DOCSLIB.ORG

Why We Reversed Our Position After 15000 Parathyroid Operations

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Why We Reversed Our Position After 15000 Parathyroid Operations ORIGINAL SCIENTIFIC ARTICLES Abandoning Unilateral Parathyroidectomy: Why We Reversed Our Position after 15,000 Parathyroid Operations James Norman, MD, FACS, FACE, Jose Lopez, MD, FACS, Douglas Politz, MD, FACS, FACE BACKGROUND: Our group championed the techniques and benefits of unilateral parathyroidectomy. As our experience has matured, it seems this limited operation might be appropriate only occasionally. METHODS: A single surgical group’s experience with 15,000 parathyroidectomies examined the ongoing differences between unilateral and bilateral techniques for 10-year failure/recurrence, multig- land removal, operative times, and length of stay. RESULTS: With limited experience, 100% of operations were bilateral, decreasing to 32% by the 500th operation (p Ͻ 0.001), and long-term failure rates increased to 6%. Failures were 11 times more likely for unilateral explorations (p Ͻ 0.001 vs bilateral), causing gradual increases in bilateral explorations to 97% at the 14,000th operation (p Ͻ 0.001). Ten-year cure rates are unchanged for bilateral operations, and unilateral operations show continued slow recurrence rates of 5% (p Ͻ 0.001). Removal of more than one gland occurred 16 times more frequently when 4 glands were analyzed (p Ͻ 0.001), increasing cure rates to the current 99.4% (p Ͻ 0.001). Of 1,060 reoperations performed for failure at another institution, intraoperative parathyroid hormone levels fell Ͼ50% in 22% of patients, yet a second adenoma was subsequently found. Operative times decreased with experience; bilateral operations taking only 5.9 minutes longer on average (22.3 vs 16.4 minutes; p Ͻ 0.001), which is 25 minutes less than unilateral at the 500th operation (p Ͻ 0.001). By the 1,000th operation, incision size (2.5 Ϯ 0.2 cm), anesthesia, and hospital stay (1.6 hours) were identical for unilateral and bilateral procedures. CONCLUSIONS: Regardless of surgical adjuncts (scanning, intraoperative parathyroid hormone), unilateral para- thyroidectomy will carry a 1-year failure rate of 3% to 5% and a 10-year recurrence rate of 4% to 6%. Allowing rapid analysis of all 4 glands through the same 1-inch incision has caused us to all but abandon unilateral parathyroidectomy. (J Am Coll Surg 2012;214:260–269. © 2012 by the American College of Surgeons) Primary hyperparathyroidism (pHPT) is a benign disease these small parathyroid tumors typically cause chronic fa- with malignant potential. Untreated, it is believed to carry tigue, memory loss, and a host of other nonspecific symp- a near 2-fold increase in development of several cancers (eg, toms associated with a considerable decrease in quality of breast, colon, prostate),1,2 and increases the risk of cardiac life.4,5 disease, hypertension, and stroke by more than double, Fortunately, pHPT is curable with removal of the source ultimately carrying a several-year decrease in life expec- of excess parathyroid hormone (PTH). In about 76% of tancy.3 Substantial if not severe osteoporosis will almost patients, the source is a single benign parathyroid tumor, always develop in affected patients, and 25% will get kid- and in the other 24% or so, there are 2, 3, or even 4 ney stones. Besides the damage to many organ systems, overproducing glands that need to be removed—all or in part.4 Because the number and location of the overproduc- ing glands are variable and usually not known before oper- Disclosure Information: Nothing to disclose. Presented at the American College of Surgeons 97th Annual Clinical Con- ation, the surgical techniques for removing these parathy- gress, San Francisco, CA, October 2011. roid tumors have historically included evaluation of all 4 Received October 24, 2011; Revised December 12, 2011; Accepted Decem- parathyroid glands to determine which of the glands needs ber 14, 2011. to be removed. As such, parathyroidectomy has necessi- From the Norman Parathyroid Center, Tampa, FL. tated general endotracheal anesthesia and bilateral explora- Correspondence address: James Norman, MD, FACS, FACE, Norman Para- thyroid Center, 2400 Cypress Glen Dr, Wesley Chapel, FL 33544. email: tion; an operation that typically includes a generous neck [email protected] incision and several hours of operating time. © 2012 by the American College of Surgeons ISSN 1072-7515/12/$36.00 Published by Elsevier Inc. 260 doi:10.1016/j.jamcollsurg.2011.12.007 Vol. 214, No. 3, March 2012 Norman et al Abandoning Unilateral Parathyroidectomy 261 be opened to remove another tumor. In retrospect, these Abbreviations and Acronyms tumors were present at the first operation, but were smaller IOPTH ϭ intraoperative parathyroid hormone and producing less PTH, so removal of the large parathy- pHPT ϭ primary