Perioperative enhanced recovery after surgery protocols with anterior mediastinal ectopic parathyroid tumor: a case report

Perioperative enhanced recovery after surgery protocols with anterior mediastinal ectopic parathyroid tumor: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Perioperative enhanced recovery after surgery protocols with anterior mediastinal ectopic parathyroid tumor: a case report Xiaodan Zhu, Yingxia Yu, Kanghui Huang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9211316/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Anterior mediastinal ectopic parathyroid tumor is a special type of lesion that can cause primary hyperparathyroidism. Due to its special anatomical location and potential complications, its treatment involves multiple disciplines. This study aims to summarize the perioperative rehabilitation experience in the successful treatment of anterior mediastinal ectopic parathyroid tumor and provide a replicable framework for perioperative rehabilitation of complex endocrine diseases. Case presentation A 50-year-old female patient was admitted to the hospital due to recurrent pancreatitis, kidney stones, hypercalcemia (2.98 mmol/L), and elevated parathyroid hormone levels (299 picograms/mL). The patient had a 7-year history of previous treatment for parathyroid adenoma, and abnormal parathyroid glands were found in an examination at an external hospital 2 months before admission. After admission, the patient was diagnosed with primary hyperparathyroidism secondary to an anterior mediastinal ectopic parathyroid tumor through multidisciplinary evaluation (MDT). Subsequently, an MDT discussion was organized immediately, and a multidisciplinary collaborative team consisting of the Department of Endocrinology, Department of Radiology, Department of Thoracic Surgery, Department of General Surgery, and Department of Nursing was established. After evaluating the patient's condition, the team decided to perform a pre-diaphragmatic tumor resection under ⁹⁹ᵐTcO₄-MIBI localization and formulated a perioperative enhanced recovery plan for the patient. The patient recovered smoothly after surgery and was discharged on the 2nd day after surgery; follow-up at 6 months after surgery showed that the patient was in good recovery condition. Conclusion The multidisciplinary Enhanced Recovery After Surgery (ERAS) protocol monitored by a Clinical Decision Support System can achieve safe ultra-early discharge of patients with anterior mediastinal ectopic parathyroid tumor, effectively address the unique challenges in the surgical treatment of this disease, and provide a valuable and replicable framework for perioperative rehabilitation of complex endocrine diseases. Enhanced Recovery After Surgery Anterior Mediastinal Ectopic Parathyroid Tumor nursing case report Figures Figure 1 Figure 2 1. Introduction Primary hyperparathyroidism is characteriz ed by hypercalcemia caused by excessive secretion of parathyroid hormone (PTH), with a prevalence of approximately 1–7 cases per 1,000 adults( 1 ). Surgical resection of abnormal parathyroid tissue remains a radical treatment with a high success rate in typical cervical cases( 2 )( 3 ). However, primary hyperparathyroidism presents significant challenges when pathogenic parathyroid tissue is ectopic. Such lesions are often difficult to detect using conventional surgical exploration and increase the risk of persistent or recurrent disease( 4 ). Ectopic parathyroid adenomas, accounting for approximately 20% of all parathyroid adenoma cases, are an important cause of refractory and recurrent hyperparathyroidism( 4 )( 5 ). Because of their concealed anatomical location adjacent to vital organs such as the thymus, aorta, and trachea, perioperative management of parathyroid adenomas is challenging. Surgery may cause extensive soft tissue damage, prolonged postoperative recovery, and increased risks of complications such as hypocalcemia, recurrent laryngeal nerve injury, and mediastinal infection , which can lead to prolonged hospital stay ( 5 ). Enhanced Recovery After Surgery (ERAS)( 6 ), a multimodal perioperative care protocol aimed at minimizing surgical stress, optimizing physiological function, and accelerating patient recovery, has been widely used in gastrointestinal, orthopedic, and thoracic surgery. The core measures of ERAS include preoperative patient education, optimized anesthesia, minimally invasive surgical techniques, early mobilization, and personalized nutritional support. These measures shorten the hospital stay, reduce postoperative complications, and improve patient satisfaction ( 5 ). However, current research on ERAS is predominantly focused on common surgical procedures and data on the use of ERAS in cases of ectopic anterior mediastinal parathyroid tumor resection. In a systematic review, Chorath et al. ( 7 ) reported that ERAS protocols in parathyroid surgery primarily focused on cervical cases and hospital stay was significantly reduced compared with traditional care ( 7 ). Nevertheless, anterior mediastinal ectopic cases involve distinct surgical approaches, such as video-assisted thoracoscopic surgery or open thoracotomy, and unique perioperative challenges, such as mediastinal drainage management and the maintenance of respiratory function . However , these approaches differ significantly from those used for cervical surgery . To date, only sporadic case reports have describe d surgical techniques for treating anterior mediastinal ectopic parathyroid tumors ( 8 ), and studies on ERAS-based perioperative nursing are lacking. Herein, we present the case of a patient with an anterior mediastinal ectopic parathyroid tumor who underwent surgical resection combined with perioperative ERAS . The treatment involved multidisciplinary collaboration, monitoring and management of serum calcium and PTH levels, personalized care-oriented psychological nursing, dynamic pain management, and early pulmonary rehabilitation exercises. The patient recovered rapid ly and was successfully discharged on the second postoperative day. To the best of our knowledge, this is the first systematic summary of ERAS nursing strategies for treating anterior mediastinal ectopic parathyroid tumors. Our findings provide practical guidance for the perioperative care of complex cases. 2. Case presentation A 50-year-old woman was admitted to our department with the main complaint of "more than 7 years after parathyroid adenoma surgery." Seven years prior, the patient had developed abdominal pain accompanied by nausea and vomiting without obvious inducement. The patient was diagnosed with pancreatitis at a different hospital. Further examination suggested that pancreatitis was caused by hyperparathyroidism. The patient underwent a left thyroid resection, left parathyroidectomy, and exploration of the right thyroid lobe . Pathological examination confirmed parathyroid adenoma. After surgery, she received cinacalcet orally for treatment and underwent regular re -examinations; however , she stopped the medication on her own. During this period, the developed recurrent pancreatitis, kidney stones, and other diseases. The ectopic parathyroid gland was found more than two months ago, and pancreatitis recurred one month ago. The patient was transferred to our department for further treatment. Upon admission, auxiliary examination revealed that the left thyroid had been resected, and no obvious abnormalities were found in the bilateral parathyroid regions. The parathyroid hormone (PTH) concentration was 299 pg/ml and the blood calcium was 2.98 mmol/l. Localization imaging with 99mTc-MIBI suggested an anterior mediastinal ectopic parathyroid tumor. We organized a multidisciplinary consultation, including specialists from the Departments of Endocrinology, Thoracic Surgery, General Surgery, Radiology, Nuclear Medicine, Anesthesiology, and a nursing team. We formulated a comprehensive treatment plan, including surgery and perioperative enhanced recovery after surgery (ERAS) nursing. The patient underwent resection of the anterior mediastinal ectopic parathyroid tumor. A multidisciplinary team managed the patient. The serum calcium and PTH levels were monitored, and the patient underwent care-oriented personalized psychological nursing, dynamic pain management, and early pulmonary rehabilitation exercises. The patient’s condition stabilized postoperatively. Both the blood calcium and PTH concentrations improved significantly, and the patient was discharged from the hospital two days after the operation. 3. Nursing care 3.1 Multidisciplinary collaboration To address the complexity of the perioperative management of this patient with an anterior mediastinal ectopic parathyroid tumor, we created a multidisciplinary team composed of specialists from endocrinology, radiology, thoracic surgery, general surgery, and nursing departments. The core objective of this team was to integrate the concept of Enhanced Recovery After Surgery (ERAS) to optimize the nursing process. Endocrinology specialists participated in the comprehensive evaluation of primary hyperparathyroidism, including monitoring of serum calcium and parathyroid hormone levels, to clarify the severity of the disease and guide preoperative metabolic regulation. Radiologists precisely localize ectopic tumors using imaging examinations, such as contrast-enhanced neck CT and 99mTcO4-MIBI parathyroid scintigraphy ( 9 ), providing a crucial basis for surgical planning. Considering the anatomical complexity of the anterior mediastinum, physicians in thoracic and general surgeries jointly discuss a surgical approach to minimize intraoperative trauma. Nursing staff participated in assessing patients’ physical and psychological status. Nutritionists evaluated baseline nutritional status to assess the risk of malnutrition, which may exacerbate surgical stress. This collaborative process resulted in a personalized perioperative nursing plan tailored to the patient’s specific conditions, with the goal s of reducing perioperative stress, minimizing complications, and accelerating postoperative recovery. The collaboration ensured seamless communication between the various disciplines, effectively integrating medical, surgical, and nursing expertise within the ERAS framework and providing a foundation for optimized perioperative care. 3.2 Serial Monitoring of Serum Calcium and Parathyroid Hormone Given the preoperative suspicion of hyperparathyroidism, we postoperatively monitored the serum calcium and parathyroid hormone (PTH) levels to track the evolution of parathyroid function and guide calcium metabolism management ( 10 ). A clinical decision support system (CDSS) ( 11 ) was integrated into this monitoring framework to enhance the precision and timeliness of interventions. Real-time serial monitoring data were integrated with the patients’ baseline characteristics, such as the preoperative calcium concentration and surgical approach. Monitoring was performed using a predefined algorithm that mapped PTH/calcium trends to evidence-based action thresholds. The monitoring data processed by the CDSS revealed characteristic changes. Admission day (1.21): serum calcium, 2.98 mmol/L, PTH, 299 pg/mL, consistent with the laboratory manifestations of hyperparathyroidism. At this point, the CDSS flagged a "high-risk" status for hypercalcemic complications and recommended increasing the monitoring frequency every four hours. Post-lesion resection (1.23): Ten minutes after lesion excision, PTH plummeted to 35.1 pg/mL, and further decreased to 24.2 pg/mL at 20 minutes post-resection. This change in PTH level triggered the CDSS to issue an early alert for impending hypoparathyroidism, prompting the nursing team to prepare for oral calcium supplementation. Pre-discharge (1.24): Serum calcium declined to 2.68 mmol/L(Fig. 2 ) , and PTH dropped to 3.77 pg/mL(Fig. 1). By cross-referencing these values with trends on postoperative day 1 , the CDSS generated a tailored calcium supplementation protocol of 500 mg twice daily, with weekly PTH rechecks. Using this dynamic monitoring augmented by the CDSS, we precisely captured the rapidly declin ing trend in PTH levels, which produced actionable recommendations within 15 min of data entry, a much faster process than manual interpretation. This synergy enabled proactive prediction of serum calcium dynamics and provided a core basis for formulating a personalized calcium supplementation regimen. Complications such as tetany and muscle spasms caused by hypocalcemia were prevented by adjusting the timing and dose of calcium supplementation based on PTH concentration. Moreover, synergy ensures the safety of early pulmonary rehabilitation exercises and ambulation, embodying the core logic of “precise monitoring-targeted intervention” in Enhanced Recovery After Surgery, with the CDSS as a critical bridge between data and clinical action. 3.3 Early pulmonary rehabilitation exercises Early pulmonary rehabilitation is an essential component of the ERAS protocol. Early rehabilitation is vital in patients undergo ing anterior mediastinal surgery. Surgical trauma, postoperative pain, and immobility may compromise respiratory function and increase the risk of atelectasis, pneumonia, and respiratory insufficiency ( 12 ). Therefore, we implemented a structured, phased pulmonary rehabilitation program to promote lung expansion, strengthen respiratory muscles, and prevent pulmonary complications, with close integration of clinical assessments to guide progression. The program was delivered in a stepwise manner, tailored to the patient’s recovery trajectory . Immediate postoperative period, 0–6 hours after awakening. Continuous monitoring of vital signs and oxygen saturation. Nurses guided the patient through gentle diaphragmatic breathing exercises (5–8 breaths/minute, sustained for 5 min, repeated every 2 h). This low-intensity intervention was intended to mitigate alveolar collapse, without causing excessive pain or fatigue. Concurrently, regular position adjustments every 2 h from supine to 30° semi-Fowler’s position were performed to optimize lung ventilation and facilitate mucus drainage. Early postoperative period (6–24 hours): With pain effectively controlled (VAS ≤ 3), exercise intensity was gradually increased. The patient was instructed to use a spirometer, 10 repetitions per session, with each inhalation sustained for 3–5 seconds, conducted every 3 h. To clear airway secretions and prevent mucus retention, guided and effective coughing exercises were introduced, with the patient supporting the incision with both hands to minimize pain during coughing. Posteroanterior chest radiography was performed 24 h postoperatively. The patient had good pulmonary re-expansion with no signs of atelectasis, pneumothorax, or pleural effusion, consistent with the effectiveness of early rehabilitation ( 13 ). Considering the stable respiratory status and minimal drainage volume (< 50 mL in the preceding 8 hours), we removed the mediastinal drain under aseptic conditions. This milestone not only reduced the physical discomfort associated with the drain but also enhanced the patient’s willingness to engage in subsequent activities. Subacute postoperative period (24–48 hours): Following drain removal, we integrated pulmonary rehabilitation with early mobilization. The patient was assisted to sit at the bedside for 5–10 minutes, followed by standing and slow ambulation, initially 5 m, gradually extended to 10–15 meters, while performing deep breathing. This synergistic approach improves lung ventilation, promotes diaphragmatic movement, and enhances the overall respiratory efficiency ( 14 ). Throughout the process, nurses continuously monitored the respiratory rate, oxygen saturation, and breath sounds. Nurses adjusted exercise intensity based on tolerance , for example, by reducing the duration of dyspnea or increasing pain. Patient education was reinforced to emphasize adherence: “Each deep breath helps your lungs expand fully, lowering infection risk and speeding your return to daily life.” This structured early pulmonary rehabilitation program coupled with timely radiological assessment and drain removal effectively maintains adequate pulmonary ventilation. Postoperatively, the patient’s oxygen saturation remained stable at 98–100% on room air, with no respiratory complications. 