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Neagoe OC, Ionică M. Improvement in Central Neck Dissection Quality in Thyroid Cancer by Use of Tissue Autofluorescence. Cancers (Basel) 2024; 16:258. [PMID: 38254749 PMCID: PMC10813481 DOI: 10.3390/cancers16020258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Risk of postoperative transient or permanent hypoparathyroidism represents one of the most common complications following total thyroidectomy. This risk increases if a cervical lymphadenectomy procedure must also be performed, as is usually the case in thyroid carcinoma patients. Parathyroid autofluorescence (AF) is a non-invasive method that aids intraoperative identification of parathyroid glands. METHODS In this prospective study, 189 patients with papillary thyroid cancer who underwent total thyroidectomy with central neck dissection were included. Patients were randomly allocated to one of two groups: NAF (no AF, surgery was performed without AF) and the AF group (surgery was performed with AF-Fluobeam LX system, Fluoptics, Grenoble, France). RESULTS The number of excised lymph nodes was significantly higher in the AF compared to the NAF group, with mean values of 21.3 ± 4.8 and 9.2 ± 4.1, respectively. Furthermore, a significantly higher number of metastatic lymph nodes were observed in the AF group. Transient hypocalcemia recorded significantly lower rates in the AF group with 4.9% compared to 16.8% in the NAF group. CONCLUSIONS AF use during total thyroidectomy with central neck dissection for papillary thyroid carcinoma patients, decreased the rate of iatrogenic parathyroid gland lesions, and increased the rate of lymphatic clearance.
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Affiliation(s)
- Octavian Constantin Neagoe
- Second Clinic of General Surgery and Surgical Oncology, Emergency Clinical Municipal Hospital Timișoara, 300079 Timișoara, Romania;
- Second Discipline of Surgical Semiology, First Department of Surgery, ”Victor Babeș” University of Medicine, 300041 Timișoara, Romania
| | - Mihaela Ionică
- Second Clinic of General Surgery and Surgical Oncology, Emergency Clinical Municipal Hospital Timișoara, 300079 Timișoara, Romania;
- Second Discipline of Surgical Semiology, First Department of Surgery, ”Victor Babeș” University of Medicine, 300041 Timișoara, Romania
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Moon H, Seok JW, Kim K, Kim HY, Park MK, Kim IJ, Pak K, Suh S. Effectiveness of prophylactic calcium and vitamin D supplementation for preventing post-thyroidectomy hypocalcemia: a meta-analysis. KOSIN MEDICAL JOURNAL 2022. [DOI: 10.7180/kmj.22.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Postsurgical hypocalcemia is the most common and troublesome consequence of thyroidectomy. We investigated the potential role of routine calcium or vitamin D supplementation in preventing postsurgical hypocalcemia. Methods: We searched MEDLINE and Embase for English-language publications using the keywords “calcium,” “vitamin D,” and “thyroid cancer.” The primary outcome was any postoperative hypocalcemia, and the secondary outcome was symptomatic hypocalcemia. Results: Four studies that included 381 patients were eligible for this meta-analysis. A random-effects model showed no significant difference in the occurrence of hypocalcemia between calcium/vitamin D treatment and placebo/no treatment. However, the occurrence of symptomatic hypocalcemia was lower in patients with calcium/vitamin D treatment. In the combined results, preoperative calcium and vitamin D supplementation were associated with a reduced incidence of symptomatic hypocalcemia. Conclusions: Our findings support the use of preoperative calcium and vitamin D supplementation in conjunction with routine postsurgical supplementation for patients after total thyroidectomy.
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Fujiogi M, Konishi T, Michihata N, Hashimoto Y, Matsu H, Ishimaru T, Fushimi K, Yasunaga H, Fujishiro J. Perioperative outcomes of thyroid cancer surgery in children and adults: a nationwide inpatient database study in Japan. ANNALS OF CLINICAL EPIDEMIOLOGY 2022; 5:20-29. [PMID: 38505377 PMCID: PMC10760474 DOI: 10.37737/ace.23004] [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] [Received: 05/27/2022] [Accepted: 09/06/2022] [Indexed: 03/21/2024]
Abstract
BACKGROUND Little is known about perioperative outcomes after pediatric thyroidectomy. This study was performed to compare perioperative outcomes between children and adults undergoing thyroid cancer surgery using a nationwide inpatient database in Japan. METHODS Using the Japanese Diagnosis Procedure Combination database, we identified patients aged 0 to 40 years with thyroid cancer who underwent thyroidectomy from July 2010 to March 2020. To compare the occurrence of in-hospital morbidities including local complications (e.g., recurrent laryngeal nerve paralysis, postoperative bleeding), duration of anesthesia, postoperative length of stay, and total hospitalization costs between children (0-18 years) and adults (19-40 years), we used multivariable logistic regression analysis for the occurrence of in-hospital morbidities and linear regression for other outcomes. RESULTS For 16,016 eligible patients (666 children vs. 15,350 adults), no significant differences between the two groups were found in any in-hospital morbidity (5.4% vs. 5.9%; adjusted odds ratio [OR], 0.80; 95% confidence interval [CI], 0.57-1.14; P = 0.23), local complications (5.0% vs. 5.5%; OR, 0.80; 95% CI, 0.55-1.15; P = 0.22), recurrent laryngeal nerve paralysis (2.1% vs. 2.4%; OR, 0.78; 95% CI, 0.45-1.35; P = 0.37), or postoperative bleeding (1.7% vs. 1.4%; OR, 0.99; 95% CI, 0.53-1.87; P = 0.98). Children showed a longer duration of anesthesia (difference, 20 minutes; 95% CI, 13-27; P < 0.001) and higher total costs (difference, 445 US dollars; 95% CI, 239-651; P < 0.001) than adults. CONCLUSION This large nationwide cohort study showed no significant difference in perioperative complications between children and adults undergoing thyroid cancer surgery.
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Affiliation(s)
- Michimasa Fujiogi
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Matsu
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Saitama Children’s Medical Center
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo
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Unexpected Benefits in Single Institution Experience With Successful Implementation of a Standardized Perioperative Protocol in Pediatric Thyroidectomy. Pediatr Qual Saf 2022; 7:e568. [PMID: 35720874 PMCID: PMC9197358 DOI: 10.1097/pq9.0000000000000568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 04/13/2022] [Indexed: 11/25/2022] Open
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Li Z, Fei Y, Li Z, Wei T, Zhu J, Su A. Outcome of parathyroid function after total thyroidectomy when calcium supplementation is administered routinely versus exclusively to symptomatic patients: A prospective randomized clinical trial. Endocrine 2022; 75:583-592. [PMID: 34748169 DOI: 10.1007/s12020-021-02921-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/19/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Current guidelines for calcium supplementation for parathyroid function recovery after thyroidectomy are based on low-quality evidence. The present trial compared the effects of oral calcium and vitamin D supplementation on the recovery of parathyroid function when administered routinely or exclusively to symptomatic patients. METHODS This prospective, randomized, open-label clinical trial analyzed 203 patients who underwent total thyroidectomy and developed hypoparathyroidism on postoperative day 1 (POD1) with median age of 41 years and proportion of women of 77.8%. Participants were randomized to group A (calcium and vitamin D supplementation administered only to symptomatic patients) and group B (routine supplementation). The primary outcome was the incidence of protracted hypoparathyroidism in the two groups. Secondary outcomes included risk factors for postoperative protracted hypoparathyroidism and the incidence of symptomatic hypocalcemia. RESULTS The incidence of protracted hypoparathyroidism was not significantly different between group A and group B (11 of 99 vs. 17 of 104, P = 0.280). Parathyroid hormone (PTH) in group B exhibited a better recovery tendency. The incidence of postoperative symptomatic hypocalcemia in group B was significantly lower than group A (26.92% vs. 42.42%, P = 0.020). Independent factors predicting protracted hypoparathyroidism included sex, preoperative serum calcium, and POD1 PTH. CONCLUSION Calcium and vitamin D supplementation administered exclusively to symptomatic patients achieved the same effect on protracted hypoparathyroidism as routine supplementation. However, routine supplementation significantly reduced postoperative hypocalcemia. Extra attention is necessary in female patients with high preoperative serum calcium and patients with low POD1 PTH. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR), ChiCTR1900022194. Registered March 30, 2019.
