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Original Article |

Worldwide Trends in the Surgical Treatment of Primary Hyperparathyroidism in the Era of Minimally Invasive Parathyroidectomy FREE

Wendy R. Sackett, MD; Bruce Barraclough, MD; Tom S. Reeve, MD; Leigh W. Delbridge, MD
[+] Author Affiliations

From the University of Sydney Endocrine Surgical Unit, Department of Surgery, Royal North Shore Hospital, Sydney, Australia. No conflict of interest is held by any of the authors.


Arch Surg. 2002;137(9):1055-1059. doi:10.1001/archsurg.137.9.1055.
Text Size: A A A
Published online

Hypothesis  Minimally invasive surgery for primary hyperparathyroidism has become an accepted part of endocrine surgical practice worldwide.

Design  Survey of members of the International Association of Endocrine Surgeons.

Setting  Clinical practice of endocrine surgeons worldwide.

Main Outcome Measures  Numbers of parathyroid procedures performed, types of minimally invasive procedures undertaken, and techniques used to ensure completeness of removal of hyperfunctioning parathyroid tissue as reported by the survey respondents.

Results  Of 160 surveys completed, 95 (59%) indicate that the surgeons currently perform minimally invasive parathyroidectomy and use this technique on average for 44% of patients with primary hyperparathyroidism. The most common approach is the focused technique with a small incision, either central or lateral (92% [87 respondents]), followed by a video-assisted technique (22% [21 respondents]), and a true endoscopic technique with gas insufflation (12% [11 respondents]). Techniques used to ensure completeness of resection include the quick intraoperative intact parathyroid hormone assay (68% [65 respondents]), a same-day intact parathyroid hormone assay (17% [16 respondents]), and the nuclear probe (14% [13 respondents]). The number of parathyroidectomies performed worldwide increased from 1727 in 1980 to 6977 in 2000 with the average number per surgeon increasing from 23 in 1980 to 45 in 2000. Geographically, 20 (59%) of 34 surveys from the Americas report the use of minimally invasive parathyroidectomy, 23 (56%) of 41 from the Australasian region, and 34 (49%) of 69 from Europe or the Middle East.

Conclusions  The number of parathyroidectomies performed for primary hyperparathyroidism has increased worldwide over the past 20 years. More than half of the surgeons responding to the survey perform minimally invasive parathyroidectomy, with the most using the focused small-incision technique.

Figures in this Article

SURGERY FOR primary hyperparathyroidism seems to be on the increase for many reasons.1 It is recognized that parathyroidectomy benefits patients who have symptoms that include fatigue, bone pain, osteoporosis, muscle weakness, nephrolithiasis, abdominal symptoms, and mental status changes.25 There is also mounting evidence pointing to improved cardiovascular status and control of diabetes mellitus postoperatively611; even asymptomatic patients have been shown to have improved function and sense of wellness12 following parathyroidectomy. Despite controversy over the natural history of primary hyperparathyroidism,13 the cost and frequency of nonoperative follow-up lends weight to the argument for definitive surgical management of primary hyperparathyroidism at diagnosis14 when cure rates of 95% or better can be expected.15,16 For these reasons parathyroidectomy is recommended, even for asymptomatic patients.17

Added to these reasons has been the introduction of minimally invasive approaches to parathyroid surgery. Many techniques have been reported, including a full endoscopic approach with gas insufflation,1820 video-assisted approaches,2123 and the direct-focused approach using a small cervical incision.24 The use of various techniques to ensure completeness of removal of all abnormal parathyroid tissue, including intraoperative measurement of quick intraoperative intact parathyroid hormone (PTH) assay25 and the intraoperative nuclear probe26 has allowed early discharge from the hospital. Indeed, parathyroid surgery is being promoted as a 1-day-only local anesthetic procedure.27 A 1999 "Editorial" in the New England Journal of Medicine recommended parathyroidectomy for almost all patients based on the dual view that "most patients with primary hyperparathyroidism probably have symptoms"28(p1032) and that changes in surgical technique have made "surgical treatment simpler and faster than in the past."28(p1032)

Against this background, we felt that it would be useful to ascertain current practice among endocrine surgeons worldwide in relation to both the numbers of parathyroid procedures being performed as well as the use of minimally invasive parathyroidectomy (MIP) to determine whether the procedure had become an accepted part of endocrine surgical practice.

