The utility of parathyroid autofluorescence as an adjunct in thyroid and parathyroid surgery 2023.

Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.

Refractory Hypocalcemia Following Stomach Intestinal Pylorus-Sparing Bariatric Surgery and Thyroidectomy: Successful Management With Creation of a Proximal Roux-en-Y Gastric Bypass.

Some forms of bariatric surgery make patients susceptible to calcium malabsorption, and the parathyroid hormone (PTH) axis is important for maintaining normocalcemia in these patients. Injury to the parathyroid glands due to anterior neck surgery commonly causes PTH axis disruption and can result in severe hypocalcemia in bariatric surgery patients. Herein, we present a case of a patient with a history of stomach intestinal pylorus-sparing bariatric surgery who developed refractory hypocalcemia requiring daily intravenous (IV) calcium 2 years after thyroidectomy. PTH levels were inappropriately normal during episodes of hypocalcemia, and urinary calcium level was <3.0 mg/dL following large oral doses of calcium, suggesting that both inadequate PTH response and malabsorption contributed to her severe hypocalcemia. In order to enhance calcium absorptive capacity while minimizing the risk of weight regain, she was surgically treated with a Roux-en-Y gastric bypass proximal to the prior operation. The surgery successfully improved blood calcium levels; the patient was successfully weaned from IV calcium and was able to maintain normocalcemia with oral supplements. We discuss the case in the context of available literature and provide our recommendations.

Serum parathyroid hormone and alkaline phosphatase as predictors of calcium requirements after total parathyroidectomy for hypocalcemia in secondary hyperparathyroidism.

BACKGROUND: To prevent hypocalcemia, this study examined the efficiency of a calcium supplement formula guided by predicted calcium requirement in patients with renal failure after parathyroidectomy with autotransplantation. METHODS: In the first phase, a protocol was followed whereby intravenous calcium gluconate was repeatedly titrated based on serum calcium levels in 22 patients with parathyroidectomy with autotransplantation. In the second phase, the first equation protocol was applied in 74 patients with parathyroidectomy with autotransplantation and revised. RESULTS: There is a significant correlation between the postoperative amount of calcium requirement and preoperative serum alkaline phosphatase level (r = 0.442; P < .001) and parathyroid hormone level (PTH; r = 0.889; P < .001). For prediction of insufficient calcium supplement, the cutoff point of PTH and alkaline phosphatase level values were calculated by receiver operating characteristic (ROC) curve analysis and modified equations were developed by regression analysis. CONCLUSION: The preoperative PTH and alkaline phosphatase levels can predict postoperative calcium requirements, such that equations of calcium supplement allow the management of hypocalcemia efficiently in patients on dialysis after parathyroidectomy with autotransplantation.

Parathyroid Allotransplant for Persistent Hypocalcaemia: A New Technique Involving Short-Term Culture.

OBJECTIVES: To develop a new parathyroid allotransplant method for the treatment of permanent hypoparathyroidism. MATERIALS AND METHODS: Parathyroid cells 50 × 10(6) derived from a parathyroid hyperplasia patient were transferred to a 61-year-old patient who had thyroidectomy 17 years earlier, allowing to papillary thyroid cancer; he was admitted to our outpatient clinic with symptomatic chronic hypocalcemia. Cell isolation, cryopreservation, and culturing were conducted according to a new protocol. RESULTS: During a follow-up of 5 months, the patient had no complications that could indicate rejection, and clinical symptoms completely resolved without requiring any drug supplementation. CONCLUSIONS: Here, we report a new method, enabling fast and cost-effective parathyroid allotransplant with maintained tissue viability sufficient to treat persistent hypocalcemia.

To supplement or not to supplement: a cost-utility analysis of calcium and vitamin D repletion in patients after thyroidectomy.

BACKGROUND: Postoperative hypocalcemia is the most common complication after thyroidectomy; prevention and treatment remain areas of ongoing debate. The purpose of this study was to determine the incremental cost utility of routine versus selective calcium and vitamin D supplementation after total or completion thyroidectomy. METHODS: A cost-utility analysis using a Markov decision model was performed for a hypothetical cohort of adult patients after thyroidectomy. Routine or selective supplementation of oral calcium carbonate, vitamin D (calcitriol), and intravenous calcium gluconate, when required, was used. Selective supplementation was determined by serum intact parathyroid hormone levels. The incremental cost utility, measured in U.S. dollars per quality-adjusted life-year (QALY), was calculated. RESULTS: In the base-case analysis, the cost of routine supplementation was $102 versus $164 for selective supplementation. Patients in the routine arm gained 0.002 QALYs compared to patients in the selective arm (0.95936 QALYs vs. 0.95725 QALYs). At the population level, this translates into a savings of $29,365/QALY (95% confidence interval, -$66,650 to -$1,772) for routine supplementation. Sensitivity analyses demonstrated that the model was most sensitive to the utility of the hypocalcemic state, postoperative rates of hypocalcemia, and cost of serum parathyroid hormone testing. CONCLUSIONS: Routine oral calcium and calcitriol supplementation in patients after thyroidectomy seems to be less expensive and results in higher patient utility than selective supplementation. Surgeons who have very low rates of hypocalcemia in their patients may benefit less from routine supplementation.

