Textbook outcome in surgery for primary hyperparathyroidism: first steps toward a composite quality metric

Textbook Outcome (TO) is a composite quality metric reflecting the ideal postoperative course through the simultaneous achievement of multiple desirable endpoints. Although widely explored in other surgical specialties, its application in endocrine surgery remains limited, and has not been specifically assessed in primary parathyroidectomy for sporadic primary hyperparathyroidism. A retrospective cohort study was conducted including 100 consecutive patients who underwent parathyroidectomy for sporadic primary hyperparathyroidism (PHPT) between January 2019 and February 2023 at a tertiary endocrine surgery unit. TO was defined by the absence of postoperative complications (wound events, symptomatic hypocalcemia, vocal cord dysfunction), hospital stay ≤ 24 h, histopathological confirmation of parathyroid tissue, absence of 90-day readmission or mortality, biochemical cure at six months, and absence of recurrence at one year. Descriptive and univariate analyses were performed. TO was achieved in 78% of patients. The most frequent reasons for failure were hospital stay longer than 24 h (n = 7) and lack of biochemical cure at six months (n = 7). Most failures (68.2%) were due to a single unmet criterion. In univariate analysis, absence of dyslipidemia (p = 0.016), single-gland resection (p = 0.022), and histopathological confirmation of a solitary adenoma (p = 0.026) were significantly associated with TO achievement. Application of TO to parathyroidectomy for sporadic PHPT proved feasible and informative. The analysis of failures identified prolonged hospitalization and lack of biochemical cure at six months as the most frequent reasons for non-achievement. TO may provide a comprehensive benchmark that complements traditional outcome measures and supports future quality improvement initiatives in endocrine surgery.