INTRAOPERATIVE LOCALIZATION OF PARATHYROID-GLANDS USING METHYLOTHIONINE CHLORIDE TETRAMETHYLTHIONINE CHLORIDE IN SECONDARY HYPERPARATHYROIDISM

  • 1 January 1985
    • journal article
    • research article
    • Vol. 160  (1) , 42-48
Abstract
Over an 18 mo. interval, 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% MB (5.5 mg/kg) over a time interval of 25-60 min (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/patient) of which the predominat histopatholigc diagnosis of frozen section was chief cell hyperplasia (78.3%). Of 91 hyperplastic glands submitted for analysis after subtotal parathyroidectomy in those in the MB infusion group, 82 glands (90.1%) had positive staining with identifiable differentiation from surrounding tissues. Analyses of the correlation of the serum Ca value and probability of MB staining or its relation to serum intact parathyroid hormone (intact-PTH) values were not statistically significant (P < 0.05, r equals 0.149). No relationship existed between the glandular size (mm to the 3rd power) and probability of MB staining (chi-square equals 1.750, P > 0.05) or between hyperplastic size and serum intact-PTH value (r equals 0.068). Analysis of MB gland staining with regard to intact PTH concentration disclosed that all glands stained intensely with MB when intact-PTH concentration was not < 700 pg/ml (P < 0.01). Nonstaining of hyperplastic parathyroid tissue was observed in 28.1% of glands submitted for histopathologic analysis in which preoperative intact PTH values were > 699 pg/ml. Time of operation was reduced from 119.0 .+-. 47.53 min (mean .+-. SEM [standard error of the mean]) in control patients to 92.1 .+-. 20.12 min (mean .+-. S.E.M.) for the MB infusion group (V% equals 21.85, P < 0.01). This technique appears to have value in the detection of ectopically located parathyroid tissue as demonstrated by the in vivo staining of 7 ectopic glands in 6 patients of the infused group. Complications were restricted to the patients in the MB infusion group (21.7%) and included pseudocyanosis in 3, pain in the infusion site in 2, wound hematoma in 1 patient, pancreatitis in 1 and angina in 1. No mortality occurred in any of the 40 prospectively studied patients. MB infusion appears to be a valuable adjunct to provide reliable staining with increasing values of intact-PTH in ESRD patients by providing a method of rapid intraoperative localization in these high risk individuals.

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