SAN FRANCISCO – Surgical consultation is appropriate for all patients aged 80 years or older with primary hyperparathyroidism, the majority of whom will have a single adenoma, according to researchers from the University of Pennsylvania, Philadelphia, who evaluated safety and outcomes in the very elderly.
"General anesthesia for bilateral exploration can be performed safely in these older patients, and morbidity from parathyroidectomy is very low," said Dr. Parth Kishore Shah, a surgery resident who presented the study at the annual clinical congress of the American College of Surgeons.
Primary hyperparathyroidism is increasingly found to have a significant impact on quality of life in patients aged 80 years and older. The advantages of parathyroidectomy for primary hyperparathyroidism (pHPT) are well established, and include decreased risk of renal stones as well as improvements in constitutional symptoms, bone mineral density, and overall health-related quality of life.
The current indications for surgery include presence of symptoms, or, in asymptomatic patients, one of the following: age younger than 50 years; serum calcium 1 mg/dL above the upper limit of normal; 24-hour urinary calcium excretion less than 400 mg/24 hr; 30% reduction in creatinine clearance; diagnosis of osteoporosis; or difficulty in accomplishing medical surveillance.
"Patients aged 80 years and older, though, are often excluded from surgical management of pHPT because of their age, unappreciated symptoms, presence of comorbidities, and/or suspected high anesthesia and surgical risk," said Dr. Shah.
Large Database Analyzed
From a prospective database of 2,050 patients undergoing parathyroidectomy in 1997-2010, the investigators identified 61 patients aged 80 years or older and collected data on their preoperative clinical presentation, biochemical studies, intraoperative findings, and final pathology results.
Most patients (90%) were women, and the median age was 83 years. Presenting symptoms – including fatigue, mental impairment, depression, and bone pain – were observed in 48 patients (79%). All patients had evidence of osteoporosis, and comorbidities were also common, especially hypertension (69%).
The median preoperative calcium level was 11 mg/dL, and the median serum intact PTH level was 126 pg/mL. Two-thirds of patients had a positive preoperative localization.
In all, 13 patients (21%) were asymptomatic, and they met guidelines for parathyroidectomy in the following proportions: serum calcium level at least 1 mg/dL greater than normal (46%), 30% reduction in creatinine clearance (69%), and T score greater than –2.5 on DXA (dual-energy x-ray absorptiometry) scan to assess bone health (62%). More than half of the patients met more than one of the criteria, and 91% of the asymptomatic group had successful preoperative localization, Dr. Shah reported.
Operative Details and Pathology Results
General anesthesia was administered to 78%, whereas 19% had local anesthesia. Local was converted to general anesthesia in the remaining 3%. The method of parathyroidectomy was bilateral exploration in 49%, minimally invasive parathyroidectomy (MIP) in 41%, and MIP converted to bilateral in 10%. The median operative time was 86 minutes.
Intraoperative PTH (IOPTH) monitoring was done in 95% of patients, who had a mean IOPTH drop of 80%. A drop greater than 50% was observed in 95% of patients. "IOPTH monitoring can be used effectively in this group," Dr. Shah noted.
On final pathology review, 75% had a single adenoma, 17% had double adenomas, and 8% had four-gland hyperplasia. Presence of ectopic glands was noted in 7% of patients.
Procedure Found Safe
There were no postoperative deaths, and only four patients (6.6%) had complications, which were pneumothorax, stroke, aspiration, and reintubation for respiratory insufficiency. Complications were not related to any baseline or operative characteristics. Most patients (86%) were discharged in less than 24 hours.
"The morbidity from parathyroidectomy in this age group is very low and is comparable to that seen in patients younger than 80, although there appears to be a predilection for respiratory complications," Dr. Shah said.
Compared with a cohort of 122 patients younger than 80 years, the older patients were more likely to present with more than one symptom (62% vs. 37%; P = .001) and were more likely to have more than one comorbidity (46% vs. 30%; P = .05). The rates of general anesthesia and bilateral neck exploration were almost the same for the two age groups, as was the incidence of complications, except that there were more respiratory problems in the elderly.
"Our findings corroborate prior studies that report parathyroidectomy in patients aged 80 and older for pHPT can be safely performed, with little disruption to daily life," Dr. Shah concluded. "We believe that symptomatic patients with hypercalcemia in this age group should be strongly considered for surgery."
Dr. Shah reported no conflicts of interest.