Parathyroid hormone assay with eluent of aspirated tissues in parathyroidectomy / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the values of intraoperative fine-needle aspiration (IFNA) and parathyroid hormone (PTH) detection in the eluate of aspirated tissue during parathyroidectomy. Methods: Fifty-four patients with secondary hyperparathyroidism (SHPT) including 24 males and 30 females, aged 20-83 years, admitted to Zhongnan Hospital of Wuhan University from January 2019 to October 2019, were included. All patients received subtotal parathyroidectomy with autologous transplantation, during surgery, IFNA and PTH detection in the eluate of aspirated tissue were performed, and also routine postoperative pathological examination was performed. The results of PTH detection in the eluate of aspirated tissue and postoperative pathological examinations were compared and analyzed by SPSS and R software for evaluating of the sensitivity, specificity, positive predictive value, negative predictive value, misdiagnosis rate, missed diagnosis and accuracy. Results: Surgery was completed successfully in all patients. After surgery, the symptoms were improved in the patients except two who were asymptomatic. None had any serious postoperative complications such as hypocalcaemia or hoarseness. A total of 231 aspirated tissue samples were tested, of which 216 were identified as parathyroid and 15 non-parathyroid based on intraoperative PTH detection in tissue eluate; while 217 were confirmed as parathyroid tissues and 14 non-parathyroid tissues with postoperative pathological examinations. The specificity and sensitivity of intraoperative IFNA and PTH detection in tissue eluate for identifying parathyroid tissues were 99.5% and 100.0%, respectively. Conclusion: The IFNA and PTH detection in tissue eluate is a rapid, simple, and accurate procedure, which helps the surgeon to identify parathyroid tissue and to ensure the endocrine activity of preserved or autografted parathyroid tissue during parathyroidectomy.

Cirugía mayor ambulatoria de la glándula tiroides y paratiroides: resultados tras 6 años de experiencia / Major outpatient surgery of the thyroid and parathyroid glands: results after 6 years experience

Objetivo: La cirugía mayor ambulatoria (CMA) y con estancia inferior a 24 horas (overnight stay) se ha consolidado en muchas patologías aunque en cirugía tiroidea y paratiroidea resulta controvertido. El objetivo es valorar nuestros resultados en cirugía del tiroides y paratiroides en régimen de CMA durante un periodo de 6 años. Material y Métodos: Estudio observacional prospectivo de pacientes con indicación de hemitiroidectomía o paratiroidectomía enfocada en régimen CMA entre enero de 2011 y diciembre de 2016. Los pacientes cumplían criterios de CMA. En los primeros años se excluyeron los nodulos tiroideos mayores de 3 cm y los pacientes ASA III. Los pacientes ingresaron la mañana de la intervención, tras el acto quirúrgico pasaron a la Unidad de Recuperación Posquirúrgica y posteriormente a sala de hospitalización. Tras 8 h, si cumplían criterios, fueron dados de alta. Resultados: Se intervinieron 270 pacientes, la tasa de aplicabilidad global fue del 59%, la tasa de aceptabilidad global del 83,6% y el índice de sustitución del 49,2%. El índice de ingresos no deseados fue del 10,4% para la paratiroidectomía y del 17,6% en la cirugía del tiroides. Ningún paciente presentó complicaciones mayores en su domicilio. El grado de satisfacción fue alto o muy alto en el 94% de los pacientes. Conclusiones: La paratiroidectomía enfocada y la hemitiroidectomía realizada por cirujanos expertos en pacientes seleccionados, es segura y efectiva en régimen ambulatorio. Es posible mejorar el índice de sustitución ambulatorio aumentando la tasa de aplicabilidad y aceptabilidad.

Objetive: Ambulatory or overnight stay surgery have been consolidated in many different procedures. However, its use in thyroid and parathyroid surgery is still controversial. The aim of this report is to present the results of 6 years of ambulatory patients undergoing surgery of the thyroid or parathyroid glands. Material and Methods: Prospective observational study of patients who underwent hemithyroidectomy or selective parathyroidectomy in the ambulatory program from January 2011 to December 2016. All patients included met the general criteria of ambulatory surgery. During the first years nodules bigger than 3 cm and patients classified as ASA III were excluded. Patients arrive at hospital the morning of surgery. After the operation, patients pass to the post-anesthesia care unit and then to the hospitalization room. 8 hours after surgery patients are discharged home if they meet the criteria. Results: 270 patients were operated, 159 of them met the inclusion criteria. The overall applicability rate was 59%. The acceptance rate was 83.6% and the substitution index was 49.2%. The unwanted hospital admission was 10.4% for the parathyroidectomy and 17.6% for the hemithyroidectomy. Any patient presented major complications at home. The satisfaction rate was high or very high for 94% of the patients. Conclusion: Selective parathyroidectomy and hemithyroidectomy performed by experienced surgeons in selected patients can be safely and effectively carried out in ambulatory surgery (outpatient). It would be possible to improve the substitution index by increasing the application and acceptability ratios.

