Minimally invasive parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IOPTH) and preoperative imaging versus bilateral neck exploration for primary hyperparathyroidism in adults

Is intraoperative parathyroid monitoring during minimally invasive parathyroidectomy still justified?

Introduction

Primary hyperparathyroidism (PHPT) is the third most common endocrine disease. With parathyroidectomy, a cure rate of over 95% at initial surgery is reported. Localization of the abnormal parathyroid gland is critical for the operation to be successful. The aim of this study is to analyze data of patients with single gland disease (SGD) and positive concordant localization imaging undergoing minimally invasive parathyroidectomy (MIP) and intraoperative parathyroid hormone monitoring (IOPTH) to evaluate if IOPTH is still justified in patients with localized SGD.

Methods

A retrospective database analysis of all minimally invasive operations with IOPTH for PHPT and positive concordant localization in ultrasound (US) and 99mTc-sestamibi scintigraphy (MIBI) between 2016-2021. When both US and MIBI were negative, patients underwent either choline or methionine PET-CT. The patients were also analyzed a second time without applying IOPTH.

Results

In total, 198 patients were included in the study. The sensitivity of US, MIBI and PET-CT was 96%, 94% and 100%, respectively. Positive predictive value was 88%, 89% and 94% with US, MIBI and PET-CT, respectively. IOPTH was true positive in 185 (93.4%) patients. In 13 (6.6%) patients, no adequate IOPTH decline was observed after localizing and extirpating the assumed enlarged parathyroid gland. Without IOPTH, the cure rate decreased from 195 (98.5%) to 182 (92%) patients and the rate of persisting disease increased from 2 (1.0%) to 15 (7.5%) patients.

Conclusion

Discontinuing IOPTH significantly increases the persistence rate by a factor of 7.5 in patients with concordantly localized adenoma. Therefore, IOPTH appears to remain necessary even for this group of patients.

Comparison of endoscopic versus focused parathyroidectomy in surgical management of single-gland primary hyperparathyroidism: a randomized clinical trial

BACKGROUND

Over recent years, various advanced minimally invasive techniques have been developed for parathyroidectomy, and there was a universal acceptance of these less invasive procedures by surgeons. This study is designed to compare overall outcomes between endoscopic versus focused, single gland parathyroidectomy using intraoperative rapid parathyroid hormone (ioPTH) changes under general anesthesia in primary hyperparathyroidism (PHPT) patients.

METHOD

In this randomized clinical trial, 96 patients diagnosed with PHPT were randomly assigned into two groups endoscopic and focused parathyroidectomy. Baseline clinical and demographical data were collected along with perioperative features. The success rate was evaluated based on ioPTH changes.

RESULTS

The ioPTH levels after five minutes in the endoscopic group were significantly lower than the focused group (P = 0.005). The success rate for endoscopic and the focused method was 95.3% and 77.1% during the first five minutes (P = 0.013) and 100% in both groups after ten minutes. A decrease in parathyroid hormone levels was significant in each group but not between each other. Postoperative calcium levels were significantly lower in the focused method (P = 0.042). The focused group also had a significantly shorter operation time than the endoscopic group (P < 0.001). Patient satisfaction with cosmetic outcome was significantly higher in the endoscopic group compared to the focused group.

CONCLUSION

The endoscopic technique was superior to the unilateral focused neck exploration parathyroidectomy in the management of single-gland PHPT. Influencing aspects included higher postoperative calcium levels, more rapid success achievement, and satisfactory cosmetic outcomes in the endoscopic group. However, patient selection and accurate adenoma localization are vital in this method.