hyperparathyroidism roid tumor gave the appearance that the patient was cured. PTH ϭ parathyroid hormone These patients did not have recurrent disease; they were never completely cured at their first operation. These pa- tients had persistent disease, it just was not completely With the advent of the sestamibi scan in the early 1990s apparent for some months or years after the operation. came the concept that a surgeon could know with high It slowly become obvious within our practice that the certainty which patients harbored a single bad gland and its only way to achieve a near 100% long-term cure rate was to location. Armed with a localizing study, the operation evaluate the physiologic activity of all 4 parathyroid glands could be conducted with a unilateral approach, allowing in virtually all people at their first operation. As such, we for a quicker, smaller operation. Our group was a principal gradually gave up on unilateral parathyroidectomy in al- advocate for the unilateral approach, publishing numerous most every instance by the end of 2006. This study outlines articles between 1994 and 2005 touting the benefits of, the progression of this concept and the long-term results of and techniques used in, unilateral minimally invasive unilateral vs bilateral parathyroidectomy in 15,000 pa- parathyroidectomy.6-17 We published studies showing that tients. Lessons learned here have important implications the vast majority of patients were best served by a unilateral for all surgeons performing parathyroidectomy, regardless operation if they had a localizing study showing a single of their level of expertise. gland, provided that some form of physiologic measure of hormone production was performed in the operating room METHODS to help assure that the source of the excess PTH had been removed. This method of unilateral operation has now be- Study design come common throughout the world, with expected cure A retrospective analysis was conducted of prospectively col- rates in the low to mid-90% range, depending on surgeon lected data on 15,060 consecutive patients undergoing experience.18-21 parathyroidectomy by one surgical group during an 18- By 2005, volume of our practice had grown to Ͼ1,000 year period ending April 2011. All patients had primary parathyroid operations annually. With this volume came hyperparathyroidism; patients with secondary (renal) or the requirement of higher and higher cure rates, as a 3% to tertiary (post-transplantation) hyperparathyroidism are 6% long-term failure rate causes considerably greater not included. All patients were selected for surgery based follow-up and management problems with such high sur- on the biochemical diagnosis of pHPT as outlined in detail gical volumes. By 2010, our volume had exceeded 2,000 by our group recently.4 Preoperative scanning was never used parathyroidectomies per year, necessitating the very highest as a determinant of surgery vs no surgery. As outlined here, we cure rates available. A confounding issue for our practice do not perform any scan before the morning of surgery. was that many patients travel long distances to our center. Other patients not included in this study were those who A noncured patient who lives 3,000 miles away has differ- had undescended parathyroid tumors necessitating a ent implications for our practice than that noncured pa- nonstandard neck incision high in the neck and those with tient who lives within our community. Another confound- mediastinal tumors necessitating some form of thoracot- ing issue for our practice was the gradual but considerable omy, because evaluation of all 4 parathyroid glands is not increase in referrals of patients with negative scans who possible during these operations. All patients signed a con- were not being afforded surgery by surgeons in their com- sent for review of their clinical data, which was collected in munity because they could not localize an adenoma preop- a nonidentifiable fashion in accordance with principles eratively. As our surgical volume increased, so too did the outlined in the Declaration of Helsinki and as required for percentage of complex and/or scan-negative patients. our IRB approval. During the course of performing thousands of parathy- roidectomies, it became clear that there was no maneuver Patient groups we could perform preoperatively or intraoperatively that For purposes of comparisons, the 15,060 patients have would assure us that all abnormal parathyroid tissue had been divided into 2 groups: group 1 consists of 14,000 been removed—short of the direct evaluation of the other patients undergoing their first parathyroid operation glands. Patients who we were convinced were cured some (which was performed by the authors). This group was years earlier were showing up again with abnormal calcium used to establish short and
Load more

Recommended publications
  • When Is It Minimally Invasive?
