Copyright 2016 American Medical Association. All rights reserved.
The American Association of Endocrine Surgeons Guidelines
for Definitive Management of P rimary Hyperparathyroidism
Scott M. Wilhelm, MD; Tracy S. Wang, MD, MPH; Daniel T. Ruan, MD; James A. Lee, MD; Sylvia L. Asa, MD, PhD;
Quan-Yang Duh, MD; Gerard M. Doherty, MD; Miguel F. Herrera, MD, PhD; Janice L. Pasieka, MD;
Nancy D. Perrier, MD; Shonni J. Silverberg, MD; Carmen C. Solórzano, MD; Cord Sturgeon, MD;
Mitchell E. Tublin, MD; Robert Udelsman, MD, MBA; Sally E. Carty, MD
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.
JAMA Surg. 2016;151(10):959-968. doi:10.1001/jamasurg.2016.2310
Published online August 10, 2016.
Invited Commentary
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Author Affiliations: Author
affiliations are listed at the end of this
article.
Corresponding Author: Scott M.
Wilhelm, MD, Department of Surgery,
University Hospitals/Case Medical
Center, 11100 Euclid Ave,
Cleveland, OH 44118
(scott.wilhelm@uhhospitals.org).
Clinical Review & Education
JAMA Surgery | Special Communication
(Reprinted) 959
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T
hesurgicaltreatmentofprimaryhyperparathyroidism(pHPT)
has undergone extensivechange in the past2 decades. The
presentation,diagnosis, andmedicalmanagementhavebeen
previously addressed by an international workshop.
1-4
To meet the
need for a detailed focus on operative management, the American
Association of Endocrine Surgeons (AAES) developed evidence-
based guidelines to delineate the safe and effective practice of
parathyroidectomy to achieve definitive treatment.
Methods
A multidisciplinary panel of endocrinologists, pathologists, sur-
geons, and radiologists established PubMed search parameters for
theworldwidemedicalliteraturefromJanuary1,1985,to July 1, 2015,
usingtheNational Library of Medicine MedicalSubject Headings and
keywords (hyperparathyroidism, primary; parathyroid neoplasms;
and hyperparathyroidism) linked by boolean operators. The writ-
ing group adopted the American College of Physicians grading sys-
tem for evidence-based guidelines,
5
which uses a validated scale to
critically evaluate the strength and quality of the evidence. Recom-
mendations are designated strong when benefits clearly outweigh
risks and/or the recommendation should be applied to all or most
patients without reservation, weak for equivalent risks or uncer-
tainty, and insufficient when evidence is conflicting or of poor qual-
ity. Evidence quality is graded high for randomized clinical trials or
overwhelmingevidence, moderate forrandomizedclinical trialswith
significant limitations or large observationalstudies,and low forsmall
observational or case studies.
In guidelines construction, the evidence was rigorously exam-
ined, recommendations were graded, and text was amended to
achieve consensus. Feedback was sought from an independent
group of nonauthor clinicians, the AAES membership, and other
expert sources.
These guidelines present a process for the evaluation and sur-
gical treatment of pHPT based on evidence at the time of writing.
Theydo not represent the only approachtothemanagementofadult
pHPT and are not meant to replace an individual physician’s judg-
ment. Adherence to the guidelines is not mandatory, may require
adaptation in practice settings with barriers to implementation, and
does not constitute a legal standard of care. The writing group had
complete independence from the AAES in the production of the
evidence-based guidelines.
Recommendations
Thefull evidence statements supporting the recommendations ap-
pear in the eAppendix and eTable 1 in the Supplement.The
Supplement also includes additional details, technical descrip-
tions, discussions of controversy, and expert advice on the surgical
management of pHPT.
Diagnosis and Evaluation
Primary hyperparathyroidismis a commondisorder that arisesfrom
autonomous overproduction of parathyroid hormone (PTH) by
abnormalparathyroidglands. The disease is characterizedbytheper-
sistent elevation of total serum calcium levels with corresponding
elevated or inappropriately normal (ie, nonsuppressed) PTH lev-
els. The diagnosis of pHPT is biochemical. The clinical presentation
is heterogeneous, and the associated symptomsoverlapwith those
of aging and disease. Patients with symptomatic pHPT have overt
signs and symptoms; however, the definition of symptomatic dis-
ease is still evolving. Patients with asymptomatic pHPT have no
disease-specific symptoms.
