Endocrine Abstracts

The gold standard for the surgical cure of primary hyperparathyroidism (PHPT) for many years was cervical exploration under general anaesthetic, identification of 4 parathyroid glands and removal of enlarged/abnormal glands. Despite cure rates in expert hands of 98% with minimal morbidity the surgical management of PHPT is changing.

PHPT in most cases (85%) is caused by single gland disease. The advances in preoperative localisation of abnormal parathyroid tissue – ultrasound and MIBI, and the concept of minimally invasive surgery have led to a progression from scan directed unilateral neck exploration, small incision unilateral (focused) neck exploration and video-assisted surgery. The apparent benefits of scan directed surgery include shorter hospital stay, a lesser requirement for the use of general anaesthesia and improved cosmesis. In expert hands, concordant localisation scans and a minimally invasive surgical approach will achieve biochemical cure in 90–95% of patients with PHPT.

A minimally invasive scan directed surgical procedure is contra-indicated for patients with co-existent goitre, large parathyroid tumours, a family history of HPT or those with suspected or proven multiglandular disease. Routine intra-operative PTH assay to confirm biochemical cure is not cost effective.

A pragmatic ‘modern’ approach for patients with HPT is as follows. In the patient without clinical contra-indication to minimally invasive surgery request an ultrasound scan. If a single parathyroid gland is localised, request a MIBI scan. If the scans are concordant, consider the patient for focused neck surgery under local or general anaesthesia. Patients with suspected or proven multiple gland disease, renal HPT and MEN require conventional neck exploration and assessment of all parathyroid tissue.