Weight difference between double parathyroid adenomas is the cause of false-positive IOPTH test after resection of the first lesion.

BACKGROUND: Some patients with double parathyroid adenoma show a greater than 50% decline in intraoperative parathyroid hormone (IOPTH) after resection of the first lesion. The present study was designed to test the hypothesis that significant adenoma weight differences may explain this inappropriate decline of IOPTH. METHODS: We reviewed prospective database records at two tertiary institutions. Patients with a histopathologic diagnosis of double adenoma and no familial history of hyperparathyroidism were included. Diagnosis of double adenoma was confirmed either preoperatively (double uptake), intraoperatively (bilateral exploration), or at reintervention. IOPTH was determined following the Miami protocol. The 10-min postexcision sample was considered as the 0-min sample for IOPTH determinations at the time of resection of the second lesion. RESULTS: Thirteen patients met the inclusion criteria. After resection of the first lesion, IOPTH failed to decline in four patients and a second adenoma was removed. They had similar weight (404 vs. 598 mg). In nine patients IOPTH showed a false greater than 50% decline. These patients had the largest adenoma removed first (846 +/- 226 mg), and only two had normal PTH serum concentrations 10 min after resection. The second adenoma was always smaller (284 +/- 177 mg; P = 0.02) and its resection either during the same operation (7 cases) or at reoperation (2 cases) led to normalization of IOPTH at 10 min in all cases. CONCLUSIONS: Two-thirds of patients with double parathyroid adenoma show a false-positive decline of IOPTH after resection of the first adenoma. This appears to be due to the initial removal of the larger lesion.

Valor de la ecoendoscopia transesofágica en el diagnóstico de localización en el hiperparatiroidismo primario / Oesophageal endoscopic ultrasound in the accurate location of primary hyperparathyroidism (HPT)

Objetivos. Considerar la utilidad de la ecoendoscopia trasesofágica en la localización del hiperparatiroidismo primario recidivado o persistente. Material y método Durante 7 años consecutivos, hemos intervenido a 352 pacientes con hiperparatiroidismo primario (HPP). Sistemáticamente se realiza gammagrafía paratiroidea con 99Tc-sestamibi preoperatorio y determinación intraoperatoria de paratirina. Sólo 5 (1,4%) pacientes han presentado problemas de localización: 3 por persistencia tras cirugía paratiroidea, 1 por recidiva y 1 por HPP con antecedente de hemitiroidectomía derecha. Antes de indicar una cervicotomía exploradora, se decide la realización de una ecoendoscopia trasesofágica para intentar una localización definitiva. Resultados La ecoendoscopia detecta una imagen clara de adenoma con localización precisa en 4 pacientes. Sólo en 1 paciente no se visualiza tumoración. Los 5 pacientes fueron intervenidos. Se confirmó la exactitud del diagnóstico en los 4 pacientes con visualización positiva. La exploración quirúrgica del quinto paciente resultó ser una paratireosis. Los 5 pacientes tuvieron un postoperatorio favorable, sin lesiones recurrenciales ni morbilidad asociada a la ecoendoscopia. Conclusiones La ecoendoscopia trasesofágica resulta muy útil en los hiperparatiroidismo que presenta dificultades para localizar la glándula patológica, especialmente en casos con alteración anatómica por cirugía previa. Así, ayuda a que el cirujano pueda explorar la zona sospechosa de forma más selectiva y más eficiente (AU)

Aim. Our aim was to estimate the usefulness of oesophageal endoscopic ultrasound in the accurate location of recurrent or persistent primary hyperparathyroidism (HPT).Material and methodA total of 352 patients with primary hyperparathyroidism were operated on over the last seven years. A preoperative parathyroid 99Tc- sestamibi gammagraphy and an intraoperative PTH determination were performed routinely. Only 5 patients (1.4%) had localization problems: three with persistent HPT after parathyroid extirpation, one recurrent HPT and one HPT after a right hemithyroidectomy. An oesophageal endoscopic ultrasound was carried out before any new exploratory neck surgery in order to find the definitive location. Results The endoscopic ultrasound showed a clear image of adenoma with an accurate location in four patients. No tumour was present in one patient. All five patients were operated on. The exact location was confirmed in the four patients with positive endoscopic ultrasound images. The fifth surgical exploration revealed a parathyreosis. All five patients had a favourable post-operative period, with no nerve lesions or morbidity associated with the endoscopic ultrasound. Conclusions Oesophageal endoscopic ultrasound is a very useful diagnostic tool in HPT patients with location problems, particularly in cases having anatomical changes due to previous surgery. It is a procedure that helps the surgeon to make a more selective and efficient exploration of parathyroid glands (AU)

[Oesophageal endoscopic ultrasound in the accurate location of primary hyperparathyroidism (HPT)]. / Valor de la ecoendoscopia transesofágica en el diagnóstico de localización en el hiperparatiroidismo primario.

