[Anatomic localization of parathyroid adenomas. Experience of 1200 cases of primary hyperparathyroidism]

From 1969 to December 1988 1200 patients were successfully operated on for primary hyperparathyroidism. In 1086 cases the parathyroid lesion was an adenoma and in 252 cases (23.2%) we considered this adenoma in an unusual location. Analysis of the patient's records enables us to describe the operative difficulties for each of those locations, and to assess the value of complementary investigations in the patients whose adenomas are difficult to find.

Secondary hyperparathyroidism: diagnosis of site of recurrence

Persistent or recurrent hyperparathyroidism after total parathyroidectomy with forearm implant may be caused by hyperplastic grafted tissue, residual parathyroid tissue left in the neck or the presence of a supernumerary gland not found during surgery. A correct assessment of graft function is needed to localize the source of hormone excess and to avoid an unnecessary neck reoperation in cases of graft dependent hyperparathyroidism. In 12 patients with relapsing hyperparathyroidism after total parathyroidectomy with forearm implant, total ischemic blockade of the arm bearing the parathyroid graft produced a "transitory implantectomy" with a significant reduction of serum levels of intact PTH in those with graft hyperfunction. In 6 patients with proved supernumerary glands, total ischemia of the graft was not followed by significant changes in intact PTH. Hyperparathyroidism was reversed after surgical resection of the parathyroid implants in the 6 patients with positive responses to the ischemic maneuver. A repeat neck reoperation removing cervical or mediastinal supernumerary glands was followed by control of recurrent hyperparathyroidism in the 6 patients with a negative response to the ischemic blockade. Total ischemic blockade of the arm bearing the parathyroid graft is a valuable method for a correct assessment of graft function after total parathyroidectomy with forearm autotransplantation.

[Tracheal injury caused by intubation for compressive endothoracic goiter]

The tube cannot pass along the marked curve of the trachea, which is displaced by a large goiter extending into the posterior mediastinum. The trachea is perforated in a low thoracic location. Tracheal suture and exeresis of the goiter are performed through sternotomia. This serious accident seems to be exceptional. Can it be predicted?

Ventricular septal defect associated with aortic valve incompetence: results of two surgical managements

Aortic valve insufficiency with ventricular septal defect is usually treated by plication of the commissures. However, long-term deterioration is common. We propose a new technique that corrects the aortic annulus dilatation and the leaflet prolapse and reinforces the sinus of Valsalva. Two groups were compared: group I (29 patients) had plication of the prolapsed leaflet(s) and folding of the free edge; group II (26 patients) had triangular resection of the prolapse cusp, annuloplasty, and reinforcement of the aortic wall. The two groups were similar with regarding to preoperative clinical data. There was no perioperative mortality. Primary failure (aortic valve replacement) occurred in 8 patients in group I (28%) and in 2 patients in group II (8%). The rate of secondary failure was 31% in group I and 4% in group II. The actuarial rate of freedom from reoperation at 5 years is 55% in group I and 88% in group II (p less than 0.05). The late mortality was 6.5% in group I and 10.9% in group II (no difference). We conclude that aortic valve insufficiency with ventricular septal defect is a malformation of the aortic leaflets, the annulus, and the sinus of Valsalva, and that the proposed technique offers a better result than the usual methods in terms of residual aortic valve insufficiency.

[Surgery of endomyocardial fibrosis. Apropos of 32 cases]

From 1971 to 1984, 32 patients with endomyocardial fibrosis (EMF) were treated by endocardial resection (decortication) and valve replacement. The population consisted in 20 men and 12 women (age ranged from 8 to 64); 19 patients were european and 13 african. All were symptomatic, 78 p. 100 in stages III or IV of the NYHA. Hypereosinophilia was detected in 21 patients and its cause was determined in 11 cases. Cardiac involvement was biventricular in 22 patients and monoventricular in 10 patients. Six patients died in the immediate postoperative period and 6 late deaths were observed, owing to extracardiac causes in 4. There were no recurrence of EMF. Despite a high mortality rate, the authors suggest that all symptomatic EMF should benefit from endocardial resection.

Beta 2-microglobulin amyloidosis: a sternoclavicular joint biopsy study in hemodialysis patients

The incidence of beta 2-microglobulin deposits appears to increase with time on dialysis. However, the precise prevalence of the disease is not known at present because adequate, noninvasive diagnostic procedures are still lacking. We performed systematic synovial biopsies of the sternoclavicular joint during surgical parathyroidectomy in 22 chronic hemodialysis patients with severe hyperparathyroidism. Nine of the patients proved to have beta 2-microglobulin amyloid deposits as demonstrated by Congo red staining and by immunofluorescence. They had undergone dialysis for longer time periods (12.6 vs 8.5 years, p less than 0.02) and tended to be older than the 13 amyloid-negative patients. They also had a significantly higher body aluminum overload, as demonstrated by a higher increase of plasma aluminum after desferrioxamine infusion. Finally, the presence of Congo-red-positive deposits correlated well with clinical and x-ray findings suggestive of dialysis amyloidosis.

