The impact of surgeon-based ultrasonography for parathyroid disease on a British endocrine surgical practice

INTRODUCTION

Surgeon-based ultrasonography (SUS) for parathyroid disease has not been widely adopted by British endocrine surgeons despite reports worldwide of accuracy in parathyroid localisation equivalent or superior to radiology-based ultrasonography (RUS). The aim of this study was to determine whether SUS might benefit parathyroid surgical practice in a British endocrine unit.

METHODS

Following an audit to establish the accuracy of RUS and technetium sestamibi (MIBI) in 54 patients, the accuracy of parathyroid localisation by SUS and RUS was compared prospectively with operative findings in 65 patients undergoing surgery for primary hyperparathyroidism (pHPT).

RESULTS

The sensitivity of RUS (40%) was below and MIBI (57%) was within the range of published results in the audit phase. The sensitivity (64%), negative predictive value (86%) and accuracy (86%) of SUS were significantly greater than RUS (37%, 77% and 78% respectively). SUS significantly increased the concordance of parathyroid localisation with MIBI (58% versus 32% with RUS).

CONCLUSIONS

SUS improves parathyroid localisation in a British endocrine surgical practice. It is a useful adjunct to parathyroid practice, particularly in centres without a dedicated parathyroid radiologist, and enables more patients with pHPT to benefit from minimally invasive surgery.     

术中甲状旁腺素监测在腔镜辅助甲状旁腺切除术中的应用

目的:探讨术中甲状旁腺素监测在腔镜辅助甲状旁腺切除术中的作用及效果。方法:回顾分析2006年10月至2012年12月有完整资料的10例腔镜辅助甲状旁腺切除患者的临床资料,其中男3例,女7例。患者术前血钙2.76～3.82 mmol/L,平均(2.87±0.69)mmol/L。术前甲状旁腺激素(parathyroid hormone,PTH)268.0～1390.8 pg/ml,平均(627.58±156.30)pg/ml。患者均通过B超、核素99mTc-MIBI(99锝m-甲氧基异丁基异腈)和/或CT定位。结果:10例均成功完成手术,无一例中转开放及再次探查手术。术中出血量平均(7.5±3.5)ml,手术时间平均(38.3±12.6)min。腺瘤切除后5 min,PTH平均(306.3±59.38)pg/ml;腺瘤切除后20 min,PTH平均(51.7±13.20)pg/ml,多降至正常。术后石蜡病理证实为甲状旁腺腺瘤,术后均无声嘶、呛咳、出血发生,2例发生短暂性低钙血症,术后随访9例患者2～73个月,美容效果满意,未见复发。结论:临床上内镜辅助甲状旁腺手术安全、可行,术后患者康复快,颈部美容效果好,术中结合甲状旁腺监测可有效保证手术的彻底性,避免盲目探查。     

Parathyroid Hormone as a Marker for Predicting the Severity of Hypocalcaemia Following Parathyroidectomy

The purpose of this study is to determine preoperative predictors of the severity of the hypocalcaemia following parathyroidectomy. The case records of 70 patients who underwent parathyroidectomy for primary hyperparathyroidism from 2000 to 2013 was retrospectively studied. Their symptoms at presentation, biochemical parameters serum calcium, parathyroid hormone, alkaline phosphatase and parathyroid size on ultrasound were compared with their serial post-operative serum calcium levels at 24, 48, 72 and 96 h. For the purpose of analysis, patients were divided into three groups. Group 1—asymptomatic, biochemically normal (serum calcium always ≥8.5 mgs%); Group 2—asymptomatic, biochemically below normal (at least one reading <8.5, but none <8.0); Group 3—symptomatic (any one reading <8.0). No correlation was found between the severity of the presenting symptoms, pre-operative serum calcium levels or the parathyroid size with the post-operative calcium levels in the three groups. Though preoperative serum alkaline phosphatase levels were higher in Group 3, it was not statistically significant (p = 0.069). However, preoperative serum parathyroid hormone levels significantly correlated with postoperative serum calcium levels in all three groups (p = 0.006). Pre-operative serum parathyroid hormone levels may serve as a marker for severe post-operative hypocalcaemia and thus identify patients requiring closer monitoring and longer hospitalization following parathyroidectomy.     

