PAPER

Surgical Treatment of Hyperparathyroidism

Improves Health-Related Quality of Life
David G. Sheldon, MD; Faye T. Lee, RN; Nancy J. Neil, PhD; John A. Ryan, Jr, MD

Hypothesis: The surgical treatment of primary hyperparathyroidism results in an improved health-related

quality of life.

Main Outcome Measures: Statistical analysis of preoperative and postoperative SF-36 scores, and comparisons with national norms.

Design: Prospective cohort analysis of consecutive patients with primary hyperparathyroidism analyzed preoperatively and 1 year postoperatively.

Results: The SF-36 was completed preoperatively and

Setting: Academic multispecialty referral clinic.

Patients: We prospectively evaluated 74 consecutive

patients who underwent parathyroid exploration for primary hyperparathyroidism during a 15-month period.
Interventions: The Medical Outcomes Study ShortForm Health Survey (SF-36) was administered before consultation with a surgeon. Patients were categorized based
on reason for referral as either asymptomatic (group 1;
n = 43) or symptomatic (group 2; n = 29). All patients
underwent parathyroid exploration and normalization of
calcium levels postoperatively. The SF-36 was then readministered after 1 year.

T
From the Section of General,
Thoracic, and Vascular Surgery
(Drs Sheldon and Ryan and
Ms Lee) and Clinical Decision
Support (Dr Neil), Virginia
Mason Medical Center, Seattle,
Wash. The authors have no
commercial, proprietary, or
financial interest in any of the
products or companies
mentioned in this article.

1 year postoperatively by 72 (97%) of 74 patients. When

the results were compared with published national norms,
the preoperative population was significantly impaired
in 5 of 8 domains, whereas the postoperative one had
improved and was nearly indistinguishable from the norm.
In 7 of 8 domains, the postoperative scores were significantly improved compared with preoperative scores.
Group 1 patients showed significant preoperative impairment in 3 domains and significantly improved in 2,
whereas group 2 patients showed significant impairment and improvement in 7 domains.
Conclusion: The surgical treatment of primary hyper-

parathyroidism is associated with durable, statistically significant improvements in health-related quality of life.
Arch Surg. 2002;137:1022-1028

HE MORBIDITY of primary hy-

perparathyroidism can range

from subtle to severe. Primary hyperparathyroidism is
associated with nephrolithiasis, osteoporosis, peptic ulcers, pancreatitis, renal failure, cardiovascular disease, and
premature death.1-3 Patients without classic symptoms may experience hypertension, depression, and a host of nonspecific
neuromuscular symptoms including
fatigue.2,4-7 All of these conditions may be
reversible with a successful parathyroidectomy.2,4,8
Despite the fact that operation for primary hyperparathyroidism offers the benefit of a cure with minimal morbidity, there
is continued controversy concerning the
need for intervention in the mildly symptomatic patient. Indications for operative

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1022

intervention in the asymptomatic patient

were proposed at the 1991 National Institutes of Health (NIH) Consensus Development Conference.9 The conference
did not address the neuropsychiatric manifestations of the disease or the healthrelated quality of life in primary hyperparathyroidism.
We believe that most patients with
primary hyperparathyroidism have an impaired health-related quality of life. Our
hypothesis was that a successful parathyroid operation would improve functional
health status. We studied health status before and after parathyroidectomy in all patients referred for primary hyperparathyroidism. The Medical Outcomes Study
Short-Form Health Survey (SF-36),10 a
multidimensional health assessment tool,
was used to objectively document pa-

