Surgery News - January 2008 - (Page 19) J A N U A RY 2 0 0 8 • SURGERY NEWS POSTOP MANAGEMENT 19 High PTH Level Flags Need for Long-Term Follow-Up BY BRUCE JANCIN Else vier Global Medical Ne ws C O L O R A D O S P R I N G S — An elevated parathyroid hormone level develops in one-third of patients who undergo parathyroidectomy, and although this outcome does not itself signify operative failure, it did herald recurrent hyperparathyroidism in 7% of those who were followed over the long term. The key lesson of this large single-center series is that, once patients develop eucalcemic elevated parathyroid hormone (PTH) postoperatively, they should be followed regularly on a long-term basis to identify those who will eventually develop hypercalcemia along with their high PTH level, thus meeting the definition for recurrent hyperparathyroidism, Dr. William Mendez said at the annual meeting of the Western Surgical Association. In this series, the first case of recurrent hyperparathyroidism didn’t happen until 2 years after surgery, noted Dr. Mendez of the University of Miami. The long-term clinical significance of an elevated PTH level in a eucalcemic patient after parathyroidectomy has been surrounded by uncertainty. To shed light on the subject, Dr. Mendez reported on 522 patients who had primary sporadic hyperparathyroidism and who underwent parathyroidectomy guided by intraoperative PTH monitoring. Operative success was defined as a normal serum calcium level—that is, not greater than 10.2 mg/dL—for at least the first 6 months post surgery. A PTH in excess of 70 pg/mL at any time during follow-up was deemed elevated. Serum calcium and PTH were routinely measured 1 week after surgery, at 2 and 6 months, and then yearly. Ninety-seven percent of patients had a successful procedure. During an average follow-up of 43 months, two-thirds of these 505 patients with operative success continued to maintain consistently normal PTH and serum calcium levels. But the other 33% developed an elevated PTH. Compared with those who did not develop an elevated PTH, these patients were significantly older (62 years vs. 57 years) and had a higher mean preoperative PTH level (227 pg/mL vs. 172 pg/mL). However, preoperative gland volume was similar in the two groups. Hormone levels eventually returned to normal in 35% of patients who developed an elevated PTH. Of the 107 whose PTH remained high and who were followed for more than 2 years, 7% developed recurrent hyperparathyroidism that warranted reoperation. Discussant Dr. Peter Angelos praised the Miami study for its unusually long followup, which has provided new insights into what he characterized as “a very vexing problem for anyone who does parathyroid surgery: Why are there some patients who seem to have a successful operation with long-term eucalcemia and yet their parathyroid hormone levels are found to be elevated? “Perhaps more important, what should we do about this when we find it?” asked Dr. Angelos, an ACS Fellow who is professor of surgery and chief of endocrine surgery at the University of Chicago. Dr. Mendez replied that he and his colleagues do not reoperate on such patients. Instead, they try to identify an underlying cause by looking for vitamin D deficiency and measuring ionized calcium and urinary calcium. “If the urinary calcium is high, we may be dealing with a urinary leak. In those cases, we treat with a calcium-sparing diuretic. If the serum calcium becomes elevated with the diuretic therapy, then we definitely have sporadic primary hyperparathyroidism,” he explained. If an underlying cause for the isolated elevated PTH can’t be found, Dr. Mendez recommended obtaining a serum calcium level every 6 months indefinitely. “An elevated calcium is what will tell you if there is a recurrence,” he said. ■ SAVE THE DATES! THE AMERICAN COLLEGE OF SURGEONS AT THE SOUTHEASTERN SURGICAL CONGRESS SUNDAY, FEBRUARY 10, 2008 2:00 –5:45 PM Panel: What’s New at the ACS Panel: What Practicing Surgeons Need to Know About Maintenance of Certification and How the American College of Surgeons Can Help Presenters: L. D. Britt, MD, MPH, FACS; Edward M. Copeland III, MD, FACS; Josef E. Fischer, MD, FACS; Thomas R. Russell, MD, FACS; Ajit K. Sachdeva, MD, FACS, FRCSC; and Steven C. Stain, MD, FACS THE AMERICAN COLLEGE OF SURGEONS AT THE SOUTHWESTERN SURGICAL CONGRESS MONDAY, MARCH 31, 2008 8:00 AM–12:00 NOON Panel: What’s New at the ACS Panel: What Practicing Surgeons Need to Know About Maintenance of Certification and How the American College of Surgeons Can Help Presenters: Barbara L. Bass, MD, FACS; L. D. Britt, MD, MPH, FACS; Josef E. Fischer, MD, FACS; Gerald B. Healy, MD, FACS; Russell G. Postier, MD, FACS; Thomas R. Russell, MD, FACS; Ajit K. Sachdeva, MD, FACS, FRCSC; and Alan G. Thorson, MD, FACS Southeastern Surgical Congress FEBRUARY 9–12, 2008 Sheraton Birmingham Birmingham, AL visit www.sesc.org or call 800/558-8958 To register, Southwestern Surgical Congress MARCH 30–APRIL 2, 2008 Fairmont Princess Acapulco, Mexico To register, visit www.swscongress.org or call 913/402-7102 INDEX OF ADVERTISERS The Chatham Institute/Wyeth Pharmaceuticals Inc. CME 10 Ethicon, Inc. ULTRAPRO Plug General Scientific Corporation SurgiTel KCI InfoV.A.C. Nashville Surgical Instruments Kumar PRE-VIEW Wyeth Pharmaceuticals Inc. TYGACIL 3 9 7 11 23-24 An exhibit will be presented at the time of each Surgical Congress demonstrating the new educational programs and products of ACS that are specially designed to help practicing surgeons meet MOC requirements. F O R M O R E I N F O R M AT I O N , contact Julie Tribe, MSEd, Senior Manager, Educational Programs, Division of Education, at jtribe@facs.org or 312/202-5433. FOR INFORMATION ON ACS, visit www.facs.org or call 800/621-4111. http://www.sesc.org http://www.swscongress.org http://www.facs.org
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