3.4 Dynamic pain management Dynamic pain management, a cornerstone of ERAS ( 15 ), was implemented to mitigate postoperative pain and facilitate early rehabilitation with scheduled flurbiprofen administration (Q12H) as the core intervention. Six hours postoperatively, flurbiprofen (100 mg orally) was administered every 12 h to establish preemptive analgesia, with a target pain score (VAS) of ≤ 3 and movement-related pain , for example, during pulmonary rehabilitation, ≤ 4. Pain was assessed every 4 h, with additional evaluations before mobilization or respiratory training. If breakthrough pain (VAS score > 3) occurred, rescue analgesia (e.g., 50 mg tramadol) was administered, and the nursing team adjusted non-pharmacological measures, such as optimizing the semi-Fowler’s position (30° elevation) during coughing or applying cold compresses to the surgical site, to enhance efficacy. This multimodal strategy combin ing scheduled flurbiprofen (Q12H) administration with real-time pain monitoring provided consistent analgesia. The patient’s average VAS remained at 2.1 (rest) and 3.2 (movement) during hospitalization, which avoided pain-induced respiratory suppression or delayed ambulation. 3.5 Psychological nursing Centered on humane care, personalized perioperative psychological nursing is tailored to patients’ emotional needs ( 16 ). Preoperatively, nurses used in-depth interviews to identify stressors such as concerns about surgical outcomes and anxiety over postoperative recovery. Nurses built trust by empathetic communication, e.g., "It’s normal to worry about recovery; we’ll adjust the plan based on how you feel." Therefore , postoperative intervention should be considered. Because of the patient’s introverted personality, we provided a "mood diary" to help the patient express unspoken concerns, and her emotional experiences were validated. Family support was integrated by guiding relatives to use supportive communication, and the patients’ favorite music playlists were curated to reduce their unfamiliarity with the environment. When the patient’s anxiety intensified during tube removal, the nurses used process visualization, explain ed the steps using hand-drawn diagrams, and held the patient’s hand during the procedure to convey a sense of security. This approach improved patient satisfaction and enhanced adherence to rehabilitation training. By prioritizing individual experiences over standardized protocols, nurses conveyed a sense of security and embodied humane care to facilitate holistic recovery. 3.6 Discharge guidance and follow-up To support the patient’s rapid recovery and safe transition to home care, discharge guidance was streamlined around key self-management priorities, while continuous care was provided by "Internet +" teleconsultation ( 17 ). Upon discharge on postoperative day 2, personalized guidance was focused on key matters such as the recognition of hypocalcemia symptoms (paresthesia and muscle cramps) and a progressive rehabilitation plan (30 min of daily walking, avoiding weight-bearing). A printed checklist with illustrations including symptom comparison charts and medication schedules was provided to enhance adherence. The core of the follow-up was an online consultation platform through which patients could access 24/7 text and image consultation services from a nursing team. For urgent situations , such as persistent numbness, remote video links to a multidisciplinary team (endocrinologists and surgeons) ensure timely assessment within two hours. This model addresses the post-discharge safety gaps. Readmission was avoided through remote consultation. By bridging in-hospital and home care via digital tools, the goal of accelerated recovery was sustained while ensuring ongoing safety, with 100% patient satisfaction reported in follow-up feedback. 4. Discussion The innovation of this nursing model is its "three-dimensional integration" of anatomical adaptability, metabolic precision, and digital empowerment. The model not only extends ERAS principles to complex ectopic cases, but also establishes a replicable framework for the perioperative management of deep mediastinal surgeries involving endocrine dysfunction. The limitations of this study include its preliminary nature, single-case focus , and conflicting validation s with larger multicenter cohorts. Additional research should measure the long-term impact of this protocol on calcium homeostasis and quality of life as well as the potential of artificial intelligence-driven predictive models to further refine real-time calcium regulation. Overall, this tailored ERAS nursing protocol is a valuable advancement in the care of patients undergoing anterior mediastinal ectopic parathyroid tumor resection. This protocol emphasizes the importance of specialized strategies for optimizing outcomes in complex endocrine surgical populations. Declarations Conflict of interest statement The authors have no conflict of interest. Data acailability statement All raw data and code are available upon request. Funding information This case report was conducted without the financial support of grants, foundations, or pharmaceutical companies. Clinical trial number not applicable Ethics statement Ethical approval was granted by the Ethics Committee of the Fourth Affiliated Hospital Zhejiang University School of Medicine (K2025229). This study was carried out in accordance with the ethical guidelines and regulations for human subject research formulated by the Ethics Committee of the Fourth Affiliated Hospital Zhejiang University School of Medicine. Written informed consent was freely obtained from the patient for participation in this study and the publication of this case report. Author contributions Writing – original draft: Xiaodan Zhu. Writing – review & editing: Kanghui Huang , Yingxia Yu Acknowledgments The authors thank AiMi Academic Services (www.aimieditor.com) for English language editing and review services. Consent to Publish Informed written consent for the publication of this case report, including any accompanying images and identifiable personal clinical data, has been obtained from the patient. A copy of the written consent is available for review by the journal's editorial office upon request. References Glasgow C, Lau EYC, Aloj L, et al. An Approach to a Patient With Primary Hyperparathyroidism and a Suspected Ectopic Parathyroid Adenoma. J Clin Endocrinol Metab. 2022;107(6):1706–13. 10.1210/clinem/dgac024 . Bilezikian JP, Khan AA, Silverberg SJ et al. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. J Bone Miner Res. 2022;37(11):2293–2314. 10.1002/jbmr.4677 Kowalski GJ, Buła G, Żądło D, Gawrychowska A, Gawrychowski J. Primary hyperparathyroidism. Endokrynol Pol. 2020;71(3):260–70. 10.5603/EP.a2020.0028 . Hemead HM, Abdellatif AA, Abdel Rahman MA. Ectopic pure mediastinal parathyroid adenoma: A case report. Int J Surg Case Rep. 2022;90:106598. 10.1016/j.ijscr.2021.106598 . Rabazzi G, Elia G, Aprile V, et al. Surgical Management of Mediastinal Ectopic Parathyroids. J Pers Med. 2025;15(7):276. 10.3390/jpm15070276 . Published 2025 Jun 30. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292–8. 10.1001/jamasurg.2016.4952 . Chorath K, Luu N, Go BC, Moreira A, Rajasekaran K. ERAS Protocols for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2022;166(3):425–33. 10.1177/01945998211019671 . Hemead HM, Abdellatif AA, Abdel Rahman MA. Ectopic pure mediastinal parathyroid adenoma: A case report. Int J Surg Case Rep. 2022;90:106598. 10.1016/j.ijscr.2021.106598 . Petranović Ovčariček P, Giovanella L, Carrió Gasset I, et al. The EANM practice guidelines for parathyroid imaging. Eur J Nucl Med Mol Imaging. 2021;48(9):2801–22. 10.1007/s00259-021-05334-y . Palermo A, Tabacco G, Makras P, et al. Primary hyperparathyroidism: from guidelines to outpatient clinic. Rev Endocr Metab Disord. 2024;25(5):875–96. 10.1007/s11154-024-09899-5 . Olakotan O, Mohd Yusof M, Ezat Wan Puteh S. A Systematic Review on CDSS Alert Appropriateness. Stud Health Technol Inf. 2020;270:906–10. 10.3233/SHTI200293 . Tang Z, Lu M, Qu C, et al. Enhanced Recovery After Surgery Improves Short-term Outcomes in Patients Undergoing Esophagectomy. Ann Thorac Surg. 2022;114(4):1197–204. 