Paratiroidectomía transoral endoscópica por acceso vestibular oral: cirugía de paratiroides sin cicatriz: primer caso realizado en Sudamérica / Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA)

Introducción: El abordaje de elección de la glándula tiroides y paratiroides, desde su descripción, ha sido la cervicotomía transversal. En el hiperparatiroidismo, con la optimización de los métodos de localización preoperatoria de las glándulas anómalas, se han creado técnicas abiertas mínimamente invasivas, con un mejor resultado estético y un menor tiempo de recuperación. Con el objetivo de eliminar las cicatrices externas se ha implementado una nueva técnica quirúrgica que utiliza abordajes endoscópicos a través de orificios naturales (NOTES). En los últimos años se ha hecho conocida una técnica de tiroidectomía y paratiroidectomía transoral endoscópica a través de incisiones en el vestíbulo oral. Caso clínico: Paciente de 65 años con hiperparatiroidismo primario con nódulo hiperfuncionante superior derecho que se somete a una paratiroidectomía parcial transoral endoscópica por abordaje vestibular. Resultados: El procedimiento se realiza sin incidentes con buena evolución posoperatoria de la paciente. Discusión: La paratiroidectomía transoral endoscópica por abordaje vestibular (TOEPVA) ha demostrado ser una técnica bastante segura, con resultados similares a los de la técnica abierta, pero sin dejar cicatrices visibles.

Introduction: The approach of choice of the thyroid and parathyroid glands, since its description, has been the transverse cervicotomy. In hyperparathyroidism, with the optimization of the preoperative localization methods of the anomalous glands, minimally invasive open techniques have been created, with a better aesthetic result and a shorter recovery time. With the aim of eliminating external scars, a new surgical technique has been implemented that uses endoscopic approaches through natural orifices (NOTES). In recent years, a transoral endoscopic thyroidectomy and parathyroidectomy technique through incisions in the oral vestibule has been known. Clinical case: A 65-year-old patient with primary hyperparathyroidism with right upper hyperfunctioning nodule who underwent partial transoral endoscopic parathyroidectomy due to vestibular approach. Results: The procedure is performed without incidents with good postoperative evolution of the patient. Discussion: Transoral endoscopic parathyroidectomy by vestibular approach (TOEPVA) has proven to be a fairly safe technique, with results similar to open technique, but without leaving visible scars.

Hiperparatiroidismo persistente debido a paratiromatosis / Persistent hyperparathyroidism due to parathyromatosis

RESUMEN La paratiromatosis se describe como una dolencia en la que existen múltiples nódulos de tejido paratiroideo hiperfuncionante diseminados por cuello y el mediastino, en la cual las pruebas de imagen no son efectivas para localizar las glándulas paratiroides y requiere de la combinación de un tratamiento médico y quirúrgico que en ocasiones se presenta como un desafío. Describimos el caso de una mujer de 61 años con hiperparatiroidismo primario recurrente a la que se le extirpan un total de 9 glándulas paratiroideas en 3 cirugías diferentes, y realizamos revisión de la literatura.

ABSTRACT Parathyromatosis is described as a condition in which there are multiple nodules of hyperfunctioning parathyroid tissue disseminated by the neck and mediastinum. Imaging tests are not effective in locating the parathyroid glands and requires the combination of medical and surgical treatment that sometimes is challenging. We describe the case of a 61-year-old woman with recurrent primary hyperparathyroidism. A total of 9 parathyroid glands where removed in 3 different surgeries. We also reviewed the literature.