Utility of 99mTc-Sestamibi Single-Photon Emission Computed Tomography (SPECT)/CT Single Imaging Strategy in the Preoperative Localization of Parathyroid Adenoma

Background Primary hyperparathyroidism is an endocrinopathy associated with dysregulated calcium homeostasis. The most common etiology is a parathyroid adenoma most definitely managed via a parathyroidectomy. The two main surgical approaches include a minimally invasive parathyroidectomy (MIP) and open four-gland exploration (4-GE). MIP is the preferred operative strategy since it is associated with less postoperative complications. Accurate preoperative imaging is essential in informing the optimal approach to surgery. MIP is only considered if adenoma is able to be localized precisely. The most commonly used imaging modality includes ultrasound and sestamibi single-photon emission computed tomography (SPECT)/CT, either as a single or combination strategy. Other options include MRI, PET, and 4D CT. There is no universally accepted preoperative imaging strategy. The literature is discordant and recommendations proposed by existing guidelines are incongruous. Objectives This study aimed to evaluate currently utilized preoperative parathyroid imaging modalities at our institution and correlate them with surgical and histological findings to determine the most efficient imaging strategy to detect adenomas for our patient cohort. This will ultimately guide the best surgical approach for patients receiving parathyroidectomies. Methods This is a retrospective observational study of all patients undergoing first-time surgery for biochemically proven primary hyperparathyroidism at our institution over the past five years. Multiple data points were collected including modality of preoperative disease localization, operation type, final histopathology, biochemical investigations, and cure rate. Patients were categorized into one of three groups based on the method of disease localization. Results A total of 244 patients had parathyroidectomies performed at our institution in the past five years from January 2018 to December 2022. Ninety-six percent (n=235) of all patients received dual imaging preoperatively with SPECT/CT and ultrasound performed on the same day and therefore included in this study. A total of 64.3% (n=151) underwent MIP. Eighty percent (n=188) of all histopathology revealed adenomas and 26.8% (n=63) of patients had adenoma localized on SPECT/CT only (sensitivity: 58.1%, specificity: 71%, and positive predictive value {PPV}: 85.7%). A total of 9.8% (n=23) had adenoma localized on ultrasound only (sensitivity: 15.6%, specificity: 73.3%, and PPV: 65.2%). A total of 45.1% (n=106) were dual localized on both SPECT/CT and ultrasound (sensitivity: 75.6%, specificity: 46.6%, and PPV: 84.9%). The cure rate was 91.5% in the dual-localized group, 86% in the dual-unlocalized group, and 96.5% when localized with SPECT/CT alone. Conclusion A dual-imaging modality with SPECT/CT and ultrasound should remain the first-line imaging strategy. This approach has higher sensitivity rates and poses no inherent patient or surgical-related risks. Patients with disease unlocalized on SPECT/CT alone had a positive predictive value, specificity, and likelihood ratio for adenoma detection comparable to dual-localized patients. Therefore, SPECT/CT alone is sufficient for directing MIP in the presence of a negative ultrasound.

Italian Guidelines for the Management of Sporadic Primary Hyperparathyroidism

AIM

This guideline (GL) is aimed at providing a clinical practice reference for the management of sporadic primary hyperparathyroidism (PHPT) in adults. PHPT management in pregnancy was not considered.

METHODS

This GL has been developed following the methods described in the Manual of the Italian National Guideline System. For each question, the panel appointed by Associazione Medici Endocrinology (AME) and Società Italiana dell'Osteoporosi, del Metabolismo Minerale e delle Malattie dello Scheletro (SIOMMMS) identified potentially relevant outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as "critical" and "important" were considered in the systematic review of evidence. Those classified as "critical" were considered for the clinical practice recommendations.

RESULTS

The present GL provides recommendations about the roles of pharmacological and surgical treatment for the clinical management of sporadic PHPT. Parathyroidectomy is recommended in comparison to surveillance or pharmacologic treatment in any adult (outside of pregnancy) or elderly subject diagnosed with sporadic PHPT who is symptomatic or meets any of the following criteria: • Serum calcium levels >1 mg/dL above the upper limit of normal range. • Urinary calcium levels >4 mg/kg/day. • Osteoporosis disclosed by DXA examination and/or any fragility fracture. • Renal function impairment (eGFR <60 mL/min). • Clinic or silent nephrolithiasis. • Age ≤50 years. Monitoring and treatment of any comorbidity or complication of PHPT at bone, kidney, or cardiovascular level are suggested for patients who do not meet the criteria for surgery or are not operated on for any reason. Sixteen indications for good clinical practice are provided in addition to the recommendations.