Normocalcemic pHPT is a recently recognized, incompletely
characterized variant that presents with high PTH levels and nor-
mal total and ionized serum calcium levels. Some, but not all,
patients may progress over time to hypercalcemic pHPT.
6
Establishing the Diagnosis: Laboratory Testing
In pHPT, patients may occasionally have normal total and/or ion-
ized calcium levels but are hypercalcemic most of the time. Thus,
repeated measurements of calcium are required.
3
Total serum cal-
ciumlevelsare reported inmilligramsper deciliter (to convertto mil-
limoles per liter, multiply by 0.25) and should be corrected for se-
rum albumin (eAppendix in the Supplement). Although pHPT and
malignant tumors are the most common causes of hypercalcemia
in adults, other causes should be considered. Patients with normo-
calcemic pHPT have normal serum and ionized calcium levels; thus,
measurement of ionized calcium is necessary to establish the
diagnosis of normocalcemic, but not hypercalcemic, pHPT.
In pHPT, PTH levels are high or inappropriately normal (ie, not
suppressed despite hypercalcemia). Diagnosis of normocalcemic
pHPT requires the exclusion of other causes of secondary eleva-
tion of PTH (eTable 2 in the Supplement). Nonparathyroid causes
of hypercalcemia are associated with suppressed PTH. Renal
function and vitamin D status should be assessed preoperatively.
• Recommendation 1-1: The biochemical evaluation of suspected
pHPT should include serum total calcium, PTH, creatinine, and 25-
hydroxyvitamin D levels (strong recommendation; moderate-
quality evidence).
A24-hoururinary calcium level is importantto distinguishpHPT
from familial hypocalciuric hypercalcemia, which is an autosomal
dominant disorder of the renal calcium-sensing receptor that can
mimic pHPT. Familial hypocalciuric hypercalcemia should be con-
sidered in patients with long-standing hypercalcemia, urinary cal-
cium levels less than 100 mg/24 hours, and a calcium to creatinine
clearance ratio less than 0.01 (eAppendix in the Supplement).
• Recommendation 1-2: A 24-hour urine measurement of calcium
and creatinine should be considered in patients undergoing evalu-
ation for possible pHPT (strong recommendation; moderate-
quality evidence).
Investigation of Symptoms, Features,
and Complications
A careful history should be performed for objective renal and skel-
etal manifestations, including nephrolithiasis, fragility fractures, and
osteoporosis. Subjective symptoms, including neuropsychiatric,
cognitive, musculoskeletal, and gastrointestinal complaints (eAp-
pendix in the Supplement), should be documented because para-
thyroidectomy may lead to improvement or resolution of these
symptoms.Certainmedications can cause biochemical changesthat
mimicpHPT(eAppendixinthe Supplement). In 3%to5%of patients,
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pHPT occurs as a component of an inherited syndrome (eAppen-
dix in the Supplement).
7-9
• Recommendation 1-3: In patients with suspected pHPT, a per-
sonal and family history should be taken (strong recommenda-
tion; moderate-quality evidence).
Patients with otherwise asymptomatic pHPT may have neph-
rocalcinosis or silent nephrolithiasis; both are indications for
parathyroidectomy.
4
• Recommendation 1-4: In patients with asymptomatic pHPT, ab-
dominal imaging should be performed fordetection of nephrocal-
cinosis or nephrolithiasis (weak recommendation; low-quality
evidence).
Primary hyperparathyroidism causes site-specific reduction in
bone mineral density (BMD) and may predispose patients to fragil-
ity fractures.
4
Dual-energy x-ray absorptiometry (DXA) examina-
tion is appropriate for all patients with pHPT and should be
performed to screen for clinically relevantskeletalmanifestations.
4
• Recommendation 1-5: Bone mineral density should be mea-
sured at the lumbar spine, hip, and distal radius, preferably using
DXA (strong recommendation; high-quality evidence).
Inpatientswith pHPT attributable to a hereditarysyndrome, the
timing and extent of parathyroidectomy are affected by the pres-
ence and specific type of mutation present (eAppendix in the
Supplement).