Crisis hipercalcémica causada por adenoma paratiroideo: reporte de un caso clínico / Hypercalcemic crisis due to parathyroid adenoma: report of a clinical case

La hipercalcemia es un trastorno común que representa aproximadamente el 0,6% de todas las admisiones médicas agudas. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las dos causas más comunes de elevación de los niveles séricos de calcio; constituyen, en conjunto, alrededor del 90% de todos los casos. La presentación sintomática clásica de la hipercalcemia se observa con relativa poca frecuencia en el mundo desarrollado; la presentación más común es la detección asintomática en las pruebas bioquímicas. Sin embargo, en casos raros, el HPTP puede desarrollar hipercalcemia aguda, grave y sintomática, llamada crisis hipercalcémica (CH). Esta condición se asocia a alteraciones profundas en el estado mental y las funciones cardíaca, renal y gastrointestinal en presencia de concentraciones marcadamente elevadas de calcio sérico y paratohormona (PTH). Mientras que algunas elevaciones en el calcio sérico pueden ser bien toleradas, los síntomas de la CH son severos. Si el tratamiento se retrasa, la CH puede provocar la muerte. Describimos el caso de un paciente masculino que ingresa en la unidad de cuidados críticos por una CH secundaria a un HPTP por adenoma paratiroideo. (AU)

Hypercalcaemia is a most common disorder, accounting for approximately 0,6% of all acute medical admissions. Primary hyperparathyroidism (PHPT) and malignancy are the two most common causes of increased serum calcium levels, together accounting for about 90% of all cases. The classical symptomatic presentation of hypercalcaemia is seen relatively rarely in the developed world, the most common presentation being asymptomatic and detected following on biochemical testing. However, in rare cases HPTP can result in acute, severe and symptomatic hypercalcemia, called hypercalcemic crisis (HC). This condition is associated with profound disturbances in mental status, and cardiac, renal, and gastrointestinal function in the presence of markedly increased serum calcium and parathyroid hormone (PTH) concentrations. While some elevations in serum calcium can be well tolerated, symptoms of HC are severe. If treatment is delayed, HC can result in death. We describe herein a case of a male patient who was admitted to the intensive care unit as a consequence of HC resulting from elevated PTH, secondary to a parathyroid adenoma. We describe the case of a male patient who was admitted to the critical care unit for a HC mediated by PTH secondary to a parathyroid adenoma. (AU)

Hipercalcemia hipocalciurica familiar en una paciente con mutación del receptor de calcio: forma atípica de presentación y tratamiento con cinacalcet / Familial hypocalciuric hypercalcemia in a patient with calcium-sensing receptor mutation: atypical clinical presentation and treatment with cinacalcet

El hiperparatiroidismo familiar y la hipercalcemia hipocalciúrica familiar (HHF) constituyen un subgrupo heterogéneo de trastornos con herencia mendeliana, que representan en conjunto el 5% de las causas de hipercalcemia PTH dependiente. La HHF se asocia con mutaciones del gen del receptor sensor de calcio (CaSR). Esta entidad se manifiesta, en la mayoría de los casos, con la presentación asintomática y familiar de hipercalcemia e hipocalciuria y valores elevados o normales de hormona paratiroidea (PTH). Los avances en la biología molecular han contribuido al diagnóstico, evaluación del fenotipo de cada entidad y elección del tratamiento. Se describe el caso de una paciente con hipercalcemia estudiada a partir de una tumoración de cuello asociada con una glándula paratiroides quística. Luego de un exhaustivo proceso diagnóstico se halló en el estudio genético una mutación inactivante en el gen CaSR. Teniendo en cuenta la presencia de la relación clearance calcio/clearance creatinina <0,01 y la falta de respuesta al tratamiento quirúrgico, se consideró la entidad de HHF con forma de presentación atípica. La paciente, sin tratamiento, presentaba un progresivo incremento de la calcemia luego de la cirugía de las glándulas paratiroides, que no se controló con el uso de bifosfonatos y evolucionó con episodios de mareos y desmayos frecuentes sin causa neurológica o cardiovascular detectada. Por lo tanto, se inició el tratamiento con cinacalcet, con el cual se obtuvo una buena respuesta terapéutica: descenso de la calcemia y mejoría de la sintomatología luego de un año de su comienzo. El cinacalcet es una herramienta terapéutica de importancia en estos raros casos de HHF. (AU)

Familial hyperparathyroidism including familial hypocalciuric hypercalcemia (FHH) is an heterogeneous subgroup of disorders with Mendelian inheritance, that account for 5% of PTH dependent hypercalcemia. FHH is associated with mutations of the calcium receptor (CaSR) gene. This entity is manifested by hypercalcemia with hypocalciuria and high or normal levels of parathyroid hormone (PTH) generally asymptomatic and with familial presentation. Advances in molecular biology have contributed to the diagnosis, evaluation of the phenotype of each entity and the choice of treatment. We describe a patient with hypercalcemia diagnosed following the finding of a neck tumor associated with cystic parathyroids. After an exhaustive diagnostic process, an inactivating mutation in the CaSR gene was found. Considering the presence of a ratio clearance calcium / clearance creatinine <0.01 and the lack of response to surgical treatment, HHF entity with atypical presentation was considered. The patient exhibited progressive increase in serum calcium following parathyroid surgery, which was not controlled with the use of bisphosphonates and evolved into episodes of frequent dizziness and fainting, without neurological or cardiovascular causes. Treatment with cinacalcet was initiated, with a good therapeutic response. The use of cinacalcet is a useful therapeutic tool in these rare cases of FHH. (AU)