CONCLUSION

The present GL is directed to endocrinologists and surgeons - working in hospitals, territorial services or private practice - and to general practitioners and patients. The recommendations should also consider the patient's preferences and the available resources and expertise.

Open Minimally Invasive Parathyroidectomy Versus Minimally Invasive Video-Assisted Parathyroidectomy: A Systematic Review and Meta-Analysis

Various minimally invasive techniques exist for surgical parathyroidectomy. The aim of this study was to conduct a meta-analysis comparing two popular minimally invasive techniques: minimally invasive video-assisted parathyroidectomy (MIVAP) and open minimally invasive parathyroidectomy (OMIP). An extensive search was conducted of online databases to identify all previous studies that had compared MIVAP and OMIP. The primary outcome measures considered were visual analog scale (VAS) score 24 hours postoperatively, conversion of operation (to open), failure rate and analgesic consumption. The data from these studies was extracted and compiled into a meta-analysis. The literature search yielded 104 studies of which four were included, enrolling 903 patients in this analysis. A significant difference was found regarding rates of conversion to open parathyroidectomy between the two groups, with the OMIP group demonstrating fewer conversions (MD = 3.52, CI = (2.04-6.08), P< 0.00001). No statistically significant differences were found between the two groups when comparing postoperative VAS scores at 24 hours (MD = -1.75, CI = (-9.8-6.3), P = 0.67), consumption of analgesia (OR = 0.49, CI = 0.07-3.54, P = 0.48) or failure rates (OR = 1.81, CI = 0.58-5.72, P = 0.31). OMIP was seen to require less need to convert to open parathyroidectomy with shorter operative times, while similar complication rates and scar lengths to MIVAP. More studies are required to evaluate the superior technique for parathyroidectomy.

[Localization diagnostics and operative strategy for the first intervention in sporadic primary hyperparathyroidism]

Primary hyperparathyroidism (pHPT) is a frequent endocrine disease, the incidence of which is clearly increasing. In addition to the classical symptoms of bone pain, osteoporosis and renal calculi, nonspecific complaints, such as listlessness and exhaustion, anxiety states and depressive symptoms also often occur. The diagnosis is simple and is carried out by determination of calcium and parathormone (PTH) serum levels. The majority of parathyroid adenomas can be localized by ultrasound and Tc-99m-MIBI scintigraphy. The indications for surgery can normally already be identified by the laboratory biochemical detection. Surgery is the only curative treatment of pHPT and is normally successful. In addition to bilateral exploration, a focused parathyroidectomy can be planned. The success of surgery can be intraoperatively documented by the determination of intraoperative Quick PTH (IOPTH).

Surgery for primary hyperparathyroidism in Germany, Switzerland, and Austria: an analysis of data from the EUROCRINE registry

PURPOSE

EUROCRINE is an endocrine surgical register documenting diagnostic processes, indication for surgical treatment, surgical procedures, and outcomes. The purpose was to analyse data for PHPT in German speaking countries regarding differences in clinical presentation, diagnostic workup, and treatment.

METHODS

All operations for PHPT performed from 07/2015 to 12/2019 were analysed.

RESULTS

Three thousand two hundred ninety-one patients in Germany (9 centres; 1762 patients), Switzerland (16 centres; 971 patients) and Austria (5 centres; 558 patients) were analysed. Hereditary disease was seen in 36 patients in Germany, 16 patients in Switzerland and 8 patients in Austria. In sporadic disease before primary operation, PET-CT showed the highest sensitivity in all countries. In re-operations, CT and PET-CT achieved the highest sensitivities. The highest sensitivity of IOPTH was seen in Austria (98.1%), followed by Germany (96.4%) and Switzerland (91.3%). Operation methods and mean operative time reached statistical significance (p<0.05). Complication rates are low. Overall, 656 (19.9%) patients were asymptomatic; the remainder showed bone manifestations, kidney stones, fatigue and/or neuropsychiatric symptoms.

