Br. J . Surg. 1992, Vol. 79, September, 931 -934
A. Bergenfelz, L. Algotsson* and B. Ahren Departments of Surgery and *Anaesthesiology, Lund University, S-22185 Lund, Sweden Correspondence to: Dr A. Bergenfelz
Surgery for primary hyperparathyroidism performed under local anaesthesia Patients with primary hyperparathyroidism are often elderly with cardiovascular disease and in some an operation might be hazardous owing to anaesthetic complications. A technique f o r operation f o r primary hyperparathyroidism under local anaesthesia is described. The method uses a unilateral approach. Seventeen consecutive patients operated on under local anaesthesia were compared with a group of 15 patients undergoing surgery under general anaesthesia. Normocalcaemia was achieved in 14 patients in each group. There was no diflerence in the extent of pain or the overall well-being between the two groups as determined by a visual analogue scale. Patients receiving local anaesthesia, however, experienced significantly less nausea after operation ( P < 0.01). There was more fluctuation in blood pressure and heart rate in the general anaesthesia group compared with the other group. Surgery f o r primary hyperparathyroidism can be performed safely under local anaesthesia, and could be ofSered to patients if general anaesthesia were not suitable or involved an increasedperioperative risk. It should not be recommended f o r routine use in patients who are f i t for general anaesthesia.
Primary hyperparathyroidism is being diagnosed with an increasing frequency’ and patients have lower serum calcium levels than previously’. The patients are usually elderly with no or only neuromuscular symptom^^-^. The results of surgery for primary hyperparathyroidism are excellent, with a cure rate3*7-11of around 90 per cent. Surgery results in a reduction of symptoms”.’’ even in patients with ‘mild’ d i ~ e a s e ’ . ’ ~ - ~ ~ . There is a trend to operate on more mild cases than previously. Many patients with primary hyperparathyroidism are compromised by coexistent cardiovascular d i ~ e a s e ’ ~ - ’and ~ for some of these surgery might be hazardous owing to anaesthetic complications. Patients at high risk may be operated on safely and with acceptable results under local anaesthesia, provided that preoperative localization of the enlarged parathyroid gland(s) is obtained’’. How is such an operation for primary hyperparathyroidism under local anaesthesia tolerated by the patient? This issue was investigated in a consecutive series of patients with the condition who were explored under local anaesthesia and compared with a group having exploration under general anaesthesia.
Patients and methods Patients Thirty-two consecutive patients entered the study. Seventeen were explored under local anaesthesia and 15 under general anaesthesia (one of these explorations was a reoperation because of hyperplasia). The clinical and biochemical profile of the two groups is shown in Table I . No significant differences were found between the two groups. Preoperative localization procedures in all patients included ultrasonography, thallium-technetium subtraction scintigraphy, and large vein sampling for intact parathyroid hormone (PTH). Definitive localization of an enlarged parathyroid gland was accomplished before operation if two procedures identified a lesion in the same location and/or ultrasonography with fine-needle aspiration for PTH content was positive (i.e. with a PTH concentration twice the serum PTH level) or if large venous sampling demonstrated an unequivocal unilateral gradient. In these cases, the operation was performed under local anaesthesia in patients older than 75 years with complicating diseases (cardiovascular, pulmonary or thromboembolic) and in some patients who preferred local to general anaesthesia.
0007-1323/9?/09093144 0 1992 Butterworth-Heinemann Ltd
Operation Patients having exploration under local anaesthesia were investigated by one surgeon (A.B.).The 15 patients explored under general anaesthesia were operated on by four different surgeons. Surgery under general anaesthesia was performed through a standard collar incision and exploration was unilateral or bilateral according to the preference of the surgeon. The dissection was always begun on the side where the preoperative localization procedures had indicated the existence of an enlarged parathyroid gland. Patients explored under local anaesthesia underwent unilateral exposure with removal of the enlarged parathyroid gland and biopsy or excision of the other ipsilateral parathyroid gland”. All removed parathyroid glands were sent for frozen section, and serum samples for determination of intact PTH were obtained before and 15 min after ligation of the vascular pedicle of the enlarged parathyroid gland. A definite diagnosis of an adenoma was based on conventional histological criteria and in most cases the intraoperative fall of serum levels of intact PTH after removal of the enlarged glandzz. Hyperplasia was diagnosed on the basis of removal of two or more enlarged parathyroid glands. Anaesthesia Induction of anaesthesia in the general anaesthesia group was performed by administration of thiopentone, fentanyl and pancur-
Table 1 Clinical and biochemical proJle of the two groups of patients operated on for suspected primary hyperparathyroidism
Mean(s.d.) age (years) Sex ratio ( M : F ) Mean(s.d.) serum calcium (mmol/l)* Mean(s.d.) serum intact parathyroid hormone (pmol/l)* Mean(s.d.) serum alkaline phosphatase (units/l)*
Local anaesthesia
General anaesthesia
65(9) 4:13 2.79(0.22) 10.5(9.1)
61(15) 5:lO 2.77(0.21) 11~1(102)
3.8( 1.1 )
4.2( 1.8)
*Normal ranges: serum calcium 2.20-2.60 mmol/l; serum intact parathyroid hormone 1.0-5.0 pmol/l; serum alkaline phosphatase 0.8-4.6 units/l
931
Surgery for primary hyperparathyroidism under local anaesthesia: A. Bergenfelz et al.
