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Background: Management of asymptomatic primary hyperparathyroidism (PHPT) in older patients (age >50) is controversial. The 4th International Workshop on the Management of Asymptomatic PHPT recommends surveillance for older patients who lack objective signs of disease, whereas The American Association of Endocrine Surgeons (AAES) guidelines recommend consideration of parathyroidectomy for patients of any age with subjective constitutional, neuropsychiatric, or cognitive symptoms. Therefore, the primary objective of this study was to evaluate the association between patient age and both practice patterns and outcomes in the management of patients with sporadic PHPT., Methods: The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database was queried for all adults (age ≥18) who underwent an index parathyroidectomy for sporadic primary hyperparathyroidism between 2014 and 2020. Associations between patient age (≤50 years vs. >50 years) and both practice patterns and outcomes were evaluated separately using adjusted multivariable logistic and multinomial regression models., Results: Of 9,938 patients who underwent parathyroidectomy, 8,080 (81.3%) were >50 years old and 1,858 (18.7%) were ≤50. Of this cohort, 17% of older patients and 26% of younger patients presented with only subjective symptoms. Compared to younger patients, older patients were more likely to have an objective indication for parathyroidectomy (aOR = 1.8, 95%CI: 1.6-2.0, p < 0.001). They were also more likely to undergo ≥2 imaging studies pre-operatively (aOR = 1.2, 95%CI: 1.1-1.3, p = 0.003), to undergo bilateral neck exploration (aOR = 1.4, 95%CI: 1.3-1.6, p < 0.001), and to have multi-gland disease (aOR = 1.6, 95%CI: 1.4-1.8, p < 0.001). There was no difference between age groups and parathyroidectomy-related complications including hypocalcemia, vocal cord dysfunction, hematoma requiring evacuation, or reintubation, however, older patients were less likely to have any peri-operative morbidity (aOR = 0.7, 95%CI: 0.6-0.9, p = 0.011)., Conclusions: Older patients were more likely to meet objective criteria prior to undergoing parathyroidectomy by CESQIP participating high-volume endocrine surgeons, however they were less likely to have peri-operative complications compared to younger patients. Given the growing evidence demonstrating improvement of both objective and subjective symptoms after parathyroidectomy for PHPT, additional studies are still needed to fully understand the benefit of surgical referral in older adults for less objective indications., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Parathyroidectomy is the only cure for primary hyperparathyroidism and is effective in more than 95% of cases at initial surgical intervention. However, 2.5-5% of cases have recurrent or persistent disease. Pre-operative imaging is recommended in patients undergoing redo parathyroidectomy to localize the diseased gland. Parathyroid 4D CT scan is now widely used for localization and has been reported to have improved accuracy when compared to other imaging modalities. We conducted a retrospective study of all redo parathyroidectomies from 2017 to 2021 at a single tertiary parathyroid referral center. We evaluated pre-operative 4D CT scan results and compared them to intra-operative findings to determine if 4D CT scan correctly predicted the location of the diseased gland. 4D CT scan had a concordance of 87% with intra-operative findings. 4D CT scan is highly effective identifying parathyroid pathology in re-operative cases and can be used as a pre-operative tool to guide surgical management.

Background: The aim of the present study was to determine whether PTH spikes in renal hyperparathyroidism can interfere with the interpretation of intraoperative PTH monitoring and to determine its frequency and characteristics., Methods: This was a prospective observational study of consecutive patients who underwent surgical treatment in a single tertiary institution. Patients were divided into two groups: spike and no spike. Patients with secondary and tertiary hyperparathyroidism were analyzed separately. Intraoperative PTH monitoring by venous serial samples: two samples were taken before the excision of the parathyroid gland, and two others were taken after resection., Results: PTH spikes occurred in 23.5% (53 of 226), and their occurrence was similar between secondary and tertiary hyperparathyroidism patients (p = 0.074). The relative PTH spike intensity was higher in transplanted patients than in dialysis patients (55 vs. 20%, p = 0.029). A characteristic of the secondary hyperparathyroidism patients was the highest frequency of surgical failure (23 vs. 7.5%, p = 0.016) and the higher occurrence of supernumerary glands in the spike group (23 vs. 10.3%, p = 0.035). Supernumerary parathyroid was associated with surgical failure [19.1 (6.5-55.7) odds ratio [confidence interval], p < 0.001). In the studies evaluating the diagnostic test validity for patients on dialysis and experiencing spikes, the most significant impacts were in the sensitivity, accuracy, and negative predictive value of the method., Conclusions: PTH spikes occurred in up to 23.5% of renal hyperparathyroidism surgical treatments and can negatively influence the intraoperative parathyroid hormone monitoring. Regarding the phenomenon of PTH spikes, it is prudent to think about the possibility of a hyperplastic supernumerary gland., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

We compared the efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) and parathyroidectomy (PTX) for the treatment of secondary hyperparathyroidism (SHPT). In this single-center retrospective study, we divided patients into PTX (n = 53) and RFA (n = 47) groups. The primary outcome was the proportion of patients who achieved the target intact parathyroid hormone (iPTH) concentration range (≤ 300 pg/mL). Secondary outcomes were the differences in the changes in iPTH, calcium, and phosphorus levels over time and prognosis. iPTH concentrations of 82.1% and 64.1% in the PTX and RFA groups, respectively, were within the recommended range at the endpoint (P = 0.07). iPTH concentrations in the PTX and RFA groups dropped sharply after treatment (82 ± 163 pg/mL and 280 ± 307 pg/mL, respectively, P < 0.001). There was no difference in the trends of iPTH, calcium, and phosphorus levels between the two groups (P > 0.05). Survival analysis revealed no differences in all-cause mortality and cumulative response rate between the two groups (P = 0.90, P = 0.14, respectively). Notably, the incidence of infection and length of the hospital stay in the RFA group were significantly lower. The preoperative bone-specific alkaline phosphatase concentration was a risk factor for postoperative hypocalcemia. US-guided RFA is minimally invasive and compared to PTX in terms of long-term efficacy and complications in the treatment of severe SHPT in maintenance dialysis patients. It may be used as an alternative technique to PTX; however, further studies are needed., (© 2022. The Author(s).)

Background: Near-infrared (NIR) autofluorescence detection is an effective method for identifying parathyroid glands (PGs) in thyroidectomy or parathyroidectomy. Fiber optical probes provide quantitative autofluorescence measurements for PG detection owing to its high sensitivity and high excitation light cut-off efficiency at a fixed detection distance. However, an optical fiber probe lacks the imaging capability and cannot map the autofluorescence distribution on top of normal tissue background. Therefore, there is a need for intraoperative mapping of PGs with high sensitivity and imaging resolution., Methods: We have developed a fluorescence scanning and projection (FSP) system that combines a scanning probe and a co-axial projector for intraoperative localization and in situ display of PGs. Some of the key performance characteristics, including spatial resolution and sensitivity for detection, spatial resolution for imaging, dynamic time latency, and PG localization capability, are characterized and verified by benchtop experiments. Clinical utility of the system is simulated by a fluorescence-guided PG localization surgery on a tissue-simulating phantom and validated in an ex vivo experiment., Results: The system is able to detect indocyanine green (ICG) solution of 5 pM at a high signal-to-noise ratio (SNR). Additionally, it has a maximal projection error of 0.92 mm, an averaged projection error of 0.5 ± 0.23 mm, and an imaging resolution of 748 μm at a working distance ranging from 35 to 55 cm. The dynamic testing yields a short latency of 153 ± 54 ms, allowing for intraoperative scanning on target tissue during a surgical intervention. The simulated fluorescence-guided PG localization surgery has validated the system's capability to locate PG phantom with operating room ambient light interference. The simulation experiment on the PG phantom yields a position detection bias of 0.36 ± 0.17 mm, and an area intersection over unit (IoU) of 76.6% ± 6.4%. Fluorescence intensity attenuates exponentially with the thickness of covered tissue over the PG phantom, indicating the need to remove surrounding tissue in order to reveal the weak autofluorescence signal from PGs. The ex vivo experiment demonstrates the technical feasibility of the FSP system for intraoperative PG localization with accuracy., Conclusion: We have developed a novel probe-based imaging and navigation system with high sensitivity for fluorescence detection, capability for fluorescence image reconstruction, multimodal image fusion and in situ PG display function. Our studies have demonstrated its clinical potential for intraoperative localization and in situ display of PGs in thyroidectomy or parathyroidectomy., (© 2022. The Author(s).)