    ORIGINAL ARTICLE Incision Length for Standard Thyroidectomy and Parathyroidectomy When Is It Minimally Invasive? Laurent Brunaud, MD; Rasa Zarnegar, MD; Nobuyuki Wada, MD; Philip Ituarte, PhD; Orlo H. Clark, MD; Quan-Yang Duh, MD Hypothesis: Current techniques for open conven- parathyroidectomy (PϽ.001). It was 4.1 cm for bilateral tional thyroidectomy or parathyroidectomy have evolved parathyroid exploration, but was reduced to 3.2 and 2.8 to enable a shorter incision (main proposition), and the cm for unilateral (PϽ.001) and focal (PϽ.001) explora- length of the incision is influenced by objective factors. tions, respectively. By multiple regression analysis, thy- roid specimen volume and patient body mass index were Design: Case series. independent predictors of incision length in thyroidec- tomy. Extent of exploration and resident training level Setting: University referral center. were independent predictors of incision length in parathyroidectomy. Patients and Intervention: Retrospective study of the most recent 200 primary consecutive routine thyroid and Conclusions: Current techniques for open conven- parathyroid operations (excluding neck dissections). tional thyroidectomy or parathyroidectomy have evolved to enable a shorter incision. Thyroid volume, patient body Main Outcome Measures: The length of incision was mass index, extent of the planned parathyroid explora- routinely measured with a ruler before the incision. tion, and the resident clinical training stage are impor- Univariate and multivariate analysis was performed to dis- tant variables for incision length in open operation and tinguish variables affecting length of incision. should be taken into account when minimally invasive thyroidectomy and parathyroidectomy are evaluated. Results: Mean length of the incision was 5.5 cm for to- tal thyroidectomy, 4.6 cm for lobectomy, and 3.5 cm for Arch Surg.
    [Show full text]
  • Inadvertent Parathyroidectomy During Thyroid Surgery for Papillary Thyroid Carcinoma and Postoperative Hypocalcemia
    ORIGINAL J Korean Thyroid Assoc ARTICLE Vol. 5, No. 1, May 2012 Inadvertent Parathyroidectomy during Thyroid Surgery for Papillary Thyroid Carcinoma and Postoperative Hypocalcemia Dongbin Ahn, MD1, Jin Ho Sohn, MD, PhD1, Jae Hyug Kim, MD1, Ji Young Park, MD2 and Junesik Park, MD, PhD3 Departments of Otolaryngology-Head and Neck Surgery1, Pathology2, School of Medicine, Kyungpook National University, Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Catholic University of Daegu3, Daegu, Korea Background and Objectives: The aim of this article is to report our experience of inadvertent parathyroidectomy during thyroid surgery and to analyze its associated factors and clinical implications. In addition, we attempted to determined causative factors that result in permanent hypocalcemia after thyroid surgery. Materials and Methods: We performed a retrospective review of 500 patients who underwent thyroid surgery for the treatment of papillary thyroid carcinoma from 2004 to 2008. Results: Inadvertent parathyroidectomy was identified in 7.4% of patients and only 1 parathyroid gland was inadvertently removed in most cases. The incidence of inadvertent parathyroidectomy was not associated with gender, age, type of surgical procedure, tumor size, coexisting Hashimoto’s thyroiditis (HT), extra-thyroidal extension (ETE), lymph node (LN) metastasis, and surgeon’s experience. Nor was inadvertent parathyroidectomy associated with permanent postoperative hypocalcemia. Although operating time >120 min, ETE, and total thyroidectomy (TT) with central neck dissection (CND) were found to be related to permanent hypocalcemia on univariate analysis, tumor size ≥1 cm and surgeon’s experience ≤5 years was statistically associated with permanent hypocalcemia on both univariate and multivariate analyses. Conclusion: Although inadvertent parathyroidectomy is not an uncommon complication of thyroid surgery, it appears to have only modest clinical implications.