Paratiroidectomía subtotal: último recurso en el tratamiento de hiperparatiroidismo secundario en los pacientes con enfermedad renal crónica / Subtotal parathyroidectomy: last resource in the treatment of secondary hyperparathyroidism in patients with chronic kidney disease

El fracaso del tratamiento médico del HPTs hace necesario la utilización de una solución más agresiva. La paratiroidectomía subtotal (PTXs) ha sido efectiva en el control de los niveles de PTH para disminuir las complicaciones derivadas de su secreción descontrolada: astenia, dolores y deformidades óseas y calcificaciones vasculares que serán finalmente responsables de la muerte por trastornos cardiacos en edades tempranas de los pacientes renales crónicos. Se describe la eficiencia de la ecografía y centellografía con sestamibi para la correcta ubicación, número y tamaño de las glándulas paratiroideas y la determinación del descenso del nivel de PTH intraquirúrgico como factor predictor del éxito quirúrgico (AU)

Failure of medical management of hyperparathyroidism has warranted a more aggressive solution. Subtotal parathyroidectomy (sPTX) has been effective in the control of parathyroid hormone (PTH) levels decreasing complications related to uncontrolled secretion: asthenia, bone pain and deformities, and vascular calcifications leading to death due to early heart disease in patients with chronic kidney disease. Here we describe the efficiency of ultrasonography and sestamibi whole body scan for the precise location and evaluation of number and size of the parathyroid glands and determination of the intraoperative decrease of PTH levels as a predictive factor for surgical success (AU)

Hiperplasia paratiroidea en un adolescente / Parathyroid hyperplasia in an adolescente

El hiperparatiroidismo primario esporádico es una de las causas de hipercalcemia en la edad pediátrica. Constituye una entidad muy poco frecuente, más aún si es debido a hiperplasia paratiroidea. Se presenta el caso de un adolescente con historia de litiasis renal, hipercalcemia asociada a cifras elevadas de la hormona paratiroidea, e imágenes sugestivas de adenoma en paratiroide inferior izquierda por gammagrafía con sestamibi marcado con tecnecio-99m. Se realizó exéresis quirúrgica de la glándula afectada. El examen anatomo-patológico de la pieza arrojó hiperplasia paratiroidea. La presentación de este caso contribuye al reconocimiento del hiperparatiroidismo primario, entre las posibilidades diagnósticas al evaluar un paciente pediátrico con hipercalcemia(AU)

Sporadic primary hyperparathyroidism is one of the causes of hypercalcemia in pediatric ages. A very uncommon condition, it is even less frequent when caused by parathyroid hyperplasia. A presentation is provided of the case of an adolescent with a history of renal lithiasis, hypercalcemia associated to high parathyroid hormone values, and imaging suggestive of lower left parathyroid adenoma by gammagraphy with sestamibi marked with technetium-99m. Surgical exeresis of the affected gland was performed. Anatomopathological examination of the piece revealed the presence of parathyroid hyperplasia. This case presentation contributes to the recognition of primary hyperparathyroidism as one of the diagnostic possibilities when evaluating a pediatric patient with hypercalcemia(AU)

Diagnosis and management of primary hyperparathyroidism: a scientific statement from the Department of Bone Metabolism, the Brazilian Society for Endocrinology and Metabolism / Diagnóstico e manejo do hiperparatireoidismo primário: uma posição científica do Departamento de Metabolismo Ósseo, a Sociedade Brasileira de Endocrinologia e Metabolismo

OBJECTIVE: To conduct a literature review on the diagnosis and management of primary hyperparathyroidism including the classical hipercalcemic form as well as the normocalcemic variant. MATERIALS AND METHODS: This scientific statement was generated by a request from the Brazilian Medical Association (AMB) to the Brazilian Society for Endocrinology as part of its Clinical Practice Guidelines program. Articles were identified by searching in PubMed and Cochrane databases as well as abstracts presented at the Endocrine Society, Brazilian Society for Endocrinology Annual Meetings and the American Society for Bone and Mineral Research Annual Meeting during the last 5 years. Grading quality of evidence and strength of recommendation were adapted from the first report of the Oxford Centre for Evidence-based Medicine. All grades of recommendation, including "D", are based on scientific evidence. The differences between A, B, C and D, are due exclusively to the methods employed in generating evidence. CONCLUSION: We present a scientific statement on primary hyperparathyroidism providing the level of evidence and the degree of recommendation regarding causes, clinical presentation as well as surgical and medical treatment.