10.1016/j.athoracsur.2021.08.073 . Medbery RL, Fernandez FG, Khullar OV. ERAS and patient reported outcomes in thoracic surgery: a review of current data. J Thorac Dis. 2019;11(Suppl 7):S976–86. 10.21037/jtd.2019.04.08 . Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019;55(1):91–115. 10.1093/ejcts/ezy301 . Gottumukkala V, Joshi GP. Challenges and opportunities in enhanced recovery after surgery programs: An overview. Indian J Anaesth. 2024;68(11):951–8. 10.4103/ija.ija_546_24 . Lv J, Su Y, Tang H, Jiang X, Chen X. Humanistic nursing care management strategies: from formulation to implementation. Front Public Health. 2025;13:1591077. 10.3389/fpubh.2025.1591077 . Published 2025 May 12. Zhang GW, Li B, Gu ZM, et al. In-Depth Examination of the Functionality and Performance of the Internet Hospital Information Platform: Development and Usability Study. J Med Internet Res. 2024;26:e54018. 10.2196/54018 . Published 2024 Nov 8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 06 May, 2026 Reviews received at journal 24 Apr, 2026 Reviews received at journal 21 Apr, 2026 Reviewers agreed at journal 21 Apr, 2026 Reviews received at journal 18 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor invited by journal 07 Apr, 2026 Editor assigned by journal 02 Apr, 2026 Submission checks completed at journal 31 Mar, 2026 First submitted to journal 30 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9211316","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":627260628,"identity":"44351a0d-e610-46c2-93c4-679c2aa401dd","order_by":0,"name":"Xiaodan Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYDCCA2DShoGxAUjxkKAljXQthyEcorTwHT97TOLjnvP2zDMSGB+8bWOQNyekRfJMXprkjGe3mRlnJDAbzm1jMNzZQECLwYEcM2meA7fZgFrYpHnbGBIMDhDScv6NmfSfA+d4gFrYfxOn5QbQFoYDByRAtjATpUXyxhtjy54DyQaMPQ+bJeeckzDcQEgL3/kcwxs/DtjZG7YnH/zwpsxGnqAtQMAiASING8CRKUFYPRAwfwCR8kSpHQWjYBSMghEJACEgQKqYznLmAAAAAElFTkSuQmCC","orcid":"","institution":"the Fourth Affiliated Hospital of School of Medicine , and International School of Medicine ,International Institutes of Medicine, ZheJiang University","correspondingAuthor":true,"prefix":"","firstName":"Xiaodan","middleName":"","lastName":"Zhu","suffix":""},{"id":627260629,"identity":"218f63f4-2e3b-453f-b481-a73be6e0aea2","order_by":1,"name":"Yingxia Yu","email":"","orcid":"","institution":"the Fourth Affiliated Hospital of School of Medicine , and International School of Medicine ,International Institutes of Medicine, ZheJiang University","correspondingAuthor":false,"prefix":"","firstName":"Yingxia","middleName":"","lastName":"Yu","suffix":""},{"id":627260630,"identity":"b7d567b9-908c-4b40-910f-5725ccffcce0","order_by":2,"name":"Kanghui Huang","email":"","orcid":"","institution":"the Fourth Affiliated Hospital of School of Medicine , and International School of Medicine ,International Institutes of Medicine, ZheJiang University","correspondingAuthor":false,"prefix":"","firstName":"Kanghui","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2026-03-24 11:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9211316/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9211316/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107675967,"identity":"497615c1-38b8-472f-a8f9-dcf9f6eab192","added_by":"auto","created_at":"2026-04-24 00:48:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36354,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in Parathyroid Hormone (PTH)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9211316/v1/1be6a28a7cf95ab4e3f90822.png"},{"id":107706842,"identity":"852a7561-0b50-4784-a6f9-6820ff756a18","added_by":"auto","created_at":"2026-04-24 09:18:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24370,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in Serum Calcium\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9211316/v1/38e4ccfd6e646c1a0b1c5a82.png"},{"id":107709094,"identity":"46d58daa-b8e4-47ad-9796-79ff5308c81b","added_by":"auto","created_at":"2026-04-24 09:34:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":228412,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9211316/v1/1c464afb-3a4f-4451-8e54-0c5bcd764d47.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative enhanced recovery after surgery protocols with anterior mediastinal ectopic parathyroid tumor: a case report","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePrimary hyperparathyroidism is characteriz\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eed\u003c/span\u003e by hypercalcemia caused by excessive secretion of parathyroid hormone (PTH), with a prevalence of approximately 1\u0026ndash;7 cases per 1,000 adults(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Surgical resection of abnormal parathyroid tissue remains a radical treatment with a high success rate in typical cervical cases(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, primary hyperparathyroidism presents significant challenges when pathogenic parathyroid tissue is ectopic. Such lesions are often difficult to detect using conventional surgical exploration and increase the risk of persistent or recurrent disease(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Ectopic parathyroid adenomas, accounting for approximately 20% of all parathyroid adenoma cases, are an important cause of refractory and recurrent hyperparathyroidism(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Because of their concealed anatomical location adjacent to vital organs such as the thymus, aorta, and trachea, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eperioperative management of parathyroid adenomas is challenging.\u003c/span\u003e Surgery may cause extensive soft tissue damage, prolonged postoperative recovery, and increased risks of complications \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esuch as hypocalcemia, recurrent laryngeal nerve injury, and mediastinal infection\u003c/span\u003e, which can lead to prolonged hospital stay (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEnhanced Recovery After Surgery (ERAS)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), a multimodal perioperative care protocol aimed at minimizing surgical stress, optimizing physiological function, and accelerating patient recovery, has been widely used in gastrointestinal, orthopedic, and thoracic surgery. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe\u003c/span\u003e core measures of ERAS include preoperative patient education, optimized anesthesia, minimally invasive surgical techniques, early mobilization, and personalized nutritional support. These measures shorten \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe hospital stay, reduce postoperative complications, and improve patient satisfaction\u003c/span\u003e (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, current research on ERAS is predominantly focused on common surgical procedures and data on the use of ERAS in cases of \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eectopic anterior mediastinal\u003c/span\u003e parathyroid tumor resection.\u003c/p\u003e \u003cp\u003eIn a systematic review, Chorath et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) reported that ERAS protocols in parathyroid surgery primarily focused on cervical cases and hospital stay was significantly reduced \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ecompared with traditional care\u003c/span\u003e (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Nevertheless, anterior mediastinal ectopic cases involve distinct surgical approaches, such as video-assisted thoracoscopic surgery or open thoracotomy, and unique perioperative challenges, such as mediastinal drainage management and \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe maintenance of respiratory function\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHowever\u003c/span\u003e, these approaches differ significantly from \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethose used for cervical surgery\u003c/span\u003e. To date, only sporadic case reports have describe\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ed surgical techniques for treating anterior mediastinal ectopic parathyroid tumors\u003c/span\u003e (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), and studies on ERAS-based perioperative nursing \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eare\u003c/span\u003e lacking.