title: Operation for primary hyperparathyroidism: the new versus the old order. A randomised controlled trial of preoperative localisation.
abstract: OBJECTIVE
  In patients with primary hyperparathyroidism (PHPT), parathyroid imaging is nowadays routinely used for the purpose to perform a focused unilateral minimally invasive operation. The outcome of this new strategy has, however, not been established in randomised trials.
  
  
  METHODS
  Patients were randomised to either preoperative localisation with sestamibi scintigraphy and ultrasonography (group I) or no preoperative localisation (group II). In group I, a minimally invasive parathyroidectomy was performed in patients in whom both localisation studies were consistent with a single pathological gland, whereas a conventional bilateral neck exploration was performed in cases with negative localisation findings. In group II all patients underwent conventional bilateral neck exploration. Primary outcome measure was normocalcaemia at 6 months postoperatively.
  
  
  RESULTS
  In the preoperative localisation group (group I) 23/50 (46%) of the patients could be operated on with the focused operation whereas 26/50 (52%) were operated on by bilateral neck exploration. All patients in the no localisation group (group II; n = 50) were operated on with the intended bilateral neck operation. Normocalcaemia was obtained in 96% and 94% in group I and II, respectively. Total (localisation and operative) costs were 21% higher in group I.
  
  
  CONCLUSIONS
  Routine preoperative localisation, with the intention to perform minimally invasive parathyroidectomy, is not cost effective if concordant results of scintigraphy and ultrasonography are a prerequisite for the focused operation. Less than half of the patients were successfully managed with this strategy, at a higher cost and without obtaining a more favourable clinical outcome.
authors.affiliation: Department of Molecular Medicine and Surgery, Section of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: S
authors.initials: S
authors.lastname: Aarum
authors.forename: J
authors.initials: J
authors.lastname: Nordenström
authors.forename: E
authors.initials: E
authors.lastname: Reihnér
authors.forename: J
authors.initials: J
authors.lastname: Zedenius
authors.forename: H
authors.initials: H
authors.lastname: Jacobsson
authors.forename: R
authors.initials: R
authors.lastname: Danielsson
authors.forename: M
authors.initials: M
authors.lastname: Bäckdahl
authors.forename: H
authors.initials: H
authors.lastname: Lindholm
authors.forename: G
authors.initials: G
authors.lastname: Wallin
authors.forename: B
authors.initials: B
authors.lastname: Hamberger
authors.forename: L O
authors.initials: LO
authors.lastname: Farnebo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D009333:Neck / Q000601:surgery; D016105:Parathyroidectomy / Q000379:methods*; D011877:Radionuclide Imaging; D012189:Retrospective Studies; D016896:Treatment Outcome; D014463:Ultrasonography