Symptoms of gastroesophageal reflux disease improve after parathyroidectomy

Article (PDF Available)inSurgery 152(6):1232-7 · December 2012with75 Reads
DOI: 10.1016/j.surg.2012.08.051 · Source: PubMed
Abstract
Primary hyperparathyroidism can be associated with symptoms related to GERD, but it is unclear which symptoms of GERD improve after parathyroidectomy. Our goal was to assess prospectively for changes in specific GERD symptoms after parathyroidectomy using a validated questionnaire. Using the GERD health-related quality of life (GERD-HRQL) questionnaire, symptoms of heartburn were prospectively assessed before and 6 months after treatment of hyperparathyroidism with parathyroidectomy. This validated questionnaire includes 10 items, with a Likert scale of 0-5. Scores range from 0 to 45, a lesser score indicates fewer/less severe symptoms. Pre- and postoperative surveys were available for 51 patients. Parathyroidectomy improved the overall questionnaire score (12.5 ± 1.3 vs 4.5 ± 0.9, P < .0001). Overall scores for each question improved after parathyroidectomy, including symptoms of dysphagia (P = .001) and overall satisfaction with symptoms (P < .0001). However, the number of patients taking antireflux medication before and after parathyroidectomy was not substantially different (34 vs 28 patients, P = .17). All symptoms of GERD improved after parathyroidectomy for hyperparathyroidism. Despite the decrease in symptoms, there was not a change in the number of patients who remained on anti-reflux therapy. For patients with symptoms of GERD, a trial off antireflux medications after parathyroidectomy should be considered.
Symptoms of gastroesophageal
reflux disease improve after
parathyroidectomy
Alexandra E. Reiher, MD,
a,b
Haggi Mazeh, MD,
a
Sarah Schaefer, NP,
a
Jon Gould, MD,
c
Herbert Chen, MD,
a
and Rebecca S. Sippel, MD,
a
Madison and Milwaukee, WI, and Evanston, IL
Background. Primary hyperparathyroidism can be associated with symptoms related to GERD, but it is
unclear which symptoms of GERD improve a fter parathyroidectomy. Our goal was to assess prospectively
for changes in specific GERD symptoms after parathyroidectomy using a validated questionnaire.
Methods. Using the GERD health-related quality of life (GERD-HRQL) questionnaire, symptoms of
heartburn were prospectively assessed before and 6 months after treatment of hyperparathyroidism with
parathyroidectomy. This validated questionnaire inclu des 10 items, with a Likert scale of 0–5. Scores
range from 0 to 45, a lesser score indicates fewer/less severe symptoms.
Results. Pre- and postoperative surveys were available for 51 patients. Parathyroidectomy improved the
overall questionnaire score (12.5 ± 1.3 vs 4.5 ± 0.9, P < .0001). Overall scores for each question
improved after parathyroidectomy, including symptoms of dysphagia (P = .001) and overall satisfactio n
with symptoms (P < .0001). However, the number of patients taking antireflux medication before and
after parathyroidectomy was not substantially different (34 vs 28 patients, P = .17).
Conclusion. All symptoms of GERD improved after parathyroidectomy for hyperparathyroidism. Despite
the decrease in symptoms, there was not a change in the number of patients who remained on anti-reflux
therapy. For patients with symptoms of GERD, a trial off antireflux medications after parathyroidectomy
should be considered. (Surgery 2012;152:123 2-7.)
From the Section of Endocrine Surgery, Department of Surgery,
a
University of Wisconsin, Madison, WI;
Division of Endocrinology, Department of Internal Medicine,
b
Northshore University Healthcare System,
Evanston, IL; and Department of General Surgery,
c
Medical College of Wisconsin, Milwaukee, WI
CLASSIC SYMPTOMS ASSOCIATED WITH PRIMARY HYPERPARA-
THYROIDISM
(PHPT) include nephrolithiasis and
bone disease. However, several symptoms can be
related to PHPT, including polydipsia, polyuria,
depression, and decreased appetite. Gastric and
duodenal ulceration, as well as heartburn or gas-
troesophageal reflux disease (GERD), also have
been described. The incidence of heartburn in
patients with PHPT is as great as 30%. Other
gastrointestinal (GI) manifestations include consti-
pation (33%), nausea (24%), and decreased appe-
tite (15%). The underlying mechanism remains
unclear.
