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A preoperative transesophageal exploration of the parathyroids by endosonography was performed on 23 patients with primary hyperparathyroidism. The system used was a 7.5 MHz transducer mounted on the tip of an endoscope with an external diameter of 13 mm. The field of visualization was 360 degrees. A retrograde exploration was done moving up from the aortic arch to the upper esophageal sphincter. All patients underwent surgery afterward, and adenomas were found. In 12 cases the adenoma was visualized. All 12 adenomas were posteriorly located on the right side (four cases) and left side (eight cases) of the esophagus. Nine of these 12 tumors were on the posterior face of the thyroid lobes, with six tumors in the middle one third of the thyroid lobe and three in the lower one third of the thyroid lobe. The other three tumors were located below the lower pole of the thyroid lobes in the upper posterior mediastinum. Mean tumor weight was 1165 mg. Of the 11 tumors that could not be visualized, eight tumors were anteriorly located; three of these tumors were on the anterior and lateral surface of the lower pole of the thyroid, and five were in the thyrothymic tracts. The remaining three tumors were located on the back of the thyroid lobes; two of these tumors were at the upper esophageal sphincter, and one was on the side of the pharynx. Mean tumor size was 1334 mg. Localization of parathyroid tumors by endosonography appears possible but only if lesions are located posteriorly, close to the esophagus. Endosonography is not indicated before routine cervical exploration for primary or secondary hyperparathyroidism. As in other such studies, endosonography could be useful in cases of persistent or recurrent hyperparathyroidism.

Thyrotoxicosis may be held responsible for osteoporosis. The question is whether a very slight subclinical hyperthyroidism, as is desirable in the post-operative treatment of differentiated thyroid carcinoma, can in the long run be detrimental to bone tissue. In a series of 37 patients, aged 50.9 +/- 11.1 years, presenting with the features of subclinical hyperthyroidism of 8.0 +/- 4.8 years duration, the authors have been unable to find any change in paraclinical parameters of bone and calcium-phosphate metabolism. Thirty-six of these 37 patients showed no abnormal decrease of vertebral bone density measured by dual photon absorptiometry.

Among 258 patients operated on for secondary hyperparathyroidism (HPT II) from 1971 to 1988, a total of 33 had one or more reoperations for persistent or recurrent HPT II. These reoperations did not induce any mortality or significant morbidity. After inadequate parathyroidectomy (25 cases), 15 patients were reoperated. Twelve of these had undergone initial surgery at another institution. Three patients died of causes unrelated to their HPT II. The other 12 patients are disease-free. After successful subtotal parathyroidectomy (79 cases), 2 patients (2.5%) had a recurrence 5 and 6 years later, respectively. Currently, the 2 patients remain disease-free. After total parathyroidectomy with autotransplantation (152 cases), 16 patients (10.5%) had reoperations on the grafts. The mean time before reoperation was 2 1/2 years. Hypertrophy of grafted fragments was observed in 4 cases (2.6%), but only 2 of these 4 patients were cured by removal of the grafts. Residual parathyroid tissue or a supernumerary gland in the neck or the mediastinum was suspected in 5 patients, but this could not be confirmed because one had already been reoperated on in the neck without success, another still refuses reoperation, and 3 died. In 6 other patients, the recurrence was debatable and HPT II was not confirmed. In the last 3 patients, the diagnosis was incorrect and aluminum intoxication was proved later. Results of reoperations for persistent or recurrent HPT II depend, first, on a correct diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

In a series of 301 bilateral thyroidectomies carried out over a 6 month period, immediate parathyroid autotransplantation was performed in 44 patients, i.e. 14.6%. Hypoparathyroidism was transient in 14 patients, i.e. 4.7% but was permanent in 4 patients, i.e. 1.3%. We attempted to determine the conditions justifying parathyroid autotransplantation during thyroidectomies. In our opinion parathyroid autotransplantation should be performed only to save a parathyroid gland accidentally removed or devascularized. It should not be used simply as a means of avoiding dissection no matter how long or tedious.

Autotransplantation of the parathyroid gland was performed in 28 out of 95 patients undergoing total thyroidectomy for carcinoma. The autotransplantation was supplementary in 15 patients who kept at least one parathyroid gland in the neck and substitutive in 12 patients who had total cervical parathyroidectomy. After 1 to 30 months' follow-up none of these patients had signs of hypoparathyroidism. The incidence of permanent hypothyroidism after total thyroidectomy was reduced from 7% to 2.1%. However, autotransplantation should be considered as a means of saving any cervical parathyroid that cannot be preserved and has been shown by histopathological examination to have escaped invasion by the carcinoma.

Nineteen cases of non-recurrent inferior laryngeal nerve were identified during 3791 cervicotomies for thyroid or parathyroid excision over the last 7 years, the nervous anomaly being of vascular anomaly origin in all cases. Predisposing factors for its onset during aortic arch development are discussed, together with possible symptomatology and means for preoperative diagnosis. Frequency in the cases reported was 0,54% from 3098 dissections on the right and 0,07% from 2846 dissections on the left. Although rare on the right and exceptional on the left, an aberrant non-recurrent pathway for the inferior laryngeal nerve represents a major, surgical risk during thyroid or parathyroid excision.