Intraoperative parathormone measurement from the internal jugular vein predicts post-thyroidectomy hypocalcaemia.

BACKGROUND: The most common significant complication of total thyroidectomy is hypoparathyroidism. Intraoperative prediction of which patients are likely to be affected would allow both intraoperative and postoperative interventions to be utilised in these patients. Selection of these patients is essential if we are to be successful at discharging total thyroidectomy patients on the first postoperative day. We investigated the utility of intraoperative parathormone measurement from the internal jugular vein at predicting postoperative hypocalcaemia. MATERIALS AND METHODS: Prospective collection of data was done on 45 consecutive total thyroidectomy patients. Preoperative calcium, intraoperative parathormone and postoperative calcium and parathormone were collected. The accuracy of intraoperative parathormone in predicting those with postoperative hypocalcaemia was assessed. RESULTS: Intraoperative parathormone of less than 2 pmol l(-1) had a sensitivity of 100% and a specificity of 95% in predicting those with postoperative hypocalcaemia. An intraoperative sample less than 2 pmol l(-1) was a highly significant predictor (p < 0.0001) of postoperative hypocalcaemia. CONCLUSION: Intraoperative assessment of parathormone is an accurate predictor of those patients who will become hypoparathyroid in the postoperative period. Intraoperative prediction allows for targeted autotransplantation of glands in those at risk and selected early institution of postoperative supplementation in these patients. Patients not identified as at risk can be safely discharged.

Cirugía selectiva bajo anestesia local para el tratamiento de los adenomas paratiroideos / Selective surgery under local anesthesia for parathyroid adenomas

Introducción. El hiperparatiroidismo primario por adenoma, identificado y localizado por ecografía y gammagrafía, puede ser tratado mediante un acceso limitado, bajo anestesia local y sedación, con la condición de controlar el efecto de la exéresis mediante la dosificación intraoperatoria de la parathormona intacta (PTH-i), y respetar las limitaciones y/o contraindicaciones de esta técnica. Pacientes y método. Se analizan los resultados obtenidos en el tratamiento de 14 pacientes afectados por un hiperparatiroidismo ocasionado por un adenoma de paratiroides (localizado por ecografía y gammagrafía) mediante cirugía selectiva bajo anestesia local y sedación con monitorización intraoperatoria de la PTH-i. Resultados. La anestesia local y la posición operatoria fueron bien toleradas y no hubo complicaciones locales ni re currenciales. La exéresis del adenoma en el orden técnico, no planteó ninguna dificultad. El éxito de la operación se confirmó durante el acto operatorio al comprobar la normalización de los valores de PTH-i a los 30 y 60 minutos tras la exéresis lesional. Conclusiones. La cuestión que subyace es si este método podrá sustituir al acceso quirúrgico tradicional. No obstante, la adenomectomía selectiva paratiroidea, con anestesia local y sedación constituye, en caso de monitorización de la PTH-i, el preludio de una cervicotomía estándar bajo anestesia general (AU)

Improvement of postoperative hypocalcemia by repeated allotransplantation of parathyroid tissue without anti-rejection therapy.

Long lasting postoperative hypocalcemia, an uncomfortable complication of a thyroid operation for hyperthyroidism, was treated with allotransplantation of parathyroid tissue. Small pieces of the parathyroid tissue offered from two unrelated donors were transplanted to an 18-year-old male with severe postoperative hypoparathyroidism. Prednisolone was given for 2 days, but no other immunosuppressive drugs were used. The remaining tissue was stored in frozen for the repeat transplantation. The functional activity of the frozen tissue was determined by the production of parathyroid hormone in the tissue culture medium adjusted to appropriate concentration of calcium. Loss of the graft function, probably due to rejection, was supplemented with repeated grafting. Hypocalcemia was improved by three times of transplantation using frozen tissue (once) and fresh tissue (twice). This preliminary trial demonstrates that the tissue transplantation of the parathyroid gland is effective to lessen the symptoms and medication of postoperative hypoparathyroidism.