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Intraoperative localization of parathyroid glands using methylthionine chloride / tetramethylthionine chloride in
Abstract:
Over an 18 month interval at the University of Louisville Affiliated Hospitals, 40 patients were evaluated in a nonrandomized prospective study to determine the value of methylthionine chloride / tetramethylthionine chloride (methylene blue--MB) as an aid for the rapid intraoperative identification of parathyroid hyperplasia of end-stage renal disease (ESRD). Patients assigned to the MB infusion subgroup had infusion of 1 per cent MB (5.5 milligrams per kilogram) over a time interval of 25 to 60 minutes (mean of 43.9) prior to anesthetic induction. A total of 159 glands were identified in both the control and MB infusion groups (3.98 glands per patient) of which the predominant histopathologic diagnosis on frozen section was chief cell hyperplasia (78.3 per cent). Of 91 hyperplastic glands submitted for analysis after subtotal parathyroidectomy in those in the MB infusion group, 82 glands (90.1 per cent) were observed to have positive staining with identifiable differentiation from surrounding tissues. Analyses of the correlation of the serum calcium value and probability of MB staining or its relation to serum intact parathyroid hormone (intact-PTH) values were not statistically significant (p greater than 0.05, correlation coefficient equals 0.149). Furthermore, no relationship existed between the glandular size (millimeter to the third power) and probability of MB staining (chi-square equals 1.750, p greater than 0.05) or between hyperplastic size and serum intact-PTH value (correlation coefficient equals 0.068). Conversely, analysis of MB gland staining with regard to intact PTH concentration disclosed 59 of 59 glands stained intensely with MB when intact-PTH concentration was not less than 700 picograms per milliliter (p less than 0.01). Non-staining of hyperplastic parathyroid tissue was observed in 28.1 per cent of glands submitted for histopathologic analysis in which preoperative intact PTH values were more than 699 picograms per milliliter. Time of operation was reduced from 119.0 +/- 47.53 minutes (mean +/- S.E.M.) in control patients to 92.1 +/- 20.12 minutes (mean +/- S.E.M.) for the MB infusion group (V per cent equals 21.85, p less than 0.01). Furthermore, this technique appears to have value in the detection of ectopically located parathyroid tissue as demonstrated by the in vivo staining of seven ectopic glands in six patients of the infused group. Complications were restricted to the patients in the MB infusion group (21.7 per cent) and included: pseudo-cyanosis in three; pain in the infusion site in two, wound hematoma in one patient, pancreatitis in one and angina in one.(ABSTRACT TRUNCATED AT 400 WORDS)