The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism

Scott M. Wilhelm*, Tracy S. Wang, Daniel T. Ruan, James A. Lee, Sylvia L. Asa, Quan Yang Duh, Gerard M. Doherty, Miguel F. Herrera, Janice L. Pasieka, Nancy D. Perrier, Shonni J. Silverberg, Carmen C. Solórzano, Cord Sturgeon, Mitchell E. Tublin, Robert Udelsman, Sally E. Carty

*Corresponding author for this work

Research output: Contribution to journalArticle

144 Citations (Scopus)

Abstract

Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendationswere created to assist clinicians in the optimal treatment of patients with pHPT.

Original languageEnglish (US)
Pages (from-to)959-968
Number of pages10
JournalJAMA Surgery
Volume151
Issue number10
DOIs
StatePublished - Oct 1 2016

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Parathyroidectomy
Primary Hyperparathyroidism
Guidelines
Hypocalcemia
Computer-Assisted Surgery
Calcium
Parathyroid Neoplasms
Vitamin D Deficiency
Thyroid Diseases
Surgeons
Parathyroid Hormone
PubMed
Hematoma
Ultrasonography
Observation
X-Rays
Urine
Physicians
Biopsy
Costs and Cost Analysis

ASJC Scopus subject areas

  • Surgery

Cite this

Wilhelm, S. M., Wang, T. S., Ruan, D. T., Lee, J. A., Asa, S. L., Duh, Q. Y., ... Carty, S. E. (2016). The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surgery, 151(10), 959-968. https://doi.org/10.1001/jamasurg.2016.2310
Wilhelm, Scott M. ; Wang, Tracy S. ; Ruan, Daniel T. ; Lee, James A. ; Asa, Sylvia L. ; Duh, Quan Yang ; Doherty, Gerard M. ; Herrera, Miguel F. ; Pasieka, Janice L. ; Perrier, Nancy D. ; Silverberg, Shonni J. ; Solórzano, Carmen C. ; Sturgeon, Cord ; Tublin, Mitchell E. ; Udelsman, Robert ; Carty, Sally E. / The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. In: JAMA Surgery. 2016 ; Vol. 151, No. 10. pp. 959-968.
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abstract = "Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendationswere created to assist clinicians in the optimal treatment of patients with pHPT.",
author = "Wilhelm, {Scott M.} and Wang, {Tracy S.} and Ruan, {Daniel T.} and Lee, {James A.} and Asa, {Sylvia L.} and Duh, {Quan Yang} and Doherty, {Gerard M.} and Herrera, {Miguel F.} and Pasieka, {Janice L.} and Perrier, {Nancy D.} and Silverberg, {Shonni J.} and Sol{\'o}rzano, {Carmen C.} and Cord Sturgeon and Tublin, {Mitchell E.} and Robert Udelsman and Carty, {Sally E.}",
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Wilhelm, SM, Wang, TS, Ruan, DT, Lee, JA, Asa, SL, Duh, QY, Doherty, GM, Herrera, MF, Pasieka, JL, Perrier, ND, Silverberg, SJ, Solórzano, CC, Sturgeon, C, Tublin, ME, Udelsman, R & Carty, SE 2016, 'The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism', JAMA Surgery, vol. 151, no. 10, pp. 959-968. https://doi.org/10.1001/jamasurg.2016.2310

The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. / Wilhelm, Scott M.; Wang, Tracy S.; Ruan, Daniel T.; Lee, James A.; Asa, Sylvia L.; Duh, Quan Yang; Doherty, Gerard M.; Herrera, Miguel F.; Pasieka, Janice L.; Perrier, Nancy D.; Silverberg, Shonni J.; Solórzano, Carmen C.; Sturgeon, Cord; Tublin, Mitchell E.; Udelsman, Robert; Carty, Sally E.

In: JAMA Surgery, Vol. 151, No. 10, 01.10.2016, p. 959-968.

Research output: Contribution to journalArticle

TY - JOUR

T1 - The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism

AU - Wilhelm, Scott M.

AU - Wang, Tracy S.

AU - Ruan, Daniel T.

AU - Lee, James A.

AU - Asa, Sylvia L.

AU - Duh, Quan Yang

AU - Doherty, Gerard M.

AU - Herrera, Miguel F.

AU - Pasieka, Janice L.

AU - Perrier, Nancy D.

AU - Silverberg, Shonni J.

AU - Solórzano, Carmen C.

AU - Sturgeon, Cord

AU - Tublin, Mitchell E.

AU - Udelsman, Robert

AU - Carty, Sally E.

PY - 2016/10/1

Y1 - 2016/10/1

N2 - Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendationswere created to assist clinicians in the optimal treatment of patients with pHPT.

AB - Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendationswere created to assist clinicians in the optimal treatment of patients with pHPT.

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