Photodynamic Identification of Human Parathyroid Glands with 5-aminolevulinic Acid

OBJECTIVE: Identification of parathyroid glands is often a challenge even for experienced surgeons. The feasibility and efficacy of fluorescence diagnosis for localization of parathyroids has already been proven in an experimental setting. In preparation for a clinical application of this technique in patients undergoing surgery for hyperparathyroidism, we evaluated the kinetics of fluorescence diagnosis. DESIGN AND METHODS: Fifty rats were randomized into eight groups with different photosensitization parameters using the photosensitizer aminolevulinic acid (ALA): a peritoneal lavage was performed with either 1.5 or 3.0% ALA solution and the induced photosensitization times varied from 0.5, 1 and 2 to 4 h. Under special fluorescence illumination, D-light, the exposed operative site with thyroid, parathyroid glands and neck muscles was examined. The identified parathyroid glands were studied according to fluorescence intensity by spectrometric measurement and compared with surrounding tissue. RESULTS: Photosensitizer accumulation in parathyroid glands, indirectly measured by spectrometry, was up to 3.2 times higher than in thyroid and 2.6 times higher than in muscle tissue (2 h photosensitization with 3.0% ALA). Using 1.5% ALA, the optimum fluorescence intensity and ratio/contrast was slightly lower (parathyroid-to-thyroid ratio x 3.0, parathyroid-to-muscle ratio x 1.9) but was reached earlier (1 h) and hence considered as the parameter of choice for a clinical application. CONCLUSIONS: In future clinical application, intraoperative fluorescence diagnosis is expected to increase the ease of identification of atypically located or supernumeric glands. In combination with preoperative diagnostics, this may result in reduced operation time and avoidance of persistent hypercalcaemia.

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P1390METHOD FOR AN EFFECTIVE INTRAOPERATIVE IDENTIFICATION OF PARATHYROID GLANDS IN HEMODIALYSIS PATIENTS WITH SEVERE HYPERPARATHYROIDISM FOR ADEQUATE PARATHYROIDECTOMY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1390 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Renata Vakhitova ◽

Sergey Zinchenko

Keyword(s):

Thyroid Gland ◽

Oral Administration ◽

Blue Light ◽

Surgical Intervention ◽

Aminolevulinic Acid ◽

Intraoperative Imaging ◽

Hemodialysis Patients ◽

Parathyroid Glands ◽

Anatomical Location ◽

Tertiary Hyperparathyroidism

Abstract Background and Aims Secondary and tertiary hyperparathyroidism (HPT) in patients undergoing chronic hemodialysis is one of the most important problems of clinical nephrology. The removal of altered parathyroid glands has a number of difficulties: the detection and accurate allocation of the entire volume of the parathyroid glands due to their small size, similar structure to the surrounding tissues (thyroid gland, lymph nodes and adipose tissue) and complex anatomical location. Usually parathyroid glands are located directly on the posterior surface of the thyroid lobes, but in some cases they can be located atypically. In addition, the parathyroid glands are often “immersed” in the tissue of the thyroid gland, which also makes their visualization difficult. Isolation and differentiated intraoperative visualization of the parathyroid glands is extremely important for an adequate amount of surgical intervention. Method Seven dialysis patients with severe hyperparathyroidism were operated on using oral administration of 5-aminolevolenic acid for intraoperative imaging of the parathyroid glands. Secondary and tertiary hyperparathyroidism ware diagnosed in patients with C5D stage CKD by a significant increase in the level of intact parathyroid hormone (iPTH) and increased parathyroid glands detected by ultrasound. In all patients, the level of iPTH before surgery was more than 1500 pg / ml. At the prehospital stage, in all patients, according to the results of ultrasound, enlarged parathyroid glands were revealed (the number of parathyroid glands in one patient was 4 +/- 2). For intraoperative identification of changed parathyroid glands in these patients, the oral administration of a solution of 5-aminolevulinic acid was used (given in 180 minutes before the start of surgery at a dose of 10 -15 mg / kg body weight). Then the surgical field was irradiated with polarized blue light with a wavelength of 395–405 nm to record fluorescence. If fluorescent formations were detected in the area of irradiated tissues, they were removed with subsequent reimplantation of a less altered part of the hyperplastic parathyroid gland into the forearm region. Results Specific bright red fluorescence and luminescence of the parathyroid glands caused by special external sources of polarizing blue light during the operation were observed in all 7 patients. In each patient from 3 to 6 light portions of parathyroid glands were detected. These lightning portions were isolated, removed, and in 3 patients the most unchanged areas of the parathyroid glands were autotransplanted into the forearm. In the postoperative period, all patients showed the decrease in the level of iPTH less than 300 pg/ml, a syndrome of "hungry" bone, which was corrected by the administration of calcium and vitamin D preparations. Histologically all the found tissues were characterized as tissue of the parathyroid glands. The duration of operations was 48 +/- 12 minutes. Patients did not have any side effects indicated in the annotation to the drug. Conclusion Intraoperative fluorescence diagnostics of the parathyroid glands with preoperative oral use of 5-aminolevolenic acid is a simple and effective method of their visualization. This method promotes adequate parathyroidectomy and allows to reduce the time of surgical intervention in hemodialysis patients.