CONCLUSION

Early postoperative normocalcaemia ranged between 96.8 and 97.1%. Complication rates are low. PET-CT had the highest sensitivity in all three countries in patients undergoing primary operation as well as in Switzerland and Austria in patients undergoing re-operation. PET-CT could be considered a first-line preoperative imaging modality in patients with inconclusive ultrasound examination. The EUROCRINE registry is a beneficial and comprehensive data source for outcome analysis of endocrine procedures on a supranational level.

Parathyroidectomy for adults with primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (PHPT), a disorder in which the parathyroid glands produce excessive amounts of parathyroid hormone, is most common in older adults and postmenopausal women. While most people with PHPT are asymptomatic at diagnosis, symptomatic disease can lead to hypercalcaemia, osteoporosis, renal stones, cardiovascular abnormalities and reduced quality of life. Surgical removal of abnormal parathyroid tissue (parathyroidectomy) is the only established treatment for adults with symptomatic PHPT to prevent exacerbation of symptoms and to be cured of PHPT. However, the benefits and risks of parathyroidectomy compared to simple observation or medical therapy for asymptomatic and mild PHPT are not well established.

OBJECTIVES

To evaluate the benefits and harms of parathyroidectomy in adults with PHPT compared to simple observation or medical therapy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, LILACS, ClinicalTrials.gov and WHO ICTRP from their date of inception until 26 November 2021. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing parathyroidectomy with simple observation or medical therapy for the treatment of adults with PHPT.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. cure of PHPT, 2. morbidity related to PHPT and 3. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. health-related quality of life and 3. hospitalisation for hypercalcaemia, acute renal impairment or pancreatitis. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We identified eight eligible RCTs that included 447 adults with (mostly asymptomatic) PHPT; 223 participants were randomised to parathyroidectomy. Follow-up duration varied from six months to 24 months. Of the 223 participants (37 men) randomised to surgery, 164 were included in the analyses, of whom 163 were cured at six to 24 months (overall cure rate 99%). Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up: 163/164 participants (99.4%) in the parathyroidectomy group and 0/169 participants in the observation or medical therapy group were cured of their PHPT (8 studies, 333 participants; moderate certainty).  No studies explicitly reported intervention effects on morbidities related to PHPT, such as osteoporosis, osteopenia, kidney dysfunction, urolithiasis, cognitive dysfunction or cardiovascular disease, although some studies reported surrogate outcomes for osteoporosis and cardiovascular disease. A post-hoc analysis revealed that parathyroidectomy, compared to observation or medical therapy, may have little or no effect after one to two years on bone mineral density (BMD) at the lumbar spine (mean difference (MD) 0.03 g/cm2,95% CI -0.05 to 0.12; 5 studies, 287 participants; very low certainty). Similarly, compared to observation, parathyroidectomy may have little or no effect on femoral neck BMD after one to two years (MD -0.01 g/cm2, 95% CI -0.13 to 0.11; 3 studies, 216 participants; very low certainty). However, the evidence is very uncertain for both BMD outcomes. Furthermore, the evidence is very uncertain about the effect of parathyroidectomy on improving left ventricular ejection fraction (MD -2.38%, 95% CI -4.77 to 0.01; 3 studies, 121 participants; very low certainty). Four studies reported serious adverse events. Three of these reported zero events in both the intervention and control groups; consequently, we were unable to include data from these three studies in the pooled analysis. The evidence suggests that parathyroidectomy compared to observation may have little or no effect on serious adverse events (RR 3.35, 95% CI 0.14 to 78.60; 4 studies, 168 participants; low certainty).  Only two studies reported all-cause mortality. One study could not be included in the pooled analysis as zero events were observed in both the intervention and control groups. Parathyroidectomy compared to observation may have little or no effect on all-cause mortality, but the evidence is very uncertain (RR 2.11, 95% CI 0.20 to 22.60; 2 studies, 133 participants; very low certainty). Three studies measured health-related quality of life using the 36-Item Short Form Health Survey (SF-36) and reported inconsistent differences in scores for different domains of the questionnaire between parathyroidectomy and observation. Six studies reported hospitalisations for the correction of hypercalcaemia. Two studies reported zero events in both the intervention and control groups and could not be included in the pooled analysis. Parathyroidectomy, compared to observation, may have little or no effect on hospitalisation for hypercalcaemia (RR 0.91, 95% CI 0.20 to 4.25; 6 studies, 287 participants; low certainty). There were no reported hospitalisations for renal impairment or pancreatitis.

