Hyperparathyroid crisis: The timing of surgery

Background: Hyperparathyroid crisis is a rare, critical, and potentially fatal disease. The aim of this study was to classify different clinical courses of this disease, according to their preoperative medical responses and suggest the proper timing for surgery. Methods: Patients who had undergone parathyroidectomies for hyperparathyroid crisis, were enrolled between January 1, 1994 and January 31, 2009. Preoperative medical treatment and responses in terms of predisposing factors, preoperative localization, operative and pathological findings, postoperative outcome, and intervals from medicine to surgery, were retrospectively reviewed. Results: A total of 11 patients, receiving more than 72 hours of medical treatment, were divided into three types by preoperative medical responses. These included: Type I (three patients were resistant to medicine with persistent serum Ca > 14 mg/mL and were eventually treated with emergency surgery; two died of postoperative respiratory and hepatic failure), Type II (six patients with abnormal serum Ca < 14 mg/mL) and Type III (two patients in whom serum calcium returned to normal preoperatively. One patient was successfully treated with emergency surgery 18 hours post-hospitalization). We found no method for predicting the medical response, but all Type I patients exhibited high serum Ca >14 mg/mL after 48 hours of medical treatment. All abnormal parathyroid glands were >1.8 cm in length and easily detectable using preoperative ultrasonography. Conclusion: Because the response to pharmaceutical treatment of hyperparathyroid crisis is unpredictable, relieving the patient's dehydration is necessary first. Making a definite diagnosis and performing an early parathyroidectomy within 48 hours are then required, especially in patients exhibiting poor medical response.