The management of high-risk patients with primary hyperparathyroidism - minimally invasive parathyroidectomy vs. medical treatment.

OBJECTIVE

Parathyroidectomy (PTx) for high-risk primary hyperparathyroidism (PHPT) patients poses a surgical challenge. We hypothesize that a minimally invasive parathyroidectomy (MIP) under local anaesthesia may minimize the perioperative risks and facilitate easier clinical care than medical treatment for these patients.

DESIGN AND PATIENTS: We performed a prospective, nonrandomized, controlled study of 33 PHPT patients evaluated as poor general anaesthesia risks. The outline of the diseased parathyroids and the thyroid were mapped by Tc(99m) sestamibi scan and focused sonogram. MIPs were performed under local anaesthesia (group 1, 19 patients). Medical treatment with bisphosphonates was continued for patients refusing operation (group 2, 14 patients).

MEASUREMENTS: Serum Ca, PO(4), and i-PTH were measured the following morning, every 6 months in the first postoperative year and then yearly for group 1 patients, or every 3 months for group 2 patients. American Society of Anaesthesiologists (ASA) and New York Heart Association (NYHA) class designations were re-evaluated every 3 months.

RESULTS

In group 1, there were no operative complications, mortality or recurrent hypercalcaemia during a mean follow-up of 35.5 months. Group 2 patients had a significantly higher incidence of episodes of hypercalcaemic crisis, deteriorating renal function and weight-bearing bone fractures, while group 1 patients had a higher incidence of improved ASA and NYHA class, better 3-year overall survival rate (83.1%vs. 60.8%, P = 0.032), and less medical costs.

CONCLUSION

MIP can be safely performed under local anaesthesia and it facilitates clinical care in high-risk PHPT patients. It is recommended for those selected by image localization.