9
• Recommendation 1-6: Genetic counseling should be performed
for patients youngerthan 40 years with pHPT and multigland dis-
ease (MGD) and considered for those with a family history or syn-
dromic manifestations (strong recommendation; low-quality
evidence).
Epidemiology and Pathogenesis
Therecognition ofpHPT increased in the 1970swith automated rou-
tine calcium testing, and prevalencecontinuesto increase today.In-
cidence appears to increase with age and is 2 to 3 times higher in
women(eAppendix in the Supplement). Primary hyperparathyroid-
ism remains underdiagnosed and undertreated.
Safe and effective parathyroidectomy requires mastery of the
anatomicalandpathophysiologicfeatures of pHPT (eAppendix in the
Supplement).Autonomous PTH secretion maybe attributableto hy-
perfunction of 1 or more glands and is caused by 3 different patho-
logic conditions: adenoma, hyperplasia, or carcinoma. The overall
frequency of MGD is 6% to 33% (eAppendix in the Supplement).
• Recommendation 2-1: Multigland disease affects approximately
15% of patients with pHPT and should be routinely considered in
preoperative planning (strong recommendation; moderate-
quality evidence).
Lithium-associated pHPT occurs in up to 15% of long-term us-
ers, with increased rates of MGD.
10
Molecular alterations also affect
the pathophysiologic mechanisms and rates of MGD (eAppendix in
the Supplement). Germline inactivating mutation of the MEN1 gene
(OMIM 613733)causesmultiple endocrine neoplasia type 1, and so-
matic events occur in sporadic tumors; germline activating muta-
tions of the RET (OMIM 188550) proto-oncogene result in multiple
endocrine neoplasia type 2; the somatic PRAD1 (OMIM 168461) re-
arrangement upregulates cyclin D1 in sporadic adenomas; and in-
activating mutations of CDC73 (formerly HRPT2) (OMIM 607393)
occurasgermlinealterationsinhyperparathyroidism–jawtumor syn-
drome and familial isolated hyperparathyroidism and as somatic
events in sporadic parathyroid cancer (PCA) (eAppendix in the
Supplement).
• Recommendation 2-2: Exposure-related and genotype-
phenotype correlations are predictive of parathyroid anatomical
and pathophysiologic features and should be considered be-
cause they may affect the planning and conduct of surgery (strong
recommendation; moderate-quality evidence).
Indications and Outcomes of Intervention
Parathyroidectomy is the only definitive treatment of pHPT. Symp-
tomatic patients are expected to derive clear benefits from curative
parathyroidectomy, and patients considered to be asymptomatic
frequently report improvement in quality-of-life indexes.
11-14
Obser-
vation and pharmacologic therapy are less effective and less cost-
effective than surgery, even when the patient is considered
asymptomatic.
15
Long-term hypercalcemia should be avoided
because of potential deleterious effects (eAppendix in the
Supplement).
16-18
Referral to an experienced parathyroid surgeon is
advised to determine whether the likelihood and benefits of cure
outweigh the anticipated risks of the procedure.
• Recommendation 3-1: Parathyroidectomyis indicated, and is the
preferred treatment, for all patients with symptomatic pHPT
(strong recommendation; high-quality evidence).
• Recommendation 3-2: Parathyroidectomyis indicated when the
serum calcium levelis greater than 1 mg/dL abovenormal, regard-
less of whether objective symptomsare present or absent (strong
recommendation; low-quality evidence).
After successful parathyroidectomy, the development of
new kidney stones decreases markedly.
19
Although renal insuffi-
ciency and nephrocalcinosis do not resolve, surgery may prevent a
further decline in the glomerular filtration rate (eAppendix in the
Supplement).
• Recommendation 3-3: Parathyroidectomy is indicated for objec-
tive evidence of renal involvement, including silent nephrolithia-
sisonrenalimaging,nephrocalcinosis, hypercalciuria (24-hoururine
calcium level >400 mg/dL) with increased stone risk, or impaired
renal function (glomerular filtration rate <60 mL/min) (weak
recommendation; low-quality evidence).
