Efficient parathyroidectomy guided by SPECT-MIBI and hormonal measurements.

UNLABELLED: Parathyroidectomy is a difficult and lengthy operation which is noncurative in 6% to 10% of cases. To improve the efficiency of this operation, a new dual diagnostic approach was prospectively applied. METHODS: Preoperative tomographic 99mTc-sestamibi (MIBI) scintography and intraoperative measurements of circulating parathyroid hormone (PTH) levels by a quick assay (QPTH) were used. Scintigraphy comprised immediate and delayed planar and SPECT of the neck and chest, following 20 mCi MIBI. The presence and location of persistent foci of abnormal activity found within the neck mediastinum on volume-rendered reprojection (RPJ) of the SPECT data were reported. The surgion, guided by the three-dimensional MIBI-SPECT/RPJ images, identified and excised the single or most prominent scintigraphic focus and applied the QPTH. If PTH levels fell from baseline by at least 50%, the operation was concluded. RESULTS: The operative time of primary parathyroidectomy was reduced from an average of 90 min (before the introduction of scintigraphy and intraoperative PTH measurements) to 57 min. All but two patients became normocalcemic. In 58 consecutive patients with hyperparathyroidism, MIBI-SPECT/RPJ correctly and precisely identified 51 of 53 (96%) primary parathyroid adenomas, 14 to 15 secondary hyperplasias and 2 of 3 hyperplastic glands in MEN (sensitivity 94%, specificity 92%). QPTH verified the excision of the primary parathyroid adenomas and predicted normocalcemia in 50 of 52 patients. In 6 patients with misleading scintigraphy, QPTH was especially useful and guided the surgeon to continue the operation until the abnormal parathyroid tissue was found and excised. CONCLUSION: MIBI-SPEC/RPJ and QPTH sequentially applied improved the efficiency of parathyroidectomy.

Sequential internal mammary artery grafts for coronary artery bypass.

From 1985 to 1990, 145 patients underwent isolated coronary artery bypass with one (n = 128) or both (n = 17) internal mammary arteries (IMAs) used as sequential bypass grafts. All but 2 patients had angina pectoris preoperatively. A total of 162 sequential IMA grafts were constructed bypassing two (n = 152) or three (n = 10) coronary artery sites as in situ (n = 132) or free (n = 30) grafts. In 12 patients, one IMA was used as a nonsequential graft. Thirty-day mortality was 2.8% (n = 4 patients). Perioperative myocardial infarction occurred in 1 patient (0.7%). Only two sequential IMA grafts failed. Both were used to bypass coronary arteries 1.00 mm in diameter. Mean follow-up was 31 months (range, 6 months to 4.2 years). There were three late deaths. Of 136 survivors followed-up, 121 (89%) were free of angina. Postoperative rotational thallium 201 tomography was done in 73 patients. Myocardial ischemia was detected in 11 diabetic patients (15.1%), but corresponded to a sequential IMA graft in 4 (5.5%) and to nonsequential and venous grafts in 10 patients (13.7%). Coronary revascularization with sequential IMA grafts was safe and effective.

Transient myocardial uptake of Tc-99m methylene diphosphonate in a patient with amyloidosis.

A patient with autopsy-proven myocardial amyloidosis had been observed for 10 years with Tc-99m methylene diphosphonate bone scans. The bone scans manifested transient myocardial uptake. No cause other than the myocardial amyloid could be found to explain the fluctuating scan findings.

A new approach to parathyroidectomy.

OBJECTIVE: To decrease the operative time for parathyroidectomy in patients with hypercalcemic (primary) hyperparathyroid disease, a combination of preoperative localization of a parathyroid tumor with an effective nuclear scan (scintigram) and intraoperative monitoring of parathyroid hormone (quick parathyroid hormone measurement) to ensure excision of all hyperfunctioning tissue was studied. SUMMARY BACKGROUND DATA: For many years, persistent hypercalcemia after parathyroidectomy (3% to 10%) has been constant and is usually due to the surgeon's failure to remove all hyperfunctioning glands. A marked decrease in parathormone level after excision of a single large gland predicts operative success and a return to normal calcium levels. Conversely, persistent high levels of parathyroid hormone indicate excess secretion by another gland(s) and the need for further exploration. Recently Tc-99m-sestamibi (MIBI) scintigraphy was shown to be more effective in localizing parathyroid tumors than previous methods. A combination of both techniques could be useful to the surgeon if they improve the operative success rate and are cost-effective. METHODS: Parathyroidectomy was performed on 18 patients with primary hyperparathyroid disease, with tumors localized by MIBI scintigrams. When excision of the identified parathyroid gland was accomplished, the operation was terminated and quick parathyroid hormone was measured to confirm that all hyperfunctioning tissue was removed. RESULTS: Sixteen patients with positive results of scintigram had successful parathyroidectomies confirmed by quick parathyroid hormone measurement with a cervical approach. Two patients with mediastinal tumors localized by MIBI scintigraphy could not be resected using this approach. One false-positive/false-negative scintigram was obtained. Compared with patients having parathyroidectomy without localization and hormone monitoring, the average operative time was shortened from 90 to 36 minutes. CONCLUSIONS: Localization and successful excision of parathyroid tumors with confirmation that no other hyperfunctioning glands were present by quick parathyroid hormone monitoring can predict a return to normal calcium levels and a decrease in operative time in parathyroidectomy.

Acute renal failure due to rhabdomyolysis associated with the extreme lithotomy position.

A patient who developed acute renal failure secondary to rhabdomyolysis associated with the use of the extreme lithotomy position for 6 hours during radical perineal prostatectomy is described. It appears that muscle ischemia due to compression of the lumbar and pelvic muscles resulted in muscle injury. Intense muscle uptake of technetium 99m methylene diphosphonate assisted in localizing the muscles involved and ascertaining the extent of the injury. Review of the literature disclosed seven other patients with a similar association. All patients complained of muscle pain shortly after recovery from anesthesia. Early recognition and aggressive treatment with intravenous fluids may prevent the development of acute renal failure.

67Gallium accumulation in hepatic actinomycosis.

A case of actinomycosis involving the liver is reported. The liver scan with 99mTcS colloid showed multiple areas of focal abnormalities. 67Gallium citrate liver scan showed these areas to concentrate intensely. This pattern of differential hepatic scintigraphy is seen in pyogenic abscesses as well as malignancy of the liver. Actinomycosis may mimic the clinical picture of a malignant neoplastic process, making the differential diagnosis of 67Ga-positive lesions of the liver more difficult.