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tients functional status and compare quality of life with

national norms.
PATIENTS AND METHODS
Seventy-four consecutive patients who were referred to a
single surgeon for primary hyperparathyroidism were prospectively studied during a 15-month period. No patient with
the diagnosis of primary hyperparathyroidism was excluded.
Prior to an initial surgical consultation, informed consent was
obtained for study purposes, and patients completed the
SF-36. The SF-36 is designed to assess overall functional status and well-being for adult patients compared with agematched US population norms. The form has 36 questions
that assess 8 specific health domains: general health perception, physical function, social function, role limitations attributed to physical problems, role limitations attributed to social
problems, bodily pain, mental health, and energy/fatigue. This
instrument was selected because it is practical, well suited for
clinical use, and inexpensive and has been validated in a variety of disease conditions in adults, including primary
hyperparathyroidism.11-16
A medical history, physical examination, and appropriate serum and/or urine chemistry values confirmed primary hyperparathyroidism in all patients. All of them underwent preoperative localization studies similar to our previously described
protocol.17 Patients were categorized into 2 groups based on
the characterization of their hyperparathyroidism by their referring physician. Group 1 patients were thought to be without symptoms attributable to this condition. We labeled this
group asymptomatic. Group 2 patients were referred by their
physician for classic symptoms of hyperparathyroidism. We labeled this group symptomatic.
Table 1. Primary Reason for Referral to a Surgeon*
No. of Patients
Group 1: asymptomatic (n = 43)
Abnormal DEXA scan result
Persistent hypercalcemia
Young age (50 y)
Group 2: symptomatic (n = 29)
Nephrolithiasis
Fatigue
Mental status changes
Life-threatening hypercalcemia
Fracture
Thirst and polyuria

32
8
3
11
10
3
2
2
1

*Some patients had multiple reasons for referral. The table lists what the
referring physician perceived was the primary indication for parathyroidectomy. DEXA indicates dual-energy x-ray absorptiometry.

Parathyroid exploration was then performed in all

patients. Type of operative procedure, pathologic results,
postoperative morbidity, length of hospital stay, and postoperative serum calcium levels were recorded. One year following the procedure, a second SF-36 questionnaire was mailed
to the patient and returned for analysis. Preoperative and
postoperative responses were pooled and compared with agematched national norms. In each domain of the SF-36, we
established a 95% confidence interval (1.96 SEM) based on
the scale score for the norm. Statistical significance was
defined as a pooled patient score falling outside of the 95%
confidence interval in each domain.13,18 Quantitative analysis
of each patients preoperative and postoperative SF-36
responses was accomplished using paired comparisons with
the Wilcoxon rank sum test.
RESULTS

The study population included 72 (97%) of 74 patients

who completed both the preoperative and postoperative
SF-36 questionnaires. Group 1 (asymptomatic) had 43
patients, and group 2 (symptomatic) had 29 patients.
The total population consisted of 21 men and 51
women, with a mean age of 61 years. The type of procedure performed was 4-gland exploration in 27 patients
(37%), unilateral neck exploration in 38 patients
(53%), and minimally invasive 1-gland exploration
in 7 patients (10%). No perioperative complications
occurred, and all patients were discharged from the
hospital either on the day of their operation or the next
morning. The pathologic findings were as follows: 66
solitary adenomas (92%), 4 double adenomas (6%), 1
case of 4-gland hyperplasia (1%), and 1 case of 5-gland
hyperplasia (1%). Postoperative serum calcium levels
were normalized in 73 (99%) of 74 patients. One
patient required a second procedure after unilateral
neck exploration to remove an unexpected contralateral
adenoma.
The reasons for referral to the surgeon are outlined
in Table 1. The most common reason for referral was
osteoporosis as indicated by an abnormal result on a dualenergy x-ray absorptiometry (DEXA) scan (32/43, or 74%
of the patients in group 1).
Compared with age-matched national norms, the preoperative study population demonstrated significant impairment in functional health in 5 of 8 domains of the SF36: physical function, physical role limitations, social
function, bodily pain, and energy/fatigue (Table 2). Postoperatively, however, the study population improved and

Table 2. SF-36 Data for All Patients*

Domain
General health perception
Physical function
Role limitation (physical)
Role limitation (emotional)
Social function
Bodily pain
Mental health
Energy/fatigue

National Norm

Mean Preoperative Score

Mean Postoperative Score

72
84
81
81
83
75
75
61

67
73
59
76
74
66
73
49

69
77
74
88
85
79
79
65

*Mean preoperative and postoperative scores highlighted in boldface reached significance at P.05 compared with national norms. Scores for all patients
(N = 72) were measured on a scale of 0 to 100. SF-36 indicates Medical Outcomes Study Short-Form Health Survey.