\u003c/p\u003e \u003cp\u003eHerein, we present the case of a patient with \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ean anterior mediastinal ectopic parathyroid tumor who underwent surgical resection combined with\u003c/span\u003e perioperative \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eERAS\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe\u003c/span\u003e treatment involved multidisciplinary collaboration, monitoring and management of serum calcium and PTH \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003elevels, personalized care-oriented psychological nursing, dynamic pain management, and early pulmonary rehabilitation exercises. The patient\u003c/span\u003e recovered rapid\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ely\u003c/span\u003e and was successfully discharged on the second postoperative day. To \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe best of our knowledge, this\u003c/span\u003e is the first systematic summary of ERAS nursing strategies for \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etreating anterior mediastinal ectopic parathyroid tumors. Our findings provide practical guidance for the perioperative care\u003c/span\u003e of complex cases.\u003c/p\u003e"},{"header":"2. Case presentation","content":"\u003cp\u003eA 50-year-old woman was admitted to our department with the main complaint of \"more than 7 years after parathyroid adenoma surgery.\" Seven years prior, the patient \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehad developed abdominal pain\u003c/span\u003e accompanied by nausea and vomiting without obvious inducement. The patient was diagnosed with pancreatitis \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eat a different hospital. Further examination\u003c/span\u003e suggested that pancreatitis was caused by hyperparathyroidism. The patient underwent \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ea left thyroid resection, left parathyroidectomy, and exploration of the right thyroid lobe\u003c/span\u003e. Pathological examination confirmed parathyroid adenoma. After surgery, she received cinacalcet orally for treatment and underwent regular re\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e-examinations; however\u003c/span\u003e, she stopped the medication on her own. During this period, the developed recurrent pancreatitis, kidney stones, and other diseases. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe\u003c/span\u003e ectopic parathyroid gland was found more than two months ago, and pancreatitis recurred one month ago. The patient was \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etransferred to our department for further treatment.\u003c/span\u003e\u003c/p\u003e \u003cp\u003eUpon admission, auxiliary examination revealed that the left thyroid had been resected, and no obvious abnormalities were found in the bilateral parathyroid regions. The parathyroid hormone (PTH) concentration was 299 pg/ml and \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe blood calcium was 2.98 mmol/l. Localization imaging\u003c/span\u003e with 99mTc-MIBI suggested an anterior mediastinal ectopic parathyroid tumor. We organized a multidisciplinary consultation, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eincluding specialists from the Departments of Endocrinology, Thoracic Surgery, General Surgery, Radiology, Nuclear Medicine, Anesthesiology, and a nursing team. We formulated a comprehensive treatment plan, including surgery and perioperative enhanced recovery after surgery (ERAS) nursing.\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThe patient underwent resection of the anterior mediastinal ectopic parathyroid tumor. A multidisciplinary team managed the patient. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe\u003c/span\u003e serum calcium and PTH \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003elevels were monitored, and the patient\u003c/span\u003e underwent care-oriented personalized psychological nursing, dynamic pain management, and early pulmonary rehabilitation exercises. The patient\u0026rsquo;s condition stabilized postoperatively. Both \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe blood calcium and PTH concentrations improved significantly, and the patient was discharged from the hospital two days after the operation.\u003c/span\u003e\u003c/p\u003e"},{"header":"3. Nursing care","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Multidisciplinary collaboration\u003c/h2\u003e \u003cp\u003eTo address the complexity of \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe perioperative management\u003c/span\u003e of this patient with an anterior mediastinal ectopic parathyroid tumor, we created a multidisciplinary team composed of specialists from endocrinology, radiology, thoracic surgery, general surgery, and nursing \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003edepartments. The core objective of this team was to integrate the concept of Enhanced Recovery After Surgery (ERAS) to optimize the nursing process. Endocrinology specialists participated in the comprehensive evaluation of primary hyperparathyroidism, including monitoring of serum calcium and parathyroid hormone levels, to clarify the severity of the disease and guide preoperative metabolic regulation. Radiologists precisely localize ectopic tumors using imaging examinations, such as contrast-enhanced neck CT and 99mTcO4-MIBI parathyroid scintigraphy\u003c/span\u003e (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), providing \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ea crucial basis for surgical planning. Considering the anatomical complexity of the anterior mediastinum, physicians in thoracic and general surgeries jointly discuss a surgical approach\u003c/span\u003e to minimize intraoperative trauma. Nursing staff participated in assessing patients\u0026rsquo; physical and psychological status. Nutritionists evaluated baseline nutritional status to assess the risk of malnutrition, which may exacerbate surgical stress. This collaborative process resulted in a personalized perioperative nursing plan tailored to the patient\u0026rsquo;s specific conditions, with the goal\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003es of reducing perioperative stress, minimizing complications, and accelerating postoperative recovery. The collaboration ensured seamless communication between the various disciplines, effectively integrating medical, surgical, and nursing expertise within the ERAS framework and providing a foundation for optimized perioperative care.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Serial Monitoring of Serum Calcium and Parathyroid Hormone\u003c/h2\u003e \u003cp\u003eGiven the preoperative suspicion of hyperparathyroidism, we postoperatively monitored \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe serum calcium and parathyroid hormone (PTH) levels to track the evolution of parathyroid function and guide calcium metabolism management\u003c/span\u003e (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA clinical decision support system (CDSS)\u003c/span\u003e (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewas integrated into this monitoring framework to enhance the precision and timeliness of interventions. Real-time serial monitoring data were integrated with the\u003c/span\u003e patients\u0026rsquo; baseline characteristics, such as \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe preoperative calcium concentration and surgical approach. Monitoring\u003c/span\u003e was performed using a predefined algorithm that mapped PTH/calcium trends to evidence-based action thresholds. The monitoring data processed by the CDSS revealed characteristic changes.\u003c/p\u003e \u003cp\u003eAdmission day (1.21): serum calcium, 2.98 mmol/L, PTH, 299 pg/mL, consistent with \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe laboratory manifestations of hyperparathyroidism. At this point, the CDSS flagged a \"high-risk\" status for hypercalcemic complications and recommended increasing the monitoring frequency\u003c/span\u003e every four hours.