1-3
Patients with symptomatic PHPT should un-
dergo parathyroid surgery to achieve cure, and
certain asymptomatic patients should undergo
surgical resection of their adenoma. Currently,
symptoms of GERD are not considered an indica-
tion for parathyroidectomy (PTX). Criteria devel-
oped by the NIH Managem ent of Asymptomatic
Primary Hyperparathyroidism for operative inter-
vention include serum calcium concentration of
1.0 mg/dL or more above the upper limit of
normal; creatinine clearance <60 mL/min; bone
density at the hip, lumbar spine, or distal radius
that is more than 2.5 standard deviations less than
peak bone mass (T score <2.5) and/or previous
fragility fracture; or age less than 50 years.
4
PTX
cures PHPT, improves bone mineral density, may
decrease the risk of fracture, decreases the risk
of kidney stones, and improves some quality of
life (QOL) measurements
5
; however, its effect on
gastrointestinal symptoms have been poorly
defined.
GERD is defined by the American College of
Gastroenterology as symptoms or mucosal damage
produced by the abnormal reflux of gastric
Presented as an oral presentation at the American Association
of Endocrine Surgeons, Iowa City, IA, May 1, 2012.
Accepted for publication August 23, 2012.
Reprint requests: Rebecca S. Sippel, MD, Department of Sur-
gery, University of Wisconsin, 600 Highland Avenue, Clinical
Science Center J4/703, Madison, WI 53792-3284. E-mail:
sippel@surgery.wisc.edu.
0039-6060/$ - see front matter
Ó 2012 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.surg.2012.08.051
1232 SURGERY
contents into the esophagus.
6
The most common
symptoms associated with GERD are heartburn,
dysphagia, and regurgitation. Diagnostic testing
for GERD includes upper endoscopy, ambulatory
esophageal pH monitoring, barium swallow stud-
ies, and assessing response to treatment with anti-
secretory therapy such as proton pump inhibitors
or H2 antagonists.
6,7
Treatment of GERD includes antireflux medi-
cations or operative intervention for refractory
cases. Standard medical treatment with antireflux
medications is safe overall but there are side-effects
and risks associated with taking these medications.
The side-effect profile for proton-pump inhibitors
(PPIs) includes headaches (1–2 %), diarrhea (1.9
4.1%), nausea (0.02–0.9%), and rash (0.4–1.1%).
Chronic use of PPIs has been associated with
decreased calcium absorption due to decreased
gastric acid, as well as community-acquired pneu-
monia.
8
There have also been conflicting studies
regarding a possible increased risk of fractures in
patients using proton pump inhibitors for longer
than 6 months.
9
Removing such medications
from a patient’s medication list would, therefore,
be of benefit to the patient.
Health-related QOL questionnaires are consid-
ered a standardized instrument to evaluate the
effects of treatment of GERD in clinical trials.
10
The GERD-HRQL questionnaire was designed to
measure symptomatic outcomes of GERD with
the use of a simple instrument---a questionnaire.
The questionnaire was designed and validated by
Velanovich et al
11
in 1996 and includes 10 items,
with a Likert scale of 0–5. The GERD-HRQL total
score is the sum of the individual item scores,
with the worse possible score reaching 45 points.
After medical or operative treatment, with an inter-
val of 1 to 6 months, patients were again asked to
complete the G ERD-HRQL questionnaire. The
questionnaire was able to identify the most com-
mon and bothersome symptoms of GERD, as well
as differentiate between satisfied and unsatisfied
GERD patients. Velanovich et al
11
evaluated 72 pa-
tients who were asked to complete the GERD-
HRQL at initial assessment.
Although the authors of previous studies have
described symptoms of heartburn improving after
PTX,
1
no published studies have investigated spe-
cific symptoms of GERD before and after PTX.
