The purpose of this review is to assess the most recent evidence in the management of primary hyperparathyroidism (PHPT) and provide updated recommendations for its evaluation, diagnosis and treatment. A Medline search of "Hyperparathyroidism. Primary" was conducted and the literature with the highest levels of evidence were reviewed and used to formulate recommendations. PHPT is a common endocrine disorder usually discovered by routine biochemical screening. PHPT is defined as hypercalcemia with increased or inappropriately normal plasma parathyroid hormone (PTH). It is most commonly seen after the age of 50 years, with women predominating by three to fourfold. In countries with routine multichannel screening, PHPT is identified earlier and may be asymptomatic. Where biochemical testing is not routine, PHPT is more likely to present with skeletal complications, or nephrolithiasis. Parathyroidectomy (PTx) is indicated for those with symptomatic disease. For asymptomatic patients, recent guidelines have recommended criteria for surgery, however PTx can also be considered in those who do not meet criteria, and prefer surgery. Non-surgical therapies are available when surgery is not appropriate. This review presents the current state of the art in the diagnosis and management of PHPT and updates the Canadian Position paper on PHPT. An overview of the impact of PHPT on the skeleton and other target organs is presented with international consensus. Differences in the international presentation of this condition are also summarized.

When performed by expert parathyroid surgeons, parathyroid surgery is safe, cost-effective, and associated with very low perioperative morbidity. Minimally invasive approaches to parathyroid surgery appear to be as effective as the classic bilateral cervical exploration approach.

Background/Aim: A gastric conduit is usually used to reconstruct the foregut after esophagectomy for cancer. The gastric emptying may be impaired after this operation, so some esophageal surgeons routinely add a pyloric drainage procedure (pyloroplasty or pyloromyotomy). We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of pyloric drainage on patient outcomes. Methods: Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of pyloric drainage procedures during gastric conduit reconstruction of the esophagus. The selection process was inclusive; no trials were excluded. Trial validity assessment was done, and a trial quality score was assigned. Early outcomes assessed by meta-analysis included operative mortality, esophagogastric anastomotic leaks, pulmonary morbidity, pyloric drainage complications, fatal pulmonary aspiration, and gastric outlet obstruction. A random-effects model was used, and the relative risk was the principal measure of effect. Systematic semiquantitative review was used for late outcomes such as gastric emptying, bile reflux, nutritional status, and obstructive foregut symptoms. Results: Nine RCTs, that included a total of 553 patients, were selected, with quality scores ranging from 1 to 4 (5-point Jadad scale). Selection and validity agreement was strong. The relative risk (95% CI; p value), expressed as pyloric drainage versus no drainage (treatment vs. control), was 0.92 (0.34, 2.44; p = 0.86) for operative mortality, 0.90 (0.47, 1.76; p = 0.77) for esophagogastric anastomotic leaks, 0.69 (0.42, 1.14; p = 0.15) for pulmonary morbidity, 2.55 (0.34, 18.98; p = 0.36) for pyloric drainage complications, 0.25 (0.04, 1.60; p = 0.14) for fatal pulmonary aspiration, and 0.18 (0.03, 0.97; p = 0.046) for gastric outlet obstruction. Systematic semiquantitative review showed a nonsignificant trend favoring pyloric drainage for the late outcomes of gastric emptying, nutritional status, and obstructive foregut symptoms. For the late outcome of bile reflux, there was a nonsignificant trend favoring the no-drainage group. The scintographic gastric emptying time, expressed as a ratio (pyloric drainage/no drainage), was 0.53. Conclusions: Data synthesized from existing RCTs show that pyloric drainage procedures reduce the occurrence of early postoperative gastric outlet obstruction after esophagectomy with gastric reconstruction, but they have little effect on other early and late patient outcomes.

Gastric transposition with esophagogastric anastomosis is a common method of reconstruction after esophagectomy for cancer. The anastomosis can be fashioned using a handsewn or stapled technique. The choice of anastomotic technique is often debated but there is little evidence to support the use of one method over the other. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of esophagogastric anastomotic method (handsewn or circular stapled) on patient outcomes. Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of handsewn or stapled esophagogastric anastomosis after esophagectomy for cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Major outcomes for quantitative data synthesis included operative mortality, anastomotic leaks, anastomotic strictures, cardiac morbidity, and pulmonary morbidity. A random-effects model was used and relative risk was the principal measure of effect. Systematic qualitative review was used for other outcomes such as duration of operation and time to complete the anastomosis. Data on cancer survival were not available in the RCTs. Five RCTs were selected with quality scores ranging from 2 to 3 (5-point Jadad scale). Selection and validity agreement was strong. Relative risk (95% confidence interval, CI; P-value), expressed as handsewn vs. stapled (treatment vs. control), was 0.45 (0.20, 1.00; P=0.05) for operative mortality, 0.79 (0.44, 1.42; P=0.43) for anastomotic leaks, 0.60 (0.27, 1.33; P=0.21) for anastomotic strictures, 0.99 (0.55, 1.77; P=0.97) for cardiac morbidity, and 0.93 (0.63, 1.37; P=0.72) for pulmonary morbidity. Data synthesized from existing RCTs show that handsewn and circular stapled esophagogastric anastomotic techniques give similar results for anastomotic outcomes, such as leaks and strictures. The stapled anastomotic method appears to increase operative mortality (P=0.05). Although it is difficult to explain this finding, it should not be dismissed. Several hypotheses are discussed.