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Affiliation(s)
- Zhe Li
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Laboratory of thyroid and parathyroid disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuan Fei
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Laboratory of thyroid and parathyroid disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhihui Li
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Laboratory of thyroid and parathyroid disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Wei
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Laboratory of thyroid and parathyroid disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jingqiang Zhu
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Laboratory of thyroid and parathyroid disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Anping Su
- Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
- Laboratory of thyroid and parathyroid disease, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Giant Parathyroid Adenoma-Associated Fracture, Not All Lytic Bone Lesions are Cancer: A Case-Based Review. Case Rep Med 2022; 2022:3969542. [PMID: 35132322 PMCID: PMC8817849 DOI: 10.1155/2022/3969542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/11/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction. Due to the early diagnosis of primary hyperparathyroidism the musculoskeletal manifestations of this disease are becoming less frequent. When this disease manifests secondary to a giant adenoma, it presents with more aggressive symptoms and can have important repercussions such as the hungry bone syndrome after parathyroidectomy. There are few reported cases of hyperparathyroidism secondary to a giant adenoma in the literature, as the presence of a brown tumor is often misinterpreted as a metastatic lesion from an unknown primary tumor. Methods. We describe a case and performed a literature review to identify all case reports. A literature search was carried out on PubMed/MEDLINE and EMBASE bibliographic databases. All available studies from May 2009 to May 2021 were included. Data were tabulated, and outcomes were cumulatively analyzed. Results. Twenty-four cases of primary hyperparathyroidism due to giant adenoma have been described; the majority were women, with a mean age of 52 years. They presented with heterogeneous symptoms such as palpable nodules (45%), bone pain (33%), brown tumor (12.5%), asymptomatic (12.5%), metabolic profile with a mean calcemia of 13.8 mg/dL, PTH 1109 ng/L, and mean tumor weight of 47.24 g. Conclusion. Primary hyperparathyroidism due to giant adenoma increases the risk of developing potentially serious postoperative complications such as hungry bone syndrome. This implies the need of implementing preventive measures comprising administration of intravenous zoledronic acid and early supplementation of oral calcium to prevent complications after resection.
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Konishi T, Fujiogi M, Michihata N, Niwa T, Morita K, Matsui H, Fushimi K, Tanabe M, Seto Y, Yasunaga H. Impact of body mass index on short-term outcomes after differentiated thyroid cancer surgery: a nationwide inpatient database study in Japan. Eur Thyroid J 2022; 11:ETJ-21-0081. [PMID: 34981742 PMCID: PMC9142812 DOI: 10.1530/etj-21-0081] [Citation(s) in RCA: 2] [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: 09/22/2021] [Accepted: 09/30/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Recent studies have shown worse post-operative outcomes following several surgeries in underweight or obese patients. However, the association between body mass index (BMI) and short-term outcomes following thyroid cancer surgery remains unclear because of the small number of patients, deficits in background data known as risk factors (e.g. cancer stage, operative procedure, intraoperative device use and hospital volume) and categorisation of BMI. METHODS We identified patients who underwent thyroidectomy for differentiated thyroid cancer from July 2010 to March 2017 using a Japanese nationwide inpatient database. We used restricted cubic spline (RCS) analyses to investigate potential non-linear associations between BMI (without categorisation) and outcomes: post-operative complications (local and general), duration of anaesthesia, post-operative length of hospital stay and hospitalisation costs. The analyses were adjusted for demographic and clinical backgrounds including the above-stated factors. We also performed multivariable regression analyses for the outcomes with categorisation of BMI. RESULTS Among 59,671 eligible patients, the median BMI was 22.9 kg/m2 (interquartile range (IQR), 20.7-25.6 kg/m2). In total, 3860 patients (6.5%) had local complications and 787 patients (1.3%) had general complications. Although there were no significant associations with local complications, such as bleeding, recurrent laryngeal nerve paralysis and surgical site infection, the occurrence of general complications was significantly associated with higher BMI. BMI showed a linear association with the duration of anaesthesia and U-shaped associations with post-operative length of stay and hospitalisation costs. The lowest points of the U-shaped curves occurred at a BMI of approximately 24 kg/m2. The multivariate regression analyses showed consistent results with the RCS analyses. DISCUSSION/CONCLUSION Whereas RCS analyses revealed no significant associations between BMI and post-operative local complications, obesity was significantly associated with the occurrence of general complications. The linear association between BMI and duration of anaesthesia corresponds to previous studies. Although post-operative length of stay and total hospitalisation costs demonstrated U-shaped associations, the slight differences would not be clinically important. Even if surgeons must pay attention to general complications in obese patients undergoing thyroid cancer surgery as well as other surgeries, underweight and overweight patients can undergo thyroidectomy as safely as patients with normal BMI.
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Affiliation(s)
- Takaaki Konishi
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Correspondence should be addressed to T Konishi:
| | - Michimasa Fujiogi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takayoshi Niwa
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Department of Health Services, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Díaz-Granados Goenaga E, Granados Calixto Á, Zambrano JDF, Ulloa Gordon FM, Salgar Sarmiento JC. Trastornos posoperatorios del metabolismo del calcio postiroidectomía. REPERTORIO DE MEDICINA Y CIRUGÍA 2021. [DOI: 10.31260/repertmedcir.01217372.1078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introducción: revisión narrativa que revela como la tiroidectomía ha aumentado en los últimos años y con ella sus complicaciones: la hipocalcemia y el hipoparatiroidismo. Métodos: los motores de búsqueda utilizados fueron PubMed, Clinical Key, Embase, Cochrane y Lilacs, se incluyeron referencias en español e inglés, publicadas entre 2016 y 2020. Los artículos seleccionados se revisaron utilizando CONSORT, STROBE o PRISMA, según el caso. Resultados: fueron seleccionados 35 artículos que tenían relación directa con el tema, entre ellos: metanálisis, revisiones sistemáticas, estudios prospectivos y observacionales, revisiones narrativas y consensos de expertos, procedentes de los cinco continentes. La hipocalcemia y el hipotiroidismo en sus dos formas se relacionan con la afectación de la vascularización de las glándulas paratiroides o su exérecis accidental, existiendo factores predisponentes propios del paciente, derivados de la técnica quirúrgica o la característica patológica de la lesión en el tiroides. Como estrategias de prevención disponemos de herramientas ópticas para definir en el perioperatorio la disposición de las paratiroides; además existe la posibilidad de autotrasplantarlas al identificarlas en la pieza anatómica. El mejor marcador del estado metabólico del calcio es la PTHi. Conclusiones: la preservación de las paratiroides y de su irrigación es la mejor estrategia para prevenir los trastornos posoperatorios del calcio.
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Sessa L, De Crea C, Zotta F, Pia Cerviere M, Gallucci P, Pennestri' F, Princi P, Revelli L, Arcuri G, Bellantone R, Raffaelli M. Post-thyroidectomy hypocalcemia: Is a routine preferable over a selective supplementation? Am J Surg 2021; 223:1126-1131. [PMID: 34711410 DOI: 10.1016/j.amjsurg.2021.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/09/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Comparative studies among protocols for the management of post-total thyroidectomy (TT) hypocalcemia are lacking. We compared the effectiveness of PTH-driven selective supplementation (PD-SS) and routine calcium and calcitriol supplementation with preoperative calcitriol administration in preventing symptomatic hypocalcemia (SH) and readmission. METHODS Three-hundred consecutive patients undergoing TT were assigned to 3 groups: the PD-SS group, the high-dose routine supplementation (HD-RS) group and the low-dose routine supplementation (LD-RS) group. RESULTS Mean post-operative stay was shorter in HD-RS patients when compared to PD-SS and LD-RS (p < 0.001). Significantly more patients in the PD-SS group experienced SH (p = 0.042). The rate of post-operative hypocalcemia was not significantly different among the groups (p = 0.063). No readmission for SH or hypercalcemia occurred. CONCLUSIONS HD-RS emerged as the most effective treatment to prevent SH, without increasing the risk of readmission for calcitriol-related hypercalcemia. Basing on the present results, HD-RS should be recommended as the preferable protocol.
