Annals of Surgical Oncology

, Volume 21, Issue 4, pp 1369–1373

Parathyroid Surgery in the Elderly: Should Minimally Invasive Surgery Be Abandoned?

  • Michal Mekel
  • Hayim Gilshtein
  • Katya Chapchay
  • Bishara Bishara
  • Michael M. Krausz
  • Herbert R. Freund
  • Yoram Kluger
  • Ahmed Eid
  • Haggi Mazeh
Endocrine Tumors

Abstract

Background

Single adenoma is the cause of 80 % of primary hyperparathyroidism (PHPT) resulting in wide acceptance of minimally invasive parathyroidectomy (MIP). The incidence of PHPT increases with age. Little information is available regarding the prevalence of multiglandular disease (MGD) in older patients.

Methods

The records of 537 patients that underwent parathyroid surgery between January 2005 and October 2012 at two endocrine surgery referral centers were retrospectively reviewed. Comparison was performed between patients younger than 65 and older than 65 years of age. Clinical variables included preoperative laboratories and imaging, extent of neck exploration, number of glands excised, and intraoperative parathyroid hormone levels during surgery.

Results

There were 374 (70 %) patients in the younger age group (YG) and 163 (30 %) patients in the older age group (OG). The mean age was 50 ± 0.5 and 71 ± 0.4 years, respectively. There was no difference between the groups in terms of gender or laboratory results. MGD was significantly more common in the OG (24 % vs. 12 %; p = 0.001) and similarly MIP was less commonly completed in the OG (49 % vs. 68 %; p < 0.001). Cure rates were comparable between the OG and YG (93 % vs. 95 %; p = 0.27). In the OG, patients with MGD had significantly smaller glands as compared to patients with single adenomas in this group (331 ± 67 vs. 920 ± 97 mg; p = 0.006, respectively).

Conclusions

MGD in PHPT was found to be more prevalent in older patients. Planning a bilateral neck exploration should be considered in older patients, especially when a relatively small gland is suggested by imaging or encountered during surgery.