OBJETIVO: Conduzir uma atualização das últimas evidências científicas a respeito da apresentação, do diagnóstico e do manejo clínico e cirúrgico do hiperparatireoidismo primário clássico e normocalcêmico. MATERIAIS E MÉTODOS: Este documento foi concebido pelo Departamento de Metabolismo Ósseo da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM) a partir daquele oriundo do Programa de Diretrizes da Associação Médica Brasileira (AMB) da SBEM. Realizamos uma revisão dos artigos mais relevantes obtidos nos bancos de dados PubMed e Cochrane, além de abstracts apresentados nos encontros anuais da Endocrine Society, da Sociedade Brasileira de Endocrinologia e da American Society for Bone and Mineral Research dos últimos cinco anos, e classificamos as evidências em níveis de recomendações de acordo com a força científica por tipo de estudo, adaptando o primeiro relato do "Oxford Centre for Evidence-based Medicine". Todos os graus de recomendação, incluindo-se o "D", foram basea-dos em evidência científica, sendo as diferenças entre o A, B, C e D devidas exclusivamente ao desenho empregado na geração da evidência. CONCLUSÃO: Apresentamos uma atualização científica a respeito do hiperparatireoidismo primário, classificando e graduando em níveis de recomendações as principais evidências científicas sobre as suas causas, as variadas formas de apresentação, seu diagnóstico e tratamento.

Supernumerary parathyroid glands in hyperparathyroidism associated with multiple endocrine neoplasia type 1 / Paratireoides supranumerárias em hiperparatireoidismo primário associado a neoplasia endócrina múltipla tipo 1

OBJECTIVE: To evaluate frequency, anatomic presentation, and quantities of supernumerary parathyroids glands in patients with primary hyperparathyroidism (HPT1) associated with multiple endocrine neoplasia type 1 (MEN1), as well as the importance of thymectomy, and the benefits of localizing examinations for those glands. METHODS: Forty-one patients with hyperparathyroidism associated with MEN1 who underwent parathyroidectomy between 1997 and 2007 were retrospectively studied. The location and number of supernumerary parathyroids were reviewed, as well as whether cervical ultrasound and parathyroid SESTAMIBI scan (MIBI) were useful diagnostic tools. RESULTS: In five patients (12.2%) a supernumerary gland was identified. In three of these cases (40%), the glands were near the thyroid gland and were found during the procedure. None of the imaging examinations were able to detect supernumerary parathyroids. In one case, only the pathologic examination could find a microscopic fifth gland in the thymus. In the last case, the supernumerary gland was resected through a sternotomy after a recurrence of hyperparathyroidism, ten years after the initial four-gland parathyroidectomy without thymectomy. MIBI was capable of detecting this gland, but only in the recurrent setting. Cervical ultrasound did not detect any supernumerary glands. CONCLUSION: The frequency of supernumerary parathyroid gland in the HPT1/MEN1 patients studied (12.2%) was significant. Surgeons should be aware of the need to search for supernumerary glands during neck exploration, besides the thymus. Imaging examinations were not useful in the pre-surgical location of these glands, and one case presented a recurrence of hyperparathyroidism.

OBJETIVO: Avaliação da frequência, da localização anatômica e do número de paratireoides extranumerárias em pacientes com hiperparatireoidismo primário (HPT1) associado a neoplasia endócrina múltipla tipo 1(NEM1), além da avaliação da importância da timectomia e da utilidade dos exames radiológicos para localização destes. MÉTODOS: Foram avaliados de forma retrospectiva 41 pacientes portadores de NEM1 com HPT1 submetidos a paratireoidectomia entre 1997 e 2007. O número de glândulas supranumerárias encontradas e a sua localização foram revisados, assim como a utilidade do ultrassom cervical e do SESTAMIBI (MIBI) de paratireoide como ferramentas diagnósticas. RESULTADOS: Em cinco pacientes (12,2%) foram identificadas glândulas supranumerárias. Em três destes (40%), as glândulas estavam próximas à glândula tireoide e foram encontradas durante a exploração cirúrgica. Os exames de imagem não foram úteis para a localização destas glândulas. Em um caso, apenas o exame anatomopatológico foi capaz de encontrar uma glândula extranumerária microscópica localizada no timo. No último caso, uma quinta glândula foi ressecada por meio de esternotomia após a recidiva do hiperparatireoidismo, cerca de 10 anos após a paratireoidectomia realizada sem timectomia na ocasião. Neste caso o MIBI detectou esta paratireoide apenas após a recidiva da doença. Em nenhum dos casos o ultrassom cervical foi capaz de detectar glândulas extranumerárias. CONCLUSÃO: A frequência de paratireoides supranumerárias em nossa casuística foi significativa (12,2%). Durante a exploração cervical, o cirurgião deve estar atento para localizar glândulas extranumerárias além do timo. Exames de imagem não foram úteis na localização préoperatória dessas glândulas, e em um caso houve recidiva do hiperparatireoidismo.