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Affiliation(s)
- Luca Sessa
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carmela De Crea
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale - Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Francesca Zotta
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Milena Pia Cerviere
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pierpaolo Gallucci
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Pennestri'
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pietro Princi
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Revelli
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Arcuri
- UOC Tecnologie Sanitarie, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Bellantone
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Raffaelli
- UOC of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale - Università Cattolica del Sacro Cuore, Rome, Italy
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Use of pre-operative calcium and vitamin D supplementation to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy: a systematic review. The Journal of Laryngology & Otology 2021; 135:568-573. [PMID: 34120662 DOI: 10.1017/s0022215121001523] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This systematic review aimed to establish the evidence behind the use of pre-operative calcium, vitamin D or both calcium and vitamin D to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy. METHOD This review included prospective clinical trials on adult human patients that were published in English and which studied the effects of pre-operative supplementation with calcium, vitamin D or both calcium and vitamin D on the rate of post-operative hypocalcaemia following total thyroidectomy. RESULTS Seven out of the nine trials included reported statistically significantly reduced rates of post-operative laboratory hypocalcaemia (absolute risk reduction, 13-59 per cent) and symptomatic hypocalcaemia (absolute reduction, 11-40 per cent) following pre-operative supplementation. CONCLUSION Pre-operative treatment with calcium, vitamin D or both calcium and vitamin D reduces the risk of post-operative hypocalcaemia and should be considered in patients undergoing total thyroidectomy.
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Shonka DC, Maxwell AK, Petroni GR, Jameson MJ. Phase II randomized study of preoperative calcitriol to prevent hypocalcemia following thyroidectomy. Head Neck 2021; 43:2935-2945. [PMID: 34076308 DOI: 10.1002/hed.26775] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/07/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND A prospective, stratified, randomized, double-blind, placebo-controlled study was conducted to observe the impact of preoperative calcitriol supplementation on serum calcium levels following total thyroidectomy. METHODS Subjects were randomized 1:1 to receive 1 μg calcitriol or placebo for 1 week preceding thyroidectomy. The primary outcome measure was change in serum calcium from baseline to 18 h post-thyroidectomy. Subjects were also assessed for incidence of symptomatic hypocalcemia, length of stay, readmission for hypocalcemia, and intravenous calcium supplementation. RESULTS Forty-seven patients underwent thyroidectomy; 23 received preoperative calcitriol supplementation, and 24 received placebo. Repeated measures regression demonstrated no difference in postoperative serum calcium over time (p = 0.22). There were no occurrences of hypocalcemia, intravenous calcium supplementation, or readmission in either group. No difference was observed in length of stay (p = 0.38). One patient in the calcitriol group developed Grade 3 hypercalcemia. CONCLUSIONS Preoperative calcitriol supplementation had no impact on postoperative serum calcium levels compared to placebo.
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Affiliation(s)
- David C Shonka
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Anne K Maxwell
- University of Virginia School of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Gina R Petroni
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark J Jameson
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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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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Festa F, Costanzo D, Cestino L, Festa V, Cavuoti G, Ciccarelli E, Vella G, Quaglino F. Combined ionized calcium and PTH evaluation in the management of post-thyroidectomy hypocalcemia. MINERVA CHIR 2020; 75:216-224. [PMID: 32456391 DOI: 10.23736/s0026-4733.20.08257-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of our study was to investigate the postoperative course of calcium and parathyroid hormone (PTH) levels after total thyroidectomy to define a proper and low cost protocol. METHODS We studied 144 patients who underwent total thyroidectomy between 2007 and 2010. Ionized calcium was determined preoperatively and on day 1 (POD1), day 2 (POD2) and day 7 (POD7) postoperatively; PTH preoperatively and on POD7. Patients with ionized calcium ≤1.11 mmol/L were considered hypocalcemic and treated only if symptoms, ≤1 mmol/L were treated in all cases. RESULTS Ionized calcium and PTH declined postoperative in all patients compared to preoperative levels (P=0.000). Ionized calcium increased on POD7 compared to POD1 and POD2 (P=0.000). All hypocalcemic untreated 30 patients returned normocalcemic on POD7. Thirty-eight hypocalcemic patients were treated but 23 (61%) safely suspended therapy on POD7. We tested PTH and ionized calcium as independent factors of prolonged hypocalcemia (that required therapy beyond 7 days) with the following results (sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy): PTH ≤11 pg/mL (80%, 100%, 100%, 96% and 97%, respectively), ionized calcium ≤1.11 mmol/L (80%, 88%, 59%, 95%, and 87%, respectively) and ionized calcium ≤1 mmol/L (28%, 100%, 100%, 87% and 88%, respectively). CONCLUSIONS Our data show that our protocol, including serum ionized calcium on 1<sup>st</sup>, 2<sup>nd</sup>, 7<sup>th</sup> days and PTH on 7<sup>th</sup> day after surgery, is safe and low cost and therefore may be useful in the post-surgical management of total thyroidectomy.
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Affiliation(s)
- Federico Festa
- Section of General Surgery, Maria Vittoria Hospital, ASL Città di Torino, Turin, Italy -
| | - Donatella Costanzo
- Section of General Surgery, Maria Vittoria Hospital, ASL Città di Torino, Turin, Italy
| | - Luca Cestino
- Section of General Surgery, Maria Vittoria Hospital, ASL Città di Torino, Turin, Italy
| | - Valentino Festa
- Section of General Surgery, Maria Vittoria Hospital, ASL Città di Torino, Turin, Italy
| | - Giuseppe Cavuoti
- Section of General Surgery, Maria Vittoria Hospital, ASL Città di Torino, Turin, Italy
| | - Enrica Ciccarelli
- Section of Endocrinology, Martini Hospital, ASL Città di Torino, Turin, Italy
| | - Gioacchino Vella
- Laboratory of Informatics, Video-Ergonomics, and Statistics (LIVES), Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Francesco Quaglino
- Section of General Surgery, Maria Vittoria Hospital, ASL Città di Torino, Turin, Italy
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Priya SR, Dravid C. Central Compartment Nodal Bulk: A Predictor of Permanent Postoperative Hypocalcaemia. Indian J Surg Oncol 2020; 11:92-100. [PMID: 32205978 PMCID: PMC7064669 DOI: 10.1007/s13193-019-01010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022] Open
Abstract
Central compartment clearance (CCC) for Papillary thyroid cancers (PTC) is one of the factors causing postoperative hypocalcaemia. We aimed to examine determinants of this major sequela. 41 patients treated for PTCs between 2014 and 2016 were studied. Surgical details, tumour and nodal characteristics, incidence of transient, temporary and permanent hypocalcaemia were noted. Central clearance was done bilaterally in 24 (58.5%) cases, ipsilaterally in 17 (41.6%). Central nodes were involved in 26 (63.4%) cases, unilaterally in 15 (36.6%), bilaterally in 11 (26.8%). Transient hypocalcaemia developed in 10 (24.4%) cases, temporary hypocalcaemia in 6 (14.6%) cases, and permanent hypocalcaemia in 2 (4.9%) cases. 17 (41%) patients were symptomatic. 9 (21.9%) patients received intravenous calcium. The only factor consistently associated with development of hypocalcaemia of all patterns, was the presence of matted central compartment nodes (p = 0.021). Matted nodes also related to a longer length of stay (p = 0.04) and requirement of intravenous calcium (p = 0.000). Extent of CCC, nodal yield, nodal positivity, perinodal extension, number of parathyroids identified, gender or pT size were not significantly associated. Symptomatic patients did not necessarily become permanently hypocalcaemic (p = 0.8). Patients requiring intravenous calcium were more likely to take oral calcium after discharge (p = 0.002). Postoperative hypocalcaemia is more likely in cases with bulky involved central nodes where extensive clearance is done. In routine CCC, even if done bilaterally, preservation of parathyroid function is possible. Permanent hypocalcaemia after CCC need not be taken as inevitable.