AIM: Our aim was to estimate the usefulness of oesophageal endoscopic ultrasound in the accurate location of recurrent or persistent primary hyperparathyroidism (HPT). MATERIAL AND METHOD: A total of 352 patients with primary hyperparathyroidism were operated on over the last seven years. A preoperative parathyroid 99Tc- sestamibi gammagraphy and an intraoperative PTH determination were performed routinely. Only 5 patients (1.4%) had localization problems: three with persistent HPT after parathyroid extirpation, one recurrent HPT and one HPT after a right hemithyroidectomy. An oesophageal endoscopic ultrasound was carried out before any new exploratory neck surgery in order to find the definitive location. RESULTS: The endoscopic ultrasound showed a clear image of adenoma with an accurate location in four patients. No tumour was present in one patient. All five patients were operated on. The exact location was confirmed in the four patients with positive endoscopic ultrasound images. The fifth surgical exploration revealed a parathyreosis. All five patients had a favourable post-operative period, with no nerve lesions or morbidity associated with the endoscopic ultrasound. CONCLUSIONS: Oesophageal endoscopic ultrasound is a very useful diagnostic tool in HPT patients with location problems, particularly in cases having anatomical changes due to previous surgery. It is a procedure that helps the surgeon to make a more selective and efficient exploration of parathyroid glands.

Tumor adrenal productor de corticotropina determinante de síndrome de Cushing / Cushing’s syndrome due to an ACTH-producing adrenal tumor

No disponible

The pattern of the descent of PTH measured by intraoperative monitoring of intact-PTH in surgery for renal hyperparathyroidism.

BACKGROUND: In the setting of total parathyroidectomy and autotransplantation surgery (TPTxAS) treatment for secondary hyperparathyroidism (SHPT) we evaluated whether intraoperative parathyroid hormone (iPTH) monitoring is an useful tool as a reference for total parathyroid removal. DESIGN: Prospective open single value measurement efficacy study of one intraoperative (i.o.) diagnostic monitoring method (iPTH) on a cohort of surgical patients. PATIENTS: All patients (n = 35) undergoing TP and SCTx at the Department of Surgery, Donostia Hospital from January 2002 to December 2006. MAIN OUTCOME MEASURES: Serum levels of iPTH during surgery and prediction time of the of descent of PTH levels (measured in the clinic, at admission day and intra-operatively during induction of anesthesia, and every 5 and 10 minutes after removal of adenoma and 24 hours thereafter) were analyzed. RESULTS: iPTH levels dropped clearly at ten minutes in all 35 patients and were non-measurable at 24 hours. iPTH decreased from pathological (1302.24 + 424.9 pg/ml) to half (50%) the values at the third intra-operative determination - minute 10 - (614.8 ± 196.62) and was undetectable at 24 hours. CONCLUSIONS: Intra-operative measurement of iPTH is useful in the prediction of complete removal of all parathyroid tissue prior to autotransplantation thus avoiding persistence because of incomplete surgery.

[Modifications in intact parathyroid hormone, total serum calcium, and ionized calcium levels in the surgery of primary hyperparathyroidism for single adenoma]. / Modificaciones de paratirina intacta, calcio sérico total y calcio ionizado en la cirugía por hiperparatiroidismo primario por adenoma único.

