title: The management of high-risk patients with primary hyperparathyroidism - minimally invasive parathyroidectomy vs. medical treatment.
abstract: 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.
  
  
  METHODS
  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).
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of General Surgery, Department of Surgery, Veterans General Hospital, Taipei, Taiwan.
authors.forename: Wen-Liang
authors.initials: WL
authors.lastname: Fang
authors.forename: Ling-Ming
authors.initials: LM
authors.lastname: Tseng
authors.forename: Jui-Yu
authors.initials: JY
authors.lastname: Chen
authors.forename: See-Ying
authors.initials: SY
authors.lastname: Chiou
authors.forename: Yi-Hong
authors.initials: YH
authors.lastname: Chou
authors.forename: Chew-Wun
authors.initials: CW
authors.lastname: Wu
authors.forename: Chen-Hsen
authors.initials: CH
authors.lastname: Lee
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000772:Anesthesia, Local; D005260:Female; D006801:Humans; D006961:Hyperparathyroidism / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D016105:Parathyroidectomy / Q000379:methods*; D019990:Perioperative Care; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome