o_19j73iiphe7unh51i6ij57lbfa.pdf

World J. Surg. 28, 583–588, 2004
DOI: 10.1007/s00268-004-7321-8
WORLD
Journal of
SURGERY
© 2004 by the Société
Internationale de Chirurgie
Assessing the Site of Recurrence in Patients with Secondary Hyperparathyroidism
by a Simplified Casanova Autograftectomy Test
Katja Schlosser, M.D., 1 Helmut Sitter, Ph.D., 2 Matthias Rothmund, M.D., 1 Andreas Zielke, M.D. 1
1 Department of Visceral, Thoracic, and Vascular Surgery, Philipps University, Baldingerstrasse, D-35043 Marburg, Germany
2 Institute of Theoretical Surgery, Philipps University, Baldingerstrasse, D-35043 Marburg, Germany
Published Online: May 19, 2004
Abstract. Patients with recurrent secondary hyperparathyroidism
(rSHPT) following total parathyroidectomy and autotransplantation were
prospectively studied by a modified Casanova test to discriminate between
the graft-bearing arm and the neck as the site of the recurrence. The test
measures intact parathyroid hormone (PTH) in blood obtained from the
non-graft-bearing arm before an ischemic period and from the arm bearing
the parathyroid graft during an ischemic period caused by an Esmarch
bandage. The aim of this study was to evaluate the time course of PTH levels
during the test and to establish an abbreviated procedure. A series of 30
patients with rSHPT who were admitted for reoperative surgery between
1994 and 2002 were studied. Systemic PTH levels were determined prior to
suprasystolic exclusion of the graft-bearing arm as well as 2, 4, 6, 8, 10, 20,
and 30 minutes during it and at 10 minutes afterward. Results were interpreted
with a simple algorithm that suggested graft-dependent recurrence
(GDR) whenever PTH levels dropped by more than 50% and neckdominated
recurrence (NDR) whenever the PTH levels dropped to less
than 20%. Patients were operated on accordingly. Biochemical normalization
of calcium and PTH was defined as success. Altogether, 15 patients
had GDR and were cured after graft explantation. All of these patients were
identified within 4 minutes of starting the test. Another 12 patients had
NDR and were cured by excising overlooked or supernumerary glands.
PTH levels were indeterminate in three patients (10%). Clinically, NDR is
likely in all of these cases, but the test results were firmly established with
100% accuracy 8 minutes after the start of the test procedure. This abbreviated
form of the Casanova test is advantageous for accurately determining
the site of recurrence in the presence of rSHPT. It is less timeconsuming,
satisfactory in an ambulatory setting, equally effective, and
less invasive than the original Casanova procedure.
Correspondence to: Katja Schlosser, M.D., e-mail: pluntke@mailer.unimarburg.de
Secondary hyperparathyroidism (SHPT) is a frequent complication
of chronic renal insufficiency (CRI) and end-stage renal disease
(ESRD). The prevalence and severity of SHPT increase with
declining renal function in patients with CRI [1–4]. Despite advances
in medical therapy, nonsurgical treatment is not always successful
and parathyroidectomy (PTX) is necessary in a considerable
number of patients who are on maintenance dialysis. The need
for PTX increases with the duration of CRI [5]. A 22% risk of having
to undergo PTX after being on dialysis for 10 to 15 years was
reported by the European Dialysis and Transplantation Association
Registry in 1988 [6]. Patients undergo either total parathyroidectomy
with autotransplantation of parathyroid tissue to the nondominant
forearm (TPTX+AT) or subtotal parathyroidectomy as
alternative procedures. The recurrence rate is comparable (3–9%)
after subtotal PTX or TPTX+AT; and in the case of an incomplete
parathyroidectomy the recurrence incidence may increase to approximately
30% [7, 8].