AUTHORS' CONCLUSIONS

In accordance with the literature, our review findings suggest that parathyroidectomy, compared to simple observation or medical (etidronate) therapy, probably results in a large increase in cure rates of PHPT (with normalisation of serum calcium and parathyroid hormone levels to laboratory reference values). Parathyroidectomy, compared with observation, may have little or no effect on serious adverse events or hospitalisation for hypercalcaemia, and the evidence is very uncertain about the effect of parathyroidectomy on other short-term outcomes, such as BMD, all-cause mortality and quality of life. The high uncertainty of evidence limits the applicability of our findings to clinical practice; indeed, this systematic review provides no new insights with regard to treatment decisions for people with (asymptomatic) PHPT. In addition, the methodological limitations of the included studies, and the characteristics of the study populations (mainly comprising white women with asymptomatic PHPT), warrant caution when extrapolating the results to other populations with PHPT. Large-scale multi-national, multi-ethnic and long-term RCTs are needed to explore the potential short- and long-term benefits of parathyroidectomy compared to non-surgical treatment options with regard to osteoporosis or osteopenia, urolithiasis, hospitalisation for acute kidney injury, cardiovascular disease and quality of life.

Persistence of primary hyperparathyroidism: a single-center experience

BACKGROUND

Parathyroidectomy is the only definitive treatment for primary hyperparathyroidism (PHPT). Precise localization of abnormal glands is a key to a successful surgery. Most patients are expected to be successfully treated with focused parathyroidectomy. However, this approach is associated with a risk of existing multiglandular disease which may lead to the postoperative persistence of PHPT.

METHODS

Eight hundred ten patients who underwent an initial surgery for PHPT at SPBU Hospital in 2017-2018 were included in the study. Preoperative imaging results were evaluated. Multivariate logistic regressions were calculated to estimate predictive values of preoperative data for the risk of postoperative persistence and risk of MGD.

RESULTS

Multiglandular disease was found to be a leading cause of persistent hyperparathyroidism. An anamnesis of thyroid surgery was found to be a significant risk factor for the persistence of hyperparathyroidism. The rate of persistence did not differ significantly between groups with bilateral neck exploration and focused parathyroidectomy. Age, sex, body mass index as well as negative results of preoperative US, MIBI, and 4D CT were not independently associated with a higher risk of MGD. All preoperative imaging modalities showed from low to moderate sensitivity for the detection of MGD. The frequency of cases of a missed second adenoma did not differ significantly between patients with concordant and discordant preoperative data. There were 7 cases with previously unsuspected second adenomas found solely due to bilateral neck exploration.

CONCLUSIONS

None of the combination of preoperative visualization modalities was able to rule out the MGD and reliably identify patients for focused parathyroidectomy. Additional preoperative visualization failed to improve overall results. Bilateral neck exploration appeared to have a slight benefit for the patients with concordant preoperative imaging results.

Contribution of intraoperative parathyroid hormone monitoring to the surgical success in minimal invasive parathyroidectomy

Background

The contribution of intraoperative parathyroid hormone monitoring to minimally invasive parathyroidectomy remains controversial. We aimed to evaluate whether intraoperative parathyroid hormone monitoring monitoring could contribute to minimally invasive parathyroidectomy in these patients.

