PRIMARY HYPERPARATHYROIDISM: OPTIMIZATION OF ANAESTHESIA

Background and Aims. The majority of cases of primary hyperparathyreosis (PHPT) due to solitary adenoma and require the target surgery. Research of new anesthesia/analgesia methods, which afford to have an opioid-sparing effect, is going. Methods. 127 patients with PHPT were divided into 3 groups: the group STI-BCSPB (n=26) was used combined general anesthesia (GA) with sevoflurane (SEV), the tracheal intubation (TI) with the myorelaxant introduction and bilateral cervical superficial plexus blockade (BCSPB); the group STI (n=82) was used SEV anaesthesia with IT and no BCSPB; the group PLM-BCSPB (n=19) was provided propofol (P) GA with protection air-ways by laryngeal mask (LM) and BCSPB. In both groups (STI-BCSPB and PLM-BCSPB) were used co-analgesics, such as dexamethasone (DXM) 8 mg IV, 2% lidocaine (L) 1,0-1,5 mg/kg IV, metamizole (M) or paracetamol (P) 1 g IV, dexketoprofen (DKTP) 50 mg IV as pre-emptive analgesia 30 min before surgery. Ketamine 25 mg IV was used for induction anaesthesia in these groups. In STI group only opioid with P were used for induction of GA. Duration of surgery (DoS), anaesthesia (DoA), opioid consumption, time from the operation ending until the eyes opening (EyOp), desaturation was measured. All data M±m Results. DoS for STI-BCSPB, STI and PLM-BCSPB was respectively 38.7±2.7, 37.8±1.3 and 35.6±1.7 min (NS), DoA was respectively 63.8±3.1, 59.4±1.4 m and 53,8±2.7 min (p= 0.028 STI vs PLM-BCSPB, p= 0.024 STI-BCSPB vs PLM-BCSPB, the difference is significant (DS). EyOp was 15.4±1.1, 15.6±1.2 and 11.6±0.9 min respectively for STI-BCSPB, STI and PLM-BCSPB (p=0.022 STI vs PLM-BCSPB (DS) and p=0.025 STI-BCSPB vs PLM-BCSPB (DS). Desaturation (SpO2 below 92%) due to residual sedation and the effect of muscles relaxants was observed in 39 (47.6%) and 11 (42,3%) patients in STI and STI-BCSPB during the first 30 min postop compared to 2 cases (10.5%) in PLM-BCSPB (both STI groups were DS vs PLM-BCSPB, chi-square test). The dose of intra-op fentanyl was 334.3±17.1, 256.5±16.9 197.3±15.3 mcg in STI, STI-BCSPB and PLM-BCSPB respectively, (DS for PLM-BCSPB vs other groups, DS between STI groups). Conclusions. Combine methods GA with BCSPB have some benefits over mono GA. Co-analgesics afford to achieve an opioidsparing effect. Under ectomy of single parathyroid adenoma, the use of propofol and BSCPB with the laryngeal mask without muscles relaxants seems more preferable compared to sevoflurane anesthesia with BBSCP and tracheal intubation due to the shorter anesthesia duration, time to eye-opening after surgery, lower desaturation frequency.

Parathyroid Glands

The parathyroid glands develop from the endoderm: the superior glands from the fourth pharyngeal pouch, and the inferior glands from the third pharyngeal pouch. Parathyroid glands are usually found on the posterior surface of the thyroid gland. Chief cells secrete PTH, which has a half-life of 3 to 6 minutes. Primary HPT is most often asymptomatic and serendipitously found when the serum calcium value is increased on routine testing. The parathyroid glands can be evaluated with US, CT, MRI, or sestamibi scanning. Cervical exploration for primary HPT involves resection of a solitary adenoma in approximately 85% of patients. Injury to the RLN and superior laryngeal nerve does occur.

Miniinvasive video-assisted interventions on the thyroid and parathyroid glands

Objective. To study the efficacy of miniinvasive video-assisted interventions on the thyroid and parathyroid glands. Materials and methods. In a frame of the investigation accomplished in 2012-2018 yrs 50 patients were operated for nodular goiter (40) and primary hyperparathyrosis with solitary adenoma of a parathyroid gland (10). In all the patients miniinvasive video-assisted interventions were performed in accordance to procedure, proposed by P. Miccoli. Results. A pain syndrome was minimal in all the patients. Stable paresis of nn. Recurrens and parathyrosis were not observed. Transitory paresis of n. Recurrens have occurred in 2 patients. The wound infection was absent. In all the patients with primary hyperparathyrosis the calcium content have lowered down to normal or subnormal value. Stationary stay after miniinvasive operations have been reduced down to (2.2 ± 0.3) bed-days, while after open operations they constituted (5/7 ± 1.2) bed-days. While further follow-up of the patients during one year the disease recurrence was not registered. Excellent cosmetic result was obtained in majority of the patients. In 3 of them only keloid cicatrices have formatted, causing a cosmetic effect lowering. Conclusion. The procedure for miniinvasive video-assisted interventions on thyroid gland was proposed by P. Miccoli, and is still actual. It may be applied also in patients with primary parathyrosis and solitary adenoma of parathyroidal gland. But the patients must be thoroughly selected for this operative interventions.

Primary hyperparathyroidism

Primary hyperparathyroidism is a disorder of bone mineralization and renal physiology due to excess parathyroid hormone secretion. Parathyroid hormone (PTH) is produced and released by the parathyroid chief cells, under regulation of the G- protein-coupled calcium-sensing receptor. Primary hyperparathyroidism occurs when there is a loss of the inhibitory feedback of PTH release by extracellular calcium. The rise in PTH levels is initially associated with a normal serum calcium, and then over time with hypercalcaemia. The most common cause of primary hyperparathyroidism is a benign solitary adenoma (80%). Other causes include multiple adenomas and hyperplasia. This chapter reviews the causes, clinical features, and management of primary hyperparathyroidism.

Parathyroid, Adrenal, Gonadal, and Pituitary Disease

Endocrine disorders can cause diverse changes in cognition and affect as well as changes in neuromuscular function that may simulate primary neurologic disease, and they generally require a specialized endocrine workup to make a diagnosis. For example, hypoparathyroidism, which may be congenital (e.g., DiGeorge syndrome or Kearns-Sayre syndrome) or disease-acquired (e.g., autoimmune hypoparathyroidism) can present as neuromuscular irritability or tetany due to hypocalcemia, the most distinctive features, which may manifest as carpopedal spasm or laryngospasm. Primary hyperparathyroidism is the most common cause of hypercalcemia and is usually due to oversecretion of PTH by a solitary adenoma of the parathyroid glands. This chapter covers most common primary endocrine disorders that can present as neurological disorders.

Solitary adenoma in the proventriculus of a budgerigar (Melopsittacus undulatus) diagnosed by immunochemistry — Short communication

The authors describe a solitary adenoma in a 5.5-year-old female Budgerigar (Melopsittacus undulatus). The tumour was partially blocking the lumen of the proventriculus and filled it almost completely. Decreased passage of food towards the gizzard and the intestines developed in the bird as result of the obstruction, which periodically hindered the passage, leading to slow emaciation. An epithelial tumour composed of irregular glandular acini was diagnosed by histological examination. Immunohistochemical reaction with pancytokeratin showed a positive cytoplasmic reaction both in the neoplastic and the normal glandular structures.