\u003c/p\u003e \u003cp\u003ePost-lesion resection (1.23): Ten minutes after lesion excision, PTH plummeted to 35.1 pg/mL, and further decreased to 24.2 pg/mL at 20 minutes post-resection. This change in PTH level \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etriggered the CDSS to issue an early alert for impending hypoparathyroidism, prompting the nursing team to prepare for oral calcium supplementation.\u003c/span\u003e\u003c/p\u003e \u003cp\u003ePre-discharge (1.24): Serum calcium declined to 2.68 mmol/L(Fig.\u0026nbsp;2\u003cb\u003e)\u003c/b\u003e, and PTH dropped to 3.77 pg/mL(Fig.\u0026nbsp;1). By cross-referencing these values with \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etrends on postoperative day 1\u003c/span\u003e, the CDSS generated a tailored calcium supplementation protocol of 500 mg twice daily, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewith weekly PTH rechecks.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e\n \u003cp\u003eUsing this dynamic monitoring augmented by \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe CDSS, we precisely captured the rapidly declin\u003c/span\u003eing trend in PTH \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003elevels, which produced actionable recommendations within 15 min of data entry, a much faster process than manual interpretation. This synergy enabled proactive prediction of serum calcium dynamics and provided a core basis for formulating a personalized calcium supplementation regimen. Complications such as tetany and muscle spasms caused by hypocalcemia were prevented by adjusting the timing and dose of calcium supplementation based on PTH concentration. Moreover, synergy ensures the safety of early pulmonary rehabilitation exercises and ambulation, embodying the core logic of \u0026ldquo;precise\u003c/span\u003e monitoring-targeted intervention\u0026rdquo; in Enhanced Recovery After Surgery, with the CDSS as a critical bridge between data and clinical action.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Early pulmonary rehabilitation exercises\u003c/h2\u003e \u003cp\u003eEarly pulmonary rehabilitation is an essential component of the ERAS protocol. Early rehabilitation is vital in patients undergo\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eing anterior mediastinal surgery. Surgical trauma, postoperative pain, and immobility may compromise respiratory function and\u003c/span\u003e increase \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe risk\u003c/span\u003e of atelectasis, pneumonia, and respiratory insufficiency (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Therefore, we implemented a structured, phased pulmonary rehabilitation program to promote lung expansion, strengthen respiratory muscles, and prevent pulmonary complications, with \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eclose integration of clinical assessments to guide progression. The program was delivered in a stepwise manner, tailored to the patient\u0026rsquo;s recovery trajectory\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImmediate postoperative period, 0\u0026ndash;6 hours after awakening. Continuous monitoring of vital signs and oxygen saturation. Nurses guided the patient through gentle diaphragmatic breathing exercises (5\u0026ndash;8 breaths/minute, sustained for 5 min, repeated every 2 h). This low-intensity intervention was intended to mitigate alveolar collapse, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewithout\u003c/span\u003e causing excessive pain or fatigue. Concurrently, regular position adjustments every 2 h from \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esupine to 30\u0026deg; semi-Fowler\u0026rsquo;s position were performed to optimize lung ventilation and facilitate mucus drainage.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEarly postoperative period (6\u0026ndash;24 hours): With pain effectively controlled (VAS\u0026thinsp;\u0026le;\u0026thinsp;3), exercise intensity \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewas gradually increased. The patient was instructed to use a\u003c/span\u003e spirometer, 10 repetitions per session, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewith each inhalation sustained for 3\u0026ndash;5 seconds, conducted every 3 h. To clear airway secretions and prevent\u003c/span\u003e mucus retention, guided \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eand effective coughing exercises were introduced, with the patient supporting the incision with both hands to minimize pain during coughing.\u003c/span\u003e Posteroanterior chest radiography was performed \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e24 h postoperatively. The patient had good pulmonary re-expansion with no signs of atelectasis, pneumothorax, or pleural effusion, consistent with the effectiveness of early rehabilitation\u003c/span\u003e (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Considering the stable respiratory status and minimal drainage volume (\u0026lt;\u0026thinsp;50 mL in the preceding 8 hours), we removed the mediastinal drain under aseptic conditions. This milestone not only reduced \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe physical discomfort associated with the drain but\u003c/span\u003e also enhanced the patient\u0026rsquo;s willingness to engage in subsequent activities.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSubacute postoperative period (24\u0026ndash;48 hours): Following drain removal, we integrated pulmonary rehabilitation with early mobilization. The patient was assisted to sit at the bedside for 5\u0026ndash;10 minutes, followed by standing and slow ambulation, initially 5 m, gradually extended to 10\u0026ndash;15 meters, while performing deep breathing. This synergistic approach improves lung ventilation, promotes diaphragmatic movement, and enhances \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe overall respiratory efficiency\u003c/span\u003e (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Throughout the process, nurses continuously monitored \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe respiratory rate, oxygen saturation, and breath sounds. Nurses adjusted exercise intensity based on tolerance\u003c/span\u003e, for example, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eby reducing the duration of dyspnea or increasing pain. Patient education was reinforced to emphasize adherence: \u0026ldquo;Each deep breath helps your lungs expand fully, lowering infection risk and speeding your return to daily life.\u0026rdquo; This structured early pulmonary rehabilitation program\u003c/span\u003e coupled with timely radiological assessment and drain removal effectively maintains adequate pulmonary ventilation. Postoperatively, the patient\u0026rsquo;s oxygen saturation remained stable at 98\u0026ndash;100% on room air, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewith no respiratory complications.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Dynamic pain management\u003c/h2\u003e \u003cp\u003eDynamic pain management, a cornerstone of ERAS (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), was implemented to mitigate postoperative pain and facilitate early rehabilitation with scheduled flurbiprofen administration (Q12H) as the core intervention. Six hours postoperatively, flurbiprofen (100 mg orally) was administered every 12 h to establish preemptive analgesia, with a target pain score (VAS) \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eof \u0026le;\u0026thinsp;3 and movement-related pain\u003c/span\u003e, for example, during pulmonary rehabilitation, \u0026le;\u0026thinsp;4. Pain was assessed every 4 h, with additional evaluations before mobilization or respiratory training. If breakthrough pain (VAS \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003escore\u0026thinsp;\u0026gt;\u0026thinsp;3) occurred, rescue analgesia (e.g., 50 mg tramadol) was administered, and the nursing team adjusted non-pharmacological measures, such as optimizing the semi-Fowler\u0026rsquo;s position (30\u0026deg; elevation) during coughing or applying cold compresses to the surgical site, to enhance efficacy. This multimodal strategy combin\u003c/span\u003eing scheduled flurbiprofen (Q12H) \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eadministration with real-time pain monitoring provided consistent analgesia. The patient\u0026rsquo;s average VAS remained at 2.1 (rest) and 3.2 (movement) during hospitalization, which avoided pain-induced respiratory suppression or delayed ambulation.