Patients with recurrent secondary hyperparathyroidism
(rSHPT) following TPTX+AT continue to be a diagnostic and operative
challenge. In these patients it is essential to determine the
site of recurrence, which may be located in the neck or the transplant-bearing
forearm. In 1991 Casanova et al. devised a test procedure
that allows accurate discrimination of the source of recurrent
hyperparathormonemia [9]. During this test procedure, the
arm bearing the parathyroid graft is submitted to total ischemia
under intravenous regional analgesia: Two pneumatic tourniquets
are applied around the proximal end of the limb, and exsanguination
of the arm is achieved by means of an Esmarch bandage. The
proximal tourniquet is then inflated up to 100 mmHg over the basal
systolic blood pressure until no radial pulse can be found. Lidocaine
0.5% at a dose of 3 mg/kg is slowly injected into the ischemic
limb. If the patient complains of tourniquet-induced pain, the distal
tourniquet is inflated and the proximal one deflated. Blood
samples for measurement of intact parathyroid hormone (PTH)
are obtained from the contralateral arm before and then during the
ischemic period (at 10, 20, and 30 minutes) as well as 10 minutes
afterward.
Because the initial results reported by the original authors allowed
a sound assessment of the site of recurrence in 100% of patients,
the method was quickly adopted by many endocrine surgery
centers. Although the test procedure is quite simple, it is timeconsuming
and may have significant side effects.
In our own experience, symptoms induced by the systemic effects
of lidocaine after deflating the tourniquets occurred in almost all
patients. Patients complained of vertigo and vision abnormalities,
even hallucinations. Others developed rhythm abnormalities such
as bradycardia. We therefore began to use a simplified procedure:
We omitted the intravenous lidocaine and found that the procedure
was still feasible.

584 World J. Surg. Vol. 28, No. 6, June 2004
Table 1. Clinical and biochemical data of patients.
Patient
Sex
Age
(years)
Time after
PTX (years)
Total calcium
(mmol/l) prior
to surgery
PTH prior to
surgery (x-fold the
upper normal level)
No. of glands
found at initial
operation
Test
prediction
Reoperation on
neck or arm
Follow-up
(3 days postop.
PTH/calcium)
1 F 60 5 2.9 35.7 4 N Refused operation
2 F 50 3 3.0 35.7 4 N N Cured
3 F 46 3 3.3 28.6 4 A A Cured
4 F 54 3 2.8 5.1 4 U A Not cured
5 F 64 5 2.8 28.6 2 A A Cured
6 F 47 3 2.9 9.4 3 N N Cured
7 F 42 5 2.9 17.1 4 U N Cured
8 F 28 7 2.7 24.6 4 A A Cured
9 F 39 4 2.5 22.0 4 N N Cured
10 F 44 2 2.4 13.4 4 N N Cured
11 F 47 11 2.9 39.5 4 A A Cured
12 F 55 7 3.0 8.6 4 A A Cured
13 F 58 1 2.4 13.8 4 N N Cured
14 F 47 3 2.7 5.6 3 N Not cured a Not cured a
15 F 44 20 2.8 5.0 4 A A Cured
16 F 44 20 2.7 38.5 4 A A Cured
17 F 49 4 3.0 5.4 6 A A Cured
18 F 26 5 2.7 11.3 4 N N Cured
19 F 46 7 2.5 32.2 3 N N Cured
20 F 37 5 2.7 5.8 4 A A Cured
21 F 51 1 2.6 14.2 4 A A Cured
22 F 50 1 2.7 20.0 4 A A Cured
23 F 35 10 2.7 14.7 3 N N Cured
24 F 61 0 2.7 8.7 2 N N Cured
25 M 30 2 2.3 12.9 4 N N Cured
26 M 56 5 2.5 34.0 4 A A Cured
27 M 37 8 2.7 5.5 4 A A Cured
28 M 56 5 2.6 8.7 4 A A Not cured
29 M 33 2 2.5 9.4 4 A A Cured
30 M 59 2 2.7 37.0 4 N N Cured
PTX: parathyroidectomy; PTH: intact parathyroid hormone; N: neck; A: arm; U: source of PTH unpredictable.
a No gland found.
We observed a significant decrease in PTH levels in some patients
within a rather short period of time, even within the first few
minutes. Casanova et al. had already suggested that an abbreviated
test may be sufficient to localize the site of recurrence in patients
with rSHPT [9]. This prompted us to evaluate a simplified Casanova
autograftectomy test (SCAT).