A survey was mailed to all 326 members of the International Association of Endocrine Surgeons listed in the 2000 membership directory. Mail, facsimile, and e-mail were the available methods of response. The survey questions included the following:

  • How many parathyroid operations overall did you perform in the last 12 months?

  • Do you perform minimally invasive/minimal access/endoscopic parathyroidectomy?

  • If "yes," what percentage of all your parathyroid operations is currently performed by this technique?

  • Which technique do you currently use?

  • Which technique do you use to ensure adequate removal of all abnormal parathyroid tissue?

  • How many parathyroid operations did you perform in each year: 1980, 1985, 1990, 1995, and 2000?

  • Any other comments?

Specific choices were given for each question as well as the opportunity to note techniques not listed. Respondents were also asked to indicate whether their data were absolute or estimated numbers. The survey was anonymous, although most responders provided a return address or facsimile number imprint that was used to determine the region of practice, that is, the Americas, the Australasian region, or Europe and the Middle East.

Of the 326 surveys mailed, 177 were returned. Of those, 17 were marked "return to sender," or the surgeon was no longer in practice and, therefore, did not complete the survey, leaving 160 surveys (49%) for analysis. Two respondents indicated that they had replied on behalf of a surgical department rather than as an individual, marginally affecting the estimate of the average numbers of procedures performed per surgeon. Within that group of respondents, 95 surgeons or groups (59%) indicated that MIP was performed in their center. Calculated on the basis of individual surgeons, 101 (61%) of 166 perform MIP. Those surgeons who performed MIP did so for 44% of all patients undergoing parathyroidectomy for primary hyperparathyroidism.

Minimally invasive techniques used are summarized in Table 1. The endoscopic mammary approach was not reported as being performed by any responding endocrine surgeon. The focused technique using a small cervical incision was reported as being used by 87 surgeons (92%). Of these, 54 surgeons (62%) performed the procedure through a central incision and 52 surgeons (60%) used a lateral incision, with some using both approaches. Clearly many surgeons use or have used a variety of techniques as the percentages, when summed, total more than 100%. In relation to the "Comments" section, one group used hypnosis instead of general anesthesia for outpatient parathyroidectomy. Several cited local anesthesia as a less invasive method, with either a focused small-incision approach or formal 4-gland exploratory surgery. Thoracoscopic parathyroidectomy was mentioned for ectopic mediastinal parathyroid adenomas. Some surgeons reserve MIP for patients undergoing another operation or for patients with high general risk under anesthesia. Comments also included having commenced MIP using an endoscopic technique but having now changed to the focused small-incision technique.

Table Graphic Jump LocationTable 1. Summary of Survey Findings for the Types of Procedures Used

To assure complete removal of hyperfunctioning parathyroid glands during MIP, surgeons used various techniques as summarized in Table 2. Four surgeons commented on using methylene blue injection. Other comments included the use of macroscopic appearance or "good judgment" and several surgeons pointed out the ability to monitor postoperative calcium and PTH levels.

Table Graphic Jump LocationTable 2. Summary of Survey Findings for the Techniques Used to Ensure Complete Removal of Hyperfunctioning Parathyroid Tissue*

Several comments addressed factors influencing the number of MIPs performed. For example, only symptomatic patients were referred for surgery in some areas. Similarly, routine calcium level screening was not performed in all areas. One surgeon pointed out that in India, with a goiter rate of 50% to 70%, patients with primary hyperparathyroidism frequently required concomitant thyroidectomy, thus, obviating MIP. Some surgeons had "cost-benefit concerns" for using MIP. Referral patterns had changed as well, with referrals going to a "new endocrine surgeon in town," or going from all surgical units to a single unit managing hyperparathyroidism. Several centers were running their own pilot series or prospective randomized studies, after which they hoped to embrace MIP. Although many surgeons reported a trend over the last 2 to 5 years of increasing MIP, others, such as survey respondent 83, did not. Survey respondent 83 commented: "Concerning MIP, I don't really see the point . . . even elderly patients can be operated on with minimal risk and a good cosmetic result via a 5- to 6-cm centrally placed neck incision. . . . "