    [Show full text]
  • Postoperative Calcium Requirements in 6000 Patients Undergoing
    Postoperative Calcium Requirements in 6,000 Patients Undergoing Outpatient Parathyroidectomy: Easily Avoiding Symptomatic Hypocalcemia Marie Vasher, MD, Arnold Goodman, MD, FACS, Douglas Politz, MD, FACS, FACE, James Norman, MD, FACS, FACE BACKGROUND: To determine the amount and duration of supplemental oral calcium for patients with varying clinical presentations discharged immediately after surgery for primary hyperparathyroidism. STUDY DESIGN: A 4-year, prospective, single-institution study of 6,000 patients undergoing parathyroidectomy for primary hyperparathyroidism and discharged within 2.5 hours. Based on our previous studies, patients are started on a sliding scale of oral calcium determined by a number of preoperative measures (ie, serum calcium, body weight, osteoporosis) beginning 3 hours post- operation and decreasing to a maintenance dose by week 3. Patients reported all hypocalcemia symptoms daily for 2 weeks. RESULTS: Seven parameters were found to have a substantial impact on the amount of calcium required to prevent symptomatic hypocalcemia: preoperative serum calcium Ͼ12 mg/dL, Ͼ13 mg/dL, and Ͼ13.5 mg/dL, bone density T score less than Ϫ3, morbid obesity, removal of Ͼ1 parathyroid, and manipulation/biopsy of all remaining glands (all p Ͻ 0.05). Each independent variable increased the daily calcium required by 315 mg/day. Using our scaled protocol, Ͻ8% of patients showed symptoms of hypocalcemia, nearly all of whom were successfully self-treated with additional oral calcium. Only 6 patients (0.1%) required a visit to the emergency room for IV calcium, all occurring on postoperative day 3 or later. CONCLUSION: After outpatient parathyroidectomy, a specific calcium protocol has been verified that elimi- nates development of symptomatic hypocalcemia in Ͼ92% of patients, identifies patients at high risk for hypocalcemia, and allows self-medication with confidence in a predictable fashion for those patients in whom symptoms develop.
    [Show full text]
  • Radioguided Surgery of Primary Hyperparathyroidism Using the Low
    Radioguided Surgery of Primary Hyperparathyroidism Using the Low-Dose 99mTc- Sestamibi Protocol: Multiinstitutional Experience from the Italian Study Group on Radioguided Surgery and Immunoscintigraphy (GISCRIS) Domenico Rubello, MD1; Maria Rosa Pelizzo, MD2; Giuseppe Boni, MD3; Riccardo Schiavo, MD4; Luca Vaggelli, MD5; Giuseppe Villa, MD6; Sergio Sandrucci, MD7; Andrea Piotto, MD2; Gianpiero Manca, MD3; Pierluigi Marini, MD8; and Giuliano Mariani, MD3 1Nuclear Medicine Service, “S. Maria della Misericordia” Hospital, Rovigo, Italy; 2Department of Surgery, University of Padua Medical School, Padua, Italy; 3Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, Italy; 4Nuclear Medicine Service, “S. Camillo-Forlanini” Hospital, Rome, Italy; 5Nuclear Medicine Service, “Careggi” University Hospital, Florence, Italy; 6Nuclear Medicine Service, “S. Martino” University Hospital, Genoa, Italy; 7Department of Surgery, University of Turin Medical School, Turin, Italy; and 8Division of Surgery, “S. Camillo-Forlanini” Hospital, Rome, Italy (11%) of transient postoperative hypocalcemia. The probe was 99m This study evaluated the accuracy of 99mTc-sestamibi scintigra- of little help in patients with concomitant Tc-sestamibi–avid phy and neck ultrasonography in patients with primary hyper- thyroid nodules and not helpful at all in patients with negative parathyroidism (PHPT) and the role of intraoperative hand-held scan findings preoperatively. IQPTH measurement helped to ␥-probes in minimally invasive radioguided surgery (MIRS) of disclose some cases of multigland parathyroid disease. Con- patients with a high likelihood of a solitary parathyroid adenoma clusion: 99mTc-Sestamibi scintigraphy, especially if combined (PA). The study was undertaken under the aegis of the Italian with neck ultrasonography, is highly accurate in selecting PHPT Study Group on Radioguided Surgery and Immunoscintigraphy candidates for MIRS.