Can SPECT change the surgical strategy in patients with primary hyperparathyroidism? / O SPECT pode mudar a estratégia cirúrgica nos pacientes com hiperparatireoidismo primário?

Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in outpatients. It is more common in females, after menopause, and the prevalence is 1 to 4:1000 in the general population. Patients with PHPT have abnormal regulation of PTH secretion, resulting in elevated serum calcium and inappropriately high or normal PTH in relation to the calcium value. Sporadic PTH-secreting adenoma alone accounts for 90% of cases of PHPT, while multiglandular hyperplasia is more common in familial hyperparathyroidism syndromes (5%) and parathyroid carcinomas represent less than 1% of cases. Only after making sure there is functional autonomy of one or more parathyroid glands, localization imaging tests should be performed to guide a possible surgical procedure. It is important to highlight that these tests have limitations and can yield false-positive and false-negative results. There are cases in which the parathyroid gland is difficult to be located, requiring a combination of imaging methods for pre-operative localization, such as 99mTc-pertechnetate, SPECT, SPECT/CT, and US. We describe the case of a 50-year-old female patient diagnosed with PHPT, who underwent a surgical procedure without success, with maintenance of hypercalcemia and hyperparathyroidism. In this case, the hyperfunctioning parathyroid was located in the retrotracheal region only after scintigraphy combined with SPECT/CT were used.

O hiperparatireoidismo primário (HPTP) é a causa mais comum de hipercalcemia diagnosticada ambulatorialmente. É mais frequente no sexo feminino e na pós-menopausa e a prevalência é de 1 a 4:1000 na população geral. O adenoma solitário esporádico secretor de PTH corresponde a 90% dos casos de HPTP, enquanto a doença multiglandular é mais comum nas síndromes de hiperparatireoidismo familiar (5%) e o carcinoma de paratireoide representa menos de 1% dos casos. Somente após a certeza da autonomia funcional de uma ou mais glândulas paratireoides é que devem ser realizados exames de imagem localizatórios, com a finalidade de planejar o procedimento cirúrgico. Além disso, esses exames apresentam limitações e podem resultar em falsos-positivos e negativos. Há casos em que a localização da glândula paratireoide é de extrema dificuldade, sendo necessária a associação de métodos de imagem para localização pré-operatória como o uso do 99mTc-pertecnetato, SPECT, SPECT/CT e a ultrassonografia. Descrevemos um caso de paciente feminina, 50 anos, com diagnóstico de hiperparatireoidismo primário, submetida a um procedimento cirúrgico sem sucesso, com manutenção da hipercalcemia e do hiperparatireoidismo, em que, somente após a realização da cintilografia associada ao SPECT/CT, foi possível localizar a glândula paratireoide hiperfuncionante em região retrotraqueal.

Abordaje periauricular en las lesiones de la glándula parótida / Parothid glan lesions incision aroud ear

Evaluar la posibilidad de resección de las lesiones de la glándula parótida por incisiones periauriculares (grupo I) y valorar las complicacionesin mediatas derivadas de esta técnica, resultados cosméticos y dolor posoperatorio, comparándolas con el abordaje preauricular-transcervical (grupo II). Los 61 pacientes, de ambos sexos, entre julio de 2006 a julio de 2009, fueron sometidos a este estudio prospectivo, aleatorizado doble ciego, evaluando dos grupos, categorizados grupo I yII, haciendo comparaciones en cuanto a dolor posoperatorio según la escala analógica de niveles de dolor, complicaciones relacionadas al nervio facial, posibilidad de resección indistintamente del tipo histológico, del lóbulo afectado, y por último, la satisfacción cosmética. Los 59 pacientes completaron este estudio, no obteniendo diferencias estadísticamente significativas en cuanto al dolor posoperatorio, ni en cuanto a las complicaciones, pero si en lo referido a la visualización de la cicatriz operatoria; 96% de los pacientes (grupo I), refirió satisfacción con el resultado cosmético en comparación con 65% del grupo II; siendo estadísticamente significante. No hubo diferencias en cuanto a la presentación de dolor ni complicaciones posoperatorias en cuanto al abordaje periauricular en comparación a los que se les realizó el abordaje preauricular-transcervical. Fue mayor la manifestación de satisfacción cosmética en el abordaje periauricular, la cual recomendamos, porque no produce dificultades técnicas, indistintamente del sexo, edad, tipo histológico o ubicación de la lesión dentro de la glándula parótida.