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Table 3. Group 1 SF-36 Data*

Domain
General health perception
Physical function
Role limitation (physical)
Role limitation (emotional)
Social function
Bodily pain
Mental health
Energy/fatigue

National Norm

Mean Preoperative Score

Mean Postoperative Score

72
84
81
81
83
75
75
61

70
75
67
82
82
73
78
55

70
77
73
88
86
77
82
66

*Mean preoperative and postoperative scores highlighted in boldface reached significance at P.05 compared with national norms. Scores for asymptomatic
patients (n = 43) were measured on a scale of 0 to 100. SF-36 indicates Medical Outcomes Study Short-Form Health Survey.

Table 4. Group 2 SF-36 Data*

Domain
General health perception
Physical function
Role limitation (physical)
Role limitation (emotional)
Social function
Bodily pain
Mental health
Energy/fatigue

National Norm

Mean Preoperative Score

Mean Postoperative Score

72
84
81
81
83
75
75
61

62
70
48
67
63
57
66
41

67
77
76
90
83
80
76
65

*Mean preoperative and postoperative scores highlighted in boldface reached significance at P.05 compared with national norms. Scores for symptomatic
patients (n = 29) were measured on a scale of 0 to 100. SF-36 indicates Medical Outcomes Study Short-Form Health Survey.

Table 5. Comparison of the Postoperative Population to the Preoperative Population on the SF-36*
Domain
General health perception
Physical function
Role limitation (physical)
Role limitation (emotional)
Social function
Bodily pain
Mental health
Energy/fatigue

All Patients (N = 72)

Group 1: Asymptomatic (n = 43)

Group 2: Symptomatic (n = 29)

.10
.01
.01
.03
.001
.001
.001
.001

.76
.17
.38
.37
.20
.21
.05
.004

.07
.03
.01
.03
.001
.001
.001
.001

*The Wilcoxon rank sum test was used to compare individual patients postoperative responses with their preoperative responses (paired comparisons). Data
are presented as P values, which indicate the likelihood of a difference in the postoperative population compared with the preoperative one. Significant P values
are shown in boldface. SF-36 indicates Medical Outcomes Study Short-Form Health Survey.

was nearly indistinguishable from the age-matched norms

for the general US population. Table 3 demonstrates that
group 1 (asymptomatic) was significantly impaired preoperatively compared with national norms in 3 domains:
physical function, physical role limitations, and energy/
fatigue. Table 4 demonstrates that group 2 (symptomatic) was significantly impaired preoperatively compared
with national norms in 7 of 8 domains: general health perception, physical function, physical role limitations, social function, bodily pain, mental health, and energy/
fatigue.
Table 5 outlines the statistical differences between
the postoperative study population and the preoperative
study population. There was significant improvement in
7 of 8 domains of the SF-36 after parathyroidectomy. Table
5 also demonstrates that the asymptomatic population
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1024

(group 1) improved significantly in 2 domains: mental

health and energy/fatigue. Group 2 (symptomatic) significantly improved in 7 of 8 domains.
COMMENT

In our consecutive series of patients with primary hyperparathyroidism, parathyroidectomy improved