Finally, the surgeons were asked to include the number of parathyroidectomies performed over the past 20 years in increments of 5 years. The total number of parathyroidectomies increased from 1727 in 1980 to 6977 in 2000 (Figure 1). Given that fact, when looked at for each individual surgeon, this increase was almost universal, with only a small minority reporting a decrease in the number of parathyroidectomies performed over the decades. Since many surgeons were not in practice during this entire interval, averages were calculated. In 1980, 76 of the responding surgeons were already in practice. By 2000, 155 of the responding surgeons were still in practice. The average number of parathyroidectomies performed in 1980 by the surgeons reporting was 22.7. The average number of parathyroidectomies performed increased to 24.6 in 1985, 28.8 in 1990, 34.1 in 1995, and 45.0 in 2000.

Place holder to copy figure label and caption

Overall increase in the number of minimally invasive parathyroidectomies performed worldwide from 1980 to 2000.

Graphic Jump Location

Of 177 surveys returned, 34 were from the Americas, 41 from the Australasian regions, 68 from Europe or the Middle East, and 34 were unidentifiable as to region of the world. Of 34 surveys from the Americas, 20 (59%) performed MIP and 14 (41%) did not. In the Australasian region, 23 (56%) of 41 performed MIP and 18 (44%) did not. In Europe and the Middle East, 34 (50%) of 68 performed MIP, and the other 50% did not. The difference in the number of MIPs by region was not statistically significant (P = .99).

This study has confirmed that the rate of parathyroid surgery seems to be increasing worldwide. Not only has this occurred across the group as a whole but also, on an individual basis, with most of the actively practicing surgeons reporting a progressive increase in MIPs being performed. We have previously reported an exponential increase in parathyroidectomy for primary hyperparathyroidism in our own state of New South Wales, Australia,1,29 and similar marked increases have been reported in other centers such as Madrid, Spain.30 Whether this increase is because of an increasing incidence of primary hyperparathyroidism, the greater use of routine testing of blood calcium levels, or simply because of more patients being referred for parathyroidectomy remains unclear. Although some major referral centers in the United States have reported a constant number of parathyroidectomies over the years, they already maintain a high number of parathyroid operations.31 The very few surgeons in this study who reported decreasing numbers commented on either a slowdown in practice because of pending retirement or on changing referral patterns, such as "a new endocrine surgeon in town." It is highly likely that part of the increase seen in parathyroid surgery relates to the introduction of MIP, with the perception by referring physicians that parathyroid surgery is much quicker, simpler, and safer than in the past. This was certainly the view expressed by Utiger in the New England Journal of Medicine editorial, in which parathyroidectomy was universally recommended based on the view that "most patients with primary hyperparathyroidism probably have symptoms"28(p1032) and that changes in surgical technique have made "surgical treatment simpler and faster than in the past."28(p1032)

This study has demonstrated that most endocrine surgeons undertake MIP for just under half their patients who are intially seen with primary hyperparathyroidism. Presumably, the other half have contraindications to a minimally invasive approach such as the presence of a multinodular goiter, familial disease, or the absence of confident preoperative localization. The key to successful MIP is careful patient selection, with avoidance of those patients who are likely to have multiglandular disease,32 as well as confident preoperative localization with techniques such as sestamibi nuclear scanning33 or ultrasonography. A concordant result with these modalities affords the most reliable preoperative localization of parathyroid adenomas.34 In our own unit, if the sestamibi nuclear scan and ultrasound are not concordant, patients undergo open bilateral neck exploratory surgery.

The earliest reports of MIP described the use of true endoscopic1820 and video-assisted techniques.2123 Although it is accepted that these techniques provide excellent visualization of the anatomical structures, they can be time consuming and are associated with a steep learning curve. Many surgeons commented on having started using these techniques and having shifted to the focused small-incision techniques more recently. This study has demonstrated that most (87 respondents or 92%) of endocrine surgeons prefer to use the focused small-incision technique with a small cervical incision placed either centrally or laterally. We prefer a 2-cm lateral incision placed directly over the presumed site of the adenoma as directed by the preoperative localization studies.24 The adenoma can then be retrieved through the incision with more than a 97% success rate, even without the use of the intraoperative PTH assay.32 We draw intraoperative PTH levels but monitor them routinely postoperatively, obtaining results prior to discharging the patient on the day of surgery. If the quick PTH assay fails to show a decrease in PTH level and the calcium level fails to normalize, the patient undergoes an open exploratory procedure the next day. Those advocating a central small-incision point to the ability to surgically explore both sides of the neck if required. In our experience this has not been necessary provided patients are appropriately selected for an MIP approach. We also believe that a lateral scar has the potential for a superior cosmetic result. The focused small-incision approach certainly shortens operative and hospital time and shortens incision length.2427 A thorough knowledge of neck anatomy and embryology is mandatory for this approach, however, as visualization of the anatomy through the small hole is necessarily restricted.

