Surgical Management of Primary Hyperparathyroidism: An Institutional Study on Surgical Quality Control

Abstract

Introduction: Surgery is key treatment of primary hyperparathyroidism. With the inclusion of serum calcium measurement in routine biochemistry panel, majority of primary hyperparathyroidism can be detected in earlier asymptomatic phase. Preoperative localization by Ultrasonography and Sestamibi scan combined together along with CT or MRI in ectopic adenoma enables for focused minimal invasive surgery. Intraoperative intact PTH (IPTH) measurement is used as a surgical quality control in primary hyperparathyroidism surgery. This study was undertaken to look into current status of surgical management of primary hyperparathyroidism in the tertiary care center in Nepal.

Methods: This was a prospective observational study conducted in Department of Surgery. Tribhuvan University Teaching Hospital Kathmandu, Nepal from November 2014 to October 2016. Demography profile, preoperative symptoms, duration of symptoms, preoperative serum calcium, phosphate, immediate preoperative iPTH level and intraoperative iPTH level, post-operative calcium level and localization techniques were recorded. Final pathology report of each of the patients were recorded.

Results: Thirteen patients were operated for primary hyperthyroidism. Mean age of the patients was 36:15 years. None of the patient had multi-glandular disease on preoperative localization. Mean preoperative Calcium level was 12.8±0.9 mg/dl and mean preoperative iPTH level was 998+805 pg ml. As Intraoperative iPTH measurement was used to ascertain the successful adenoma removal, mean IPTH intraoperative iPTH after the removal of the adenoma was 175±167 pg/ml. Mean difference of iPTH was 823±725 (p 0.024). There was mean decrease of 81% of iPTH after surgery well above 50% decrease confirmatory of successful adenoma removal. None of patients had reported with recurrent symptoms till date.

Conclusion: Hypercalcemia should be subjected for iPTH scanning to identify more asymptomatic patients and Surgery is key treatment and intraoperative iPTH assay is used for confirmation of adenoma removal.