health-related quality of life. This finding was consistent whether patients were classified as symptomatic or
asymptomatic. Notably, patients characterized by their
referring physician as asymptomatic were impaired preoperatively and demonstrated improvement after parathyroidectomy. Our results affirm the argument that
few people referred for primary hyperparathyroidism
are truly without symptoms.16,19-22
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The NIH panel recommended operative intervention in the asymptomatic patient with any of the following factors: markedly elevated serum calcium level, a previous episode of life-threatening hypercalcemia, reduced
creatinine clearance, asymptomatic kidney stones, elevated 24-hour urinary calcium excretion, age younger
than 50 years, or substantially reduced bone mass. Because the consensus conference did not address healthrelated quality of life in primary hyperparathyroidism,
its recommendations may undertreat a patient population with impaired physical or emotional function and
fatigue. Our results imply that an evaluation of healthrelated quality of life may be helpful in the assessment
of patients with hyperparathyroidism.
The gains in perceived health status were even more
pronounced in the symptomatic group, with the data
reaching statistical significance in nearly all domains of
the SF-36. This group was more impaired preoperatively and made greater gains in health status after parathyroidectomy.
Our findings rely on patient-reported symptoms, and
this method is inherently subject to bias. Bias was minimized in several ways. First, no patient with primary hyperparathyroidism was excluded from the prospective
study. Previous studies of symptom evaluation in primary hyperparathyroidism have used selected populations or those in which many potential subjects refused
to participate.11,16,21,23 Second, our postoperative evaluation was comprehensive. Based on 97% of consecutive
patients responding at 1 year, our data are among the most
complete reported in the literature with regard to parathyroid surgery. Third, we minimized the potential for
a surgeons bias to influence the patients health perception by administering the SF-36 prior to consultation.
Similarly, patients completed the follow-up SF-36 by mail
so that they did not have to visit the surgeons office to
respond. Fourth, reevaluation 1 year after the procedure limits interventional bias, or the phenomenon of patients wanting and expecting to feel better following an
operation. In addition, the 1-year interval assesses the durability of our results.
Our study, like others, is subject to referral bias; all
patients were selected for operation by either an endocrinologist or a primary care physician. Attributing improvements in quality of life to an operative procedure
without a control population is problematic. However,
our data demonstrate that patients with primary hyperparathyroidism are a distinct population as compared with
age-matched controls. When these patients are cured with
parathyroidectomy, they are indistinguishable from the
norm. We feel that this is an important finding.
Although primary hyperparathyroidism can be a mild
disease, the natural history of untreated hyperparathyroidism is not necessarily benign.1,8 The absence of symptom progression does not mean that patients with hyperparathyroidism feel healthy. Several recent reports have
demonstrated that up to 30% of presumably asymptomatic patients with primary hyperparathyroidism will
progress to serious morbidity from their disease.1,8,24 The
observation of mild hyperparathyroidism has also been
implicated in premature death.25-28 The morbidity rate of
modern parathyroid surgery is in the 1% to 2% range,
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1025

with mortality almost nonexistent. With serum analysis

and modern imaging techniques, hyperparathyroidism
is easily diagnosed using few resources. Additionally, the
disease is easily cured and has minimal morbidity, resulting in high patient satisfaction.22,29,30 We believe that
a patient with primary hyperparathyroidism should be
referred for parathyroidectomy at the time of diagnosis.
Although controversy exists concerning the type and extent of procedure, it is clear in this era of ambulatory surgery that parathyroidectomy can be safely performed with
minimal risk to the patient.
CONCLUSIONS

Our consecutive series of patients with primary hyperparathyroidism demonstrated statistically significant impairment regarding preoperative quality of life as measured with the SF-36. Parathyroidectomy significantly
improved quality of life, and the effect is durable at 1
year. Most notable are the findings that patients thought
to be asymptomatic by the referring physician were
preoperatively impaired and that they made improvements in mental health and energy/fatigue levels after
parathyroidectomy.
Presented at the 73rd Annual Meeting of the Pacific Coast
Surgical Association, Las Vegas, Nev, February 17, 2002.
The discussions are based on the originally submitted manuscript and not the revised manuscript.
Corresponding author: John A. Ryan, Jr, MD, Section
of General, Vascular, and Thoracic Surgery, Virginia Mason Medical Center, PO Box 900 C6-GSUR, 1100 Ninth Ave,
Seattle, WA 98111 (e-mail: gtsjar@vmmc.org).
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DISCUSSION
Quan-Yang Duh, MD, San Francisco, Calif: Six years ago,
Richard Burney of Michigan presented at the American Association of Endocrine Surgeons meeting in Napa Valley, Calif.
He was the first to use the SF-36 to show an improved healthrelated quality of life in patients with primary hyperparathyroidism after parathyroidectomy. At that time, Dr Burney
showed that patients with primary hyperparathyroidism had
impaired health-related quality of life as measured by the SF36. Six months after parathyroidectomy, 7 of 8 domains in the
SF-36 improved by 10 or more points, and the scores became
the same as those for the normal controls. Several more studies since then have confirmed these findings. Some skeptics,
however, are still not convinced; they are concerned that the
selection of patients can introduce biases; that is, those whose
quality of life has improved may be more likely to complete
the survey.
Dr Sheldon and colleagues addressed this question of patient selection by both including consecutive patients and
having a near-perfect survey response. Those of you who have
tried to perform surveys know that this is extremely difficult.
This paper convincingly demonstrated that this improvement
in quality of life is real, and not just an artifact of patient
selection.