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Photodynamic diagnosis of parathyroid glands with nano-stealth aminolevulinic acid liposomes

Photodiagnosis and Photodynamic Therapy ◽

10.1016/j.pdpdt.2017.11.004 ◽

2018 ◽

Vol 21 ◽

pp. 71-78 ◽

Cited By ~ 1

Author(s):

Shaimaa Elbassiouny ◽

Maha Fadel ◽

Tarek Elwakil ◽

Mahmoud S. Elbasiouny

Keyword(s):

Aminolevulinic Acid ◽

Parathyroid Glands ◽

Photodynamic Diagnosis

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Intraoperative photodynamic detection of normal parathyroid glands using 5-aminolevulinic acid

The Laryngoscope ◽

10.1002/lary.21857 ◽

2011 ◽

Vol 121 (7) ◽

pp. 1462-1466 ◽

Cited By ~ 20

Author(s):

Takeshi Suzuki ◽

Tsutomu Numata ◽

Mariko Shibuya

Keyword(s):

Aminolevulinic Acid ◽

Parathyroid Glands

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Topographic, anatomical and clinical rationale of the optimal minimally invasive technique of parathyroidectomy

Grekov s Bulletin of Surgery ◽

10.24884/0042-4625-2021-180-4-11-17 ◽

2021 ◽

Vol 180 (4) ◽

pp. 11-17

Author(s):

P. N. Romashchenko ◽

N. F. Fomin ◽

D. O. Vshivtsev ◽

N. A. Maistrenko ◽

Yu. V. Maleev ◽

...

Keyword(s):

