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All truth passes through three phases. First, it is ridiculed. - - PDF document

Dec 23, 2023 106 likes •332 views

Management of Primary Hyperparathyroidism in 2013: Have We Come Full Circle? LTC Christopher Klem, MD Tripler Army Medical Center All truth passes through three phases. First, it is ridiculed. Second, it is violently opposed. Third, it is

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Management of Primary Hyperparathyroidism in 2013: Have We Come Full Circle?

LTC Christopher Klem, MD Tripler Army Medical Center

All truth passes through three phases. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.

Arthur Schopenhauer

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Disclaimer

  • “The views expressed in this presentation

are those of the author and do not reect the ofcial policy or position of the Department of the Army, Department of Defense, or the U.S. Government.”

Agenda

  • The “usual stuff”
  • Indications for surgery
  • Localization
  • Surgical controversies
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SLIDE 3

Diamond Head Crater

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Epidemiology

  • Common!
  • 1% of adults
  • Peak = 30-40 years old
  • F:M 4:1
  • Women > 60, incidence = 2%
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SLIDE 5

The Past...

Primary Hyperparathyroidism Surgery

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SLIDE 6

Primary Hyperparathyroidism

Symptomatic Asymptomatic Surgery ?

Consensus Guidelines

  • Age < 50
  • Creatinine clearance < 60 ml/min
  • Serum calcium > 1.0 mg/dl above upper limit
  • f normal
  • T-score < -2.5 (lumbar spine, hip, femoral neck,

distal radius) and/or previous fracture fragility

  • Request surgery
  • Difcult follow-up
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SLIDE 7

Is Anyone REALLY Asymptomatic?

  • Cardiovascular
  • BMD
  • Renal
  • Psychiatric
  • QOL

J Clin Endocrinol Metab, February 2009, 94(2):351–365

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SLIDE 8

Asymptomatic Primary Hyperparathyroidism Surgery Observation

Manoa Falls

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“The only localization study indicated in a patient with untreated primary hyperparathyroidism is the localization of an experienced parathyroid surgeon.”

Doppman, 1986

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Localization Find the Adenoma!

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The Ectopic Adenoma

Imaging

Parathyroid localization studies Noninvasive Invasive High-resolution US Selective venous sampling

99mTc-Sestamibi scan

Angiogram CT scan Digital subtraction MRI US-guided FNA SPECT/CT US-guided jugular venous sampling 4D-CT

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How Good Are They?

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Which is Best?

Makapu’u Lighthouse

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SLIDE 14

Minimally Invasive

  • Preop localization
  • Local anesthesia (?)
  • Unilateral exploration
  • Intraop PTH
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SLIDE 15

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christopher.klem@gmail.com

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Decade of Change Lanikai Pill-Box Trail

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Prospective Study in 3,000 Consecutive Parathyroid Operations Demonstrates 18 Objective Factors that Influence the Decision for Unilateral versus Bilateral Surgical Approach

James Norman, MD, FACS, FACE, Douglas Politz, MD, FACS

J Am Coll Surg 2010;211:244–249.

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Abandoning Unilateral Parathyroidectomy: Why We Reversed Our Position after 15,000 Parathyroid Operations

James Norman, MD, FACS, FACE, Jose Lopez, MD, FACS, Douglas Politz, MD, FACS, FACE

.

J Am Coll Surg 2012;214:260–269

10-Year Cure Rates

J Am Coll Surg 2012;214:260–269.

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Multi-gland Disease (?)

Table 1. Number of Parathyroid Glands Removed in Unilateral vs Bilateral Operations

Variable Unilateral exploration (n 3,000) Bilateral exploration (n 3,000) p Value

Single gland removed, % 96.9 75.3 0.0001 Two glands removed, % 3.1 16.7 0.0001 Three glands removed, % 5.1 0.001 3.5 glands removed, % 2.9 0.03

The number of parathyroid glands removed during 3,000 unilateral operations was dramatically lower than the number of glands removed during 3,000 bilateral

  • perations.

J Am Coll Surg 2012;214:260–269.

Surgical Techniques Forthcoming...

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Controversy! Olomana

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“The only localization study needed is an experienced parathyroid surgeon...”

?

In Summary...

  • Up-to-date “asymptomatic” guidelines
  • Surgery curative (still!)
  • Improved localization studies
  • Improved (?) operative techniques
  • Unilateral vs. 4-gland exploration
  • Controversy (still!)
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SLIDE 22

Big Island Lava Questions?