Materials and Methods
Patients
A prospective observational study was undertaken in 30 consecutive
patients admitted to our institution for recurrent hyperparathyroidism
after TPTX+AT. The study population consisted of 6
men (mean age 45.1 ± 13.1 years) and 24 women (mean age 46.8 ±
9.5 years) with evidence of rSHPT. Patients were admitted to our
hospital a median of 4 years (± 4.8 years) after TPTX+AT for
reoperative surgery between 1994 and 2002. The initial operation
was performed in our hospital in 16 patients and in other hospitals
in the other 14 patients.
Neck exploration during the initial operation revealed the presence
of four parathyroid glands in 23 patients: three glands in 4
patients, two glands in 2 patients, and six glands in 1 patient. Cervical
thymectomy had been performed in 11 patients. Parathyroid
tissue had been autotransplanted to the arm contralateral to the
arteriovenous fistula in all patients.
In 17% of the study population, fewer than four glands were removed
on initial exploration. In none of these patients was the primary
operation performed at our hospital. Operation reports
revealed that an incomplete cervical thymectomy had been performed
in two of these cases. Autotransplantation of parathyroid
tissue had been performed in all patients even if fewer than four
glands were found during the primary procedures. In all of these
patients thyroid tissue was removed at the site of the missing
gland(s).
At the time of presentation, all 30 patients had higher than normal
PTH levels (5.0–39.5 times the normal level, mean 18.4 ± 11.9,
median 14.0). Of the 30 patients, 23 were hypercalcemic, and 7
were normocalcemic but within the upper normal range (mean 2.72
± 0.21 mmol/l, median 2.7 mmol/l). Table 1 summarizes the clinical
and biochemical data for these patients.
Recurrent secondary hyperparathyroidism was defined as follows:
(1) hyperparathormonemia more than five times the upper
normal level with hypercalcemia of > 2.6 mmol/l; or (2) hyperparathormonemia
more than five times the upper normal level with
typical symptoms of SHPT such as bone pain, muscle weakness, or
pruritus and the calcium level within the normal range.
The patients all gave informed consent.
Methods
To determine the source of PTH secretion, patients were submitted
to a modified Casanova test. After padding the upper arm with cotton
wool, a pneumatic tourniquet was placed and the blood pres-

Schlosser et al.: Simplified Casanova Test
585
sure measured. With the arm elevated, the tourniquet was inflated
to at least 80 mmHg over the systolic blood pressure. Lack of a
radial pulse was assessed. Ischemia of the arm was maintained for
30 minutes. Blood samples were obtained from the contralateral
arm before the ischemic period, during it (at 2, 4, 6, 8, 10, 20, and 30
minutes), and 10 minutes after deflating the tourniquet.
Intact parathyroid hormone was assayed using the N-tact Immunoassay
kit (ADVIA Centaur Multi Diluent 11; Bayer, Leverkusen,
Germany) with the upper limit of normal at 65 ng/l. The intraassay
coefficient of variation was 3.5%.
The source of PTH secretion was defined according to the time
course of PTH levels during ischemia, as previously suggested by
Casanova et al. [9].
1. Forearm: PTH decrease of more than 50% of the preischemic
value. Patients in whom the test predicted the arm as the source
of rSHPT underwent ultrasound-guided graft explantation exclusively.
2. Neck: PTH decrease of less than 20% of the preischemic value.
Patients in whom the test predicted the neck as the source of
rSHPT underwent reexploration of the neck after additional diagnostic
test procedures, including ultrasonography of the neck,
99 Tc-sestamibi scanning, and magnetic resonance imaging
(MRI) of the neck and upper mediastinum.
3. Source of recurrence unpredictable: PTH decrease of at least
20% but less than 50% of the preischemic value. Patients in
whom the source of PTH was unpredictable underwent additional
diagnostic testing, such as ultrasonography of the arm and
neck, 99 Tc-sestamibi scanning, MRI imaging of the neck and upper
mediastinum, and selective venous sampling until two test
procedures pointed to the same localization. Depending on
these results, patients underwent either reexploration of neck or
graft explantation, respectively.
Cure of rSHPT was defined as normalization of calcium levels
and a drop in PTH to at least 50% of the preoperative systemic
values in blood samples obtained on the third day after reoperation.
Statistical analysis was performed using the Mann-Whitney U-
test of unpaired data (the Wilcoxon rank sum test). Statistical significance
was defined as p < 0.05.