INTRODUCTION: We evaluated total serum calcium (TSC) and ionized calcium (IC) and their correlation with intraoperative intact parathyroid hormone (iPTH) in the surgery of primary hyperparathyroidism in patients with a single adenoma. MATERIAL AND METHOD: We performed a prospective, blind trial with determination of iPHT, TSC and IC in a cohort of surgical patients (n = 279; 244 were valid for the study) who underwent surgery in the Department of Surgery, Hospital de Cruces, between October 1999 and April 2006. Total calcium, ionic calcium and iPTH were measured in the outpatient department, on admission and intraoperatively (at anesthesia induction and every 5 minutes after surgical excision). RESULTS: Levels of calcium and iPTH were corrected in 234 (95.9%) patients. iPTH decreased from abnormal preoperative values of 294.43 +/- 286.38 pg/ml to 97.89 +/- 121.01 mg/dl (minute 5), 58.58 +/- 58.37 pg/ml (minute 10), 44.62 +/- 54.77 pg/ml (minute 15), and 38.42 +/- 51.72 pg/ml (minute 20). TSC decreased from preoperative values of 10.93 +/- 1.04 mg/dl to 10.2 +/- 0.97 mg/dl (minute 5), 10.17 +/- 1.00 mg/dl (minute 10), 10.12 +/- 0.98 mg/ml (minute 15), and 10.09 +/- 1.03 mg/ml (minute 20). The results for ionized calcium were as follows: 4.90 +/- 0.63 mg/dl at induction, 4.84 +/- 0.61 mg/dl (minute 5), 4.84 +/- 0.66 mg/dl (minute 10), 4.82 +/- 0.63 mg/dl (minute 15), and 4.82 +/- 0.63 mg/dl (minute 20). Frozen samples were conclusive for parathyroid tissue (19.56 +/- 15.3 after excision). CONCLUSIONS: Intraoperative total calcium levels may help to predict adequate elimination of parathyroid tissue in primary hyperparathyroidism when intraoperative iPTH is not available. Ionized calcium levels did not show the same decrease.

Modificaciones de paratirina intacta, calcio sérico total y calcio ionizado en la cirugía por hiperparatiroidismo primario por adenoma único / Modifications in intact parathyroid hormone, total serum calcium, and ionized calcium levels in the surgery of primary hyperparathyroidism for single adenoma

Introducción. Evaluamos el calcio total en suero (CTS) y el calcio ionizado (CI) y su correlación con la paratirina intacta (iPTH) intraoperatoria en la cirugía del hiperparatiroidismo primario seleccionando los casos que correspondieron a adenoma único. Material y método. Ensayo prospectivo, determinando (iPTH, CTS y CI) y con enmascaramiento en una cohorte de pacientes quirúrgicos (n = 279; 244 válidos para el estudio) que fueron intervenidos en el Departamento de Cirugía del Hospital de Cruces (octubre de 1999 a abril de 2006). Se valoró: CTS, CI e iPTH medida en consulta, en admisión e intraoperatoriamente: inducción anestésica, y cada 5 min tras la exéresis quirúrgica. Resultados. Se logró corregir las concentraciones de calcio e iPTH en 234 (95,9%) pacientes. La iPTH descendió de valores patológicos preoperatorios 294,43 ± 286,38 pg/ml a 97,89 ± 121,01 mg/dl (minuto 5), 58,58 ± 58,37 pg/ml (minuto 10), 44,62 ± 54,77 pg/ml (minuto 15) y 38,42 ± 51,72 pg/ml (minuto 20). El CTS descendió de valores preoperatorios: 10,93 ± 1,04 mg/dl a 10,2 ± 0,97 mg/dl (minuto 5), 10,17 ± 1,00 mg/dl (minuto 10), 10,12 ± 0,98 mg/ml (minuto 15) y 10,09 ± 1,03 mg/ml (minuto 20). El CI ofreció los siguientes resultados: de 4,90 ± 0,63 mg/dl en tiempo de inducción a 4,84 ± 0,61 mg/dl (minuto 5), 4,84 ± 0,66 mg/dl (minuto 10), 4,82 ± 0,63 mg/dl (minuto 15) y 4,82 ± 0,63 mg/dl (minuto 20). Las muestras congeladas fueron concluyentes para tejido paratiroideo (19,56 ± 15,3 tras la exéresis). Conclusiones. La determinación intraoperatoria de CT puede ser de ayuda para predecir la eliminación adecuada de tejido paratiroideo en el hiperparatiroidismo primario cuando no sea posible la determinación intraoperatoria de iPTH. El CI no muestra la misma pauta de descenso (AU)