Primary hyperparathyroidism causes a decrease in BMD, most
pronounced at cortical bone sites, such as the distal third of the ra-
dius.ParathyroidectomyimprovesBMD andappears to reduce frac-
ture rate, even for normal or osteopenic bone (eAppendix in the
Supplement).
16
• Recommendation 3-4: Parathyroidectomy is indicated in pa-
tients with pHPT and osteoporosis, fragility fracture, or evidence
of vertebral compression fracture on spine imaging (strong
recommendation; high-quality evidence).
Patients 50 years or younger at diagnosis require prolonged
monitoring and compared with older patients have a higher inci-
dence of progression (eAppendix in the Supplement).
20
• Recommendation 3-5: Parathyroidectomyis indicated when pHPT
is diagnosed at 50 years or younger regardless of whether objec-
tive or subjective features are present or absent (strong recom-
mendation; moderate-quality evidence).
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Thepreoperative diagnosis of PCAmaybe difficult.IfPCA issus-
pected, patients should be treated surgically because this is the only
potentially curative treatment (eAppendix in the Supplement).
• Recommendation 3-6: Parathyroidectomyis indicated when the
clinical or biochemical evidence is consistent with PCA (strong
recommendation; high-quality evidence).
Patients who choose not to undergo surgery should undergo
annual biochemical evaluation and periodic DXA.If the patientdoes
not have the means or desire to adhere to a planned observation
schedule, parathyroidectomy should be offered (eAppendix in the
Supplement).
14
•
Recommendation 3-7: Parathyroidectomyis the preferred treat-
ment for patients who are unable or unwilling to comply with
observation protocols (strong recommendation; low-quality
evidence).
Patients with pHPT frequently have neurocognitive and neu-
ropsychiatricsymptoms. With varying response patterns,3random-
izedclinical trials demonstratedneurocognitive benefitsof surgery
vs observation.
13,14,21
• Recommendation 3-8: Parathyroidectomy is recommended for
patients with neurocognitive and/or neuropsychiatric symptoms
that are attributable to pHPT (strong recommendation; low-
quality evidence).
Patientswith pHPT mayhavehigher rates of myocardial infarc-
tion, hypertension, stroke, congestive heart failure, diabetes, and
mortality (eAppendix in the Supplement). Observational studies in
mild pHPT have yielded conflicting data about the improvement of
cardiac parameters after parathyroidectomy. It is prudent to weigh
the possibility of mitigating cardiovascular morbidity and mortality
on a case-by-case basis.
• Recommendation 3-9:Parathyroidectomymaybe offered to sur-
gical candidates with cardiovascular disease who might benefit
from mitigation of potential cardiovascular sequelae other than
hypertension (weak recommendation; low-quality evidence).
Observational studies
16
suggest that several nontraditional
and/or newly studied symptoms improve after successful parathy-
roidectomy, including muscle strength, functional capacity, gastro-
esophageal reflux, sleep patterns, and fibromyalgia (eAppendix in
the Supplement).
• Recommendation 3-10a: The nontraditional symptoms of muscle
weakness,functional capacity,and abnormal sleep patternsshould
be considered in the decision for parathyroidectomy (weak
recommendation; moderate-quality evidence).
• Recommendation 3-10b: The nontraditional features of gastro-
esophageal reflux and fibromyalgia symptoms may be considered
in the decision for parathyroidectomy (insufficient evidence).
Thesuccess rate for surgeons who performfewerthan 10 para-
thyroidectomies per year is lower than for experienced surgeons
(eAppendix in the Supplement). Volume of operations inversely
correlates with complications, cost, and length of stay.
22
• Recommendation 3-11: Parathyroidectomy should be conducted
by surgeons with adequate training and experience in pHPT man-
agement (strong recommendation; moderate-quality evidence).
Although many pharmacologic agents have been used in an at-
temptto reduce the serumcalcium levelor stabilizeBMD, none have
improved both (eAppendix in the Supplement). In formal cost-
effectiveness analyses, pharmacologic treatment is not optimal at
any life expectancy.
15,23
• Recommendation 3-12: Operative management is more effec-
tive and cost-effective than long-term observation or pharmaco-
logic therapy (strong recommendation; moderate-quality
evidence).