[Vicissitudes of the surgery of primary hyperparathyroidism]

The difficult and disappointing cases encountered in patients who were operated upon for hyperparathyroidism between 1960 and 1987 have been studied. Ninety two patients underwent negative cervicotomy. Among the 12 patients who underwent a second operation, 4 were found to have cervical adenomas and in 6 others mediastinal adenomas were discovered by sternotomy. Most of the other cases were diagnostic errors. The present frequency of negative surgical operations is very low: 2 to 3 per cent of the cases; errors of diagnosis are exceptional, and the unusual sites of adenomas are better known. Seventeen patients were reoperated upon for persistent or recurrent hypercalcaemia despite excision of a 1st parathyroid lesion; 3 cancers which had been mistaken for adenomas at the 1st operation; 6 had a 2nd adenoma which had passed unnoticed during an exploration that was probably too limited and as hypercalcaemia persisted all 6 were reoperated upon with success at different intervals; finally, 8 patients had undiagnosed primary hyperplasia (as part of polyadenomatosis in 5 cases). Recurrences were observed, often after a long period, up to 3 to 5 years. Hypercalcaemia was corrected by the 2nd operation in only 5 out of 8 cases. In retrospect, it was found that the pathological examination could not always determine if the lesion was malignant or distinguish between adenoma and glandular hyperplasia.

Acute primary hyperparathyroidism: experience of 59 cases

Acute primary hyperparathyroidism is a rare disease with a high mortality rate in some series. Between 1960 and 1986, 1000 patients were treated for primary hyperparathyroidism, among them 59 patients with acute hyperparathyroidism. All these patients were successfully operated on; none of them died before surgery. This study reveals the importance of resuscitation and urgent surgery. It is necessary to rehydrate, to correct electrolyte disorders and to lower serum calcium levels, but it is not necessary to obtain normal serum calcium levels before surgery.

Short-term effects of parathyroidectomy on plasma biochemistry in chronic uremia

Parathyroidectomy (PTx) is indicated in hemodialysis (HD) patients who have severe osteitis fibrosa unresponsive to vitamin D therapy or in whom the latter treatment is contraindicated. Immediately after PTx, plasma immunoreactive parathyroid hormone, calcium and phosphorus concentrations decline abruptly. However, little is known in such patients about the short-term effects of PTx on plasma alkaline phosphatase (AP) activity and plasma aluminum (Al) levels. The present, preliminary study was performed to determine such parameters in 37 HD patients, and to correlate them with data of bone histology. Mean plasma AP activity started to increase after PTx from day 4 onwards. Thus, AP values significantly higher than pre-PTx values were observed at day 7 and 14 (415 +/- 54 vs. 619 +/- 77 and 749 +/- 83 IU/liter, means +/- SEM; N = 37; P less than 0.05 and 0.001, respectively). This increase, in the absence of changes in liver function, was mainly due to the bone-specific iso-AP. Moreover, the degree of increase in plasma AP activity was higher in the subgroup with negative (group I, 21 patients) than in that with positive bone Al staining (group II, 16 patients). However, plasma osteocalcin (BGP) did not change after PTx (N = 8). Basal plasma Al levels were significantly higher in group II both before and two weeks after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Severe hyperparathyroidism in 2 uremic patients. Diagnostic and therapeutic difficulties]

We report here the unusually difficult cases of two patients with end-stage renal failure who suffered from severe hyperparathyroidism requiring surgical correction. The first patient had previously undiagnosed primary hyperparathyroidism. A first surgical neck exploration led to the discovery of four glands, paradoxically normal in size and aspect, which were removed. Subsequently, a supernumerary gland was localized in the mediastinum by computerized tomography and removed via sternotomy. After confirming the hypoparathyroid state, parathyroid autotransplantation was performed using cryopreserved tissue. The second patient had five hyperplastic parathyroid glands removed during the first neck exploration, followed by immediate parathyroid autografting. Because of the persistence of severe hyperparathyroidism, forearm autografts were subsequently removed and a sternotomy performed. Both failed to improve parathyroid hyperfunction. Numerous localization procedures remained negative. A repeat surgical neck exploration was performed because of positive double isotope scanning but was of no success in preventing fatal outcome, as were all medical treatments. These observations of two patients illustrate the difficulties in localizing and removing ectopic parathyroid lesions. Even when relying on the presently available powerful diagnostic means, correction of severe hyperparathyroidism may be extremely difficult.

