Intraoperative strategies in identification and functional protection of parathyroid glands for patients with thyroidectomy: a systematic review and network meta-analysis

Background: This study aimed to assess the benefits and limitations of four intraoperative visualization of parathyroid gland (IVPG) strategies in the identification and functional protection of parathyroid glands (PGs). Methods: We searched PubMed, the Cochrane Central Register of Controlled Trials, CNKI, EMBASE, Web of Science and Google Scholar databases until 30 June 2023. Four IVPG strategies were composed of the naked eyes (NE) and three imaging strategies: autofluorescence (AF), indocyanine green fluorescence (ICGF), and carbon nanoparticles (CN). We performed a pairwise meta-analysis (PMA) for direct comparisons and a Bayesian network meta-analysis (NMA) for indirect comparisons. Results: A total of 29 eligible studies were included. According to NMA and PMA, AF had significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, PG inadvertent resection, and PG auto-transplantation compared to NE, while had significantly higher rate of PG identification. CN showed significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, and PG inadvertent resection compared to NE in PMA and NMA. ICGF showed a significantly higher rate of PG auto-transplantation compared to NE in PMA and AF in NMA. According to SUCRA values, AF showed the best advantage in reducing the rate of postoperative hypocalcemia (0.85) and PG inadvertent resection (0.89), and increasing the rate of PG identification (0.80). CN had the greatest advantage in reducing the rate of postoperative hypoparathyroidism (0.95). ICGF ranked the highest in the rate of PG auto-transplantation (0.98). Conclusions: Three imaging strategies demonstrate significant superiority over NE in the intraoperative PG identification and functional protection. AF is the best strategy in reducing the incidence of postoperative hypocalcemia, increasing the rate of PG identification, and reducing the rate of PG inadvertent resection and auto-transplantation. ICGF has great value in assessing PG viability, leading to the trend towards PG auto-transplantation. CN is the best strategy in reducing the incidence of postoperative hypoparathyroidism.


Did the research questions and inclusion criteria for the review include the components of PICO?
For Yes: √ Population √ Intervention √ Comparator group √ Outcome Optional (recommended)  Timeframe for follow-up √ Yes  No 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?
For Partial Yes: The authors state that they had a written protocol or guide that included ALL the following: For Yes: As for partial yes, plus the protocol should be registered and should also

Did the review authors perform study selection in duplicate?
For Yes, either ONE of the following: and achieved consensus on which studies to include  OR two reviewers selected a sample of eligible studies and √ at least two reviewers independently agreed on selection of eligible studies achieved good agreement (at least 80 percent), with the remainder selected by one reviewer.

√ Yes  No
AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or nonrandomised studies of healthcare interventions, or both

Did the review authors perform data extraction in duplicate?
For Yes, either ONE of the following: included studies  OR two reviewers extracted data from a sample of eligible studies √ at least two reviewers achieved consensus on which data to extract from and achieved good agreement (at least 80 percent), with the remainder extracted by one reviewer.

Did the review authors explain their selection of the study designs for inclusion in the review
?For Yes, the review should satisfy ONE of the following: Explanation for including only RCTs  OR Explanation for including only NRSI √ OR Explanation for including both RCTs and NRSI √ Yes  No 4.

the review authors report on the sources of funding for the studies included in the review? For
Yesin the review.Note: Reporting that the reviewers looked for this information √ Must have reported on the sources of funding for individual studies included but it was not reported by study authors also qualifies

If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?
RoB, the authors performed analyses to investigate possible impact of  included only low risk of bias RCTs √ OR, if the pooled estimate was based on RCTs and/or NRSI at variable RoB on summary estimates of effect.

they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?
critical appraisal tool for systematic reviews that include randomised or nonrandomised studies of healthcare interventions, or both 16.

Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
For Yes:√ The authors reported no competing interests OR  The authors described their funding sources and how they managed potential conflicts of interest Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, Henry DA.AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both.BMJ.2017 Sep 21;358:j4008.