Background: Computer-aided examination of digital tissue images has attracted attention in recent years. Application in the field of parathyroid pathology has not been studied previously. It holds a potential to assist in the examination of parathyroid gland adenoma or hyperplasia., Objectives: To explore parathyroid cell detection of slide images by digital tissue analysis and compare the results to standard human processing., Methods: 47 incisional biopsies of healthy appearing parathyroid glands were evaluated for their cellularity level. First, by the standard examination using microscopy by three independent pathologists. We compared the mean cellularity grading of the pathologists to the output of a computerized cell detection software., Results: A disagreement was found between the standard human cellularity grading and the digital analysis output. However, the digital analysis reaches a 94% specificity and 48% sensitivity to predict high cellularity (>60% parenchymal cells)., Conclusions: Digital analysis of parathyroid tissue can be used as a tool for hypercellularity elimination, therefore assisting in the diagnosis of parathyroid cell hyperplasia. Additional studies using more advanced algorithms are necessary for further precision enhancement., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Parathyroid imaging is essential for the detection and localization of hyperfunctioning parathyroid tissue in patients with primary hyperparathyroidism (pHPT). Surgical treatment of pHPT mainly consists of minimally invasive parathyroidectomy (MIP), as a single adenoma represents the most common cause of this endocrine disorder. Successful surgery requires an experienced surgeon and relies on the correct preoperative detection and localization of hyperfunctioning parathyroid glands. Failure to preoperatively identify the culprit parathyroid gland by imaging may entail a more invasive surgical approach, including bilateral open neck exploration, with higher morbidity compared to minimally invasive parathyroidectomy. Parathyroid imaging may be also useful before surgery in case of secondary hyperparathyroidism (sHPT) or hereditary disorders (MEN 1, 2, 4) as it enables correct localization of typically located parathyroid glands, detection of ectopic as well as supernumerary glands. It is now accepted by most surgeons experienced in parathyroid surgery that preoperative imaging plays a key role in their patients' management. Recently, the European Association of Nuclear Medicine (EANM) issued an updated version of its Guidelines on parathyroid imaging. Its aim is to precise the role and the advantages and drawbacks of the various imaging modalities proposed or well established in the preoperative imaging strategy. It also aims to favor high performance in indicating, performing, and interpreting those examinations. The objective of the present article is to offer a summary of those recent EANM Guidelines and their originality among other Guidelines in this domain issued by societies of nuclear medicine physicians or other disciplines.

Importance: Patients with primary hyperparathyroidism (pHPT) appear to have an increased risk of fractures and other comorbidities, such as cardiovascular disease, although results from previous studies have been inconsistent. Evidence of the association of parathyroidectomy (PTX) with these outcomes is also limited because of the lack of large well-controlled trials., Objective: To investigate whether untreated pHPT was associated with an increased risk of incident fractures and cardiovascular events (CVEs) and whether PTX was associated with a reduced risk of these outcomes., Design, Setting, and Participants: This cohort study included all patients who were diagnosed with pHPT at hospitals in Sweden between July 1, 2006, and December 31, 2017. Each patient was matched with 10 control individuals from the general population by sex, birth year, and county of residence. The patients were followed up until December 31, 2017. Data analyses were performed from October 2021 to April 2022., Main Outcomes and Measures: The primary outcomes were fractures, CVEs, and death. Cumulative incidence of events was estimated using the 1-minus Kaplan-Meier estimator of corresponding survival function. Cox proportional hazards regression models were used to calculate hazard ratios (HRs)., Results: A total of 16 374 patients with pHPT were identified (mean [SD] age, 67.5 [12.9] years; 12 806 women [78.2%]), with 163 740 control individuals. The follow-up time was 42 310 person-years for the pHPT group and 803 522 person-years for the control group. Compared with the control group, the pHPT group had a higher risk of any fracture (unadjusted HR, 1.39; 95% CI, 1.31-1.48), hip fracture (unadjusted HR, 1.51; 95% CI, 1.35-1.70), CVEs (unadjusted HR, 1.45; 95% CI, 1.34-1.57), and death (unadjusted HR, 1.72; 95% CI, 1.65-1.80). In a time-dependent Poisson regression model, PTX was associated with a reduced risk of any fracture (HR, 0.83; 95% CI, 0.75-0.93), hip fracture (HR, 0.78; 95% CI, 0.61-0.98), CVEs (HR, 0.84; 95% CI, 0.73-0.97), and death (HR, 0.59; 95% CI, 0.53-0.65)., Conclusions and Relevance: Results of this study suggest that pHPT is associated with increased risk of fractures, CVEs, and death, highlighting the importance of identifying patients with this condition to prevent serious unfavorable outcomes. The reduced risk of these outcomes associated with PTX suggests a clinical benefit of surgery.

Background: Normocalcemic primary hyperparathyroidism (NCpHPT) and normohormonal primary hyperparathyroidism (NHpHPT) are recently recognized variants of primary hyperparathyroidism. Current guidelines for the management hyperparathyroidism recognize NCpHPT as one of the areas that are recommended for more research due to limited available data., Methods: A retrospective review of patients who had parathyroidectomy between 2014 and 2019. We excluded patients with multiple endocrine neoplasia syndromes and secondary and tertiary hyperparathyroidism. Included patients were classified based on the biochemical profile into classic or normocalcemic hyperparathyroidism group. Collected data included demographics, preoperative localizing imaging, intraoperative parathyroid hormone levels, and postoperative cure rates., Results: 261 patients were included: 160 patients in the classic and 101 patients in the normocalcemic group. Patients in the normocalcemic group had significantly more negative sestamibi scans (n = 58 [8.2%] vs 78 [51.3%], P = <.01), smaller parathyroid glands (mean weight 436.0 ± 593.0 vs 742.4 ± 1109.0 mg, P = .02), higher parathyroid hyperplasia rates (n = 51 [50.5%] vs 69 [43.1%]), and significantly higher intraoperative parathyroid hormone at 10 minutes (78.1 ± 194.6 vs 43.9 ± 62.4 1, P = .04). Positive predictive value of both intraoperative parathyroid hormone and cure rate was lower in the normocalcemic group (84.2% vs 95.7%) and (80.5% vs 95%), respectively., Conclusion: Normocalcemic hyperparathyroidism is a challenging disease. Surgeons should be aware of the lower cure rate in this group, interpret intraoperative parathyroid hormone with caution, and have a lower threshold for bilateral neck exploration and 4 glands visualization.

The main causes of hypoparathyroidism are unintentional parathyroidectomy and/or impaired blood supply. Therefore, accurate identification and preservation of parathyroid glands in situ during thyroid or parathyroid surgery has become one of the problems that plague endocrine surgeons. In recent years, near-infrared autofluorescence imaging technology has gradually attracted more and more attention from surgeons because of its simplicity, safety, accuracy, real-time, no-contrast agent, and non-invasiveness. This article reviews the development history, clinical application, and application prospects of the parathyroid gland autofluorescence imaging technology in recent years., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

BACKGROUND. In patients with primary hyperparathyroidism (PHPT), bilateral neck exploration is necessary for multigland disease (MGD), whereas minimally invasive parathyroidectomy is often preferred for single-gland disease (SGD). An existing system (the 4D-CT MGD score) for differentiating SGD from MGD with the use of preoperative parathyroid CT considers the size of only the largest candidate lesion. OBJECTIVE. The purpose of this study was to assess the utility of the size of the second-largest lesion on parathyroid CT for differentiating SGD from MGD as well as the utility of individual gland size for predicting the need for surgical removal and to derive optimal size thresholds for these purposes. METHODS. This retrospective study included patients with PHPT who underwent biochemically successful parathyroidectomy after preoperative parathyroid CT. Clinical radiology reports were reviewed to classify reported candidate parathyroid lesions as low-, intermediate-, or high-confidence lesions. Resected hypercellular parathyroid lesions were correlated with clinically reported candidate lesions. Patients were classified as having SGD or MGD on the basis of operative and pathology reports, independent of CT findings. One observer retrospectively determined the estimated volume (0.52 × length × width × height) and maximum diameter of clinically reported high-confidence lesions, as well as the 4D-CT MGD scores from the examinations. Diagnostic performance was assessed. RESULTS. The sample comprised 62 patients (41 women, 21 men; median age, 65 years), 47 of whom had SGD and 15 of whom had MGD, with 151 candidate lesions, including 106 high-confidence lesions. Based on the second-largest high-confidence lesions, an estimated volume threshold of 60 mm 3 or greater achieved 53% sensitivity and 96% specificity, whereas a maximum diameter threshold of 7 mm or greater achieved 67% sensitivity and 96% specificity for MGD; a 4D-CT MGD score of 3 or greater achieved 47% sensitivity and 68% specificity for MGD. For predicting the need to remove a gland for successful parathyroidectomy, an estimated volume threshold of 114 mm 3 or greater achieved 84% sensitivity and 97% specificity, and a threshold of 55 mm 3 or greater achieved 93% sensitivity and 87% specificity; a maximum diameter threshold of 7 mm or greater achieved 93% sensitivity and 84% specificity. CONCLUSION. The estimated volume and maximum diameter of high-confidence candidate lesions can differentiate SGD from MGD and identify individual glands requiring removal for successful parathyroidectomy. Differentiating SGD from MGD may be aided by considering both the first- and second-largest high-confidence lesions. CLINICAL IMPACT. The findings will help identify patients who are likely to require bilateral neck explorations, informing preoperative patient counseling and individualized operative planning.

