A commentary on “The role of rapid intraoperative parathyroid hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis” (Int J Surg 2021; 92:106042)

Dear Editor, Primary hyperparathyroidism (PHPT) is a disease caused by intrinsic increase in parathyroid cell activity accompanied by excessive parathyroid hormone (PTH) secretion and subsequent modifications of calcium and bone metabolism [1]. PHPT has a higher incidence than previously thought, because many patients are diagnosed with mild, paucisymptomatic or even asymptomatic forms of the disease on routine calcium measurement, evaluation of bone mass and turnover, and cervical ultrasound check. Parathyroid surgery remains the only definitive therapy of choice. Since its introduction in clinical practice, determination of intraoperative level of parathormone (ioPTH) has changed minimally invasive parathyroidectomy (MIP) in patients affected by primary PHPT. Medas et al. [2] performed a systematic review and meta-analysis to investigate the effectiveness of ioPTH in reducing incidences of surgical failure, defined as persistent or recurrent disease after MIP. They concluded that ioPTH monitoring to be effective in reducing incidences of persistent and recurrent PHPT. Its routine use should be included in the next guidelines on management of PHPT. Assessment of surgical adequacy may be achieved by ioPTH monitoring. This is based on the assumption that when the affected gland is excised, the ensuing rapid decrease in circulating PTH levels can demonstrate biological healing [3,4]. This enables the surgical team to either end the operation if success of surgery is confirmed, or to change surgical strategy when needed. Over years, various protocols for ioPTH monitoring have been used, and they differ in PTH decay cut off values, sampling times, and sampling frequency. There is a complete lack of uniformity. Thus, the choice of ioPTH criteria in predicting operative success remains controversial. In 2009, the European Society of Endocrine Surgeons published a position statement on modern techniques in PHPT surgery. In addressing ioPTH level, they concluded it is of little added value provided that the patient has undergone preoperative localization with technetium-99m-sestamibi scan and ultrasonography concordant for a single-gland disease [5]. Furthemore, ioPTH has a relevant cost when used indiscriminately. Obviously, even guidelines or large case series are not able to settle the controversy between surgeons who favour ioPTH and those who do not. The former group of surgeons employs ioPTH to maximize cure rate, thus reducing patients’ stress and anesthesia-related risks. The latter group prefers to reduce procedure times and costs. Randomized clinical trials and meta-analysis covering all these aspects are the next goal in shaping primary hyperparathyroidism surgery. “Provenance and peer review Commentary, internally reviewed” Conflicts of interest The authors declare that they have no completing interests. Sources of funding Funding: Postdoctoral Science Fund project of Chongqing Natural Science Foundation (cstc2019jcyj-bshX0123). Ethical approval Not Needed. Research registration unique identifying number (UIN) Not Needed. Trial registry number – ISRCTN Not Needed. Author contribution Chong Zhang conceived the study; Hongyu Liu wrote and edited the paper; all authors read and approved the final manuscript. Guarantor Hongyu Liu