    [Show full text]
  • Minimally Invasive Parathyroidectomy Versus Bilateral Neck Exploration for Primary Hyperparathyroidism
    Minimally Invasive Parathyroidectomy Versus Bilateral Neck Exploration for Primary Hyperparathyroidism Amanda M. Laird, MD*, Steven K. Libutti, MD KEYWORDS Primary hyperparathyroidism Parathyroidectomy Intraoperative parathyroid hormone Surgery Minimally invasive parathyroidectomy KEY POINTS The gold-standard surgical management of primary hyperparathyroidism (10HPT) is cer- vical exploration and identification of all 4 parathyroid glands. Imaging techniques, including ultrasound, sestamibi scans, and 4D-CT scans, have made identification of single parathyroid adenomas possible. Intraoperative parathyroid hormone (PTH) monitoring is a method to confirm biochemical cure before a patient leaves the operating room. There is some debate surrounding optimal surgical management of 10HPT because cure rates between minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE) are equivalent. Advantages of MIP include reduced operative time, reduced recovery time, less postop- erative pain, and lower complication rate with respect to injury to parathyroid glands and recurrent laryngeal nerves. INTRODUCTION 10HPT is a common disease, with a prevalence as high as 3%.1 Many advances in the surgical management of 10HPT have been made since the first parathyroidectomy was performed by Felix Mandl in 1925.2 Traditional surgical management consists of identification of all 4 parathyroid glands through a transverse cervical incision.3 Bet- ter understanding of the disease, interest in the practice of endocrine neck surgery, The authors have nothing to disclose. Montefiore Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 3400 Bainbridge Avenue, 4th Floor, Bronx, NY 10467, USA * Corresponding author. E-mail address: [email protected] Surg Oncol Clin N Am 25 (2016) 103–118 http://dx.doi.org/10.1016/j.soc.2015.08.012 surgonc.theclinics.com 1055-3207/16/$ – see front matter Ó 2016 Elsevier Inc.
    [Show full text]
  • Advances in Risk-Oriented Surgery for Multiple Endocrine Neoplasia Type 2
    25 2 Endocrine-Related A Machens et al. Advances in risk-oriented 25:2 T41–T52 Cancer surgery for MEN2 THEMATIC REVIEW Advances in risk-oriented surgery for multiple endocrine neoplasia type 2 Andreas Machens1 and Henning Dralle2 1Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle, Saale, Germany 2Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany Correspondence should be addressed to A Machens: [email protected] This paper is part of a thematic review section on 25 Years of RET and MEN2. The guest editors for this section were Lois Mulligan and Frank Weber. Abstract Genetic association studies hinge on definite clinical case definitions of the disease of Key Words interest. This is why more penetrant mutations were overrepresented in early multiple f biochemical screening endocrine neoplasia type 2 (MEN2) studies, whereas less penetrant mutations went f DNA-based screening underrepresented. Enrichment of genetic association studies with advanced disease f RET proto-oncogene may produce a flawed understanding of disease evolution, precipitating far-reaching f gene test surgical strategies like bilateral total adrenalectomy and 4-gland parathyroidectomy in f gene carrier MEN2. The insight into the natural course of the disease gleaned over the past 25 years f multiple endocrine caused a paradigm shift in MEN2: from the removal of target organs at the expense of neoplasia type 2A greater operative
    [Show full text]
  • Analysis of the Role of Thyroidectomy and Thymectomy in the Surgical Treatment of Secondary Hyperparathyroidism
    Am J Otolaryngol 40 (2019) 67–69 Contents lists available at ScienceDirect Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto Analysis of the role of thyroidectomy and thymectomy in the surgical ☆ treatment of secondary hyperparathyroidism T Mateus R. Soares, Graziela V. Cavalcanti, Ricardo Iwakura, Leandro J. Lucca, Elen A. Romão, ⁎ Luiz C. Conti de Freitas Division of Head and Neck Surgery, Department of Ophthalmology, Otolaryngology, Head and Neck Surgery, Ribeirao Preto Medical School, University of Sao Paulo, Brazil ARTICLE INFO ABSTRACT Keywords: Purpose: Parathyroidectomy can be subtotal or total with an autograft for the treatment of renal hyperpar- Parathyroidectomy athyroidism. In both cases, it may be extended with bilateral thymectomy and total or partial thyroidectomy. Hyperparathyroidism Thymectomy may be recommended in combination with parathyroidectomy in order to prevent mediastinal Thymectomy recurrence. Also, the occurrence of thyroid disease observed in patients with hyperparathyroidism is poorly Thyroidectomy understood and the incidence of cancer is controversial. The aim of the present study was to report the ex- perience of a single center in the surgical treatment of renal hyperparathyroidism and to analyse the role of thyroid and thymus surgery in association with parathyroidectomy. Materials and methods: We analysed parathyroid surgery data, considering patient demographics, such as age and gender, and surgical procedure data, such as type of hyperparathyroidism, associated thyroid or thymus surgery, surgical duration and mediastinal recurrence. Histopathological results of thyroid and thymus samples were also analysed. Results: Medical records of 109 patients who underwent parathyroidectomy for secondary hyperparathyroidism were reviewed. On average, thymectomy did not have impact on time of parathyroidectomy (p = 0.62) even when thyroidectomy was included (p = 0.91).