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Once the benefit of parathyroidectomy was demonstrated, a second aspect of this paper was to stratify the patients to determine whether some groups may benefit more and
others may not. The authors stratified these patients into an
asymptomatic group and a symptomatic group and found
that both groups improved in their SF-36 scores 1 year after
parathyroidectomy, although the improvement was more significant in the symptomatic group. This stratification seems to
help us predict the expected improvement from parathyroidectomy by preoperative symptoms.
Since the NIH consensus conference of 1991, there has been
a sea change in the field of surgery for the parathyroid. First of
all, more unilateral exploration and focused exploration are now
done, with results as good as the traditional operation. This was
made possible by improved preoperative localization studies,
especially sestamibi scan, and intraoperative quick PTH [parathyroid hormone] assay. In addition, our study and others have
shown that patients benefit from parathyroidectomy even if they
do not fit the so-called NIH criteria. What we have learned over
the past 10 years is that (1) parathyroidectomy can be performed safely with less invasiveness, and (2) more patients, especially those with milder disease, can benefit from parathyroidectomy. Dr Sheldons paper supports this growing opinion
among the endocrine surgeons. We all hope that when the NIH
revisits this issue in the consensus conference this April, 2
months from now, it will liberalize the indications for parathyroidectomy in patients with less severe primary hyperparathyroidism.
I have 2 questions for the authors: (1) Since control
group is always an issue, and a randomized study has not yet
been done, have you studied a surrogate control group (for
example, patients with primary hyperparathyroidism who
may have delayed or declined their operations, or patients
who have had a thyroidectomy)? (2) Since stratifying patients
as symptomatic or asymptomatic, as you have noted, is
not precise, have you also stratified the patients differently
(for example, either by whether or not they fit the NIH criteria
for parathyroidectomy or by the severity of their biochemical
abnormalities, such as the calcium or PTH levels)?
It is good to know that parathyroidectomy not only prevents morbidity and premature death associated with hyperparathyroidism but also improves the quality of life and makes
the patient feel better.
John A. Butler, MD, Orange, Calif: The major question
addressed by this paper concerns the asymptomatic group. What
you showed is that preoperatively they were significantly impaired in 3 of the 8 categories. Postoperatively they improved
in 2 of 8, but it was actually only in 1 of the 3 that they were
preoperatively impaired. In the other category in which they
significantly improved, they were actually better than the norm
in the preoperative assessment. Whereas I agree with your bias,
I just wonder how strongly you feel your data support your conclusions, particularly in that asymptomatic group.
Michael J. Hart, MD, Seattle, Wash: My question is similar to Dr Butlers and has to do with your survey instrument.
I assume, and please let me know if this is true, that there has
been validation of the SF-36 health questionnaire by using it
on the same population over a number of different years to determine the variability in responses. Likewise, the things that
you mention most frequentlymental health, fatigue, energy
levelsare probably the most nebulous and hardest areas to
measure. Im not sure that if I took that test from year to year
I would be all that consistent, or even from day to day. I would
like for you to give us a little bit more background about the
SF-36 questionnaire and its referencing.
Orlo H. Clark, MD, San Francisco: I congratulate Dr Sheldon and colleagues on this excellent paper. They address a currently controversial issue; that is, do asymptomatic and symp-

