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Vaiman M, Mizrakli Y, Taha A, Gavriel H. An individual approach to intraoperative parathyroid hormone measurement during total thyroidectomy. Am J Otolaryngol 2024; 45:104159. [PMID: 38113776 DOI: 10.1016/j.amjoto.2023.104159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/03/2023] [Accepted: 12/03/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Hypocalcemia is a common complication of thyroidectomy. Measurement of the intraoperative serum parathyroid hormone (PTH) levels became an established technique but it requires further improvements. We aimed to assess intraoperative PTH level testing results against the hypothesis that the PTH assay may be performed almost immediately after thyroid gland removal. METHODS A retrospective cohort study. During total thyroidectomy surgery, the patients had PTH levels measured at the cutting time and again immediately after the thyroid gland is removed. Post-operatively, serial total blood calcium levels were obtained twice daily and recorded. RESULTS Among 63 enrolled patients, 39 had multinodular goiter, 15 thyroid carcinoma, and nine had Graves' disease. The mean age was 59.8 ± 15.3 years, 43 females. The mean PTH level before surgery was 45.8 ± 22.0 pg/mL. Post-operatively, 11/63 patients developed hypocalcemia with serum calcium levels <8 mg/dL. Four patients with ≥50 % decrease in PTH concentration were normocalcemic a day after surgery and were discharged early. Four patients with ≥70 % PTH decrease were treated accordingly during prolonged hospitalization and did not suffer from permanent hypocalcemia. The cut-off value of 70 % decrease after the gland removal was able to predict postoperative hypocalcemia with a sensitivity of 100 %, specificity 82.9 %, PPV 60.0 % and NPV 100 %. CONCLUSION Measurements of intraoperative PTH may not be performed at fixed time intervals but after 1-2 min after removal of the thyroid gland. Defining those not at risk would allow the majority of patients to be waived from post-operative blood calcium testing and safely discharged early after surgery.
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Affiliation(s)
- Michael Vaiman
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yuval Mizrakli
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmed Taha
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Gavriel
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Devgan Y, Mayilvaganan S, Mishra A, Chand G, Agarwal G, Agarwal A. Comparison of indocyanine green angiography vs intraoperative parathyroid hormone in early prediction of risk of post-thyroidectomy hypocalcemia: a prospective cohort study. Ann Med Surg (Lond) 2024; 86:678-688. [PMID: 38333253 PMCID: PMC10849419 DOI: 10.1097/ms9.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/22/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction Indocyanine green (ICG) angiography is the 'real-time intraoperative imaging' technique used to reduce the chances of hypoparathyroidism in post-thyroidectomy patients. In our study, the authors predicted the risk of early post-thyroidectomy hypocalcemia by intraoperative evaluation of parathyroid gland perfusion by ICG angiography. Materials and methods In patients who underwent total thyroidectomy, ICG angiography was done using the SPY PHI imaging system (Stryker). Post-thyroid specimen removal, scoring of parathyroids was done in spy contrast mode. All 4 or <4 visualized parathyroids were scored for vascularity with the highest score of 8. Serum ionized calcium was done 6 h postsurgery and on the morning and evening of postoperative days 1 and 2. Calcium supplements were given to only those who developed clinical or severe biochemical hypocalcemia. Results Out of 60, postoperative hypocalcemia was noted in 41 patients. Total ICG score ≤5 was seen in 34 patients, out of which 28 developed postoperative hypocalcemia showing PPV 82.3% and diagnostic accuracy of 68.3% while iPTH (4.28 pmol/l) showed PPV 76.7 and diagnostic accuracy 70 %. In eight patients, none of the glands was scored as 2 (White) and all these patients developed hypocalcemia requiring calcium infusion. Conclusion The absence of visualization of at least 1 well-perfused (score 2) gland on ICG angiography is highly predictive of hypocalcemia and the majority of patients with total ICG score ≤5 developed hypocalcemia in the immediate postoperative period. ICG is a good predictor of the absence of hypoparathyroidism after thyroidectomy and is comparable to iPTH in the prediction of post-thyroidectomy hypocalcemia.
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Affiliation(s)
| | - Sabaretnam Mayilvaganan
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Jan BS, Alamri AH, Alkaff HH, Almuqati WQ, Sayed SI, Abdelmonim SK, Alessa MA, Marglani OA, Bawazir OA, Alherabi AZ. Risk factors for postoperative hypocalcemia following total thyroidectomy: a retrospective study. Ann Saudi Med 2024; 44:39-47. [PMID: 38311865 PMCID: PMC10839454 DOI: 10.5144/0256-4947.2024.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/15/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND and Objectives: Hypocalcemia is a commonly reported complication after thyroid surgery. Many possible risk factors have been identified. The purpose of this study is to analyze various risk factors possibly associated with development of postoperative hypocalcemia after thyroid surgery by dividing the sample population into postoperative hypocalcemia and normal calcium groups. DESIGN Retrospective. SETTING Multiple centers in the Makkah region of Saudi Arabia. PATIENTS AND METHODS Risk factors for postoperative hypocalcemia that were obtained for analysis include patient factors, perioperative blood parameters factors, disease-related factors, and surgical factors. Postoperative hypocalcemia was defined as a reduction of the total calcium level to <8.0 mg/dL. Hypocalcemic and normocalcemic patients were compared by multivariate logistic regression. MAIN OUTCOME MEASURES Distinguish independent risk factors for postoperative hypocalcemia after thyroidectomy. SAMPLE SIZE 215 patients. RESULTS The incidence of hypocalcemia was 52.1% (112 of 215 patients). According to multivariate analysis, statistically significant risk factors for predicting postoperative hypocalcemia included postoperative parathyroid hormone level <10 pg/dL, inadvertent parathyroid gland resection, and neck dissection surgeries. CONCLUSION The causes of postoperative hypocalcemia are multi-factorial. Because many of these factors are modifiable, they should be identified postoperatively to distinguish high-risk groups and implement early preventive measures. LIMITATIONS Retrospective with a relatively small size. We encourage additional prospective studies with a larger sample size in multiple regions of the country, which might reveal further significant results.
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Affiliation(s)
- Bayan S. Jan
- From the Department of Otorhinolaryngology Head & Neck Surgery, Al Noor Hospital, Makkah, Saudi Arabia
| | - Ahlam H. Alamri
- From the Department of Otolaryngology-Head & Neck Surgery, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Haddad H. Alkaff
- From the Department of Otorhinolaryngology Head & Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Wejdan Q. Almuqati
- From the Department of Otorhinolaryngology Head & Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Suhail I. Sayed
- From the Department of Otorhinolaryngology Head & Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Sherif K. Abdelmonim
- From the Department of Otorhinolaryngology Head & Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Mohammad A. Alessa
- From the Department of Otorhinolaryngology Head & Neck Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Osama A. Marglani
- From the Department of Otolaryngology-Head & Neck Surgery, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
- From the Department of Otolaryngology-Head & Neck Surgery, International Medical Center, Jeddah, Saudi Arabia
- From the Otorhinolaryngology Head & Neck Surgery, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Osama A. Bawazir
- From the Department of Pediatric Surgery, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- From the Department of Pediatric Surgery, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | - Ameen Z. Alherabi
- From the Department of Otolaryngology-Head & Neck Surgery, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
- From the Department of Otolaryngology-Head & Neck Surgery, International Medical Center, Jeddah, Saudi Arabia
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Alharbi BA, Alareek LA, Aldhahri S, Alqaryan S, Al Essa M, Al-Qahtani K. Total Number of Identified Parathyroid Glands During Total Thyroidectomy and Its Relation to Postoperative Hypoparathyroidism. Cureus 2023; 15:e50597. [PMID: 38107216 PMCID: PMC10723786 DOI: 10.7759/cureus.50597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES To evaluate the correlation between the intraoperative number of identified parathyroid glands (PGs) and the risk of developing hypoparathyroidism postoperatively. Also, to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism. METHODS A retrospective study of 499 patients who underwent total thyroidectomy at two tertiary care institutions, King Saud University Medical City (KSUMC) and King Fahad Medical City (KFMC) in Riyadh, Saudi Arabia was included. Individual demographic characteristics with detailed clinical information were recorded, focusing mainly on operative reports for a total number of identified PGs intraoperatively and investigating the risk of developing hypoparathyroidism postoperatively. Factors such as age, gender, comorbidity, and number of excised and reimplanted parathyroid glands were investigated to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism. RESULTS The findings from the analysis showed that the number of identified PGs intraoperatively had a positive correlation with a higher postoperative risk of developing hypoparathyroidism. For zero, one, two, three, and four identified PGs, the risk of hypoparathyroidism in one-hour parathyroid hormone level postoperative was 6.6%, 7.3%, 34.4%, 34.4%, and 17.2% respectively. CONCLUSION The greater the number of identified PGs intraoperatively, the less likely it was to prevent inadvertent hypoparathyroidism post-total thyroidectomy.
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Affiliation(s)
- Bushra A Alharbi
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Latefa A Alareek
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Saleh Aldhahri
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Saleh Alqaryan
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Mohammed Al Essa
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Khalid Al-Qahtani
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
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Lalos A, Wilhelm A, Linke K, Taha-Mehlitz S, Müller B, Posabella A, Kern B. Low serum iPTH at the end of surgery is the earliest predictor of postoperative hypocalcemia after total thyroidectomy. Langenbecks Arch Surg 2023; 408:450. [PMID: 38030913 PMCID: PMC10687095 DOI: 10.1007/s00423-023-03194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/26/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND The most frequent complication of total thyroidectomy remains hypocalcemia due to low postoperative levels of serum intact parathyroid hormone (iPTH). The purpose of this study was to investigate the role of decreased iPTH at the end of surgery in predicting hypocalcemia. In addition, we examined the percentage decrease of iPTH as potential indicator of hypocalcemia. METHODS We retrospectively collected the data of patients who underwent total thyroidectomy for benign and malignant diseases at our institution between 2010 and 2022. The iPTH level was measured before and at the end of surgery, and serum calcium levels on the first postoperative day. Demographic, clinical, and biochemical characteristics of patients with low iPTH were compared with patients with normal iPTH levels using ANOVA for continuous variables and χ2-tests for categorical variables. Multivariable logistic regression analysis evaluated the association of iPTH at the end of surgery and the relative reduction of iPTH with postoperative hypocalcemia. RESULTS The mean age of the 607 patients in this study was 55.6 years, and the female-to-male ratio was 5:1. Goiter was the most common indication for surgery (N = 382, 62.9%), followed by Graves' disease (N = 135, 22.2%). The mean preoperative iPTH was 49.0 pg/ml, while the mean postoperative iPTH was 29.3 pg/ml. A total of 197 patients (32.5%) had an iPTH level below normal, 77 patients (39%), had iPTH levels of 10-15.0 pg/ml and 120 patients (61%) of < 10.0 pg/ml at the end of surgery. Among all patients, 124 (20.4%) developed hypocalcemia on the first postoperative day. The mean percentage of decrease of iPTH was highest among patients with iPTH < 10 pg/ml (76.9%, p < 0.01); this group of patients had also the highest rate of postoperative hypocalcemia on day one (45.0% vs. 26.0% vs 12.2%, p < 0.01). CONCLUSIONS Measurement of iPTH at the end of total thyroidectomy predicts patients who are at risk for postoperative hypocalcemia. The combination of low serum iPTH with a decrease in iPTH level of ≥ 50% may improve prediction of hypocalcemia compared to iPTH levels alone allowing for early calcium substitution in these patients at high risk of developing postoperative hypocalcemia.
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Affiliation(s)
- Alexandros Lalos
- Clarunis - University Digestive Health Care Center, St. Clara Hospital and University Hospital of Basel, Basel, Switzerland
| | - Alexander Wilhelm
- Clarunis - University Digestive Health Care Center, St. Clara Hospital and University Hospital of Basel, Basel, Switzerland.
| | - Katja Linke
- Clarunis - University Digestive Health Care Center, St. Clara Hospital and University Hospital of Basel, Basel, Switzerland
| | - Stephanie Taha-Mehlitz
- Clarunis - University Digestive Health Care Center, St. Clara Hospital and University Hospital of Basel, Basel, Switzerland
| | - Beat Müller
- Clarunis - University Digestive Health Care Center, St. Clara Hospital and University Hospital of Basel, Basel, Switzerland
| | - Alberto Posabella
- Clarunis - University Digestive Health Care Center, St. Clara Hospital and University Hospital of Basel, Basel, Switzerland
| | - Beatrice Kern
- Clarunis - University Digestive Health Care Center, St. Clara Hospital and University Hospital of Basel, Basel, Switzerland
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Rao SS, Rao H, Moinuddin Z, Rozario AP, Augustine T. Preservation of parathyroid glands during thyroid and neck surgery. Front Endocrinol (Lausanne) 2023; 14:1173950. [PMID: 37324265 PMCID: PMC10266226 DOI: 10.3389/fendo.2023.1173950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/13/2023] [Indexed: 06/17/2023] Open
Abstract
The parathyroid glands are situated in close proximity to the thyroid gland. They have an important endocrine function maintaining calcium and phosphate homeostasis in the body by the secretion of parathormone (PTH), which is responsible for this function. The parathyroid glands are commonly damaged during thyroid surgeries. This could lead to transient or permanent hypoparathyroidism in 30% of cases. Preservation of the parathyroid glands, is an important and integral part of thyroidectomy and other surgical interventions in the neck. The main principle underlying this is a thorough understanding of parathyroid anatomy in relation to the thyroid gland and other important structures in the area. There can also be significant variation in the anatomical location of the glands. Various techniques and methods have been described for parathyroid preservation. They include intraoperative identification utilizing indocyanine green (ICG) fluorescence, carbon nanoparticles, loupes, and microscopes. The techniques of surgery (meticulous capsular dissection), expertise, central compartment neck dissection, preoperative vitamin D deficiency, extent and type of thyroidectomy are the risk factors associated with damaged thyroids, inadvertent parathyroidectomy and subsequent hypoparathyroidism. Parathyroid Autotransplantation is a treatment option for inadvertent parathyroidectomy. Ultimately, the best way to assure normal parathyroid function is to preserve them in situ intraoperatively undamaged.