onium. Anaesthesia was maintained by addition of isoflurane together with incremental doses of fentanyl. In the local anaesthesia group, no premcdication was given but, at the beginning of the operation, 1-2 ml glycopyrronium bromide (0.2 mg/ml) (Robinul; A. H. Robins, Crawley, UK) was administered intravenously. During surgery, intermittent injections with 50 mg/ml pethidine hydrochloride ( Petidin; Kabi Pharmacia, Solna, Sweden ) and 1 mg/ml midazolam (Dormicum; Hoffman-La Roche, Basel, Switzerland ) were given intravenously to supplement the local anaesthesia. Postoperatiue i are Patients were monitored after operation for hypocdkaemia, and therapy given if symptoms occurred. Follow-up was carried out at 8 weeks. Visual analogue scale The patients’ and nurses’ opinion of overall well-being,pain and nausea were recorded on a visual to-grade analogue scale (where 10 signified no pain, no nausea and total well-being). This was performed during operation for patients operated on under local anaesthesia and after operation ( < 6 h ) for both groups. Analysis Serum levels of intact PTH were measured using the commercially available N-tact PTH assay (Incstar, Stillwater, Minnesota, USA). The sensitivity of this assay is 0.13 pmol/l with an interassay variation of < 11 per cent and an intra-assay variation of < 6 per cent at both high and low levels. (The precision data are expressed as coefficients of variation. ) Total serum calcium values were corrected for serum albumin concentration according to the formula:
Ca, (mmol/l) = measured serum calcium (mmol/l)
+ 0.02 x
[40
-
serum albumin (g/l)]
Blood glucose levels were determined with the glucose oxidase technique. Serum levels of alkaline phosphatase were determined by routine autoanalysis.
Table 2 Results from the operations in the two groups ofpatients
Mean(s.d.) operation time (min)* Mean(s.d.) weight of excised enlarged parathyroid gland (9) No. of patients with normocalcaemia at 8 weeks Mean(s.d.) serum Ca, at 8 weeks after operation (mmol/l)
Local anaesthesia
General anaesthesia
85(30) 1,10(1.28) ( n = 16) 14
122(35) 0.93(0.60 ) ( n = 14) 14
2.32(0.10) ( n = 14)
2.34(0.10) ( n = 14)
Ca,, calcium concentration corrected for albumin. *Time for the surgical procedure excluding anaesthesia
Statistics Results arc expressed as mean(s.d.). For statistical evaluation of differences between groups, Student’s t test for unpaired data and the Mann-Whitney U test were used. For calculation of heart rate, blood pressure and blood glucose intragroup differences, analysis of variance (ANOVA) was performed. A probability level of P < 0.05 was considered significant.
