Increased identification of parathyroid glands using near infrared light during thyroid and parathyroid surgery.

BACKGROUND: Parathyroid gland (PG) identification during thyroid and parathyroid surgery is challenging. Accidental parathyroidectomy increases the rate of postoperative hypocalcaemia. Recently, autofluorescence with near infrared light (NIRL) has been described for PG visualization. The aim of this study is to analyze the increased rate of visualization of PGs with the use of NIRL compared to white light (WL). MATERIALS AND METHODS: All patients undergoing thyroid and parathyroid surgery were included in this study. PGs were identified with both NIRL and WL by experienced head and neck surgeons. The number of PGs identified with NIRL and WL were compared. The identification of PGs was correlated to age, sex, and histopathological diagnosis. RESULTS: Seventy-four patients were included in the study. The mean age was 48.4 (SD ±13.5) years old. Mean PG fluorescence intensity (47.60) was significantly higher compared to the thyroid gland (22.32) and background (9.27) (p < 0.0001). The mean number of PGs identified with NIRL and WL were 3.7 and 2.5 PG, respectively (p < 0.001). The difference in the number of PGs identified with NIRL and WL and fluorescence intensity was not related to age, sex, or histopathological diagnosis, with the exception of the diagnosis of thyroiditis, in which there was a significant increase in the number of PGs visualized with NIRL (p = 0.026). CONCLUSION: The use of NIRL for PG visualization significantly increased the number of PGs identified during thyroid and parathyroid surgery, and the differences in fluorescent intensity among PGs, thyroid glands, and background were not affected by age, sex, and histopathological diagnosis.

[Intrathyroidal location of parathyroid glands. Atypical presentation of multiple endocrine neoplasia type 1 syndrome]. / Localización intratiroidea de glándulas paratiroides. Presentación atípica del síndrome de neoplasia endocrina múltiple tipo 1.

BACKGROUND: The most common manifestation of MEN 1 syndrome is primary hyperparathyroidism (PHPT) with parathyroid multiglandular affectation. The intrathyroidal situation represents 3-4% of all glands, and it is the second most frequent location in the cervical ectopias. CLINICAL CASE: 11 year old patient, with a family history of MEN1 syndrome and carrier of this same mutation. Patient presents HPTP with osteopenia. The cervical ultrasound shows three compatible images with pathological parathyroid glands (bilateral lower and upper left). The Scan and MRI are normal. Bone densitometry displays data on osteopenia. The patient is surgically intervened, only the upper parathyroid glands are located and removed, after this implantation is performed on the forearm, to prevent the possible devascularization in the dissection of the other glands. However, osteopenia persists and an elevated PTH, therefore new diagnostic tests are held which seem to show two lower parathyroid glands with intrathyroidal location. The patient is reoperated. A subtotal parathyroidectomy of the lower right gland and the resection of the left gland is performed, with the use of intraoperative ultrasound and placement of harpoon. The intraoperative pathology study confirms parathyroid tissue in both cases. DISCUSSION: It is necessary to locate the parathyroid glands preoperatively in order to alert us of the existence of topographical and ectopia abnormalities, as well as their intrathyroidal location (0.5-3.6%). CONCLUSION: The intraoperative ultrasound can be a complement to the experience of the endocrine surgeon for the localization of the parathyroid glands and therefore can help determine the best surgical strategy for each clinical case.

Parathyroid cysts: the Latin-American experience.

BACKGROUND: Parathyroid cyst is an infrequent and unsuspected disease. There are more than 300 hundred cases reported in the world literature, a few of them are from Latin America. The experience of our centers and a review of the cases are presented. METHODS: Case report of a series of patients with parathyroid cyst from our institutions according to the CARE guidelines (Case Reports). A search of Medline, Embase, BIREME (Biblioteca Regional de Medicina) LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), Google Scholar and Scielo (Scientific Electronic Library on Line) databases and telephonic or email communications with other experts from Latin-America was performed . RESULTS: Six patients with parathyroid cyst were found in our centers in Colombia. Most of them were managed with aspiration of the cyst. Two of them required surgery. Only one case was functional. Twelve reports from Latin America were found for a total of 18 cases in our region adding ours. CONCLUSIONS: Parathyroid cysts are uncommonly reported in Latin America. Most of them are diagnosed postoperatively. Suspicion for parathyroid cyst should be raised when a crystal clear fluid is aspirated from a cyst. The confirmation of the diagnosis may be easily done if parathyroid hormone (PTH) level is measured in the cyst fluid.

Maxillofacial Fibrous Osteodystrophy in Equine: Case Report

A 14 year-old pregnant mare developed poor body condition (2/5) and diarrhea while grazing in kikuyu grass (Pennisetum clandestinum). Clinical findings included bulging of nasal and maxillary bones and mouth lacerations associated to spicules on the surface of molars and premolars. Teeth were easily fragmented and fell off. Necropsy findings included severe softening of the maxillary and mandibular bones. The mandible was easily breakable near to the masseter´s fossa. The parathyroid gland was increased in size. Histological findings were characterized by multiple irregular and very thin bone spicules in the bone tissue, most of them with microfractures, severe osteoclasts-mediated bone resorption and fibrous connective tissue proliferation. Hyperplasia and hypertrophy of parathyroid chief cells with cytoplasmic vacuolization were also observed. In conclusion, maxillofacial fibrous osteodystrophy caused by nutritional secondary hyperparathyroidism developed in a pregnant mare while grazing kikuyu grass for long periods of time without appropriate supplements. Kikuyu grass is characterized by high levels of oxalic acid that forms insoluble oxalates responsible for low calcium absorption in the small intestine and the progress of hyperparathyroidism.(AU)

Maxillofacial Fibrous Osteodystrophy in Equine: Case Report

A 14 year-old pregnant mare developed poor body condition (2/5) and diarrhea while grazing in kikuyu grass (Pennisetum clandestinum). Clinical findings included bulging of nasal and maxillary bones and mouth lacerations associated to spicules on the surface of molars and premolars. Teeth were easily fragmented and fell off. Necropsy findings included severe softening of the maxillary and mandibular bones. The mandible was easily breakable near to the masseter´s fossa. The parathyroid gland was increased in size. Histological findings were characterized by multiple irregular and very thin bone spicules in the bone tissue, most of them with microfractures, severe osteoclasts-mediated bone resorption and fibrous connective tissue proliferation. Hyperplasia and hypertrophy of parathyroid chief cells with cytoplasmic vacuolization were also observed. In conclusion, maxillofacial fibrous osteodystrophy caused by nutritional secondary hyperparathyroidism developed in a pregnant mare while grazing kikuyu grass for long periods of time without appropriate supplements. Kikuyu grass is characterized by high levels of oxalic acid that forms insoluble oxalates responsible for low calcium absorption in the small intestine and the progress of hyperparathyroidism.

Parathyroid hormone: an early predictor of symptomatic hypocalcemia after total thyroidectomy / Hormônio da paratireoide: um preditor precoce da hipocalcemia sintomática após a tireoidectomia total

OBJECTIVE: The purpose of this study was to evaluate if the measurement of peri-operative parathyroid hormone (PTH) is able to identify patients with increased risk of developing symptoms of hypocalcemia. SUBJECTS AND METHODS: Forty patients who underwent total thyroidectomy were studied prospectively. Ionized serum calcium and PTH were measured after induction of anesthesia, one hour (PTH1) and one day after surgery (PTH24). Patients were evaluated for symptoms of hypocalcemia and treated with calcium and vitamin D supplementation as necessary. RESULTS: Symptomatic hypocalcemia developed in 16 patients. Symptomatic patients had significant lower PTH1 and greater drops in PTH levels. The selection of 12.1 ng/L as PTH1 level cutoff level divided patients with and without symptoms with 93.7% sensitivity and 91.6% specificity. The selection of 73.5% as the cutoff value for PTH decrease resulted in 91.6% sensitivity and 87.5% specificity. CONCLUSION: PTH1 levels and the drop in PTH levels are reliable predictors of developing symptomatic hypocalcemia after total thyroidectomy.

OBJETIVO: O objetivo deste estudo é avaliar se a medida perioperatória do hormônio da paratireoide (PTH) pode identificar os pacientes com maior risco de desenvolver sintomas de hipocalcemia. SUJEITOS E MÉTODOS: Foram estudados quarenta pacientes submetidos à tireodiectomia total. A medida do cálcio sérico e do PTH foi feita após a indução anestésica, uma hora (PTH1) e um dia após a cirurgia. Os pacientes foram avaliados quanto à presença de sintomas de hipocalcemia e tratados com suplementação de cálcio e vitamina D quando necessário. RESULTADOS: Dezesseis pacientes apresentaram sintomas de hipocalcemia. Os pacientes sintomáticos apresentaram PTH1 significantemente menor e queda no PTH significativamente maior. Usando o valor de 12,1 ng/L como corte, conseguimos distinguir pacientes com e sem sintomas de hipocalcemia com sensibilidade de 93,7% e especificidade de 91,6%. Utilizando como corte a queda de 73,5% no valor do PTH, temos sensibilidade de 91,6% e especificidade de 87,5%. CONCLUSÃO: O PTH1 e a queda no PTH são bons preditores de hipocalcemia no pós-operatório de tireoidectomia total.

