Surgical workshop the vein is opened longitudinally for the same length, and spread along the prolongation of the flattened prosthesis (Fiyur-e 2c j. The prosthesis is cut along the prolongation of an edge o f t h e C u t vein, so that a flap may be lifted up. One edge of the flap is equal therefore to half the circumference of the prosthesis, while the other is equal to the circumference of the vein. The flap is excised. The prosthesis in the flattened position is then rolled up ( F i q u r r Z d ) and bevelled (along the dotted lines). The extremity of the bevel is excised to round it 08, making suturing around the corner easier (Figure Ze ). The anastomosis is carried out with a running vascular suture.
References 1.
Merlini M P . Composite femoropopliteal bypass: a new method of centered end-to-end anastomosis between polytetrafluoroethylene and autologous vein with a diameter discrepancy. J V t r . ~ S U K ~1990: 12: 761-2 (Letter).
Paper accepted 5 May 1992
Case report Br. J. Surg. 1992, Vol. 79, November, 1158
Unprecipitated rupture of the brac hiocepha Iic artery du r ing repeated surgery for parathyroid carcinoma L. J. Buist and A. D. Barnes Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, UK Correspondence to: Miss L. J. Buist, Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham 61 5 2TH, U K
Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. Despite increasing reporting of cases' over the past 20 years. an individual surgeon's experience of this disease is limited, particularly in relation to complications of repeated surgery in such patients. The best results are achieved by adequate excision at the first operation, but occasionally the malignant component is not recognized at this stage and the patient returns over a period of years for further excision of neoplastic tissue from the neck and mediastinurn. Two such patients are presented who developed an identical previously unreported complication of repeated parathyroid cancer excision.
Case reports Prrrlcwr
I
In 1987 a 58-year-old man presented with renal calculous disease. was found to be hypercalcaemic (calcium level 3.0 mmol ' I ) and was diagnosed a s having primary hyperparathyroidism (parathyroid hormone concentration 0.76 ng ml ). Neck exploration was undertaken and one enlarged parathyroid gland excised from the right inferior position; the remaining glands appeared normal. The enlarged gland was reported histologically as an adenoma. The patient presented again 20 months later with a lump in the scar that. when excised, proved to be parathyroid carcinoma. The serum calcium level was 3.4 mmol ' I and further neck exploration was undertaken. Locally infiltrating carcinoma was encountered. which was excised radically by total thyroidectomy. thymectomy. excision of the right internal jugular nodes. and sacrifice of the right recurrent laryngeal nerve. After a further 14 months the serum calcium concentration had risen to 3.7 mmol,'l. At further operation there was no evidence of neoplasm in the neck but recurrent tumour was present adjacent to the brachiocephalic artery in the superior mediastinurn. As this tissue was being dissected with no direct manipiilation of the arterial trunk, the artery spontaneously ruptured. The brachiocephalic artery was therefore transected proximal to the defect and the carotid and subclavian arteries divided after vascular control had been achieved.
1158
A Y shaped polytetrafluoroethylene ( P T F E ) graft was used to repair the defect. The patient developed left hemiplegia 2 days later and died 1 week later from bronchopneumonia. Post-mortem examination confirmed thrombotic occlusion of the carotid limb of the graft. Ptr/icw/ -7 A 60-year-old man presented in 1979 with constipation and polydipsia. The serum calcium level was 3.1 mmol.'I and the parathyroid hormone concentration was raised. At parathyroidectomy an enlarged right inferior gland was removed: histological examination confirmed a parathyroid adenoma. The patient presented again 8 years later with similar symptoms and a serum calcium level of 3.7 mmol.'I. At repeat operation. locally invasive carcinoma was found in the neck: this was excised and normocalcaemia achieved. The patient's serum calcium level was again grossly raised after ii further year, necessitating further exploration of the neck and mediastinurn. Total thyroidectomy, thymectomy, node clearance and excision of the right recurrent laryngeal nerve achieved normocalcaemia. Despite medical treatment designed to reduce recurrent hypercalcaemia. further exploration was undertaken I year later. Again. extensive tumour in the superior mediastinurn was found. which was dissected from around and behind the great vessels. During gentle traction the brachiocephalic artery ruptured. After resection of the ruptured arterial ends an interpositional PTFE graft was used to repair the defect. Histological examination showed no direct invasion of the artery with tumour. The patient died 4 months later from hypercalcaemia but with no arterial complication.
Discussion Ideally. parathyroid carcinoma should be completely excised at initial operation but it often goes unrecognized at this time or is partially irresectable. creating the need for repeated neck and mediastinal surgery to remove recurrent disease. As demonstrated by the patients reported, the cancer tends to progress into the superior mediastinurn and can be found adjacent to or surrounding the great vessels. Qvist r t ~ t 1 . lhave reported one case in which the brachiocephalic artery was resected at initial mediastinal exploration to facilitate tumour clearance, with vascular reconstruction. There appear to be no reports of rupture of the vessels at mediastinal dissection when not subjected to direct trauma. The brachiocephalic artery is relatively unsupported if the surrounding tissue is excised and, if already weakened by having been encased in neoplastic or inflammatory tissue, may rupture on the slightest provocation, even in the absence of direct invasion into the arterial wall.
References I.
2.
Obara T. Fujimoto Y . Diagnosis and treatment of patients with parathyroid carcinoma: an update and review. WorltlJ Srrq I991 : 15: 738-44. Qvist N. Kroll L, Ladefoged C, Blichert-Toft M, Rohr N. Parathyroid carcinoma: a case with recurrence treated with extensive vascular surgery to the neck. Errr J Srrn/ Orwol 1986: 12: 187-91.
