Top

Published in:

01-10-2018 | Original Scientific Report

Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism

Authors: Carolyn D. Seib, Kathryn Chomsky-Higgins, Jessica E. Gosnell, Wen T. Shen, Insoo Suh, Quan-Yang Duh, Emily Finlayson

Published in: World Journal of Surgery | Issue 10/2018

Abstract

Background

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that predominantly affects patients >60 and is increasing in prevalence. Identifying risk factors for poor outcomes after parathyroidectomy in older adults will help tailor operative decision making. The impact of frailty on surgical outcomes in parathyroidectomy has not been established.

Methods

We performed a retrospective review of patients ≥40 years who underwent parathyroidectomy in the 2005–2010 ACS NSQIP. Frailty was assessed using the modified frailty index (mFI). Multivariable regression was used to determine the association of frailty with 30-day complications, length of stay (LOS), and reoperation.

Results

We identified 13,123 patients ≥40 who underwent parathyroidectomy for PHPT. The majority of patients were not frail, with 80% with a low NSQIP mFI score (0–1 frailty traits), 19% with an intermediate mFI score (2–3), and 0.9% with a high mFI score (≥4). Overall 30-day complications were rare, occurring in 141 (1.1%) patients. Increasing frailty was associated with an increased risk of complications with adjusted odds ratios (ORs) of 1.76 (95% CI 1.20–2.59; p = 0.004) for intermediate and 8.43 (95% CI 4.33–16.41; p < 0.001) for high mFI score. Patient age was independently associated with an increased risk of complications only when ≥75, as was African-American race. Anesthesia with local, monitored anesthesia care, or regional block was the only factor associated with decreased odds of complications. A high NSQIP mFI was also associated with a significant 4.77-day adjusted increase in LOS (95% CI 4.28–5.25; p < 0.001) and increased odds of reoperation (OR 4.20, 95% CI 1.64–10.74; p = 0.003).

Conclusion

Patient frailty is associated with increased complications, reoperation and prolonged LOS in patients undergoing parathyroidectomy for PHPT. The risks of surgical management should be weighed against potential benefits in frail patients with PHPT to individualize treatment decisions in this vulnerable population.

Available only for authorised users

Yeh MW, Ituarte PHG, Zhou HC et al (2013) Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab 98:1122–1129CrossRefPubMedPubMedCentral

Yeh MW, Zhou H, Adams AL et al (2016) The relationship of parathyroidectomy and bisphosphonates with fracture risk in primary hyperparathyroidism an observational study fracture risk in primary hyperparathyroidism. Ann Intern Med 164:715–723CrossRefPubMed

Ambrogini E, Cetani F, Cianferotti L et al (2007) Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial. J Clin Endocrinol Metab 92:3114–3121CrossRefPubMed

Roman SA, Sosa JA, Pietrzak RH et al (2011) The effects of serum calcium and parathyroid hormone changes on psychological and cognitive function in patients undergoing parathyroidectomy for primary hyperparathyroidism. Ann Surg 253:131–137CrossRefPubMed

Wilhelm SM, Wang TS, Ruan DT et al (2016) The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg 151:959–968CrossRefPubMed

Wu B, Haigh PI, Hwang R et al (2010) Underutilization of parathyroidectomy in elderly patients with primary hyperparathyroidism. J Clin Endocrinol Metab 95:4324–4330CrossRefPubMedPubMedCentral

Kuo EJ, Al-Alusi MA, Du L et al (2017) Surgery for primary hyperparathyroidism: adherence to consensus guidelines in an Academic Health System. Ann Surg. https://doi.org/10.1097/SLA.0000000000002474 CrossRefPubMedPubMedCentral

Joseph B, Zangbar B, Pandit V et al (2016) Emergency general surgery in the elderly: too old or too frail? J Am Coll Surg 222:805–813CrossRefPubMed

Makary MA, Segev DL, Pronovost PJ et al (2010) Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 210:901–908CrossRefPubMed

10.

Oresanya LB, Lyons WL, Finlayson E (2014) Preoperative assessment of the older patient: a narrative review. JAMA 311:2110–2120CrossRefPubMed

11.

Robinson TN, Wallace JI, Wu DS et al (2011) Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient. J Am Coll Surg 213:37–42CrossRefPubMedPubMedCentral

12.

Seib CD, Rochefort H, Chomsky-Higgins K et al (2018) Association of patient frailty with increased morbidity after common ambulatory general surgery operations. JAMA Surg 153(2):160–168CrossRefPubMed

13.

Khavanin N, Mlodinow A, Kim JYS et al (2015) Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients. Ann Surg Oncol 22:429–436CrossRefPubMed

14.

Thomas DC, Roman SA, Sosa JA (2011) Parathyroidectomy in the elderly: analysis of 7313 patients. J Surg Res 170:240–246CrossRefPubMed

15.