Parathyroidectomy for pHPT is not recommended when the
risksofsurgery or anesthesiaare outweighed by the anticipated ben-
efits of cure, as with severe or overriding medical illness (eAppen-
dix in the Supplement). In patients who meet none of these indica-
tions for surgical intervention, refuse surgery, or are considered
prohibitivelyhighrisk, medical interventionaimed at mitigatingspe-
cific sequelae should be used.
2
For many patients, mild disease will
progress over time.
24
Parathyroid Localization Modalities:
What Imaging to Perform and When
Guiding Principles
1. Imaging has no utility in confirming or excluding the diagnosis
of pHPT.
2. Imaging results should not be used to select patients for surgi-
cal referral. Patients with negative imaging results remain
candidates for parathyroidectomy.
3. There is marked regional variability in imaging accuracy. When
imagingwith initially negativeresults is performed again at high-
volumecenters,the sensitivity of localizationimprovestoas high
as 92%.
25
4. Imaging is performed after deciding to proceed with parathy-
roidectomy and is performed for operative planning.
5. Parathyroid imaging is significantly less accurate for MGD.
26
6. Recommendation 4-1: Patients who are candidates for parathy-
roidectomy should be referred to an expert clinician to decide
which imaging studies to perform based on their knowledge of
regional imaging capabilities (strong recommendation; low-
quality evidence).
7. Recommendation 4-2: Patients who are candidates for sur-
gery and have negative or discordant imaging results should still
be referred to a parathyroid surgeon for evaluation (strong
recommendation; low-quality evidence).
Cervical ultrasonography performed by an experienced parathy-
roidsonographeris theleastcostly imaging modalityand, when com-
binedwith sestamibi or 4-dimensional computed tomography, is the
most cost-effective strategy (eAppendix in the Supplement).
26-28
Preoperative ultrasound-directed fine-needle aspiration biopsy of
parathyroid lesions is highly specific but is rarely necessary and can
have undesirable consequences (eAppendix in the Supplement).
• Recommendation 4-3: Cervical ultrasonography is recom-
mended to localize parathyroid disease and assess for concomi-
tant thyroid disease (strong recommendation; low-quality
evidence).
• Recommendation 4-4: Preoperative parathyroid fine-needle as-
piration biopsy is not recommended except in unusual, difficult
cases of pHPT and should not be performed if PCA is suspected
(insufficient evidence).
Technetium Tc 99m sestamibi is the dominant radioisotope in
parathyroid scintigraphy. Each sestamibi protocol (dual-phase,
iodine 131 subtraction, single-photon emission computed tomog-
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raphy) has individual strengths and weaknesses (eAppendix in the
Supplement). Sensitivity in MGD is poor. Combined ultrasonogra-
phy and sestamibi imaging increases localization accuracy and im-
proves sensitivity (eAppendix in the Supplement). Although tradi-
tional computed tomography has little utility, the 4-dimensional
computed tomography protocol has emerged as a useful modality,
although sensitivity in MGD is limited.
• Recommendation 4-5: An experienced clinician should help de-
termine which type of imaging to use based on knowledge of their
region’simaging capabilities (strongrecommendation; moderate-
quality evidence).
• Recommendation 4-6: Magnetic resonance imaging and ve-
nous sampling can be considered in cases of subsequent opera-
tion, difficult localization, or ionizing radiation contraindication
(weak recommendation; low-quality evidence).
Preoperative Management
A daily intake of 1000 to 1200 mg of calcium is recommended for
adults and appears appropriate for patients with pHPT as well.
Dietary restriction of calcium is not advised in pHPT. Preoperative
vitamin D repletion is advised and should be performed carefully in
patients with hypercalciuria (eAppendix in the Supplement).
• Recommendation 5-1: Most patients with pHPT should followIn-
stitute of Medicine guidelines for calcium intake (strong recom-
mendation; moderate-quality evidence).
• Recommendation 5-2: Before parathyroidectomy, patients with
pHPTwhoarevitaminDdeficient can safely begin vitamin D supple-
mentation (weak recommendation; low-quality evidence).
Subjective assessment of voice quality is an essential compo-
nent of preoperative examination. Additional objective evaluation
is recommended forsubjective changes, surgeon-identified abnor-
malities, or any history of prior operations in which the vagus nerve
or recurrent laryngeal nerve (RLN) was at risk (eAppendix in the
Supplement).
