Outpatient minimally invasive parathyroidectomy is safe for elderly patients

Primary Hyperparathyroidism in Older Adults: A Narrative Review of the Most Recent Literature on Epidemiology, Diagnosis and Management

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder among older adults. The aim of this review is to shed light on PHPT, particularly in this age group, in terms of prevalence, clinical manifestations, medical and surgical management, and post-operative complications.

METHODS

Eligible studies were those considering PHPT exclusively in the older population (main databases: PubMed, Medline, Google Scholar and the University Online database). Articles published in the last 10 years (2013-2023) were considered. Eligibility criteria followed the SPIDER (sample, phenomenon of interest, design, evaluation, research type) tool. The methodological quality of the studies was assessed using the Joanna Briggs Institute critical appraisal tool. A total of 29 studies (mainly observational) matched the inclusion criteria.

RESULTS

The prevalence of PHPT is approximately 1 per 100 in the elderly, and it is more common in females. The clinical presentation varies by age and can include osteoporosis, fractures, and neuropsychiatric symptoms. Conservative management can be an option whenever surgery is not indicated or feasible. However, parathyroidectomy (PTX) remains a safe and effective modality in aging populations with improvement to symptoms, bone mineral density, fracture risk, frailty, quality of life, and metabolic derangements. Complication rates are similar in elderly people compared to younger ones, except for mildly longer length of hospital stay and reoperation for those with higher frailty.

CONCLUSION

PHPT is a common yet overlooked and underdiagnosed condition among the older population. The safety and efficacy of PTX in the older population on different levels is now well demonstrated in the literature.

Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded?

Context

Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy.

Objective

This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy.

Methods

A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons.

Results

Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; P = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; P = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively.

Conclusion

Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.

Primary hyperparathyroidism in the geriatric population: A case report and mini literature review

We report a case of a 93‐year‐old woman with PHPT secondary to a left inferior parathyroid adenoma. The patient met criteria to be a surgical candidate; however, literature about parathyroidectomy in the elderly was limited and controversial. The patient remained stable through medical management for the next 5 years.

Diagnosis and management of PHPT in the geriatric population remains challenging. Although parathyroidectomy is the definitive treatment in the general population, medical management can be strongly considered in the geriatric population with PHPT.

Parathyroidectomy in the elderly is beneficial and safe with similar improvements in postoperative bone mineral density

BACKGROUND

This study evaluated bone health outcomes of parathyroidectomy in elderly primary hyperparathyroidism (pHPT) patients.

METHODS

A retrospective review was performed of parathyroidectomy patients with pHPT at a single institution from 2010 to 2019. Bone mineral density (BMD) improvements at postoperative dual-energy X-ray absorptiometry (DEXA) scans were analyzed between groups aged ≥75 and < 75 years using 1:1 matching on preoperative BMD.

RESULTS

Patients ≥75 had BMD improvements through the second postoperative DEXA scans. While mean T-scores slightly improved in the ≥75 group during the study period, T-score improvement was more significant in the <75 group at first and third postoperative DEXA scans with +0.7 < 75 and +0.1 improvements ≥75 by the third DEXA (p = 0.026). Postoperative fragility fracture rates were similar in the ≥75 group, but significantly improved in patients <75 (10.4% preoperatively to 1.4% postoperatively, p = 0.020). Both cohorts had low complication rates with recurrent laryngeal nerve injury and permanent hypocalcemia of <1% (p = 0.316).

CONCLUSIONS

Postoperative BMD improvement was similar between the two cohorts with no difference in complication rates suggesting parathyroidectomy is safe and effective in the elderly.

Non-surgical management of primary hyperparathyroidism in the aging population

Primary hyperparathyroidism (PHPT) is commonly observed in the aging population, and the average age at diagnosis has increased in the last 20 years. Parathyroidectomy, the only definitive cure for PHPT, is indicated in symptomatic and asymptomatic older PHPT patients with skeletal and renal disease. It is as effective in older patients as it is in younger patients. Nevertheless, older patients may present with comorbidities and greater frailty, leading to the possibility of more complications, higher morbidity and mortality after surgery. This review focuses on the non-surgical clinical management of PHPT in elderly patients. We also summarize the most recent literature regarding the pharmacological management of PHPT to reduce serum calcium levels, to improve bone mineral density or to do both in the aging population.

Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations

Importance

Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.

Objective

To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.

Design, Setting, and Participants

A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.

Main Outcomes and Measures

The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.

Results

A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001).

Conclusions and Relevance

Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.

Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that predominantly affects patients >60 and is increasing in prevalence. Identifying risk factors for poor outcomes after parathyroidectomy in older adults will help tailor operative decision making. The impact of frailty on surgical outcomes in parathyroidectomy has not been established.

METHODS

We performed a retrospective review of patients ≥40 years who underwent parathyroidectomy in the 2005-2010 ACS NSQIP. Frailty was assessed using the modified frailty index (mFI). Multivariable regression was used to determine the association of frailty with 30-day complications, length of stay (LOS), and reoperation.

RESULTS

We identified 13,123 patients ≥40 who underwent parathyroidectomy for PHPT. The majority of patients were not frail, with 80% with a low NSQIP mFI score (0-1 frailty traits), 19% with an intermediate mFI score (2-3), and 0.9% with a high mFI score (≥4). Overall 30-day complications were rare, occurring in 141 (1.1%) patients. Increasing frailty was associated with an increased risk of complications with adjusted odds ratios (ORs) of 1.76 (95% CI 1.20-2.59; p = 0.004) for intermediate and 8.43 (95% CI 4.33-16.41; p < 0.001) for high mFI score. Patient age was independently associated with an increased risk of complications only when ≥75, as was African-American race. Anesthesia with local, monitored anesthesia care, or regional block was the only factor associated with decreased odds of complications. A high NSQIP mFI was also associated with a significant 4.77-day adjusted increase in LOS (95% CI 4.28-5.25; p < 0.001) and increased odds of reoperation (OR 4.20, 95% CI 1.64-10.74; p = 0.003).

CONCLUSION

Patient frailty is associated with increased complications, reoperation and prolonged LOS in patients undergoing parathyroidectomy for PHPT. The risks of surgical management should be weighed against potential benefits in frail patients with PHPT to individualize treatment decisions in this vulnerable population.

Surgical management of primary hyperparathyroidism: A single-center experience

BACKGROUND

Primary hyperparathyroidism (PHPT) can occur at any age. This study aimed to compare the necessity, feasibility, safety, and outcomes of parathyroidectomy in the management of minor-symptomatic or asymptomatic PHPT patients according to age (young vs. old).

METHODS

We retrospectively reviewed the medical records of 146 consecutive patients who underwent surgery for PHPT from January 2005 to June 2016 in our institution. The patients ranged in age from 12 to 85 years. For the analysis, the included patients (n = 137) were separated into young (age <50 years; n = 31, 22.6%) and old (age ≥50 years; n = 106, 77.4%) patients. The biochemical characteristics (parathyroid hormone, calcium, and creatinine levels), T-score of bone densitometry, surgical reports, pathology reports, perioperative intensive care unit care, and 30-day mortality were reviewed.

RESULTS

The average medical treatment course after diagnosis tended to be longer in the old group (33.3 vs. 26.2 weeks, p = 0.62). During the medical treatment course, the old group had a higher risk of developing new symptoms or severe complications (5.6% vs. 3.2%, p = 0.05), and the older patients seemed to have a longer postoperative hospitalization (p = 0.17). However, there were no significant differences in the 30-day mortality, immediate complications, and follow-up duration.

CONCLUSION

In older patients, surgical treatment of PHPT is safe and feasible, with comparable outcomes to in younger patients, and helps prevent the development or progression of symptoms and complication. Hence, parathyroidectomy should be the recommended treatment and should be performed in PHPT patients as early as possible, regardless their age and initial symptoms.

Parathyroidectomy for primary hyperparathyroidism in the elderly: experience of a single endocrine surgery center

BACKGROUND

Primary hyperparathyroidism is a common endocrine disease, and its incidence increases with age.