Results The results of surgery are shown in Tuble2. Twenty-eight patients were found t o have a solitary adenoma, three had primary hyperplasia an d in one n o parathyroid enlargement was found. In the group operated o n under local anaesthesia, three patients had persistent hypercalcaemia, two of whom had primary hyperplasia. Th e operative an d clinical details of these patients are shown in Tuble3. All three patients underwent successful re-exploration. I n patient 1, a second enlarged gland (weight 300 m g ) was found o n the left side a t re-exploration under local anaesthesia. I n patient 2, dissection during the first operation was complicated by a haematoma around the lower pole of the thyroid following fine-needle aspiration for P T H . At reoperation with bilateral exploration under general anaesthesia, a second enlarged parathyroid gland was found within the thyroid o n the right side. A further three parathyroid glands were biopsied. This patient had five parathyroid glands. I n patient 3, localization procedures indicated enlargement of a parathyroid gland o n the right side. At reoperation under local anaesthesia, a parathyroid adenoma (weight 270 m g ) was found o n the left side, i.e. the preoperative localization was wrong. I n the group of patients explored under general anaesthesia, one had persistent hypercalcaemia a t follow-up. F o u r normal glands had been identified a t biopsy an d the reason for hypercalcaemia is not known. There was n o difference in the weight of the removed glands between the patients explored under local an d general anaesthesia. I n one patient, the parathyroid adenoma was found in the thyroid gland an d the weight could not be estimated. At follow-up a t 8 weeks n o significant difference in serum calcium levels between the two groups of patients was found. Paralysis of the recurrent laryngeal nerve did not occur. There was n o difference between the nurses’ an d patients’ opinion of overall well-being, pain and nausea. After operation no difference with regard to pain or well-being scores was found between the two groups of patients. Patients operated on under local anaesthesia had, however, significantly less nausea ( P < 0.01 ) (Figure I ). ANOVA demonstrated differences in heart rate before, during an d after operation in the local anaesthesia ( P < 0.05 ) an d in the general anaesthesia ( P < 0.001 ) groups of patients. Patients operated o n under local anaesthesia had a significantly
Table 3 Intraoperative findings, results from frozen section, localization procedures and diagnosis at reoperation f o r the three patients explored under local anaesthesia with persistent hypercalcaemia after the primary operation Patient no.
Intraoperative findings
Histology (frozen section)
Preoperative localization (prediction of procedure)
Diagnosis ( reoperation )
1
Two parathyroid glands excised: one enlarged ( R U ) and one normally sized (RL)
Adenoma (RU), weight 160 mg Normal parathyroid with signs of ‘suppression’ (RL )
H yperplasia
2
One enlarged parathyroid gland excised (RU)
Adenoma or hyperplasia (RU), weight 140mg
3
Two parathyroid glands excised: one slightly enlarged (RL) and one normally sized ( R U )
Both parathyroid glands normal, weight of RL 130 mg
Ultrasonography : one enlarged gland (RU ) Scintigraphy : one enlarged gland ( RU ) Ultrasonography with fine-needle aspiration for PTH: one enlarged gland ( RU ) Venous sampling for PTH: gradient to right side Scintigraphy : one enlarged gland (RL)
Hyperplasia
Adenoma
RU, right upper; RL, right lower; PTH, parathyroid hormone
932
Br. J. Surg., Vol. 79, No. 9, September 1992
Surgery for primary hyperparathyroidism under local anaesthesia: A. Bergenfelz et al.
r-5
T
T
Well-being
Pain
Nausea
Figure 1 Nurse rating of well-being, pain and nausea after operation and general anaesthesia ( B ) groups on a for the local anaesthesia (0) scale of 10, where 10 indicates no symptoms and total well-being. Values are mean(s.d.). * P < 0.01 (Mann- Whitney U test)
E 6ot
+
Figure 2 Heart rate during and after operation in the two groups of patients. Values are mean(s.d.). 0 , Local anaesthesia; 0 , general anaesthesia. * P < 0.05;t P < 0.01 (local versus general anaesthesia, Student’s unpaired t test)
b)
I
Discussion
’,
Medical follow-up’ treatment with biphosphonatesz3 and percutaneous biochemical inactivationz4 have been suggested for the management of high-risk patients with primary hyperparathyroidism. Medical follow-up and treatment with biphosphonates require close patient surveillance. Chemical parathyroidectomy yields unacceptable results and a high complication rate24. Surgery under local anaesthesia may be an alternative approach provided the results are adequate and the well-being of the patients acceptable. The first successful parathyroidectomy was performed under local anaesthesia by Mand12’ in Vienna in 1925. The present study demonstrates that patients operated on under local anaesthesia show a high degree of well-being during and after the operative procedure. The difference in intraoperative systolic blood pressure between the two groups of patients was probably due to a physiological reaction to the anaesthetic drugs given in the general anaesthesia group, since the systolic blood pressure in the local anaesthesia group did not change significantly. A significantly higher heart rate during operation compared with after surgery was evident in the patients operated on under local anaesthesia. This may indicate extra stress in this patient group. There was, however, no significant difference between the heart rate before anaesthesia and that recorded during operation. The postoperative changes in heart rate may be of importance. To prevent myocardial ischaemia it is essential to avoid excessive changes in heart rate and blood pressurez6. Many patients with primary hyperparathyroidism have ischaemic heart disease”. In terms of well-being and stress, operation under local anaesthesia seems to be at least as good as operation performed under general anaesthesia. There were three operative failures in the local anaesthesia group, giving similar results to those in the first published series of patients operated on under local anaesthesia by Pyrtek et al.”. Incorrect preoperative localization was the major reason for surgical failure. Frozen section error contributed to the failure in one patient and a complication from ultrasonographically guided fine-needle aspiration for PTH assay in another. High sensitivity and accuracy of localization procedures are of paramount importance when performing operation for primary hyperparathyroidism under local anaesthesia. Operation under local anaesthesia should be offered to elderly and fragile patients with primary hyperparathyroidism when operation under general anaesthesia is unsuitable. With present results the routine use of the method cannot be recommended for patients who are fit for general anaesthesia.