Parathyroid adenoma in third pharyngeal pouch cyst as a rare case of primary hyperparathyroidism

The primitive thymus and inferior parathyroid derive from the third branchial cleft. During embryonic development, these structures descend, reaching their final localisation. Third branchial cleft anomalies present usually as a fistula, abscess or cyst. However, there are no reports on parathyroid adenomas in the literature other than as a morphological possibility.We describe the case of a 47-year-old man, who had been diagnosed with arterial hypertension and who presented with a cervical mass at the edge of the lower third of the sternocleidomastoid muscle. On ultrasonography, the mass had a cystic walled appearance. Laboratory analysis only revealed an intact parathyroid hormone level of 140.5pg/ml. Sestamibi imaging showed a probable parathyroid adenoma in the anterior mediastinum. During surgery, a tract running from beyond the superior thyroid pedicle to the superior mediastinum was dissected and removed. In the inferior end of the tract, a brown mass was visible. Pathological examination revealed a thymus cyst surrounding a parathyroid adenoma. The primal alteration was the lack of division between the thymus and inferior parathyroid gland, and the prompt prevention of their development. In the case of our patient, a parathyroid adenoma had grown by chance.     

The value and role of low dose methylene blue in the surgical management of hyperparathyroidism

Introduction

Methylene blue (MB) has been used in the identification of abnormal parathyroid glands in surgery for hyperparathyroidism. Its efficacy and safety profile have been questioned recently and this study sought to demonstrate such aspects in a unit where its use is routine.

Methods

Prospective data collected over six years in a single surgeon’s practice were interrogated to identify factors affecting MB staining, side effects suffered and unusual cases where the dye was invaluable in locating the diseased gland.

Results

A total of 98 patients underwent MB infusion. Of these, 77 cases (78.6%) stained positively with MB and 21 (21.4%) did not. Six patients suffered side effects but there were no cases of neurotoxicity. No positive predictive factors of dye uptake were found. MB was particularly useful in cases of intrathyroidal and ectopic glands as well as improving efficiency in both targeted and open parathyroidectomy.

Conclusions

This series shows that when used correctly, MB is efficacious in locating diseased parathyroid glands, with similar sensitivity rates to preoperative ultrasonography and radionucleotide imaging. Adverse effects were much lower than published previously, which may be attributed to the low dose of MB used (3.5mg/kg).     

Normocalcemic hyperparathyroidism: preoperatively a disease,postoperatively cured?

Background

Up to 44% of primary hyperparathyroidism patients have elevated parathyroid hormone (ePTH) with normal calcium postparathyroidectomy (PTx). The question is whether the surgical approach affects the incidence of this phenomenon.

Methods

Patients with hyperparathyroidism and presumed single-gland disease on preoperative imaging who underwent PTx between 1994 and 2008 were identified and contacted for long-term follow-up. PTx was either a focused approach (minimally invasive approach [MIP]) or a bilateral neck exploration (BNE).

Results

In total, 171 patients had PTH measured postoperatively (95 MIP and 76 BNE); 30 of 171 (17%) had ePTH with normal calcium (MIP 21 [22%] and BNE 9 [12%], P = .08). This occurred within 2 years in 48% and 67% and after 2 years in 52% and 33%, MIP vs BNE, respectively. Four patients recurred, 2 MIP and 2 BNE.

Conclusions

There is a trend toward a higher incidence of ePTH in patients having undergone an MIP. The etiology of ePTH is multifactorial but may represent an early recurrence.     

99mTc-甲氧基异丁基异腈引导甲状旁腺切除术对继发性甲状旁腺功能亢进的疗效分析△

目的 比较甲状旁腺切除术与锝99标记的甲氧基异丁基异腈(^99mTc-MIBI)引导甲状旁腺切除术治疗继发性甲状旁腺功能亢进对生化及骨密度指标的影响。方法 分析127例行甲状旁腺全切除合并前臂移植术的继发性甲状旁腺功能亢进患者,其中60例对照组行传统甲状旁腺全切除联合前臂移植术,67例实验组在^99mTc-MIBI引导下行甲状旁腺切除联合前臂移植术。比较2组患者术前、术后甲状旁腺激素、血钙、血磷、碱性磷酸酶等生化指标及骨密度指标的变化。结果 对照组有10例患者复发,实验组有2例患者复发。2组患者术后生化及骨密度指标均有明显改善(P值均<0.05)。实验组术后生化指标明显低于对照组(P值均<0.05),实验组腰4节段T评分改善程度明显高于对照组(P=0.029)。结论 与传统手术相比,^99mTc-MIBI引导甲状旁腺切除术能更大程度地降低甲状旁腺激素水平,改善血钙、血磷代谢,提高腰4节段的T评分,且复发率更低。     