AIMS

Our aim was to retrospectively evaluate the impact of age on patient outcomes following parathyroidectomy for primary hyperparathyroidism.

METHODS

Two-hundred fifty-six consecutive patients undergoing parathyroidectomy with preoperative diagnosis of primary hyperparathyroidism were divided into three groups according to patient age: group A, ≤64 years; group B, 65-74 years; and group C, ≥75 years.

RESULTS

Thyroid disease was associated with the hyperparathyroidism in 44 patients (28.2%) in group A, 34 (44.7%) in B, and 10 (41.7%) in C (p < 0.01). Minimally invasive parathyroidectomy was performed in 104 patients (66.7%) in group A, 35 (46.1%) in B, and 8 (33.3%) in C (p < 0.01). Conversion to bilateral exploration was carried out in five cases in group A (4.6%), three in B (8.3%), and two in C (20%). Multiglandular disease was observed in six patients (3.8%) in group A, seven (9.2%) in B, and five (20.8%) in C (p = 0.012). Mean postoperative stay was similar between groups; no major complications and no cases of mortality occurred.

DISCUSSION

Multiglandular disease is more common in older patients than younger individuals, and minimally invasive approaches are less used in this patient group. Increased surgical risk and paucity of symptoms in these patients sometimes result in a delay in surgical treatment.

CONCLUSIONS

Parathyroidectomy is a safe and effective procedure to perform in elderly patients. Multiglandular disease was found to be more prevalent in older patients, but minimally invasive parathyroidectomy can be performed safely. Surgeons should consider parathyroidectomy in patients with primary hyperparathyroidism regardless of age.

Outpatient Parathyroid Surgery: Ten-Year Experience: Is it Safe?

Outpatient parathyroid surgery is increasing in frequency especially for patients undergoing minimally invasive operations. From January 1, 2000 to December 31, 2009, 585 operations were performed on patients with untreated primary hyperparathyroidism. Outpatient operations were performed on 43 per cent (249/585), whereas 57 per cent (336/585) were admitted. Comorbidities were present in 63 per cent of outpatients and 72 per cent of inpatients, whereas systemic complications occurred in 0.8 per cent of outpatients and 7 per cent of inpatients. Ninety-four per cent of outpatients were minimally invasive although inpatient procedures were evenly divided. Local complications were low (8% and 6%) in both groups. Using zip codes to determine distance from home to hospital, no differences were noted. Readmission rates were low (< 0.5%) and the same in each group. Inpatients longer than 23 hours tended to be older with higher local and systemic complication rates. Over a decade, most patients undergoing same day parathyroid surgery had minimally invasive operations with lower comorbidities and lower systemic complications than inpatients. Minimally invasive and less complex nonminimally invasive operations can safely be performed on an outpatient basis with careful patient selection. Patient with more severe comorbidities and multiple comorbidities are less favorable candidates for outpatient surgery because of a higher risk of systemic complications.

Ambulatory Thyroidectomy

Objective

Determine rates and reasons for revisits after ambulatory adult thyroidectomy.

Study Design

Cross-sectional analysis of multistate ambulatory surgery and hospital databases.

Setting

Ambulatory surgery data from the State Ambulatory Surgery Databases of California, Florida, Iowa, and New York for calendar years 2010 and 2011.

Subjects and Methods

Ambulatory thyroidectomy cases were linked to state ambulatory, emergency, and inpatient databases for revisit encounters occurring within 30 days. The numbers of revisits, mortality, and associated diagnoses were analyzed.

Results

A total of 25,634 cases of ambulatory thyroid surgery were identified: 44.2% total thyroidectomy (TT) and 55.8% partial thyroidectomy (PT). Common indications for surgery included goiter/cyst (39.5%), benign/uncertain neoplasm (24.2%), and malignant neoplasm (24.0%). The 30-day revisit rate was 7.2% (n = 1858; 61.8% emergency department, 22.4% inpatient admission, and 15.8% ambulatory surgery center). The most common diagnosis at revisit was hypocalcemia (20.8% of revisits), followed by wound hematoma/seroma/bleeding (7.1%). Higher rates of revisit, hypocalcemia, and hematoma/seroma/bleeding were seen in patients undergoing TT ( P < .016 for all). Sixteen patients had bleeding less than 24 hours after the index procedure (0.1% overall, 0.9% of revisits). Most hypocalcemia and hematoma/bleeding occurred over the first postoperative week. Three deaths occurred within 30 days of the index procedure.