Methods

The data of the patients whose preoperative ultrasonography and technetium-99 m sestamibi scintigraphy imagings were positive and concordant for one gland and who underwent minimally invasive parathyroidectomy between 2003 and 2018 in our clinic, were evaluated retrospectively. Blood samples were collected at pre-excisional period, and at post-excisional 10 and 20 min; the intaoperative parathyroid hormone was measured, and the surgery was terminated without waiting for the result. Patients were divided into 2 groups according to the postoperative results, as those with normocalcemia (Group 1) and those with persistence (Group 2).

Results

There were 195 patients in Group 1 and 14 patients in Group 2. The cure rate at the first surgery was 93.3%. Cure was achieved after the second operation in all patients in Group 2. Recurrent disease developed in 1 patient in group 1 and the overall cure rate was 99.5%. If intraoperative parathyroid hormone had been evaluated, cure could have been achieved at the first surgery with additional exploration, in 10 (71.4%) of 14 patients according to the insufficient decrease in parathyroid hormone value at the 10 min in Group 2, and in 9 (64.3%) of 14 patients according to the parathyroid hormone value at 20 min. However, due to insufficient decrease (false negative) in the parathyroid hormone value at the 10 and 20 min the rate of false negatives and unnecessary exploration would be 9.5% and 2.5%, respectively. With additional exploration, the cure rate in the first surgery could be increased by 4.3%–97.6% according to the 20 min intraoperative parathyroid hormone value.

Conclusion

The cure rate in minimally invasive parathyroidectomy can be increased by minimizing unnecessary conversion to bilateral neck exploration, by evaluating intraoperative parathyroid hormone at 10 min in patients with positive and concordant scans, and intraoperative parathyroid hormone at 20 min in patients with inadequate decrease at 10 min intraoperative parathyroid hormone.

[Role of preoperative visualization in the choice of surgery for primary hyperparathyroidism]

BACKGROUND

Precise localization of abnormal parathyroid glands is important for a successful surgery for primary hyperparathyroidism (PHPT). While a large number of patients can be successfully treated with the focused parathyroidectomy, there is a considerable rate of the persistent PHPT mostly because of undetected multiglandular disease (MGD).

AIM

The aim of the study was to evaluate the meaning of preoperative visualization data for planning the surgery for patients with PHPT.

MATERIALS AND METHODS

The study was conducted at SPBU Hospital in 2017-2018. 810 patients who underwent a primary surgery for PHPT were included in the study. Preoperative imaging results were investigated and multivariative logistic regressions were calculated to assess the predictive values of preoperative data. The rate of cases with persistent disease and cases with MGD were compared between patients with different results of preoperative data.

RESULTS

Age, sex, body mass index, negative results of preoperative US, MIBI and 4D CT were not independently associated with the higher risk of multiglandular disease. The larger number of performed preoperative visualization studies were associated with the higher risk of persistence. 37% cases of MGD were not identified preoperatively. There were 7 cases with previously unsuspected second adenomas found only due to bilateral neck exploration.

CONCLUSION

Any combination of preoperative visualization modalities was not able to rule out the MGD reliably. Efficacy of surgical treatment was not associated with the higher number of preoperative studies. Bilateral neck exploration may decrease the rate of the persistent hyperparathyroidism improving the identification of multiglandular disease.

Accuracy of Parathyroid Adenoma Localization by Preoperative Ultrasound and Sestamibi in 1089 Patients with Primary Hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (pHPT) is well treatable surgically. Sonography (US) and sestamibi scintigraphy (MIBI) are used routinely, but it is unclear how valuable they are in determining Parathyroid glands' different locations. This study aimed to evaluate the prognostic value of US and MIBI in relation to the different localization of parathyroid adenomas in one of the largest study populations analyzed to date.

METHODS

1089 patients with pHPT who had treatment in one tertiary referral center between 2007 and 2016 were analyzed. Preoperative US and MIBI reports were compared with the parathyroid adenoma's intraoperative localization. All parathyroid glands were confirmed by histological diagnosis.

