The high degree of accuracy afforded by ultrasonographic examination immediately prior to surgery allows placement of the needle and guide wire, with confidence. Only six patients out of nine were confirmed to have parathyroid tissue on cytopathological examination at time of biopsy. In the other four patients, cytology was nondiagnostic. selleck bio All patients had PTH washout, which confirmed the correct localization of the parathyroid tissue. Frasoldati and colleagues [13] showed that FNA-PTH washout more than 101pg/mL had a 100% sensitivity and specificity for verification of parathyroid tissue. One patient from our current series underwent this procedure during her pregnancy and we reported recently a successful outcome in this patient [14].

A review of the literature revealed a total of four additional cases where wire or needle localization was utilized for surgery in the neck, however all of them utilized CT guidance [15�C17]. The overall technique is similar, using image guidance to precisely place a guide wire into the target lesion. The ability to follow the wire intraoperatively avoids unnecessary trauma to other structures from dissection and alleviates the need for a more extensive operation. This guide-wire technique is an effective method to prevent damage to the recurrent laryngeal nerve (RLN). This is of utmost importance in reoperative cases, where RLN injury rates as high as 10% have been reported [18]. The technical difficulties posed by the scar tissue and distorted anatomy in the reoperative neck are such that even traditional intraoperative nerve monitoring has not always decreased the rate of RLN injury in these patients [19].

Allowing the surgeon to follow the path of an image-guided wire to the target lesion, combined with standard nerve monitoring, has facilitated avoiding recurrent laryngeal nerve injury. Preoperative image-guided Homer needle wire placement and methylene blue injection for reoperative hyperparathyroid patients was able to correctly identify all lesions in our series. While preoperative wire placement is certainly not indicated in every reoperative patient, this technique provides another tool in the armamentarium available to physicians treating hyperparathyroidism in high-risk patients with prior neck surgery. Conflict of Interests The authors declare that there is no conflict of interests.

Acknowledgment All financial and material support for this research and work was fully supported by Tulane University and Tulane University Anacetrapib Hospital. The authors have no financial interests in companies or other entities that have an interest in the information included in the contribution.
The patient was a 79-year-old man with concomitant pre-dialytic kidney failure who was initially operated for two synchronous adenocarcinomas of which one was located in the ascending colon and the other at the rectosigmoid junction.