Paper accepted I7 June 1992
0007-1323/92/111158-01
0 1992 Butterworth-Heinemann Ltd
References 1.
Merlini M P . Composite femoropopliteal bypass: a new method of centered end-to-end anastomosis between polytetrafluoroethylene and autologous vein with a diameter discrepancy. J V t r . ~ S U K ~1990: 12: 761-2 (Letter).
Paper accepted 5 May 1992
Case report Br. J. Surg. 1992, Vol. 79, November, 1158
Unprecipitated rupture of the brac hiocepha Iic artery du r ing repeated surgery for parathyroid carcinoma L. J. Buist and A. D. Barnes Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, UK Correspondence to: Miss L. J. Buist, Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham 61 5 2TH, U K
Parathyroid carcinoma is a rare cause of primary hyperparathyroidism. Despite increasing reporting of cases' over the past 20 years. an individual surgeon's experience of this disease is limited, particularly in relation to complications of repeated surgery in such patients. The best results are achieved by adequate excision at the first operation, but occasionally the malignant component is not recognized at this stage and the patient returns over a period of years for further excision of neoplastic tissue from the neck and mediastinurn. Two such patients are presented who developed an identical previously unreported complication of repeated parathyroid cancer excision.
Case reports Prrrlcwr
I
In 1987 a 58-year-old man presented with renal calculous disease. was found to be hypercalcaemic (calcium level 3.0 mmol ' I ) and was diagnosed a s having primary hyperparathyroidism (parathyroid hormone concentration 0.76 ng ml ). Neck exploration was undertaken and one enlarged parathyroid gland excised from the right inferior position; the remaining glands appeared normal. The enlarged gland was reported histologically as an adenoma. The patient presented again 20 months later with a lump in the scar that. when excised, proved to be parathyroid carcinoma. The serum calcium level was 3.4 mmol ' I and further neck exploration was undertaken. Locally infiltrating carcinoma was encountered. which was excised radically by total thyroidectomy. thymectomy. excision of the right internal jugular nodes. and sacrifice of the right recurrent laryngeal nerve. After a further 14 months the serum calcium concentration had risen to 3.7 mmol,'l. At further operation there was no evidence of neoplasm in the neck but recurrent tumour was present adjacent to the brachiocephalic artery in the superior mediastinurn. As this tissue was being dissected with no direct manipiilation of the arterial trunk, the artery spontaneously ruptured. The brachiocephalic artery was therefore transected proximal to the defect and the carotid and subclavian arteries divided after vascular control had been achieved.
1158
A Y shaped polytetrafluoroethylene ( P T F E ) graft was used to repair the defect. The patient developed left hemiplegia 2 days later and died 1 week later from bronchopneumonia. Post-mortem examination confirmed thrombotic occlusion of the carotid limb of the graft. Ptr/icw/ -7 A 60-year-old man presented in 1979 with constipation and polydipsia. The serum calcium level was 3.1 mmol.'I and the parathyroid hormone concentration was raised. At parathyroidectomy an enlarged right inferior gland was removed: histological examination confirmed a parathyroid adenoma. The patient presented again 8 years later with similar symptoms and a serum calcium level of 3.7 mmol.'I. At repeat operation. locally invasive carcinoma was found in the neck: this was excised and normocalcaemia achieved. The patient's serum calcium level was again grossly raised after ii further year, necessitating further exploration of the neck and mediastinurn. Total thyroidectomy, thymectomy, node clearance and excision of the right recurrent laryngeal nerve achieved normocalcaemia. Despite medical treatment designed to reduce recurrent hypercalcaemia. further exploration was undertaken I year later. Again. extensive tumour in the superior mediastinurn was found. which was dissected from around and behind the great vessels. During gentle traction the brachiocephalic artery ruptured. After resection of the ruptured arterial ends an interpositional PTFE graft was used to repair the defect. Histological examination showed no direct invasion of the artery with tumour. The patient died 4 months later from hypercalcaemia but with no arterial complication.
Discussion Ideally. parathyroid carcinoma should be completely excised at initial operation but it often goes unrecognized at this time or is partially irresectable. creating the need for repeated neck and mediastinal surgery to remove recurrent disease. As demonstrated by the patients reported, the cancer tends to progress into the superior mediastinurn and can be found adjacent to or surrounding the great vessels. Qvist r t ~ t 1 . lhave reported one case in which the brachiocephalic artery was resected at initial mediastinal exploration to facilitate tumour clearance, with vascular reconstruction. There appear to be no reports of rupture of the vessels at mediastinal dissection when not subjected to direct trauma. The brachiocephalic artery is relatively unsupported if the surrounding tissue is excised and, if already weakened by having been encased in neoplastic or inflammatory tissue, may rupture on the slightest provocation, even in the absence of direct invasion into the arterial wall.
References I.
2.
Obara T. Fujimoto Y . Diagnosis and treatment of patients with parathyroid carcinoma: an update and review. WorltlJ Srrq I991 : 15: 738-44. Qvist N. Kroll L, Ladefoged C, Blichert-Toft M, Rohr N. Parathyroid carcinoma: a case with recurrence treated with extensive vascular surgery to the neck. Errr J Srrn/ Orwol 1986: 12: 187-91.
Paper accepted I7 June 1992
0007-1323/92/111158-01
0 1992 Butterworth-Heinemann Ltd