Our goal was to prospectively assess the changes
in specific GERD symptoms before and after PTX
by using a validated questionnaire, the GERD
health-related quality of life (GERD-HRQL)
questionnaire.
METHODS
This prospective study wa s performed at a single
academic institution from March 2010 through
June 2011 and approved by its institutional review
board. Patients undergoing PTX were asked to
complete a survey as part of their preoperative
evaluation. PTX was performed by 1 of 2 endo-
crine surgeons at our institution. All patients were
asked whether they had symptoms of heartburn. If
patients answered yes to having heartburn, they
were asked to complete an additional survey, the
GERD-HRQL questionnaire. The questionnaire
was then provided to patients to complete at their
follow-up appointment 6 months after PTX.
The GERD-HRQL validated questionnaire in-
cludes 10 items, with a Likert scale of 0–5. Six items
measure satisfaction with the degree of heartburn
symptoms, 2 with dysphagia/odynophagia, and
1 with the impact of medication on daily life.
One item measures overall satisfaction with the
present condition. Sco res range from 0 to 45, with
a lower score indicating fewer/less severe symp-
toms (Supplementary File 1).
10,11
Paired t tests were used to compare individual
data pre and op post-op eratively, and unpaired t
tests and the Fisher exact were used to compare
the responders and nonresponders. Statistical anal-
ysis was performed with Microsoft Excel (2003 for
Microsoft Windows; Microsoft, Redmond, WA). Re-
sults are expressed as the mean ± SEM.
RESULTS
Pre- and postoperative surveys were available for
51 patients. Mean age at time of PTX was 59 ± 2
years, and 78% of patients were female. Mean body
mass index (BMI) was 30.7 ± 6.3 kg/m
2
(range,
20.1–52.0 kg/m
2
). Mean preoperative calcium
was 10.6 ± 0.1 mg/dL, and mean preoperative
PTH was 142 ± 24 pg/mL. Forty-eight patients
had PHPT, 2 patients had secondary hyperparathy-
roidism, and 1 patient had tertiary hyperparathy-
roidism. Thirty-two patients had 1 parathyroid
adenoma (63%), 11 patients had 2 parathyroid ad-
enomas (22%), and 8 patients underwent subtotal
PTX (16%). Follow-up surveys were completed 6
months postoperatively and were available on
100% of patients. Average 6-month postoperative
calcium was 9.4 ± 0.1 mg/dL and average postoper-
ative PTH was 50.7 ± 6.7 pg/mL. All patients were
eucalcemic at 6 months’ follow-up.
Overall score s for each question improved after
PTX, including severity of symptoms (P < .0001),
the presence of heartburn lying down (P = .001)
or standing up (P = .004), symptoms after meals
Surgery
Volume 152, Number 6
Reiher et al 1233
(P = .002), impact of symptoms on diet (P = .03),
difficulty swallowing (P = .002), pain with swallow-
ing (P = .03), and overall satisfaction with symp-
toms (P < .0001). Also, the impact of symptoms
on daily life improved (P = .02). Interestingly, the
overall number of patients on antireflux medica-
tion before and after PTX was not significantly dif-
ferent (34 vs 28 patients, P = .11; Table I) Patients
with a preoperative score <20 were older than pa-
tients with a pre-operative score $20 (60 ± 2 vs 54 ±
2 years, respectively; P = .02.
Surgery significantly improved the overall ques-
tionnaire score (12.5 ± 1.3 vs 4.5 ± 0.9; P < .0001).
BMI did not explain the changes observed. There
was not a significant difference in percent change
in score between patients with an average BMI <25
(41 ± 30%) and patients with an average BMI
$25 (63 ± 8%), P = .49. Greater than 50%
improvement in scores was recorded in 67% of pa-
tients after PTX. Only 7 patients (14%) reported
no change in symptoms or worsening of symptoms.
There was no difference in preoperative
PTH levels (P = 1.0) or calcium levels (P = .57)
between patients wh o had >50% improvement (re-
sponders) versus those with <50% improvement
(nonresponders) in symptoms of GERD after sur-
gery (Table II). Interestingly, the nonresponders
had lesser base line scores before surgery than the
responders, but this difference was not significant.