Despite careful selection, the presence of multiglandular disease leading to failure of MIP remains a possibility. If outpatient or same-day surgery is to be performed, some technique should be used to ensure complete removal of all hyperfunctioning parathyroid tissue so that the patient may be discharged from the hospital "cured." The development and modification of the chemiluminescent assay for the intact PTH level (quick PTH) allowed fast measurement of the PTH level without the use of radioisotopes.35 This is a highly accurate technique with a success rate of 95% to 98%25,36,37 and was demonstrated in our survey to be the technique of choice for 65 surgeons (68%). Although quick intraoperative intact PTH assay is the most frequently chosen modality to confirm cure with MIP, it is not readily available throughout the world and is expensive. It is also not accurate when it is needed most, that is, for patients with multiple abnormal parathyroid glands.38 As the alternative to same-day PTH measurement, using a series of routine laboratory tests still allows same-day discharge from the hospital but is significantly more cost-effective,39 and does require reoperation. Same-day PTH measurement is used by 17% of surgeons (16 respondents). It must be pointed out, however, that, provided patients are appropriately selected for an MIP, 97% of them will be cured with MIP even if no testing of any sort is performed.32,39

The radioguided approach using a nuclear probe similar to that used for sentinel node biopsy met with initial enthusiasm because of the presumed increased ability to localize an adenoma as well as the ability to ensure complete removal by comparing the count in the adenoma with the background radioactivity.40 As this study has shown, enthusiasm for that technique has waned with only 13 surgeons (14%) still using the technique because of both the initial good results not being confirmed as well as the logistics of timing of the administration of sestamibi nuclear scanning on the morning of surgery.

In a previous systematic review of MIP published in the ARCHIVES in 2000,41 we questioned whether there was sufficient evidence to justify the introduction of MIP into clinical practice. In conclusion, it would seem as if MIP has gained an acceptable place in the armamentarium of endocrine surgeons worldwide. Most surgeons are performing MIP in just fewer than 50% of patients. The focused small-incision technique with direct removal of the adenoma through a small cervical incision has come to be used by almost all surgeons performing MIP.

Reprints: Leigh W. Delbridge, MD,University of Sydney Endocrine Surgical Unit, Department of Surgery, Royal North Shore Hospital, St Leonards, New South Wales 2065, Sydney, Australia (e-mail: leighd@med.usyd.edu.au).