To evaluate the possibility of resection of the lesions of the parotid gland by the incisions around the ear (Group I) and assess immediate complications arising fromthis technique, the cosmetics results and the post operative pain, comparing them with the ahead ear - transcervical approach (Group II). In 61 patients of both sex, from July 2006 to July 2009, were subjected to this prospective study, and randomized double blind, evaluating the two groups, categorized group I and II, making comparisons on post operative by the analog levels of the pain, complications related to the facial nerve, possibility of resection regardless of the histological type, the affected lobe, and finally, the cosmetic satisfaction. The 59 patients that completed this study, no statistically significant differences we found in the post operative pain getting. There were no differences also on complications, but if in connection with the post operative scar, the 96%patients (Group I), spoke to us, their satisfaction with the cosmetic outcome compared with 65% of Group II; that being statistically significant. There was no differences as regards the presentation of the painor the post operating complications in the around ear compared to the ahead ear - transcervical approach. The manifestation of cosmetic satisfaction in around ear were approach, we recommend it because it does not produce technical difficulties, without any distinction of sex, age, histological type, or location into the parotid gland.

Parathyroidectomy after kidney transplantation: short-and long-term impact on renal function

INTRODUCTION: Kidney transplantation corrects endocrine imbalances. Nevertheless, these early favorable events are not always followed by rapid normalization of parathyroid hormone secretion. A possible deleterious effect of parathyroidectomy on kidney transplant function has been reported. This study aimed to compare acute and longterm renal changes after total parathyroidectomy with those occurring after general surgery. MATERIALS AND METHODS: This was a retrospective case-controlled study. Nineteen patients with persistent hyperparathyroidism underwent parathyroidectomy due to hypercalcemia. The control group included 19 patients undergoing various general and urological operations. RESULTS: In the parathyroidectomy group, a significant increase in serum creatinine from 1.58 to 2.29 mg/dl (P < 0.05) was noted within the first 5 days after parathyroidectomy. In the control group, a statistically insignificant increase in serum creatinine from 1.49 to 1.65 mg/dl occurred over the same time period. The long-term mean serum creatinine level was not statistically different from baseline either in the parathyroidectomy group (final follow-up creatinine = 1.91 mg/dL) or in the non-parathyroidectomy group (final follow-up creatinine = 1.72 mg/dL). CONCLUSION: Although renal function deteriorates in the acute period following parathyroidectomy, long-term stabilization occurs, with renal function similar to both preoperative function and to a control group of kidney-transplanted patients who underwent other general surgical operations by the final follow up.

Postoperative Complications of Thyroid Cancer in a Single Center Experience

The aim of this study was to investigate the complications following surgical treatment of thyroid cancer and the association between the extent of surgery and complication rates. A total of 2,636 patients who underwent surgery due to thyroid cancer were retrospectively reviewed to identify surgical complications. Complication rates were assessed according to the extent of surgery, which was classified as follows; less-than-total thyroidectomy with central compartment node dissection (CCND) (Group I, n=636), total thyroidectomy with CCND (Group II, n=1,390), total thyroidectomy plus ipsilateral neck dissection (Group III, n=513), and total thyroidectomy plus bilateral neck dissection (Group IV, n=97). The most common surgical complication was symptomatic hypoparathyroidism, of which 28.4% of cases were transient and 0.3% permanent. The other surgical complications included vocal cord palsy (0.7% transient, and 0.2% permanent), hematoma (0.5%), seroma (4.7%), chyle fistula (1.8%), and Horner's syndrome (0.2%). The complication rates increased significantly with increasing the extent of surgery from Group I to Group IV. The more extensive surgery makes more complications, such as hypoparathyroidism, seroma, and others.

