight patients had autotransplantation of parathyroid glands resected or devascularized during total thyroidectomy. Data were collected prospectively regarding demographics, indication for surgery, operative procedure, pathologic diagnosis, number of glands transplanted, and subsequent course. Thyroid nodules were evaluated by ultrasonography, radionuclide scanning, and/or fine-needle aspiration cytology. All patients had serum ionized calcium, phosphorus, and intact parathyroid hormone (PTH) levels measured preoperatively and monitored regularly postoperatively for a period of 14 weeks and again at 6 months after operation. Patients were categorized into three groups according to the number of glands transplanted: one (group 1, n = 6), two (group 2, n = 14), or three glands (group 3, n = 8). In three other volunteers, one parathyroid gland was transplanted in the brachioradialis and subjected to electron microscopy 1, 2, and 4 weeks after transplantation. RESULTS: Total thyroidectomy was performed for malignant disease in 16 patients (57.1%) and for benign disease in 12 (42.9%) patients. All patients reverted to asymptomatic normocalcemia without the need for any medications within 4 to 14 weeks. Normal levels of serum markers were regained slower when one gland was transplanted compared with two or three glands (P <.01). Electron microscopic examination showed evidence of ischemic degeneration in the transplanted tissues 1 week postoperatively. Regeneration started by the second week and coincided with normalization of PTH levels. Optimum resting and nearly normal status of parathyroid tissue was achieved by the fourth week. CONCLUSIONS: This study showed that active PTH production coincides with regeneration of parathyroid cells and that autotransplantation of at least two resected or devascularized glands during total thyroidectomy nearly eliminates permanent postoperative hypoparathyroidism, thus improving the safety of total thyroidectomy performed for malignant or benign disease.     

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.     

Routine parathyroid autotransplantation during thyroidectomy

BACKGROUND: Parathyroid autotransplantation (PTHAT) during thyroidectomy has been shown to reduce the incidence of permanent hypoparathyroidism. Although selective PTHAT is most commonly adopted, the value of routine PTHAT has not been well documented. METHODS: From January, 1998 to March, 1999, an operative strategy incorporating routine autotransplantation of at least 1 parathyroid gland was used during thyroidectomy. The postoperative outcome of patients (n = 118) was evaluated and compared with patients (n = 271) operated during a policy of selective PTHAT (January, 1995 to October, 1997). RESULTS: Two or more parathyroid glands were autotransplanted in 26 patients (22%) while 92 patients (78%) received autotransplantation of 1 parathyroid gland. Postoperative hypocalcemia occurred in 29 patients (25%) and 2 patients (1.7%) had permanent hypocalcemia develop. When a policy of selective PTHAT was adopted, 98 patients (36%) underwent PTHAT, and 5 patients developed permanent hypocalcemia (1.8%). The incidence of postoperative hypocalcemia was higher in patients who underwent routine PTHAT (25%) compared with that in patients who underwent selective PTHAT (15%) (P =.014). In addition, the operating time was significantly longer when routine PTHAT was adopted (153 minutes vs 130 minutes; P <.001). CONCLUSIONS: A low incidence of permanent hypoparathyroidism can be achieved by either routine or selective PTHAT during thyroidectomy but routine PTHAT is associated with a high incidence of postoperative hypocalcemia.     

LigaSure in total thyroidectomy

PURPOSE: LigaSure is a bipolar diathermy system, which achieves vessel sealing with reduced thermal spread. The device has been used successfully in abdominal operations and because of its features, it has been applied recently in thyroid surgery to minimize the risk of complications such as laryngeal nerve palsy and hypocalcemia, and also to reduce the operating time. METHODS: Between June and December 2005, we performed total thyroidectomy for various disorders in 105 patients. We used the LigaSure diathermy system in 53 patients and traditional hemostatic procedures in the other 52. We evaluated the demographic features, histopathological diagnosis, operating times, and relevant postoperative complications. RESULTS: The two study groups had similar demographic and histopathological features. The mean operating time +/- SD was not significantly shorter in the LigaSure group than in the traditional group (104 +/- 12.7 vs 110 +/- 15.6 min). None of the patients in either group suffered hemorrhage, definitive hypocalcemia, or definitive laryngeal nerve palsy. Transient hypocalcemia and transient laryngeal nerve palsy developed in 7.54% and in 1.88%, respectively, of the patients in the LigaSure group, and in 7.69% and 1.92%, respectively, of the patients in the traditional group; these differences were not significant. CONCLUSIONS: LigaSure is a safe and effective method of hemostasis control, but it did not reduce the incidence of complications or operating times compared with traditional hemostatic procedures; moreover, the operative costs were higher.     

Nearly total thyroidectomy: versus total thyroidectomy: our experience

AIM: Generally, the classification of thyroidectomy as benign pathology is: multinodular toxic goitre, simple goitre, toxic adenoma, Base-dow disease, Hashimoto's tyroiditis Subtotal thyroidectomy provides for the removal of the gland except for a bilateral residue of about 6-10 g, near total thyroidectomy provides for the near total removal of the gland except for a residue inferior to 5 grams. Near total thyroidectomy has taken the place of the subtotal thyroidectomy. METHODS: In two years, in our institute, there have been exeuted: 96 near total thyrodectomies, 96 total thyroidetomies, 8 lobectomies ad two revues for recurrencies. RESULTS: In 2 cases there have been haemorrhagies after nearly total thyroidetomy. Only in 1 case we practiced tracheotomy for follicular carcinoma infiltering thiroidic cartilage. In 2 cases treated with nearly total thyroidetomy and in 4 cases treated with total thyroidetomy, there has been temporary hypoparathyroidism. In no case treared wih nearly total thyroidetomy and in 2 cases treated with total thyroidetomy, there has been permanent hypo-parathyroidism. In 5 cases treated with total thyroidetomy and in no case treated with nearly total thyroidetomy, there has been, monolateral, temporary paralysis of the inferior laryngeal nerve that solved in 6 months for 3 patients and in 2 months for 2 patients. CONCLUSIONS: There has not been permanent paralysis of the mono or bilateral inferior laryngeal nerve. Even if the surgical approach to the benign disease is now orientated to the total thyroidectomy, a more conservative surgery is, in our opinion, justified when a malignant pathology is excluded and considering also the low effect of recurrencies and hypothyroidism.