Objective: Parathyroidectomy (PTx) improves quality of life (QoL) in patients with primary hyperparathyroidism (PHPT). Whether this effect is modified according to the patients' age is unknown. The aim of this study was to evaluate the impact of age on the effect of PTx on QoL and frailty in patients with PHPT, six months post-PTx., Methods: This was a prospective cohort study, including patients with PHPT, admitted from January 2016 to December 2019, divided into two categories: younger (≤ 65 years old) and older (> 65 years old). QoL was assessed with the Pasieka questionnaire (PAS-Q) two days pre- and six months post-operatively. Frailty was also assessed at the same time intervals, with the Frailty Index (FI)., Results: One hundred and thirty-four patients (younger group: 96 patients, mean age 50.4 ± 9.8 years; older group: 38 patients, mean age 72.1 ± 4.9 years) were included. PTx resulted in a significant reduction in PAS-Q score in both groups. Notably, a greater reduction in "mood swings", "irritability", "itchy skin" and "feeling thirsty" PAS-Q domains was observed in the younger group. In contrast, a greater decrease in "bone pain", "tiredness", "weakness", "joint pain", "getting off chair" and "headaches" items was observed in the older group. Moreover, PTx led to a decrease in FI only in this group., Conclusions: PTx leads to an improvement in QoL both in older (> 65 years) and younger (≤ 65 years) patients with PHPT, attributed to a differential effect on PAS-Q items. Frailty improves only in the older group., (© 2021. Italian Society of Endocrinology (SIE).)

Background: Fluorescence angiography (FA) using indocyanine green dye (ICG) has recently been introduced for real-time identification of parathyroid adenomas. However, time to peak fluorescence has not yet been critically evaluated., Methods: This was a retrospective review of parathyroidectomies with ICG FA over a one-year period., Results: There were 66 patients with average age of 64 years. The average time to initial fluorescence was 26.7 s and to peak fluorescence was 38.0 s. The time to saline flush administration significantly correlated with times to initial and peak fluorescence (p < .0001). The rate of in-situ fluorescence was 97%. The rates of suspected adenoma detection were 69% for sestamibi scan, 71% for ultrasound, and 96% for CT scan. Imaging was discordant in 13 cases (20%), with the adenoma located on the opposite side of the neck in 4 cases., Conclusions: ICG FA is a rapid and effective adjunct for the intraoperative identification of parathyroid adenomas., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The evidence of hyperparathyroidism associated with cerebral calcifications is rare. We report a case with primary hyperparathyroidism (PHPT) and cerebral calcifications. A 63-year-old female patient with a history of hypertension presented to the neurology department due to bradykinesia and declining memory for one year.   Cranial CT and magnetic resonance imaging (MRI) scan revealed symmetrical calcifications in the basal ganglia, dentate nucleus of the cerebellum and in the gray and white matter junction. In the literature review, a total of 6 patients with PHPT had cerebral calcifications. Parathyroidectomy may provide a significant remission of cerebral calcifications in a patient with PHPT.

Preoperative localisation of pathological glands in patients with primary hyperparathyroidism (PHP) is the mainstay for mini-invasive parathyroidectomy. Nevertheless, a not negligible number of patients presents discordant or negative neck ultrasound (US) and 99m Tc-Sestamibi (MIBI) scan. The aim of this study was to assess if a mini-invasive approach is feasible in this kind of patients. In this retrospective study were included patients that underwent parathyroidectomy for PHP. Patients were divided into two groups according to concordance of US and MIBI scan results. 242 patients were included: 183 had concordant preoperative studies, and 59 had discordant or negative studies. A mini-invasive approach was possible in 42 (72.9%) patients with unclear preoperative studies, whereas 12 (20.3%) additional patients required conversion to BNE. The incidence of persistent PHP was higher in patients with unclear preoperative studies (8.5% vs 2.7%), but this difference did not reach a statistical significance (p = 0.121). In patients with unclear preoperative studies, a negative result of intraoperative PTH allowed to avoid a persistent disease in 12 patients, while in 3 cases led to an unnecessary additional exploration. In patients with discordant preoperative studies a mini-invasive approach is feasible; in this setting, the use of intraoperative PTH is mandatory to reduce the incidence of persistent PHP., (© 2021. Italian Society of Surgery (SIC).)

Introduction: The standard gold treatment of primary hyperparathyroidism (PHP) is parathyroidectomy. Imaging in particular, cervical ultrasound (US) and technetium-99 m- méthoxyisobutylisonitrileparathyroid scintigraphy using the single-photon emission computed tomography (TC-99 m-MIBI-SPECT) are always indicated prior to parathyroid surgery, allowing the location of parathyroid adenomas. The objective of our study is to evaluate the contribution of TC-99 m-MIBI-SPECT and US in the preoperative topographic diagnosis of PHP., Materials and Methods: this is a descriptive and analytical retrospective study, conducted in our department of Endocrinology, Diabetology and Metabolic Diseases in Hassan II University Hospital of Fez between 2009 and 2018. All patients who received a para-thyroidectomy for PHP were recruited. All patients had received a cervical US and a TC-99 m-MIBI-SPECT. We compared imaging data before surgery with data from intraoperative exploration and anatomopathological findings of surgical samples., Results: Forty-eight patients were collected. US correctly identified parathyroid adenoma in 85.40% of patients with PHP versus 89.50% in TC-99 m-MIBI-SPECT. US correctly predicted surgical outecomes in 97.60% of patients and TC-99 m-MIBI-SPECT in 97.72% of cases. Their combination had better results in sensitivity and positive predictive value., Conclusion: TC-99 m-MIBI-parathyroid scintigraphy SPECT had a higher probability for solitary parathyroid adenoma compared to cervical US. Its use coupled with the TC-99 m-MIBI-parathyroid scintigraphy SPECT allows reliable preoperative tracking., Competing Interests: None

Introduction: Bilateral neck exploration (BNE) has been the gold standard for the treatment of primary hyperparathyroidism (PHPT). Minimally invasive parathyroidectomy (MIP) has emerged as an alternative procedure for localised solitary adenomas. The most popular MIP techniques are the open MIP (OMIP) and the minimally invasive video-assisted parathyroidectomy (MIVAP). This study aims to assess whether we achieved a smooth transition from OMIP to MIVAP without compromising the results or increasing the cost., Methods: A parathyroid adenoma was successfully localised preoperatively in 77/86 patients with PHPT. MIP was contraindicated in 27/86 cases. For MIVAP, a 5mm, 30 degree camera was employed, along with special instruments., Results: Median preoperative parathyroid hormone (PTH) level was 145.9pg/dl (59-2,151) and median calcium (Ca) was 10.8mg/dl (9.3-19). Comparing MIVAP ( N =31) with OMIP ( N =28), there was no significant difference in the age, sex, location of the adenoma, preoperative PTH and Ca levels as well as in all the other factors compared, apart from the size of adenomas, which were bigger in the OMIP group (1.85cm vs 1.4cm, p =0.032). Moreover, cure rates, operating time, hospital stay and rates of postoperative normocalcaemia were similar between the two groups., Conclusions: Despite the learning curve, MIVAP was not found to be inferior to OMIP for localised adenomas. The final cost was no higher for MIVAP than OMIP with the use of common reusable instruments. This, along with surgeons' experience in parathyroid and endoscopic surgery facilitates a smooth and cost-effective transition from OMIP to MIVAP.