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Psychological nursing\u003c/h2\u003e \u003cp\u003eCentered on humane care, personalized perioperative psychological nursing is tailored to patients\u0026rsquo; emotional needs (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Preoperatively, nurses used in-depth interviews to identify stressors such as concerns about surgical outcomes and anxiety over postoperative recovery. Nurses built trust by empathetic communication, e.g., \"It\u0026rsquo;s normal to worry about recovery; we\u0026rsquo;ll adjust the plan based on how you feel.\" \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTherefore\u003c/span\u003e, postoperative intervention \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eshould be considered. Because of the patient\u0026rsquo;s introverted personality, we provided a \"mood diary\" to help the patient express unspoken concerns, and her emotional experiences were validated. Family support was integrated by guiding relatives to use supportive communication, and the patients\u0026rsquo; favorite music playlists were curated to reduce their unfamiliarity with the environment. When the patient\u0026rsquo;s anxiety intensified during tube removal, the nurses used process visualization, explain\u003c/span\u003eed the steps using hand-drawn diagrams, and held the patient\u0026rsquo;s hand during the procedure to convey a sense of security. This approach improved patient satisfaction and enhanced adherence to rehabilitation training. By prioritizing individual experiences over standardized protocols, nurses conveyed a sense of security and embodied humane care to facilitate holistic recovery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Discharge guidance and follow-up\u003c/h2\u003e \u003cp\u003eTo support the patient\u0026rsquo;s rapid recovery and safe transition to home care, discharge guidance was streamlined around key self-management priorities, while continuous care was provided by \"Internet +\" teleconsultation (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Upon discharge on postoperative day 2, personalized guidance was focused on key matters \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esuch as the recognition of hypocalcemia symptoms (paresthesia and muscle cramps) and a progressive rehabilitation plan (30 min of daily walking, avoiding weight-bearing). A printed checklist with illustrations\u003c/span\u003e including symptom comparison charts and medication schedules was provided to enhance adherence. The core of \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe follow-up was an online consultation platform through which patients could access 24/7 text and image consultation services from a nursing team. For urgent situations\u003c/span\u003e, such as persistent numbness, remote video links to a multidisciplinary team (endocrinologists and surgeons) ensure timely assessment within two hours. This model addresses \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe post-discharge safety gaps. Readmission was avoided\u003c/span\u003e through remote consultation. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eBy bridging in-hospital and home care via digital tools, the goal of accelerated recovery was sustained while ensuring ongoing safety, with 100% patient satisfaction reported in follow-up feedback.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe innovation of this nursing model is its \"three-dimensional integration\" of anatomical adaptability, metabolic precision, and digital empowerment. The model not only extends ERAS principles to complex ectopic cases, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ebut also establishes a replicable framework for the perioperative management of deep mediastinal surgeries involving endocrine dysfunction.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe\u003c/span\u003e limitations of this study include its preliminary nature, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esingle-case focus\u003c/span\u003e, and conflicting validation\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003es with larger multicenter cohorts. Additional research should measure the long-term impact of this protocol on calcium homeostasis and quality of life as well as the potential of artificial intelligence-driven predictive models to further refine real-time calcium regulation.\u003c/span\u003e\u003c/p\u003e \u003cp\u003eOverall, this tailored ERAS nursing protocol is a valuable advancement in the care of patients undergoing anterior mediastinal ectopic parathyroid tumor resection. This protocol emphasizes the importance of specialized strategies for optimizing outcomes in complex endocrine surgical populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest statement \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData acailability statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll raw data and code are available upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was conducted without the financial support of grants, foundations, or pharmaceutical companies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Ethics Committee of the Fourth Affiliated Hospital Zhejiang University School of Medicine (K2025229). This study was carried out in accordance with the ethical guidelines and regulations for human subject research formulated by the Ethics Committee of the Fourth Affiliated Hospital Zhejiang University School of Medicine.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was freely obtained from the patient for participation in this study and the publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: Xiaodan Zhu.\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Kanghui Huang , Yingxia Yu\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank AiMi Academic Services (www.aimieditor.com) for English language editing and review services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed written consent for the publication of this case report, including any accompanying images and identifiable personal clinical data, has been obtained from the patient. A copy of the written consent is available for review by the journal\u0026apos;s editorial office upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlasgow C, Lau EYC, Aloj L, et al. An Approach to a Patient With Primary Hyperparathyroidism and a Suspected Ectopic Parathyroid Adenoma. J Clin Endocrinol Metab. 2022;107(6):1706\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1210/clinem/dgac024\u003c/span\u003e\u003cspan address=\"10.1210/clinem/dgac024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBilezikian JP, Khan AA, Silverberg SJ et al. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. J Bone Miner Res. 2022;37(11):2293\u0026ndash;2314. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jbmr.4677\u003c/span\u003e\u003cspan address=\"10.1002/jbmr.4677\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKowalski GJ, Buła G, Żądło D, Gawrychowska A, Gawrychowski J. Primary hyperparathyroidism. Endokrynol Pol. 2020;71(3):260\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5603/EP.a2020.0028\u003c/span\u003e\u003cspan address=\"10.5603/EP.a2020.0028\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemead HM, Abdellatif AA, Abdel Rahman MA. Ectopic pure mediastinal parathyroid adenoma: A case report. Int J Surg Case Rep. 2022;90:106598. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijscr.2021.106598\u003c/span\u003e\u003cspan address=\"10.1016/j.ijscr.2021.106598\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabazzi G, Elia G, Aprile V, et al. Surgical Management of Mediastinal Ectopic Parathyroids. J Pers Med. 2025;15(7):276. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jpm15070276\u003c/span\u003e\u003cspan address=\"10.3390/jpm15070276\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2025 Jun 30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLjungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamasurg.2016.4952\u003c/span\u003e\u003cspan address=\"10.1001/jamasurg.2016.4952\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChorath K, Luu N, Go BC, Moreira A, Rajasekaran K. ERAS Protocols for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2022;166(3):425\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/01945998211019671\u003c/span\u003e\u003cspan address=\"10.1177/01945998211019671\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemead HM, Abdellatif AA, Abdel Rahman MA. Ectopic pure mediastinal parathyroid adenoma: A case report. Int J Surg Case Rep. 2022;90:106598. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijscr.2021.106598\u003c/span\u003e\u003cspan address=\"10.1016/j.ijscr.2021.106598\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetranović Ovčariček P, Giovanella L, Carri\u0026oacute; Gasset I, et al. The EANM practice guidelines for parathyroid imaging. Eur J Nucl Med Mol Imaging. 2021;48(9):2801\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00259-021-05334-y\u003c/span\u003e\u003cspan address=\"10.1007/s00259-021-05334-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalermo A, Tabacco G, Makras P, et al. Primary hyperparathyroidism: from guidelines to outpatient clinic. Rev Endocr Metab Disord. 2024;25(5):875\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11154-024-09899-5\u003c/span\u003e\u003cspan address=\"10.1007/s11154-024-09899-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlakotan O, Mohd Yusof M, Ezat Wan Puteh S. A Systematic Review on CDSS Alert Appropriateness. Stud Health Technol Inf. 2020;270:906\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3233/SHTI200293\u003c/span\u003e\u003cspan address=\"10.3233/SHTI200293\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang Z, Lu M, Qu C, et al. Enhanced Recovery After Surgery Improves Short-term Outcomes in Patients Undergoing Esophagectomy. Ann Thorac Surg. 2022;114(4):1197\u0026ndash;204. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.athoracsur.2021.08.073\u003c/span\u003e\u003cspan address=\"10.1016/j.athoracsur.2021.08.073\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedbery RL, Fernandez FG, Khullar OV. ERAS and patient reported outcomes in thoracic surgery: a review of current data. J Thorac Dis. 2019;11(Suppl 7):S976\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/jtd.2019.04.08\u003c/span\u003e\u003cspan address=\"10.21037/jtd.2019.04.08\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS\u0026reg;) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019;55(1):91\u0026ndash;115. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ejcts/ezy301\u003c/span\u003e\u003cspan address=\"10.1093/ejcts/ezy301\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGottumukkala V, Joshi GP. Challenges and opportunities in enhanced recovery after surgery programs: An overview. Indian J Anaesth. 2024;68(11):951\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ija.ija_546_24\u003c/span\u003e\u003cspan address=\"10.4103/ija.ija_546_24\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLv J, Su Y, Tang H, Jiang X, Chen X. Humanistic nursing care management strategies: from formulation to implementation. Front Public Health. 2025;13:1591077. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2025.1591077\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2025.1591077\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2025 May 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang GW, Li B, Gu ZM, et al. In-Depth Examination of the Functionality and Performance of the Internet Hospital Information Platform: Development and Usability Study. J Med Internet Res. 2024;26:e54018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2196/54018\u003c/span\u003e\u003cspan address=\"10.2196/54018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2024 Nov 8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Enhanced Recovery After Surgery, Anterior Mediastinal Ectopic Parathyroid Tumor, nursing, case report","lastPublishedDoi":"10.21203/rs.3.rs-9211316/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9211316/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e Anterior mediastinal ectopic parathyroid tumor is a special type of lesion that can cause primary hyperparathyroidism. Due to its special anatomical location and potential complications, its treatment involves multiple disciplines. This study aims to summarize the perioperative rehabilitation experience in the successful treatment of anterior mediastinal ectopic parathyroid tumor and provide a replicable framework for perioperative rehabilitation of complex endocrine diseases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCase presentation\u003c/b\u003e A 50-year-old female patient was admitted to the hospital due to recurrent pancreatitis, kidney stones, hypercalcemia (2.98 mmol/L), and elevated parathyroid hormone levels (299 picograms/mL). The patient had a 7-year history of previous treatment for parathyroid adenoma, and abnormal parathyroid glands were found in an examination at an external hospital 2 months before admission. After admission, the patient was diagnosed with primary hyperparathyroidism secondary to an anterior mediastinal ectopic parathyroid tumor through multidisciplinary evaluation (MDT). Subsequently, an MDT discussion was organized immediately, and a multidisciplinary collaborative team consisting of the Department of Endocrinology, Department of Radiology, Department of Thoracic Surgery, Department of General Surgery, and Department of Nursing was established. After evaluating the patient's condition, the team decided to perform a pre-diaphragmatic tumor resection under ⁹⁹ᵐTcO₄-MIBI localization and formulated a perioperative enhanced recovery plan for the patient. The patient recovered smoothly after surgery and was discharged on the 2nd day after surgery; follow-up at 6 months after surgery showed that the patient was in good recovery condition.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e The multidisciplinary Enhanced Recovery After Surgery (ERAS) protocol monitored by a Clinical Decision Support System can achieve safe ultra-early discharge of patients with anterior mediastinal ectopic parathyroid tumor, effectively address the unique challenges in the surgical treatment of this disease, and provide a valuable and replicable framework for perioperative rehabilitation of complex endocrine diseases.\u003c/p\u003e","manuscriptTitle":"Perioperative enhanced recovery after surgery protocols with anterior mediastinal ectopic parathyroid tumor: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 00:48:33","doi":"10.21203/rs.3.rs-9211316/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-06T23:59:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T00:39:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T18:57:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254839162686044213099164152494449423550","date":"2026-04-21T18:55:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T11:29:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34171321025416428825092145943707731798","date":"2026-04-18T04:12:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232585895451766244746527208924164236452","date":"2026-04-18T04:08:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T03:11:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-07T06:14:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T21:01:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-31T04:21:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Oncology","date":"2026-03-30T15:38:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6f37029-8dff-4766-9863-b878bf897bfb","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-06T23:59:43+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T00:08:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 00:48:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9211316","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9211316","identity":"rs-9211316","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}