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Affiliation(s)
- Smitha S. Rao
- Department of Endocrine and Breast Surgery, Oncology, K.S. Hegde Medical Academy, Nitte University, Mangalore, India
| | - Himagirish Rao
- Department of Endocrine and General Surgery, St. John's National Academy of Health Sciences, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Zia Moinuddin
- Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Anthony P. Rozario
- Department of Endocrine and General Surgery, St. John's National Academy of Health Sciences, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Titus Augustine
- Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Frey S, Van Den Heede K, Triponez F, Bizard JP, Godiris-Petit G, Pattou F. Prevention of hypocalcemia and hypoparathyroidism after total thyroidectomy. Recommendations of the Francophone Association of Endocrine Surgery (AFCE) with the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine (SFMN). J Visc Surg 2023:S1878-7886(23)00084-X. [PMID: 37211443 DOI: 10.1016/j.jviscsurg.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Postoperative hypoparathyroidism, resulting from removal and/or devascularization of one or more parathyroid glands, is a feared complication of total thyroidectomy. Two forms, which are distinguished by their frequency, their time to onset and their duration as well as by their presentation, must be individualized: early postoperative hypocalcemia, often secondary to early hypoparathyroidism is a frequent and often transient situation occurring within the first days after surgery; permanent hypoparathyroidism, which is rarer, manifests when parathyroid function remains impaired for more than six months after surgery. Because of their severity, these conditions must be known and ideally prevented during total thyroidectomy. The objective of this article is to provide surgeons with practical recommendations for the prevention, diagnosis, and treatment of hypoparathyroidism after total thyroidectomy. These recommendations, which are the fruit of a medico-surgical consensus, were developed by the Francophone Association of Endocrine Surgery (AFCE), the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine and Molecular Imaging. (SFMN). The content, grade and level of evidence for each recommendation was decided after consultation within a panel of experts, based on an analysis of recent literature.
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Affiliation(s)
- Samuel Frey
- Digestif Cancer, Digestive and Endocrine Surgery, Institute of Digestive Tract Diseases, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Klaas Van Den Heede
- Visceral and Endocrine General Surgery Department, Pitié-Salpêtrière Hospital, Pierre-et-Marie-Curie-Sorbonne University (Paris 6), 75013 Paris, France
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospitals (HUG), Faculty of Medicine of Geneva, 1211 Genève, Switzerland
| | - Jean-Pierre Bizard
- Endocrine and Visceral Surgery, Hospital of Arras-lès-Bonnettes Hospital, 62000 Arras, France
| | - Gaëlle Godiris-Petit
- Visceral and Endocrine General Surgery Department, Pitié-Salpêtrière Hospital, Pierre-et-Marie-Curie-Sorbonne University (Paris 6), 75013 Paris, France
| | - François Pattou
- General and Endocrine Surgery, University Hospital of Lille, 59000 Lille, France.
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Nagel K, Hendricks A, Lenschow C, Meir M, Hahner S, Fassnacht M, Wiegering A, Germer CT, Schlegel N. Definition and diagnosis of postsurgical hypoparathyroidism after thyroid surgery: meta-analysis. BJS Open 2022; 6:6683841. [PMID: 36050906 PMCID: PMC9437325 DOI: 10.1093/bjsopen/zrac102] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
Background Postsurgical hypoparathyroidism (PH) is the most frequent complication after thyroid surgery. The aim of this systematic review and meta-analysis is to summarize a unifying definition of PH and to elucidate the best possible approach for early detection of PH. Methods A systematic review of the literature according to the PICO framework using Embase, PUBMED and the Cochrane library was carried out on 1 December 2021 followed by analysis for risk of bias, data extraction and meta-analysis. All studies addressing the definition of postoperative hypoparathyroidism and/or diagnostic approaches for early detection and diagnosis were included. Case reports, commentaries, non-English articles, book chapters and pilot studies and reviews were excluded. Results From 13 704 articles, 188 articles were eligible for inclusion and further analysis. These articles provided heterogeneous definitions of PH. Meta-analysis revealed that postoperative measurements of parathormone (PTH) levels have a higher sensitivity and specificity than intraoperative PTH measurements to predict PH after thyroid surgery. None of the timeframes analysed after surgery within the first postoperative day (POD1) was superior to predict the onset of PH. PTH levels of less than 15 pg/ml and less than 10 pg/ml are both reliable threshold levels to predict the postoperative onset of PH. A relative reduction of mean(s.d.) PTH levels from pre- to postoperative values of 73 (standard deviation 11) per cent may also be predictive for the development of PH. The estimation of calcium levels on POD1 are recommended. Conclusion PH is best defined as an undetectable or inappropriately low postoperative PTH level in the context of hypocalcaemia with or without hypocalcaemic symptoms. PTH levels should be measured after surgery within 24 h. Both threshold levels below 10 and 15 pg/ml or relative loss of PTH before/after thyroid surgery are reliable to predict the onset of PH.
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Affiliation(s)
- Kathrin Nagel
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Anne Hendricks
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Christina Lenschow
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Michael Meir
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Stefanie Hahner
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg , Würzburg , Germany
| | - Martin Fassnacht
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg , Würzburg , Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
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Predictive value of postoperative day 1 parathyroid hormone levels for early and late hypocalcaemia after thyroidectomy. Langenbecks Arch Surg 2022; 407:1653-1658. [PMID: 35247092 PMCID: PMC9283344 DOI: 10.1007/s00423-022-02480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/18/2022] [Indexed: 10/25/2022]
Abstract
PURPOSE Early parathyroid hormone (PTH) levels after total thyroidectomy can predict patients at low risk of hypocalcaemia who can be discharged early without calcium supplementation. For centres without facility to perform early PTH levels, PTH levels sent on the first postoperative day (POD1) may be an alternative. However, there is less data regarding optimal cut-off PTH levels for POD1 discharge. METHODS Retrospective review of prospective database of thyroid operations between September 2009 and February 2020 at tertiary referral centre. Main outcome measure was symptomatic hypocalcaemia. RESULTS Five hundred seventy patients undergoing total (521) or completion thyroidectomy with POD1 PTH levels available were included. Among patients with POD1 PTH levels ≥ 20 pg/ml and POD1 calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia was 1% (3/300), and need for intravenous calcium 0.3% (1/300). For POD1 PTH levels 15-19 pg/ml and POD1 calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia and need for intravenous calcium was 5.4% (3/55). For PTH levels 10-14 pg/ml and calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia and need for intravenous calcium was 11.7% (7/60). The risk of permanent hypoparathyroidism was < 1% for POD1 PTH levels ≥ 15 pg/ml; 5.4% for levels 10-14 pg/ml; and 19.8% for levels < 10 pg/ml. CONCLUSIONS POD1 PTH levels ≥ 15 pg/ml along with calcium ≥ 2.0 mmol/l are associated with low risk of symptomatic hypocalcaemia, and represent a safe criterion for discharge of most patients without calcium supplementation. For certain patient groups, a higher threshold of 20 pg/ml could be considered.
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Lacroix C, Potard G, Thuillier P, Le Pennec R, Prévot J, Roudaut N, Marianowski R, Leclere JC. Use of the parathyroid hormone assay at H6 post thyroidectomy: an early predictor of hypocalcemia. J Endocrinol Invest 2022; 45:1-8. [PMID: 34216371 DOI: 10.1007/s40618-021-01601-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/22/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Hypocalcemia linked to a diminished circulating intact parathormone (iPTH) is the most common complication after total thyroidectomy. The objective of this study was to evaluate iPTH as a predictor of post-thyroidectomy hypocalcemia. METHODS Hundred-and-eight patients who underwent total thyroidectomy were included. Blood samples (iPTH, calcium and albumin) were performed at different times: preoperatively (H0), after removal of the gland (Hdrop), 6 h (H6) and one day (D1) after the surgery. Hypocalcemia was defined by total calcium corrected by serum albumin ≤ 2.10 mmol/l. The area under the ROC curve (AUC) was used to determine the best cut-off value and predictability of iPTH for hypocalcemia in terms of absolute value (ng/L), decrease in the slope (ng/L) and decline (%) between two times. RESULTS The study included 101 patients. Among them, 39 had hypocalcemia (38.6%). At H6, an iPTH absolute value less than 14.35 ng/L (Se = 0.706; Sp = 0.917) and a decline from the preoperative time of more than 59.5% (Se = 0.850; Sp = 0.820) were predictive of hypocalcemia. Other absolute values, decrease in the sloop and decline between preoperative and postoperative values were less relevant. CONCLUSION The iPTH 6 h after total thyroidectomy is predictive of hypocalcemia. It might be used to identify patients not at risk of hypocalcemia and earlier discharge could be considered.
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Affiliation(s)
- C Lacroix
- Department of Head and Neck Surgery, University Hospital of Brest, 4, av Foch, 29200, Brest, France
- Department of Head and Neck Surgery, Cochin University Hospital, Paris, France
| | - G Potard
- Department of Head and Neck Surgery, University Hospital of Brest, 4, av Foch, 29200, Brest, France
| | - P Thuillier
- Department of Endocrinology, University Hospital of Brest, Brest, France
| | - R Le Pennec
- Department of Nuclear Medicine, University Hospital of Brest, Brest, France
| | - J Prévot
- Department of Head and Neck Surgery, University Hospital of Brest, 4, av Foch, 29200, Brest, France
| | - N Roudaut
- Department of Endocrinology, University Hospital of Brest, Brest, France
| | - R Marianowski
- Department of Head and Neck Surgery, University Hospital of Brest, 4, av Foch, 29200, Brest, France
| | - J-C Leclere
- Department of Head and Neck Surgery, University Hospital of Brest, 4, av Foch, 29200, Brest, France.
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11
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Wu YJ, Wang JB, Li FB, Jin L, Zhou L, Xie L. Fine-Needle Pricking Test of the Parathyroid Gland during Thyroid Surgery in Predicting Parathyroid Function. Int J Endocrinol 2022; 2022:8747680. [PMID: 35795846 PMCID: PMC9252692 DOI: 10.1155/2022/8747680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Permanent hypoparathyroidism is a serious complication following total thyroidectomy plus central neck dissection (CND). How to evaluate the vascularization of the parathyroid gland in real time is a major concern of thyroid surgeons. This study aimed to evaluate the fine-needle pricking (FNP) test in predicting parathyroid gland function. METHODS The FNP test was performed in patients undergoing total thyroidectomy plus CND between January 1, 2014, and December 31, 2019, to visualize the vascularization of the parathyroid glands. Patients were classified according to the number of parathyroid glands preserved in situ with excellent vascularity (PGPIEV) demonstrated by FNP: group 0 (without PGPIEV), group 1 (with one PGPIEV), group 2 (with two PGPIEV), group 3 (with three PGPIEV), and group 4 (with four PGPIEV). RESULTS A total of 608 patients with four parathyroid glands underwent FNP testing during thyroidectomy. At least one PGPIEV was demonstrated by FNP testing in 581 patients who had intact parathyroid hormone (iPTH) levels in the normal range after the operation. The prevalence of hypocalcemia decreased from 77.8% in group 0 to 9.8% in group 4 (P < 0.001), and the incidence of hypoparathyroidism decreased from 44.4% in group 0 to 0% in groups 1-4 (P < 0.001). iPTH concentrations on postoperative day 1 were positively correlated with PGPIEV groups (increased from 14.58 ng/l in group 0 to 45.22 ng/l in group 4, P < 0.001). CONCLUSIONS The FNP test is a safe and reliable method to predict parathyroid function. One PGPIEV demonstrated by the FNP test rules out the possibility of patients developing hypoparathyroidism.