Conclusion

In carefully selected patients, ambulatory thyroidectomy demonstrates a good postoperative morbidity and mortality profile. Common reasons for revisits included hypocalcemia and bleeding/seroma/hematoma, which occurred with relatively high frequencies as late as a week after surgery. Quality improvement measures should be targeted at lowering revisit rates and safely managing complications.

Operative Treatment of Primary Hyperparathyroidism in Daycare Surgery

OBJECTIVE

The standard of care for primary hyperparathyroidism is surgical removal of hyperfunctional parathyroid tissue. Here, we describe 20 patients with primary hyperparathyroidism who were treated surgically in the setting of daycare surgery.

DESIGN

Prospective observational study.

METHODS

A total of 20 patients with primary hyperparathyroidism were operated between March 2005 and May 2010. The follow-up period had a median of 41 weeks (5-245 weeks). Results are presented as mean (± standard deviation) or median (minimum-maximum).

RESULTS

A total of 20 patients (15 women, mean age 54 ± 14 years) were included. Nine patients were provided with post-operative calcium supplementation. One of the patients visited the emergency department the next day with paresthesia and normocalcemia; this patient was sent home. Four patients, without prophylaxis, also reported themselves to the emergency department. Only one had mild hypocalcemia (2.09 mmol/L) and was supplemented. Comparing the emergency department group (n = 5) with the others, we found that pre-operative calcium levels were similar (p = 0.40); however, the emergency department group had significantly lower post-operative calcium levels (2.27 ± 0.14 vs 2.55 ± 0.25, p = 0.008) and the decrease-percentage was significantly higher (17.5% ± 5.4% vs 10.5% ± 6.4%, p = 0.21).

CONCLUSION

Parathyroidectomy in the daycare setting is feasible and safe. However, many patients return to the emergency department. This could be related to the strict information that is provided or due to a large decrease in their calcium levels, albeit normocalcemia. Calcium supplementation is cheap and safe, so we will provide all future patients with calcium supplementation and herewith aim to reduce the amount of emergency department visits.

A decade of change in the uptake of parathyroidectomy in England and Wales

INTRODUCTION

Since the late 1990s, a number of factors have reduced the threshold for parathyroidectomy in patients with primary hyperparathyroidism. This study examined whether this has translated into increased numbers of parathyroid operations over the last decade.

METHODS

A retrospective analysis was performed of the Patient Episode Database for Wales and English Hospital Episode Statistics annual data from 2000 to 2010 for parathyroidectomy admissions per 100,000 population. Statistical analysis was by linear regression.

RESULTS

Between 2000 and 2010 there were 24,247 parathyroid operations in England and Wales (0.005% of the population), with 3 times as many women treated as men. Overall, incidence of parathyroidectomy rose from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010 (p<0.0001). In England, it increased from 3.3/100,000 population to 5.8/100,000 and in Wales, it increased from 2.4/100,000 population to 4.6/100,000. Despite similar population demographics, the difference in the rate of change between England and Wales was significant (p<0.05). Uptake also varied according to age; in those aged 0-14 years, incidence of parathyroidectomy remained static whereas in all other age groups, uptake of parathyroidectomy increased significantly from 2000 to 2010. Most notably, surgical intervention in those aged 60-74 and >75 years nearly doubled over the decade (p<0.0001).

CONCLUSIONS

The incidence of parathyroidectomy in adults has increased significantly in the last decade in England and Wales. This likely reflects changes in population demography, available guidelines, lower threshold for referral, changing surgical approach and the realisation that surgical morbidity is now infrequent.