Results
Patients
Withholding lidocaine from the Casanova test apparently did not
cause a significant problem. Patients reported some feeling of
numbness and mild pain after deflation of the tourniquet, but they
did well even without oral analgesics. The previously observed systemic
side effects of lidocaine following tourniquet release were no
longer observed.
The site of recurrence was assessed by comparing PTH values at
10 and 30 minutes of ischemia to the preischemic values. Fourteen
patients had a significant drop in PTH (more than 50%) (mean
PTH was 19.97% ± 10.1% of preischemic values at 10 minutes and
14.24% ± 8.15% at 30 minutes). Ultrasound-guided total surgical
excision of parathyroid graft tissue was followed by an immediate
reduction of PTH in all patients. The serum calcium level returned
to normal, and symptoms related to hyperparathyroidism (e.g.,
pruritus and bone pain) were alleviated in all patients. In all, 13
Fig. 1. Time course of percent changes of parathyroid hormone (PTH)
values during suprasystolic exclusion of the graft-bearing forearm. Values
are represented as means and standard deviations. The dashed line with
circles represents patients who were cured after excision of the parathyroid
autograft. The solid line with squares represents the patients in whom the
source of recurrent disease was in the neck. The dashed line with triangles
represents patients in whom the source of PTH was unpredictable. Significant
differences between the groups are marked with an asterisk. Wilcoxon´s
paired signed rank test: *p > 0.01; **p > 0.001.
patients had a PTH drop of less than 20% of preischemic values
(mean PTH was 105.48% ± 16.01% of preischemic values at 10
minutes and 107.78% ± 11.26% at 30 minutes). These patients
were scheduled for neck reexploration. One patient refused the repeat
neck surgery. The remaining 12 patients underwent cervical
ultrasonography, 99 Tc-sestamibi scanning, and MRI imaging of the
neck and mediastinum prior to surgery. Accessory glands were
found in all but 1 of these 12 patients: Seven patients had one gland,
two had two glands, one had three glands, and another had four
supernumerary or missed cervical glands excised, respectively.
PTH and calcium levels decreased to normal, and symptoms diminished
in all patients in whom parathyroid tissue was excised.
The source of PTH was classified as unpredictable in three patients.
The prediction of the test was similar when the values at 10
minutes were compared to those after 30 minutes of ischemia. PTH
decreased to a mean of 69.61% ± 6.87% at 10 minutes and 72.62%
± 2.26 ng/ml at 30 minutes. One of these patients was submitted to
neck reexploration after appropriate diagnostic testing with excision
of a supernumerary gland. PTH and calcium levels decreased
to normal, and symptoms diminished. The other two patients underwent
ultrasonography and 99 Tc-sestamibi scintigraphy. In one
of these patients no regionalization to the arm or the neck could be
determined. The patient refused further testing and underwent explantation
of the autograft. The PTH values decreased moderately.
It is most likely that this patient had an accessory gland in the neck.
He did not undergo reoperative neck exploration because he received
a renal transplant with subsequent normalization of his PTH
and calcium levels within the first year. The third patient showed
slight enhancement in the region of the arm during 99 Tc-sestamibi
scintigraphy and underwent explantation of the autograft with only
a moderate drop in the PTH level. This patient refused further diagnostic
testing and died 13 months later as a result of a perforated
gastric ulcer.

