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

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

Disclaimer “The views expressed in this presentation • are those of the author and do not re � ect the of � cial 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

Diamond Head Crater

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

The Past... Primary Hyperparathyroidism Surgery

Primary Hyperparathyroidism Symptomatic Asymptomatic Surgery ? Consensus Guidelines • Age < 50 • Creatinine clearance < 60 ml/min • Serum calcium > 1.0 mg/dl above upper limit of normal • T-score < -2.5 (lumbar spine, hip, femoral neck, distal radius) and/or previous fracture fragility • Request surgery • Dif � cult follow-up

Is Anyone REALLY Asymptomatic? • Cardiovascular • BMD • Renal • Psychiatric • QOL J Clin Endocrinol Metab, February 2009, 94(2):351–365

Asymptomatic Primary Hyperparathyroidism Surgery Observation Manoa Falls

“The only localization study indicated in a patient with untreated primary hyperparathyroidism is the localization of an experienced parathyroid surgeon.” Doppman, 1986

Localization Find the Adenoma!

The Ectopic Adenoma Imaging Parathyroid localization studies Noninvasive Invasive High-resolution US Selective venous sampling 99m Tc-Sestamibi scan Angiogram CT scan Digital subtraction MRI US-guided FNA SPECT/CT US-guided jugular venous sampling 4D-CT

How Good Are They?

Which is Best? Makapu’u Lighthouse

Minimally Invasive • Preop localization • Local anesthesia (?) • Unilateral exploration • Intraop PTH

christopher.klem@gmail.com minimally invasive parathyroid surgery Web Images Maps Shopping Videos More Search tools About 210,000 results (0.18 seconds) Ads Ads related to minimally invasive parathyroid surgery MD Anderson Cancer Center - MDAnderson.org Best Parathyroid Surgeons www.mdanderson.org/ www.ask.com/Best+ Parathyroid + Surgeons Minimally Invasive Surgery From World Renowned Experts. Learn More Search for Best Parathyroid Surgeons . Find Answers on Ask.com. Mini Invasive Parathyroid - Surgery . 20-30 Min. Procedure. y . 20 20 20 20-3 -3 -3 -30 Mi M n. Mi Mi n. n. Pro ro ro ro r ce ce ce cedu du du dure re re. e www.thyroid- parathyroid .com/ Got Hyperparathyroidism? Go G Got Hy Go Go o Hy Hy Hy Hy ype pe pe pe pe p rp rp rp rp r ar p ar ar ar ara ar at at athy at t hy hyro hy hy roid ro ro ro id id id idis d is ism? s m? m? m? m? m? No Charge For Record Review. parathyroid .com/ parathyroid - surgery .htm p par par par par ar a ath athyro ath ath ath yro yro yro yroid id id id id d .co .co .co .co .com/ m/ m/ m/ m / par p par par par par ath ath ath ath athyro yro yro yro yroid yro id id d - sur sur sur sur sur u rger ger ger ger g ger y .ht .ht .ht .ht htm Dr Norman's surgery video explains D Dr Dr Dr D Nor Nor Nor N or o man man man man ma 's ' sur 's 's 's s sur sur sur su g ur ger ger ger ery vi er v deo vi vi deo deo ex deo deo expla ex pla pla p in pla pla i in ns ns n ns s s d different surgery options available if if if if i fer fer fer fer fer e ent r ent ent ent n sur su ger sur sur sur r ger ger ger gery o er op optio op op op tio ti tio t ns tio o ns ns ns n ava a ava ava v a ila ila ila ila able b ble ble ble e Parathyroid Center - Parathyroid MD.com www. parathyroid md.com/ Minimally Invasive Surgery by Expert Parathyroid Surgeon Leader in Spine Surgery www.heartandspine surgery .com/ Minimally Invasive Parathyroidectom - Hyperparathyroidism - Parathyroid Facts World leader in spine surgery and 50% cheaper than USA Minimally Invasive Parathyroidectomy - UCLA Endocrine Surgery endocrine surgery .ucla.edu/ surgery _mip.html Para Thyroid Surgery In experienced hands, the sensitivity of each of these techniques approaches 90 % (6, www.izito.com/Para+Thyroid+ Surgery 7). Therefore, most people with primary hyperparathyroidism can be ... Find Para Thyroid Surgery Anesthesia - Surgical Technique - Length of Operation In 7 Search Engines at Once. Minimally Invasive Radioguided Parathyroid Surgery (MIRP ... After Parathyroid Surgery www. parathyroid .com/mirp- surgery .htm surgery .webcrawler.com/ May 23, 2012 – Highest cure rate of all Parathyroid surgeries to treat parathyroid Search for After Parathyroid Surgery disease. Mini- parathyroid surgery for parathyroid disease. MIRP mini ... With 100's of Results at WebCrawler

Decade of Change Lanikai Pill-Box Trail

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.

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.

Multi-gland Disease (?) Number of Parathyroid Glands Removed in Unilateral vs Bilateral Operations Table 1. Unilateral exploration Bilateral exploration Variable (n � 3,000) (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, % 0 5.1 � 0.001 3.5 glands removed, % 0 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 operations. J Am Coll Surg 2012;214:260–269. Surgical Techniques Forthcoming...

Controversy! Olomana

“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!)

Big Island Lava Questions?