In addition, there were fewer responders on antire-
flux medications 6 months after surgery than non-
responders (P = .005).
Patients with a preoperative score of >15 (n =
15) had a 68 ± 9% improvement in their score
post-operatively, while patients with a preoperative
score <15 (n = 36) had a 54 ± 12% improvement in
their score postoperatively. The differences in
score improvement were not substantially different
(P = .35).
DISCUSSION
This is the first study to investigate specific GERD
symptoms in patients with PHPT before and 6
months after parathyroidectomy. Patients with
symptoms of GERD before parathyroidectomy had
an average score on the GERD-HRQL questionnaire
of 12.5 ± 1.3, which significantly improved to 4.5 ±
0.9 after PTX (P < .0001). Overall, each symptom
score improved after PTX. Although symptoms of
GERD have been linked to hyperparathyroidism
and hypercalcemia, the pathophysiology of GERD
symptoms and peptic ulcer disease in these patients
remains unclear.
12
In a study published in 1982,
Mowschenson et al
13
demonstrated changes in
lower esophageal sphincter pressures before and
after PTX. Patients with heartburn had a lower
esophageal sphincter pressure below normal before
operation, and 4 of the 5 patients had an increase in
lower esophageal pre ssure.
13
Studies have demon-
strated increased gastric acid secretion and gastrin
levels in the presence of hypercalcemia, but other
studies have found conflicting results.
14-18
GERD can impact substantially a patient’s QOL
and work productivity. In a study that used surveys,
authors demonstrated that greater 30% of patients
experiencing heartburn reported decreased work
productivity.
19
The impact of GERD symptoms on
a patient’s QOL is most important when evaluating
for treatment response.
Despite significant improvement in symptoms
of GERD, there was not a substantial change in the
number of patients receiving antireflux medica-
tion before and after PTX in our study (P = .11).
Only 6 patients (12%) had been taken off antire-
flux medication after PT X. A study from the Uni-
versity of Pittsburgh demonstrated that 11% of
patients had medications discontinued or de-
creased after PTX. However, only 3 patients were
noted to have proton pump inhibitors discontin-
ued after surgery.
3
A Swedish study demonstrated
that 27% of 97 long-term PPI users were able to
discontinue PPIs after PTX without recurrence of
symptoms.
20
Given the financial and psychologic
burden for patients to take medications on a daily
basis, patients and their primary care providers
need to be educated that discontinuation of antire-
flux medications after PTX should be considered,
especially in patients with a significant improve-
ment or resolution of their GERD symptoms.
Classic symptoms of PHPT---nephrolithiasis,
bone disease, and neuropsychiatric symptoms---are
Table I. Questionnaire scores before and 6
months after PTX
Preoperative Postoperative P value
Overall score 12.5 ± 1.3 4.5 ± 0.9 <.0001
Severity 2.01 ± 0.20 0.84 ± 0.14 <.0001
Present lying down 1.53 ± 0.21 0.76 ± 0.15 .001
Present standing up 1.04 ± 0.18 0.49 ± 0.13 .004
After meals? 1.16 ± 0.18 0.55 ± 0.13 .002
Affects diet 0.71 ± 0.17 0.37 ± 0.11 .03
Wakes you from sleep 1.04 ± 0.18 0.49 ± 0.13 .004
Difficulty swallowing 1.03 ± 0.21 0.37 ± 0.12 .002
Pain with swallowing 0.48 ± 0.13 0.18 ± 0.09 .03
Affects daily life 0.55 ± 0.16 0.14 ± 0.07 .02
Satisfaction 2.16 ± 0.25 0.55 ± 0.14 <.0001
No. patients on
heartburn
medications (%)
34 (67%) 28 (55%) .11
PTX, Parathyroidectomy.
Surgery
December 2012
1234 Reiher et al
an indication for curative PTX.
1-3
For patients with-
out these symp toms, the indications for PTX are de-
batable.
