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Original Investigation
November 19, 2020

Use of Intraoperative Parathyroid Hormone in Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Surgery, Galway University Hospitals, Galway, Ireland
  • 2Department of Otorhinolaryngology, Head & Neck Surgery, Galway University Hospitals, Galway, Ireland
  • 3Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland
  • 4The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, Ireland
JAMA Otolaryngol Head Neck Surg. Published online November 19, 2020. doi:10.1001/jamaoto.2020.4021
Key Points

Question  Is use of intraoperative parathyroid hormone associated with higher cure rates in minimally invasive parathyroidectomy for primary hyperparathyroidism?

Findings  In this systematic review and meta-analysis of 12 studies involving 2290 patients with primary hyperparathyroidism, use of intraoperative parathyroid hormone in minimally invasive parathyroidectomy was associated with increased rates of cure and reduced need for reoperation.

Meaning  These study findings suggest that there is a reduction in surgical failure and need for reoperation in patients undergoing minimally invasive parathyroidectomy for primary hyperparathyroidism when intraoperative parathyroid hormone is used.

Abstract

Importance  Intraoperative parathyroid hormone (ioPTH) is a surgical adjunct that has been increasingly used during minimally invasive parathyroidectomy (MIP). Despite its growing popularity, to our knowledge a meta-analysis comparing MIP with ioPTH vs MIP without ioPTH has not yet been conducted.

Objective  To evaluate the safety and efficacy of MIP with ioPTH for treatment of primary hyperparathyroidism.

Data Sources  A systematic search of the databases PubMed, Embase, Scopus, Web of Science, and Cochrane Collaboration was performed to identify studies that compared MIP with and without ioPTH. Data were analyzed between August and September 2019.

Study Selection  Inclusion criteria consisted of randomized clinical trials and observational studies with a retrospective/prospective design, comparing MIP using ioPTH vs MIP not using ioPTH for treatment of primary hyperparathyroidism. Eligible studies had to present odds ratio (OR), risk ratio, or hazard ratio estimates (with 95% CI), standard errors, or number of events necessary to calculate these for the outcome of interest rate. Studies involving patients with secondary or tertiary hyperparathyroidism or those with multiple endocrine neoplasia syndrome were excluded.

Data Extraction  Two reviewers independently reviewed the literature according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Dichotomous variables were pooled as ORs while continuous variables were compared using weighted mean differences. Quality assessment was performed using the Newcastle-Ottawa Scale.

Main Outcomes and Measures  The primary outcome was rate of cure. Secondary outcomes included need for reoperation, need for bilateral neck exploration, morbidity, and length of surgery.

Results  A total of 12 studies, involving 2290 patients with primary hyperparathyroidism, were eligible for inclusion. The median (SD) age of participants was 60.1 (11.8) years and 77.3% of participants were women. The median Newcastle-Ottawa score was 7. Patients who underwent MIP with ioPTH had higher cure rates (OR, 3.88; 95% CI, 2.12-7.10; P < .001). There was a greater need for reoperation in the group of patients who had surgery without ioPTH (OR, 0.40; 95% CI, 0.19-0.86; P = .02). There was a trend toward longer operating times/increased duration of surgery in the ioPTH group; however, this did not reach statistical significance (weighted mean difference, 21.62 minutes; 95% CI, −0.93 to 44.17 minutes; P = .06). The use of ioPTH was associated with higher rates of bilateral neck exploration (OR, 3.55; 95% CI, 1.27-9.92; P = .02).

Conclusions and Relevance  Use of ioPTH is associated with higher cure rates for patients with primary hyperparathyroidism undergoing MIP. Minimally invasive parathyroidectomy performed without ioPTH is associated with less conversion to bilateral neck exploration at initial surgery but with lower cure rates and an increased risk for reoperation.

Trial Registration  PROSPERO identifier: CRD42020148588

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