| Idioma original | English |
|---|---|
| Páginas (desde-hasta) | 297 |
| Número de páginas | 1 |
| Publicación | Journal of the American College of Surgeons |
| Volumen | 215 |
| N.º | 2 |
| DOI | |
| Estado | Published - ago 2012 |
Nota bibliográfica
Funding Information:Richard Hodin MD Massachusetts General Hospital Peter Angelos MD, PhD University of Chicago Sally Carty MD University of Pittsburgh Herb Chen MD University of Wisconsin Orlo Clark MD University of California, San Francisco Gerard Doherty MD Boston University Quan-Yang Duh MD University of California, San Francisco Douglas B. Evans MD Medical College of Wisconsin Keith Heller MD NYU Langone Medical Center William Inabnet MD Mt Sinai School of Medicine Electron Kebebew MD National Institutes of Health, National Cancer Institute Janice Pasieka MD University of Calgary Nancy Perrier MD MD Anderson Cancer Center Cord Sturgeon MD Northwestern University We read with interest the article by Norman and colleagues 1 regarding the abandonment of unilateral parathyroidectomy. It is clear from this report and many others that experienced endocrine surgeons are able to accomplish high cure rates with minimal morbidity using the standard bilateral approach. Although many questions can be raised with this study related to patient follow-up, outcomes in those patients with multigland disease, the definition of cure, etc, we would like to focus our letter on the main conclusion of the paper regarding the abandonment of unilateral parathyroidectomy. We believe this conclusion is based on flawed data and reasoning. The success of targeted parathyroid operations relies on 2 important recent developments in this field: improvements in preoperative imaging to identify the diseased gland(s) and intraoperative parathyroid hormone (ioPTH) monitoring to prove cure after excision of the diseased gland(s). Intraoperative PTH provides a functional assessment of adequate resection; 4-gland exploration provides an evaluation based on visual assessment of gland size and texture. Both methods have been validated to work well. The problem with this study is that these authors never used ioPTH, even when performing targeted operations. As such, the conclusions drawn from this series of patients cannot be applied to those who undergo targeted parathyroid operations that are based on both preoperative imaging and ioPTH monitoring, the standard approach used by most all endocrine surgeons. 2 Further, the subset analysis of previous surgeons' operative failures with unilateral or targeted parathyroid operations cannot be used to impugn ioPTH monitoring. The data presented on this patient subset (failures with ioPTH) represent a highly selected group of patients who had their initial, failed operations somewhere else and were then referred for reoperation. This flawed study design does not allow one to assess the outcomes of the ioPTH approach. To be clear, we are not arguing against the standard 4-gland operation, which, in fact, is appropriate for many patients. However, there are many large series of targeted parathyroid operations with ioPTH monitoring and accurate preoperative imaging (including SPECT sestamibi scans, ultrasonography, and/or CT scanning, based on institutional preference and expertise) that have shown excellent, long-term success rates comparable to those with bilateral exploration. The unilateral approach should not be abandoned.
Financiación
Richard Hodin MD Massachusetts General Hospital Peter Angelos MD, PhD University of Chicago Sally Carty MD University of Pittsburgh Herb Chen MD University of Wisconsin Orlo Clark MD University of California, San Francisco Gerard Doherty MD Boston University Quan-Yang Duh MD University of California, San Francisco Douglas B. Evans MD Medical College of Wisconsin Keith Heller MD NYU Langone Medical Center William Inabnet MD Mt Sinai School of Medicine Electron Kebebew MD National Institutes of Health, National Cancer Institute Janice Pasieka MD University of Calgary Nancy Perrier MD MD Anderson Cancer Center Cord Sturgeon MD Northwestern University We read with interest the article by Norman and colleagues 1 regarding the abandonment of unilateral parathyroidectomy. It is clear from this report and many others that experienced endocrine surgeons are able to accomplish high cure rates with minimal morbidity using the standard bilateral approach. Although many questions can be raised with this study related to patient follow-up, outcomes in those patients with multigland disease, the definition of cure, etc, we would like to focus our letter on the main conclusion of the paper regarding the abandonment of unilateral parathyroidectomy. We believe this conclusion is based on flawed data and reasoning. The success of targeted parathyroid operations relies on 2 important recent developments in this field: improvements in preoperative imaging to identify the diseased gland(s) and intraoperative parathyroid hormone (ioPTH) monitoring to prove cure after excision of the diseased gland(s). Intraoperative PTH provides a functional assessment of adequate resection; 4-gland exploration provides an evaluation based on visual assessment of gland size and texture. Both methods have been validated to work well. The problem with this study is that these authors never used ioPTH, even when performing targeted operations. As such, the conclusions drawn from this series of patients cannot be applied to those who undergo targeted parathyroid operations that are based on both preoperative imaging and ioPTH monitoring, the standard approach used by most all endocrine surgeons. 2 Further, the subset analysis of previous surgeons' operative failures with unilateral or targeted parathyroid operations cannot be used to impugn ioPTH monitoring. The data presented on this patient subset (failures with ioPTH) represent a highly selected group of patients who had their initial, failed operations somewhere else and were then referred for reoperation. This flawed study design does not allow one to assess the outcomes of the ioPTH approach. To be clear, we are not arguing against the standard 4-gland operation, which, in fact, is appropriate for many patients. However, there are many large series of targeted parathyroid operations with ioPTH monitoring and accurate preoperative imaging (including SPECT sestamibi scans, ultrasonography, and/or CT scanning, based on institutional preference and expertise) that have shown excellent, long-term success rates comparable to those with bilateral exploration. The unilateral approach should not be abandoned.
| Financiadores |
|---|
| National Institutes of Health (NIH) |
| National Childhood Cancer Registry – National Cancer Institute |
| Massachusetts General Hospital |
| University of California, Los Angeles |
| Department of Psychiatry, Columbia University Irving Medical Center, New York, USA; New York State Psychiatric Institute, New York, USA |
| Northwestern Polytechnical University |
| Boston University School of Public Health/Boston University Medical Campus |
| University of Texas Anderson Cancer Center |
| University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh |
| University of California San Francisco |
| Jikei University School of Medicine |
| University of Calgary |
ASJC Scopus subject areas
- General Medicine
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