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Affiliation(s)
- Ying-Jun Wu
- Department of Operation Room Nursing, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Jian-Biao Wang
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Fei-Bo Li
- Second Department of General Surgery, Zhejiang Putuo Hospital, Zhoushan, Zhejiang 316100, China
| | - Lei Jin
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Liang Zhou
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Lei Xie
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
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12
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Díez JJ, Anda E, Sastre J, Pérez-Corral B, Álvarez-Escolá C, Manjón L, Paja M, Sambo M, Santiago-Fernández P, Blanco-Carrera C, Galofré JC, Navarro E, Zafón C, Sanz E, Oleaga A, Bandrés O, Donnay S, Megía A, Picallo M, Sánchez-Ragnarsson C, Baena-Nieto G, Fernández-García JC, Lecumberri B, Vega MSDL, Romero-Lluch AR, Iglesias P. Recovery of parathyroid function in patients with thyroid cancer treated by total thyroidectomy: An analysis of 685 patients with hypoparathyroidism at discharge of surgery. ENDOCRINOL DIAB NUTR 2021; 68:398-407. [PMID: 34742473 DOI: 10.1016/j.endien.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We aimed to study the predictive factors for recovery of parathyroid function in hypoparathyroid patients after total thyroidectomy for thyroid cancer. METHODS We designed a retrospective, multicentre and nation-wide analysis of patients with total thyroidectomy who were seen in twenty endocrinology departments from January to March 2018. We selected patients with histologically proven thyroid cancer and retrieved information related to surgical procedure and thyroid cancer features. Survival analysis and Cox regression analysis were used to study the relationship between these variables and the recovery of parathyroid function. RESULTS From 685 patients with hypoparathyroidism at discharge of surgery, 495 (72.3%) recovered parathyroid function over time. Kaplan-Meier analysis showed that this recovery was significantly related to the presence of specialized surgical team (P<0.001), identification of parathyroid glands at surgery (P<0.001), papillary histopathology (P=0.040), and higher levels of postoperative calcium (Ca) (P<0.001) and parathyroid hormone (PTH) (P<0.001). Subjects with gross extrathyroidal extension (P=0.040), lymph node metastases (P=0.004), and surgical re-intervention after initial surgery (P=0.024) exhibited a significant risk of persistence of hypoparathyroidism. Multivariate Cox regression analysis showed that the significant and independent factors for recovery of parathyroid function were postoperative concentrations of Ca (P=0.038) and PTH (P=0.049). The presence of lymph node metastases was a negative predictor of recuperation of parathyroid function (P=0.042) in this analysis. CONCLUSION In patients with thyroid cancer, recovery of parathyroid function after total thyroidectomy was directly related to postoperative Ca and PTH concentrations, and inversely related to lymph node metastases.
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Affiliation(s)
- Juan J Díez
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Emma Anda
- Department of Endocrinology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Julia Sastre
- Department of Endocrinology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Begoña Pérez-Corral
- Department of Endocrinology, Complejo Asistencial Universitario de León, León, Spain
| | | | - Laura Manjón
- Department of Endocrinology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Miguel Paja
- Department of Endocrinology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Marcel Sambo
- Department of Endocrinology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Concepción Blanco-Carrera
- Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Juan C Galofré
- Department of Endocrinology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Elena Navarro
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Carles Zafón
- Department of Endocrinology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Eva Sanz
- Department of Endocrinology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Amelia Oleaga
- Department of Endocrinology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Orosia Bandrés
- Department of Endocrinology, Hospital Royo Villanova, Zaragoza, Spain
| | - Sergio Donnay
- Department of Endocrinology, Fundación Hospital de Alcorcón, Alcorcón, Madrid, Spain
| | - Ana Megía
- Department of Endocrinology, Hospital Universitari de Tarragona Joan XXIII, IISPV, Universitat Rovira i Virgili, Ciberdem, Tarragona, Spain
| | - María Picallo
- Department of Endocrinology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Gloria Baena-Nieto
- Department of Endocrinology, Hospital de Jerez, Jerez de la Frontera, Cádiz, Spain
| | | | - Beatriz Lecumberri
- Department of Endocrinology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Ana R Romero-Lluch
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain
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13
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The utility of indocyanine green (ICG) for the identification and assessment of viability of the parathyroid glands during thyroidectomy. Updates Surg 2021; 74:97-105. [PMID: 34727341 DOI: 10.1007/s13304-021-01202-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
We conducted this study to evaluate the ability of indocyanine green (ICG) and near infra-red fluorescence (NIRF) camera to aid in the identification and assessment of viability of parathyroid glands during thyroid surgery. A prospective observational study was conducted between May and October 2020 among 50 consecutive patients who underwent total thyroidectomy at a single institution. Parathyroid glands were identified under white light during thyroidectomy following which reconstituted ICG was injected through a peripheral vein and the location of parathyroid glands was confirmed. The perfusion to the parathyroid gland was assessed by documenting the fluorescence intensity score (FIS) and the parathyroid angiogram score (PAS). There was no difference in the number of parathyroid glands seen on visual inspection 147 (73.5%) when compared to under NIRF camera, 146 (73%). Though the rate of postoperative hypoparathyroidism was lower in the cohort with FIS 3 (14.2%) compared to score 2 and 1 (28.5% and 100%, respectively), this was not significant (p = 0.35). A significant correlation was noted between a delayed flow on PAS and the development of post-thyroidectomy hypoparathyroidism (p = 0.01). PAS had a sensitivity of 100%, specificity of 88.6%, NPV of 100% and PPV of 55.6% to predict the development of post-thyroidectomy hypoparathyroidism. In this study, there was no additional benefit of ICG and NIRF camera in the identification of parathyroid glands. However, ICG angiogram seems to be a good adjunct for the intraoperative assessment of the viability of the parathyroid glands and accurately predicts the development of postoperative hypoparathyroidism.
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14
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Moreno Llorente P, García Barrasa A, Francos Martínez JM, Alberich Prats M, Pascua Solé M. Intraoperative Indocyanine Green Angiography of Parathyroid Glands and the Prevention of Post-Thyroidectomy Hypocalcemia. World J Surg 2021; 46:121-127. [PMID: 34561745 DOI: 10.1007/s00268-021-06322-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We compared the reliability of indocyanine green (ICG) angiography and intraoperative PTH levels for predicting early post-thyroidectomy hypocalcemia. METHODS Prospective study of 94 patients (71% women, mean age 53.7 years) undergoing total thyroidectomy. An ICG score of 2 (white) indicated a well-vascularized gland. PTH preoperative levels-PTH postresection levels divided by preoperative PTH × 100 was used to determine the PTH decline percentage. A decrease of at least 62.5% or <17.1 pg/mL in ioPTH was the criterion for predicting hypocalcemia. RESULTS At surgery, the four parathyroid glands were identified in 50 (53.2%) patients and <4 glands in 44. Calcium supplements were needed by 22 patients (23.4%) postoperatively, 11 patients in each group of 4 and <4 parathyroid glands identified. The diagnostic accuracy of ICG angiography (0.883, 95% confidence interval [CI] 0.800-0.940) and ioPTH (0.862, 95% CI 0.775-0.92) was similar. When all four parathyroid glands were identified, ICG angiography showed a slightly higher diagnostic accuracy, specificity and positive predictive than ioPTH levels, but when < 4 glands were identified, the ioPTH showed a slightly higher diagnostic accuracy, specificity and positive predictive value. Differences were not statistically significant for any of the comparisons. CONCLUSIONS The presence of one well-perfused parathyroid gland (ICG score 2) using ICG angiography or ioPTH decline, measured before and after completion of thyroid surgery, is both reliable methods in prediction of early post-thyroidectomy hypocalcemia independently of the number of glands identified intraoperatively.
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Affiliation(s)
- Pablo Moreno Llorente
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain.
| | - Arantxa García Barrasa
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
| | - José Manuel Francos Martínez
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Marta Alberich Prats
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Mireia Pascua Solé
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
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15
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Mattoo S, Agarwal A, Mayilvaganan S, Mishra P, Agarwal G, Mishra A, Chand G, Gupta SK, Mishra SK. Role of postoperative intact serum PTH as an early predictor of severe post-thyroidectomy hypocalcemia: a prospective study. J Endocrinol Invest 2021; 44:1961-1970. [PMID: 33502721 DOI: 10.1007/s40618-021-01511-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Post thyroidectomy hypocalcemia is a major sequel of thyroidectomy and continues to trouble the endocrinologists and the endocrine surgeons as there is no ideal predictive marker of hypocalcemia which has the potential to develop into a life-threatening complication. The role of early serum intact parathormone (iPTH) to predict post thyroidectomy hypocalcemia is becoming useful but the literature is still unclear regarding the optimal time of testing and the optimal cut-off value of serum iPTH. PATIENTS AND METHODS This is a prospective cohort study of 111 patients who underwent total thyroidectomy in a tertiary care endocrine surgery referral unit. Serum iPTH was measured after 20 min and 4 h of surgery. Receiver-Operator characteristic Curve (ROC) was used to find out of the best cut-off value of S. iPTH 20 min and 4 h after surgery in predicting hypocalcemia. RESULTS Hypocalcemia was noted in 60 (54%) out of 111 subjects who underwent total thyroidectomy. The best cut-off values of Serum iPTH to predict hypocalcemia was found to be 4.28 pmol/l at 20 min post total thyroidectomy with a sensitivity and specificity of 81.7% and 51%, respectively. In addition, patients with malignancy or central lymph nodal dissection were significantly over-represented in the hypocalcemia group with serum iPTH above the threshold level of 4.28 pmol/l. Below the cut off level, parenteral calcium supplementation was required in 23% (17/74) subjects while the rate was only 5.4% (2/37) patients when serum iPTH was above the cut-off level. CONCLUSIONS The decline of serum iPTH below a specific level after surgery has predictive value together with other factors strictly related to patient, the thyroid disease itself and surgery. The risk of development of hypocalcemia and consequent need for calcium supplementation should be evaluated by clinical assessment along with serum PTH measurement.
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Affiliation(s)
- S Mattoo
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
| | - A Agarwal
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India.
| | - S Mayilvaganan
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
| | - P Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
| | - G Agarwal
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
| | - A Mishra
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
| | - G Chand
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
| | - S K Gupta
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
| | - S K Mishra
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, 226014, India
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16
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Essa MS, Ahmad KS, Fadey MA, El-Shaer MO, Salama AMF, Zayed ME. Role of perioperative parathormone hormone level assay after total thyroidectomy as a predictor of transient and permanent hypocalcemia: Prospective study. Ann Med Surg (Lond) 2021; 69:102701. [PMID: 34429957 PMCID: PMC8368998 DOI: 10.1016/j.amsu.2021.102701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background The researchers are trying to evaluate the measurement of: Intact parathyroid hormone (iPTH) and serum total calcium (sCa) levels for predicting hypocalcemia after total thyroidectomy (TT). Methods The sample of this single center prospective study consists of (100) patients, where (77) females and (23) males with an age range between (28) and (65) (the mean level is, 48.17 ± 6.54). These selected patients underwent total thyroidectomy (TT) in the general surgery department, Benha university hospital from the period of June 2019 to February 2020. Levels of sCa and iPTH were measured aat several times preoperatively, 10 min, 48 h, 3, 6, 9 months, and 1 year after being after gone TT. Results Among the entire study sample, 23 patients (23%) developed transient hypoparathyroidism and hypocalcemia (˂8.5 mg/dl), none of them developed permanent hypoparathyroidism and hypocalcemia. The cut-off point of PTH has been 10 min after TT was at 23 pg/mL as it was the best compromise between sensitivity and specificity for predicting hypocalcaemia. It has been found that Patients who have a PTH greater than 23 pg/mL can be discharged safely after 24 h. Patients who have PTH of less than 23 pg/mL were observed for an additional 24 h, and the study found that timely treatment initiation is recommended. A PTH ˂ 10 pg/mL measured at 48 h after surgery had a sensitivity, specificity as well as an accuracy of 100%, for predicting hypocalcemia after TT. The accuracy of a single PTH concentration at 48 h was useful for predicting hypocalcemia [Area under receiver–operator characteristic curve (AUC) 1; confidence interval (CI), 95%, 0.85–0.94]. Conclusion Patients with iPTH ˂ 10 pg/mL, and sCa levels ˂ 7.4 mg/dL are at higher risk of developing hypoparathyroidism and hypocalcemia after TT. Incidence of Post-thyroidectomy transient hypoparathyroidism ranges between 0.3 and 49%, while permanent hypoparathyroidism is 13%. Incidence of hypocalcemia following total thyroidectomy ranging between 3% and 40% and is usually transient, while permanent hypocalcemia is ≤ 2%. Post-thyroidectomy PTH accurately predict hypocalcemia.
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Affiliation(s)
- Mohamed S Essa
- Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
| | - Khaled S Ahmad
- Department of General Surgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Mohammed A Fadey
- Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mohamed O El-Shaer
- Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
| | - Ahmed M F Salama
- Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mohamed E Zayed
- Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
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17
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Kakava K, Tournis S, Makris K, Papadakis G, Kassi E, Dontas I, Karatzas T. Identification of Patients at High Risk for Postsurgical Hypoparathyroidism. In Vivo 2021; 34:2973-2980. [PMID: 32871840 DOI: 10.21873/invivo.12128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/02/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM Postsurgical hypoparathyroidism (PostHypo) is a common complication after total thyroidectomy. We studied the risk factors associated with PostHypo. PATIENTS AND METHODS The study included 109 women, (mean age: 50.7±10.75 years), who underwent total thyroidectomy for thyroid diseases. RESULTS Based on the development of biochemical hypocalcemia on the first postoperative day following total thyroidectomy, (cCa<8.4 mg/dl), 37 women developed PostHypo and 72 did not. Younger age, a lower preoperative corrected calcium and the presence of parathyroid glands in the specimens were related to the development of PostHypo. Of all patients, 51.4% had a vitamin D deficiency. A parathyroid hormone (PTH) value ≤9.4 pg/ml was 84.9% sensitive and 71.4% specific to predict PostHypo on the 1st postoperative day. A 50% reduction of the PTH value on the 1st postoperative day from the preoperative level could identify patients who develop PostHypo with 76% sensitivity and 75% specificity. CONCLUSION PTH postoperative measurement and its alteration from the preoperative level can be used to identify patients who are at increased risk to develop PostHypo.