• Recommendation 5-3: Preoperative voice evaluation should in-
clude specific inquiry about subjective voice changes, with addi-
tional evaluation for significant voice changes or a history of prior
at-risk surgery (strong recommendation; low-quality evidence).
Hypercalcemic crisis is defined by a rapid-onset, albumin-
corrected serum calcium level greater than 14 mg/dL and signs or
symptoms of multiorgan dysfunction.
29
Intravenous fluid resusci-
tation and pharmacologic management are used to stabilize
patientsbeforeexpeditious parathyroidectomy. The presence of PCA
should be considered (eAppendix in the Supplement).
• Recommendation 5-4: Patientswith pHPT who presentwith hy-
percalcemiccrisis should bemedically managed, followed by para-
thyroidectomy (strong recommendation; low-quality evidence).
Intraoperative PTH Monitoring
Intraoperative PTH monitoring (IPM) provides real-time assess-
ment of parathyroid function and has a major effect on focused op-
erations when the surgeon removes an image-identified abnormal
gland without additional dissection. The success of focused opera-
tions guided by IPM has been excellent, with cure rates as high as
97% to 99% (eTable 3 in the Supplement).
30
Focused operations
guided solely by imaging studies without IPM can miss MGD, with
failure rates that may be higher than accepted standards (eAppen-
dixintheSupplement). For initial image-guided surgery, positive
imaging directs where to start exploration, and the results of intra-
operative PTH monitoring help to terminate it.
• Recommendation 6-1: When image-guidedfocused parathyroid-
ectomy is planned, IPM is suggested to avoidhigher operativefail-
ure rates (strong recommendation; moderate-quality evidence).
The accuracy of IPM depends on the protocol used. Surgeons
shouldusea protocol that is practical, accurate,and reproducible and
beawareof potential sources of error (eAppendix in the Supplement).
Inaddition,IPMisusefulindifferentialjugularvenoussamplingand ex
vivo parathyroid aspiration (eAppendix in the Supplement).
• Recommendation 6-2: Surgeons who use IPM should use a sam-
pling protocol that is reliable in the local environment and should
be familiar with the interpretation of PTH decay dynamics (strong
recommendation; low-quality evidence).
Minimally Invasive Parathyroidectomy
Approximately 85% of patients with pHPT have a solitary ad-
enoma, the resection of which results in durable cure. Thus, sur-
geons have adapted a variety of methods to streamline parathy-
roidectomyand reduce the risk ofcomplications,collectively termed
minimally invasive parathyroidectomy(MIP). All MIP techniques are
designed to limit dissection, hasten recovery, reduce postopera-
tive discomfort, and reduce incision length. These techniques typi-
cally require preoperative imaging and other adjuncts.
Regardless of MIP technique, specific strategies are advised to
improve the likelihood of success (eAppendix in the Supplement),
including selection by imaging results. Minimally invasive parathy-
roidectomy can achieve cure in 97% to 99% of selected patients
whenadjunctive IPM is used to confirmadequacy of resection (eAp-
pendixin the Supplement).
31
DuringMIP,ifIPM suggests residualhy-
persecreting tissue, conversion to bilateral exploration (BE) is
warranted and has equivalent cure rates to planned BE.
• Recommendation 7-1: Defined as a focused dissection,MIPis ide-
ally used in patients who appear clinically and by imaging to have
a single parathyroid adenoma. It is not routinely recommended in
patients with known or suspected high risk of MGD (strong
recommendation; high-quality evidence).
• Recommendation 7-2: Ex vivo PTH aspiration or frozen section
analysis may be used to confirm the resection of parathyroid
tissue (weak recommendation; low-quality evidence).
• Recommendation 7-3: During MIP, the discovery of MGD, the
inability to identify an abnormal gland, or the failure to achieve an
appropriateIPM decrease should prompt conversionto BE (strong
recommendation; high-quality evidence).
Bilateral Exploration
In BE, all parathyroid glands should be identified and compared to
deduce the presence of a single adenoma or MGD. Bilateral explo-
ration has long-term success rates greater than 95% and low com-
plication rates.
22,32
Familiarity with parathyroid anatomy, the loca-
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