Gani F, Canner JK, Pawlik TM (2017) Use of the modified frailty index in the American College of Surgeons National Surgical Improvement Program database: highlighting the problem of missing data. JAMA Surg 152:205–207CrossRefPubMed

16.

Khuri SF, Daley J, Henderson W et al (1998) The Department of Veterans Affairs’ NSQIP—the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Ann Surg 228:491–504CrossRefPubMedPubMedCentral

17.

Velanovich V, Antoine H, Swartz A et al (2013) Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database. J Surg Res 183:104–110CrossRefPubMed

18.

Calò PG, Medas F, Loi G et al (2017) Parathyroidectomy for primary hyperparathyroidism in the elderly: experience of a single endocrine surgery center. Aging Clin Exp Res 29:15–21CrossRefPubMed

19.

Dobrinja C, Silvestri M, de Manzini N (2012) Primary hyperparathyroidism in older people: surgical treatment with minimally invasive approaches and outcome. Int J Endocrinol 2012:6CrossRef

20.

Egan KR, Adler JT, Olson JE et al (2007) Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a risk–benefit analysis. J Surg Res 140:194–198CrossRefPubMed

21.

Kebebew E, Q-y D (2003) Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a plea for early surgical referral. Arch Surg 138:867–871CrossRefPubMed

22.

Shin SH, Holmes H, Bao R et al (2009) Outpatient minimally invasive parathyroidectomy is safe for elderly patients. J Am Coll Surg 208:1071–1076CrossRefPubMed

23.

Yeo H, Mehta P, Boudourakis L et al (2007) High price of endocrine surgery in octogenarians. J Am Coll Surg 205:S41CrossRef

24.

Mohanty S, Rosenthal RA, Russell MM et al (2016) Optimal perioperative management of the geriatric patient: a best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg 222:930–947CrossRefPubMed

25.

Noureldine SI, Abbas A, Tufano RP et al (2014) The impact of surgical volume on racial disparity in thyroid and parathyroid surgery. Ann Surg Oncol 21:2733–2739CrossRefPubMed

26.

Kandil E, Tsai HL, Somervell H et al (2008) African Americans present with more severe primary hyperparathyroidism than non-African Americans. Surgery 144:1023–1027CrossRefPubMed

27.

Kark AE, Kurzer MN, Belsham PA (1998) three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg 186:447–455CrossRefPubMed

28.

Chu C-C, Weng S-F, Chen K-T et al (2015) Propensity score–matched comparison of postoperative adverse outcomes between geriatric patients given a general or a neuraxial anesthetic for hip surgery: a population-based study. J Am Soc Anesthesiol 123:136–147CrossRef

29.

Carling T, Donovan P, Rinder C et al (2006) Minimally invasive parathyroidectomy using cervical block: reasons for conversion to general anesthesia. Arch Surg 141:401–404CrossRefPubMed

30.

Chau JK, Hoy M, Tsui B et al (2010) Minimally invasive parathyroidectomy under local anesthesia: patient satisfaction and overall outcome. J Otolaryngol Head Neck Surg 39(4):361PubMed

31.

Maisie L, Shindo M, Joshua M, Rosenthal M, Thomas Lee M (2008) Minimally invasive parathyroidectomy using local anesthesia with intravenous sedation and targeted approaches. Otolaryngol Head Neck Surg 138:381–387CrossRef

32.

Gani F, Canner JK, Pawlik TM (2017) Use of the modified frailty index in the american college of surgeons national surgical improvement program database: highlighting the problem of missing data. JAMA Surg 152(2):205–207CrossRefPubMed

33.

Berian JR, Mohanty S, Ko CY et al (2016) Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg 151:e161689CrossRefPubMed

Title: Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism
Authors: Carolyn D. Seib
Kathryn Chomsky-Higgins
Jessica E. Gosnell
Wen T. Shen
Insoo Suh
Quan-Yang Duh
Emily Finlayson
Publication date: 01-10-2018
Publisher: Springer International Publishing
Published in: World Journal of Surgery / Issue 10/2018
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-018-4629-3

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 10/2018

Exploring the Relationship Between Surgical Capacity and Output in Ghana: Current Capacity Assessments May Not Tell the Whole Story

Radical Gastrectomy After Chemotherapy May Prolong Survival in Stage IV Gastric Cancer: A Korean Multi-institutional Analysis

Intravenous Local Anaesthetic Compared with Intraperitoneal Local Anaesthetic in Abdominal Surgery: A Systematic Review

Routine Pathology and Postoperative Follow-Up are Not Cost-Effective in Cholecystectomy for Benign Gallbladder Disease

A Nationwide Assessment of Pediatric Surgical Capacity in Mongolia

Alternative Laparoscopic Intracorporeal Pringle Maneuver by Huang’s Loop