Calcimimetics is a new drug for lowering serum parathyroid hormone (PTH), calcium and phosphate in patients with hyperparathyroidism (HPT) on long-term dialysis. It became available on market in 2006. The impact of calcimimetics on the treatment by parathyroidectomy (PTx) was reviewed from the surgeons' point of view. Cure of renal HPT by calcimimetics is not feasible, but calcimimetics can improve preoperative cardiac ventricle ejection fractions by lowering serum PTH. Heart failure is not necessarily a contraindication for PTx. PTx should be done before irreversible organ damage occurs. Limb gangrenes is an ominous sign and should be prevented by frequent checkup for peripheral arterial circulation. The impact of renal osteodystrophy on the quality of life and as indirect cause of mortality deserves more attention in patients with renal HPT. Delayed referral to PTx leads to more complicated patients. A consensus between nephrologists and surgeons about propitious timing for PTx is necessary. Future prospect on the surgical treatment of renal HPT is proposed. Supplemental figure; http://links.lww.com/ASAIO/A782., Competing Interests: Conflicts of interest: Dr. Chen-Hsen Lee, an editorial board member at Journal of the Chinese Medical Association, had no role in the peer review process of or decision to publish this article. The other authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article., (Copyright © 2022, the Chinese Medical Association.)

Purpose: To evaluate the diagnostic accuracy of near-infrared autofluorescence-based identification in the identification of parathyroid glands during thyroidectomy or parathyroidectomy., Methods: The clinical studies were retrieved from PubMed, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, SCOPUS, and Google Scholar. The study protocol was registered on Open Science Framework ( https://osf.io/um8rj/ ). The search period ranged from the date of each database's inception to May 2021. Cohort studies dealing with patients of whom parathyroid glands were detected by near-infrared autofluorescence and confirmed clinically or pathologically during thyroidectomy or parathyroidectomy were included. Editorials, letters, "how-I-do-it" descriptions, other site head and neck tumors, and articles with lack of diagnostic identification data were excluded. True positive, true negative, false positive, and false negative were extracted. The QUDAS ver. 2 was used to evaluate the methodological quality., Results: Seventeen studies with 1198 participants were evaluated in this analysis. Near-infrared autofluorescence-based identification of parathyroid glands showed a diagnostic odds ratio of 228.8759 (95% confidence interval, 134.1099; 390.6063). The area under the summary receiver operating characteristic curve was 0.967. The sensitivity, specificity, negative predictive value, and positive predictive value were 0.9693 (0.9491; 0.9816), 0.9248 (0.8885; 0.9499), 0.9517 (0.8981; 0.9778), and 0.9488 (0.9167; 0.9689), respectively. Subgroup analyses were performed to compare two autofluorescence detection methods, because there was high heterogeneity in the outcomes. The diagnostic accuracy was higher in probe-based detection than in image-based detection., Conclusions: Near-infrared autofluorescence-based identification is valuable for identifying the parathyroid glands of patients during thyroidectomy or parathyroidectomy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey., Materials and Methods: Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020., Results: Of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20 min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1 day. No persistence was documented on follow up., Conclusion: TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Introduction: Parathyroid tumor, in particular carcinoma, is fairly rare among neoplasms of the endocrine system, unlike its benign counterpart. However, there is no bibliometric analysis in the field of parathyroid tumors comprehensively summarizing and discussing a large number of publications by a machine learning-based method., Materials and Methods: Parathyroid tumor-related publications in PubMed from January 2001 to December 2020 were searched using the MeSH term "parathyroid neoplasms". Latent Dirichlet allocation was adopted to identify the research topics from the abstract of each publication using Python., Results: A total of 3,301 parathyroid tumor-associated publications were identified from the past 20 years, and included in further analyses. Research articles and case reports occupied the most proportion of publications, while the number of clinical studies and clinical trials decreased, especially in recent years. Technetium Tc 99m sestamibi was most studied among the diagnosis-related MeSH terms, while parathyroidectomy was among the treatment-related MeSH terms. The Latent Dirichlet allocation analyses showed that the top topics were 99m Tc-MIBI imaging, parathyroidectomy, gene expression in the cluster of diagnosis research, treatment research, and basic research. Notably, scarce connections were shown between the basic research cluster and the other two clusters, indicating the requirements of translational study turning basic biological knowledge into clinical practice., Conclusion: The annual scientific publications on parathyroid tumors have scarcely changed during the last two decades. 99m Tc-MIBI imaging, parathyroidectomy, and gene expression are the most concerned topics in parathyroid tumor research., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Zhang, Xia and Li.)

Background: For a comprehensive assessment of the effect of surgery in patients with primary hyperparathyroidism (PHPT), as well as for monitoring the condition of patients after treatment, it sounds reasonable to evaluate quality of life (QoL) and symptoms in PHPT patients before and after surgery., Aim: The aim of this study was to assess changes in the QoL and symptoms in patients with PHPT after surgery., Materials and Methods: During prospective observational study, patients filled out QoL questionnaires and evaluated the presence and severity of their symptoms prior to parathyroidectomy (PTE) and 3, 12 months after surgery. Statistical analysis included the following methods: Student's t-test or Wilcoxon's non-parametric test, the generalized estimating equations (GEE), correlation analysis, χ2 and McNemar tests., Results: The study included 72 patients (mean age 52 years, 97.2% female) with symptomatic (68.1%) and asymptomatic (31.9%) PHPT. Before surgery patients with PHPT exhibited significantly decreased role functioning, physical and social well-being, and vitality. Half of PHPT patients experienced moderate-to-severe symptoms such as weakness, fatigue, loss of concentration, mood changes, as well as joint and bone pain; the association between symptoms experienced and the extent of QoL impairment before surgery was shown. Three months after PTE improvement in both physical and psychological components of QoL was shown. Positive QoL changes were demonstrated in patients with both symptomatic and asymptomatic PHPT and they preserved for 12 months after surgery. Also within 12 months after PTE significant decrease in PHPT-associated symptoms such as weakness, fatigue, loss of concentration and mood changes was found., Conclusion: The results obtained demonstrate efficacy of PTE from the patient's perspective and confirm the value of QoL assessment in PHPT patients in management of this patients' population both for decision making and for evaluation of benefits of surgery and the degree of recovery of patients at long term follow-up.

