Urgent parathyroidectomy

Abstract

Urgent parathyroidectomya ns_6002 193..197 Endocrine surgery is increasingly seen as a '23-hour specialty'; 1 calcium and parathyroid hormone assays are readily available, and localizing studies in hyperparathyroidism are improving. Consequently, parathyroidectomy in asymptomatic hyperparathyroidism and expanding indications for minimally invasive parathyroidectomy (MIP) 2 are being debated. Patients are requesting and endocrine surgical trainees are seeking experience in MIP. Profound hypercalcaemia from hyperparathyroidism (a metabolic emergency), when localizing studies may be unavailable and an urgent parathyroidectomy is indicated, also occurs. Training in MIP risks being ill prepared for such emergencies and the formal neck exploration technique often required. Following patient stabilization and transfer to a specialist centre, it is essential that surgical teams are equipped to manage these sick and vulnerable patients appropriately.Hypercalcaemic crisis is the presenting feature in 1.6-6.7% of hyperparathyroid patients 3-7 and may occur in primary or secondary disease. It typically presents with gastrointestinal symptoms and fatigue culminating in weakness, impaired cognition, cardiac arrhythmias or even coma and death, 7 either on a background of long-standing hyperparathyroidism or as the first presentation. 5 Precipitating events include haemorrhage into a cystic adenoma, introduction of thiazide diuretics, parturition and intercurrent illness. 5 Crisis patients have higher calcium and parathyroid hormone levels, greater weights of the pathological parathyroid glands 3,5 and increased rates of ectopic mediastinal glands (10-50%) 3,5 compared with non-crisis populations. However, the underlying pathology is similar in the two groups: a single adenoma (80-85%), multi-gland disease (10-15%) and parathyroid carcinoma (3.6-4.6%). [3][4][5] Treatment is initially with rehydration, which enhances calcium excretion through diuresis. Bisphosphonates and cinacalcet are useful in lowering calcium levels, as a bridge to surgery. The former are contraindicated in pregnancy, the latter (a calcimimetic agent that effectively lowers calcium), used mostly in secondary hyperparathyroidism, has funding limitations for its use in Australasia in primary hyperparathyroidism. Urgent parathyroidectomy within 72 h of presentation is advised; 5,7 however, a longer period may be required for patient stabilization. General anaesthesia in the presence of severe hypercalcaemia can induce cardiac arrhythmia; therefore, efforts to achieve eucalcaemia should be made preoperatively. 5 The average time to surgery from presentation was 5 days in one recent series. 4 Other situations requiring urgent parathyroidectomy include: PERSPECTIVESANZJSurg.com