Use of Intraoperative Parathyroid Hormone in Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism

Abstract

IMPORTANCEIntraoperative 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 MEASURESThe 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 RELEVANCEUse 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.

Role and Recent Trend of Intraoperative Parathyroid Hormone Monitoring During Parathyroidectomy in Patients With Primary Hyperparathyroidism

“…The half-life of PTH is approximately 3-5 min, allowing PTH decay to be measured quickly and quantitatively during parathyroidectomy. 20) Although the detailed protocol is different according to several IOPTH interpretation criteria, PTH measurement is required before and after excision, and is usually performed preoperatively, before excision (just before excision of pathological PTG during surgery), and 10-20 min after excision. 6,12,15) At least four different systems have been proposed and used for the determination of IOPTH: the QuiCK-Pak system (Nichols Institute Diagnostics, San Juan Capistrano, CA, USA), STAT-IntraOperative-Intact-PTH Immunoassay (Future Diagnostics, Wijchen, Netherlands), Immulite Turbo PTH assay (Diagnostic Products, Los Angeles, CA, USA), and Cobas Elecsys PTH assay (Roche, Mannheim, Germany).…”

“…15) A recent meta-analysis involving 2290 patients from 12 studies also showed a trend toward increased length of operation in the IOPTH group, with a weighted mean difference of 21.6 min, although this trend did not reach statistical significance (p=0.06). 20) This extra time could be attributed to sample transportation from operating room to the laboratory of the institution, as well as the turnaround time of the assay. 9,27) Extra time resulting from sample transportation would be negligible if a Point-of-Care (POC) system for IOPTH assay is established, allowing measurement of IOPTH in the operating room.…”

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

“…In addition to the developments in imaging methods, ioPTH measurement has also a critical role in the development of MIP. In a recent meta-analysis, patients who underwent MIP with ioPTH had a higher cure rate (OR, 3.88; 95%CI, 2.12–7.10; p < .001), and the need for reoperation was lower compared to MIP without ioPTH (OR, 0.40; 95%CI, 0.19–0.86; p = .02) ( 5 ). In these patients, it is the more common accepted opinion that ioPTH may not have a significant contribution or that it has a small contribution ( 23 , 24 ).…”

“…Intraoperative monitoring of parathyroid hormone (ioPTH) in parathyroidectomy is an adjunctive method used to confirm cure or to detect whether there is still hyperfunctional residual parathyroid tissue after the pathological gland has been removed. It has been shown that ioPTH contributes to MIP, increasing the cure rate and reducing the need for reoperation ( 5 , 6 ).…”

Manejo quirúrgico del hiperparatiroidismo primario con pruebas de localización prequirúrgicas negativas

“…Los defensores de la cirugía radioguiada afirman que es una técnica segura y útil durante la paratiroidectomía, reduciendo el tiempo quirúrgico en la mitad aproximadamente, incluso en los casos de MIP, al confirmar la glándula patológica tras la resección [23]. Sin embargo, otros refieren que no se han podido reproducir en la realidad los supuestos beneficios obtenidos mediante cirugía radioguiada, y que por lo tanto no está clara su verdadera utilidad [17].…”