Background: Several studies have reported on the use of intraoperative parathyroid hormone (ioPTH) measurements during parathyroidectomy (PTX) for renal hyperparathyroidism (rHPT), but there is no consensus on whether it is helpful and, if so, what protocol should be used. Therefore, the literature was systematically reviewed to assess a correlation between ioPTH and early postoperative parathyroid hormone (PTH) levels in patients undergoing PTX for rHPT, separately for those on dialysis and those with a functioning renal transplant., Methods: A systematic literature search was performed in electronic databases. Quality assessment was performed using the Quality In Prognosis Studies tool. Mean ioPTH values were calculated at different time points and correlated to the postoperative PTH levels within 1 month. Fixed-effect and random-effects models were performed to assess the mean ioPTH levels at 10 or 20 min after resection (T10 and T20). Stratified analyses were performed for patients on dialysis and those with a functioning renal transplant., Results: Of the 3087 records screened, 14 studies were included, including some 1177 patients; 1091 were on dialysis and 86 had a functioning kidney transplant. Risk of bias was moderate for most studies. For patients on dialysis, T10 and T20 mean ioPTH levels were 32.1 (95 per cent c.i. 24.3 to 39.9) pmol/l and 15.4 (95 per cent c.i. 7.8 to 22.9) pmol/l) in the random effects meta-analysis. Between individual studies, ioPTH ranged from 4.0-65.1 pmol/l at T10 and 8.6-25.7 pmol/l at T20. T10 and T20 ioPTH were 9.6 and 4.1 times the postoperative PTH-after T20 ioPTH stabilized in those on dialysis. In patients with a functioning renal transplant, ioPTH levels seemed to plateau after 10 min and measured 2.6 times the postoperative PTH., Conclusion: There is a strong correlation between ioPTH and early postoperative PTH levels, indicating that ioPTH is potentially a useful instrument during PTX in patients with rHPT. For patients on dialysis, at T20 ioPTH levels have stabilized and are approximately four times the postoperative PTH. Therefore, it is recommended to use ioPTH 20 min after resection in patients on dialysis, which might be longer than necessary for those with a kidney transplant., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: Preventing cervical reoperations is important-especially after parathyroidectomy. We sought to examine early predictors of recurrence of primary hyperparathyroidism after surgical cure., Methods: Adult patients with sporadic primary hyperparathyroidism treated with parathyroidectomy between September 1, 1997, and September 1, 2019, with confirmed eucalcemia at 6 months postoperatively were identified. Recurrence was defined as hypercalcemia (>10.2 mg/dL) with an elevated or nonsuppressed parathyroid hormone level on subsequent follow-up., Results: Parathyroidectomy was performed in 522 patients (median age, 62.1 years, 77% female) with the majority undergoing planned minimally invasive parathyroidectomy (85.4%, n = 446). After a median follow-up of 30.9 months, 13 patients (2.5%) recurred (median time to recurrence 50.2 months, interquartile range 27.9-66.5), all of whom underwent planned minimally invasive parathyroidectomy (n = 13/446, 2.9%). Recurrence was more common in those with higher (but still normal) 6-month calcium (10.1 vs 9.3 mg/dL, P < .001) or parathyroid hormone values (64 vs 46 pg/mL, P < .01). Multivariate analysis revealed that age >66.5 years, calcium ≥9.8mg/dL and parathyroid hormone ≥80 pg/mL at 6 months were associated with increased risk of recurrence. In addition, the presence of at least 1 preoperative imaging study that conflicted with intraoperative findings among minimally invasive parathyroidectomy patients (n = 446) was associated with increased risk of recurrence (hazard ratio 4.93, 95% confidence interval 1.25-16.53, P = .016)., Conclusion: Recurrence of sporadic primary hyperparathyroidism after initial surgical cure in the era of minimally invasive parathyroidectomy is 2.5%. Identification of those at risk for recurrence using 6-month serum calcium ≥9.8 mg/dL, parathyroid hormone ≥80 pg/mL, and/or potentially conflicting localization studies may inform surveillance strategies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Voice quality disorders remain a problem with classical surgical method which is expected to decrease with new minimally invasive methods. We aimed to examine whether there is an impairment in voice quality among our patients who have undergone open minimally invasive parathyroid surgery., Methods: Forty-seven primer hyperparathyroidism patients included in the study. Their video laryngoscopic evaluations and voice analyses were done in pre-operative and post-operative 6 th month, and changes in the voice quality were examined., Results: Eighty-five (85.1%) of patients were female, with a mean age of 51.5 ± 9.4. According to the voice analysis in the preoperative-postoperative 6 th months, F0 (%): 210.616-211.443, Jitt (%): 0.699-0.735, RAP (%): 0.420-0.444, Shim (%): 2.535-2.736, NHR (dB): 0.119-0.123, and VTI: 0.044-0.045, respectively. No significant differences were observed in any of the acoustic parameters between the pre- and post-operative periods., Conclusion: No deterioration in voice quality was observed in patients undergoing novel minimally invasive surgical technique. In this respect we think that this new method will be much more advantageous in terms of preserving the voice quality in eligible patients., (Copyright: © 2022 Permanyer.)

Objective: To emphasize the main stages of safe endoscopic surgery on endocrine organs of the neck., Material and Methods: There were 79 patients with diseases of thyroid and parathyroid glands who underwent surgery between 2018 and 2021. Of these, 69 ones underwent transaxillary thyroidectomy, 10 patients underwent transaxillary parathyroidectomy., Results: At initial stage of development of this technique, we obtained 2 intraoperative and 2 postoperative complications. Adverse events were completely cured., Conclusion: Endoscopic procedures on the endocrine organs of the neck are a safe alternative to traditional approaches. There are certain advantages of this approach. Compliance with surgical technique and focusing on dangerous stages minimize the risk of complications.

Background and Objective: Preoperative localization of pathologic parathyroid glands is essential in the preparation of a parathyroidectomy. We evaluated the use of a C-11 methionine positron emission tomography/computed tomography scan in a 7-year period in selected patients with primary hyperparathyroidism. The indications to perform a C-11 methionine positron emission tomography/computed tomography were either persistent primary hyperparathyroidism after parathyroidectomy or inconclusive preoperative localization on ultrasound and sestaMIBI., Methods: A group of 36 patients was referred for a C-11 methionine positron emission tomography/computed tomography. Biochemical data, pathology, and results of sestaMIBI were collected retrospectively. The primary hyperparathyroidism patients were divided into two groups. In group 1 ( N = 17), the C-11 methionine positron emission tomography/computed tomography was performed before parathyroidectomy. In group 2 ( N = 19), the C-11 methionine positron emission tomography/computed tomography was performed after unsuccessful parathyroidectomy and before a reoperation., Results: Overall, in 30 of the 36 patients (83%), C-11 methionine positron emission tomography/computed tomography identified a true-positive pathologic parathyroid gland confirmed by an experienced pathologist, consistent with a positive predictive value of 91%. In group 1, 94% of the patients ( N = 16) had pathologic parathyroid tissue identified by C-11 methionine positron emission tomography/computed tomography. This resulted in a clinical benefit in 13 patients (76%). In group 2, the benefit was slightly lower, as 74% of the patients ( N = 14) had a true-positive C-11 methionine positron emission tomography/computed tomography scan resulting in a clinical benefit in nine patients (47%)., Conclusions: In two selected groups of patients planned for an initial operation or reoperation of primary hyperparathyroidism and inconclusive conventional imaging, we found C-11 methionine positron emission tomography/computed tomography to give parathyroid surgeons a clinical benefit in the majority of cases, electing the patients for unilateral surgery.

Introduction: Primary Hyperparathyroidism (PHPT) is a systemic pathology caused by an excessive secretion of parathyroid hormone. Parathyroidectomy is the treatment of choice in PHPT, and the success of surgery is based on precise localization of the abnormal parathyroid gland. Preoperative diagnosis makes use of imaging techniques and functional examinations, however these are insufficient in some cases for the precise location of the pathological gland. Therefore the need arises for an intraoperative localization technique., Materials and Methods: We have retrospectively analyzed 20 consecutive patients with PHPT undergoing parathyroidectomy from April 2019 to September 2021, and divided them in two groups, in base of the use of Indocyanine Green (ICG) fluorescence during the surgery., Results: Of the twenty patients considered in the two groups, all received a preoperative ultrasound evaluation, while second level examinations were reserved for the more difficult cases, with small volume parathyroid adenomas. In the group where the fluorescence method was employed, fluorescence was especially useful in doubtful cases, allowing easier identification of the parathyroid adenoma and consequently a reduction of time and operatory risks. In two procedures using Indocyanine green, a fluorescence signal was weak., Conclusions: ICG represents a convenient and safe way to detect parathyroid adenomas. We found that ICG fluorescence was very useful in all patients with non-localizing preoperative imaging studies. However further investigation is needed, to demonstrate how ICGfluorescence could be a useful localization method during parathyroid surgery., Key Words: Endocrine surgery, Indocyanine green, Parathyroid surgery.

