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Masters Degrees (Clinical Medicine)

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Browsing Masters Degrees (Clinical Medicine) by Subject "Bilateral neck exploration."

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    Feasability of focused parathyroidectomy in developing countries - a scoping review.
    (2023) Rugnath, Kapil.; Suman, Mewa Kinoo.
    Hyperparathyroidism (HPT) is characterized by pathologically excessive parathyroid hormone production. This may be as a consequence of pathology within the parathyroid gland (primary HPT) or as a sequela of pathology outside the parathyroid gland (secondary & tertiary HPT). The gold standard surgical management of HPT was bilateral neck exploration (BNE) but with improvement in localising methods, focused parathyroidectomy (FP) has made the gold standard contentious. BNE, entailing a large neck incision and 4 gland exploration, demonstrates excellent cure rates of 95%. FP, whereby a single targeted miniature incision is made over the offending gland, is possible in the category of primary HPT as in up to 80% of cases the aetiology is a single gland adenoma. The prerequisites to embarking on this minimally invasive operative technique are accurate pre-operative localisation of the exact site of the offending gland adenoma and assistance of intra-operative adjuncts to confirm successful excision. Considering the prerequisites required for FP, the initial concern of cost arose. Additionally, concerns of potential inferior success rates were initially entertained. Subsequently, numerous studies revealed this technique to be superior in terms of operative time; cost; convalescence; cosmesis; success rates and the ability to be performed under local anaesthetic, as a day case. As such, the current standard of care for primary HPT where a single gland adenoma is localised, is the FP. The majority of the studies and trials demonstrating the superiority of FP emanate from developed high-income countries where there is a relative abundance of resources, and as such, the questioning of applicability or relevance of these studies to developing middleincome countries is valid. With the natural hesitancy to adopt these recommendations uncritically in developing countries, where the lack of resources might impede this technique, this concern of applicability, and therefore feasibility, needed to be addressed. To address this, a scoping review of the literature was conducted, looking specifically at FP, pre-operative localisation and intra-operative adjuncts, in developing countries (upper and lower-middle income). The aim of this review was to ascertain if FP is feasible in these countries by assessing the availability and accuracy of pre-operative localisation, success of FP judged by cure rates and the availability and utility of intra-operative adjuncts. This review will benefit surgeons in developing countries by demonstrating that FP is not an esoteric procedure described in ivory towers to be entertained in reverie only. Dispelling the myth of non-applicability due to resource constraints, by establishing the technique to be feasible in developing countries, more local surgeons can now, for localised single parathyroid gland adenomas, diverge away from knee-jerk routine bilateral neck explorations. Reassured with support of relevant local literature, they may now confidently embark on learning and performing the technique of FP resulting in satisfied patients who enjoy the superior outcomes associated with this technique.