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Affiliation(s)
- Kassiani Kakava
- Head and Neck Surgery Department of Metaxa Anti-Cancer Hospital, Pireaus, Greece
| | - Symeon Tournis
- Laboratory for the Research of the Musculoskeletal System "Th. Garofalidis", School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | | | | | - Evanthia Kassi
- Endocrinology Unit, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Ismene Dontas
- Laboratory for the Research of the Musculoskeletal System "Th. Garofalidis", School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
| | - Theodore Karatzas
- 2 Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
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Recovery of parathyroid function in patients with thyroid cancer treated by total thyroidectomy: An analysis of 685 patients with hypoparathyroidism at discharge of surgery. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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19
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Lammert A, Nowak K, Weber R, Rotter N, Schölch S, Krämer BK, Lammert A. [Postoperative hypocalcemia - the most common complication of endocrine head and neck surgery: acute management]. Laryngorhinootologie 2021; 100:610-617. [PMID: 33652494 DOI: 10.1055/a-1381-8286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In Germany, 8000 patients are affected by postoperative hypoparathyroidism per year following surgery of the thyroid gland, parathyroidal glands and the larynx. Patients do not only suffer from paresthesia in the acute phase of this complication, but are also adversely affected by the fear of loss of control following episodes of tetany even years after the first episode. OBJECTIVES Discussion of a diagnostic pathway and presentation of a management pathway for postoperative hypocalcemia. METHODS Narrative review, analysis and discussion of current literature and expert recommendations. RESULTS Early determination of calcium and parathyroid hormone allows timely diagnosis and treatment of postoperative hypoparathyroidism. Active vitamin D is pivotal for the resorption of calcium. Only the combined treatment with active vitamin D and calcium can mitigate or prevent the postoperative drop of calcium levels. CONCLUSIONS A standard operating procedure (SOP) for postoperative hypoparathyroidism should be implemented in every surgical department. An SOP for diagnosis and treatment of postoperative hypoparathyroidism is proposed for institutional individualization and implementation.
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Affiliation(s)
- Anne Lammert
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Kai Nowak
- Klinik für Allgemein-, Gefäß- und Thoraxchirurgie, RoMed Klinikum, Rosenheim, Germany
| | - Roland Weber
- Medizinische Klinik II, RoMed Kliniken, Rosenheim, Germany
| | - Nicole Rotter
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Sebastian Schölch
- Chirurgische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Bernhard K Krämer
- V. Medizinische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Alexander Lammert
- V. Medizinische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany.,Apherese- und Dialysezentrum Grünstadt, Praxis für Diabetes, Stoffwechsel und Nierenerkrankungen, Grünstadt, Germany
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20
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Xing Z, Qiu Y, Xia B, Abuduwaili M, Fei Y, Zhu J, Su A. Surgical strategy when identifying less than four parathyroid glands during total thyroidectomy: a retrospective cohort study. Gland Surg 2021; 10:10-22. [PMID: 33633958 DOI: 10.21037/gs-20-486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Parathyroid glands protection is still controversial in patients with less than 4 parathyroid glands during thyroidectomy. The aim of this study was to investigate the strategy of parathyroid autotransplantation or in situ preservation in patients with 3 parathyroid glands. Methods Consecutive patients who underwent primary total thyroidectomy with bilateral central neck dissection for papillary thyroid carcinoma (PTC) in our center were included retrospectively. Serum calcium and parathyroid hormone (PTH) levels (pg/mL), incidence of hypocalcemia and hypoparathyroidism during 24 months follow-up were compared grouping by the number of parathyroid glands both identified intraoperatively and confirmed postoperatively by pathology. Results A total of 1,424 patients were included. Serum PTH and calcium levels were lower and the incidence of hypocalcemia was higher in patients with 3 identified parathyroid glands. When excluding patients with accidental parathyroid resection, the results remained similar. Of the 212 patients with 3 identified parathyroid glands, PTH levels at postoperative 12-month in patients underwent autotransplantation were significantly lower than patients with all parathyroid glands preserved in situ (3.65±1.30 vs. 4.67±1.89, P=0.026). Conclusions The parathyroid function was weaker in patients with 3 parathyroid glands than patients with 4 before and after operation. Parathyroid glands preserved all in situ promoted better recovery of postoperative function in patients with 3 identified parathyroid glands.
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Affiliation(s)
- Zhichao Xing
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxuan Qiu
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China.,Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Baoying Xia
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Munire Abuduwaili
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Fei
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jingqiang Zhu
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Anping Su
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
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21
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Díez JJ, Anda E, Sastre J, Pérez Corral B, Álvarez-Escolá C, Manjón L, Paja M, Sambo M, Santiago Fernández P, Blanco Carrera C, Galofré JC, Navarro E, Zafón C, Sanz E, Oleaga A, Bandrés O, Donnay S, Megía A, Picallo M, Sánchez Ragnarsson C, Baena-Nieto G, Fernández-García JC, Lecumberri B, Sahún de la Vega M, Romero-Lluch AR, Iglesias P. Permanent postoperative hypoparathyroidism: an analysis of prevalence and predictive factors for adequacy of control in a cohort of 260 patients. Gland Surg 2020; 9:1380-1388. [PMID: 33224813 DOI: 10.21037/gs-20-288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Recent guidelines for the treatment of hypoparathyroidism emphasize the need for long-term disease control, avoiding symptoms and hypocalcaemia. Our aim has been to analyze the prevalence of poor disease control in a national cohort of patients with hypoparathyroidism, as well as to evaluate predictive variables of inadequate disease control. Methods From a nation-wide observational study including a cohort of 1792 patients undergoing total thyroidectomy, we selected 260 subjects [207 women and 53 men, aged (mean ± SD) 47.2±14.8 years] diagnosed with permanent hypoparathyroidism. In every patient demographic data and details on surgical procedure, histopathology, calcium (Ca) metabolism, and therapy with Ca and calcitriol were retrospectively collected. A patient was considered not adequately controlled (NAC) if presented symptoms of hypocalcemia or biochemical data showing low serum Ca levels or high urinary Ca excretion. Results Two hundred and twenty-one (85.0%) patients were adequately controlled (AC) and 39 (15.0%) were NAC. Comparison between AC and NAC patients did not show any significant difference in demographic, surgical, and pathological features. Rate of hospitalization during follow-up was significantly higher among NAC patients in comparison with AC patients (35.9% vs. 10.9%, P<0.001). Dose of oral Ca and calcitriol were also significantly higher in NAC subjects. In a subgroup of 129 patients with serum parathyroid hormone (PTH) levels available, we found that NAC patients exhibited significantly lower postoperative PTH concentrations than AC patients [median (interquartile range) 3 (1.9-7.8) vs. 6.9 (3.0-11) pg/mL; P=0.009]. Conclusions In a nation-wide cohort of 260 subjects with definitive hypoparathyroidism, 15% of them had poor disease control. These patients required higher doses of oral Ca and calcitriol, had higher rate of hospitalization during follow-up and showed lower PTH concentrations in the postoperative period.
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Affiliation(s)
- Juan J Díez
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Present address: Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain
| | - Emma Anda
- Department of Endocrinology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Julia Sastre
- Department of Endocrinology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Begoña Pérez Corral
- Department of Endocrinology, Complejo Asistencial Universitario de León, León, Spain
| | | | - Laura Manjón
- Department of Endocrinology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Miguel Paja
- Department of Endocrinology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Marcel Sambo
- Department of Endocrinology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Piedad Santiago Fernández
- Department of Endocrinology, Complejo Hospitalario de Jaén, Jaén, Spain.,Department of Endocrinology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Concepción Blanco Carrera
- Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Juan C Galofré
- Department of Endocrinology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Elena Navarro
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Carles Zafón
- Department of Endocrinology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Eva Sanz
- Department of Endocrinology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Amelia Oleaga
- Department of Endocrinology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Orosia Bandrés
- Department of Endocrinology, Hospital Royo Villanova, Zaragoza, Spain
| | - Sergio Donnay
- Department of Endocrinology, Fundación Hospital de Alcorcón, Alcorcón, Madrid, Spain
| | - Ana Megía
- Department of Endocrinology, Hospital Universitari de Tarragona Joan XXIII, IISPV, Universitat Rovira i Virgili, Ciberdem, Tarragona, Spain
| | - María Picallo
- Department of Endocrinology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Gloria Baena-Nieto
- Department of Endocrinology, Hospital de Jerez, Jerez de la Frontera, Cádiz, Spain
| | | | - Beatriz Lecumberri
- Department of Endocrinology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Ana R Romero-Lluch
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Present address: Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Madrid, Spain
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22
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Liu X, Bian X, Li C, Xin J, Fu Q, Zhang C, Li F, Jiang J, Dionigi G, Sun H. Comparison of iPTH and calcium levels between total thyroidectomy and lobectomy: a prospective study of 840 thyroid cancers with three years of follow-up. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1243. [PMID: 33178775 PMCID: PMC7607111 DOI: 10.21037/atm-20-4554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Hypocalcemia is the most frequent complication after thyroidectomy and central neck dissection (CND). Early intact parathyroid hormone (iPTH) determination has been proposed as an early predictor parathyroid gland state. We aim to describe iPTH kinetics after central compartment lymph node dissection (CLND). Methods A large prospective observational study was conducted among 840 patients who underwent thyroid cancer surgery between July and December 2016 in China-Japan Union Hospital of Jilin University. Data were obtained from the patient’s iPTH evaluation 15 min after CND and serum calcium records during three years of post-operative follow-up. Age, sex, BMI, preoperative PTH, operative and pathologic details were analyzed. Backward stepwise logistic regression analyses were performed to find potential risk factors for predicting iPTH <15 pg/mL. The odds ratio and 95% confidence interval are estimated using the logistic regression coefficients. The prediction model was assessed using the receiver operating characteristic curve. Results The incidence of permanent hypocalcemia was 0.12%, while, 44.52% of patients were central lymph node metastasis. Multivariate analyses found associations among iPTH <15 pg/mL and several risk factors, especially preop PTH and type of surgery. The risk of iPTH <15 pg/mL, after total thyroidectomy plus CND, is almost 17 times that of lobectomy plus CND (OR =17.648, 95% confidence interval: 10.011–31.110). A model was created using multivariate analysis, which involved surgical procedure, and preop PTH could separate thyroid operation with iPTH <15 pg/mL. The biological index showed an area under the ROC curve of 0.697 and 0.613 separately. Using values below the lowest or above the highest cut-off point, the presence or absence of iPTH <15 pg/mL could possibly be predicted before thyroidectomy and CND. Conclusions A lobectomy procedure for papillary thyroid carcinoma patients with clinically uninvolved neck lymph nodes (cN0) who have primary tumors (T1 or T2) could accompany prophylactic CND (ipsilateral or bilateral) to provide clearance of disease compared to total thyroidectomy.
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Affiliation(s)
- Xiaoli Liu
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Xuehai Bian
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Changlin Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Jingwei Xin
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Qingfeng Fu
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Chunhai Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Fang Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Jinxi Jiang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi" University Hospital - Policlinico "G. Martino" - The University of Messina Via C. Valeria 1, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China
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23
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Sekar S, Belavendra A, Jacob PM. Early Discharge and Selective Calcium Supplementation after Thyroidectomy Based on Post-Operative Day 1 Parathormone and Calcium Level: A Prospective Study. Indian J Endocrinol Metab 2020; 24:319-324. [PMID: 33088754 PMCID: PMC7540830 DOI: 10.4103/ijem.ijem_172_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/28/2020] [Accepted: 06/25/2020] [Indexed: 11/13/2022] Open
Abstract
AIM This study aimed to evaluate a protocol using post thyroidectomy parathyroid hormone (PTH) levels on the day after surgery to facilitate early discharge of patients. METHODS This prospective observational study was done in Christian Medical College, India over 1 year with 125 consecutive patients who had serum PTH and calcium values measured in the morning following thyroidectomy/first postoperative day (D1). Patients with no symptoms and signs of hypocalcemia and with serum calcium ≥8 mg/dL and PTH ≥6 pg/ml according to the protocol were discharged without supplements on D1. Patients were followed up and tested for a week after surgery in the outpatient clinic to assess hypocalcemia and readmission rates. RESULTS Seventy five patients (60%) could be discharged early on D1without calcium supplementation; only one patient had mild hypocalcemia symptoms managed with oral calcium supplements during outpatient follow-up within 1 week and none who followed the protocol required readmission. Temporary biochemical hypocalcemia was encountered in 36 patients (28.8%) including symptomatic hypocalcemia in 13 patients (10.4%). Among the 36 patients with hypocalcemia, 26 patients (72.2%) had a PTH level <6 pg/ml. Three patients required intravenous calcium infusion to correct hypocalcemia. Sensitivity, specificity and positive predictive value, and ROC of PTH 6 pg/ml in predicting hypocalcemia were 70.5%, 94.5% and 83.3%, 0.86, respectively. The low PTH could also guide early supplementation of calcium and all the severe hypocalcemia patients had PTH lower than the cut off of 6 pg/ml. CONCLUSION A PTH and calcium-based protocol can be effectively used for early discharge of thyroidectomy patients the day after surgery without calcium supplementation. The compliance of the patient for early discharge was good.