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tomatic patients benefit symptomatically from successful

parathyroidectomy?
Most investigations suggest that about 75% to 80% of patients improve following parathyroidectomy. This means that
20% to 25% do not. We have studied whether patients who fit
and who did not fit the NIH criteria for parathyroidectomy receive the same psychological improvement after successful parathyroidectomy. We found that both groups benefit.
My first question is, did you study the duration of symptoms prior to parathyroidectomy and whether patients who had
symptoms for a shorter time preoperatively were more likely
to benefit symptomatically? Second, were there any other factors that might help predict whether a patient would improve
symptomatically, such as PTH level, calcium level, patient
age, or symptom complex? Although other investigations
using SF-36 testing support your findings, including those of
Burney, Pasieka, Talpos, and colleagues, I believe your new findings not only confirm their studies but also document that the
symptomatic benefit of parathyroidectomy continues for at least
1 year.
Julie A. Freischlag, MD, Los Angeles, Calif: We administer the SF-36 in our clinic every time a patient comes to visit
us. Part of that is for entertainment while they wait in the lobby,
but it is also for scientific purposes. Our group of patients that
we really worry about are TOS [thoracic outlet syndrome] patients, and we are trying to do a study looking at the SF-36 to
see if we really help them. One of the specialists told us, you
need to give this survey to your patients and then ask them if
there is something you missed, or should you have asked them
if something was really bothering them, to know whether this
general survey reflects their true improvement. My question
to you is, did you ask them about symptoms or feelings that
perhaps an instrument may have missed that they would have
liked to be asked about?
Philip D. Schneider, MD, Sacramento, Calif: Its the closest
approximation to the aborted Mayo Clinic trial that was started
in the 1960s studying asymptomatic hypercalcemic patients.
It really gets at the issue of what may happen to patients who
do not have surgery. I have a couple of questions.
There were a large number of patients who were referred
with abnormal DEXA scans, and I am curious whether they were
referred only because the DEXA scan was abnormal and they
were known to be hypercalcemic, or whether because they were
about to go on hormone replacement therapy, they had a DEXA
scan and it had not been appreciated that they were hypercalcemic. Finally, I would be curious if you administered the SF-36
to patients who came to your clinic and then refused surgery,
and then had the opportunity to do long-term follow-up on those
patients to see if their condition deteriorated.
Lawrence Way, MD, San Francisco: I would like to expand on previous comments concerning the possibility of
bias. Cognitive psychologists report that peoples mood influences a variety of subjective assessments, such as those
contained in the quality-of-life grid (Psych Res. 1999;88:173).
Before their first quality-of-life assessment, the patients in this
study, although asymptomatic, would have been told that
they had hyperparathyroidism and had probably received
conflicting opinions on the significance of the disease and the
importance of treatment. The resulting confusion could well
have affected their mood and hence their quality-of-life assessments. Since all of this uncertainty would have been relieved by the operation, reported improvement in quality of
life might have stemmed, at least in part, from these uncontrolled psychological factors.
Dr Ryan: I appreciate the interest in this paper and Dr
Quan-Yang Duhs excellent discussion. I will try to answer the
questions that were asked, and then I have a short video to
show you.

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Dr Duh asked 3 questions. Did we have a control group