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Affiliation(s)
- S. R. Priya
- Head Neck Unit, Delhi State Cancer Institute, Delhi, India
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Melikyan A, Menkov A. Postoperative Hypoparathyroidism: Prognosis, Prevention, and Treatment (Review). Sovrem Tekhnologii Med 2020; 12:101-108. [PMID: 34513060 PMCID: PMC8353683 DOI: 10.17691/stm2020.12.2.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 12/19/2022] Open
Abstract
This review summarizes the results of studies concerning the problem of post-surgical hypoparathyroidism, a common complication of thyroid gland surgery, decreasing the quality of life in patients and, in some cases, leading to disability. A search for publications was carried out in electronic databases Web of Science, Scopus, Academic Search Complete (EBSCO), eLIBRARY, using keywords. The search depth was 7-10 years. Prevalence of post-surgical hypoparathyroidism was evaluated, the pathogenetic causes of the disease development, its clinical forms, methods of diagnosis and treatment were studied. It has been found that there is no single algorithm for analyzing the prognostic factors for the development of this pathological condition. It is emphasized that drug therapy of post-surgical hypoparathyroidism has a number of adverse effects. Therefore, the issues of prevention and surgical correction are of particular relevance. However, controversial opinions of contemporary authors about their clinical effectiveness determine the scientific and practical significance of further research on these issues.
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Affiliation(s)
- A.A. Melikyan
- Surgeon, Nizhny Novgorod Regional Clinical Hospital named after N.A. Semashko, 190 Rodionova St., Nizhny Novgorod, 603126, Russia
| | - A.V. Menkov
- Professor, Department of General, Operative Surgery and Topographic Anatomy named after A.I. Kozhevnikov, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
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16
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Mercante G, Anelli A, Giannarelli D, Giordano D, Sinopoli I, Ferreli F, Digiesi G, Appetecchia ML, Barnabei A, Cristalli G, Conti L, Pellini R, Piazza F, Lombardi D, De Virgilio A, Spriano G. Cost-effectiveness in transient hypocalcemia post-thyroidectomy. Head Neck 2019; 41:3940-3947. [PMID: 31472003 DOI: 10.1002/hed.25934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 08/06/2019] [Accepted: 08/15/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Three different strategies to manage transient hypocalcemia after total thyroidectomy were compared to evaluate cost-effectiveness. The reliability of total serum calcium (TSCa), ionized calcium (ICa), and intact parathyroid hormone (iPTH) were investigated to achieve this goal. METHODS A multicenter, prospective randomized study was carried out with 169 patients. The strategies were "preventive" (oral calcium + vitamin D supplementation), "reactive" (therapy in hypocalcemia), and "predictive" (therapy if iPTH <10 pg/mL). RESULTS TSCa had higher accuracy in identifying patients who developed hypocalcemia-related symptoms than ICa (84.6% vs 50.0%). TSCa 24 h after surgery showed 24.8% of patients with hypocalcemia, whereas TSCa 48 h after surgery identified a further 10.6% with hypocalcemia (only in the "reactive" and "predictive" groups). iPTH showed low sensitivity as a predictor of hypocalcemia. Between the 3 groups, there was no significant difference in hospitalization time or number of symptomatic hypocalcemic patients. Interestingly, the cost-per-patient was significantly different among the groups. CONCLUSIONS None of the discussed strategies allowed for early discharge of patients without any risk of transient hypocalcemia. The "preventive" strategy was the most cost-effective, despite overtreatment.
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Affiliation(s)
- Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Andrea Anelli
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Diana Giannarelli
- Department of Biostatistics and Bioinformatics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Davide Giordano
- Otolaryngology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Ilenia Sinopoli
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Fabio Ferreli
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Giovanna Digiesi
- Clinical Pathology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maria L Appetecchia
- Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Agnese Barnabei
- Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giovanni Cristalli
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Laura Conti
- Clinical Pathology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Raul Pellini
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Fabio Piazza
- Department of Otolaryngology-Head and Neck Surgery, "Carlo Poma" Civil Hospital, Mantua, Italy
| | - Davide Lombardi
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
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de Carvalho GB, Giraldo LR, Lira RB, Macambira IBM, Tapia MA, Kohler HF, Novoa JA, Kowalski LP. Preoperative vitamin D deficiency is a risk factor for postoperative hypocalcemia in patients undergoing total thyroidectomy: retrospective cohort study. SAO PAULO MED J 2019; 137:241-247. [PMID: 31340251 PMCID: PMC9744000 DOI: 10.1590/1516-3180.2018.0336140319] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 03/14/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The relationship between preoperative vitamin D deficiency and postoperative hypocalcemia in cases of total thyroidectomy (TT) is a matter of controversy and may vary according to geographical scenarios and populations. OBJECTIVE The objective here was to evaluate whether preoperative vitamin D deficiency was associated with postoperative symptomatic hypocalcemia in a population in South America. DESIGN AND SETTING Retrospective cohort study on data from all patients undergoing total thyroidectomy, with or without central compartment lymph node dissection, from January 2014 to December 2017, at the A. C. Camargo Cancer Center. METHODS Patients with benign thyroid disease (Graves' disease, multinodular goiter or hyperthyroidism) or thyroid cancer who underwent primary total thyroidectomy with or without central compartment lymph node dissection were included. The exclusion criteria were simultaneous parathyroidectomy and conditions that could affect serum calcium levels. The data collected included patient demographics, thyroid pathology, extent of the surgical procedure and complications. Information on preoperative and postoperative calcium, parathyroid hormone (PTH) and vitamin D levels were retrieved from the medical records. RESULTS 1,347 patients were assessed and postoperative hypocalcemia was diagnosed in 284 patients (21%). The vitamin D levels were considered deficient in 243 patients (18%). Postoperative hypocalcemia was diagnosed in 357 patients (31.5%). Multivariate analysis showed that central compartment dissection and preoperative total calcium and deficient vitamin D levels were significant risk factors for postoperative hypocalcemia. CONCLUSION Deficient preoperative vitamin D levels were a significant risk factor for postoperative hypocalcemia. Preoperative oral supplementation should be considered, to minimize this risk.
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Affiliation(s)
- Genival Barbosa de Carvalho
- MD, MSc. Attending Physician of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, and Head and Neck Surgery Sector, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo (SP), Brazil.
| | - Lina Restrepo Giraldo
- MD. Master’s Student of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo (SP), Brazil.
| | - Renan Bezerra Lira
- MD, PhD. Attending Physician of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Palo (SP), Brazil.
| | - Isabela Bergh Martins Macambira
- MD. Resident of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo (SP), Brazil.
| | - Marcel Adalid Tapia
- MD. Resident of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo (SP), Brazil.
| | - Hugo Fontan Kohler
- MD. Attending Physician of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo (SP), Brazil.
| | - Joel Arévalo Novoa
- MD. Resident of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo (SP), Brazil.
| | - Luiz Paulo Kowalski
- MD, PhD. Director of Head and Neck Surgery, Department of Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo (SP), Brazil.