References

  1. 1.
    Yeh MW, Ituarte PH, Zhou HC, et al. Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab. 2013;98:1122–9.PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Yu N, Donnan PT, Murphy MJ, Leese GP. Epidemiology of primary hyperparathyroidism in Tayside, Scotland, UK. Clin Endocrinol (Oxf). 2009;71:485–93.PubMedCrossRefGoogle Scholar
  3. 3.
    Wermers RA, Khosla S, Atkinson EJ, et al. Incidence of primary hyperparathyroidism in Rochester, Minnesota, 1993–2001: an update on the changing epidemiology of the disease. J Bone Miner Res. 2006;21:171–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Siperstein A, Berber E, Barbosa GF, et al. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008;248:420–8.PubMedGoogle Scholar
  5. 5.
    Kebebew E, Hwang J, Reiff E, Duh QY, Clark OH. Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model. Arch Surg. 2006;141:777–82; discussion 782.PubMedCrossRefGoogle Scholar
  6. 6.
    Grant CS, Thompson G, Farley D, van Heerden J. Primary hyperparathyroidism surgical management since the introduction of minimally invasive parathyroidectomy: Mayo Clinic experience. Arch Surg. May 2005;140(5):472–8; discussion 478–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Thompson NW, Eckhauser FE, Harness JK. The anatomy of primary hyperparathyroidism. Surgery. 1982;92:814–21.PubMedGoogle Scholar
  8. 8.
    Chen H, Parkerson S, Udelsman R. Parathyroidectomy in the elderly: do the benefits outweigh the risks? World J Surg. 1998;22:531–5; discussion 535–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Politz D, Norman J. Hyperparathyroidism in patients over 80: clinical characteristics and their ability to undergo outpatient parathyroidectomy. Thyroid. 2007;17:333–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Stechman MJ, Weisters M, Gleeson FV, Sadler GP, Mihai R. Parathyroidectomy is safe and improves symptoms in elderly patients with primary hyperparathyroidism (PHPT). Clin Endocrinol (Oxf). 2009;71:787–91.PubMedCrossRefGoogle Scholar
  11. 11.
    Uden P, Chan A, Duh QY, Siperstein A, Clark OH. Primary hyperparathyroidism in younger and older patients: symptoms and outcome of surgery. World J Surg.1992;16:791–7; discussion 798.PubMedCrossRefGoogle Scholar
  12. 12.
    Kebebew E, Duh QY, Clark OH. Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a plea for early surgical referral. Arch Surg.2003;138:867–71.PubMedCrossRefGoogle Scholar
  13. 13.
    Richards ML, Thompson GB, Farley DR, Grant CS. An optimal algorithm for intraoperative parathyroid hormone monitoring. Arch Surg. 2011;146(3):280–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Starker LF, Fonseca AL, Carling T, Udelsman R. Minimally invasive parathyroidectomy. Int J Endocrinol. 2011;2011:206502.Google Scholar
  15. 15.
    Egan KR, Adler JT, Olson JE, Chen H. Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a risk-benefit analysis. J Surg Res. 2007;140:194–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Morris LF, Zelada J, Wu B, Hahn TJ, Yeh MW. Parathyroid surgery in the elderly. Oncologist. 2010;15:1273–84.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Shin SH, Holmes H, Bao R, et al. Outpatient minimally invasive parathyroidectomy is safe for elderly patients. J Am Coll Surg. 2009;208:1071–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Bachar G, Gilat H, Mizrachi A, et al. Comparison of perioperative management and outcome of parathyroidectomy between older and younger patients. Head Neck. 2008;30:1415–21.PubMedCrossRefGoogle Scholar
  19. 19.
    Bilezikian JP, Khan AA, Potts JT, Jr. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab. 2009;94:335–9.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Andersson P, Rydberg E, Willenheimer R. Primary hyperparathyroidism and heart disease–a review. Eur Heart J. 2004;25:1776–87.PubMedCrossRefGoogle Scholar
  21. 21.
    Hagstrom E, Hellman P, Larsson TE, et al. Plasma parathyroid hormone and the risk of cardiovascular mortality in the community. Circulation. 2009;119:2765–71.PubMedCrossRefGoogle Scholar
  22. 22.
    Miller BS, Dimick J, Wainess R, Burney RE. Age- and sex-related incidence of surgically treated primary hyperparathyroidism. World J Surg. 2008;32:795–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Young VN, Osborne KM, Fleming MM, Flynn MB, Goldstein RE, Bumpous JM. Parathyroidectomy in the elderly population: does age really matter? Laryngoscope. 2010;120(2):247–52.PubMedGoogle Scholar
  24. 24.
    Irvin GL, 3rd, Carneiro DM, Solorzano CC. Progress in the operative management of sporadic primary hyperparathyroidism over 34 years. Ann Surg. 2004;239:704–8; discussion 708–11.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Norman J, Lopez J, Politz D. Abandoning unilateral parathyroidectomy: why we reversed our position after 15,000 parathyroid operations. J Am Coll Surg. 2012;214(3):260–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Schneider DF, Mazeh H, Sippel RS, et al. Is minimally invasive parathyroidectomy associated with greater recurrence compared to bilateral exploration? Analysis of more than 1,000 cases. Surgery. 2012;152:1008–15.Google Scholar
  27. 27.
    Bergenfelz A, Lindblom P, Tibblin S, Westerdahl J. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial. Ann Surg. 2002;236:543–51.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Nehs MA, Ruan DT, Gawande AA, Moore FD, Jr., Cho NL. Bilateral neck exploration decreases operative time compared to minimally invasive parathyroidectomy in patients with discordant imaging. World J Surg. 2013;37:1614–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Heller KS, Blumberg SN. Relation of final intraoperative parathyroid hormone level and outcome following parathyroidectomy. Arch Otolaryngol Head Neck Surg. 2009;135:1103–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Mazeh H, Chen H, Leverson G, Sippel RS. Creation of a “Wisconsin index” nomogram to predict the likelihood of additional hyperfunctioning parathyroid glands during parathyroidectomy. Ann Surg. 2013;257:138–41.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Michal Mekel
    • 1
    • 2
  • Hayim Gilshtein
    • 1
  • Katya Chapchay
    • 3
  • Bishara Bishara
    • 1
    • 2
  • Michael M. Krausz
    • 2
    • 4
  • Herbert R. Freund
    • 3
  • Yoram Kluger
    • 1
    • 2
  • Ahmed Eid
    • 3
  • Haggi Mazeh
    • 3
  1. 1.Department of General SurgeryRambam-Health Care CampusHaifaIsrael
  2. 2.Technion—Israel Institute of TechnologyHaifaIsrael
  3. 3.Hadassah-Hebrew University Medical CenterJerusalemIsrael
  4. 4.Hillel Yaffe Medical CenterHaderaIsrael

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