Acknowledgements This study was supported financially by the Medical Faculty, Lund University, Figure 3 Systolic blood pressure in the two groups of patients during and after operation. Values are mean(s.d.). o, Local anaesthesia; 0 , general anaesthesia. * P < 0.05; t P < 0.01 (local versus general anaesthesia. Student’s unpaired t test)
References 1.
2.
higher heart rate during the operation compared with those undergoing surgery under general anaesthesia. Heart rate was, however, significantly higher after operation in the general anaesthesia group (Figure 2 ) . The systolic blood pressure changed only in patients operated on under general anaesthesia ( P < 0,001 ). Those receiving local anaesthesia had a significantly higher systolic blood pressure during operation than those receiving general anaesthesia (Figure 3). No significant differences were found in blood glucose levels within or between the groups of patients.
Br. J . Surg.. Vol. 79, No. 9, September 1992
3.
4.
5.
Heath H 111, Hodgson SF, Kennedy MA. Primary hyperparathyroidism. Incidence, morbidity, and potential economic impact in a community. N Engl J Med 1980; 302: 189-93. Hedback G, Oden A, Tisell LE. The influence of surgery on the risk of death in patients with primary hyperparathyroidism. World J Surg 1991; 15: 399-407. Russell C F , Edis AJ. Surgery for primary hyperparathyroidism: experience with 500 consecutive cases and evaluation of the role of surgery in the asymptomatic patient. Br J Surg 1982; 69: 244-7. Trigonis C , Hamberger B, Farnebo LO, Abarca J, Granberg PO. Primary hyperparathyroidism; changing trends over fifty years. Acta Chir Scand 1983; 149: 675-9. Palmer M, Ljunghall S, Akerstrom G et al. Patients with primary hyperparathyroidism operated on over a 24-year period: temporal trends of clinical and laboratory findings: J Ch& Dis 1987; 40: 121-30.
933
Surgery for primary hyperparathyroidism under local anaesthesia: A. Bergenfelz et al. 6. 7. 8. 9. 10.
11.
12. 13. 14. 15. 16. 17.
934
Sivula A, Ronni-Sivula H. The changing picture of primary hyperparathyroidism in the years 1956-1979. Ann Chir Gynaecol 1984; 73: 319-24. Rudberg C , Akerstrom G, Palmer M et al. Late results of operation for primary hyperparathyroidism in 441 patients. Surgery 1986; 99: 643-51. Farnebo LO, Trigonis C, Forsgren L, Granberg PO, Hamberger B. Surgery for primary hyperparathyroidism. Acta Chir Scand Suppl 1984; 520: 11-16. Satava RM, Beahrs OH, Scholz DA. Success rate of cervical exploration for hyperparathyroidism. Arch Surg 1975; 110: 625-8. Sivula A, Ronni-Sivula H . Observations of 334 patients operated on for primary hyperparathyroidism. Ann Chir Gynaecol 1985; 74: 66-73. Lafferty FW, Hubay CA. Primary hyperparathyroidism. A review of the long term surgical and nonsurgical morbidities as a basis for rational approach to treatment. Arch Intern Med 1989; 149: 789-96. Ronni-Sivula H, Sivula A. Long term effect of surgical treatment on the symptoms of primary hyperparathyroidism. Ann Clin Res 1985; 17: 141-7. Kaplan RA, Snyder WH, Stewart A, Pdk CYC. Metabolic effects of parathyroidectomy in asymptomatic primary hyperparathyroidism. J CIin Endocrinol Metah 1976; 42: 415-26. Joborn C, Hetta J, Johansson H et al. Psychiatric morbidity in primary hyperparathyroidism. World J Sury 1988; 12: 476-81. Abugassa S, Jarhult J, Nordenstrom J. Effect of calcium supplementation on bone mass in patients operated on for hyperparathyroidism. Eur J Surg 1991; 157: 313-17. Graham JJ, Harding PE, Hoare LL, Thomas DW, Wise PH. Asymptomatic hyperparathyroidism: an assessment of operative intervention. Br J Surg 1980; 67: 115-18. Palmer M, Bergstrom R, Akerstrom G, Adami H O , Jakobsson S, Ljunghall S. Survival and renal function in untreated
18.
19. 20. 21. 22.
23.
24.
25. 26
hypercalcaemia. Lancet 1987; i : 59-62. Palmer M , Adami HO, Bergstrom R, Akerstrom G , Ljunghall S. Mortality after surgery for primary hyperparathyroidism: a follow up of 441 patients operated on from 1956-1979. Surgery 1987; 102: 1-7. Ronni-Sivula H. Causes of death in patients previously operated on for primary hyperparathyroidism. Ann Chir Gynaecol 1985; 74: 13-18. Hedback G, Tisell LE, Bengtsson BA, Hedman I, Oden A. Premature death in patients operated on for primary hyperparathyroidism. WorM J Surg 1990; 14: 829-35. Pyrtek LJ, Belkin M , Bartus S, Schweizer R. Parathyroid gland exploration with local anesthesia in elderly and high-risk patients. Arch Surg 1988; 123: 614-17. Bergenfelz A, Norden NE, Ahren B. Intraoperative fall in plasma levels of intact parathyroid hormone after removal of one enlarged parathyroid gland in hyperparathyroid patients. Eur J Surg 1991; 157: 109-12. Jansson S, Tisell LE, Lindstedt G , Lundberg PA. Disodium pamidronate in the preoperative treatment of hypercalcemia in patients with primary hyperparathyroidism. Surgery 1991 ; 110: 480-6. Karstrup S, Transberl I, Holm HH, Glentherj A, Hegedus L. Ultrasound-guided chemical parathyroidectomy in patients with primary hyperparathyroidism: a prospective study. Br J Radio1 1989; 62: 1037-42. Mandl F. Therapeutischer Versuch bei Ostitis fibrosa generalisata mittels Exstirpation eines Epitelkorperchentumors. Wien Klin Wochenschr 1925; 50: 1343-4. Stoelting RK, Dierdorf SF, McCammon RL. Anesthesiu and Coexisting Diseases. 2nd ed. New York: Churchill Livingstone, 1988: 1-36.
Paper accepted 8 April 1992
Br. J. Surg., Vol. 79, No. 9, September 1992
A. Bergenfelz, L. Algotsson* and B. Ahren Departments of Surgery and *Anaesthesiology, Lund University, S-22185 Lund, Sweden Correspondence to: Dr A. Bergenfelz
Surgery for primary hyperparathyroidism performed under local anaesthesia Patients with primary hyperparathyroidism are often elderly with cardiovascular disease and in some an operation might be hazardous owing to anaesthetic complications. A technique f o r operation f o r primary hyperparathyroidism under local anaesthesia is described. The method uses a unilateral approach. Seventeen consecutive patients operated on under local anaesthesia were compared with a group of 15 patients undergoing surgery under general anaesthesia. Normocalcaemia was achieved in 14 patients in each group. There was no diflerence in the extent of pain or the overall well-being between the two groups as determined by a visual analogue scale. Patients receiving local anaesthesia, however, experienced significantly less nausea after operation ( P < 0.01). There was more fluctuation in blood pressure and heart rate in the general anaesthesia group compared with the other group. Surgery f o r primary hyperparathyroidism can be performed safely under local anaesthesia, and could be ofSered to patients if general anaesthesia were not suitable or involved an increasedperioperative risk. It should not be recommended f o r routine use in patients who are f i t for general anaesthesia.