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Sanabria A, Rojas A, Arevalo J. Meta-analysis of routine calcium/vitamin D3 supplementation versus serum calcium level-based strategy to prevent postoperative hypocalcaemia after thyroidectomy. Br J Surg 2019; 106:1126-1137. [PMID: 31236917 DOI: 10.1002/bjs.11216] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/07/2018] [Accepted: 03/23/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim was to assess the effectiveness of routine administration of calcium +/- vitamin D3 compared with a serum calcium level-based strategy to prevent symptomatic hypocalcaemia after thyroidectomy. METHODS RCTs comparing routine supplementation of calcium +/- vitamin D3 with treatment based on serum calcium levels measured after total thyroidectomy, published between 1980 and 2017, were identified in MEDLINE, Embase, LILACS and Google Scholar databases. Risk of bias was evaluated using the Cochrane Collaboration tool. Risk differences were calculated by random-effects meta-analysis. Meta-regression and cumulative meta-analysis were used to explore the best therapeutic approach. RESULTS Fifteen studies with 3037 patients were included, and seven treatment comparisons were made. Routine supplementation with calcium + vitamin D3 offered a lower risk of symptomatic (risk difference (RD) -0·25, 95 per cent c.i. -0·32 to -0·18) and biochemical (RD -0·24, -0·31 to -0·17) hypocalcaemia than treatment based on measurement of calcium levels. The number needed to treat was 4 (95 per cent c.i. 3 to 6) for symptomatic hypocalcaemia. No publication bias was found; although heterogeneity was high for some comparisons, sensitivity analysis did not change the main results. CONCLUSION Routine postoperative administration of calcium + vitamin D3 is effective in decreasing the rate of symptomatic and biochemical hypocalcaemia.
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Affiliation(s)
- A Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, Medellin, Colombia.,Head and Neck Service, Fundacion Colombiana de Cancerologia, Clinica Vida, Medellin, Colombia
| | - A Rojas
- Head and Neck Service, Fundacion Colombiana de Cancerologia, Clinica Vida, Medellin, Colombia
| | - J Arevalo
- Head and Neck Service, Fundacion Colombiana de Cancerologia, Clinica Vida, Medellin, Colombia
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19
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Malik MZ, Mirza AA, Farooqi SA, Chaudhary NA, Waqar M, Bhatti HW. Role of Preoperative Administration of Vitamin D and Calcium in Postoperative Transient Hypocalcemia after Total Thyroidectomy. Cureus 2019; 11:e4579. [PMID: 31281762 PMCID: PMC6605693 DOI: 10.7759/cureus.4579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Thyroid surgery is one of the most frequently performed surgical procedures worldwide. Total thyroidectomy is a recommended procedure for most of the thyroid diseases. The most common complication resulting after this surgery is transient hypocalcemia - the incidence is 24% - which increases the morbidity rate and increases the length of stay in the hospital. The objective of our study was to compare the frequency of transient hypocalcemia after vitamin D and calcium supplementation with the control group for patients undergoing total thyroidectomy. Patients and methods It was a randomized controlled trial conducted at Department of Surgery, Pakistan Atomic Energy Commission General Hospital, Islamabad, Pakistan from January 2017 to July 2017. A total of 92 patients of both genders undergoing total thyroidectomy were included in the study. Patients undergoing reoperation for thyroid disease, American Society of Anesthesiologists (ASA) grade 3 or above, patients with chronic renal failure, preoperative hypocalcemia or hypercalcemia were excluded. The patients were sorted into two groups by lottery method; Group 1 in which Vitamin D (2,00,000 IU) and calcium (1 gm) was given 24 hours preoperatively. Group 2 was the control group. Total thyroidectomy was done and serum calcium levels were evaluated immediately after surgery on day two, seven and on the 30th day. The final outcome was measured at one month. Data was analyzed via the Statistical Package for Social Sciences version 22.0 (IBM Corp, Armonk, NY, USA). P value ≤ 0.05 was considered significant. Results The age ranged from 18 to 65 years with the mean age of 38.673 ± 8.63 years in group 1 while 41.217 ± 9.52 years in group 2, mean preoperative calcium level was 9.482 ± 0.49 mg/dl in group 1 and 9.678 ± 0.54 mg/dl in group 2. Hypocalcemia was seen in 3 (6.5%) in group 1 as compared to 12 (26.1%) patients in group 2 (p = 0.011). Conclusion Preoperative oral calcium and vitamin D supplements may prevent postoperative hypocalcemia, allowing a safe and early discharge. This will ultimately lead to improved patient satisfaction and significant cost savings.
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Affiliation(s)
- Muhammad Z Malik
- Surgery, Pakistan Atomic Energy Commission General Hospital, Islamabad, PAK
| | - Ahsan A Mirza
- Surgery, Pakistan Atomic Energy Commission General Hospital, Islamabad, PAK
| | | | | | - Mahnoor Waqar
- Surgery, Rawalpindi Medical University, Rawalpindi, PAK
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Arman S, Vijendren A, Mochloulis G. The incidence of post-thyroidectomy hypocalcaemia: a retrospective single-centre audit. Ann R Coll Surg Engl 2019; 101:273-278. [PMID: 30644321 DOI: 10.1308/rcsann.2018.0219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION The aim of this single centre retrospective observational record-based audit was to assess the incidence of post-thyroidectomy hypocalcaemia. The setting was a district general hospital in Hertfordshire covering a population of 500,000 people. A total of 196 patients who had had total or completion thyroidectomy during a five-year period were included in the study. MATERIALS AND METHODS The primary outcome measure was to determine the rate of biochemical and symptomatic hypocalcaemia in patients undergoing total or completion thyroidectomy. Secondary outcome measures assessed time taken for biochemical and clinical hypocalcaemia to resolve, whether malignancy affected the rate of hypocalcaemia and if removal of parathyroid glands during surgery were a predictor of hypocalcaemia. RESULTS The overall incidence of post-thyroidectomy hypocalcaemia (PTHC) within 24 hours was 21.4%. The incidence increased from 6 hours (13.8%) to 24 hours post-thyroidectomy (15.8%) and there was evidence of both transient and delayed PTHC within the first 24 hours. By 6 months post-surgery, 3.6% remained hypocalcaemic and required continual oral supplementation. Patients with benign thyroid disease had a higher risk of PTHC (P = 0.04) and patients younger than 50 years of age had a higher risk of symptomatic hypocalcaemia (P = 0.016). Other clinical factors including sex, type of surgery, neck dissection, oral calcium and/or vitamin D supplementation and inadvertent histological parathyroid gland excision were not associated with an increased incidence of PTHC or symptomatic hypocalcaemia. CONCLUSIONS Our audit shows that the rate of PTHC within our population was below the national average with higher risk in benign thyroid disease.
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Affiliation(s)
- S Arman
- East and North Hertfordshire NHS Trust, Stevenage , Hertfordshire , UK
| | - A Vijendren
- East and North Hertfordshire NHS Trust, Stevenage , Hertfordshire , UK
| | - G Mochloulis
- East and North Hertfordshire NHS Trust, Stevenage , Hertfordshire , UK
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[Symptomatic hypocalcemia after thyroidectomy : Prevention by a combination of prophylaxis and risk-adapted substitution]. Chirurg 2018; 89:909-916. [PMID: 29637240 DOI: 10.1007/s00104-018-0631-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Treatment of hypocalcemia after thyroidectomy consists of an individual substitution, prophylaxis or a daily administration of calcium/vitamin D3. OBJECTIVE Does prophylactic therapy combined with a risk-adapted substitution of calcium and vitamin D3 reduce symptomatic hypocalcemia compared to individual substitution? MATERIAL AND METHODS After implementation of a new algorithm, patient data were prospectively documented and analyzed compared to a historical patient population. The algorithm consisted of a single prophylactic i. v. administration of calcium (1 g calcium gluconate 10% in 250 ml saline) and a risk-adapted oral administration of calcium and vitamin D3 after surgery. Patients without risk (parathyroid hormone, PTH > 15 pg/ml) were not treated. Patients with a low risk (PTH ≥ 6 ≤ 15 pg/ml and Ca > 2.0 mmol/l) received 3 g calcium, patients with a high risk (PTH ≥ 6 ≤ 15 pg/ml and Ca < 2.0 mmol/l) received 3 g calcium and 2 × 0.5 µg vitamin D3 and patients with a very high risk (PTH < 6 pg/ml) got 4 g calcium and 2 × 0.5 µg vitamin D3. RESULTS In this study 415 patients were included (230 prospectively and 185 retrospectively). Serum calcium of patients with individual substitution increased significantly at day 1 (p = 0.0001) and the number of patients with critical hypocalcemia (Ca < 2.0 mmol/l) decreased by half (27% vs. 12.2%; p = 0.0001). There was a significantly lower rate of symptomatic patients (24.9% vs 13.0%; p = 0.002) and a clear reduction of patients with a prolonged hospitalization (10.8% vs. 6.5%; p = 0.08). The rate of permanent hypocalcemia was comparable (2.2% vs. 2.1%). In the risk groups there was a significantly different rate of hypocalcemia: patients without risk (n = 170) in 2.2%, patients with low risk (n = 36) in 25%, patients with high risk (n = 13) in 69.2% and patients with very high risk (n = 11) in 71%. CONCLUSION This new treatment regimen is practicable, significantly lowers the symptoms, also in comparison to the literature and shows a clear differentiation between the risk groups.
