Endocrine Abstracts (2004) 7 S41

When and how to remove the overactive parathyroid

GP Sadler

John Radcliffe Hospital, Oxford, UK.

Primary hyperparathyroidism has an overall incidence of 25 per 100,000 of the UK population but may be present in 1 in 500 or more women over the age of 45. Surgery is the treatment of choice in symptomatic primary hyperparathyroidism (pHPT). Selected patients with asymptomatic hyperparathyroidism may also benefit from parathyroidectomy.

Traditionally, parathyroidectomy has been based on a collar incision coupled with bilateral cervical neck exploration. In experienced hands in large volume centres cure rates of up to 97% with minimal morbidity have been reported.However, as the vast majority (80%) of patients with pHPT have a solitary adenoma many Endocrine Surgeons have recently adopted a policy of trying to identify the affected gland preoperatively to allow a “minimal” or “focused” approach.

Localisation involves the use of both technetium Tc 99M sestamibi and ultrasound scanning. When the two modalities are concordent there is a 98% likelihood that the lesion localised is a single adenoma. In this instance a minimal access targeted approach to single adenoma parathyroidectomy is possible.

The technique using a focused approach through a small neck incision is the current method of choice of 92% of members of the International Association of Endocrine Surgeons favouring a minimal access approach. The minimal access parathyroidectomy (MIP) is achieved through a 2cm skin incision placed over the appropriately localised parathyroid gland. MIP can be usually performed in less than 20 minutes under local anaesthetic or laryngeal mask airway, often as a day case.

Elderly and co-morbid patients affected by pHPT are often not referred for surgery, presumably at least in part due to the nature of the traditional surgical approach. The technique of parathyroidectomy however has radically altered in the past couple of years and many patients previously deemed unsuitable or unfit for surgery may indeed benefit from this new procedure.

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