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Parathyroid surgery during the COVID-19 pandemic: Time to think about the “New Normal”
Fábio Luiz de Menezes Montenegro
Corresponding author
fabiomonte@uol.com.br

Corresponding author.
, Marília D'Elboux Guimarães Brescia, Sergio Samir Arap, Marco Aurélio Valmondes Kulcsar, Marcos Roberto Tavares, Luiz Paulo Kowalski
Divisao de Cirurgia de Cabeca e Pescoco, LIM-28, Laboratorio de Cirurgia de Cabeca e Pescoco, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Annual Parathyroid operations before the 2020 COVID-19 pandemic &#40;1HPT&#61;primary hyperparathyroidism&#44; 2HPT&#61;renal hyperparathyroidism&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">Since the first case in China at the end of 2019&#44; the global spread of coronavirus disease &#40;COVID-19&#41; has been rapid&#44; leading the World Health Organization to declare it a pandemic in March 2020 &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#41;&#46; Infected individuals have mild disease in almost 80&#37; of cases&#46; In contrast&#44; 15&#37; of patients with COVID-19 have moderate symptoms&#44; requiring in-hospital care&#44; and 5&#37; have very severe disease&#44; requiring hospitalization in the intensive care unit &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41;&#46; Although the number of severe cases is relatively low&#44; the spread of severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41; has been exponential&#44; and the unexpected situation has caused the medical resources in many countries to be exhausted&#44; leading to several non-COVID-19-related deaths &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41;&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">It has become clear that&#44; in addition to measures to slow the spread of the disease&#44; health facilities should optimize their use to face this massive challenge &#40;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41;&#46; The concern of infection of surgeons permeated some medical specialties more than others&#44; with a high risk of infection among head and neck surgeons and otolaryngologists &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#41;&#46; In addition&#44; initial reports of fatal outcomes after surgical procedures in previously asymptomatic patients frightened surgeons &#40;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#41;&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">The shortage of treatment resources &#40;including hospital beds&#44; ventilators&#44; health professionals&#44; and personal protective equipment&#41; and the high risk of unfavorable postoperative outcomes in infected subjects led many medical societies to recommend postponing non-emergency operations &#40;<a class="elsevierStyleCrossRefs" href="#bib7">7&#8211;9</a>&#41;&#46;</p><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">International recommendations for parathyroid surgery during the initial response to COVID-19</span><p id="para40" class="elsevierStylePara elsevierViewall">The Society of Surgical Oncology issued a statement with some recommendations for endocrine surgery on March 30&#44; 2020 &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41;&#46; This statement endorsed the opinion of the American Association of Endocrine Surgeons for parathyroid surgery&#46; Parathyroidectomy was recommended only for life-threatening hypercalcemia that could not be controlled by medical treatment &#40;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#41;&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">The Head and Neck Service and institutional pandemic preparedness and response planning</span><p id="para50" class="elsevierStylePara elsevierViewall">At the end of March 2020&#44; the S&#227;o Paulo State Governor ordered that the Central Institute of the Hospital das Clinicas of the University of S&#227;o Paulo Medical School be dedicated to only patients with suspected or confirmed COVID-19&#46; The Central Institute has 900 beds&#44; and 300 were prepared for intensive care&#46; The Central Institute is one of the eight specialized institutes of the Hospital das Clinicas complex&#44; with 2&#44;400 beds in total &#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#41;&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">All elective procedures at the Hospital das Clinicas would be postponed&#44; except those considered time-sensitive or medical emergencies&#46; Thus&#44; patients usually treated at the Central Institute&#44; such as those with hyperparathyroidism &#40;HPT&#41;&#44; would be transferred and the operations would be performed at other institutes&#46; At the time&#44; we determined that we should operate upon patients with a total calcium level of 14 mg&#47;dL or higher&#46; In addition&#44; patients with neurological symptoms&#44; cardiac complications&#44; pancreatitis&#44; calciphylaxis&#44; or acute kidney injury would receive urgent treatment&#44; even if they had lower levels of blood calcium&#46; Bone pain would be preferably treated with analgesics &#40;<a class="elsevierStyleCrossRef" href="#bib13">13</a>&#41;&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">Parathyroid