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Affiliation(s)
- Suganya Sekar
- Department of Endocrine and Breast Surgery, Velammal Medical College and Research Centre, Madurai, Tamil Nadu, India
| | - Antonisamy Belavendra
- Department of Biostatistics and, Christian Medical College, Vellore, Tamil Nadu, India
| | - Paul M. Jacob
- Department of Endocrine Surgery, Christian Medical College, Vellore, Tamil Nadu, India
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Predictors of post-thyroidectomy hypocalcaemia: a systematic and narrative review. The Journal of Laryngology & Otology 2020; 134:541-552. [PMID: 32519635 DOI: 10.1017/s0022215120001024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Hypocalcaemia is the most common complication after total or completion thyroidectomy. This study assesses recent evidence on predictive factors for post-thyroidectomy hypocalcaemia in order to identify the patients affected and aid prevention. METHOD Two authors independently assessed articles and extracted data to provide a narrative synthesis. This study was an updated systematic search and narrative review regarding predictors of post-thyroidectomy hypocalcaemia using the Ovid Medline, Embase, Cochrane and Cinahl databases. Results were limited to papers published from January 2012 to August 2019. RESULTS Sixty-three observational studies with a total of 210 401 patients met the inclusion criteria. The median incidence was 27.5 per cent for transient biochemical hypocalcaemia, 12.5 per cent for symptomatic hypocalcaemia and 2.2 per cent for permanent hypocalcaemia. The most frequent statistically significant predictor of hypocalcaemia was peri-operative parathyroid hormone level. Symptomatic hypocalcaemia and permanent hypocalcaemia were seen more frequently in patients undergoing concomitant neck dissection. CONCLUSION Many factors have been studied for their link to post-thyroidectomy hypocalcaemia, and this study assesses the recent evidence presented in each case.
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25
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Gutiérrez Fernández G, López Useros A, Muñoz Cacho P, Casanova Rituerto D. Prediction of post-idroidectomy hypocalcemia through rapid PTH determination. Cir Esp 2020; 99:115-123. [PMID: 32522336 DOI: 10.1016/j.ciresp.2020.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Hypocalcemia is the most frequent complication after thyroidectomy. The aim of this work is to identify biochemical risk factors of hypocalcemia using quick perioperative (pre and post-thyroidectomy) intact parathyroid hormone (PTHi) and postoperative calcemias. METHODS In a consecutive series of 310 total thyroidectomies, samples of quick PTHi at the anaesthetic induction and 10 minutes after surgery, together with serum calcemias every 12 hours were obtained. The sensitivity, specificity, positive and negative predictive value are analyzed and related to hypocalcemia. A control group of hemithyroidectomies is also analyzed to compare the effects of surgery on PTH secretion. RESULTS Of the 310 patients, 202 (65.1%) remained normocalcemic and asymptomatic (group A), 108 (34.9%) presented hypocalcemia (Group B), requiring oral calcium (79 symptomatic). After analysis of several cut-off points, combining a PTHr drop gradient of 60% or calcemia inferior to 7.4 mg/dl at 24 hours, a sensitivity of 100% is achieved without leaving false negatives. Compared to the control group, there is a significant difference with respect to the post-operative calcemias and PTHr, p < 0.001. CONCLUSIONS Total thyroidectomy affects parathyroid function with evident decrease in rPTH and risk of hypocalcemia. The combination of PTHr decrease of 60% or less than 7.4 mg/dl calcemia at 24 hours gives a 100% sensitivity for predicting patients at risk of hypocalcemia.
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Affiliation(s)
- Gonzalo Gutiérrez Fernández
- Servicio Cirugía General. Unidad Cirugía Endocrino-Metabólica. Hospital Universitario Marques de Valdecilla, Santander, España.
| | - Antonio López Useros
- Servicio Cirugía General. Unidad Cirugía Endocrino-Metabólica. Hospital Universitario Marques de Valdecilla, Santander, España
| | - Pedro Muñoz Cacho
- Unidad Docente de Medicina Familiar y Comunitaria, Servicio Cántabro de Salud, Santander, España
| | - Daniel Casanova Rituerto
- Servicio Cirugía General. Unidad Cirugía Endocrino-Metabólica. Hospital Universitario Marques de Valdecilla, Santander, España
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 231] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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Torabi SJ, Avery JM, Salehi PP, Lee Y. Risk factors and effects of hypocalcemia prior to discharge following thyroidectomy. Am J Otolaryngol 2020; 41:102420. [PMID: 32139087 DOI: 10.1016/j.amjoto.2020.102420] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To find patient and surgical characteristics associated with hypocalcemia prior to discharge (HPTD) in thyroidectomy patients. MATERIALS AND METHODS In a retrospective analysis of the 2016-2017 National Surgical Quality Improvement Program, eligible total thyroidectomy patients were stratified into cohorts based on development of HPTD. We identified demographic and surgical risk factors for the development of hypocalcemia via binary logistic regression and identified the negative sequelae of HPTD utilizing univariate and multivariate methods. RESULTS We identified a total of 6519 patients who underwent total thyroidectomy, of which 450 (6.9%) had HPTD. Predictors associated with an increased incidence of HPTD included female sex (OR: 1.737 [95% CI: 1.319-2.288]; p < .001), increased operative time (OR: 1.003 [1.002-1.004]; p < .001), and central neck dissection (OR: 1.484 [1.190-1.850]; p < .001). However, factors that decreased incidence of HPTD included increased age, obesity (OR: 0.648 [0.501-0.837]; p = .001), and the use of vessel sealant devices (VSD) (OR: 0.650 [0.527-0.803]; p < .001). Multivariate analysis further revealed that HPTD independently led to an increased hospitalization length after surgery (B: 0.708 [0.607-0.809]; p < .001) and an increased 30-day readmission rate (OR: 2.429 [1.594-3.704]; p < .001). CONCLUSION Obesity, increased age, and intra-operative VSD use were significantly associated with decreased rates of HPTD after total thyroidectomy. Female sex, longer operations, and central neck dissections were associated with HPTD. Delineating risk factors and protective factors for HPTD in total thyroidectomy patients is important as patients with HPTD were found to be at a significantly higher risk for longer post-operative stays, increased odds of 30-day readmission, and increased hypocalcemia-related event.
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Affiliation(s)
- Sina J Torabi
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
| | - Jonathan M Avery
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
| | - Parsa P Salehi
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
| | - Yan Lee
- Department of Surgery, Division of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America.
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Zhang D, Wang T, Dionigi G, Zhang J, Zhao Y, Xue G, Liang N, Sun H. Comparison of parathyroid hormone kinetics in endoscopic thyroidectomy via bilateral areola with open thyroidectomy. BMC Surg 2019; 19:190. [PMID: 31829211 PMCID: PMC6907128 DOI: 10.1186/s12893-019-0656-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/27/2019] [Indexed: 11/29/2022] Open
Abstract
Background In this study, we aimed to compare the kinetics of intact parathyroid hormone (iPTH) during the perioperative period of endoscopic thyroidectomy via bilateral areola approach (ETBAA) in the same period, following a traditional open thyroidectomy approach (OTA). Methods We conducted a prospective observational study of patients who were undergoing thyroidectomy and level VI clearance. Patients who had been affected by papillary thyroid cancer (PTC) were stratified into three groups: those eligible for endoscopic treatment (ETBAA); patients who were eligible for ETBAA but had opted for OTA (OTA-L); and patients who were not suitable for endoscopic intervention (OTA-H). A process for locating parathyroid glands was utilized to stratify gland dissection laboriousness. In Type A, the gland is firmly fixed to thyroid gland. This type can be sub-classified into three subtypes. A1: the parathyroid gland is attached to the inherent thyroid capsule. A2: the gland is partially embedded in the thyroid gland. A3: the gland is located in the thyroid tissue. Type B is defined as a gland which is separated from the thyroid gland. The iPTH was sampled at wound closure. Results There were 100 patients in each group. We found a significant difference between the ETBAA and OTA-H groups for type A2, as well as a loss of parathyroid glands and a number of parathyroid transplantation procedures. The endoscopic group was treated during an earlier stage of thyroid cancer. The iPTH profile of each group decreased, although this was the most consistent in the OTA-H group. A comparison of ETBAA with OTA-L demonstrates that the iPTH level change is similar. Conclusion There is no advantage of endoscopic treatment for preserving parathyroid function.
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Affiliation(s)
- Daqi Zhang
- Department of Thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China
| | - Tie Wang
- Department of Thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy
| | - Jiao Zhang
- Department of Thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China
| | - Yishen Zhao
- Department of Thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China
| | - Gaofeng Xue
- Department of Thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China
| | - Nan Liang
- Department of Thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China.
| | - Hui Sun
- Department of Thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun city, Jilin province, People's Republic of China.
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Díez JJ, Anda E, Sastre J, Pérez Corral B, Álvarez-Escolá C, Manjón L, Paja M, Sambo M, Santiago Fernández P, Blanco Carrera C, Galofré JC, Navarro E, Zafón C, Sanz E, Oleaga A, Bandrés O, Donnay S, Megía A, Picallo M, Sánchez Ragnarsson C, Baena-Nieto G, García JCF, Lecumberri B, de la Vega MS, Romero-Lluch AR, Iglesias P. Prevalence and risk factors for hypoparathyroidism following total thyroidectomy in Spain: a multicentric and nation-wide retrospective analysis. Endocrine 2019; 66:405-415. [PMID: 31317524 DOI: 10.1007/s12020-019-02014-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The prevalence of postoperative hypoparathyroidism has been studied in registries and in surgical series with highly variable and imprecise results. However, the frequency of this hormonal deficiency in the clinical practice of endocrinologists is not known with accuracy. We aimed to assess the prevalence and risk factors of hypoparathyroidism in patients undergoing total thyroidectomy in Spain. METHODS We designed a retrospective, multicentre and nation-wide protocol including all patients with total thyroidectomy who were seen in the endocrinology clinic of the participant centers from January to March 2018. Prevalence of hypoparathyroidism was evaluated at discharge of surgery, 3-6 months after surgery, 12 months after surgery and at last visit. Twenty hospitals participated in the study. RESULTS Of 1792 patients undergoing total thyroidectomy, 866 (48.3%) developed postoperative hypoparathyroidism at discharge of surgery. Most of them recover parathyroid function over time. Prevalence of hypoparathyroidism at 3-6 months, 12 months and at last visit was 22.9%, 16.7% and 14.5%, respectively. The risk of developing definitive hypoparathyroidism was related to the presence of parathyroid tissue at histology, lymph node dissection, and two-stage thyroidectomy. Patients with thyroid cancer, with higher postoperative calcium levels and treated by expert surgical teams exhibited lower risk of developing permanent hypoparathyroidism. CONCLUSIONS Although most patients with postsurgical hypoparathyroidism recover parathyroid function, the prevalence of permanent disease in clinical practice is non negligible (14.5%). Postoperative calcium, extent and timing of surgery, the presence of cancer, expert surgical team, and parathyroid tissue at histology are predictors of permanent hypoparathyroidism.
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Affiliation(s)
- Juan J Díez
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
| | - Emma Anda
- Department of Endocrinology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Julia Sastre
- Department of Endocrinology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Begoña Pérez Corral
- Department of Endocrinology, Complejo Asistencial Universitario de León, León, Spain
| | | | - Laura Manjón
- Department of Endocrinology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Miguel Paja
- Department of Endocrinology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Marcel Sambo
- Department of Endocrinology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Concepción Blanco Carrera
- Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Juan C Galofré
- Department of Endocrinology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Elena Navarro
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Carles Zafón
- Department of Endocrinology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eva Sanz
- Department of Endocrinology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Amelia Oleaga
- Department of Endocrinology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Orosia Bandrés
- Department of Endocrinology, Hospital Royo Villanova, Zaragoza, Spain
| | - Sergio Donnay
- Department of Endocrinology, Fundación Hospital de Alcorcón, Alcorcón, Madrid, Spain
| | - Ana Megía
- Department of Endocrinology, Hospital Universitario de Tarragona Joan XXIII, IISPV, Universitat Rovira i Virgili, Ciberdem, Tarragona, Spain
| | - María Picallo
- Department of Endocrinology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Gloria Baena-Nieto
- Department of Endocrinology, Hospital de Jerez, Jerez de la Frontera, Cádiz, Spain
| | | | - Beatriz Lecumberri
- Department of Endocrinology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Ana R Romero-Lluch
- Department of Endocrinology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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Del Rio P, Rossini M, Montana CM, Viani L, Pedrazzi G, Loderer T, Cozzani F. Postoperative hypocalcemia: analysis of factors influencing early hypocalcemia development following thyroid surgery. BMC Surg 2019; 18:25. [PMID: 31074401 PMCID: PMC7402573 DOI: 10.1186/s12893-019-0483-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/30/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Early Hypocalcemia is the most frequent complication after thyroid surgery. Several studies have tried to identify factors (patient caracteristics or surgical technique variations) affecting hypocalcemia following thyroid surgery. This studiy evaluates the role of several factors in postoperative hypocalcemia development. METHODS A retrospective study conducted on 2108 patients that underwent thyroid surgery in a single center (1669 women and 439 men). Postoperative early hypocalcemia was defined as serum calcium levels lower than 8,0 mg/dl measured 24 h after surgery. Following factors were evaluated in the study: sex, age, glandular hyperfunction, preoperative diagnosis, preoperative serum calcium levels, preoperative serum PTH levels, type of surgery performed (total thyroidectomy vs. lobectomy); minimally invasive video assisted thyroidectomy (MIVAT); number of parathyroid preserved in situ, postoperative serum calcium levels, changes in perioperative calcium levels (difference between preoperative values and postoperative calcium levels), presence of carcinoma in the surgical specimen, presence of thyroiditis based on histopatology reports. RESULTS Among evaluated factors only gender and surgical procedure revealed to be significantly correlated to early hypocalcemia development. In fact female patients experienced postoperative hypocalcemia in 42% (701/1669) of cases, which was signicantly higher than the 21.4% (94/439) identified in men. We also noticed a greater hypocalcemia incidence in patient undergoing total thyroidectomy (38.8%) than in patient undergoing lobectomy group (13.8%). Early hypocalcemia development didn't appear to be related to preoperative serum calcium levels but it showed a statistically significant correlation with perioperative serum calcium level drop. CONCLUSION This findings suggest that sex (female gender is a strong risk factor),surgical procedure and perioperative changes in serum calcium are the only factors (among all variables examined) that influence early hypocalcemia development.
