Autotransplantation of parathyroid grafts into the tibialis anterior muscle after parathyroidectomy: a novel autotransplantation site

Abstract

BackgroundSurgical management of renal secondary hyperparathyroidism (sHPT) is varying. Total parathyroidectomy with heterotopic autotransplantation (TPTX + AT) is one of the standard surgical procedures in sHPT, but there is no consensus about the optimal site for graft insertion. At the surgical department of the University Hospital of Heidelberg we prefer the autotransplantation into the tibialis anterior muscle. The aim of this study was to assess the long-term function of the auto-transplanted parathyroid tissue in this type of surgical procedure.MethodsThe function of the autograft of 42 patients was assessed 8.2 ± 2.5 years after surgery, using a modified Casanova-test of the leg bearing the parathyroid tissue. Ischemic blockage was induced by tourniquet and the levels of parathyroid hormone (PTH) were assessed during the test.ResultsAt the point of assessment, the ischemic blockage led to a significant reduction in the concentration of PTH (≥50 % of the baseline value) in 19 patients (45 %) indicating well-functioning autografts. In 11 patients (26 %), ischemic blockage did not cause any change in the concentration of PTH (≤20 % of the baseline value), indicating functioning residual parathyroid tissue from another site. The source of PTH production was classified as unidentifiable in five patients (12 %). Two patients had developed graft-dependent recurrent HPT (5 %) without therapeutic consequences and three patients suffered from persistent symptomatic hypoparathyroidism (7 %).ConclusionsThese results indicate that TPTX + AT into the tibialis anterior muscle is a successful surgical treatment for renal HPT and that the modified Casanova-test is a suitable diagnostic tool for autografts function.

Total parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: systematic review and meta-analysis

“…After resection, tPTX + AT required another procedure: AT. The sites used for AT were the sternocleidomastoid muscle, brachioradialis muscle and tibialis anterior muscle [20,28,29]. Most surgeons chose the brachioradialis muscle for AT because this site is simple for reoperation.…”

Parathyroid autotransplantation at a novel site for better evaluation of the grafted gland function: study protocol for a prospective, randomized controlled trial

“…The experimental group involves the participants with PA at the novel sites closer to the cephalic vein, while the participants in the control group generally receive subcutaneous transplantion. Since the survival rate of the traditional assessing method was reported as 45% [16], and that of the new method was predicted as 65% in our preliminary study (unpublished data). We set α as 0.05 (bilateral), power as 0.90 and obtained the sample size N 1 = N 2 = 128 by PASS 11.…”

“…It was mostly applied to monitor PTH in hyperparathyroidism patients with parathyroidectomy after PA [13, 14]. Rothmund et al reported that the survival rate of PA with hyperparathyroidism was 31% (20 patients) [15], and Anamaterou et al suggested that the survival rate was 45% in 19 patients using the ischemic-blockage Casanova test [16]. There are few reports regarding randomized controlled trials to evaluate the function of transplanted parathyroid glands using this PTH-gradient method.…”

PTH monitoring after total parathyroidectomy with forearm auto-transplantation: Potential for spuriously high levels from grafted forearm

“…In the event of recurrent hyperparathyroidism, it is generally easy to determine if the forearm graft is the cause based on parathyroid scanning, through selective venous sampling, or using a limb ischemia test which should result in substantial reduction of PTH after 15 min of ischemia if the forearm graft is indeed the cause of recurrent disease [ 7 ]. There are numerous documented graft locations such as the neck, abdomen, pre-sternal area, or the leg [ 8 – 10 ]. While these locations may be less likely to generate misleading blood test results as they are remote from common blood-drawing locations, there can be disadvantages to these sites such as an inability to perform some of the aforementioned localization and functional testing, more difficult surgical accessibility for removal, concerns regarding leg wound healing in patients with circulatory disease, and cosmesis.…”