Sywak  MSRobinson  BGClifton-Bligh  P  et al.  Presentations and procedure rates for hyperparathyroidism in Northern Sydney and NSW are increasing. Med J Aust. In press.
Graham  JJHarding  PEHoare  LLThomas  DWWise  PH Asymptomatic hyperparathyroidism: an assessment of operative intervention. Br J Surg. 1980;67115- 118
Link to Article
Clark  OHWilkes  WSiperstein  AEDuh  QY Diagnosis and management of asymptomatic hyperparathyroidism: safety, efficacy, and deficiencies in our knowledge. J Bone Miner Res. 1991;6Suppl 2S135- S142discussion 151-152.
Link to Article
Kaplan  RASnyder  WHStewart  APak  CY Metabolic effects of parathyroidectomy in asymptomatic primary hyperparathyroidism. J Clin Endocrinol Metab. 1976;42415- 426
Link to Article
Silverberg  SJShane  EJacobs  TPSiris  EBilezikian  JP A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. N Engl J Med. 1999;3411249- 1255
Link to Article
Smith  JCEvans  LMCockcroft  JRDavies  JS Impaired vascular reactivity in primary hyperparathyroidism may contribute to cardiovascular risk. Clin Endocrinol (Oxf). 2001;55279- 280
Link to Article
Kautzky-Willer  APacini  GNiederle  BSchernthaner  GPrager  R Insulin secretion, insulin sensitivity and hepatic insulin extraction in primary hyperparathyroidism before and after surgery. Clin Endocrinol (Oxf). 1992;37147- 155
Link to Article
Cheung  PSThompson  NWBrothers  TEVinik  AI Effect of hyperparathyroidism on the control of diabetes mellitus. Surgery. 1986;1001039- 1047
Prager  RSchernthaner  GNiederle  BRoka  R Evaluation of glucose tolerance, insulin secretion and insulin action in patients with primary hyperparathyroidism before and after surgery. Calcif Tissue Int. 1990;461- 4
Link to Article
Abdu  TAElhadd  TPfeifer  MClayton  RN Endothelial dysfunction in endocrine disease. Trends Endocrinol Metab. 2001;12257- 265
Link to Article
Kosch  MHausberg  MBarenbrock  MPosadzy-Malaczynska  AKisters  KRahn  KH Arterial distensibility and pulse wave velocity in patients with primary hyperparathyroidism before and after parathyroidectomy. Clin Nephrol. 2001;55303- 308
Talpos  GBBone  HGKleerekoper  M  et al.  Randomized trial of parathyroidectomy in mild asymptomatic primary hyperparathyroidism: patient description and effects on the SF-36 health survey. Surgery. 2000;1281013- 1021
Link to Article
Silverberg  SJ Natural history of primary hyperparathyroidism. Endocrinol Metab Clin North Am. 2000;29451- 464
Link to Article
Cormier  CSouberbielle  JCKindermans  C Hyperparathyroidism: the limits of surgery in cases of bone or cardiovascular involvement. Curr Opin Rheumatol. 2000;12349- 353
Link to Article
Clark  OH Surgical treatment of primary hyperparathyroidism. Adv Endocrinol Metab. 1995;61- 16
Rude  RK Hyperparathyroidism. Otolaryngol Clin North Am. 1996;29663- 679
Russell  CFEdis  AJ Surgery for primary hyperparathyroidism: experience with 500 consecutive cases and evaluation of the role of surgery in the asymptomatic patient. Br J Surg. 1982;69244- 247
Link to Article
Gagner  M Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism [letter]. Br J Surg. 1996;83875
Link to Article
Naitoh  TGagner  MGarcia-Ruiz  AHeniford  BT Endoscopic endocrine surgery in the neck: an initial report of endoscopic subtotal parathyroidectomy. Surg Endosc. 1998;12202- 205discussion 206.
Link to Article
Henry  JFDefechereux  TGramatica  Lde Boissezon  C Minimally invasive videoscopic parathyroidectomy by lateral approach. Langenbecks Arch Surg. 1999;384298- 301
Link to Article
