(b) Same patient, with guide wire in place (white dot). (c) CT of parathyroid adenoma in retrosternal space. (d) Same patient, with guide selleck chemical wire in place (white line). Table 1 Results of ultrasound-guided FNA, PTH washout before guide wire placement and pre/postoperative calcium and PTH levels after parathyroid adenoma removal using guide wire localization. The skin incision was made to include the point of entry of the guide wire (Figure 2), and the wire was followed with meticulous dissection until the lesion was identified both by palpation and the presence of methylene blue. The mass containing the hook wire was subsequently dissected and excised. Intraoperative nerve monitoring was performed in all the patients. Figure 2 Guide wire in situ in operating room.

Skin incision has been made to incorporate point of entry of guide wire. All patients were successfully treated, with identification and excision of the lesion identified by the guide wire, and despite the vascular nature of parathyroid adenomas, no significant hematomas occurred. In four patients, extremely small hematomas were noted within the parathyroid adenoma on final histology; these did not affect the dissection in any way. Serum PTH levels decreased by at least 50% postoperatively. Curative resection was established in all ten patients by intraoperative monitoring of serum intact PTH levels. Histopathology confirmed the diagnosis of parathyroid adenoma in all 10 patients. The calcium and PTH levels are detailed in Table 1. Seven of the 10 patients had been hyperparathyroid for approximately one year prior to reoperative surgery, with a mean preoperative PTH level of 213.

9pg/mL. The mean levels fell to 27.84pg/mL (sM = 11.2) postoperatively. Nine of the ten patients were discharged home on the day of surgery. One patient was observed overnight because of asymptomatic postoperative hypocalcemia, which was treated with calcium supplementation, and resolved prior to follow-up examination in clinic. 4. Discussion The classic treatment approach for primary hyperparathyroidism has been bilateral neck exploration with identification of all parathyroid glands. Numerous recent reports have shown benefits of more selective approaches, including better cosmesis and decreased risk of nerve injury. These make focused parathyroidectomy techniques very desirable [7, 8].

Both ultrasound and CT-guided FNA are well-described, successful techniques for the definitive diagnosis of lesions in the neck. Both techniques can provide a diagnosis in >90% of patients [10, 11]. Surgeon-performed ultrasound has been shown in some studies to increase the rate of localization of parathyroid adenomas, even in the setting of Batimastat a nonlocalizing sestamibi scan [12]. Part of this increase in success may be due to the real-time nature of surgeon-performed ultrasound, allowing a more immediate and thorough sonographic examination of the area of interest at the time of surgery.