Management of Primary Hyperparathyroidism in a VAMC Health System: Evidence‐Based Management Protocol and Future Directions

Abstract

Objectives: (1) Establish a best practices guideline for the surgical treatment of primary hyperparathyroidism within the context of single hospital system. (2) Stratify the group of patients who underwent directed excision by the accuracy of preoperative localization studies, and whether intraoperative techniques impacted cure, and at what resource costs. Methods: In this retrospective chart review, patients were identified by searching all parathyroid-related procedures that took place at our institution from January 1, 2002, to December 31, 2013. Information related to the aims of the study, including demographics, operative details, and laboratory values were recorded, and imaging studies were reviewed by the senior investigator. Results: Of those patients with preoperative localization and directed excision, the preoperative studies most predictive of cure were a combination of Sestamibi parathyroid scan and surgeon-performed ultrasound. When these were in disagreement, surgical findings supported the ultrasound results. Intraoperative parathyroid hormone rapid assay was helpful in predicting cure, but added 68 minutes to the operating time on average. Most patients were surgically cured, and of the few patients with persistent high parathyroid hormone levels, vitamin D deficiency was the primary associated lab abnormality. Conclusions: Analysis of techniques that predict a surgical cure allowed the development of a best practices algorithm that includes the following: (1) Obtain 2 preoperative localization studies, including a surgeon-performed ultrasound; (2) Obtain preoperative vitamin D levels and supplement as indicated; and (3) Reserve intraoperative parathyroid hormone assay only for those patients who do NOT have 2 corroborating localization studies.