What Should We Tell Our Patients? Lifetime Guarantee or is it 5- to 10-year Warranty on a Parathyroidectomy for Primary Hyperparathyroidism?

Abstract

In the endocrine surgical world, a new debate has emerged—that being which operation is the best for sporadic primary hyperparathyroidism (HPT). Advances in technology, preoperative imaging, and intra-operative adjuncts have expanded the operative choices for our patients [1, 2]. No longer is it a mandatory 4-gland bilateral parathyroid exploration as it was in the days of Oliver Cope [3]. Today, with appropriate patient selection, surgeons are successfully utilizing a more focused approach such as imaged-directed or unilateral explorations in order to avoid a bilateral exploration and the additional risks [4–6]. However, recent data have emerged that 10-year cure rates following a focused approach may be lower than bilateral exploration [7, 8]. It has been long recognized that if one looks at all the glands at the initial operation, more histological abnormal glands are found [9]. Siperstein et al. found unrecognized multi-gland disease 16 % of the time when they proceeded to a 4-gland exploration following a ‘successful’ focused parathyroidectomy [10]. That, along with the fact that the now-recognized incidence of elevated PTH with normal calcium levels following parathyroid surgery (a potential harbinger for recurrence) appears to be higher following a focused approach compared to a bilateral exploration [11–13], has at least caused me to pause and reflect on which operation for sporadic HPT is the best. I attempted to bring about some reflection among the audience on this very topic at the 2014 Asian Association of Endocrine Surgeons meeting in Sri Lanka. I presented data demonstrating a long-term recurrence rate of 4–6 % with a focused approach compared to 1–2 % with a bilateral operation [7, 8]. Yet given over 80 % of patients with sporadic HPT have solitary adenomas, clearly the majority do achieve a life-long cure from a focused approach. I concluded my talk by stating that parathyroid surgeons need to reflect on the how far the pendulum has swung away from the gold-standard operation. A focused approach may not provide as robust long-term cure as the bilateral operation does, but it clearly has many advantages and should not be totally abandoned as some have advocated [8]. Since access to advanced preoperative imaging and adjuncts like intra-operative PTH (iPTH) are not always possible or have proven not to be cost-effective in some surgical units, many surgeons are providing an operative strategy that best suits their patients within their local healthcare environment and this is not wrong. We have to recognize that what works for one unit may not be the best strategy for another. Surgeons need to define their ‘go to operation’ and how successful it has been both in shortand long-term followup. When I sat down, the senior author of the Norlen paper (LD) leaned over and asked me ‘why do we endocrine surgeons feel the need to give a lifetime guarantee to our operations? The orthopedic surgeons give a 5–10 year warranty on the joints they replace and that is still considered a success.’ I have been reflecting on that provocative statement ever since. I believe our need to provide a lifetime guarantee of our work comes from our general surgical background. It is true that we guarantee no further attacks of biliary colic or appendicitis once we perform a cholecystectomy or appendectomy. Yet in our oncology work, we rarely provide a lifetime warrantee for disease-free survival at the time of informed consent. So instead of debating which & Janice L. Pasieka Janice.pasieka@albertahealthservices.ca