The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism
The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism
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DOI：
10.1001/jamasurg.2016.2310
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发表时间：
2016-10-01
期刊：
影响因子：
16.9
通讯作者：
Carty, Sally E.
中科院分区：
文献类型：
--
作者：
Wilhelm, Scott M.;Wang, Tracy S.;Carty, Sally E.
重要性原发性甲状旁腺功能亢进（pHPT）是一种常见的临床问题，其唯一明确的治疗方法是手术。手术管理在过去的几十年里已经发展了相当大的。目的制定循证指南，以提高适当的，安全的，有效的做法甲状旁腺切除术。证据审查一个多学科小组使用PubMed审查医学文献从1985年1月1日至2015年7月1日。证据水平的确定使用美国医师学院分级系统，并建议进行了讨论，直到consensus.FINDINGS初步评估应包括25-羟基维生素D测量，24小时尿钙测量，双能X线吸收测定法，并补充维生素D缺乏症。甲状旁腺切除术适用于所有有症状的患者，对于大多数无症状的患者应考虑，并且比观察或药物治疗更具成本效益。建议在制定手术计划时进行宫颈超声检查或其他高分辨率成像。非定位成像的患者仍然是手术候选者。术前应避免甲状旁腺活检。进行大量手术的外科医生有更好的结果。应常规考虑多腺体疾病的可能性。聚焦、图像引导手术（微创甲状旁腺切除术）和双侧探查都是实现高治愈率的合适手术。对于微创甲状旁腺切除术，建议通过可靠的方案进行术中甲状旁腺激素监测。微创甲状旁腺切除术不推荐用于已知或疑似多腺体疾病。切除的甲状旁腺组织的离体抽吸可用于术中确认甲状旁腺组织。临床相关的甲状腺疾病应评估术前和甲状旁腺切除术期间管理。正常甲状旁腺组织应自体移植。术后应观察患者是否有血肿，评估是否有低钙血症和低钙血症症状，并随访6个月以上以评估定义为正常钙血症的治愈情况。术后可能需要补充钙。家族性pHPT，再次手术甲状旁腺切除术，甲状旁腺癌是具有挑战性的实体，需要特别考虑和expertinence.CONCLUSIONS和RELEVANCE循证建议，以协助临床医生在最佳治疗pHPT患者。
IMPORTANCE Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades.OBJECTIVE To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy.EVIDENCE REVIEW A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus.FINDINGS Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise.CONCLUSIONS AND RELEVANCE Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.