AAES evidence based guidelines for parathyroidectomy
Recent evidence based guidelines for the surgical management of hyperparathyroidism (HPT) have been developed by an expert panel of the AAES (American Association of Endocrine Surgeons) comprising specialists with expertise in the fields of Endocrine Surgery, Endocrinology, Radiology, and Pathology. The guidelines cover the spectrum of management including who should have parathyroid surgery, what investigations should be carried out, who should do the operation and what is the correct operative approach, as well as how patients should be followed up. Each recommendation is based upon careful review of all the available evidence. Whilst generally relevant to practice worldwide, there are a number of areas where accepted practice in Australia differs from that in the USA, due to differences in hospital practice and service delivery. A brief personal comment by Professor Delbridge explaining the recommendations, as well as noting any differences from accepted Australian practice, is included. The most signifcant recommendation of the guidelines is that:
"Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacological therapy".
What the authors are really saying is that parathyroidectomy should be performed for everyone with a diagnosis of primary hyperparathyroidism unless there a major contraindications to surgery, such as being too unfit for an anaesthetic. This is a major policy statement which represents a change from previous guidelines issued by other groups such as the NIH. It represents an understanding and analysis of newer evidence that pHPT leads to progressive end-organ damage in most patients, even those previously considered “asymptomatic”. This includes bone mineral density loss with osteoporosis, increased risk of hypertension, cardiovascular disease and heart attack, cerebrovascular disease, neurocognitive impairment as well as neuropsychiatric disturbances, muscle weakness and fatigue, kidney stones and renal impairment, fibromyalgia and musculoskeletal pain. Untreated pHPT is also associated with a significantly increased risk of early death.
The guidelines are in seven groups as follows:
1: EVALUATION: these recommendations cover the diagnosis and assessment of primary hyperparathyroidism
2. PATHOGENESIS: some recommendations in relation to multiglandular disease
3. INDICATIONS: these recommendations cover the question of who should have surgery as well as the anticipated benefits
4. LOCALISATION: recommendations about who should have parathyroid localisation and which are the best techniques
5: IOPTH MONITORING: a recommendation about the use of PTH monitoring during surgery
6: SURGICAL APPROACH: recommendations about minimally invasive vs open four gland exploration and which is appropriate
7. THYROID NODULES: recommendations about what to do with concurrent thyroid pathology
8. CURE RATE AND POSTOP CARE: these recommendations define cure and expectations of surgery