Gauger  PGReeve  TSDelbridge  LW Endoscopically assisted minimally invasive parathyroidectomy. Br J Surg. 1999;861563- 1566
Link to Article
Miccoli  PMonchik  JM Minimally invasive parathyroid surgery. Surg Endosc. 2000;14987- 990
Link to Article
Miccoli  PBerti  PConti  MRaffaelli  MMaterazzi  G Minimally invasive video-assisted parathyroidectomy: lessons learned from 137 cases. J Am Coll Surg. 2000;191613- 618
Link to Article
Agarwal  GBarraclough  BReeve  TSDelbridge  LW Minimally invasive parathyroidectomy using the "focused" lateral approach, 2: surgical technique. ANZ J Surg. 2002;72147- 151
Link to Article
Irvin  GL Chasin' hormones. Surgery. 1999;126993- 997
Link to Article
Norman  JCheda  H Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery. 1997;122998- 1003
Link to Article
Chen  HSokoll  LJUdelsman  R Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia and intraoperative parathyroid hormone assay. Surgery. 1999;1261016- 1021
Link to Article
Utiger  RD Treatment of primary hyperparathyroidism [editorial]. N Engl J Med. 1999;3411301- 1302
Link to Article
Delbridge  LWYounes  NAGuinea  AIReeve  TSClifton-Bligh  PRobinson  BG Surgery for primary hyperparathyroidism 1962-1996: indications and outcomes. Med J Aust. 1998;168153- 156
Rapado  ASan Roman  JM Trescientos seis casos operados de hiperparatiroidismo primario: una experiencia compartida. Reemo. 1995;439- 41
Wermers  RAKhosla  SAtkinson  EJHodgeson  SFO'Fallon  WMMelton  J The rise and fall of primary hyperparathyroidism: a population-based study in Rochester, Minnesota, 1965-1992. Ann Intern Med. 1997;126433- 434
Link to Article
Agarawal  GBarakate  MRobinson  BGBarraclough  BReeve  TSDelbridge  L Minimally invasive parathyroidectomy using the "focused" lateral approach, 1: results of the first 100 cases. Aust N Z J Surg. 2002;72100- 104
Link to Article
Ho Shon  IABernard  EJRoach  PJDelbridge  LW The value of oblique pinhole images in pre-operative localisation with 99mTC-MIBI for primary hyperparathyroidism. Eur J Nucl Med. 2001;28736- 742
Link to Article
Lumachi  FErmani  MBasso  SZucchetta  PBorsato  NFavia  G Localization of parathyroid tumors in the minimally invasive era: which technique should be chosen? population-based analysis of 253 patients undergoing parathyroidectomy and factors affecting parathyroid gland detection. Endocr Relat Cancer. 2001;863- 69
Link to Article
Endres  DBVillanueva  RSharp  CF  JrSinger  FR Measurement of parathyroid hormone. Endocrinol Metab Clin North Am. 1989;18611- 629
Irvin  GL  IIICarneiro  DM Management changes in primary hyperparathyroidism. JAMA. 2000;284934- 936
Link to Article
Carneiro  DMIrvin  GL  III Late parathyroid function after successful parathyroidectomy guided by intraoperative hormone assay (QPTH) compared with the standard bilateral neck exploration. Surgery. 2000;128925- 929discussion 935-936.
Link to Article
Gauger  PGAgarwal  GEngland  BG  et al.  Intraoperative parathyroid hormone monitoring fails to detect double parathyroid adenomas: a two-institution experience. Surgery. 2001;1301005- 1010
Link to Article
Agarwal  GBarakate  MSRobinson  B  et al.  Intraoperative quick parathyroid hormone versus same-day parathyroid hormone testing for minimally invasive parathyroidectomy: a cost-effectiveness study. Surgery. 2001;130963- 970
Link to Article
Norman  JMurphy  S Radioguided minimally invasive parathyroidectomy—the 20% rule. Surgery. 1999;61023- 1029
Reeve  TSBabidge  WParkyn  R  et al.  Minimally invasive parathyroidectomy for primary hyperparathyroidism: a systematic review. Arch Surg. 2000;135481- 487
Link to Article