586 World J. Surg. Vol. 28, No. 6, June 2004
Table 2. Changes in PTH levels after arm ischemia
PTH (%) a after ischemia
Patient After 2 min After 4 min After 6 min After 8 min After 10 min After 20 min After 30 min
1 n.m. n.m. n.m. n.m. 96.0 141.1 126.2 N
2 n.m. n.m. n.m. n.m. 23.1 n.m. 15.0 A
3 n.m. n.m. n.m. n.m. 31.7 19.9 19.4 A
4 63.1 84.4 71.0 79.6 70.7 68.8 71.0 U
5 8.2 8.3 7.4 5.6 18.9 18.6 13.9 A
6 n.m 87.0 n.m 94.4 104.1 91.5 105.2 N
7 n.m n.m n.m n.m 75.9 77.7 74.2 U
8 n.m n.m n.m n.m 35.4 32.2 27.9 A
9 85.8 88.5 101.6 89.5 116.8 109.4 101.4 N
10 n.m n.m n.m n.m 102.0 118.1 112.2 N
11 n.m n.m n.m n.m 13.5 10.6 10.5 A
12 n.m n.m n.m n.m 40.5 30.5 31.3 A
13 n.m 181.6 n.m n.m 147.1 131.5 127.8 N
14 n.m n.m n.m n.m 118.2 119.9 n.m. N
15 62.1 42.1 39.0 35.8 21.1 15.8 12.6 A
16 n.m n.m n.m n.m 24.9 15.8 13.0 A
17 n.m n.m n.m n.m 26.1 23.3 19.9 A
18 95.6 85.1 72.2 80.9 83.8 73.8 88.8 N
19 106.5 106.5 102.5 100.9 100.9 100.5 101.1 N
20 41.3 29.7 19.8 15.9 13.6 9.2 7.1 A
21 38.8 27.8 19.8 15.8 13.6 7.6 5.8 A
22 4.7 3.4 2.8 2.0 1.6 1.2 n.m. A
23 81.2 115.3 88.6 96.7 96.7 80.4 104.6 N
24 100 100.7 102.9 106.4 97.9 102.5 110.5 N
25 105.5 106.2 102.2 99.7 105.1 101.2 105.7 N
26 17.1 14.7 13.4 12.9 11.9 10.5 7.6 A
27 45.2 38.1 16 9.5 4.8 2.4 2.4 A
28 90.6 70.1 70.1 72.8 62.3 n.m. 67.9 U
29 64.9 47.4 30.0 24.6 19.2 13.6 12.8 A
30 96.5 95.6 100.5 100.5 97.3 107.2 102.1 N
A: prediction arm; N: prediction neck; U: source of PTH unpredictable; n.m.: not measured.
a This is a percentage of the preischemic PTH level, which is considered to be 100%.
Prediction
of test
Test Procedures
The dynamics of PTH levels under temporary ischemic autograftectomy
in this study allowed identification of the dominant source
of recurrent hyperparathormonemia in 90% of the cases. The classification
of the putative site of recurrence as proposed by Casanova
et al. proved to be reliable and feasible. The differences in
PTH values in the group of patients with a neck-dependent recurrence
compared to the group of patients with an autograftdependent
recurrence were already significant after the first 2 minutes
of the test, and they remained highly significant thereafter (p <
0.001) (Fig. 1). This was confirmed when individual time courses of
PTH values were analyzed (Table 2). With respect to the accuracy
by which individual PTH values allowed sound classification of the
site of recurrence (i.e., arm, neck, unpredictable), it should be
noted that test results were available with an accuracy of 1.0 as early
as 8 minutes into the test procedure (Fig. 2). No further changes
were observed in the test results beyond this point in time.
In some instances, the source was identified even earlier. For
instance, the 50% drop in PTH that classified the parathyroid autograft
as the source of the recurrence was already obtainable with
100% accuracy after only 4 minutes of temporary ischemic autograftectomy.
Measurement at later time points did not show any
increase in the accuracy or any change in the individual test results.
Likewise, whenever the PTH level remained grossly unchanged
(i.e., did not drop more than 20% of preischemic values during the
test), the source of recurrence was suspected to be in the neck. This
statement could be made accurately at 8 minutes into the test. Even
Fig. 2. Accuracy of the site of recurrence in patients with recurrent secondary
hyperparathyroidism (rSHPT) over time. Site of recurrence in the
neck was classified as either autotransplant-dominated or indeterminate.
Accuracy was 1.0 after 8, 10, and 30 minutes of temporary ischemic autograftectomy.
Test prediction was accurate in 14 of 17 patients at 2 minutes
(82.4%), 18 of 19 patients at 4 minutes (94.7%), 16 of 17 patients at 6 minutes
(94.1%), 18 of 18 patients at 8 minutes (100%), 30 of 30 patients at 10
minutes, and 29 of 29 patients at 30 minutes.
in those patients in whom the test was unable to predict the dominant
site of recurrence the indeterminate result was firmly accessible
after 8 minutes. Prolonged ischemia did not increase the
accuracy of this particular test result, nor did it alter the indetermi-

Schlosser et al.: Simplified Casanova Test
587
nate classification: PTH levels decreased to a mean of 69.6% ±
6.9% after 10 minutes and were virtually unchanged (72.6% ±
2.3%) after 30 minutes of ischemia.
