Clinical Science Techniques of parathyroid exploration at North American endocrine surgery fellowship programs: what the next generation is being taught Tracy S. Wang, M.D., M.P.H. a , Janice L. Pasieka, M.D. b , Sally E. Carty, M.D. c, * a Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; b Department of Surgery, University of Calgary, Calgary, AB, Canada; c Department of Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann 101, Pittsburgh, PA 15213, USA KEYWORDS: Primary hyperparathyroidism; Minimally invasive parathyroidectomy; Endocrine surgery; Fellowship programs Abstract BACKGROUND: Minimally invasive techniques are now often used to treat primary hyperparathy- roidism but with uncertain conformity and some controversy. Endocrine surgery fellowships (ESFPs) have recently proliferated. METHODS: The directors of the 19 ESFPs recognized by the American Association of Endocrine Surgeons were polled to identify the approaches currently taught to trainees. RESULTS: With 100% participation, all ESFPs obtain R1 imaging study, and 95% use ultrasound to assess for concurrent thyroid nodules that require care. For an apparent single adenoma, all ESFPs min- imize dissection, use intraoperative parathyroid hormone monitoring, and, if multiglandular disease is identified, perform 4-gland exploration. Outpatient surgery (89%) and postoperative oral calcium use (68%) are common. All programs define cure as durable normocalcemia (median, 6 months). CONCLUSIONS: American Association of Endocrine Surgeons fellowship programs teach congruent management strategies that include focused dissection, intraoperative parathyroid hormone use, and in- tent to cure. These consistencies define a future standard for assessment of parathyroidectomy out- comes. Ó 2014 Elsevier Inc. All rights reserved. The first successful parathyroidectomy for primary hy- perparathyroidism (PH) was performed in 1925. Ever since, surgeons have been challenged to achieve operative cure given the fact that only about 85% of patients with sporadic PH have single parathyroid adenomas, while the rest have multiglandular disease that is often occult on imaging. Thus, the gold standard in the surgical management of PH has long been bilateral cervical exploration, with visual identification of all parathyroid glands, comparison of relative gland sizes and weights, and resection of only enlarged glands. Over the past 2 decades, however, with improvements in preoperative imaging techniques and the development of immunoassays that allow rapid, intraoperative measurement of parathyroid hormone (PTH) levels, the surgical approach to patients with PH has undergone a fundamental and rapid shift. 1–5 At most but not all US medical centers, routine bilateral cervical ex- ploration has largely been supplanted by minimally invasive approaches that allow a direct, focused dissection of the The authors declare no conflicts of interest. Presented at the 100th American College of Surgeons Annual Clinical Congress, October 2, 2012, Chicago, IL * Corresponding author. Tel.: 11-412-647-0467; fax: 11-412-648-9551. E-mail address: cartyse@upmc.edu Manuscript received January 31, 2013; revised manuscript May 7, 2013 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.05.012 The American Journal of Surgery (2014) 207, 527-532