RESULTS

No gland was detectable in 22.5% and 27.7% of all patients, by US or by MIBI, respectively. In relation to the different adenoma locations, the sensitivity of US ranged from 21.3% (upper right) to 68.9% (lower left) and of MIBI ranged from 23.5% (upper right) to 72% (lower left). The specificity for US ranged from 85% (lower right) to 99.2% (upper right) and for MIBI ranged from 86.1% (lower right) to 99.1% (upper right. Positive predictive values for all gland sites were 54% and 59% for MIBI and US, respectively. The value increased for side-only prediction to 73% and 78%, respectively. Neither the parathyroid hormone level nor the calcium value level influenced the sensitivity or specificity of the two test methods.

CONCLUSIONS

The validity of preoperative US and MIBI depends crucially on the specific localization of adenomas. This should be considered when planning the extent of parathyroid surgery.

Advances in the diagnosis and the management of primary hyperparathyroidism

The parathyroid glands, one of the last organs to be discovered, are responsible for maintaining calcium homeostasis, and they continue to present the clinician with diagnostic and management challenges that are reviewed herein. Primary hyperparathyroidism (PHPT) comprises the vast majority of pathology of the parathyroid glands. The classic variant, presenting with elevated calcium and parathyroid hormone levels, has been studied extensively, but the current body of literature has added to our understanding of normocalcemic and normohormonal variants of PHPT, as well as syndromic forms of PHPT. All variants can lead to bone loss, kidney stones, declining renal function, and a variety of neurocognitive, gastrointestinal, and musculoskeletal complaints, although the majority of PHPT today is asymptomatic. Surgery remains the definitive treatment for PHPT, and advances in screening, evolving indications for surgery, new imaging modalities, and improvements in intra-operative methods have greatly changed the landscape. Surgery continues to produce excellent results in the hands of an experienced parathyroid surgeon. For those patients who are not candidates for surgery, therapeutic advances in medical management allow for improved control of the hypercalcemic state. Parathyroid cancer is extremely rare; the diagnosis is often made intra-operatively or on final pathology, and recurrence is common. The mainstay of treatment is normalization of serum calcium via surgery and medical adjuncts.

Minimally invasive video-assisted parathyroidectomy (MIVAP) without intraoperative PTH determination

BACKGROUND

Minimally invasive video-assisted parathyroidectomy (MIVAP) has become a standard approach to primary hyperparathyroidism (pHPT) since described. Although intraoperative parathyroid hormone assay (IOPTH) has been generalized as a complementary technique to MIVAP, its actual impact on the surgical success of this technique is not without controversy. The aim of this study was to describe our results in the management of pHPT with successful preoperative localization, by MIVAP technique, without IOPTH determination, confirming in a larger series our preliminary results.

METHODS

A retrospective descriptive study was conducted in pHPT patients treated by MIVAP with no IOPTH determination in a tertiary hospital between 2007 and 2019.

RESULTS

A total of 167 patients were included in the study. Biochemical cure was achieved in 96.4%, and 94.1% did not present any surgical complication. The mean duration of surgery was 61 min, and the mean length of hospital stay was 1.8 days CONCLUSIONS: In case of positive preoperative localization studies, MIVAP is a safe and effective technique for the surgical treatment of pHPT due to a parathyroid adenoma, regardless of IOPTH determination, with a success rate > 95% and a low complication rate.

Minimally invasive parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IOPTH) and preoperative imaging versus bilateral neck exploration for primary hyperparathyroidism in adults

BACKGROUND

Bilateral neck exploration (BNE) is the traditional approach to sporadic primary hyperparathyroidism. With the availability of the preoperative imaging techniques and intraoperative parathyroid hormone assays, minimally invasive parathyroidectomy (MIP) is fast becoming the favoured surgical approach.

OBJECTIVES

To assess the effects of minimally invasive parathyroidectomy (MIP) guided by preoperative imaging and intraoperative parathyroid hormone monitoring versus bilateral neck exploration (BNE) for the surgical management of primary hyperparathyroidism.

SEARCH METHODS

We searched CENTRAL, MEDLINE, WHO ICTRP and ClinicalTrials.gov. The date of the last search of all databases was 21 October 2019. There were no language restrictions applied.