Overall, the significant differences in the individual or mean
PTH values after 8, 10, 20, or 30 minutes of temporary ischemic
autograftectomy were not registered. Also, single test results never
changed after 8 minutes. Hence, predictions of the site of recurrence
were established at this point in time, suggesting that a 10-
minute test period is sufficient to obtain 100% accuracy.
Discussion
The incidence of rSHPT after TPTX+AT varies considerably in
the literature [10, 11]. The risk of developing rSHPT increases with
time, and 20% to 30% of patients undergo a second operation for
recurrent disease [12, 13]. Assessing the site of recurrence in patients
with SHPT is of paramount importance to allow adequate
treatment decisions. Casanova’s test has been adopted by many endocrine
surgery centers [14, 15].
The procedure originally described by Casanova et al. [9], however,
is time-consuming, requires intravenous lidocaine administration,
and thus is associated with potentially dangerous side effects.
This is not satisfactory in an ambulatory setting. We therefore
sought to develop an alternative procedure that is equally effective
but less invasive. A simplified test protocol that no longer used regional
lidocaine anesthesia proved feasible. All patients did well
during and after the test. Moreover, withholding regional anesthesia
did not impair patients’ compliance with the test procedure.
We had hypothesized that simple suprasystolic exclusion of the
graft (i.e., temporary ischemic parathyroidectomy) for only a few
minutes would be sufficient to cause a significant drop in circulating
intact PTH if the autograft were the source of the recurrence.
The peripheral metabolism of PTH in patients with end-stage renal
disease on hemodialysis reportedly does not vary much from that of
healthy individuals [16]. Degradation of circulating PTH occurs
with a half-time of 3 to 4 minutes [17, 18].
In this study, we found the discriminating power of the abbreviated
Casanova test to be exceptional. The dynamics of PTH levels
during the first 10 minutes following suprasystolic exclusion allowed
us to define the accuracy of the test at 1.0 as soon as 8 minutes.
We did not observe a change in any of the test predictions
after that time. The site of recurrence could be determined accurately
in 27 of 30 patients (90%). Prolonging the test did not increase
the diagnostic yield.
For instance, a graft-dependent recurrence could be predicted
within 4 minutes of starting the test. Each patient with a drop in
systemic PTH of more than 50% at this point was cured after excision
of the autograft. The predictive accuracy of this drop in the
PTH level is such that no further diagnostic test is necessary and the
patient can be scheduled immediately for sonographically guided
resection of the autograft. If the PTH level remains virtually unchanged
or is decreased by no more than 20% after 10 minutes of
suprasystolic exclusion of the autograft, the source of the rSHPT is
invariably the neck. These patients should then be scheduled for
reoperation at an expert endocrine center where additional diagnostic
imaging (e.g., cervical ultrasonography, 99 Tc-sestamibi scanning,
and MRI of the neck and mediastinum) can be performed.
Some 10% of patients are shown to have “indeterminate” PTH levels
during the test. It is noteworthy that after 8 minutes no further
diagnostic gain can be expected in any case, and the test therefore
could have been terminated safely after 10 minutes of temporary
ischemic autograftectomy.
The operative approach to patients in whom the site cannot be
predicted with certainty by the test procedure is an individual one.
In these patients other localization tests such as MRI and selective
venous sampling may be justified prior to making the decision of
whether to operate on the autograft or the neck.
Conclusions
We have shown that an abbreviated, simplified adaptation of the
Casanova test is equally effective, less time-consuming, and less invasive
than the original procedure. Our 10-minute procedure allows
accurate prediction of the site of recurrence in 90% of patients,
and it is certainly feasible in an ambulatory setting. It is
therefore suggested that the modified test procedure become the
standard initial diagnostic modality in patients in whom recurrent
sHPT develops after total parathyroidectomy and autotransplantation
of parathyroid tissue.