Objective: To evaluate the feasibility and efficacy of total parathyroidectomy followed by modified needle-quantified injection of parathyroid autograft compared with classic incision and transplantation., Methods: We conducted a retrospective study of 171 patients with secondary hyperparathyroidism treated by hemodialysis or peritoneal dialysis. These patients were included in our study from April 2006 to December 2016, who had undergone total parathyroidectomies with autotransplantation. Patients were divided into classic incision for transplantation of parathyroid autograft group and modified needle-quantified injection group. Clinical and biochemical characteristics, including preoperative and postoperative intact parathyroid hormone levels were recorded and compared between two group patients., Results: To compare the techniques of modified needle-quantified injection and classic incision and transplantation, pre- and postoperative biochemistry and length of operation was recorded and analyzed. Preoperative biochemistry was similarly in both groups. However, autograft function achieved was significantly faster in the group with modified needle-quantified injection compared with classic incision and transplantation (P = 0.03). Median time to parathyroid function regain was 3 months for injection compared with 7 months for classic incision. There was no remarkable difference in the recurrence rates between the two groups., Conclusion: The modified needle-quantified injection of parathyroid tissue is a feasible and simple alternative to the more commonly used method of classic incision and transplantation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Concern regarding suboptimal cure rates has led to some endocrine surgery units abandoning focused parathyroidectomy for primary hyperparathyroidism in favor of open bilateral neck exploration or making intraoperative parathyroid hormone estimation mandatory in focused parathyroidectomy. This study explores whether focused parathyroidectomy for radiologically localized primary hyperparathyroidism without intraoperative parathyroid hormone is still a valid approach., Methods: Retrospective review of a tertiary referral endocrine surgery unit database. All parathyroidectomies for primary hyperparathyroidism over 6 years (2013-2019) were included. Lithium-induced hyperparathyroidism, reoperations, familial disease, and concurrent thyroid surgery were excluded. Characteristics and outcomes for focused parathyroidectomy and open bilateral neck exploration were compared by intention-to-treat and treatment delivered. Persistence and recurrence, conversions and complications were analyzed as endpoints., Results: A total of 2,828 parathyroidectomies were performed and 2,421 analyzed. By intention to treat there were 1,409 focused parathyroidectomies and 1,012 open bilateral neck explorations. Focused parathyroidectomy patients were younger: 63 vs 66 years (P < .01); however, gender (77%, 79% female), preoperative peak serum calcium (2.72, 2.70 mmol/L [P = .23]), and serum parathyroid hormone (11.5, 11.0 pmol/L [P = .52]) did not differ. In total, 229 (16.3%) focused parathyroidectomies were converted to open bilateral neck exploration. Multiple gland disease was confirmed in 54.5% of converted patients. Median follow-up was 41 months (3-60 months). Persistence or recurrence requiring reoperation totaled 2.2% and did not differ between focused parathyroidectomy and open bilateral neck exploration in either intention to treat or final treatment analyses. Complications occurred in 1.2% of focused parathyroidectomy and 3.2% open bilateral neck exploration (P < .01)., Conclusions: In experienced hands and with a ready-selective approach to conversion, focused parathyroidectomy based on concordant imaging and without intraoperative parathyroid hormone may deliver equivalent cure rates to open bilateral neck exploration with significantly fewer complications. Focused parathyroidectomy without intraoperative parathyroid hormone should therefore be maintained in the endocrine surgeon's armamentarium., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Parathyroid carcinoma (PC) is rare and often diagnosed incidentally after local resection (LR) for other indications. Although recommended treatment has traditionally been radical surgery (RS), more recent guidelines suggest that LR alone may be adequate. We sought to further investigate outcomes of RS versus LR for localized PC., Materials and Methods: PC patients from 2004 to 2015 with localized disease were identified from the National Cancer Database, then stratified by surgical therapy: LR or RS. Demographic and clinicopathologic data were compared. Cox proportional hazard models were constructed to estimate associations of variables with overall survival (OS). OS was estimated from time of diagnosis using Kaplan-Meier curves., Results: A total of 555 patients were included (LR = 522, RS = 33). The groups were comparable aside from LR patients having higher rates of unknown nodal status (66.9% versus 39.4%; p = 0.003). By multivariable analysis, RS did not have a significant association with OS (hazard ratio (HR) = 0.43, 95% confidence interval (95%CI) = 0.10, 1.83; p = 0.255), nor did positive nodal status (HR = 0.66, 95%CI = 0.09, 5.03; p = 0.692) and unknown nodal status (HR = 1.30, 95%CI = 0.78, 2.17; p = 0.311). There was no difference in OS between the LR and RS groups, with median survival not reached by either group at 10 years (median follow-up = 60.4 months; p = 0.20)., Conclusions: There was no difference in OS between LR and RS for localized PC. RS and nodal status may not impact survival as previously identified, and LR should remain a valid initial surgical approach. Future higher-powered studies are necessary to assess the effects of surgical approaches on morbidity and oncologic outcomes., Competing Interests: Declaration of competing interest David S. Kwon is a paid consultant for Ethicon, Inc. This affiliation did not represent a conflict of interest. The authors have no other disclosures to report., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objectives/hypothesis: Identification of parathyroid glands and adjacent tissues intraoperatively can be quite challenging because of their small size, variable locations, and indistinct external features. The objective of this study is to test the efficacy of the dynamic optical contrast imaging (DOCI) technique as a tool in specifically differentiating parathyroid tissue and adjacent structures, facilitating efficient and reliable tissue differentiation., Study Design: Prospective study., Methods: Both animal and human tissues were included in this study. Fresh specimens were imaged with DOCI and subsequently processed for hematoxylin and eosin (H&E) stain. The DOCI images were analyzed and compared to the H&E results as ground truth., Results: In both animal and human experiments, significant DOCI contrast was observed between parathyroid glands and adjacent tissue of all types. Region of interest analysis revealed most distinct DOCI values for each tissue when using 494 and 572 nm-specific band pass filter for signal detection (P < .005 for porcine tissues, and P = .02 for human specimens). Linear discriminant classifier for tissue type prediction based on DOCI also matched the underlying histology., Conclusions: We demonstrate that the DOCI technique reliably facilitates specific parathyroid gland localization. The DOCI technique constitutes important groundwork for in vivo precision endocrine surgery., Level of Evidence: 4 Laryngoscope, 131:2391-2397, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Abstract: To examine the effects of multidisciplinary approach and adjunct methods, on the surgical strategy, complications and treatment success of parathyroid surgery.Patients, who were operated for primary hyperparathyroidism (n = 411) at our institution between 2012 and 2019 were reviewed retrospectively. Preoperative imaging studies, surgical method, additional diagnostic methods used during surgery, frozen section results, and histopathology findings, complications, persistence, and recurrence were examined.Localization was determined by first-line examinations in 79.9% (n = 348). Four-dimensional computed tomography was used with an 83.3% success rate. Lateralization success for angiographic selective venous sampling was 80.3% and exact localization success was 65.1%. Bilateral neck exploration was performed in 10.6% (n = 37) of the patients, and in the remaining 89.4% (n = 311), minimally invasive parathyroidectomy (MIP) was performed. While the complication rate was higher in the bilateral neck exploration group (P = .019), persistence and recurrence rates were similar between 2 groups. During the study period, annual case volume increased from 9 cases to 103 cases (P < .001) and the rate of MIP increased from 44.4% to 92.8% over the years (P < .001).Effective use of adjunct techniques has increased the rates of MIP. The multidisciplinary approach has also provided low complication rates with the increasing number of cases., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Parathyroid carcinoma is a rare etiology of primary hyperparathyroidism (PHPT) and subsequent hypercalcemia. Among clinical manifestations of hypercalcemia, acute pancreatitis is very uncommon. Nevertheless, acute pancreatitis may be an initial clinical manifestation of parathyroid cancer., Patients and Methods: We present a case report and literature review on hypercalcemia-induced acute pancreatitis secondary to parathyroid carcinoma., Results: A 56 years-old man, who had previously received a diagnosis of pancreatic cancer with peritoneal and bone metastasis, complained of persistent postprandial epigastric pain, weight loss (12 kg) and hypercalcemia. He underwent endoscopic ultrasound, which did not identify any solid masses, but a pseudocyst of the pancreas body consistent with a local complication of acute pancreatitis. Plasma levels of parathyroid hormone were markedly increased, and neck ultrasound and scintigraphy confirmed the diagnosis of PHPT. Parathyroidectomy was performed and histological examination revealed parathyroid carcinoma. Searching on PubMed for the keywords "parathyroid carcinoma" AND "acute pancreatitis", from 1969 to March 2021 we found only 12 case reports of acute pancreatitis due to parathyroid cancer. The causal relationship between PHPT and acute pancreatitis has been widely discussed in literature but is still a controversial issue., Conclusions: Acute pancreatitis induced by primary hyperparathyroidism due to parathyroid carcinoma is an extremely rare condition. However, when hypercalcemia is found, serum PTH levels should always be determined in order to rule out PHPT and hypercalcemia-induced acute pancreatitis should be suspected in presence of hypercalcemia and abdominal symptoms.

Background: Parathyroidectomy has been proposed as a method for reducing parathyroid hormone levels. We evaluated the effects of ultrasound-guided bilateral superficial cervical plexus block (BSCPB) on the quality of recovery of uremia patients with secondary hyperparathyroidism (SHPT) following parathyroidectomy., Methods: Eighty-two uremia patients who underwent parathyroidectomy and exhibited SHPT were randomly allocated to the BSCPB group or the control group (CON group). The patients received ultrasound-guided BSCPB with 7.5 ml of ropivacaine 0.5% on each side (BSCPB group) or equal amount of 0.9% normal saline (CON group). The primary outcome of the Quality of Recovery-40(QoR-40) score was recorded on the day before surgery and postoperative day 1(POD1). Secondary outcomes including total consumption of remifentanil, time to first required rescue analgesia, number of patients requiring rescue analgesia, and total consumption of tramadol during the first 24 h after surgery were recorded. The occurrence of postoperative nausea or vomiting (PONV) and the visual analogue scale (VAS) scores were assessed and recorded., Results: The scores on the pain and emotional state dimensions of the QoR-40 and the total QoR-40 score were higher in the BSCPB group than in the CON group on POD1 (P = 0.000). Compared with the CON group, the total consumption of remifentanil was significantly decreased in the BSCPB group (P = 0.000). The BSCPB group exhibited longer time to first required rescue analgesia (P = 0.018), fewer patients requiring rescue analgesia (P = 0.000), and lower postoperative total consumption of tramadol during the first 24 h after surgery (P = 0.000) than the CON group. The incidence of PONV was significantly lower in the BSCPB group than in the CON group (P = 0.013). The VAS scores in the BSCPB group were lower than those in the CON group at all time-points after surgery (P = 0.000)., Conclusion: Ultrasound-guided BSCPB with ropivacaine 0.5% can enhance the quality of recovery, postoperative analgesia, and reduce the incidence of PONV in uremia patients with SHPT following parathyroidectomy., Trial Registration: ChiCTR1900027185 . (Prospective registered). Initial registration date was 04/11/2019., (© 2021. The Author(s).)