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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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Impact of pre-operative serum 25-hydroxyvitamin D on post-operative serum calcium in patients undergoing total thyroidectomy for benign goitre: retrospective study of 246 patients. The Journal of Laryngology & Otology 2017; 131:925-929. [PMID: 28874217 DOI: 10.1017/s0022215117001797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine whether pre-operative serum 25-hydroxyvitamin D has an impact on post-operative parathyroid hormone and serum calcium levels in patients undergoing total thyroidectomy for benign goitre. METHODS This single-centre, retrospective study comprised 246 unselected surgical patients who had undergone total thyroidectomy for bilateral, benign, multinodular goitre. The correlation between pre-operative serum 25-hydroxyvitamin D and post-operative serum parathyroid hormone and serum calcium was studied to determine whether low pre-operative serum 25-hydroxyvitamin D was predictive of post-operative hypocalcaemia. RESULTS Seventy-nine patients (32 per cent) had post-operative hypocalcaemia. Eighteen patients (7.32 per cent) experienced unintentional parathyroidectomy (1 parathyroid gland in 15 patients, 2 parathyroid glands in 3 patients). In univariate analysis, pre-operative serum 25-hydroxyvitamin D was not correlated with post-operative serum calcium (p = 0.69) or post-operative serum parathyroid hormone (p = 0.5804). Furthermore, in multivariate analysis, which took into account unintentional parathyroidectomy, no correlation was found (p = 0.33). Bilateral unintentional parathyroidectomy was statistically associated with post-operative hypocalcaemia (p = 0.032). CONCLUSION Pre-operative serum 25-hydroxyvitamin D did not appear to have any impact on post-operative serum calcium in patients undergoing total thyroidectomy for benign goitre.
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Maxwell AK, Shonka DC, Robinson DJ, Levine PA. Association of Preoperative Calcium and Calcitriol Therapy With Postoperative Hypocalcemia After Total Thyroidectomy. JAMA Otolaryngol Head Neck Surg 2017; 143:679-684. [PMID: 28418509 DOI: 10.1001/jamaoto.2016.4796] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hypocalcemia is the most common complication after total thyroidectomy and can result in prolonged hospital admissions and increased hospital charges. Objective To determine the effectiveness of preoperative calcium and calcitriol supplementation in reducing hypocalcemia following total thyroidectomy. Design, Setting, and Participants A retrospective cohort study was conducted at a tertiary care center in 65 patients undergoing total thyroidectomy by a single surgeon. Patients were divided into 2 groups: those receiving preoperative as well as postoperative supplementation with calcium carbonate, 1000 to 1500 mg, 3 times daily and calcitriol, 0.25 to 0.5 µg, twice daily, and those receiving only postoperative supplementation with those agents at the same dosages. Data on patients who underwent surgery between January 1, 2008, and December 31, 2011, were acquired, and data analyses were conducted from March through June 2012, and from October through December 2016. Interventions Calcium and calcitriol therapy. Main Outcomes and Measures Postoperative serum calcium levels and development of postoperative hypocalcemia. Results Of the 65 patients who underwent total thyroidectomy 27 (42%) were men; mean (SD) age was 49.7 (16.7) years. Thirty-three patients received preoperative calcium and calcitriol supplementation, and 32 patients received only postoperative therapy. In the preoperative supplementation group, 15 of 33 (45%) patients underwent complete central compartment neck dissection and 11 of 33 (33%) had lateral neck dissection, compared with 16 of 32 (50%) and 12 of 32 (38%), respectively, patients without preoperative supplementation. The mean measured serum calcium level in those without preoperative supplementation vs those with supplementation are as follows: preoperative, 9.6 vs 9.4 mg/dL (absolute difference, 0.16; 95% CI, -0.12 to 0.49 mg/dL); 12 hours postoperative, 8.3 vs 8.6 mg/dL (absolute difference, -0.30; 95% CI, -0.63 to 0.02 mg/dL); and 24 hours postoperative, 8.4 vs 8.5 mg/dL (absolute difference, -0.13; 95% CI, -0.43 to 0.16 mg/dL). In patients not receiving preoperative supplementation, 5 of 32 (16%) individuals became symptomatically hypocalcemic vs 2 of 33 (6%) in the preoperative supplementation group; an absolute difference of 10% (95% CI, -6.6% to 26.3%). Compared with the group not receiving preoperative supplementation, the mean [SD] length of stay was significantly shorter in the preoperative supplementation group (3.8 [1.8] vs 2.9 [1.4] days; absolute difference, -0.9; 95% CI, -1.70 to -0.105 days). Preoperative supplementation resulted in an estimated $2819 savings in charges per patient undergoing total thyroidectomy. Conclusions and Relevance Preoperative calcium and calcitriol supplementation, in addition to routine postoperative supplementation, was associated with a reduced incidence of symptomatic hypocalcemia, length of hospital stay, and overall charges following total thyroidectomy.
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Affiliation(s)
- Anne K Maxwell
- University of Virginia School of Medicine, University of Virginia Health System, Charlottesville2Now with Department of Otolaryngology, University of Colorado, Denver
| | - David C Shonka
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
| | - Derek J Robinson
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
| | - Paul A Levine
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
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Kim WW, Chung SH, Ban EJ, Lee CR, Kang SW, Jeong JJ, Nam KH, Chung WY, Park CS. Is Preoperative Vitamin D Deficiency a Risk Factor for Postoperative Symptomatic Hypocalcemia in Thyroid Cancer Patients Undergoing Total Thyroidectomy Plus Central Compartment Neck Dissection? Thyroid 2015; 25:911-8. [PMID: 26061175 DOI: 10.1089/thy.2014.0522] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although some studies have reported that preoperative vitamin D deficiency (VDD) is a risk factor for hypocalcemia after total thyroidectomy (TT) in patients with nontoxic multinodular goiter or Graves' disease, the association between VDD and postoperative hypocalcemia in thyroid cancer patients undergoing TT plus central compartment neck dissection (CCND) remains unclear. This study evaluated whether preoperative VDD was associated with postoperative symptomatic hypocalcemia. MATERIALS AND METHODS Data were collected prospectively between September 2012 and May 2013. A total of 267 consecutive thyroid cancer patients who underwent TT with CCND were analyzed. Patients were divided into two groups--VDD or non-VDD--by preoperative vitamin D level of <10 or ≥10 ng/mL. Symptomatic hypocalcemia was defined as serum calcium <8.2 mg/dL and symptoms or signs of hypocalcemia. The rates of postoperative symptomatic hypocalcemia and clinicopathological features were compared between the two patient groups. RESULTS The rate of postoperative symptomatic hypocalcemia was higher in the VDD group than in the non-VDD group (43.8% vs. 30.4%, p=0.043). By logistic regression analysis, predictive factors for postoperative symptomatic hypocalcemia included a preoperative vitamin D level of <10 ng/mL (p=0.007; odds ratio=3.00). In patients who had postoperative intact parathyroid hormone (iPTH) levels <15 pg/mL, symptomatic hypocalcemia was more common in the VDD group than in the non-VDD group (77.5% vs. 53.2%, p=0.008). The findings show that a preoperative vitamin D threshold level of >20 ng/mL reduced the risk of symptomatic hypocalcemia by 72% when compared with patients with VDD (p=0.003). CONCLUSION VDD is significantly associated with postoperative symptomatic hypocalcemia in thyroid cancer patients undergoing TT plus CCND. VDD was predictive for symptomatic hypocalcemia when patients had postoperative serum iPTH levels <15 pg/mL. Thus, preoperative supplementation with oral vitamin D should be considered to minimize postoperative symptomatic hypocalcemia.