Figures

Place holder to copy figure label and caption

Overall increase in the number of minimally invasive parathyroidectomies performed worldwide from 1980 to 2000.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Summary of Survey Findings for the Types of Procedures Used
Table Graphic Jump LocationTable 2. Summary of Survey Findings for the Techniques Used to Ensure Complete Removal of Hyperfunctioning Parathyroid Tissue*

References

Sywak  MSRobinson  BGClifton-Bligh  P  et al.  Presentations and procedure rates for hyperparathyroidism in Northern Sydney and NSW are increasing. Med J Aust. In press.
Graham  JJHarding  PEHoare  LLThomas  DWWise  PH Asymptomatic hyperparathyroidism: an assessment of operative intervention. Br J Surg. 1980;67115- 118
Link to Article
Clark  OHWilkes  WSiperstein  AEDuh  QY Diagnosis and management of asymptomatic hyperparathyroidism: safety, efficacy, and deficiencies in our knowledge. J Bone Miner Res. 1991;6Suppl 2S135- S142discussion 151-152.
Link to Article
Kaplan  RASnyder  WHStewart  APak  CY Metabolic effects of parathyroidectomy in asymptomatic primary hyperparathyroidism. J Clin Endocrinol Metab. 1976;42415- 426
Link to Article
Silverberg  SJShane  EJacobs  TPSiris  EBilezikian  JP A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. N Engl J Med. 1999;3411249- 1255
Link to Article
Smith  JCEvans  LMCockcroft  JRDavies  JS Impaired vascular reactivity in primary hyperparathyroidism may contribute to cardiovascular risk. Clin Endocrinol (Oxf). 2001;55279- 280
Link to Article
Kautzky-Willer  APacini  GNiederle  BSchernthaner  GPrager  R Insulin secretion, insulin sensitivity and hepatic insulin extraction in primary hyperparathyroidism before and after surgery. Clin Endocrinol (Oxf). 1992;37147- 155
Link to Article
Cheung  PSThompson  NWBrothers  TEVinik  AI Effect of hyperparathyroidism on the control of diabetes mellitus. Surgery. 1986;1001039- 1047
Prager  RSchernthaner  GNiederle  BRoka  R Evaluation of glucose tolerance, insulin secretion and insulin action in patients with primary hyperparathyroidism before and after surgery. Calcif Tissue Int. 1990;461- 4
Link to Article
Abdu  TAElhadd  TPfeifer  MClayton  RN Endothelial dysfunction in endocrine disease. Trends Endocrinol Metab. 2001;12257- 265
Link to Article
Kosch  MHausberg  MBarenbrock  MPosadzy-Malaczynska  AKisters  KRahn  KH Arterial distensibility and pulse wave velocity in patients with primary hyperparathyroidism before and after parathyroidectomy. Clin Nephrol. 2001;55303- 308
Talpos  GBBone  HGKleerekoper  M  et al.  Randomized trial of parathyroidectomy in mild asymptomatic primary hyperparathyroidism: patient description and effects on the SF-36 health survey. Surgery. 2000;1281013- 1021
Link to Article
Silverberg  SJ Natural history of primary hyperparathyroidism. Endocrinol Metab Clin North Am. 2000;29451- 464
Link to Article
Cormier  CSouberbielle  JCKindermans  C Hyperparathyroidism: the limits of surgery in cases of bone or cardiovascular involvement. Curr Opin Rheumatol. 2000;12349- 353
Link to Article
Clark  OH Surgical treatment of primary hyperparathyroidism. Adv Endocrinol Metab. 1995;61- 16
Rude  RK Hyperparathyroidism. Otolaryngol Clin North Am. 1996;29663- 679
Russell  CFEdis  AJ Surgery for primary hyperparathyroidism: experience with 500 consecutive cases and evaluation of the role of surgery in the asymptomatic patient. Br J Surg. 1982;69244- 247
Link to Article
Gagner  M Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism [letter]. Br J Surg. 1996;83875
Link to Article
Naitoh  TGagner  MGarcia-Ruiz  AHeniford  BT Endoscopic endocrine surgery in the neck: an initial report of endoscopic subtotal parathyroidectomy. Surg Endosc. 1998;12202- 205discussion 206.
Link to Article
Henry  JFDefechereux  TGramatica  Lde Boissezon  C Minimally invasive videoscopic parathyroidectomy by lateral approach. Langenbecks Arch Surg. 1999;384298- 301
Link to Article
Gauger  PGReeve  TSDelbridge  LW Endoscopically assisted minimally invasive parathyroidectomy. Br J Surg. 1999;861563- 1566
Link to Article
Miccoli  PMonchik  JM Minimally invasive parathyroid surgery. Surg Endosc. 2000;14987- 990
Link to Article
Miccoli  PBerti  PConti  MRaffaelli  MMaterazzi  G Minimally invasive video-assisted parathyroidectomy: lessons learned from 137 cases. J Am Coll Surg. 2000;191613- 618
Link to Article
Agarwal  GBarraclough  BReeve  TSDelbridge  LW Minimally invasive parathyroidectomy using the "focused" lateral approach, 2: surgical technique. ANZ J Surg. 2002;72147- 151
Link to Article
Irvin  GL Chasin' hormones. Surgery. 1999;126993- 997
Link to Article
Norman  JCheda  H Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery. 1997;122998- 1003
Link to Article
Chen  HSokoll  LJUdelsman  R Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia and intraoperative parathyroid hormone assay. Surgery. 1999;1261016- 1021
Link to Article
Utiger  RD Treatment of primary hyperparathyroidism [editorial]. N Engl J Med. 1999;3411301- 1302
Link to Article
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