Management protocol for primary hyperparathyroidism in a single institution: utility of surgeon performed ultrasound.

Abstract

We aimed to: (I) discover preoperative diagnostic studies, intraoperative techniques, and patient factors most predictive of cure within a single hospital system; (II) establish practice guidelines for surgical treatment of primary hyperparathyroidism to maximize outcomes based on this hospital system's performance. A retrospective chart review was undertaken of all parathyroid-related procedures from 01/01/02 to 7/31/15 at the Veteran's Administration Hospital. Seventy-one patients were eligible and charts available for analysis. Preoperative studies most predictive of cure were a combination of sestamibi parathyroid scan and surgeon performed ultrasound (S-US). When studies did not agree, S-US was most often correct. Intraoperative parathyroid hormone (PTH) rapid assay was helpful in predicting cure, but added an average of 33 minutes to operating room time. Patients who had two corroborating preoperative localizing studies, one of which was S-US, that agreed with intraoperative findings, and who did not undergo intraoperative PTH confirmation enjoyed equal cure rates and shorter operating room times. Successful achievement of normal calcium was high at 95.8%. Vitamin D deficiency was prevalent in this patient population, prompting more aggressive preoperative investigation and replacement. A management protocol was developed based on the findings of this study: (I) obtain two preoperative localization studies, one of which is surgeon-performed ultrasound; (II) obtain preoperative vitamin D levels and supplement as indicated; and (III) in select patients who have two strongly corroborating preoperative localization studies, one of which is surgeon performed ultrasound, and intraoperative findings are consistent with the localizing studies, intraoperative PTH (IOPTH) may not be necessary.