Objectives: To describe the evolution and recent series on transoral endoscopic vestibular approach thyroidectomy and parathyroidectomy (TOET/PVA)., Data Sources: PubMed, Google Scholar., Review Methods: Review of the available English literature., Results: TOET/PVA may offer several advantages over other remote access thyroidectomy approaches and has been adopted by many centers worldwide with excellent success rates. Indications include benign disease and early thyroid cancer patients. Complication rate is comparable to the trans-cervical approach. The suggested framework has been validated in recent studies and its feasibility confirmed., Conclusion: TOET/PVA has now been used to treat thousands of patients worldwide due to low cost, short learning curve and excellent cosmetic outcomes. Further studies will be necessary to demonstrate oncologic non-inferiority and also the true value that is added by the approach., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The study aim was to systematically review literature evaluating surgeon volume-outcome relationships for thyroid and parathyroid operations in order to inform surgical quality improvement initiatives. Current literature suggests surgeons who perform a high volume of thyroid and/or parathyroid operations have better outcomes than low volume surgeons, though specific volume definition are not standardized., Methods: Eligible studies were selected through a literature search focused on the effect of surgeon volume on thyroid and parathyroid surgery patient outcomes. The literature search was conducted in accordance with the PRISMA guidelines. Publication dates extended from January 1998 to February 2021, and were limited to articles published in English., Results: A total of 33 studies were included: 25 studies evaluating thyroid surgery outcomes, 4 studies evaluating parathyroid surgery outcomes, and 4 studies evaluating both thyroid and parathyroid (mixed) surgery outcomes. Higher volume thyroid and parathyroid surgeons were found to be associated with fewer surgical and medical complications, shorter length of hospital stay, and reduced total cost when compared to lower volume surgeons. This volume-outcome relationship was also found to specifically affect the complication and recurrence rates for thyroid cancer patients undergoing surgery, especially for individuals with advanced stage disease., Conclusion: The heterogeneity in cut-offs used for characterizing surgeons as high versus low volume, and also in subsequent patient outcome measures, limited direct study comparisons. The trend of improved patient outcomes with higher surgeon volume for both thyroid and parathyroid surgeries was consistently present in all studies reviewed., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background and Objective: The Food and Drug Administration has cleared a probe-based near-infrared autofluorescence (NIRAF) detection system called PTeye™ as an adjunct tool for label-free intraoperative parathyroid gland (PG) identification. Since PTeye™ has been investigated only in a "blinded" manner to date, this study describes the preliminary impressions of PTeye™ when used by surgeons without being blinded to the device output., Methods: Patients undergoing thyroid and parathyroid procedures were prospectively recruited. Target tissues were intraoperatively assessed with PTeye™. The surgeon's confidence in PG identification was recorded concomitantly with NIRAF parameters that were output in real-time from PTeye™., Results: A retrospective review of prospectively collected data on 83 patients was performed. PTeye™ was used for interrogating 336 target tissues in 46 parathyroid and 37 thyroid procedures. PTeye™ yielded an overall accuracy of 94.3% with a positive predictive value of 93.0% and a negative predictive value of 100%. An increase in confidence for intraoperative PG identification with PTeye™ was observed by all three participating high-volume surgeons, irrespective of their level of accrued surgical experience., Conclusions: Probe-based NIRAF detection with PTeye™ can be a valuable adjunct device to intraoperatively identify PGs for surgeons of varied training and experience., (© 2021 Wiley Periodicals LLC.)

Background: Tertiary hyperparathyroidism occurs in 25% to 50% of kidney-transplanted patients. Indication of parathyroidectomy is now discussed, since the calcimimetic agent, cinacalcet, is an alternate option. The effects of either of these treatments on graft function remain controversial, studied only in small cohorts showing either decrease or absence of modification. We performed a meta-analysis to evaluate the evolution of graft function after surgical or medical treatment., Methods: Studies assessing graft function in tertiary hyperparathyroidism after parathyroidectomy or cinacalcet introduction were enrolled into quantitative analysis using Pubmed, Embase, and Cochrane databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines. Among 68 screened studies, 18 had no missing data and were included for statistical analyses. We performed random effect meta-analysis to determine changes in serum creatinine and estimated glomerular filtration rate., Results: Seven studies assessing the evolution of graft function 6 and/or 12 months after parathyroidectomy and 13 after administration of cinacalcet were included. Meta-analysis found no significant variations after parathyroidectomy in serum creatinine (6 studies, 314 patients) and estimated glomerular filtration rate (2 studies, 105 patients). No significant variation was found after administration of cinacalcet in serum creatinine (10 studies, 404 patients) and estimated glomerular filtration rate (6 studies, 149 patients). A significant heterogeneity between the studies (P < .01, Cochran's Q) was found., Conclusion: Meta-analysis shows that parathyroidectomy and cinacalcet do not significantly impair graft function in patients with tertiary hyperparathyroidism. However, the significant heterogeneity between selected studies, partially explained by the lack of consensual definition of tertiary hyperparathyroidism, limits the conclusions of all previously published series., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: The primary objective of this study was to assess the safety of parathyroidectomy during pregnancy as treatment for hyperparathyroidism (HPTH) in comparison to nonsurgical management plans. Secondary outcomes involved analyzing the safety of surgery in the third trimester and the benefit of operating on asymptomatic pregnant patients., Study Design: Systematic review., Methods: PRISMA-guided systematic review of all cases of primary hyperparathyroidism during pregnancy published in peer-reviewed English journals on PubMed/MEDLINE, EMBASE, and SCOPUS from 1980 to 2020., Results: A total of 75 manuscripts were included in this review describing 382 cases of gestational hyperparathyroidism. The median maternal age was 31 years. Overall, 108 cases (28.3%) underwent parathyroidectomy during pregnancy while 274 cases (71.7%) were treated nonsurgically. The majority of surgeries took place during the second trimester (67.6%). Complications and/or deaths were less likely to occur after surgery in the second trimester (4.48%) as compared to surgery in the third trimester (21.1%). Nine surgically treated cases resulted in infant complications and/or death; however, none of these nine cases had any surgical complications. Despite these complications, the overall infant complication rate for patients who underwent surgical treatment remained lower than that of patients treated with conservative therapy (9.1% vs. 38.9%)., Conclusions: This review suggests that for all pregnant patients with diagnosed HPTH, parathyroidectomy should be considered regardless of symptomatology. Our data suggest that parathyroidectomy is associated with fewer risks than more conservative treatments and results in better fetal outcomes. Surgery during the third trimester is feasible and surgery should be considered in both symptomatic and asymptomatic patients. Laryngoscope, 131:1915-1921, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Purpose: Sestamibi Single-Positron Emission Computed Tomography/Diagnostic-quality Computed Tomography (MIBI-SPECT/CT) is a common technology used for primary hyperparathyroidism (PHPT) localization in clinical practice. However, the clinicopathologic factors affecting the accuracy of MIBI-SPECT/CT and the potential limitations remain unclear., Methods: Retrospectively enrolled PHPT patients (n = 280) were analyzed from August 2017 to December 2019., Results: Of 96 patients with PHPT (mean age, 54 years; 63 females), 17 had discordance between MIBI-SPECT/CT and intraoperative findings. Among the 17 patients with discordance, 58.8% had major discordance, which occurred in most patients with multigland disease (MGD). Compared with concordant patients, discordant patients exhibited increased frequencies of autoimmune thyroid disease (29.4% vs 10.1%, p = 0.035), MDG (41.2% vs 3.8%, p = 0.035), higher PTH (296 pg/mL vs 146 pg/mL; p = 0.012),and lower phosphorus levels (0.77 mmol/L vs 0.90 mmol/L; p = 0.024). MDG (odds ratio [OR], 16.95; 95% CI 2.10-142.86), parathyroid lesion size of 12 mm or less (OR, 6.93; 95% CI 1.41-34.10), and a PTH level higher than 192.5 pg/mL (OR, 12.66; 95% CI 2.17-71.43) were independently associated with discordant MIBI-SPECT/CT results., Conclusion: MGD was most strongly associated with discordance between MIBI-SPECT/CT and intraoperative findings followed by a PTH level higher than 192.5 pg/mL and parathyroid lesion size of 12 mm or less. Surgeons should recognize these potential limitations, which may improve the preoperative procedure by encouraging further localization imaging and promptly facilitate intraoperative troubleshooting., (© 2021. Italian Society of Endocrinology (SIE).)