of patients not operated on but followed up with the SF-36?
No, but Dr Talpos from Henry Ford Hospital has published a
randomized trial of patients with mild hyperparathyroidism either operated on or observed showing a benefit in the operative group as judged by the SF-36 (Talpos GB, Bone HG,
Kleerekoper M, et al. Randomized trial of parathyroidectomy
in mild asymptomatic primary hyperparathyroidism: patient
description and effects on the SF-36 health survey. Surgery.
2000;128:1013-1020).
Did we stratify the patients by the NIH criteria? No, in
our 43 so-called asymptomatic patients, all but 8 of the patients met NIH criteria; most had been referred for abnormal
bone marrow density (32), and there were 3 patients less than
50 years of age. However, Drs Burney and Thompson at the
University of Michigan did stratify patients by high and low
calcium elevations and demonstrated both impairment and
postoperative improvement by SF-36 evaluation, independent
of calcium level (Burney RE, Jones KR, Christy B, Thompson
NW. Health status improvement after surgical correction of
primary hyperparathyroidism in patients with high and low
preoperative calcium levels. Surgery. 1999;125:608-614).
Dr Duh and others complimented the completeness of our
long-term evaluation. We have a secret weapon at Virginia Mason, our coauthor and office nurse Faye Lee, RN, who somehow can find patients and get them to respond to long-term
evaluations. These patients were referred from over a 5-state
area. We realize the importance of having long-term evaluations, and we are fortunate to have someone who is extremely
persistent in getting them done.
Drs Way, Hart, and Freischlag asked questions about the
SF-36 survey. This was a questionnaire that was developed because the HCFA [Health Care Financing Administration] wanted
to have a survey for health-related quality of life. The HCFA
commissioned the Rand Corporation to form a Medical Outcome Trust to develop a questionnaire that could be used in a
variety of situations and diseases. The SF-36 was published in
1992 (Ware JE Jr, Sherbourne CD. The MOS 36-item shortform health survey (SF-36), I: conceptual framework and item
selection. Med Care. 1992;30:473-483).
No matter what group you are studying, the Medical Outcome Trust gives age- and sex-matched national norms for that
group. Perfect health in any of the 8 domains of evaluation is
given a score of 100. This questionnaire has been used widely
in the last decade and, I believe, has become an accepted standard. Dr Thirlby presented information to the PCSA [Pacific
Coast Surgical Association] in 1998 about the SF-36 in Crohn
disease.
Dr Clark asked about patients who did not improve postoperatively as judged by the SF-36. We did not specifically look
at any individual patient, but rather the aggregate of our 72 patients. In fact, although I operated on every patient, I did not
see any individual SF-36 results or have any personal involvement with administrating the test. I hope this eliminated a form
of bias.
Dr Schneider asked about the bone mineral density test.
Thirty-two of the 43 so-called asymptomatic patients were referred to us because they had a low bone mineral density. For
parathyroid surgeons, this test has been a boon. Physicians who
are following patients with slightly elevated calcium levels and
the diagnosis of hyperparathyroidism who dont have kidney
stones, broken bones, or pancreatitis (any of the traditional indications for referral) do note osteopenia or osteoporosis on a
bone mineral density test and at that point feel an obligation
to refer the patients to a surgeon.
Dr Butler asked 2 pertinent questions. How did we really
stratify the patients into the asymptomatic group? The stratification was crucial to our study. We really wanted to see if the

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patients sent as asymptomatic would improve postoperatively.

When patients came to us, we read very carefully their referring
notes by either an endocrinologist or primary care doctor, and
we asked the patients their perception of why they were sent. If
they said they were sent because of an abnormal laboratory value
or an abnormal bone density test, then we classified them into
the asymptomatic group. Although the classification was somewhat arbitrary, it was done prospectively without any knowledge of SF-36 results and did seem clinically relevant. Dr Butler, who did an advance reading of the manuscript, noted that
in the asymptomatic group in the domain of mental health, the
comparison of postoperative with preoperative scores showed
significant improvement but that the mean for the preoperative
score (78) was higher than the national norm (75). (See Table 3
in the article.) Those scores were not statistically different. But
the aggregate improvement in 43 patients postoperatively to a

mean score of 82 was a highly significant improvement when

calculated with a Wilcoxon rank sum statistic. Remember that
a score of 100 is perfect mental health.
This short video demonstrated the long interest that Virginia Mason has had in health-related quality of life in hyperparathyroidism. This movie was made in 1951 by Dr Joel Baker,
who of course was president of the PCSA over 30 years ago.
Here is Dr Baker talking about a middle-aged woman with hyperparathyroidism. Here she is pictured on the roof of Virginia Mason barely able to climb the steps. Note the view of
Puget Sound. Here is the parathyroid at the time of the operation. It was so big that it was localized by barium swallow, and
Dr Baker only explored one side of the neck. Here is the patient postoperatively back up on the roof. We didnt have the
SF-36, but boy, look how spry this patient is now: up and down
the steps, tying her shoes, and giving a huge bow to Dr Baker!

Surgical Anatomy

here are 2 types of diaphragmatic hernia: Bochdalek (posterolateral), more

common on the left than the right; and Morgagni, or anterior parasternal hernia.
Source: Blackbourne LH, Fleischer KJ, eds. Advanced Surgical Recall. Baltimore, Md: Williams & Wilkins; 1997:850.

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