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      A Retrospective Study of the Impact of Intraoperative Intact Parathyroid Hormone Monitoring During Total Parathyroidectomy for Secondary Hyperparathyroidism : STARD Study

      research-article
      , MD, , MD, PhD, , MD, , MD, PhD, , MD, PhD
      Medicine
      Wolters Kluwer Health

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          Abstract

          The study aimed to evaluate the diagnostic accuracy of intraoperative intact parathyroid hormone (IO-iPTH) in patients with secondary hyperparathyroidism (HPT).

          The cut-off for IO-iPTH monitoring remains unknown.

          This was a single-center retrospective review of 226 consecutive patients (107 males and 119 females) who underwent parathyroidectomy data for secondary HPT between May 2010 and March 2014. The predetermined cut-off for IO-iPTH was a 70% IO-iPTH drop from baseline 10 minutes after total parathyroidectomy and thymectomy. We used <60 pg/mL iPTH value on postoperative day 1 (POD1) as an indicator of successful removal of parathyroid glands and reviewed the frequency of reoperation other than in autografted sites during the observation period. This study was based on the Standards for the Reporting of Diagnositic accuracy compliant.

          The reoperation rate in patients with >60 pg/mL iPTH value (POD1) was significantly higher than that in patients with <60 pg/mL iPTH value (POD1), (13.0% versus 0.5% P = 0.003). Sensitivity, specificity, and accuracy of >70% IO-iPTH drop were 97.5%, 52.2%, and 92.9%, respectively, this criterion was demonstrated to be beneficial in 26 patients. In 5 patients, <70% IO-iPTH drop was observed and further exploration enabled sufficient removal of parathyroid glands. In 21 patients, although fewer than 4 parathyroid glands were removed after enough explorations, >70% IO-iPTH drop enabled termination of operations and iPTH value (POD1) was <60 pg/mL.

          An iPTH value of <60 pg/mL (POD1) was a good predictor for successful parathyroidectomy. A 70% IO-iPTH drop from the baseline was appropriate to determine sufficient parathyroid gland removal during parathyroidectomy for patients with secondary HPT.

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          Most cited references22

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          Incidence and location of ectopic abnormal parathyroid glands.

          Ectopic parathyroid glands are a cause for failed parathyroid exploration. Patients with hyperparathyroidism and ectopic parathyroid glands were identified from a parathyroid database. Laboratory data, gland weights, and surgical outcomes were obtained. The locations of the ectopic glands were correlated with results of technetium-99m-sestamibi imaging. Of 231 patients operated on for hyperparathyroidism, 37 (16%) had ectopic parathyroid glands. Ectopic inferior glands (N = 23 [62%]) were intrathymic, n = 7 (30%); anterosuperior mediastinal, n = 5 (22%); intrathyroidal, n = 5 (22%); within the thyrothymic ligament, n = 4 (17%); and submandibular, n = 2 (9%). Ectopic superior glands (N = 14 [38%]) were in the tracheoesophageal groove, n = 6 (43%); retroesophageal, n = 3 (22%); posterosuperior mediastinal, n = 2 (14%); intrathyroidal, n = 1 (7%); in the carotid sheath, n = 1 (7%); and paraesophageal, n = 1 (7%). Sestamibi scans were true-positive in 81%, identifying 13 of 16 retrosternal glands, and false-negative in 19%. A 16% incidence of ectopic parathyroid glands and a 100% positive predictive value of sestamibi scintigraphy underscore the importance of sestamibi imaging in patients with primary hyperparathyroidism.
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            The anatomic basis of parathyroid surgery.

            C. Wang (1976)
            A study of 645 normal adult parathyroid glands in 160 cadavers revealed that there is a definite pattern of anatomic distribution on the basis of the embryologic development of the parathyroid, thyroid, and thymic glands. The sites of predilection of the upper gland (Parathyroid IV) are, in order of frequency, the cricothyroid junction; the dorsum of the upper pole of the thyroid; and the retropharyngeal space. Those of the lower gland (Parathyroid III) are at the lower pole of the thyroid and the thymic tongue; rarely in the upper, the lateral neck, or the mediastinum. An understanding of the developmental relationship of the parathyroid glands to the thyroid and the thymus is fundamental in the delineation of the embryologic origin of the parathyroid glands. The parathyroid gland, located within the surgical capsule of the thyroid (subcapsular), when diseased, remains in place locally. A gland outside of the capsule (extracapsular) is often displaced into the posterior or anterior mediastinum. A collective assessment of the size, weight, color, shape, and consistency of the parathyroid gland is mandatory in the determination of its normalcy. Frozen section examination for stromal and intracellular fatty content is an added assurance of normalcy. That parathyroid glands sink in saline solution, and fat globules float, may aid in differentiating the two types of tissue. Supernumerary, fused, and intrathyroidal parathyroids, albeit rare, are of surgical importance.
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              Surgical anatomy of human parathyroid glands.

              In an autopsy study of 503 cases the parathyroid glands were dissected, and the number of glands in each case and the anatomic distribution of the glands were recorded. In 18 cases (3%) only three glands were found. In these cases the lower combined weight suggested that a fourth gland had been missed. In 421 cases (84%) there were four glands and in 64 cases (13%) there were supernumerary glands. Most often the supernumerary gland was a fifth gland, usually in the thymus. The anatomic distribution of the glands showed considerable constancy. The positions of the glands on the one side were symmetrical with those on the other side in approximately 80% of cases. The superior parathyroids were frequently found just above the intersection between the recurrent laryngeal nerve and the inferior thyroid artery. The inferior parathyroids most often lay somewhat more ventrally, close to the lower thyroid pole or in the upper thymus or thyrothymic ligament. In a few cases the lower parathyroids were situated higher up in the neck, obviously because of a failure of descent during the embryologic development. In view of the number of supernumerary glands and their location, it is concluded that wide excision of fat tissue surrounding the parathyroids and thymectomy should be performed during operation in patients with hyperparathyroidism secondary to uremia or those with multiple endocrine neoplasia syndromes.
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                Author and article information

                Journal
                Medicine (Baltimore)
                Medicine (Baltimore)
                MEDI
                Medicine
                Wolters Kluwer Health
                0025-7974
                1536-5964
                July 2015
                24 July 2015
                : 94
                : 29
                : e1213
                Affiliations
                From the Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital (TH, YT, MO, TY); and Department of Transplant Immunology, Nagoya University School of Medicine, Showa-ku, Nagoya, Aichi, Japan (TK).
                Author notes
                Correspondence: Takahisa Hiramitsu, Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 466-8650 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, Japan (e-mail: thira@ 123456nagoya2.jrc.or.jp ).
                Article
                01213
                10.1097/MD.0000000000001213
                4603015
                26200645
                f5aeb88d-a177-4c7e-8bfd-1b7e3657580a
                Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

                This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

                History
                : 23 February 2015
                : 22 May 2015
                : 27 June 2015
                Categories
                7100
                Research Article
                Diagnostic Accuracy Study
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