Introduction. We evaluated total serum calcium (TSC) and ionized calcium (IC) and their correlation with intraoperative intact parathyroid hormone (iPTH) in the surgery of primary hyperparathyroidism in patients with a single adenoma. Material and method. We performed a prospective, blind trial with determination of iPHT, TSC and IC in a cohort of surgical patients (n = 279; 244 were valid for the study) who underwent surgery in the Department of Surgery, Hospital de Cruces, between October 1999 and April 2006. Total calcium, ionic calcium and iPTH were measured in the outpatient department, on admission and intraoperatively (at anesthesia induction and every 5 minutes after surgical excision). Results. Levels of calcium and iPTH were corrected in 234 (95.9%) patients. iPTH decreased from abnormal preoperative values of 294.43 ± 286.38 pg/ml to 97.89 ± 121.01 mg/dl (minute 5), 58.58 ± 58.37 pg/ml (minute 10), 44.62 ± 54.77 pg/ml (minute 15), and 38.42 ± 51.72 pg/ml (minute 20). TSC decreased from preoperative values of 10.93 ± 1.04 mg/dl to 10.2 ± 0.97 mg/dl (minute 5), 10.17 ± 1.00 mg/dl (minute 10), 10.12 ± 0.98 mg/ml (minute 15), and 10.09 ± 1.03 mg/ml (minute 20).The results for ionized calcium were as follows: 4.90 ± 0.63 mg/dl at induction, 4.84 ± 0.61 mg/dl (minute 5), 4.84 ± 0.66 mg/dl (minute 10), 4.82 ± 0.63 mg/dl (minute 15), and 4.82 ± 0.63 mg/dl (minute 20). Frozen samples were conclusive for parathyroid tissue (19.56 ± 15.3 after excision). Conclusions. Intraoperative total calcium levels may help to predict adequate elimination of parathyroid tissue in primary hyperparathyroidism when intraoperative iPTH is not available. Ionized calcium levels did not show the same decrease (AU)

Parathyroid graft function after presternal subcutaneous autotransplantation for renal hyperparathyroidism.

HYPOTHESIS: Presternal subcutaneous autotransplantation of parathyroid tissue after total parathyroidectomy for renal hyperparathyroidism could be at least as effective as intramuscular grafting, without its complications. DESIGN: Prospective study of a postoperative diagnostic method of monitoring intact parathyroid hormone (iPTH) levels among a cohort of surgical patients, without loss to follow-up. SETTING: Hemodialysis unit in a university hospital. PATIENTS: Twenty-five patients (17 women and 8 men) underwent total parathyroidectomy and presternal subcutaneous autotransplantation for renal hyperparathyroidism at Donostia Hospital, San Sebastián, Spain, between January 1, 2002, and June 30, 2004. MAIN OUTCOME MEASURES: Evaluation of parathyroid graft function by measurement of serum iPTH levels at admission and 24 hours and 1, 3, 5, 15, 30, and 60 weeks after surgery. RESULTS: The mean +/- SD preoperative serum iPTH level was 1302 +/- 425 pg/mL; the iPTH level was undetectable in all patients 24 hours after surgery. Subsequent mean +/- SD iPTH levels obtained were 14 +/- 10 pg/mL after 1 week, 54 +/- 1 pg/mL after 5 weeks, 64 +/- 9 pg/mL after 15 weeks, 77 +/- 8 pg/mL after 30 weeks, and 106 +/- 21 pg/mL after 60 weeks. Autotransplanted parathyroid tissue appears to be adequately functional at week 5 (criterion level of adequate functioning, 50 pg/mL). CONCLUSIONS: Presternal subcutaneous autotransplantation after total parathyroidectomy for renal hyperparathyroidism may be an alternative to avoid musculus brachialis grafting and its complications. Our functional results compare favorably with the published data on other surgical techniques for the treatment of renal hyperparathyroidism. Long-term follow-up of this series is planned.

Ausencia-desaparición de la vesícula biliar en un paciente diagnosticado de colelitiasis / Absence/disappearance of gallbladder in a patient diagnosed with cholelithiasis

Se presenta el caso de un paciente, con diagnóstico de colelitiasis, en quien no se encuentra quirúrgicamente la vesícula biliar durante una colecistectomía por laparoscopia ni tras su reconversión a cirugía abierta. Se descarta la ectopia vesicular y se discute la posibilidad de que se trate de un caso de agenesia vesicular. Sin embargo, al paciente se le han realizado 4 ecografías previas dentro de un protocolo de tratamiento con octreóctida y en ellas hay coincidencia en la presencia de la vesícula biliar. Se apunta la eventualidad de una lisis total de vesícula tras un proceso inflamatorio, y se recuerdan los criterios de Frey para la agenesia vesicular. Creemos que estamos ante un caso de lisis completa de la vesícula tras un proceso inflamatorio (AU)

We report the case of a patient with preoperatively demonstrated cholecystitis due to cholelithiasis but with no presence of gallbladder at laparoscopy or on conversion to open surgery. Gallbladder ectopy was ruled out and the possibility of gallbladder agenesia was discussed. However, four preoperative ultrasound scans performed within a protocol of treatment with octreotide, in the setting of acute cholecystitis, ruled out this possibility. We discuss the possibility of gallbladder destruction and digestion after a severe inflammatory process, as well as Frey's criteria for gallbladder agenesia. We believe that this is a case of complete gallbladder lysis due to an inflammatory process (AU)

Intraoperative monitoring of intact PTH in surgery for renal hyperparathyroidism as an indicator of complete parathyroid removal.