Background: International multicentre outcome studies of surgery for primary hyperparathyroidism (pHPT), especially for rate of conversion to bilateral neck surgery and persistent hypercalcaemia, are scarce., Methods: Eurocrine® is a European database for endocrine surgery. Data are entered according to predefined data fields. Outcomes for patients who underwent first surgery for sporadic pHPT were analysed. Multivariable analysis was performed to identify risk factors for adverse outcome using Cox regression with constant follow-up., Results: A total of 5861 patients were registered between 2015 and 2018. Preoperative localization procedures were used in most patients, with moderate sensitivity. Intraoperative parathyroid hormone (ioPTH) measurement was used in three-quarters of patients. Bilateral surgery was performed in 1574 patients (26·9 per cent). Among 4683 patients (79·7 per cent) for whom unilateral or focused operation was planned, the procedure was converted to bilateral surgery in 396 (8·5 per cent). The risk of conversion decreased with the use of ioPTH monitoring (relative risk (RR) 0·77). Persistent hypercalcaemia was registered in 253 patients (4·3 per cent), and was less likely with the use of two (RR 0·55) or three (RR 0·44) localization procedures. In patients with a concordant localized single lesion, the rate of persistent hypercalcaemia was 2·5 per cent. The risk of persistent hypercalcaemia decreased with the use of ioPTH measurement, but was increased in patients with negative localization procedures and conversion to bilateral surgery., Conclusion: The use of ioPTH measurement decreased the risk of conversion and persistent hypercalcaemia. The use of two or three localization procedures decreased the risk of persistent hypercalcaemia; in patients with a concordant single lesion, the risk of persistent hypercalcaemia was low., (© The Author(s) 2020. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: We aim to assess the accuracy of near infrared autofluorescence in identifying parathyroid gland during thyroid and parathyroid surgery., Method: A systematic literature search was conducted by using PubMed, Embase, and the Cochrane Library electronic databases for studies that were published up to February 2021. The reference lists of the retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the combined variable. Publication bias in these studies was evaluated with the Deeks' funnel plots., Result: A total of 24 studies involving 2,062 patients and 6,680 specimens were included for the meta-analysis. The overall combined sensitivity and specificity, and the area under curve of near infrared autofluorescence were 0.96, 0.96, and 0.99, respectively. Significant heterogeneities were presented (Sen: I 2 = 87.97%, Spe: I 2 = 65.38%). In the subgroup of thyroid surgery, the combined sensitivity and specificity, and the area under curve of near infrared autofluorescence was 0.98, 0.99, and 0.99, respectively, and the heterogeneities were moderate (Sen: I 2 = 59.71%, Spe: I 2 = 67.65%)., Conclusion: Near infrared autofluorescence is an excellent indicator for identifying parathyroid gland during thyroid and parathyroid surgery., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Wang, Zhu, Liu, Yao and Wu.)

Objective: Parathyroidectomy (PTx) has an established benefit in patients with symptomatic primary hyperparathyroidism (PHPT). However, its efficacy in mild asymptomatic PHPT has not been proven. This study aimed to systematically review and meta-analyze the best available evidence from randomized-controlled trials comparing the efficacy of PTx over conservative management (non-PTx) on skeletal outcomes [fractures and bone mineral density (BMD)], nephrolithiasis risk and quality of life (QoL) in patients with mild asymptomatic PHPT., Methods: A comprehensive literature search was conducted in PubMed, Scopus and Cochrane databases, from conception to February 23, 2020. Data were extracted from the studies that fulfilled the eligibility criteria and were synthesized quantitatively (fixed or random effects model) as relative risks and percentage mean differences (MD) with 95% confidence intervals (CI). I 2 index was employed for heterogeneity., Results: Four studies were included in the meta-analysis. There was no difference in fracture risk between PTx and active surveillance. The PTx group demonstrated higher BMD [MD 3.55% (95% CI 1.81, 5.29) in lumbar spine and 3.44% (95% CI 1.39, 5.49) in total hip, without difference in femoral neck and forearm] and lower calcium concentrations (MD - 13.26%, 95% CI - 7.10, - 19.43) compared with the non-PTx group. No difference was observed between groups regarding nephrolithiasis or QoL indices, except for general health (higher in PTx group)., Conclusions: In patients with mild asymptomatic PHPT, PTx increases BMD and reduces serum calcium concentrations. However, its superiority over active surveillance in terms of fracture risk, nephrolithiasis and QoL cannot be supported by current data.

Background: The aim of this study was to develop a low-cost prototype near-infrared fluorescence device that enables contrast-free, real time, high-resolution intraoperative visualization of normal and pathological parathyroid glands (PGs) by imaging their autofluorescence (AF)., Methods: A novel near-infrared parathyroid AF (NIR-PAF) imaging device with visible laser PG targeting was developed. The device was evaluated during parathyroid and thyroid operations in a pilot clinical study., Results: Overall, of the 6 parathyroidectomies carried out in the study population a parathyroid adenoma was found to exhibit AF ex vivo in 6/6 (100%) of cases, and in vivo in 3/3 (100%) of these cases. Two of 4 thyroidectomies were evaluated in vivo and all PGs (6 PGs total) were identified by the NIR-PAF device. The NIRPAF device cost less than $1200 Canadian to build., Conclusion: The inexpensive NIR-PAF device that we developed can successfully intraoperatively identify both normal and pathological PGs., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: Tertiary hyperparathyroidism (HPT III) occurs when an excess of parathyroid hormone (PTH) is secreted by parathyroid glands, usually after longstanding secondary hyperparathyroidism. Some authorities reserve the term for secondary hyperparathyroidism that persists after successful renal transplantation. Long-standing chronic kidney disease (CKD) is associated with several metabolic disturbances that lead to increased secretion of PTH, including hyperphosphatemia, calcit-riol deficiency, and hypocalcaemia. Hyperphosphatemia has a direct stimulatory effect on the parathyroid gland cell resulting in nodular hyperplasia and increased PTH secretion. Prolonged hypocalcaemia also causes parathyroid chief cell hyperplasia and excess PTH. Af-ter correction of the primary disorder CKD by renal transplant, the hypertrophied parathyroid tissue fails to resolute, enlarge over and continues to oversecrete PTH, despite serum calcium levels that are within the reference range or even elevated. They also may become resistant to calcimimetic treatment. The main indication for treatment is persistent hypercalcemia and/or an increased PTH, and the primary treatment is surgery. Three procedures are commonly performed: total parathyroidectomy with or without autotransplantation, subtotal parathyroidectomy, and limited parathyroidectomy. It is important to remove superior parts of thymus as well. The most appropriate surgical procedure, whether it be total, subtotal, or anything less than subtotal including "limited" or "focused" parathyroidectomies, continues to be unclear and controversial. Surgical complications are rare, and para-thyroidectomy appears to be a safe and feasible treatment option for HPT III.

Background: The transoral endoscopic approach to the central neck has rapidly become one of the most widely utilized remote-access approaches for thyroid and parathyroid surgery in the world. The approach involves three small incisions inside the lower lip and has an optimal cosmetic outcome with no visible scar. However, the technique is quite difficult and poses several challenges that limit its widespread adoption. To overcome these issues, a novel lateral vestibular approach (LaVA) was explored in cadavers. Methods: Study using 7 fresh human cadavers that were dissected using open and endoscopic techniques to explore the feasibility of a transoral vestibular approach to the central neck without gas insufflation. Results: This novel approach resulted in wide access to the central neck and allowed for a total thyroidectomy and central neck dissection while preserving the marginal mandibular and mental nerves. Conclusions: LaVA permits excellent access to the central neck with a wide working space without the need for gas insufflation and overcomes many of the limitations of current transoral endoscopic approaches to the central neck.