    [Show full text]
  • Icd-9-Cm (2010)
    ICD-9-CM (2010) PROCEDURE CODE LONG DESCRIPTION SHORT DESCRIPTION 0001 Therapeutic ultrasound of vessels of head and neck Ther ult head & neck ves 0002 Therapeutic ultrasound of heart Ther ultrasound of heart 0003 Therapeutic ultrasound of peripheral vascular vessels Ther ult peripheral ves 0009 Other therapeutic ultrasound Other therapeutic ultsnd 0010 Implantation of chemotherapeutic agent Implant chemothera agent 0011 Infusion of drotrecogin alfa (activated) Infus drotrecogin alfa 0012 Administration of inhaled nitric oxide Adm inhal nitric oxide 0013 Injection or infusion of nesiritide Inject/infus nesiritide 0014 Injection or infusion of oxazolidinone class of antibiotics Injection oxazolidinone 0015 High-dose infusion interleukin-2 [IL-2] High-dose infusion IL-2 0016 Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance Pressurized treat graft 0017 Infusion of vasopressor agent Infusion of vasopressor 0018 Infusion of immunosuppressive antibody therapy Infus immunosup antibody 0019 Disruption of blood brain barrier via infusion [BBBD] BBBD via infusion 0021 Intravascular imaging of extracranial cerebral vessels IVUS extracran cereb ves 0022 Intravascular imaging of intrathoracic vessels IVUS intrathoracic ves 0023 Intravascular imaging of peripheral vessels IVUS peripheral vessels 0024 Intravascular imaging of coronary vessels IVUS coronary vessels 0025 Intravascular imaging of renal vessels IVUS renal vessels 0028 Intravascular imaging, other specified vessel(s) Intravascul imaging NEC 0029 Intravascular
    [Show full text]
  • 1 Annex 2. AHRQ ICD-9 Procedure Codes 0044 PROC-VESSEL
    Annex 2. AHRQ ICD-9 Procedure Codes 0044 PROC-VESSEL BIFURCATION OCT06- 0201 LINEAR CRANIECTOMY 0050 IMPL CRT PACEMAKER SYS 0202 ELEVATE SKULL FX FRAGMNT 0051 IMPL CRT DEFIBRILLAT SYS 0203 SKULL FLAP FORMATION 0052 IMP/REP LEAD LF VEN SYS 0204 BONE GRAFT TO SKULL 0053 IMP/REP CRT PACEMAKR GEN 0205 SKULL PLATE INSERTION 0054 IMP/REP CRT DEFIB GENAT 0206 CRANIAL OSTEOPLASTY NEC 0056 INS/REP IMPL SENSOR LEAD OCT06- 0207 SKULL PLATE REMOVAL 0057 IMP/REP SUBCUE CARD DEV OCT06- 0211 SIMPLE SUTURE OF DURA 0061 PERC ANGIO PRECEREB VES (OCT 04) 0212 BRAIN MENINGE REPAIR NEC 0062 PERC ANGIO INTRACRAN VES (OCT 04) 0213 MENINGE VESSEL LIGATION 0066 PTCA OR CORONARY ATHER OCT05- 0214 CHOROID PLEXECTOMY 0070 REV HIP REPL-ACETAB/FEM OCT05- 022 VENTRICULOSTOMY 0071 REV HIP REPL-ACETAB COMP OCT05- 0231 VENTRICL SHUNT-HEAD/NECK 0072 REV HIP REPL-FEM COMP OCT05- 0232 VENTRI SHUNT-CIRCULA SYS 0073 REV HIP REPL-LINER/HEAD OCT05- 0233 VENTRICL SHUNT-THORAX 0074 HIP REPL SURF-METAL/POLY OCT05- 0234 VENTRICL SHUNT-ABDOMEN 0075 HIP REP SURF-METAL/METAL OCT05- 0235 VENTRI SHUNT-UNINARY SYS 0076 HIP REP SURF-CERMC/CERMC OCT05- 0239 OTHER VENTRICULAR SHUNT 0077 HIP REPL SURF-CERMC/POLY OCT06- 0242 REPLACE VENTRICLE SHUNT 0080 REV KNEE REPLACEMT-TOTAL OCT05- 0243 REMOVE VENTRICLE SHUNT 0081 REV KNEE REPL-TIBIA COMP OCT05- 0291 LYSIS CORTICAL ADHESION 0082 REV KNEE REPL-FEMUR COMP OCT05- 0292 BRAIN REPAIR 0083 REV KNEE REPLACE-PATELLA OCT05- 0293 IMPLANT BRAIN STIMULATOR 0084 REV KNEE REPL-TIBIA LIN OCT05- 0294 INSERT/REPLAC SKULL TONG 0085 RESRF HIPTOTAL-ACET/FEM
    [Show full text]
  • The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism
    Supplementary Online Content Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. Published online August 10, 2016. doi:10.1001/jamasurg.2016.2310. eAppendix. The American Association of Endocrine Surgeons (AAES) Guidelines for Definitive Management of Primary Hyperparathyroidism eTable 1. Table of Contents: The American Association of Endocrine Surgeons (AAES) Guidelines for Definitive Management of Primary Hyperparathyroidism eTable 2. Common Secondary Causes of Elevated PTH Levels eTable 3. Selected Results of the Two Most Commonly Utilized IPM Protocols eTable 4. Parathyroid Carcinoma in Large Retrospective Series This supplementary material has been provided by the authors to give readers additional information about their work. © 2016 American Medical Association. All rights reserved. 