4
Our study showed subs tantial
improvement in all symptoms of GERD after PTX
for PHPT. Therefore, despite the lack of a clear un-
derstanding behind the mechanism of improved
symptoms, patients with PHPT who have symptoms
of GERD should be considered for curative PTX be-
cause it may decrease symptoms and the need for
long-term medication. The use of a preoperative
survey can help identify such patients.
This is the firs t study to evaluate specific symp-
toms of GERD attributable to hyperparathyroidism
and assess for changes in symptoms of GERD after
curative PTX using a validated questionnaire. The
GERD-HRQL questionnaire was used in this study
because it is a validated questionnaire, it is easy for
patients to use, and it is easy for physicians to
interpret the results. Despite our study relatively
small sample size, our results show a fairly impor-
tant improvement in the majority of patients. We
selected patients for this study based upon self-
reporting of heartburn symptoms. We di d not do
formal pH monitoring or radiographic imaging in
our patients; therefore, we do not know if the
symptoms they reported were truly related to
gastroesophageal reflux or if the symp toms were
related to another condition. Therefore, we do not
know if the improvement that was seen was truly
due to changes in gastric pH or decreasing reflux
time or if they are potentially attributable to other
reasons. The questionnaire that we used has been
well validated and does correlate highly with sen-
sitivity to the effects of GERD treatment.
Although all the patients in this study did
complain of GERD symptoms, this was not the
primary indication for surgery and the deg ree of
symptomatology varied among our cohort. There-
fore, our results are reflective of the general
population of patients undergoing parathyroid
surgery and may not be representative of the
subset of patients with more severe or refractory
GERD symptoms. Our findings will need to be
validated with additional studies in this popula-
tion. Interestingly, we did find that those patients
with the greatest symptoms pre-operatively were
the most likely to show improvem ent after PTX.
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Table II. Comparison between patients with >50% improvement in scores versus patients with <50%
improvement in scores after PTX
>50% improvement in
scores (n = 34, 67%)
<50% improvement in
scores (n = 17, 33%) P value
Age, years 60 ± 2 56 ± 3 .34
BMI, kg/m
2
31.2 ± 1.5 29.5 ± 1.5 .42
Preoperative calcium, mg/dL 10.6 ± 0.1 10.7 ± 0.3 .57
Preoperative PTH, pg/mL 142 ± 32 142 ± 34 1.0
25-hydroxy vitamin D, ng/mL 36 ± 3 36 ± 4 .91
Patients on antireflux medications
preoperatively, %
n = 20 (59%) n = 14 (82%) .09
Patients on antireflux medications
6 months postoperatively, %
n = 12 (34%) n = 14 (82%) .005
Average total preoperative score 12.1 ± 1.5 11.9 ± 2.3 .96
Average total postoperative score 1.1 ± 0.3 11.4 ± 1.1 <.0001
Data are presented as mean ± SEM.
BMI, Body mass index; PTH, parathyroid hormone; PTX, parathyroidectomy.
Surgery
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Reiher et al 1235
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DISCUSSION
Dr Keith Heller (New York, NY): Did you do any-
thing to control for the placebo effect of surgery?
Could you have used as a control a comparable
group of patients with GERD who had a thyroid lo-
bectomy, perhaps?
Dr Alexandra Reiher: We did not use thyroid pa-
tients as a control group. We did perform the post-
operative questionnaire 6 month s after PTX to
eliminate any placebo effect from the procedure.
Dr Wen Shen (San Francisco, CA): With Tums
being, obviously, a double agent, working both in
our realm of calcium supplementation, but also
for the symptoms of GERD, did you control for
people taking Tums as calcium supplementation
afterwards?
Dr Alexandra Reiher: You bring up an excellent
point. Again, having it be 6 months postopera-
tively, any treatment for transient hypocalcemia
or as prophylaxis had been resolved. With patients
who were taking more than 1,000 milligrams per
day, that was considered more than just calcium
supplementation.
Dr Wen Shen (San Francisco, CA): Did that
count within your preoperative GERD medication
list, Tums as well?
Dr Alexandra Reiher: Yes. Patients were asked if
they were on medications for heartburn and then
to describe it, and we looked at their doses as well.
Dr Marco Raffaelli (Rome, Italy): I would like to
know if you have any data about the diagnosis of
gastroesophageal reflux disease, if it was clinical
or if the patient had undergone an examination
before taking drugs. The second question, do
you have any data about the gastrin level s in this
group of patients that could be affected by their
calcium levels?
Dr Alexandra Reiher: If I understand your first
question regarding medications, the patients
were asked at the time of preoperative evaluation
if they had symptoms of heartburn. And if they
did, they completed the questionnaire. And then
those patients were followed postoperatively. We
did not perform any other measure of diagnosing
GERD, pre- or postoperatively. Regarding calcium
levels, postoperatively, the average calcium at 6
months was 9.4 in this group. Gastrin levels were
not measured.
Dr Ashok R. Shaha (New York, NY): One of the
best ways to evaluate the GERD effect is to perform
fiberoptic laryngoscopy and observe the laryngo-
pharyngeal changes. Another way is to measure
the pH levels. I know you did not do that, but
that may be something you may want to pursue if
you really feel that the PTX does have an effect
on GERD.
PTX does have an effect on general symptoms
of the patient, and I’m not sure whether the
patients are interpreting the general symptoms of
wellbeing or true GERD. So, in future, you may
want to look more criti cally at the pH value and
laryngoscopic findings.
Dr Alexandra Reiher: You bring up an excellent
point. And I agree that the next step would be to
use m ore diagnostic studies, such as pH monitor-
ing or endoscopy. But this study did look at specific
symptoms of GERD rather than just generalized
symptoms. So I think this is the next step towards
a study such as that.
Dr Quan-Yang Duh (San Francisco, CA): Did
any of these patients undergo manometry? The
gold standard of diagnosis would be esophageal
manometry.
Dr Alexandra Reiher: No, we did not use spe-
cific diagnostic tests. Although I think it’s
Surgery
December 2012
1236 Reiher et al
important to keep in the mind that GERD is re-
lated to how symptomatic it is for the patient,
and that guides management of GERD.
Dr Stuart Wilson (Milwaukee, WI): Quan Duh
stole some of my thunder, but I wanted to make
one comment and ask one question. I think it’s
been 31 year s ago, but right after our first annual
meeting, Bill Silen, who is one of our founding
members, was very interested in parathyroid dis-
ease and made really good observations. And he
had a group of about a dozen patients, and I think
he had talked 5 or 6 of them into esophageal
manometry. This was 31 years ago. And I think 4
of the 5 showed clearly that lower esophageal
sphincter (LES) pressure that was decreased be-
forehand had increased afterwards.
Now, of course, you can have a defect in esoph-
ageal hernia so they are not all going to respond,
but I think from a historical point of view that was
interesting. So I was going to ask one question if
you could separate out your responders and non-
responders by measuring LES pressure, because
the effect of calcium on motility of the esophagus
and LES, I think, is clear.
Surgery
Volume 152, Number 6
Reiher et al 1237
  • [Show abstract] [Hide abstract] ABSTRACT: Classical primary hyperparathyroidism (PHPT) was previously a multisystemic symptomatic disorder not only with overt skeletal and renal complications but also with neuropsychological, cardiovascular, gastrointestinal, and rheumatic effects. The presentation of PHPT has evolved, and today most patients are asymptomatic. Osteitis fibrosa cystica is rarely seen today, and nephrolithiasis is less common. Gastrointestinal and rheumatic symptoms are not part of the clinical spectrum of modern PHPT. It remains unclear whether neuropsychological symptoms and cardiovascular disease, neither of which are currently indications for recommending parathyroidectomy (PTX), are part of the modern phenotype of PHPT. A number of observational studies suggest that mild PHPT is associated with depression, decreased quality of life, and changes in cognition, but limited data from randomized controlled trials (RCTs) have not indicated consistent benefits after surgery. The increased cardiovascular morbidity and mortality in severe PHPT has not been definitively demonstrated in mild disease, although there is some evidence for more subtle cardiovascular abnormalities, such as increased vascular stiffness, among others. Results from observational studies that have assessed the effect of PTX on cardiovascular health have been conflicting. The single RCT in this area did not demonstrate that PTX was beneficial. Despite recent progress in these areas, more data from rigorously designed studies are needed to better inform the clinical management of patients with asymptomatic PHPT.
    Article · Feb 2013
  • [Show abstract] [Hide abstract] ABSTRACT: The aim of the present study was to investigate the incidence of sleep disturbance and insomnia in patients with primary hyperparathyroidism (PHPT), and to evaluate the effect of parathyroidectomy. A questionnaire was prospectively administered to adult patients with PHPT who underwent curative parathyroidectomy over an 11-month period. The questionnaire, administered preoperatively and 6 months postoperatively, included the Insomnia Severity Index (ISI) and eight additional questions regarding sleep pattern. Total ISI scores range from 0 to 28, with >7 signifying sleep difficulties and scores >14 indicating clinical insomnia. Of 197 eligible patients undergoing parathyroidectomy for PHPT, 115 (58.3 %) completed the preoperative and postoperative questionnaires. The mean age was 60.0 ± 1.2 years and 80.0 % were women. Preoperatively, 72 patients (62.6 %) had sleep difficulties, and 29 patients (25.2 %) met the criteria for clinical insomnia. Clinicopathologic variables were not predictive of clinical insomnia. There was a significant reduction in mean ISI score after parathyroidectomy (10.3 ± 0.6 vs 6.2 ± 0.5, p < 0.0001). Postoperatively, 79 patients (68.7 %) had an improved ISI score. Of the 29 patients with preoperative clinical insomnia, 21 (72.4 %) had resolution after parathyroidectomy. Preoperative insomnia patients had an increase in total hours slept after parathyroidectomy (5.4 ± 0.3 vs 6.1 ± 0.3 h, p = 0.02), whereas both insomnia patients and non-insomnia patients had a decrease in the number of awakenings (3.7 ± 0.4 vs 1.9 ± 0.2 times, p = 0.0001). Sleep disturbances and insomnia are common in patients with PHPT, and the majority of patients will improve after curative parathyroidectomy.
    Article · Oct 2013
  • [Show abstract] [Hide abstract] ABSTRACT: In minimally invasive surgery for primary hyperparathyroidism (HPT), intraoperative parathyroid hormone (IOPTH) monitoring assists in obtaining demonstrably better outcomes, but optimal criteria are controversial. The outcomes of 1,108 initial parathyroid operations for sporadic HPT using IOPTH monitoring from 1997 to 2011 were stratified by final post-resection IOPTH level. All patients had adequate follow-up to verify cure. With mean follow-up of 1.8 years (range 0.5-14.3 years), parathyroidectomy using IOPTH monitoring failed in 1.2 % of cases, with an additional 0.5 % incidence of long-term recurrence at a mean of 3.2 years (range 0.8-6.8 years) postoperatively. Operative success was equally likely with a final IOPTH drop to 41-65 pg/mL vs ≤40 pg/mL (p = 1). In the 76 patients with an elevated baseline IOPTH level that did not drop to ≤65 pg/mL, surgical failure was 43 times more likely than with a drop into normal range (13 vs. 0.3 %; p < 0.001). When the final IOPTH level dropped by >50 % but not into the normal range, surgical failure was 19 times more likely (3.8 vs. 0.2 %; p = 0.015). Long-term recurrence was more likely in patients with a final IOPTH level of 41-65 pg/mL than with a level ≤40 pg/mL (1.2 vs. 0; p = 0.016). Adjunctive intraoperative PTH monitoring facilitates a high cure rate for initial surgery of sporadic primary hyperparathyroidism. A final IOPTH level that is within the normal range and drops by >50 % from baseline is a strong predictor of operative success. Patients with a final IOPTH level between 41-65 pg/mL should be followed beyond 6 months for long-term recurrence.
    Article · Nov 2013
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