operations at the institution before the COVID-19 pandemic</span><p id="para70" class="elsevierStylePara elsevierViewall">At the Hospital das Clinicas&#44; parathyroid surgery is performed by a specialized unit of the Head and Neck Division of the Department of Surgery&#46; Most operations are performed by residents under the direct supervision of specialized attending surgeons&#46; In Brazil&#44; Hospital das Clinicas is one of the major parathyroid training and research centers &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#46; The hospital belongs to University of S&#227;o Paulo Medical School&#44; a public institution funded by the State of S&#227;o Paulo&#46; Its main revenue comes from state taxes&#46; <a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a> shows the number of parathyroid operations from 2015 to 2019 by type and year&#46; The number of total cases decreased from 140 in 2015 to a nadir of 62 in 2018 because of cost restrictions at the institution&#46; The Brazilian financial crises impacted the number of operations &#40;the Gross Domestic Product of the State of S&#227;o Paulo retracted 4&#46;1&#37; in 2015&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#46; The S&#227;o Paulo State economic activity had been slowly improving&#44; and we had recuperated in 2019&#44; with 94 cases&#46; In 2020&#44; as of March 23&#44; we had 22 patients with primary HPT &#40;18 with adenomas&#44; two with type 1 multiple endocrine neoplasia-related HPT&#44; and two who required reoperations of parathyroid carcinoma&#41; and eight with renal HPT&#46; Following this trend&#44; we would have reached about 120 cases by the end of 2020&#46; However&#44; the pandemic deeply impacted this trend&#46; From March 30 to July 1&#44; 2020&#44; only one patient was operated upon at our institution&#46; She had severe hypercalcemia &#40;total calcium&#58; 18&#46;0 mg&#47;dL&#44; normal&#58; 8&#46;6 to 10&#46;2 mg&#47;dL&#41; and acute renal failure&#46; The operation was successful&#44; with a final pathologic report citing atypical adenoma&#46; The patient&#39;s renal function has improved since the operation&#44; but some degree of permanent loss is expected&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">Mitigation phase and ethical dilemmas associated with parathyroid surgery</span><p id="para80" class="elsevierStylePara elsevierViewall">When the disease outpaces the containment phase&#44; authorities try to mitigate the problem&#46; The question is when a return to normal activities is possible &#40;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#41;&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Until an effective therapy or vaccine is available&#44; the disease is only being mitigated&#44; and it is impossible to resume &#8220;normal&#8221; activities&#46; However&#44; some strategies&#44; such as social distancing&#44; large-scale testing&#44; and the use of face masks&#44; may help lower infection rates and balance hospital capacity&#46; Thus&#44; establishing a &#8220;new normal&#8221; may be necessary to avoid suffering&#44; death&#44; or disabilities due to treatment delays&#44; not resulting from SARS-CoV-2 but caused by the effects of COVID-19 on the healthcare system&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">Fortunately&#44; parathyroid carcinoma is rare&#44; and its clinical picture is associated with marked hypercalcemia &#40;<a class="elsevierStyleCrossRef" href="#bib17">17</a>&#44;<a class="elsevierStyleCrossRef" href="#bib18">18</a>&#41;&#46; Thus&#44; patients with parathyroid carcinoma will be included in our above-mentioned&#44; initial proposal for parathyroid surgery during the COVID-19 pandemic&#46; However&#44; some patients may have recurrent disease and currently present with lower levels of calcium&#46; Despite that&#44; they have a time-sensitive disease and need to be prioritized&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">In contrast&#44; patients with sporadic primary HPT have lower levels of calcium&#44; and several of these patients are asymptomatic&#46; As the disease is usually benign&#44; these patients are typically not prioritized in a situation of limited resources&#46; This line of thought may lead to neglect of specific patients whose calcium levels are near 12 mg&#47;dL and who may have bone pain&#44; nocturia&#44; muscular weakness&#44; or brown tumors&#46; These patients cannot wait indefinitely until the healthcare system returns to &#8220;normal&#46;&#8221; Thus&#44; we propose that the strict criteria adopted initially be critically reviewed&#46; The same concepts may be applied to patients with type-1 multiple endocrine neoplasia-related hyperparathyroidism&#46; These patients often have mild elevation of serum calcium levels &#40;<a class="elsevierStyleCrossRef" href="#bib19">19</a>&#41;&#46; However&#44; they may present with early-onset disease with target-organ damage &#40;<a class="elsevierStyleCrossRef" href="#bib20">20</a>&#41;&#46; Of note&#44; these patients are frequently young&#46; Of the patients&#44; 4&#46;3&#37; are younger than 20 years &#40;<a class="elsevierStyleCrossRef" href="#bib21">21</a>&#41;&#46; In addition&#44; they may have other