Title: Parathyroidectomy preoperative and intraoperative localization of abnormal parathyroid glands
1Parathyroidectomy preoperative and
intraoperative localization of abnormal
parathyroid glands
2Anatomic distribution of the parathyroids
- Upper gland in order of frequency,
- the cricothyroid junction the dorsum of the
upper pole of the thyroid and the
retropharyngeal space - Lower gland
- at the lower pole of the thyroid and the thymic
tongue rarely in the upper, the lateral neck, or
the mediastinum - Subcapsular located within the surgical capsule
of the thyroid -
- Extracapsular in posteriorior or anterior
mediastinum -
- Supernumerary, fused, and intrathyroidal
parathyroids - Wang,. Ann Surg Mar 1976
3The anatomy of primary hyperthyroidism
- Single gland enlargement (adenoma) 218/273
patients (80) Hyperplasia of all identified
parathyroid glands 42/273 patients (15) - Two adenomas 7 patients (2.6).
- Biochemical evidence of the disease with normal
glands at neck exploration 7 patients (2.6) - Ectopic right superior gland adenomas (mean size
2.6 cm) 39 - Ectopic left superior gland adenomas (mean size
2.62 cm) 36. - Intrathyroid superior adenomas none.
- Intrathyroid inferior adenomas five of 223 (2)
- Inferior gland adenomas within the thymus
- Failure rate of cervical exploration (4)
attributed to mediastinal adenomas, and a
second adenoma, and incorrect diagnosis
Thompson NW. Surgery. 1982 Nov.
4- 48 patients with neck exploration for parathyroid
adenomas - Thirty-two of the 48 patients (67) had
successful unilateral exploration - 16 patients underwent bilateral exploration, and
7/16 had no reduction in PTH level - Of these seven, five were found to have a second
adenoma and two had slow metabolism of hormone
with no additional abnormal tissue found. - In 5 of the 16 patients, bilateral exploration
was performed for erroneous localization. - Four additional patients underwent bilateral
exploration for improved exposure or negative
results on localization tests. - Conclusions 70 rate of unilateral neck
exploration - Intrinsic 15 rate of multinodular primary
hyperparathyroidism combined with limited
results of preoperative localizing techniques
Moore, Francis D. Jr. Annals of surgery 1999
5Preoperative localization
- Hajioff d., (2004) Clin. otolarygol
- accuracy of ultrasonography, sestamibi
scintigraphy and their combination in 48 cases of
primary hyperparathyroidism - Ultrasound had a sensitivity of 64.3
- and positive predictive value (PPV) of 100
(81.5100) for correct lateralization. - Sestamibi had a sensitivity of 83.3 (69.892.5)
and PPV of 87.1 (73.795.1). - The simple combination of ultrasound with
sestamibi had a sensitivity of 82.1 (63.193.9)
and a PPV of 92.0 (74.099.0) little different
from sestamibi alone.
Hajioff d., (2004) Clin. otolarygol
6Preoperative localization
- Twenty-three consecutive patients underwent 24
operations for primary hyperparathyroidism. - preoperative technetium 99m-sestamibi planar
scintigraphy, - preoperative administration of 7.5 mg/kg
methylene blue initiated within 60 minutes of
surgical incision, and surgical neck exploration
supervised by a single surgeon. - RESULTS All patients were cured of
hypercalcemia. - Sensitivity for sestamibi and for methylene blue
staining was 76 and 79, respectively. - Specificity for sestamibi and for methylene blue
was 98 and 93, respectively. - Agreement between sestamibi and methylene blue
was 96.
Orloff, Lisa A. MD., Larygoscope 2001
7Intraoperative PTH assay
- Miami criterion (gt50 drop from highest baseline
IOPTH level at 10 minutes after excision) - criterion 1 (gt50 drop from preincision IOPTH
level at 10 minutes) - criterion 2 (gt50 drop from highest baseline
IOPTH level at 10 minutes and final IOPTH level
within the reference range) - criterion 3 (gt50 drop from highest baseline
IOPTH level at 10 minutes and final IOPTH level
less than the preincision value) - criterion 4 (gt50 drop from highest baseline
IOPTH level at 5 minutes), and criterion 5 (gt50
drop from preexcision IOPTH level at 10 minutes). - Conclusions Satisfying criterion 2 had a high
operative success but resulted in additional
unnecessary surgical exploration. Criterion 1 was
better at predicting postoperative normocalcemia
than criterion 2. - Chiu, Bill MD, Arch of Surgery, May 2006
8- The adenoma is confined by the thyroid capsule
and mimics the shape of the thyroid pole. - This conformation can often be confirmed on
anterior and lateral pinhole views using a
dual-isotope technique. In these cases, - 109 patients identified, 10 were diagnosed with
parathyroid hyperplasia and 99 with parathyroid
adenomas - Of the 99 adenomas, 16 (16) were in subcapsular
locations.Three patterns as related to thyroid - (1) focal convex distortion of the posterior
aspect of the thyroid, 11/16 - (2) polar lentiform configuration, and 3/16
- (3) compression of the posterior thyroid
parenchyma.2/16 Kraas J. Clinical Nuclear
Medicine. April 2005.
Kraas J. Clinical Nuclear Medicine. April 2005
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