1 eAppendix. The American Association of Endocrine Surgeons (AAES) Guidelines for Definitive Management of Primary Hyperparathyroidism ABSTRACT Importance 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. Objective To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review A multidisciplinary panel used PubMed to reviewed 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. Findings 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.
    [Show full text]
  • Neuropsychological Neurology the Neurocognitive Impairments of Neurological Disorders Second Edition
    more information - www.cambridge.org/9781107607606 Neuropsychological Neurology The Neurocognitive Impairments of Neurological Disorders Second Edition Neuropsychological Neurology The Neurocognitive Impairments of Neurological Disorders Second Edition A. J. Larner Consultant Neurologist Cognitive Function Clinic Walton Centre for Neurology and Neurosurgery Liverpool, UK cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, Sao˜ Paulo, Delhi, Mexico City Cambridge University Press The Edinburgh Building, Cambridge CB28RU,UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9781107607606 Second edition c A. J. Larner 2013 First edition c A. J. Larner 2008 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. Second edition first published 2013 First edition first published 2008 Printed and bound in the United Kingdom by the MPG Books Group A catalogue record for this publication is available from the British Library Library of Congress Cataloguing in Publication data Larner, A. J. Neuropsychological neurology : the neurocognitive impairments of neurological disorders / A.J. Larner. – 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-107-60760-6 (pbk.) I. Title. [DNLM: 1. Nervous System Diseases – complications. 2. Cognition Disorders – physiopathology. 3. Neuropsychology – methods. WL 140] RC553.C64 616.8 – dc23 2013006091 ISBN 978-1-107-60760-6 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
    [Show full text]
  • (CCSR) for ICD-10-PCS PROCEDURES, V2021.1
    USER GUIDE: CLINICAL CLASSIFICATIONS SOFTWARE REFINED (CCSR) FOR ICD-10-PCS PROCEDURES, v2021.1 Issued December 2020 Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP) Phone: (866) 290-HCUP (4287) Email: [email protected] Website: www.hcup-us.ahrq.gov TABLE OF CONTENTS What’s New in v2021.1 of the Clinical Classifications Software Refined (CCSR) for ICD-10-PCS Procedures? .............................................................................................................................. 1 Introduction ................................................................................................................................ 2 Comparison of the CCSR for ICD-10-PCS, the Beta Versions of the CCS for ICD-10-PCS, and the CCS for ICD-9-CM ............................................................................................................... 3 Description of the CCSR for ICD-10-PCS .................................................................................. 4 Understanding the Taxonomy of the ICD-10-PCS Procedure Codes ...................................... 4 The Structure of the CCSR for ICD-10-PCS ........................................................................... 7 General Assignment Guidelines .........................................................................................11 Using the CCSR to Trend ICD-10-PCS Across Data Years .......................................................12 Using the Downloadable CCSR Files ........................................................................................12
    [Show full text]