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Affiliation(s)
- Paolo Del Rio
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Matteo Rossini
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Chiara Montana Montana
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Lorenzo Viani
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Giuseppe Pedrazzi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Tommaso Loderer
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Federico Cozzani
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
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Lee JW, Kim JK, Kwon H, Lim W, Moon BI, Paik NS. Routine low-dose calcium supplementation after thyroidectomy does not reduce the rate of symptomatic hypocalcemia: a prospective randomized trial. Ann Surg Treat Res 2019; 96:177-184. [PMID: 30941321 PMCID: PMC6444042 DOI: 10.4174/astr.2019.96.4.177] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/14/2018] [Accepted: 12/11/2018] [Indexed: 11/30/2022] Open
Abstract
Purpose Routine supplementation of high-dose calcium significantly decreased the risk of postoperative symptomatic hypocalcemia after thyroidectomy. However, there is an ongoing debate about whether the same results can be achieved with low-dose calcium supplementation. Methods Patients (n = 138) who underwent total thyroidectomy for thyroid cancer were 1:1 randomly assigned to receive oral supplements of 1,500 mg/day elemental calcium and 1,000 IU/day cholecalciferol for 2 weeks or no supplementation. Primary objective was to compare the incidence of symptomatic hypocalcemia for 3 days after total thyroidectomy. Secondary objective was to find the predictors for postoperative hypocalcemia in patients with thyroid cancer. Results Sixty-five patients in the calcium group and 69 patients in the control group were finally analyzed. The incidence of symptomatic hypocalcemia showed no difference between the calcium and control group (32.3% vs. 21.7%, P = 0.168). The total dosage of intravenous calcium (593.4 ± 267.1 mg vs. 731.6 ± 622.7 mg, P = 0.430) administered to patients with symptomatic hypocalcemia was also comparable between groups. In a multivariate analysis, parathyroid hormone level of 13 pg/mL at postoperative day 1 was only predictive for symptomatic hypocalcemia, and its incidence was 20.9 times (95% confidence interval, 6.8-64.5) higher in patients with parathyroid hormone <13 pg/mL. Other factors did not predict the development of hypocalcemia, including clinicopathological features and routine supplementation of low-dose calcium. Conclusion Routine low-dose calcium supplementation did not reduce the risk of postoperative hypocalcemia. Patients who may benefit from calcium supplementation should be carefully selected.
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Affiliation(s)
- Jun Woo Lee
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea.,Breast and Thyroid Cancer Center, Ewha Womans University Cancer Hospital, Seoul, Korea
| | - Jong-Kyu Kim
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea.,Breast and Thyroid Cancer Center, Ewha Womans University Cancer Hospital, Seoul, Korea
| | - Hyungju Kwon
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea.,Breast and Thyroid Cancer Center, Ewha Womans University Cancer Hospital, Seoul, Korea
| | - Woosung Lim
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea.,Breast and Thyroid Cancer Center, Ewha Womans University Cancer Hospital, Seoul, Korea
| | - Byung-In Moon
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea.,Breast and Thyroid Cancer Center, Ewha Womans University Cancer Hospital, Seoul, Korea
| | - Nam Sun Paik
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea.,Breast and Thyroid Cancer Center, Ewha Womans University Cancer Hospital, Seoul, Korea
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Mazotas IG, Yen TW, Park J, Liu Y, Eastwood DC, Carr AA, Evans DB, Wang TS. A postoperative parathyroid hormone-based algorithm to reduce symptomatic hypocalcemia following completion/total thyroidectomy: A retrospective analysis of 591 patients. Surgery 2018; 164:746-753. [DOI: 10.1016/j.surg.2018.04.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/13/2018] [Accepted: 04/15/2018] [Indexed: 12/12/2022]
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Eismontas V, Slepavicius A, Janusonis V, Zeromskas P, Beisa V, Strupas K, Dambrauskas Z, Gulbinas A, Martinkenas A. Predictors of postoperative hypocalcemia occurring after a total thyroidectomy: results of prospective multicenter study. BMC Surg 2018; 18:55. [PMID: 30092793 PMCID: PMC6085643 DOI: 10.1186/s12893-018-0387-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/30/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Thyroid surgeries are among the most common operations performed in the world. Hypocalcemia following total thyroidectomy is a common complication that is sometimes difficult to correct. The aim of this study is to determine the risk factors for hypocalcemia following total thyroidectomy and their clinical value. METHODS From January 2015 through to April 2017, 400 patients were included in this prospective multicenter study. All patients underwent total thyroidectomy due to various thyroid diseases. The following risk factors were analyzed: pre-operative and post-operative biochemical blood parameters, clinical effects and factors related to surgery, the patient, and the disease. RESULTS Post-operative hypocalcemia developed in 257 patients (64.2%). Of them, 197 patients (76.7%) were diagnosed with asymptomatic hypocalcemia. Clinical symptoms were present in 60 of the 257 patients with hypocalcemia (23.3%). The statistically significant predictors of hypocalcemia were decreased calcium and ionized calcium pre-operatively (p < 0.001), parathyroid hormone on day one following surgery (p < 0.001), thyrotoxicosis <10 years before surgery (odds ratio 1.65, 95% CI 1.01-2.70, p = 0.046), the number of parathyroid glands found during surgery (odds ratio 0.52, 95% CI 0.38-0.70, p < 0.001), ligation of the trunk of the left inferior thyroid artery (odds ratio 2.04, 95% CI 1.27-3.29, p = 0.003), ligation of the trunk of the right inferior thyroid artery (odds ratio 2.37, 95% CI 1.47-3.81, p < 0.001), and the number of transplanted parathyroid glands (odds ratio 1.87, 95% CI 1.12-2.97, p = 0.015). In the multivariate analysis, age (odds ratio 1.05, 95% CI 1.01-1.09, p = 0.029) and gender (odds ratio 5.94, 95% CI 1.13-31.26, p = 0.035) were statistically significant predictors. CONCLUSIONS This study demonstrates that there is a number of different patient (gender, age, and duration of thyrotoxicosis <10 years before surgery) and surgical (number of parathyroid glands found during surgery, decreased calcium and ionized calcium before surgery, parathyroid hormone on day one following surgery, and ligation of the trunk of the left and right inferior thyroid artery) risk factors predictive of hypocalcemia following total thyroidectomy. Optimization of the surgical technique could possibly prevent the occurrence of hypocalcemia after total thyroidectomy in some cases; in other cases, identification of known risk factors post-operatively could permit early detection and effective treatment of these patients.
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Affiliation(s)
- Vitalijus Eismontas
- Department of Abdominal and Endocrine Surgery, Klaipeda University Hospital, Liepojos St. 41, 92288, Klaipeda, Lithuania.
| | - Algirdas Slepavicius
- Department of Abdominal and Endocrine Surgery, Klaipeda University Hospital, Liepojos St. 41, 92288, Klaipeda, Lithuania
| | - Vinsas Janusonis
- Department of Abdominal and Endocrine Surgery, Klaipeda University Hospital, Liepojos St. 41, 92288, Klaipeda, Lithuania
| | - Paulius Zeromskas
- Department of Abdominal and Endocrine Surgery, Klaipeda University Hospital, Liepojos St. 41, 92288, Klaipeda, Lithuania
| | - Virgilijus Beisa
- Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Kestutis Strupas
- Centre of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Zilvinas Dambrauskas
- Department of Surgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Antanas Gulbinas
- Department of Surgery, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Arvydas Martinkenas
- Department of Medical Technologies, Faculty of Health Sciences, Klaipeda University, Klaipeda, Lithuania
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Orloff LA, Wiseman SM, Bernet VJ, Fahey TJ, Shaha AR, Shindo ML, Snyder SK, Stack BC, Sunwoo JB, Wang MB. American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults. Thyroid 2018; 28:830-841. [PMID: 29848235 DOI: 10.1089/thy.2017.0309] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment. SUMMARY HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.
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Affiliation(s)
- Lisa A Orloff
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Sam M Wiseman
- 2 Department of Surgery, University of British Columbia , Vancouver, Canada
| | - Victor J Bernet
- 3 Division of Endocrinology, Mayo Clinic College of Medicine , Jacksonville, Florida
| | - Thomas J Fahey
- 4 Department of Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center , New York, New York
| | - Ashok R Shaha
- 5 Head and Neck Service, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Maisie L Shindo
- 6 Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University , Portland, Oregon
| | - Samuel K Snyder
- 7 Department of Surgery, University of Texas Rio Grande Valley School of Medicine , Harlingen, Texas
| | - Brendan C Stack
- 8 Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - John B Sunwoo
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Marilene B Wang
- 9 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA , Los Angeles, California
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Falch C, Hornig J, Senne M, Braun M, Konigsrainer A, Kirschniak A, Muller S. Factors predicting hypocalcemia after total thyroidectomy - A retrospective cohort analysis. Int J Surg 2018; 55:46-50. [PMID: 29777882 DOI: 10.1016/j.ijsu.2018.05.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/20/2018] [Accepted: 05/10/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypocalcemia after total thyroidectomy is the most frequent complication resulting in prolongation of hospitalisation. Therefore we aimed to analyse clinical risk factors predictive for hypocalcemia and its long term persistence after total thyroidectomy. METHODS Retrospective analysis of patients undergoing total thyroidectomy from 2005 until 2013. Outcome measures were initial postoperative hypocalcemia defined as serum calcium below 2.0 mmol/l after total thyroidectomy within 48 h and persistent hypocalcemia defined as serum calcium below 2.0 mmol/l above six months and/or the need for additional calcium and vitamin D supplementation. RESULTS Initial postoperative hypocalcemia was present in 160 of 702 patients (22.8%) with 91 patients (13%) developing symptoms. 48 patients (6.8%) had a persistent hypocalcemia above six months. Patients with an initial symptomatic postoperative hypocalcemia showed significantly more often a persistent hypocalcemia compared to asymptomatic patients with biochemical hypocalcemia (38 patients (41.8%) vs. 10 patients (14.5%), p < 0,001). In the binary logistic regression analysis, female gender (OR 2.4; CI95% 1.5-3.8), prolonged surgery time >189 min (OR 1.8; CI95% 1.2-2.6) and parathyroid reimplantation (OR 2.4; CI95% 1.2-4.7) were associated with initial hypocalcemia while only initial symptomatic hypocalcaemia was shown to be independently associated with persistent hypocalcemia (OR 40.9; CI95% 18.5-90.4). CONCLUSION Prolonged surgery time seems to correlate with initial postoperative hypocalcemia independently of the underlying disease and surgical expertise but does not affect the persistence of hypocalcemia. Initial symptomatic postoperative hypocalcemia after total thyroidectomy is associated with a high rate of persistent hypocalcemia.
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Affiliation(s)
- Claudius Falch
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Jan Hornig
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Moritz Senne
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Manuel Braun
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Alfred Konigsrainer
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Andreas Kirschniak
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany
| | - Sven Muller
- Working Group for Surgical Technique and Training, Clinic for Visceral, General and Transplant Surgery, Tuebingen University Hospital, Germany.