Primary hyperparathyroidism is being diagnosed with an increasing frequency’ and patients have lower serum calcium levels than previously’. The patients are usually elderly with no or only neuromuscular symptom^^-^. The results of surgery for primary hyperparathyroidism are excellent, with a cure rate3*7-11of around 90 per cent. Surgery results in a reduction of symptoms”.’’ even in patients with ‘mild’ d i ~ e a s e ’ . ’ ~ - ~ ~ . There is a trend to operate on more mild cases than previously. Many patients with primary hyperparathyroidism are compromised by coexistent cardiovascular d i ~ e a s e ’ ~ - ’and ~ for some of these surgery might be hazardous owing to anaesthetic complications. Patients at high risk may be operated on safely and with acceptable results under local anaesthesia, provided that preoperative localization of the enlarged parathyroid gland(s) is obtained’’. How is such an operation for primary hyperparathyroidism under local anaesthesia tolerated by the patient? This issue was investigated in a consecutive series of patients with the condition who were explored under local anaesthesia and compared with a group having exploration under general anaesthesia.
Patients and methods Patients Thirty-two consecutive patients entered the study. Seventeen were explored under local anaesthesia and 15 under general anaesthesia (one of these explorations was a reoperation because of hyperplasia). The clinical and biochemical profile of the two groups is shown in Table I . No significant differences were found between the two groups. Preoperative localization procedures in all patients included ultrasonography, thallium-technetium subtraction scintigraphy, and large vein sampling for intact parathyroid hormone (PTH). Definitive localization of an enlarged parathyroid gland was accomplished before operation if two procedures identified a lesion in the same location and/or ultrasonography with fine-needle aspiration for PTH content was positive (i.e. with a PTH concentration twice the serum PTH level) or if large venous sampling demonstrated an unequivocal unilateral gradient. In these cases, the operation was performed under local anaesthesia in patients older than 75 years with complicating diseases (cardiovascular, pulmonary or thromboembolic) and in some patients who preferred local to general anaesthesia.
0007-1323/9?/09093144 0 1992 Butterworth-Heinemann Ltd
Operation Patients having exploration under local anaesthesia were investigated by one surgeon (A.B.).The 15 patients explored under general anaesthesia were operated on by four different surgeons. Surgery under general anaesthesia was performed through a standard collar incision and exploration was unilateral or bilateral according to the preference of the surgeon. The dissection was always begun on the side where the preoperative localization procedures had indicated the existence of an enlarged parathyroid gland. Patients explored under local anaesthesia underwent unilateral exposure with removal of the enlarged parathyroid gland and biopsy or excision of the other ipsilateral parathyroid gland”. All removed parathyroid glands were sent for frozen section, and serum samples for determination of intact PTH were obtained before and 15 min after ligation of the vascular pedicle of the enlarged parathyroid gland. A definite diagnosis of an adenoma was based on conventional histological criteria and in most cases the intraoperative fall of serum levels of intact PTH after removal of the enlarged glandzz. Hyperplasia was diagnosed on the basis of removal of two or more enlarged parathyroid glands. Anaesthesia Induction of anaesthesia in the general anaesthesia group was performed by administration of thiopentone, fentanyl and pancur-
Table 1 Clinical and biochemical proJle of the two groups of patients operated on for suspected primary hyperparathyroidism
Mean(s.d.) age (years) Sex ratio ( M : F ) Mean(s.d.) serum calcium (mmol/l)* Mean(s.d.) serum intact parathyroid hormone (pmol/l)* Mean(s.d.) serum alkaline phosphatase (units/l)*
Local anaesthesia
General anaesthesia
65(9) 4:13 2.79(0.22) 10.5(9.1)
61(15) 5:lO 2.77(0.21) 11~1(102)
3.8( 1.1 )
4.2( 1.8)
*Normal ranges: serum calcium 2.20-2.60 mmol/l; serum intact parathyroid hormone 1.0-5.0 pmol/l; serum alkaline phosphatase 0.8-4.6 units/l
931
Surgery for primary hyperparathyroidism under local anaesthesia: A. Bergenfelz et al.