Paratireoidectomia subtotal no tratamento do hiperparatireoidismo secundário à doença renal crônica / Subtotal parathyroidectomy in the treatment of secondary hyperparathyroidism to chronic renal disease

Objetivos: apresentar os resultados obtidos com a paratireoidectomia (PTX) subtotal em pacientes com hiperparatireoidismo (HPT) secundário àinsuficiência renal crônica (IRC), enfocando a contribuição e as dificuldades técnicas da cirurgia. Pacientes e Métodos: no período de janeiro de 1998 ajunho de 2005 foram operados consecutivamente no Hospital Universitário Antonio Pedro, 33 pacientes renais crônicos portadores de HPT secundário. Ascirurgias foram realizadas pelo mesmo cirurgião e a mesma equipe de nefrologista se encarregou do controle pré e pós-operatório. Esse grupo foiconstituído por 19 homens e 14 mulheres com idade média de 40,5 (16/68) anos e todos se encontravam em tratamento dialítico regular, com tempo médiode diálise de 113 (20/189) meses. Além dos cuidados habituais, todos os pacientes receberam calcitriol após as três últimas sessões de diálise queantecederam a cirurgia. Resultados: os resultados mais expressivos se refletiram sobre o aparelho músculo-esquelético e foram muito significativas as remissões das queixas de dor ósteo-articular, fraqueza e prurido; as calcificações não vasculares foram reabsorvidas e sinais de remineralização ósseaforam identificados após a cirurgia. As complicações pós-operatórias mais freqüentes foram a rouquidão transitória (21%), a hiperpotassemia (12%) e osangramento pós-operatório (12%). Nesse grupo há uma recidiva comprovada e já reoperada e dois pacientes encontram-se em fase de investigação, por provável insucesso na cirurgia, já que o PTH continua elevado. Os resultados menos favoráveis foram mais freqüentes nos casos onde foram encontradas apenas três glândulas paratireóides. Não houve mortalidade operatória. Conclusões: a PTX subtotal pode ser realizada com segurança e é efetiva para a remissão de diversas manifestações do HPT secundário, desde que continuem sob rigoroso controle clínico para evitar possíveis recidivas por hiperplasia do resíduo glandular.

Objective: to report the results obtained with subtotal parathyroidectomy (PTX) in patients with hyperparathyroidism (HPT) secondary to chronic renaldisease (CRD), focusing on the contribution and technical difficulties of the surgery. Methods: From January of 1998 to June of 2005, thirty-three end-stagerenal disease (ESRD) patients consecutively underwent PTX in the university hospital. Their mean age was 40.5 years; Nineteen were male, and 14 female.Mean time on dialysis was 113 months. Surgeries were accomplished by the same surgeon and the same nephrologist was in charge of the pre- andpostoperative care of the whole patients. Among the clinical manifestations those related to the osteopathy were the most prevalent ones. All patientsunderwent preoperative care and received calcitriol after the last three dialysis sessions that preceded the surgery. Results: the most expressiveimprovements pertained to the muscle-skeletal system. The alleviation of bone pain, joint pain, muscle weakness and itch were marked. Extra-vascularcalcifications were reabsorbed and radiological signs of bone remineralization were identified after the surgery. The most frequent postoperativecomplications were temporary hoarseness (21%), hyperkalemia (12%), and postoperative bleeding (12%). So far, we have faced one proven recurrencethat was managed by a surgical reintervention. In addition, PTH continues to be high in two patients who are undergoing prepare for a new surgery. Bad results seemed to be more frequent on patients in which only three parathyroid glands were found during the operation. Surgery was not associated to fatalities. Conclusions: subtotal PTX can be accomplished with safety in ESRD patients being effective for the alleviation of several manifestations of the secondary HPT. Patients should be maintained under strict clinical control to monitor for recurrences due to hyperplasia of the residual glandular tissue.