Hiperparatiroidismo primario en el adolescente: caso clínico / Primary hyperparathyroidism in an adolescent: report of one case

We report a 13 year-old mate with a history of multiple fractures and kidney stones. The laboratory showed a hypercalcemia of 11.5 mg/dl, a PTH of 112.6 pg/ml and 24 hour urinary calcium of 571 mg. Bone densitometry showed spine and fémur Z scores of -2.9 and -1.6, respectively, kidney ultrasound showed nephrocalcinosis and a MIBI-SPECT scintigram showed a higher uptake in the ríght lower parathyroid gland. The diagnosis of primary hyperparathyroidism was made and the patient was operated, excising the ríght lower parathyroid gland. After surgery, serum calcium and PTH levels returned to normal values. In children, the proportion of cases with parathyroid hyperplasia is higher than in adults. Therefore, during surgery all four parathyroid glands must be explored. There is also a higher frequency of ectopic adenomas. Family history must be explored to discard the presence of a multiple endocrine neoplasia (MEN I or II), a familial hyperparathyroidism or a syndrome of primary hyperparathyroidism associated to mandibular tumor.

[Profile of graves disease in the region of kairouan: about 186 cases]

In this retrospective study we tried to determine the epidemiologic, clinical, therapeutic and evolutive features in 186 patients with Graves disease [GD] followed at the ibn el Jazzar hospital in Kairouan during 15 years. GD represents the most frequent cause of hyperthyroidism [67%], mainly in young adults [mean age: 35.8 +/- 12.3 years] with a clear female prevalence [83.9%]. The diagnosis is suggested clinically in presence of a homogeneous [80.6%] and vascular [61.2%] goitre associated or not with an exophtalmy [52.2%]. The most frequent clinical signs of hyperthyroidism are weight loss [81.2%], tachycardia [86%], asthenia [74.4%] and tremor [55.9%]. R-TSH antibodies testing was performed in 35 patients with a rate of positivity of 91,4%. Thyroid scintiscanning was practised in 77,5% of the cases and echography in 23,4%. Antithyroid drug therapy was the only management in 51,5% of the cases with a rate of euthyroidism of 67% [mean follow up of 58,2 months]. Radioactive iodine was given in the event of failure of the Antithyroid drug therapy in 35,8% of the cases with 38.7% of hypothyroidism [mean follow up of 54,6 months]. The surgical treatment was a subtotal thyroidectomy in 89,5% of the cases with euthyroidism in 22.2% of the cases and hypothyroidism in 77.8% [mean follow up of 53.4 months]; hypoparathyroidism represented the major complication of the surgery [transient: 15.9% and definitive: 5.3%]

Unilateral accessory lobe and unusual isthmus of thyroid gland: a cadaver study

The thyroid gland is known to exhibit various congenital malformations with regard to its lobes, isthmus and ectopic sites. Knowledge of variations in topographical anatomy of thyroid gland is essential for safe surgery and logical interpretation of scintiographs. To study the anomalous isthmus and accessory lobe of the thyroid gland. The thyroid gland was studied for presence of any accessory lobe and abnormal isthmus in 40 cadavers over a period of five years. We observed a single case of accessory lobe of thyroid gland with unusual isthmus

Experiencia con la cirugía radioguiada mínimamente invasiva de paratiroides / Minimally invasive radioguided parathyroidectomy

Antecedentes: El hiperparatiroidismo primario es causado por un adenoma único en alrededor del 90 por ciento de los casos; debido a la más precisa localización preoperatoria, se ha cuestionado la exploración cervical bilateral en todos los enfermos. Objetivos: Presentar la técnica y los resultados de la paratiroidectomia radioguiada mínimamente invasiva (PRM) en el tratamiento del hiperparatiroidismo primario. Lugar y aplicación: Servicio de cirugía oncológica. Diseño: Observacional retrospectivo. Población: 54 pacientes consecutivos operados por hiperparatiroidismo primario: 49 para tratamiento primario y 5 por recidiva. Método: Ecografía y centellograma con Sesta MIBI preoperatorios y paratiroidectomía radioguiada con cámara manual para detección de radiaciones gamma. Resultados: La cámara manual localizó al adenoma en el 88,8 por ciento de los casos, mientras que la ecografía y el centellograma lo hicieron en el 76 y 87 por ciento respectivamente. La combinación de los tres métodos permitió ubicar el adenoma en toda la serie; en 15 oportunidades fue necesario prolongar la cervicotomía por patología tiroidea sincrónica y en 2 por carcinoma de paratiroides. Conclusiones: La PRMI es una técnica complementaria de los estudios preoperatorios