onium. Anaesthesia was maintained by addition of isoflurane together with incremental doses of fentanyl. In the local anaesthesia group, no premcdication was given but, at the beginning of the operation, 1-2 ml glycopyrronium bromide (0.2 mg/ml) (Robinul; A. H. Robins, Crawley, UK) was administered intravenously. During surgery, intermittent injections with 50 mg/ml pethidine hydrochloride ( Petidin; Kabi Pharmacia, Solna, Sweden ) and 1 mg/ml midazolam (Dormicum; Hoffman-La Roche, Basel, Switzerland ) were given intravenously to supplement the local anaesthesia. Postoperatiue i are Patients were monitored after operation for hypocdkaemia, and therapy given if symptoms occurred. Follow-up was carried out at 8 weeks. Visual analogue scale The patients’ and nurses’ opinion of overall well-being,pain and nausea were recorded on a visual to-grade analogue scale (where 10 signified no pain, no nausea and total well-being). This was performed during operation for patients operated on under local anaesthesia and after operation ( < 6 h ) for both groups. Analysis Serum levels of intact PTH were measured using the commercially available N-tact PTH assay (Incstar, Stillwater, Minnesota, USA). The sensitivity of this assay is 0.13 pmol/l with an interassay variation of < 11 per cent and an intra-assay variation of < 6 per cent at both high and low levels. (The precision data are expressed as coefficients of variation. ) Total serum calcium values were corrected for serum albumin concentration according to the formula:
Ca, (mmol/l) = measured serum calcium (mmol/l)
+ 0.02 x
[40
-
serum albumin (g/l)]
Blood glucose levels were determined with the glucose oxidase technique. Serum levels of alkaline phosphatase were determined by routine autoanalysis.
Table 2 Results from the operations in the two groups ofpatients
Mean(s.d.) operation time (min)* Mean(s.d.) weight of excised enlarged parathyroid gland (9) No. of patients with normocalcaemia at 8 weeks Mean(s.d.) serum Ca, at 8 weeks after operation (mmol/l)
Local anaesthesia
General anaesthesia
85(30) 1,10(1.28) ( n = 16) 14
122(35) 0.93(0.60 ) ( n = 14) 14
2.32(0.10) ( n = 14)
2.34(0.10) ( n = 14)
Ca,, calcium concentration corrected for albumin. *Time for the surgical procedure excluding anaesthesia
Statistics Results arc expressed as mean(s.d.). For statistical evaluation of differences between groups, Student’s t test for unpaired data and the Mann-Whitney U test were used. For calculation of heart rate, blood pressure and blood glucose intragroup differences, analysis of variance (ANOVA) was performed. A probability level of P < 0.05 was considered significant.
Results The results of surgery are shown in Tuble2. Twenty-eight patients were found t o have a solitary adenoma, three had primary hyperplasia an d in one n o parathyroid enlargement was found. In the group operated o n under local anaesthesia, three patients had persistent hypercalcaemia, two of whom had primary hyperplasia. Th e operative an d clinical details of these patients are shown in Tuble3. All three patients underwent successful re-exploration. I n patient 1, a second enlarged gland (weight 300 m g ) was found o n the left side a t re-exploration under local anaesthesia. I n patient 2, dissection during the first operation was complicated by a haematoma around the lower pole of the thyroid following fine-needle aspiration for P T H . At reoperation with bilateral exploration under general anaesthesia, a second enlarged parathyroid gland was found within the thyroid o n the right side. A further three parathyroid glands were biopsied. This patient had five parathyroid glands. I n patient 3, localization procedures indicated enlargement of a parathyroid gland o n the right side. At reoperation under local anaesthesia, a parathyroid adenoma (weight 270 m g ) was found o n the left side, i.e. the preoperative localization was wrong. I n the group of patients explored under general anaesthesia, one had persistent hypercalcaemia a t follow-up. F o u r normal glands had been identified a t biopsy an d the reason for hypercalcaemia is not known. There was n o difference in the weight of the removed glands between the patients explored under local an d general anaesthesia. I n one patient, the parathyroid adenoma was found in the thyroid gland an d the weight could not be estimated. At follow-up a t 8 weeks n o significant difference in serum calcium levels between the two groups of patients was found. Paralysis of the recurrent laryngeal nerve did not occur. There was n o difference between the nurses’ an d patients’ opinion of overall well-being, pain and nausea. After operation no difference with regard to pain or well-being scores was found between the two groups of patients. Patients operated on under local anaesthesia had, however, significantly less nausea ( P < 0.01 ) (Figure I ). ANOVA demonstrated differences in heart rate before, during an d after operation in the local anaesthesia ( P < 0.05 ) an d in the general anaesthesia ( P < 0.001 ) groups of patients. Patients operated o n under local anaesthesia had a significantly
Table 3 Intraoperative findings, results from frozen section, localization procedures and diagnosis at reoperation f o r the three patients explored under local anaesthesia with persistent hypercalcaemia after the primary operation Patient no.
