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Special Communication |

The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism ONLINE FIRST

Scott M. Wilhelm, MD1; Tracy S. Wang, MD, MPH2; Daniel T. Ruan, MD3; James A. Lee, MD4; Sylvia L. Asa, MD, PhD5; Quan-Yang Duh, MD6; Gerard M. Doherty, MD7; Miguel F. Herrera, MD, PhD8; Janice L. Pasieka, MD9; Nancy D. Perrier, MD10; Shonni J. Silverberg, MD11; Carmen C. Solórzano, MD12; Cord Sturgeon, MD13; Mitchell E. Tublin, MD14; Robert Udelsman, MD, MBA15; Sally E. Carty, MD16
[+] Author Affiliations
1Department of Surgery, University Hospitals/Case Medical Center, Cleveland, Ohio
2Department of Surgery, Medical College of Wisconsin, Milwaukee
3Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
4Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
5Department of Pathology, University of Toronto, Toronto, Ontario, Canada
6Department of Surgery, University of California San Francisco Medical Center, San Francisco
7Department of Surgery, Boston University, Boston, Massachusetts
8Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
9Department of Surgery, University of Calgary, Calgary, Alberta, Canada
10Department of Surgery, MD Anderson Cancer Center, Houston, Texas
11Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
12Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
13Department of Surgery, Northwestern University, Chicago, Illinois
14Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania
15Department of Surgery, Yale University, New Haven, Connecticut
16Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Surg. Published online August 10, 2016. doi:10.1001/jamasurg.2016.2310
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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 recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.

Figures in this Article

Figures

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Figure 1.
Anatomical Relationships of Eutopic and Ectopic Parathyroid Glands
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Figure 2.
Algorithm for the Evaluation and Management of Persistent or Recurrent Primary Hyperparathyroidism (pHPT)

IPM indicates intraoperative parathyroid hormone monitoring.

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