Outpatient Parathyroid Surgery Data from the University Health System Consortium

Objective

To determine demographics and cost for outpatients undergoing parathyroid surgery at hospitals belonging to the University Health System Consortium (UHC).

Study Design

UHC data were accessed in 2011 and reflected data collected from 2005 through 2010 (24 quarters). Searching strategy was based on diagnoses of parathyroid disease and patients undergoing parathyroidectomy across all UHC member facilities. Complications evaluated in this analysis included: hypocalcemia, hypoparathyroidism, aspiration pneumonia, hematoma, wound infection, stroke, myocardial infarction, deep venous thrombosis/pulmonary embolism (PE), and death.

Setting

The University Health System Consortium, Oak Brook, Illinois, was formed in 1984 and consists of 112 academic medical centers and 250 of their affiliated hospitals. This represents 90% of the nonprofit academic medical centers in the United States ( www.uhc.edu ).

Subjects and Methods

Patients enrolled in the UHC database were studied retrospectively. Data were compiled from discharge summaries into a secure, interactive, Web-based database. The outpatient data collection set has been a recent addition to the originally established UHC inpatient discharge database.

Results

There were 21,057 patients who had outpatient parathyroid surgery. The average age was 59.0 (0.8-96.2) yrs. Seventy-six percent of patients were female. Outpatient parathyroidectomy had lower charges than inpatient surgery ($12,738 and $14,657, respectively; P = 0.004, Wilcoxon signed-rank test). Complications were low but were likely underreported.

Conclusion

Parathyroid surgery is increasingly being done in the outpatient setting in the United States. By virtue of omitting inpatient hospitalization, the outpatient approach becomes a more economical way to manage parathyroid disease. This is the largest known series reporting experience with outpatient parathyroid surgery.

Primary hyperparathyroidism in older people: surgical treatment with minimally invasive approaches and outcome

Introduction. Elderly patients with primary hyperparathyroidism (pHPT) are often not referred to surgery because of their associated comorbidities that may increase surgical risk. The aim of the study was to review indications and results of minimally invasive approach parathyroidectomy in elderly patients to evaluate its impact on outcome. Materials and Methods. All patients of 70 years of age or older undergoing minimally approach parathyroidectomy at our Department from May 2005 to May 2011 were reviewed. Data collected included patients demographic information, biochemical pathology, time elapsed from pHPT diagnosis to surgical intervention, operative findings, complications, and results of postoperative biochemical studies. Results and Discussion. 37 patients were analysed. The average length of stay was 2.8 days. 11 patients were discharged within 24 hours after their operation. Morbidity included 6 transient symptomatic postoperative hypocalcemias while one patient developed a transient laryngeal nerve palsy. Time elapsed from pHPT diagnosis to first surgical visit evidences that the elderly patients were referred after their disease had progressed. Conclusions. Our data show that minimally invasive approach to parathyroid surgery seems to be safe and curative also in elderly patients with few associated risks because of combination of modern preoperative imaging, advances in surgical technique, and advances in anesthesia care.

Primary hyperparathyroidism: an overview

Primary hyperparathyroidism is a common condition that affects 0.3% of the general population. Primary and tertiary care specialists can encounter patients with primary hyperparathyroidism, and prompt recognition and treatment can greatly reduce morbidity and mortality from this disease. In this paper we will review the basic physiology of calcium homeostasis and then consider genetic associations as well as common etiologies and presentations of primary hyperparathyroidism. We will consider emerging trends in detection and measurement of parathyroid hormone as well as available imaging modalities for the parathyroid glands. Surgical indications and approach will be reviewed as well as medical management of primary hyperparathyroidism with bisphosphonates and calcimimetics.

Parathyroid surgery in the elderly

The prevalence of primary hyperparathyroidism (PHPT) will increase with the growth of the elderly population. Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in elderly patients with PHPT, the majority of them reporting increased fracture-free survival and symptomatic relief postoperatively and thus experiencing improved quality of life.

Introduction.

The prevalence of primary hyperparathyroidism (PHPT) is expected to increase in developed nations as the aged population grows. This review discusses issues related to PHPT in the elderly population with a focus on differences in disease presentation, medical and surgical management, and outcomes.