Intraoperative findings
Histology (frozen section)
Preoperative localization (prediction of procedure)
Diagnosis ( reoperation )
1
Two parathyroid glands excised: one enlarged ( R U ) and one normally sized (RL)
Adenoma (RU), weight 160 mg Normal parathyroid with signs of ‘suppression’ (RL )
H yperplasia
2
One enlarged parathyroid gland excised (RU)
Adenoma or hyperplasia (RU), weight 140mg
3
Two parathyroid glands excised: one slightly enlarged (RL) and one normally sized ( R U )
Both parathyroid glands normal, weight of RL 130 mg
Ultrasonography : one enlarged gland (RU ) Scintigraphy : one enlarged gland ( RU ) Ultrasonography with fine-needle aspiration for PTH: one enlarged gland ( RU ) Venous sampling for PTH: gradient to right side Scintigraphy : one enlarged gland (RL)
Hyperplasia
Adenoma
RU, right upper; RL, right lower; PTH, parathyroid hormone
932
Br. J. Surg., Vol. 79, No. 9, September 1992
Surgery for primary hyperparathyroidism under local anaesthesia: A. Bergenfelz et al.
r-5
T
T
Well-being
Pain
Nausea
Figure 1 Nurse rating of well-being, pain and nausea after operation and general anaesthesia ( B ) groups on a for the local anaesthesia (0) scale of 10, where 10 indicates no symptoms and total well-being. Values are mean(s.d.). * P < 0.01 (Mann- Whitney U test)
E 6ot
+
Figure 2 Heart rate during and after operation in the two groups of patients. Values are mean(s.d.). 0 , Local anaesthesia; 0 , general anaesthesia. * P < 0.05;t P < 0.01 (local versus general anaesthesia, Student’s unpaired t test)
b)
I
Discussion
’,
Medical follow-up’ treatment with biphosphonatesz3 and percutaneous biochemical inactivationz4 have been suggested for the management of high-risk patients with primary hyperparathyroidism. Medical follow-up and treatment with biphosphonates require close patient surveillance. Chemical parathyroidectomy yields unacceptable results and a high complication rate24. Surgery under local anaesthesia may be an alternative approach provided the results are adequate and the well-being of the patients acceptable. The first successful parathyroidectomy was performed under local anaesthesia by Mand12’ in Vienna in 1925. The present study demonstrates that patients operated on under local anaesthesia show a high degree of well-being during and after the operative procedure. The difference in intraoperative systolic blood pressure between the two groups of patients was probably due to a physiological reaction to the anaesthetic drugs given in the general anaesthesia group, since the systolic blood pressure in the local anaesthesia group did not change significantly. A significantly higher heart rate during operation compared with after surgery was evident in the patients operated on under local anaesthesia. This may indicate extra stress in this patient group. There was, however, no significant difference between the heart rate before anaesthesia and that recorded during operation. The postoperative changes in heart rate may be of importance. To prevent myocardial ischaemia it is essential to avoid excessive changes in heart rate and blood pressurez6. Many patients with primary hyperparathyroidism have ischaemic heart disease”. In terms of well-being and stress, operation under local anaesthesia seems to be at least as good as operation performed under general anaesthesia. There were three operative failures in the local anaesthesia group, giving similar results to those in the first published series of patients operated on under local anaesthesia by Pyrtek et al.”. Incorrect preoperative localization was the major reason for surgical failure. Frozen section error contributed to the failure in one patient and a complication from ultrasonographically guided fine-needle aspiration for PTH assay in another. High sensitivity and accuracy of localization procedures are of paramount importance when performing operation for primary hyperparathyroidism under local anaesthesia. Operation under local anaesthesia should be offered to elderly and fragile patients with primary hyperparathyroidism when operation under general anaesthesia is unsuitable. With present results the routine use of the method cannot be recommended for patients who are fit for general anaesthesia.
Acknowledgements This study was supported financially by the Medical Faculty, Lund University, Figure 3 Systolic blood pressure in the two groups of patients during and after operation. Values are mean(s.d.). o, Local anaesthesia; 0 , general anaesthesia. * P < 0.05; t P < 0.01 (local versus general anaesthesia. Student’s unpaired t test)
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higher heart rate during the operation compared with those undergoing surgery under general anaesthesia. Heart rate was, however, significantly higher after operation in the general anaesthesia group (Figure 2 ) . The systolic blood pressure changed only in patients operated on under general anaesthesia ( P < 0,001 ). Those receiving local anaesthesia had a significantly higher systolic blood pressure during operation than those receiving general anaesthesia (Figure 3). No significant differences were found in blood glucose levels within or between the groups of patients.
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Paper accepted 8 April 1992
Br. J. Surg., Vol. 79, No. 9, September 1992