甲状旁腺切除对尿毒症继发性甲状旁腺功能亢进症患者生存质量的影响

目的 观察甲状旁腺切除对尿毒症继发性甲状旁腺功能亢进症（secondary hyperparathyroidism,SHPT）患者生存质量的影响.方法 选取30例尿毒症继发性甲状旁腺功能亢进患者,手术切除甲状旁腺,于手术前及手术1年后测定血钙、血磷、全段甲状旁腺激素（iPTH）水平,计算钙磷乘积,采用肾脏病生存质量KDQOL-SFTM量表评价生存质量. 结果 与手术前比较,甲状旁腺切除1年后患者血iPTH、血磷、钙磷乘积、血钙水平均明显下降（t=-9.563、-5.994、-7.197、-4.928,均P=0.000）;SF-36总分（61.3±19.比51.2±24.5,t=2.456,P=0.021）、躯体健康（PF,56.5±27.0比51.8±32.1,P＜0.05）、躯体角色功能（RP,48.2±41.9比28.5±40.1,P＜0.05）、躯体疼痛（BP,66.1±26.7比53.6±27.9,P＜0.05）、总体健康（GH,50.4±22.1比40.6±23.6,P＜0.05）评分均明显提高;肾病相关生存质量总体健康评估（OHR,73.8±11.1比65.8±15.2,t=2.699,P=0.012）、症状与不适（SP,85.8±10.5比73.8±11.1,P＜0.05）、肾病对生活的影响（EKD,77.1±16.6比65.3±20.7,P＜0.01）、睡眠（Sleep,75.1±23.0比58.9±24.5,P＜0.01）评分均明显增加.结论 甲状旁腺切除能有效改善尿毒症严重继发性甲状旁腺功能亢进患者的生活质量.     

甲状旁腺切除对血液透析患者心血管钙化影响的初步探讨

目的观 察甲状旁腺切除术（PTX）对伴有继发性甲状旁腺功能亢进症（Secondary Hyperparathyroidism,SHPT）的血液透析患者钙磷代谢以及动脉钙化、动脉僵硬度情况的影响.方法 选取21例有继发性甲状旁腺功能亢进的血液透析患者,行甲状旁腺切除术,对患者术前、术后1年应用多层螺旋CT检测冠状动脉钙化积分,并测臂踝脉搏波传导速度（baPWV）,同时将患者术前、术后1年的血钙、血磷、钙磷乘积、PTH等指标进行比较.结果 与术前比较,术后1年患者冠状动脉钙化积分有明显减低（P=0.0236）,左右两侧肢体臂踝脉搏波传导速度（baPWV）平均值减少（=0.0034,P=0.0012）,差异性有统计学意义;术后血钙、血磷、钙磷乘积、PTH水平均明显降低,差异性有统计学意义（P分别为0.0004,0.0002,0.0000,0.0000）.结论 甲状旁腺切除术（pTx）能纠正钙磷代谢紊乱,减轻动脉钙化程度,改善动脉僵硬度.     

70例尿毒症继发性甲状旁腺亢进症行甲状旁腺全切术的疗效分析

目的 探讨甲状旁腺全切术（T-PTX）治疗尿毒症继发性甲状旁腺亢进（SHPT）的疗效.方法 回顾性分析2007年7月～2013月4月在武警总医院肾内科接受T-PTX术的70例慢性肾衰竭SHPT患者的临床资料,分析手术前后及随访6个月期间血甲状旁腺激素（PTH）、血钙（Ca）、血磷（P）、血碱性磷酸酶（ALP）的变化,以及患者皮肤瘙痒、骨痛等症状的改善情况.结果 ①70例患者手术成功67例,成功率为95.7％;②术后临床症状改善情况：全部患者骨痛症状消失,全身瘙痒症状得到明显缓解,肌无力、失眠、纳差症状也迅速改善,全身营养状况好转,10例术前不能行走靠轮椅代步的患者在1年内改善为自由行走;③术后1周、1月、6月复查血PTH、P、ALP均较术前相比明显下降（P＜0.05）;④术后出现声音嘶哑症状2例,发生率为2.85％,均在1周内自行缓解;术后发生低钙血症59例,发生率84.3％,均经静脉补钙后得到缓解;⑤全部患者随访6个月,65例病情稳定,血PTH及钙磷维持在正常范围;2例患者复发,复发率为2.9％,其中1例复发患者经再次手术治疗后,PTH降至15.0pg/ml.结论 T-PTX可有效降低患者血PTH水平,改善临床症状,是治疗SHPT安全有效的方法,长期随访未见明显并发症.