SELECTION CRITERIA

We included randomised controlled trials comparing MIP to BNE for the treatment of sporadic primary hyperparathyroidism in persons undergoing surgery for the first time.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Two review authors independently screened for inclusion, extracted data and carried out risk of bias assessment. The content expert senior author resolved conflicts. We assessed studies for overall certainty of the evidence using the GRADE instrument. We conducted meta-analyses using a random-effects model and performed statistical analyses according to the guidelines in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We identified five eligible studies, all conducted in European university hospitals. They included 266 adults, 136 participants were randomised to MIP and 130 participants to BNE. Data were available for all participants post-surgery up to one year, with the exception of missing data for two participants in the MIP group and for one participant in the BNE group at one year. Nine participants in the MIP group and 11 participants in the BNE group had missing data at five years. No study had a low risk of bias in all risk of bias domains. The risk ratio (RR) for success rate (eucalcaemia) at six months in the MIP group compared to the BNE group was 0.98 (95% confidence interval (CI) 0.94 to 1.03; P = 0.43; 5 studies, 266 participants; very low-certainty evidence). A total of 132/136 (97.1%) participants in the MIP group compared with 129/130 (99.2%) participants in the BNE group were judged as operative success. At five years, the RR was 0.94 (95% CI 0.83 to 1.08; P = 0.38; 1 study, 77 participants; very low-certainty evidence). A total of 34/38 (89.5%) participants in the MIP group compared with 37/39 (94.9%) participants in the BNE group were judged as operative success. The RR for the total incidence of perioperative adverse events was 0.50, in favour of MIP (95% CI 0.33 to 0.76; P = 0.001; 5 studies, 236 participants; low-certainty evidence). Perioperative adverse events occurred in 23/136 (16.9%) participants in the MIP group compared with 44/130 (33.9%) participants in the BNE group. The 95% prediction interval ranged between 0.25 and 0.99. These adverse events included symptomatic hypocalcaemia, vocal cord palsy, bleeding, fever and infection. Fifteen of 104 (14.4%) participants experienced symptomatic hypocalcaemia in the MIP group compared with 26/98 (26.5%) participants in the BNE group. The RR for this event comparing MIP with BNE at two days was 0.54 (95% CI 0.32 to 0.92; P = 0.02; 4 studies, 202 participants). Statistical significance was lost in sensitivity analyses, with a 95% prediction interval ranging between 0.17 and 1.74. Five out of 133 (3.8%) participants in the MIP group experienced vocal cord paralysis compared with 2/128 (1.6%) participants in the BNE group. The RR for this event was 1.87 (95% CI 0.47 to 7.51; P = 0.38; 5 studies, 261 participants). The 95% prediction interval ranged between 0.20 and 17.87. The effect on all-cause mortality was not explicitly reported and could not be adequately assessed (very low-certainty evidence). There was no clear difference for health-related quality of life between the treatment groups in two studies, but studies did not report numerical data (very low-certainty evidence). There was a possible treatment benefit for MIP compared to BNE in terms of cosmetic satisfaction (very low-certainty evidence). The mean difference (MD) for duration of surgery comparing BNE with MIP was in favour of the MIP group (-18 minutes, 95% CI -31 to -6; P = 0.004; 3 studies, 171 participants; very low-certainty evidence). The 95% prediction interval ranged between -162 minutes and 126 minutes. The studies did not report length of hospital stay. Four studies reported intraoperative conversion rate from MIP to open procedure information. Out of 115 included participants, there were 24 incidences of conversion, amounting to a conversion rate of 20.8%.

AUTHORS' CONCLUSIONS

The success rates of MIP and BNE at six months were comparable. There were similar results at five years, but these were only based on one study. The incidence of perioperative symptomatic hypocalcaemia was lower in the MIP compared to the BNE group, whereas the incidence of vocal cord paralysis tended to be higher. Our systematic review did not provide clear evidence for the superiority of MIP over BNE. However, it was limited by low-certainty to very low-certainty evidence.