In the setting of total parathyroidectomy and autotransplantation surgery (TPT x AS) as treatment for secondary hyperparathyroidism (SHPT), we evaluated whether intraoperative parathyroid hormone (iPTH) monitoring is useful as a reference for total parathyroid removal. We conducted a prospective, open, single value measurement efficacy study of the intraoperative (i.o.) diagnostic monitoring of iPTH in a cohort of surgical patients. All patients (n = 25) underwent TPT x AS at the Department of Surgery, Donostia Hospital from January 2002 to October 2004. The primary outcome measures were kinetics of serum levels of iPTH during surgery and prediction time of the of descent of PTH levels (measured in the clinic on the day of admission and intraoperatively during induction of anesthesia, every 5 and 10 minutes after removal of the adenoma, and again 24 hours thereafter). iPTH levels returned to normal in all 25 patients, decreasing from pathological levels at the beginning of the operation (1302.24 + 424.9 pg/ml) to half (50%) values at the third intraoperative determination, minute 10 (614.8 +/- 196.62), becoming undetectable at 24 hours. Frozen sections were conclusive for parathyroid tissue (20.56 + 10.3 minutes after removal). Intraoperative measurement of iPTH is useful in the prediction complete removal of all parathyroid tissue prior to autotransplantation, thus avoiding persistence of disease because of incomplete surgery.

[Absence/disappearance of gallbladder in a patient diagnosed with cholelithiasis]. / Ausencia-desaparición de la vesícula biliar en un paciente diagnosticado de colelitiasis.

We report the case of a patient with preoperatively demonstrated cholecystitis due to cholelithiasis but with no presence of gallbladder at laparoscopy or on conversion to open surgery. Gallbladder ectopy was ruled out and the possibility of gallbladder agenesia was discussed. However, four preoperative ultrasound scans performed within a protocol of treatment with octreotide, in the setting of acute cholecystitis, ruled out this possibility. We discuss the possibility of gallbladder destruction and digestion after a severe inflammatory process, as well as Frey's criteria for gallbladder agenesia. We believe that this is a case of complete gallbladder lysis due to an inflammatory process.

Intraoperative monitoring of kinetic total serum calcium levels in primary hyperparathyroidism surgery.

BACKGROUND: In the setting of minimal approach Sestamibi-guided parathyroid surgery for primary hyperparathyroidism we evaluated if total serum calcium level monitoring is as valuable as intraoperative parathyroid hormone (iPTH) monitoring. STUDY DESIGN: Prospective open single-blinded efficacy trial of two intraoperative diagnostic monitoring methods (iPTH and total serum calcium level) on a cohort of surgical patients. All patients (n = 35) were undergoing parathyroid surgery at the Department of General Surgery at B Cruces' Hospital, Vizcaya, Spain, between October 1999 and March 2001. Kinetics of serum levels of Ca and iPTH during surgery and time of prediction of cure for each method (measured in the clinic, admission, and intraoperatively, such as induction of anesthesia, and every 5 minutes after removal of adenoma) were analyzed. RESULTS: Hypercalcemia and iPTH levels became corrected in 34 patients. Average serum calcium levels dropped from pathologic 11.07 +/- 0.41 mg/dL (mean +/- standard deviation) to normal values 9.7 +/- 0.82 mg/dL during the first intraoperative determination (minute 5), but mean iPTH decreased from pathologic (192 +/- 98 pg/mL) to normal values (39.93 +/- 25.12 pg/mL) during the third intraoperative determination (minute 15). Serum calcium level at 5 minutes after removal decreased by 100% in 34 patients, but iPTH only showed a similar drop during the third determination at 15 minutes. Frozen sections were conclusive for parathyroid tissue (20.56 +/- 10.3 minutes after removal). CONCLUSIONS: Intraoperative measurement of total calcium level might be an easier and less expensive method than iPTH measurement in the prediction of cure during surgery for primary hyperparathyroidism resulting from adenoma.