In 6307 cervicotomies for thyroid and parathyroid excision, 33 cases of nonrecurrent inferior laryngeal nerve were identified (0.52%). The anomaly was observed in 31 cases from 4921 dissections on the right side (0.63%) and in two cases from 4673 dissections on the left side (0.04%). Of the 31 patients who were initially seen with this anomaly on the right side, no innominate (brachiocephalic) artery was found; the right common carotid artery was arising directly from the aortic arch. The aberrant subclavian artery could always be felt against the vertebral column behind the esophagus. The two patients with the anomaly on the left side had a right aortic arch associated with situs inversus viscerum. In one case of invasive thyroid carcinoma, the nerve had to be sacrificed. In all of the other patients, postoperative laryngoscopic findings were normal. The nervous anomaly was of vascular anomaly origin in all cases. Predisposing factors for its onset during aortic arch development are discussed. Before surgical treatment, the diagnosis may only be made if vascular anomaly is suspected. Impairment of swallowing is the only clinical symptom to be looked for. The retroesophageal subclavian artery may be detected on chest x-ray films (20%) or by the compression and distortion of the esophagus shown during barium swallow tests (97%). Although rare on the right side and exceptional on the left, an aberrant nonrecurrent pathway for the inferior laryngeal nerve represents a major surgical risk. This is an additional argument in favor of systematic dissection of the inferior laryngeal nerve during thyroid or parathyroid excision.

Operation for tumors responsible for a Conn's syndrome was performed in 16 patients, 11 women and 5 men, over a period of 13 years, the average time before diagnosis being 5 1/2 years. All patients presented hypertension, permanent in 14 and paroxysmal in 2 cases while blood potassium levels were below 3 mmol/l in all patients. Diagnosis was confirmed by elevation of plasma aldosterone and of urine tetrahydroaldosterone, associated with low plasma renin activity not responding to a stimulus. The tumor was demonstrated by imaging in 15 cases before operation and its mean size was 1.7 cm. Investigatory methods for diagnosis and localization are discussed. One patient died during the immediate post-operative period from decompensated cardiac failure. Long-term review showed persistent hypertension in 5 patients but electrolyte disturbances were corrected in all cases. Lack of consistency of results of surgical reduction in case of hyperplasia suggests that only patients with hyperaldosteronism related to an adrenal cortex tumor should be operated upon.

Results are reported of four and a half years of experience with autotransplantation and cryopreservation of parathyroid tissue in thyro-parathyroid surgery. One hundred patients with hyperparathyroidism secondary to renal insufficiency were treated by total parathyroidectomy and partial autotransplantation, immediate in 98 cases and secondarily using their frozen stored tissue in the other two cases. Results were compared with those in 13 other patients treated during the same period by subtotal parathyroidectomy. Seven of 46 patients with primary parathyroid hyperplasia underwent total parathyroidectomy with immediate partial autotransplantation. Grafts were not used in the other two previously cervicotomized patients. All parathyroid tissue removed during these operations was frozen and stored if not used for grafting. Of 116 patients treated by enlarged total thyroidectomy for cancer, 34 received parathyroid autotransplants; complementary in 19 cases and substitutive in 15. Technique and results are described, and respective indications for autotransplantation and parathyroid cryopreservation discussed with respect to primary, secondary, persisting or recurrent hyperparathyroidism, and to total thyroidectomy for cancer.

Results are reported of surgical treatment of hyperparathyroidism secondary to chronic renal failure in 231 patients who had undergone 250 operations over 16 years: 152 total parathyroidectomies associated in 151 cases with an autotransplant, 58 subtotal parathyroidectomies, 9 incomplete parathyroidectomies, I white cervicotomy and 39 repeat operations for persistent or recurrent hyperparathyroidism. Results were evaluated clinically, biologically and radiologically after a mean follow up of 4 years, and were rated good in 71.4% of cases. The quality of the results was independent of the type of parathyroidectomy practised: 71% good results after total parathyroidectomy with autotransplantation and 69% after subtotal parathyroidectomy. No significant difference was demonstrated between the two techniques with respect to mortality, postoperative morbidity and late complications. The only divergence seen was in relation to recurrences: recovery surgery at the cervical level after subtotal parathyroidectomy leaving a clearly identified glandular stump associated with a better result than repeat operation on grafts at brachial level after total parathyroidectomy and autograft. These results led to the adoption of a surgical routine for hyperparathyroidism secondary to chronic renal failure using subtotal parathyroidectomy combined with bilateral thymectomy. The operation of total parathyroidectomy without immediate autotransplant is reserved for cervical recovery surgical procedures. Whatever the technique used, frozen storage of removed tissue is the indispensable complement of parathyroidectomy.

Twenty-eight patients with differentiated thyroid cancer presented with local relapse 6 months to 24 years (mean: 7 years) after limited surgery. The tumour was clinically undetectable in 7 cases. Among 22 patients reoperated upon, one died post-operatively, 17.8% had permanent recurrent nerve paralysis and 14.3%, permanent hypoparathyroidism. Metastases were discovered in 15 patients (53.8%), 4 1/2 years on average after the relapse; they resulted in death within less than 2 years in 11 (39.2%) and the survival rate was moderate (26.7%). The mean survival of the 12 patients now in remission is 7 years since the relapse and 13 years since the initial tumour.

In a series of 82 pheochromocytomas operated on, the authors report 8 cases of Sipple's syndrome, currently classified by Steiner among the type II multiple endocrine neoplasia (MEN II). Six patients were operated on, the mean follow up being 4 years. These patients all underwent total thyroidectomy and 4 of them total bilateral adrenalectomy. Gluco and mineralocorticoid and thyroid hormone replacement therapy was instituted. No clinical or biological recurrence has been noted. The ideal therapeutic schema is difficult to define given the rarity of MEN II.