Postoperative Complications ◽

Minimally Invasive ◽

Aminolevulinic Acid ◽

Parathyroid Tissue ◽

Fluorescent Labeling ◽

Parathyroid Glands ◽

Invasive Technique ◽

Video Assisted ◽

Duration Of Surgery ◽

Human Cadavers

Introduction. The information presented in the literature on the use of minimally invasive interventions in the treatment of hyperparathyroidism is not fully justified by topographical and anatomical studies and does not take into account individual features of the location and syntopia of the parathyroid glands, which requires additional scientific research.Objective.Based on the topographical and anatomical features of the structure of the anterior neck region, we determined the most rational methods of minimally invasive interventions on the parathyroid glands and evaluated their clinical effectiveness in patients with hyperparathyroidism.Methods and materials. The design of the study consisted of two stages – topographical and anatomical, and clinical. Topographical and anatomical stage was performed on 2 levels: 1) on anatomical material, which included 15 human cadavers; 2) on plastinated cross sections of the neck (n=44) of human cadavers. During the clinical stage, we studied results of examination and treatment of 53 patients with hyperparathyroidism, who underwent surgery using three methods: Сonventional (n=18/34 %); Minimally Invasive Video-Assisted Parathyroidectomy (n=32/60 %) and Transoral Endoscopic Parathyroidectomy Vestibular Approach (n=3/6 %).Results. During the topographical and anatomical stage, the validity and safety of minimally invasive video-assisted parathyroidectomy was proved. The use of this access in clinical practice as an alternative to the conventional one has shown its effectiveness in reducing the frequency of specific postoperative complications from 16.7 to 6.3 % with an acceptable increase in the duration of surgery from (42.8±15.7) to (64.4±23.5) minutes and maintaining the average duration of inpatient treatment after surgery at the level of (3.4±0.6) days.Conclusion. Minimally invasive video-assisted parathyroidectomy can be considered the operation of choice in the treatment of patients with hyperparathyroidism. The use of this technique with the implementation of lateralization of the thyroid lobe, the preservation of the superior and inferior thyroid vessels, as well as the use of intraoperative neuromonitoring and identification of pathological and normal parathyroid tissue by fluorescent labeling with 5-aminolevulinic acid can improve the results of surgical treatment, reduce the number of postoperative complications, the frequency of persistence and relapse of the disease, and improve the quality of life of patients.

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CLINICAL AND ANATOMICAL RATIONALE OF MINIMALLY INVASIVE PARATHYROID SURGERY

Tavricheskiy Mediko-Biologicheskiy Vestnik ◽

10.37279/2070-8092-2020-23-2-155-164 ◽

2020 ◽

Vol 23 (2) ◽

pp. 155-164

Author(s):

P. N. Romashchenko ◽

N. F. Fomin ◽

N. A. Maistrenko ◽

Yu. V. Maleev ◽

D. S. Krivolapov ◽

...

Keyword(s):

Postoperative Complications ◽

Minimally Invasive ◽

Aminolevulinic Acid ◽

Clinical Stage ◽

Parathyroid Tissue ◽

Fluorescent Labeling ◽

Parathyroid Glands ◽

Video Assisted ◽

Duration Of Surgery ◽

Human Cadavers

The information presented in the literature on the use of minimally invasive interventions in the treatment of hyperparathyroidism is not fully justified by topographical and anatomical studies and does not take into account individual features of the location and syntopia of the parathyroid glands, which requires additional scientific research. Purpose of the study: based on the topographical and anatomical features of the structure of the anterior neck region, determine the most rational methods of minimally invasive interventions on the parathyroid glands, evaluate their clinical effectiveness and justify their use in the implementation of a treatment and diagnostic algorithm in patients with hyperparathyroidism. Material and methods: The design of the study consisted of two stages – anatomical and clinical. Anatomical stage is performed on 2 levels: 1) on anatomical material, which included 15 human cadavers; 2) on plastinated cross-cuts of the neck (n=3) of human cadavers. During the clinical stage, the results of examination and treatment of 53 patients with hyperparathyroidism, who underwent surgery using three methods: Сonventional (n=18/34%); Minimally Invasive Video Assisted Parathyroidectomy (n=32/60%) and Transoral Endoscopic Parathyroidectomy Vestibular Approach (n=3/6%). Results: at the anatomical stage, the validity and safety of minimally invasive video-assisted Parathyroidectomy was proved. The use of this access in clinical practice as an alternative to the traditional one has shown its effectiveness in reducing the frequency of specific postoperative complications from 16.7% to 6.3% with an acceptable increase in the duration of surgery from 42.8±15.7 to 64.4±23.5 minutes and maintaining the average duration of inpatient treatment after surgery at the level of 3.4±0.6 days. Conclusion: minimally invasive video-assisted parathyroidectomy can be considered the operation of choice in the treatment of patients with hyperparathyroidism. The use of this technique with the implementation of lateralization of the thyroid lobe, the preservation of the upper and lower thyroid vessels, as well as the use of intraoperative neuromonitoring and Identification of pathological and normal parathyroid tissue by fluorescent labeling with 5-aminolevulinic acid can improve the results of surgical treatment, reduce the number of postoperative complications, the frequency of persistence and relapse of the disease, and improve the quality of life of patients.

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