Primary hyperparathyroidism: the surgical problems. A study of 1,300 operated patients

In this short presentation the surgical management and then the possible vicissitudes of primary hyperparathyroidism are successively summarized: negative investigations, and the persistence or postoperative recurrence of hyperparathyroidism. Results obtained in a series of 1,300 patients who underwent surgical treatment confirm that a single cervicotomy procedure, without risk for the patient, ensures definitive cure of this disease in 95% of cases.

Multiple endocrine neoplasia (MEN) type II b: report of a case observed at autopsy with immunohistochemical study of mucosal neuromas

A case of multiple endocrine neoplasia (MEN) II b syndrome was studied in a 28-year-old Colombian woman. The patient presented initially with medullary carcinoma of the thyroid (MTC), an unusual habitus, numerous mucosal neuromas, and intestinal ganglioneuromatosis. Recurrent medullary carcinoma in the mediastinum produced compression. The tumor mass could not be removed surgically, and the patient died of post-operative complications. At autopsy metastatic MTC was present in the liver, lymph nodes, and lungs. In addition, multiple mucosal neuromas were present in the mouth, nasopharynx, larynx, digestive tract, peri-adrenal fat, and hepatic portal spaces. There was no evidence of pheochromocytoma. Immunofluorescence study of mucosal neuromas showed hyperplasia and hypertrophy of nerves, without evidence of tumor. Kindred screening was negative.

Androgen producing adrenal adenoma. Report on a case associated with hyperparathyroidism

In a 41-year-old hirsute woman, severe hypercalcemia led to the discovery of hyperparathyroidism related to the involvement (hyperplasia/or adenoma) of the 4 parathyroid glands. Plasma and urinary DHA, plasma DHA-sulfate and delta 5 steroid precursors were elevated. Steroid hormone hypersecretion was stimulated by hCG and ACTH, and exhibited a paradoxical rise during dexamethasone administration. Computerized tomography scanning as well as arteriography disclosed bilateral adrenal hyperplasia and left adrenal adenoma. Bilateral adrenal vein catheterization indicated a left/right gradient for delta 5 steroids and delta 5 steroid sulfates. At surgery a left brown adrenal encapsulated adenoma was removed with a hyperplastic adrenal gland. Results of in vitro studies (adrenal steroid content and incubation) together with postadrenalectomy hormonal results suggest that the left brown adrenal adenoma was the main source of excessive androgen production. The infrequent association of an androgen-producing adrenal adenoma with hyperparathyroidism raises the hypothesis of multiple endocrine neoplasia syndrome. However, evidence for this diagnosis is lacking in the absence of other glandular involvement and of family history.

[Volvulus of a mobile spleen. Apropos of a case diagnosed in the preoperative period by ultrasonography]

A case of splenic volvulus, a rare complication of a rare malformation, mobile spleen, is reported, only 150 similar cases being documented in the literature. The diagnosis can be suspected preoperatively by ultrasound imaging. Different etiologies of this lesion are discussed and the various complementary examinations allowing preoperative diagnosis described.

Selective intraarterial DSA of the parathyroid glands in patients with hyperparathyroidism after parathyroidectomy

Eighteen patients with recurrent hyperparathyroidism after parathyroidectomy were prospectively examined with selective intraarterial digital subtraction angiography (DSA) of the brachiocephalic arteries. The results were compared with findings at reoperation. Seventeen of the 21 remaining abnormal parathyroid glands were correctly detected by selective DSA (sensitivity = 81%). In the neck and mediastinum, sensitivities were 73% (8/11) and 90% (9/10), respectively. All patients with histopathologic confirmation of primary hyperparathyroidism (17/18) became normocalcemic postoperatively. We conclude that selective intraarterial DSA is indicated in patients with recurrent hypercalcemia after parathyroidectomy when the results of noninvasive imaging techniques are uncertain.