tumors requiring surgical treatment or that are better managed after parathyroidectomy&#44; such as gastrinomas &#40;<a class="elsevierStyleCrossRef" href="#bib22">22</a>&#41;&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">Our initial concern with regard to infected individuals having an unfavorable postoperative course may partly be minimized by preoperative SARS-CoV-2 testing&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib23">23</a>&#41;&#46; In some cases&#44; chest tomography may be advisable to detect suspected signs of COVID-19 before the operation&#46; Despite these measures&#44; it is mandatory that the surgeon discusses the risk of acquiring COVID-19 during hospital admission or postoperatively with the patient &#40;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">Parathyroidectomy and survival&#58; the case against postponing the surgical treatment of secondary HPT</span><p id="para130" class="elsevierStylePara elsevierViewall">Unfortunately&#44; many patients with secondary hyperparathyroidism under dialysis are symptomatic&#46; They have a reduced quality of life and usually show significant improvement after parathyroidectomy &#40;<a class="elsevierStyleCrossRef" href="#bib25">25</a>&#41;&#46; Although pain relief is immediate postoperatively&#44; pain can be managed safely with medicines until COVID-19 is controlled and a more secure environment is available for these high-risk individuals&#44; as previous chronic kidney disease is a significant risk factor for severe forms of COVID-19 and for death &#40;<a class="elsevierStyleCrossRef" href="#bib26">26</a>&#41;&#46;</p><p id="para140" class="elsevierStylePara elsevierViewall">Brown tumors may pose a challenge in advanced secondary hyperparathyroidism&#46; These benign bone reactions may progress rapidly&#44; usually causing face disabilities&#46; In the hard palate&#44; these tumors often ulcerate and may cause severe bleeding&#46; In rare cases&#44; they involve vertebral bodies&#44; with the risk of fracture and neurological complications&#46; These patients should be included on the priority list for parathyroidectomy during the mitigation phase of the COVID-19 response&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">As in time-sensitive diseases&#44; such as cancer&#44; the major factor for advocating parathyroidectomy in patients with chronic kidney disease is indeed survival&#46; Surgeons not involved in the management of secondary HPT are usually unaware of this important fact&#46; Annual death rates may exceed 20&#37; in dialysis patients &#40;<a class="elsevierStyleCrossRef" href="#bib27">27</a>&#41;&#46; This mortality rate also applied to young individuals&#46; Dialysis patients aged 24-34 years have the same risk of cardiovascular mortality as do individuals aged 75-84 years in the general population &#40;<a class="elsevierStyleCrossRef" href="#bib28">28</a>&#41;&#46; This increased risk of death is mainly due to bone and mineral metabolism abnormalities caused by secondary HPT &#40;<a class="elsevierStyleCrossRef" href="#bib29">29</a>&#41;&#46; Parathyroidectomy improves survival&#46; The relative risk of death was lower in patients who underwent parathyroidectomy &#40;in the institution&#39;s experience&#44; it was 0&#46;428&#59; 95&#37; CI&#44; 0&#46;28 to 0&#46;67&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib30">30</a>&#41;&#46; Thus&#44; it is important to emphasize the need to also include patients with secondary HPT in the priority list for surgery during the COVID-19 pandemic&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">In terms of renal HPT&#44; it is relevant to discuss the problem of persistent HPT in patients with a successful kidney transplant&#46; There is evidence that this problem is not infrequent&#44; affecting up to 62&#37; of transplant patients after one year &#40;<a class="elsevierStyleCrossRef" href="#bib31">31</a>&#41;&#46; For them&#44; parathyroidectomy is necessary to protect the kidney graft from hypercalcemia&#46; Even calcium levels below 14 mg&#47;dL may jeopardize the kidney graft in this population&#46; Although a transient rise in creatinine is observed after parathyroidectomy in kidney transplant patients&#44; no significant changes persist in the long term &#40;<a class="elsevierStyleCrossRef" href="#bib32">32</a>&#44;<a class="elsevierStyleCrossRef" href="#bib33">33</a>&#41;&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">Both patients under dialysis and those with a successful kidney transplant should test negative for SARS-CoV-2 before the operation to minimize postoperative complications&#46; Again&#44; informed consent must clearly address the risk of in-hospital SARS-CoV-2 infection&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">In conclusion&#44; the initial proposal for parathyroid operations was adequate and in accordance with the guidelines on early-stage COVID-19 containment by other societies&#46; However&#44; with the passage of time&#44; experience has shown that parathyroid operations should be considered with an expanded view&#46; It is time to think about the &#8220;new normal&#46;&#8221;</p></span></span>"
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos