title: The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism.
abstract: 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.
  
  
  
  To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy.
  
  
  
  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.
  
  
  
  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.
  
  
  
  Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.
authors.affiliation: Department of Surgery, University Hospitals/Case Medical Center, Cleveland, Ohio.
authors.forename: Scott M
authors.initials: SM
authors.lastname: Wilhelm
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee.
authors.forename: Tracy S
authors.initials: TS
authors.lastname: Wang
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Daniel T
authors.initials: DT
authors.lastname: Ruan
authors.affiliation: Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.
authors.forename: James A
authors.initials: JA
authors.lastname: Lee
authors.affiliation: Department of Pathology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Sylvia L
authors.initials: SL
authors.lastname: Asa
authors.affiliation: Department of Surgery, University of California San Francisco Medical Center, San Francisco.
authors.forename: Quan-Yang
authors.initials: QY
authors.lastname: Duh
authors.affiliation: Department of Surgery, Boston University, Boston, Massachusetts.
authors.forename: Gerard M
authors.initials: GM
authors.lastname: Doherty
authors.affiliation: Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
authors.forename: Miguel F
authors.initials: MF
authors.lastname: Herrera
authors.affiliation: Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Janice L
authors.initials: JL
authors.lastname: Pasieka
authors.affiliation: Department of Surgery, MD Anderson Cancer Center, Houston, Texas.
authors.forename: Nancy D
authors.initials: ND
authors.lastname: Perrier
authors.affiliation: Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.
authors.forename: Shonni J
authors.initials: SJ
authors.lastname: Silverberg
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Carmen C
authors.initials: CC
authors.lastname: Solórzano
authors.affiliation: Department of Surgery, Northwestern University, Chicago, Illinois.
authors.forename: Cord
authors.initials: C
authors.lastname: Sturgeon
authors.affiliation: Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Mitchell E
authors.initials: ME
authors.lastname: Tublin
authors.affiliation: Department of Surgery, Yale University, New Haven, Connecticut.
authors.forename: Robert
authors.initials: R
authors.lastname: Udelsman
authors.affiliation: Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Sally E
authors.initials: SE
authors.lastname: Carty
mesh_terms: D064592:Autografts; D004704:Endocrinology / Q000592:standards*; D006801:Humans; D006961:Hyperparathyroidism / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000601:surgery*; D010280:Parathyroid Glands / Q000637:transplantation; D016105:Parathyroidectomy / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D019990:Perioperative Care; D011183:Postoperative Complications / Q000175:diagnosis; D013043:Specialties, Surgical / Q000592:standards*