Résumé. Chez les patients atteints de récidive d’hyperparathyroïdisme
secondaire (rSHPT) après parathyroïdectomie totale et autotransplantation,
on a voulu déterminer prospectivement, par un test de Casanova modifié, si
le site de récidive était au niveau du bras porteur du greffon ou au niveau du
cou. Ce test mesure le taux d’hormone parathyroïde intacte (PTH), dosée
au niveau du bras sans greffon avant et après une période d’ischémie du
bras porteur du greffon par une bande d’Esmarch. Le but de cette étude a
été d’évaluer les modifications du taux de (« the time course of ») PTH
pendant le test et d’établir un procédé de dosage abrégé. Onaétudié 30
patients atteints de rSHPT admis pour reprise chirurgicale entre 1994 et
2002. Les taux systémiques de PTH ont été déterminés avant, à 2,4,6,8,10,
20, et 30 minutes pendant et 10 minutes après l’exclusion vasculaire du
bras porteur du greffon par gonflage suprasystolique de la bande
d’Esmarch. Les résultats ont été interprétés par un algorithme simple,
suggérant une récidive greffon dépendante (GDR) lorsque les taux de PTH
ont chuté de plus de 50%, et une récidive au niveau du cou (NDR) lorsque le
taux de PTH avait chuté àmoins de 20%. Les patients ont été opérés suivant
les résultats et une normalisation biochimique des taux du calcium et de la
PTHaété définie comme un succès. Quinze patients avaient une GDR et
ont été guéris après explantation du greffon. Tous les patients ont été
identifiés en moins de 4 minutes du début du test. Douze patients avaient
une NDR et ont été guéris par l’excision d’une glande méconnue ou
surnuméraire. Les taux de PTH étaient non décisifs chez trois patients
(10%). Cliniquement, une récidive NDR était la plus probable dans tous ces
cas. Tous les résultats du test se sont établis avec une précision de 100%
huit minutes après le début du procédé. Cette forme abrégée du test de
Casanova est un procédé satisfaisant pour déterminer avec précision le site
de récidive de rSHPT. Il ne prend pas beaucoup de temps, peut être utilisé
de façon satisfaisante en ambulatoire et est efficient et moins invasif
comparé au test original.
Resumen. Se efectúa un estudio prospectivo en pacientes con
hiperparatiroidismo secundario recidivante (rSH PT) tras paratiroidectomía
total con autotrasplante para averiguar, merced al test modificado de
Casanova, sí la recidiva asienta en el cuello o en el autotrasplante
implantado en el brazo. El test mide los niveles de hormona paratiroidea
intacta (PTH) en sangre, obtenida del brazo sin injertar antes y después de
un periodo de isquemia, conseguido tras colocar una venda de Esmarch en
el brazo recipendiario del autotrasplante de paratiroides. El estudio tuvo
como objetivo valorar la evolución de los niveles de la PTH durante el test
y buscar la manera de acortar la duración del mismo. Se estudiaron 30
pacientes con rSHPT que fueron ingresados para reintervención entre
los años 1994 y 2002. Los niveles sanguíneos circulantes de PTH se
determinaron antes y a los 2, 4, 6, 8, 10, 20, y 30 minutos tras un periodo de
isquemia (por compresión superior a la presión sistólica) del brazo
portador del autoinjerto. Los resultados se interpretaron merced a un
simple algoritmo, aceptándose que la recidiva se debía al autotrasplante
(GDR) cuando los niveles de PTH disminuyeron por debajo del 50%,
mientras se sugería que la recidiva residía en el cuello (NDR) cuando la

588 World J. Surg. Vol. 28, No. 6, June 2004
PTH disminuía menos del 20%. Se consideró que los pacientes habían sido
reoperados con éxito cuando se normalizaron los niveles de calcio sérico y
de PTH intacta. 15 pacientes con GDR se curaron tras la explantación.
Todos ellos se identificaron a los 4 minutos o antes de iniciar el test. 12
pacientes con NDR se curaron tras la extirpación de glándulas paratiroideas
olvidadas o supranumerarias. En 3 enfermos (10%) los niveles de PTH no
fueron determinantes. La clínica fue similar en todos los pacientes NDR,
sin embargo, el test estableció el diagnóstico exacto en el 100% de los casos
transcurridos 8 minutos del inicio del mismo. El test abreviado de Casanova
permite el diagnóstico preciso del lugar de origen del hiperparatiroidismo
secundario recidivado (rSHPT). Su duración es mas corta, pudiéndose
realizar ambulatoriamente. Es menos agresivo y tan eficaz como el test
original.
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