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Affiliation(s)
- Won Woong Kim
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
| | - So-Hyang Chung
- 2 Department of Ophthalmology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea , Seoul, Korea
| | - Eun Jeong Ban
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
| | - Cho Rok Lee
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
| | - Sang-Wook Kang
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
| | - Jong Ju Jeong
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
| | - Kee-Hyun Nam
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
| | - Woong Youn Chung
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
| | - Cheong Soo Park
- 1 Department of Surgery, Institute of Endocrine Research, Yonsei University Health System , Seoul, Korea
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Villar del Moral JM, Soria Aledo V, Colina Alonso A, Flores Pastor B, Gutiérrez Rodríguez MT, Ortega Serrano J, Parra Hidalgo P, Ros López S. Clinical Pathway for Thyroidectomy. Cir Esp 2015; 93:283-99. [PMID: 25732107 DOI: 10.1016/j.ciresp.2014.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/17/2014] [Accepted: 11/29/2014] [Indexed: 12/14/2022]
Abstract
Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.
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Affiliation(s)
- Jesús María Villar del Moral
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Virgen de las Nieves, Granada, España.
| | - Víctor Soria Aledo
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Morales Meseguer, Murcia, España
| | - Alberto Colina Alonso
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España
| | - Benito Flores Pastor
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Morales Meseguer, Murcia, España
| | - María Teresa Gutiérrez Rodríguez
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario de Basurto, Bilbao, España
| | - Joaquín Ortega Serrano
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Clínico Universitario de Valencia, Valencia, España
| | - Pedro Parra Hidalgo
- Sección de Gestión de Calidad de la Asociación Española de Cirujanos, Consejería de Sanidad de la Región de Murcia, Murcia, España
| | - Susana Ros López
- Sección de Cirugía Endocrina de la Asociación Española de Cirujanos, Servicio de Cirugía General, Hospital Universitario Arnau de Vilanova, Lérida, España
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Antakia R, Edafe O, Uttley L, Balasubramanian SP. Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis. Thyroid 2015; 25:95-106. [PMID: 25203484 DOI: 10.1089/thy.2014.0101] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND A variety of measures have been proposed to reduce the incidence of post-thyroidectomy hypocalcemia. The aim of this study was to perform a systematic review and meta-analysis of preventive and other surgical measures on post-thyroidectomy hypocalcemia as reported in the literature. METHODS Comprehensive searches of the PubMed, EMBASE, and Cochrane databases were performed, and the quality of included papers was assessed using the Cochrane risk of bias tool or a modified Newcastle-Ottawa Scale (NOS). The results of all included studies were summarized, and meta-analyses were performed where appropriate. RESULTS Thirty-nine randomized controlled trials (RCTs) and 37 observational studies were included. Measures studied included hemostatic techniques, extent of thyroidectomy and central neck dissection, surgical approach, calcium/vitamin D/thiazide diuretic supplements, parathyroid gland autotransplantation (PGAT) and intraoperative parathyroid gland (PG) identification, truncal ligation of inferior thyroid artery (ITA), preoperative magnesium infusion, and use of magnification loupes and Surgicel. Measures associated with significantly lower rates of transient hypocalcemia in meta-analysis were postoperative calcium and vitamin D supplementation compared to either calcium supplements alone (odds ratio (OR) 0.66; p=0.04) or no supplements (OR 0.34; p=0.007), and bilateral subtotal thyroidectomy (BST) compared to Hartley Dunhill (HD) procedure (OR 0.35; p=0.01). Meta-analyses did not demonstrate any measure to be significantly associated with a reduction in permanent hypocalcemia. CONCLUSION This review identified postoperative calcium and vitamin D supplementation and bilateral subtotal thyroidectomy (over HD) as being effective in prevention of transient hypocalcemia. However, the majority of RCTs were of low quality, primarily due to a lack of blinding. The wide variability in study design, definitions of hypocalcemia, and methods of assessment prevented meaningful summation of results for permanent hypocalcemia.
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Affiliation(s)
- Ramez Antakia
- 1 Department of Oncology, School of Medicine, University of Sheffield , Sheffield, United Kingdom
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28
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Shulutko AM, Semikov VI, Gryaznov SE, Gorbacheva AV, Patalova AR, Mansurova GT, Kazakova VA. [Risk of hypocalcemia after thyroid surgery]. Khirurgiia (Mosk) 2015:35-40. [PMID: 26978621 DOI: 10.17116/hirurgia20151135-40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To reveal calcium metabolism disorders that frequently occur after thyroid surgery. MATERIAL AND METHODS The study included 202 patients who underwent thyroid surgery for different diseases and had normal calcium level in peripheral blood at baseline. RESULTS Based on laboratory data postoperative hypocalcemia was diagnosed in 57 (28.8%) patients. It was not always accompanied by clinical symptoms. Clinical picture depended on degree of hypocalcemia. Symptoms was diagnosed more frequently if calcium concentration was less than 2.1 mmol/l. Clinical manifestations were absent in 64.9% of cases on background of hypocalcemia. Incidence of hypocalcemia was higher after thyroidectomy compared to organ-preserving surgery. Symptoms of hypocalcemia occurred after thyroidectomy only. Casual parathyroidectomy does not always cause hypocalcemia. Only in 14% of patients with hypocalcemia excised parathyroid was identified in specimen. At the same time 7.6% of patients with postoperative normocalcaemia also had excised parathyroids in specimens. Symptoms of hypocalcemia does not always occur at 1 day after surgery. They can appear later, for example at 5 days postoperatively and depend on severity of hypocalcemia. Thyroidectomy has high risk of postoperative hypocalcemia with clinical symptoms (19.6%) that is transient in 15.5% of cases and permanent in 4.1% of patients.
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Affiliation(s)
- A M Shulutko
- Chair of Faculty Surgery #2, I.M. Setchenov First Moscow State Medical University, Moscow, Russia
| | - V I Semikov
- Chair of Faculty Surgery #2, I.M. Setchenov First Moscow State Medical University, Moscow, Russia
| | - S E Gryaznov
- Chair of Faculty Surgery #2, I.M. Setchenov First Moscow State Medical University, Moscow, Russia
| | - A V Gorbacheva
- Chair of Faculty Surgery #2, I.M. Setchenov First Moscow State Medical University, Moscow, Russia
| | - A R Patalova
- Chair of Faculty Surgery #2, I.M. Setchenov First Moscow State Medical University, Moscow, Russia
| | - G T Mansurova
- Chair of Faculty Surgery #2, I.M. Setchenov First Moscow State Medical University, Moscow, Russia
| | - V A Kazakova
- Chair of Faculty Surgery #2, I.M. Setchenov First Moscow State Medical University, Moscow, Russia
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Carter Y, Chen H, Sippel RS. An intact parathyroid hormone-based protocol for the prevention and treatment of symptomatic hypocalcemia after thyroidectomy. J Surg Res 2014; 186:23-8. [PMID: 24144426 PMCID: PMC3871885 DOI: 10.1016/j.jss.2013.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 09/15/2013] [Accepted: 09/18/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Symptomatic (SX) hypocalcemia after thyroidectomy is a barrier to same day surgery and the cause of emergency room visits. A standard protocol of calcium and vitamin D supplementation, dependent on intact parathyroid hormone (iPTH) levels, can address this issue. How effective is it? When does it fail? METHODS We performed a retrospective review of the prospective Thyroid database from January 2006 to December 2010. Six hundred twenty patients underwent completion thyroidectomy or total thyroidectomy and followed our postoperative protocol of calcium carbonate administration for iPTH levels ≥10 pg/mL and calcium carbonate and 0.25 μg calcitriol twice a day for iPTH <10 pg/mL. Calcium and iPTH values, pathology, and medication were compared to evaluate protocol efficacy. A P value <0.05 was considered statistically significant. RESULTS Using the protocol, sixty-one (10.2%) patients were chemically hypocalcemic but never developed symptoms and 24 (3.9%) patients developed breakthrough SX hypocalcemia. The SX and asymptomatic groups were similar with regard to gender, cancer diagnosis, and preoperative calcium and iPTH. The SX group was significantly younger (39.6 ± 2.8 versus 49 ± 0.6 y, P = 0.01), with lower postoperative iPTH levels. Thirty-three percent (n = 8) of SX patients had an iPTH ≤5 pg/mL versus only 6% (n = 37) of ASX patients. Although the majority of patients with a iPTH ≤5 pg/mL were asymptomatic, 62.5% (n = 5) of SX patients with iPTH levels ≤5 pg/mL required an increase in calcitriol dose to achieve both biochemical correction and symptom relief. CONCLUSIONS Prophylactic calcium and vitamin D supplementation based on postoperative iPTH levels can minimize SX hypocalcemia after thyroidectomy. An iPTH ≤5 pg/mL may warrant higher initial doses of calcitriol to prevent symptoms.