Methods.

Literature review of English-language studies of PHPT or parathyroidectomy (PTx) in the elderly was performed. Surgical literature reviewed included original clinical studies published after 1990. Priority was given to studies with >30 patients where institutional practice and outcomes have not changed significantly over time.

Results.

Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. They have equivalent surgical outcomes, including morbidity, mortality, and cure rates, compared with younger patients, although their length of hospital stay is significantly longer. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in an elderly population. Patients are referred for PTx less frequently with each advancing decade, although surgical referral patterns have increased over time in centers that offer minimally invasive parathyroidectomy. Elderly patients experience increased fracture-free survival after PTx. The majority of elderly patients report symptomatic relief postoperatively.

Conclusion.

PTx can offer elderly patients with PHPT improved quality of life. PTx is safe and effective in elderly patients, and advanced age alone should not deter surgical referral.

Primary hyperparathyroidism: an update

PURPOSE OF REVIEW

Primary hyperparathyroidism (PHPT) is a constantly evolving disease. As more evidence on the cardiovascular and neuropsychiatric manifestations of apparently asymptomatic disease accumulates, and since medical therapeutic options and surgical indications are being further investigated, it is important to review this disease entity to gain a fresh, updated perspective on the current disease phenotype and treatment approach.

RECENT FINDINGS

The pathogenesis of PHPT has not been completely elucidated yet, but some potential culprits, such as gene mutations, growth factors, calcium sensing receptor antibodies, and chronic vitamin D deficiency are being identified. There is increasing evidence that even mild, asymptomatic PHPT is associated with some aspects of cardiovascular and neuropsychiatric dysfunction, but the clinical significance as well as the reversibility with parathyroidectomy of these abnormalities remain to be determined. Medical therapies such as bisphosphonates and calcimimetics are showing some promise in the treatment of PHPT, although surgery remains the only curative intervention. The indications for surgical intervention in patients with asymptomatic PHPT have been recently revised.

SUMMARY

Parathyroidectomy is the treatment of choice for patients with symptomatic PHPT and patients with asymptomatic PHPT who fulfill certain age, bone density, serum calcium, and creatinine criteria. Further research is needed to determine whether patients with prominent cardiovascular and neuropsychiatric manifestations would benefit from such intervention.

Underutilization of parathyroidectomy in elderly patients with primary hyperparathyroidism

CONTEXT

Primary hyperparathyroidism (PHPT) disproportionately affects older patients, who may face higher thresholds for surgical intervention compared to young patients.

OBJECTIVE

The aim was to examine for differences in the utilization of parathyroidectomy attributable to age.

DESIGN

We conducted a retrospective cohort study.

PARTICIPANTS

Patients with biochemically diagnosed PHPT during the years 1995-2008 were identified within an integrated health care delivery system in Southern California encompassing approximately 3 million individuals.

MAIN OUTCOME MEASURES

The outcome measures were parathyroidectomy (PTx) and time interval to surgery.

RESULTS

We found 3388 patients with PHPT, 964 (28%) of whom underwent PTx. Patients aged 60+ yr comprised 60% of the study cohort. The likelihood of PTx decreased linearly among patients aged 60+ when compared to patients aged 50-59, an effect that persisted in multivariate analysis: odds ratio 0.68 for ages 60-69 (P < 0.05); 0.41 for ages 70-79 (P < 0.0001), and 0.11 for age 80+ (P < 0.0001). The PTx rate for patients aged 70+ was 14%. Among patients meeting 2002 consensus criteria for surgical treatment, 45% of those aged 60-69 and 24% of those aged 70+ underwent PTx. A Cox proportional hazards model showed that patients aged 60+ experienced significantly longer delays from diagnosis to surgery compared to young patients (P < 0.0001).

CONCLUSIONS

PHPT is undertreated in the elderly. We observed a progressive age-related decline in PTx rate that renders patients aged 70+ unlikely to have definitive treatment, irrespective of comorbidity and eligibility for surgery.