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Vidal Fortuny J, Sadowski SM, Belfontali V, Guigard S, Poncet A, Ris F, Karenovics W, Triponez F. Randomized clinical trial of intraoperative parathyroid gland angiography with indocyanine green fluorescence predicting parathyroid function after thyroid surgery. Br J Surg 2018; 105:350-357. [PMID: 29405252 PMCID: PMC6084300 DOI: 10.1002/bjs.10783] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/15/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hypoparathyroidism, the most common complication after thyroid surgery, leads to hypocalcaemia and significant medical problems. An RCT was undertaken to determine whether intraoperative parathyroid gland angiography with indocyanine green (ICG) could predict postoperative hypoparathyroidism, and obviate the need for systematic blood tests and oral calcium supplementation. METHODS Between September 2014 and February 2016, patients who had at least one well perfused parathyroid gland on ICG angiography were randomized to receive standard follow-up (measurement of calcium and parathyroid hormone (PTH) on postoperative day (POD) 1 and systematic supplementation with calcium and vitamin D; control group) or no supplementation and no blood test on POD 1 (intervention group). In all patients, calcium and PTH levels were measured 10-15 days after thyroidectomy. The primary endpoint was hypocalcaemia on POD 10-15. RESULTS A total of 196 patients underwent ICG angiography during thyroid surgery, of whom 146 had at least one well perfused parathyroid gland on ICG angiography and were randomized. None of these patients presented with hypoparathyroidism, including those who did not receive calcium supplementation. The intervention group was statistically non-inferior to the control group (exact 95 per cent c.i. of the difference in proportion of patients with hypocalcaemia -0·053 to 0·053; P = 0·012). Eleven of the 50 excluded patients, in whom no well perfused parathyroid gland could be identified by angiography, presented with hypoparathyroidism on POD 1, and six on POD 10-15, which was significantly different from the findings in randomized patients (P = 0·007). CONCLUSION ICG angiography reliably predicts the vascularization of the parathyroid glands and obviates the need for postoperative measurement of calcium and PTH, and supplementation with calcium in patients with at least one well perfused parathyroid gland. Registration number: NCT02249780 (http://www.clinicaltrials.gov).
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Affiliation(s)
- J. Vidal Fortuny
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - S. M. Sadowski
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - V. Belfontali
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - S. Guigard
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - A. Poncet
- Department of Clinical EpidemiologyUniversity Hospitals of GenevaGenevaSwitzerland
| | - F. Ris
- Department Visceral SurgeryUniversity Hospitals of GenevaGenevaSwitzerland
| | - W. Karenovics
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - F. Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
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Galy-Bernadoy C, Lallemant B, Chambon G, Pham HT, Reynaud C, Alovisetti C, Bonduelle Q, Guedj AM, Lumbroso S, De Brauwere DP. Parathyroid Hormone Assays following Total Thyroidectomy: Is There a Predictive Value? Eur Thyroid J 2018; 7:34-38. [PMID: 29594052 PMCID: PMC5836170 DOI: 10.1159/000484689] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 10/31/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Parathyroid hormone (PTH) is a risk marker for hypoparathyroidism (hypoPTH). This study aimed to determine the predictive values of early PTH assays carried out at the moment of skin closure (PTH SC), to establish a treatment algorithm, identifying two threshold values. We assessed the reproducibility of this approach with two different immunoassay kits (hypoPTH) after total thyroidectomy, but its practical application is not consensual. STUDY DESIGN We conducted a prospective descriptive study, including all patients who underwent a total thyroidectomy between March 2012 and November 2013. Postoperative PTH SC levels, corrected calcium on postoperative days, and occurrence of hypoPTH symptoms were collected. RESULTS Of 257 patients, the rate of hypoPTH was 20%. Threshold values to obtain a 100% positive predictive value to identify patients for whom hypoPTH was absolutely certain were: PTH SC <7 ng/L for the Roche kit and PTH SC <4 ng/L for the Beckman-Coulter kit. Threshold values to obtain a 100% negative predictive value to identify patients for whom the absence of hypoPTH was absolutely certain were: PTH SC ≥19 ng/L for the Roche kit and PTH SC ≥9 ng/L the Beckman-Coulter kit. CONCLUSIONS A single serum PTH sampled at skin closure is a reliable test to predict hypoPTH after a total thyroidectomy. The use of a threshold based on a 100% negative predictive value enables patients with no risk of hypoPTH to be safely discharged within the first 24 h postoperatively without unnecessary calcium and vitamin treatment. This medication can be given promptly to patients at risk of hypoPTH to limit the occurrence of hypocalcaemia.
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Affiliation(s)
- Camille Galy-Bernadoy
- Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, Nîmes, France
| | - Benjamin Lallemant
- Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, Nîmes, France
- *Prof. Benjamin Lallemant, Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, 1, Place du Professeur Robert Debré, FR-30029 Nîmes (France), E-Mail
| | - Guillaume Chambon
- Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, Nîmes, France
| | - Huy Trang Pham
- Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, Nîmes, France
| | - Christophe Reynaud
- Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, Nîmes, France
| | - Caroline Alovisetti
- Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, Nîmes, France
| | - Quentin Bonduelle
- Department of Oto-Rhino-Laryngology and Head and Neck Surgery, University Hospital of Nîmes, Nîmes, France
| | - Anne Marie Guedj
- Department of Endocrinology and Metabolic Diseases, University Hospital of Nîmes, Nîmes, France
| | - Serge Lumbroso
- Department of Biochemistry and Molecular Biology, University Hospital of Nîmes, Nîmes, France
| | - David-Paul De Brauwere
- Department of Biochemistry and Molecular Biology, University Hospital of Nîmes, Nîmes, France
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Maeda SS, Moreira CA, Borba VZC, Bandeira F, Farias MLFD, Borges JLC, Paula FJAD, Vanderlei FAB, Montenegro FLDM, Santos RO, Ferraz-de-Souza B, Lazaretti-Castro M. Diagnosis and treatment of hypoparathyroidism: a position statement from the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:106-124. [PMID: 29694629 PMCID: PMC10118685 DOI: 10.20945/2359-3997000000015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/14/2017] [Indexed: 11/23/2022]
Abstract
Objective To present an update on the diagnosis and treatment of hypoparathyroidism based on the most recent scientific evidence. Materials and methods The Department of Bone and Mineral Metabolism of the Sociedade Brasileira de Endocrinologia e Metabologia (SBEM; Brazilian Society of Endocrinology and Metabolism) was invited to prepare a document following the rules set by the Guidelines Program of the Associação Médica Brasileira (AMB; Brazilian Medical Association). Relevant papers were retrieved from the databases MEDLINE/PubMed, LILACS, and SciELO, and the evidence derived from each article was classified into recommendation levels according to scientific strength and study type. Conclusion An update on the recent scientific literature addressing hypoparathyroidism is presented to serve as a basis for the diagnosis and treatment of this condition in Brazil.
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Chang YK, Lang BHH. To identify or not to identify parathyroid glands during total thyroidectomy. Gland Surg 2017; 6:S20-S29. [PMID: 29322019 DOI: 10.21037/gs.2017.06.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hypoparathyroidism is one of the most common complications after total thyroidectomy and may impose a significant burden to both the patient and clinician. The extent of thyroid resection, surgical techniques, concomitant central neck dissection, parathyroid gland (PG) autotransplantation and inadvertent parathyroidectomy have long been some of the risk factors for postoperative hypoparathyroidism. Although routine identification of PGs has traditionally been advocated by surgeons, recent evidence has suggested that perhaps identifying fewer number of in situ PGs during surgery (i.e., selective identification) may further lower the risk of hypoparathyroidism. One explanation is that visual identification may often lead to subtle damages to the nearby blood supply of the in situ PGs and that may increase the risk of hypoparathyroidism. However, it is worth highlighting the current literature supporting either approach (i.e., routine vs. selective) remains scarce and because of the significant differences in study design, inclusions, definitions and management protocol between studies, a pooled analysis on this important but controversial topic remains an impossible task. Furthermore, it is worth nothing that identification of PGs does not equal safe preservation, as some studies demonstrated that it is not the number of PGs identified, but the number of PG preserved in situ that matters. Therefore a non-invasive, objective and reliable way to localize PGs and assess their viability intra-operatively is warranted. In this aspect, modern technology such as the indocyanine green (ICG) as near-infrared fluorescent dye for real-time in situ PG perfusion monitoring may have a potential role in the future.
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Affiliation(s)
- Yuk Kwan Chang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Brian H H Lang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
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Sadowski SM, Vidal Fortuny J, Triponez F. A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques. Gland Surg 2017; 6:S30-S37. [PMID: 29322020 DOI: 10.21037/gs.2017.07.10] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Identification of the parathyroid glands (PGs) during thyroid surgery may prevent their inadvertent surgical removal and prevent postoperative hypoparathyroidism. However, identification of the PGs does not guarantee their function, and their vascular supply needs to be preserved as well. The recent introduction of intraoperative indocyanine green (ICG) fluorescent angiography of the PGs during thyroid surgery allows for the appraisal of the vascular anatomy and evaluation of PG function. The use of this tool could lead to a significant reduction in the rate of postoperative hypoparathyroidism, as it allows surgeons to adapt their surgical technique for the preservation of the PGs. ICG fluorescent angiography is currently the only available real-time tool to assess the vascular blood supply of each individual PG intraoperatively and can thus assist surgeons in their decision-making. Herein, we review the relevant literature.
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Affiliation(s)
| | - Jordi Vidal Fortuny
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Frederic Triponez
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
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Mazotas IG, Wang TS. The role and timing of parathyroid hormone determination after total thyroidectomy. Gland Surg 2017; 6:S38-S48. [PMID: 29322021 DOI: 10.21037/gs.2017.09.06] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Postoperative hypocalcemia is a common complication of total thyroidectomy resulting from manipulation, resection, or devascularization of the parathyroid glands. Parathyroid hormone (PTH) levels assessed in the perioperative period have been used to predict development of hypocalcemia. Articles examining the role of PTH measurement in the perioperative period following total or completion thyroidectomy are reviewed. Focus is placed on the timing of PTH measurement and the ability to predict which patients will develop hypocalcemia requiring supplementation. Postoperative PTH determination is highly accurate in predicting the development of hypocalcemia. Studies have examined PTH levels drawn at differing time points, ranging from intraoperatively until postoperative day 1 (POD1) with similar accuracy. This data is used to guide postoperative selective calcium and calcitriol supplementation in patients at highest risk for hypocalcemia. When evaluated within the first 4 hours postoperatively, predictive accuracy is maintained but can allow for earlier discharge for those patients at lower risk. Alternatively, some authors argue for routine supplementation, which can reduce the rate of postoperative hypocalcemia but increases the rate of unnecessary supplementation and potential risks associated with hypercalcemia. PTH determination at four hours after total thyroidectomy is an accurate predictor of hypocalcemia and can guide selective calcium supplementation for those at high risk, as well as facilitate a safe earlier hospital discharge for those at low risk of developing postoperative hypocalcemia.
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Affiliation(s)
- Ioanna G Mazotas
- Section of Endocrine Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tracy S Wang
- Section of Endocrine Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Cinamon U, Gavish D, Ovnat Tamir S, Goldfarb A, Ezri T. Effect of general anesthesia and intubation on parathyroid levels in normal patients and those with hyperparathyroidism. Head Neck 2017; 40:555-560. [PMID: 29130559 DOI: 10.1002/hed.25002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/26/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Induction of general anesthesia and endotracheal intubation may precipitate parathyroid hormone (PTH) elevation in patients with primary hyperparathyroidism (HPT). The purposes of this study were to revisit this observation and to study its impact in healthy patients. METHODS Patients with primary HPT who underwent parathyroidectomy were retrospectively studied. The PTH was sampled and compared: before, immediately after general anesthesia and endotracheal intubation, and 15 minutes after parathyroidectomy. Healthy adults who underwent elective operations were prospectively studied. The PTH was sampled before general anesthesia and endotracheal intubation, immediately after, and 15 minutes later. RESULTS Thirty-one patients, aged 28-89 years (mean 60.1 ± 13 years), were retrospectively studied. The PTH was significantly elevated after general anesthesia and endotracheal intubation (P = .014). Fifty patients, aged 21-86 years (mean 54 ± 15 years), were prospectively studied. The PTH elevation after general anesthesia and endotracheal intubation was not significant. CONCLUSION General anesthesia and endotracheal intubation causes an immediate, steep, and significant PTH elevation in patients with primary HPT but only a minor change in healthy adults. The difference may be attributed to an impaired adrenergic response in patients with primary HPT.
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Affiliation(s)
- Udi Cinamon
- Department of Otolaryngology, Head and Neck Surgery, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Doron Gavish
- Department of Anesthesiology, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Sharon Ovnat Tamir
- Department of Otolaryngology, Head and Neck Surgery, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Abraham Goldfarb
- Department of Otolaryngology, Head and Neck Surgery, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel
| | - Tiberiu Ezri
- Department of Anesthesiology, Edith Wolfson Medical Center, Tel-Aviv University Sackler School of Medicine, Holon, Israel.,Outcomes Research Consortium, Cleveland, Ohio
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Castro A, del Rio L, Gavilan J. Stratifying the Risk of Developing Clinical Hypocalcemia after Thyroidectomy with Parathyroid Hormone. Otolaryngol Head Neck Surg 2017; 158:76-82. [DOI: 10.1177/0194599817730334] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective To identify the risk of clinical hypocalcemia in the first hours after thyroidectomy. Study Design Prospective observational study. Setting Single-institution tertiary hospital in Madrid, Spain. Subjects and Methods A total of 123 patients who underwent total or completion thyroidectomy between June 2010 and March 2012 were included. Pre- and postoperative intact parathyroid hormone (iPTH) levels were obtained. Patients remain hospitalized a minimum of 48 hours until blood calcium stabilized. Calcium and/or vitamin D supplements were prescribed only when signs or symptoms of hypocalcemia developed. Receiver operating characteristic curve analysis was employed to evaluate the postoperative iPTH level and the pre- to postoperative decrease in iPTH levels. Two cutoff values were determined to stratify the risk of developing clinical hypocalcemia into 3 groups. Results The areas under the receiver operating characteristic curve were 0.991 for the postoperative iPTH and 0.998 for the decrease in iPTH. An iPTH decrease of 80% had 100% sensitivity to detect patients who developed clinical hypocalcemia, while a postoperative iPTH <3 pg/mL had 100% specificity. Thus, patients with an iPTH decrease ≤80% are at a very low risk of clinical hypocalcemia, and patients with a postoperative iPTH <3 pg/mL are at a very high risk. Patients with an iPTH decrease >80% and a postoperative iPTH ≥3 pg/mL are at intermediate risk. No significant correlation was found between the time when the sample was obtained and iPTH values. Conclusion This study stablishes a very accurate test to stratify the risk of clinical postthyroidectomy hypocalcemia based on pre- and postoperative iPTH levels.
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Affiliation(s)
- Alejandro Castro
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
| | - Laura del Rio
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
| | - Javier Gavilan
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
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Cannizzaro MA, Lo Bianco S, Picardo MC, Provenzano D, Buffone A. How to avoid and to manage post-operative complications in thyroid surgery. Updates Surg 2017. [DOI: 10.1007/s13304-017-0475-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Kul F, Kirdak T, Sarkut P, Ocakoglu G, Korun N. Can Parathormon Levels after Ipsilateral Lobectomy Predict Postoperative Hypocalcemia in Patients Undergoing Total Thyroidectomy? Am Surg 2017. [DOI: 10.1177/000313481708300433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to investigate the relationship between the serum parathormone (PTH) levels measured after completion of hemithyroidectomy on the first side during total thyroidectomy and the postoperative hypocalcemia. The patients were divided into two groups, as those who demonstrated a decrease in PTH levels measured after completion of hemithyroidectomy of the first side (Group 1, n = 43) and those who did not demonstrate a decrease in PTH levels (Group 2, n = 24). The serum PTH levels were measured just before the incision (PTHi), when the hemithyroidectomy stage had been completed (PTHht), at the end of the operation (PTHtt), and at the postoperative 24th hour (PTH24hr). The serum total calcium (Ca21) levels were also measured. The median percentage differences in PTHtt levels based on basal PTHi levels of Groups 1 and 2 were -60.6 and -15.7 per cent, respectively, P = 0.001. The frequency of postoperative biochemical hypocalcemia was higher in Group 1, P < 0.05. It was determined that a 10 per cent or higher decrease in PTHht levels in Group 1 could predict biochemical hypocalcemia at the postoperative 24th hour. In conclusions, postoperative hypocalcemia is seen more frequent in patients with a decrease of PTHht during total thyroidectomy. A decrease of 10 per cent in PTHht levels measured after ipsilateral lobectomy and a 62 per cent or higher decrease in PTHtt levels measured in the end of the total thyroidectomy could be helpful for prediction of postoperative hypocalcemia in these patients.
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Affiliation(s)
| | | | | | - Gokhan Ocakoglu
- Biostatistics, Faculty of Medicine, Uludag University, Bursa, Turkey
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The Association of Discolored Parathyroid Glands and Hypoparathyroidism Following Total Thyroidectomy. World J Surg 2017; 40:1611-7. [PMID: 26908241 DOI: 10.1007/s00268-016-3462-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND It remains uncertain whether a parathyroid gland (PG) that appears darkened or severely bruised but still has an attached vascular pedicle should be left in situ or taken out and auto-transplanted following total thyroidectomy. Our study aimed to examine the impact of discolored PGs (DPGs) on short- and long-term hypoparathyroidism. METHODS One hundred and three patients who underwent total thyroidectomy with 4 clearly identified PGs were analyzed. Location (superior/inferior) and color of each PG were recorded. Patients without DPG were grouped into I while those with 1-2 DPGs and ≥3 DPGs were grouped into II and III, respectively. Transient hypoparathyroidism meant adjusted Ca <2.00 mol/L 24 h after surgery and/or need for supplements. Protracted hypoparathyroidism meant a subnormal PTH at 4-6 weeks and/or supplements >6 weeks. Permanent hypoparathyroidism meant supplements ≥1 year. RESULTS Relative to I, group III had greater adjusted Ca drop at postoperative 1-h (p = 0.012), 24-h (p < 0.001) and lower day-1 PTH (p = 0.015). Having ≥3 DPGs (OR 14.00, 95 % CI 1.575-124.474, p = 0.018) was an independent factor of transient hypoparathyroidism. However, permanent hypoparathyroidism rate was higher than in group I than II (p = 0.019). Eight patients (25.8 %) in group I had undetectable day-1 PTH, while none in group III had undetectable day-1 PTH. Graves' disease/toxic goiter (OR 15.166, 95 % CI 2.594-88.661, p = 0.003) and excised gland weight (OR 1.028, 95 % CI 1.010-1.046, p = 0.003) were independent factors of ≥3 DPGs. CONCLUSIONS PG discoloration is associated with transient hypoparathyroidism while normal colored PG with seemingly adequate blood supply does not always imply functionally normal gland. These findings highlights the need for a real-time intraoperative method to assess PG viability.
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Neagoe RM, Cvasciuc IT, Muresan M, Sala DT. INCIDENTAL PARATHYROIDECTOMY DURING THYROID SURGERY - RISK, PREVENTION AND CONTROVERSIES; AN EVIDENCE-BASED REVIEW. ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:467-475. [PMID: 31149218 DOI: 10.4183/aeb.2017.467] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Postoperative hypocalcemia after thyroid surgery has a high prevalence ( 16-55% in different series). Incidental parathyroidectomy (IP) is a less discussed complication of thyroidectomy with consequences not properly defined. The aim of our study was to find incidence, risk factors and how to prevent IP. Methods Extensive search of English literature publications via PubMed was performed and 73 papers from 1980 to 2017 were analysed using the GRADE system/classification, quality of evidence was classified as "strong" when the result is highly unlikely to change existing recommendation and "weak" when opposite. Results Incidence of IP is 3.7-24.9%, while prevalence of permanent hypoparathyroidism is less frequent 6-12%. Direct relation between IP and hypoparathyroidism/hypocalcemia remains controversial. Female patients, ectopic parathyroids, small thyroids, Graves', malignancy, redo surgeries and total thyroidectomy favour IP. Routine visualization of parathyroids, new hemostatic devices, magnifying instruments and fluorescence can prevent incidental removal of parathyroids. Incidence of IP during videoassisted or robotic thyroidectomies was similar to open procedures. High volume, experienced and younger surgeons have lower complication rates (including hypoparathyroidism). Conclusions Incidental parathyroidectomy is more frequent than we might have expected. It should be avoided and parathyroid glands should be kept in situ. Majority of studies are retrospective (low degree of evidence according to previous mentioned GRADE classification) and further meta-analysis or randomized control studies are welcome in order to define the impact of incidental removal of parathyroids on postoperative outcome.
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Affiliation(s)
- R M Neagoe
- University of Medicine and Pharmacy, Second Department of Surgery, Targu Mures, Romania
| | - I T Cvasciuc
- Leeds Teaching Hospitals, Dept. of Endocrine Surgery, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - M Muresan
- University of Medicine and Pharmacy, General Surgery, Targu Mures, Romania
| | - D T Sala
- Emergency Mures County Hospital, Second Department of Surgery, Targu Mures, Romania
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Arer IM, Kus M, Akkapulu N, Aytac HO, Yabanoglu H, Caliskan K, Tarim MA. Prophylactic oral calcium supplementation therapy to prevent early post thyroidectomy hypocalcemia and evaluation of postoperative parathyroid hormone levels to detect hypocalcemia: A prospective randomized study. Int J Surg 2016; 38:9-14. [PMID: 28039060 DOI: 10.1016/j.ijsu.2016.12.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/08/2016] [Accepted: 12/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative hypocalcemia is the most common complication after total thyroidectomy. Postoperative parathyroid hormone (PTH) measurement is one of the methods to detect or prevent postoperative hypocalcemia. Prophylactic oral calcium supplementation is another method to prevent early postoperative hypocalcemia. The aim of this study is to detect the accurate timing of PTH and evaluate efficacy of routine oral calcium supplementation for postoperative hypocalcemia. METHODS A total of 106 patients were performed total thyroidectomy. Rotuine oral calcium supplementation was given to group 1 and no treatment to group 2 according to randomization. Serum calcium and PTH level of patients in group 2 at postoperative 6, 12 and 24 h and patients in both groups at postoperative day 7 were evaluated. Patients were compared according to age, sex, operation findings, serum calcium and PTH levels and symptomatic hypocalcemia. RESULTS Half of the patients (50%) were in group 1. Most of the patients were female (83%). The most common etiology of thyroid disease was multinodular goiter (64.1%). Oral calcium supplementation was given to 18 (33.9%) patients in group 2. Symptomatic hypocalcemia for group 1 and 2 was found to be 1.9 and 33.9% respectively (p < 0.05). No statistical difference can be observed regarding the timing of serum biomarkers. CONCLUSION Serum PTH levels at postoperative 12 and 24 h can predict early post-thyroidectomy hypocalcemia. Prophylactic oral calcium supplementation therapy can prevent early post-thyroidectomy hypocalcemia with advantages of being cost effective and safe.
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Affiliation(s)
- Ilker Murat Arer
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Murat Kus
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Nezih Akkapulu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Huseyin Ozgur Aytac
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Hakan Yabanoglu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Kenan Caliskan
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Mehmet Akin Tarim
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
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Lang BHH, Wong CKH, Hung HT, Wong KP, Mak KL, Au KB. Indocyanine green fluorescence angiography for quantitative evaluation of in situ parathyroid gland perfusion and function after total thyroidectomy. Surgery 2016; 161:87-95. [PMID: 27839936 DOI: 10.1016/j.surg.2016.03.037] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/25/2016] [Accepted: 03/28/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Because the fluorescent light intensity on an indocyanine green fluorescence angiography reflects the blood perfusion within a focused area, the fluorescent light intensity in the remaining in situ parathyroid glands may predict postoperative hypocalcemia risk after total thyroidectomy. METHODS Seventy patients underwent intraoperative indocyanine green fluorescence angiography after total thyroidectomy. Any parathyroid glands with a vascular pedicle was left in situ while any parathyroid glands without pedicle or inadvertently removed was autotransplanted. After total thyroidectomy, an intravenous 2.5 mg indocyanine green fluorescence angiography was given and real-time fluorescent images of the thyroid bed were recorded using the SPY imaging system (Novadaq, Ontario, Canada). The fluorescent light intensity of each indocyanine green fluorescence angiography as well as the average and greatest fluorescent light intensity in each patient were calculated. Postoperative hypocalcemia was defined as adjusted calcium <2.00 mmol/L within 24 hours. RESULTS The fluorescent light intensity between discolored and normal-looking indocyanine green fluorescence angiographies was similar (P = .479). No patients with a greatest fluorescent light intensity >150% developed postoperative hypocalcemia while 9 (81.8%) patients with a greatest fluorescent light intensity ≤150% did. Similarly, no patients with an average fluorescent light intensity >109% developed PH while 9 (30%) with an average fluorescent light intensity ≤109% did. The greatest fluorescent light intensity was more predictive than day-0 postoperative hypocalcemia (P = .027) and % PTH drop day-0 to 1 (P < .001). CONCLUSION Indocyanine green fluorescence angiography is a promising operative adjunct in determining residual parathyroid glands function and predicting postoperative hypocalcemia risk after total thyroidectomy.
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Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Carlos K H Wong
- Department of Family Medicine and Primary Care, University of Hong Kong, 3/F Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong SAR, China
| | - Hing Tsun Hung
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kai Pun Wong
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ka Lun Mak
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kin Bun Au
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Famà F, Cicciù M, Polito F, Cascio A, Gioffré-Florio M, Piquard A, Saint-Marc O, Sindoni A. Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution. World J Surg 2016; 41:457-463. [PMID: 27734084 DOI: 10.1007/s00268-016-3754-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision. METHODS In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation. RESULTS We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001). CONCLUSIONS We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.
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Affiliation(s)
- Fausto Famà
- Department of Human Pathology, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy. .,Complesso MITO, Residenza Ginestre F/2, 98151, Messina, Italy.
| | - Marco Cicciù
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Francesca Polito
- Department of Clinical and Experimental Medicine, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Antonio Cascio
- Department of Human Pathology, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Maria Gioffré-Florio
- Department of Human Pathology, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Arnaud Piquard
- Department of General, Endocrine and Thoracic Surgery, Regional Hospital of Orleans, 14, Avenue de l'Hopital, 45067, Orléans (cedex 2), France
| | - Olivier Saint-Marc
- Department of General, Endocrine and Thoracic Surgery, Regional Hospital of Orleans, 14, Avenue de l'Hopital, 45067, Orléans (cedex 2), France
| | - Alessandro Sindoni
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
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