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Affiliation(s)
- Yvette Carter
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
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Genser L, Trésallet C, Godiris-Petit G, Li Sun Fui S, Salepcioglu H, Royer C, Menegaux F. Randomized controlled trial of alfacalcidol supplementation for the reduction of hypocalcemia after total thyroidectomy. Am J Surg 2013; 207:39-45. [PMID: 24119718 DOI: 10.1016/j.amjsurg.2013.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 05/17/2013] [Accepted: 05/30/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the effect of perioperative alfacalcidol on postoperative hypocalcemia after total thyroidectomy. METHODS A total of 219 patients scheduled for total thyroidectomy were randomized into groups not receiving (group A) or receiving (group B) perioperative alfacalcidol. Postoperative hypocalcemia was compared between groups on postoperative day (POD) 1 and POD2. Patients with hypocalcemia (<2.00 mmol/L) received oral calcium supplementation. Calcium and vitamin D levels were measured at 5-week and 6-month follow-ups. RESULTS The incidence of symptomatic hypocalcemia was significantly lower in group A (P = .02), whereas similarly low levels of calcemia were observed in both groups on POD1 (37% and 30%, respectively; P = not significant) and persisted on POD2 (14% and 6%, respectively; P = not significant). Patients with severe hypocalcemia (<1.90 mmol/L) showed faster recovery in group A compared with group B (6% vs 1%, P = .04). At 5 weeks, calcium and vitamin D levels were similar between the groups. Six months after surgery, 4% (group A) versus 0% (group B) of subjects exhibited permanent hypoparathyroidism (P = .04). CONCLUSIONS Although the treatment did not correct vitamin D deficiency, perioperative alfacalcidol uptake resulted in decreased transient hypocalcemia and related symptoms in patients undergoing total thyroidectomy.
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Affiliation(s)
- Laurent Genser
- Department of General, Visceral & Endocrine Surgery, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (Paris VI), Assistance Publique, Hôpitaux de Paris, 83 Boulevard de l'hôpital, 75013 Paris, Paris 6 University, Paris, France
| | - Christophe Trésallet
- Department of General, Visceral & Endocrine Surgery, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (Paris VI), Assistance Publique, Hôpitaux de Paris, 83 Boulevard de l'hôpital, 75013 Paris, Paris 6 University, Paris, France
| | - Gaëlle Godiris-Petit
- Department of General, Visceral & Endocrine Surgery, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (Paris VI), Assistance Publique, Hôpitaux de Paris, 83 Boulevard de l'hôpital, 75013 Paris, Paris 6 University, Paris, France
| | - Stéphanie Li Sun Fui
- Department of General, Visceral & Endocrine Surgery, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (Paris VI), Assistance Publique, Hôpitaux de Paris, 83 Boulevard de l'hôpital, 75013 Paris, Paris 6 University, Paris, France
| | - Harika Salepcioglu
- Department of General, Visceral & Endocrine Surgery, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (Paris VI), Assistance Publique, Hôpitaux de Paris, 83 Boulevard de l'hôpital, 75013 Paris, Paris 6 University, Paris, France
| | - Catherine Royer
- Department of Anaesthesiology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (Paris VI), Assistance Publique, Hôpitaux de Paris, Paris, France
| | - Fabrice Menegaux
- Department of General, Visceral & Endocrine Surgery, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (Paris VI), Assistance Publique, Hôpitaux de Paris, 83 Boulevard de l'hôpital, 75013 Paris, Paris 6 University, Paris, France.
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Alhefdhi A, Mazeh H, Chen H. Role of postoperative vitamin D and/or calcium routine supplementation in preventing hypocalcemia after thyroidectomy: a systematic review and meta-analysis. Oncologist 2013; 18:533-42. [PMID: 23635556 DOI: 10.1634/theoncologist.2012-0283] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Transient hypocalcemia is a frequent complication after total thyroidectomy. Routine postoperative administration of vitamin D and calcium can reduce the incidence of symptomatic postoperative hypocalcemia. We performed a systematic review to assess the effectiveness of this intervention. The primary aim was to evaluate the efficacy of routine postoperative oral calcium and vitamin D supplementation in preventing symptomatic post-thyroidectomy hypocalcemia. The second aim was to draw clear guidelines regarding prophylactic calcium and/or vitamin D therapy for patients after thyroidectomy. METHODS We identified randomized controlled trials comparing the administration of vitamin D or its metabolites to calcium or no treatment in adult patients after thyroidectomy. The search was performed in PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, and Web of Knowledge databases. Patients with a history of previous neck surgery, calcium supplementation, or renal impairment were excluded. RESULTS Nine studies with 2,285 patients were included: 22 in the vitamin D group, 580 in the calcium group, 792 in the vitamin D and calcium group, and 891 in the no intervention group, with symptomatic hypocalcemia incidences of 4.6%, 14%, 14%, and 20.5%, respectively. Subcomparisons demonstrated that the incidences of postoperative hypocalcemia were 10.1% versus 18.8% for calcium versus no intervention and 6.8% versus 25.9% for vitamin D and calcium versus no intervention. The studies showed a significant range of variability in patients' characteristics. CONCLUSIONS A significant decrease in postoperative hypocalcemia was identified in patients who received routine supplementation of oral calcium or vitamin D. The incidence decreased even more with the combined administration of both supplements. Based on this analysis, we recommend oral calcium for all patients following thyroidectomy, with the addition of vitamin D for high-risk individuals.
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Affiliation(s)
- Amal Alhefdhi
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin 53792, USA
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Lang BHH, Wong KP, Cheung CY, Fong YK, Chan DKK, Hung GKY. Does Preoperative 25-Hydroxyvitamin D Status Significantly Affect the Calcium Kinetics after Total Thyroidectomy? World J Surg 2013; 37:1592-8. [DOI: 10.1007/s00268-013-2015-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kowalski LP, Sanabria A, Vartanian JG, Lima RA, Toscano de Mendonca UB, Roberto dos Santos C, Boldrini Júnior D, Barbalho de Mello LE, Pinto FP, Lehn CN, Correa LAC, Dedivitis RA, Guimarães AV, Pedruzzi PAG, Ramos GHA, Gonçalves AJ, Suehara AB, Kanda JL, de Castro Capuzzo R, Carlos de Oliveira J, Curado MP, Francisco de Góis Filho J, Fukuyama E, Beserra Júnior IM, Bentes de Carvalho Neto P, Carvalho AL. Total thyroidectomy with ultrasonic scalpel: A multicenter, randomized controlled trial. