In view of new findings since the last International Workshop on the Management of Asymptomatic PHPT, guidelines for management have been revised. The revised guidelines include: 1) recommendations for more extensive evaluation of the skeletal and renal systems; 2) skeletal and/or renal involvement as determined by further evaluation to become part of the guidelines for surgery; and 3) more specific guidelines for monitoring those who do not meet guidelines for parathyroid surgery. These guidelines should help endocrinologists and surgeons caring for patients with PHPT. A blueprint for future research is proposed to foster additional investigation into issues that remain uncertain or controversial.

Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.

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ObjectiveTo review the outcomes of 656 consecutive parathyroid explorations performed by a single surgeon and to compare the results of conventional and minimally invasive parathyroidectomy (MIP) techniques. Summary Background DataTraditional surgery for primary hyperparathyroidism (HPTH) involves bilateral cervical exploration, which is usually accomplished under general endotracheal anesthesia. The MIP technique involves preoperative localization with sestamibi scans, surgeon-administered cervical block anesthesia, directed exploration through a small incision, intraoperative rapid parathyroid hormone assay, and discharge within 2 to 3 hours of surgery. MethodsSix hundred fifty-six consecutive patients with primary HPTH underwent exploration between January 1990 and March 2001. ResultsMIP was used with ever-increasing frequency beginning in March 1998. Four hundred one procedures (61%) were performed using the standard technique and 255 patients (39%) were selected for MIP. The success rate for the entire series was 98%, with no significant differences comparing traditional and MIP techniques. The overall complication rate of 2.3% reflects 3.0% and 1.2% rates in the standard and MIP groups, respectively. MIP was associated with approximately a 50% reduction in operating time, a sevenfold reduction in length of hospital stay, and a mean cost savings of $2,693 per procedure, which represents nearly a 50% reduction in total hospital charges. ConclusionsA dramatic and sustained shift has occurred in the surgical treatment of primary HPTH: MIP has replaced traditional exploration for most patients.Felix Mandl performed the first successful parathyroidectomy in Vienna in 1925.1 The patient, Albert J., had primary hyperparathyroidism (HPTH) associated with advanced osteitis fibrosa cystica and was severely disabled. The operation was performed under local anesthesia, at which time four parathyroid glands were identified and a single enlarged gland was resected. Although the patient experienced marked resolution of his symptoms, recurrent disease occurred 6 years later and he ultimately died of uncontrolled hypercalcemia. Standard management of primary HPTH evolved to include bilateral cervical exploration, usually under general anesthesia. However, because most cases of primary HPTH are caused by a single enlarged parathyroid adenoma, several investigators have questioned the need for routine bilateral cervical exploration. [3][4][5][6] This issue has resurfaced as the quality of noninvasive preoperative imaging techniques have improved. Technetium-99m sestamibi scans, when combined with single photon emission computed tomography (SPECT), can yield accurate preoperative three-dimensional localization of enlarged parathyroid glands.7 This allows the surgeon to plan a localized operation. In addition, the recent practicality and implementation of rapid parathyroid hormone (PTH) assays have resulted in the ability to measure PTH in the operating room, before and after tumor extraction, thereby obtaining objective eviden...