Effect of calcitriol in the control of plasma calcium after parathyroidectomy. A placebo-controlled, double-blind study in chronic hemodialysis patients

Severe, prolonged hypocalcemia in observed in some, but not all, hemodialysis patients after parathyroidectomy performed because of uncontrolled hyperparathyroidism. The aim of the present study was to investigate whether calcitriol and calcium supplementation in the immediate period after parathyroidectomy (days 1-14) was of more help in the control of plasma calcium than calcium supplementation alone. Fourteen hemodialysis patients were enrolled in a prospective, randomized, double-blind and placebo-controlled study. From the day after parathyroidectomy, 7 patients received calcitriol and the remaining 7 a placebo using incremental doses adjusted to the degree of hypocalcemia (up to 4 micrograms/day for calcitriol). Plasma calcium, phosphorus, alkaline phosphatase and immunoreactive parathyroid hormone levels before parathyroidectomy were comparable in both patients groups, as was the lowest plasma calcium achieved after parathyroidectomy. The decrease in plasma calcium after parathyroidectomy was related to plasma alkaline phosphatase and to the number of osteoclasts and osteoblasts on bone biopsy surface before parathyroidectomy. The mean decrement of plasma calcium (days 3-9) as compared to that before parathyroidectomy was less pronounced in calcitriol-treated than in placebo-treated patients (0.25 +/- 0.06 versus 0.45 +/- 0.05 mM, mean +/- SEM, p less than 0.025). Treatment with placebo was interrupted before day 14 because of persistent severe hypocalcemia in 4 of 7 patients, whereas calcitriol treatment was continued in all 7 patients up to 14 days. Patients on calcitriol treatment required less mean calcium supplements (days 1-9) than patients receiving placebo (37.4 +/- 3.2 versus 49.4 +/- 3.7 g, p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Serum lipoprotein disturbances in primary and secondary hyperparathyroidism and effects of parathyroidectomy

Serum lipoprotein disturbances were studied in 86 patients with primary (I), and 34 hemodialysis patients with severe secondary (II), hyperparathyroidism (HPTH) before and seven to 14 days after parathyroidectomy (PTx). In addition, a subset of patients had repeat studies more than 12 months after PTx. In patients with I as well as with II HPTH, mean +/- SEM fasting serum concentrations of total triglycerides (TG) (1.51 +/- 0.09 and 2.17 +/- 0.19 mmol/L, respectively) were significantly increased when compared with that of 22 age- and sex-matched healthy control subjects (1.01 +/- 0.09 mmol/L, P less than .001). No consistent anomalies of serum total cholesterol and lipoprotein cholesterol content were observed in Io HPTH patients. In uremic II HPTH patients, the cholesterol content of high-density lipoprotein (HDL) was significantly (P less than .01) depressed, compared with normal subjects. In the short term, PTx normalized serum total TGs (P less than .001) in Io HPTH patients from 1.50 +/- 0.11 to 1.19 +/- 0.07 mmol/L seven days after PTx. The surgical correction of II HPTH in dialysis patients was also followed by an improvement of hypertriglyceridemia from 2.22 +/- 0.21 to 1.46 +/- 0.08 mmol/L and 1.46 +/- 0.09 mmol/L seven and 14 days, respectively, after PTx (P less than .01). Long-term follow-up after PTx shows clearly a persistent decrease in serum TG concentration in I HPTH patients (1.17 +/- 0.11 mmol/L), as well as in II HPTH patients (1.61 +/- 0.18 mmol/L), 12 months after PTx by comparison with values determined before PTx.(ABSTRACT TRUNCATED AT 250 WORDS)

[Gastropericardial fistula. Late complication of the treatment of hiatal hernia]

An exceptional case of gastropericardial fistula is reported, the lesion developing from a gastric ulcer on an antireflux valve instituted ten years previously. A literature review showed 31 similar cases: 14 gastropericardial fistulae, 16 esophagopericardial fistulae and one jejunopericardial fistula. Three features common to all these fistulae were determined: the frequency of hiatus hernia in the genesis of these lesions, either from an ulcer on esophagitis or herniated stomach or from surgical complication; the extremely high mortality of these fistulae (68% mortality); the need for aggressive treatment.

[Persistent or recurrent hyperparathyroidism in periodically hemodialyzed patients. Value of preoperative cervical ultrasonography. 6 cases]

In 2 cases of recurrent secondary hyperparathyroidism and 4 cases of persisting secondary hyperparathyroidism observed in patients treated by chronic haemodialysis, 8 hyperplastic parathyroid masses and 1 parathyroid adenoma, all located in the lower part of the neck, were removed after percutaneous ultrasonographic detection. There were 7 true positive and 1 unexplained false positive results. In 1 out of the 2 false negative results, the mass located behind the esophagus could not be detected because of the laryngotracheal gas. Two masses located inside the thyroid gland and a 5th hyperplastic gland were correctly identified by ultrasound. Two reluctant patients accepted a new cervicotomy because of the ultrasound reports. The reports played a prominent role in the operative technique in 3 cases.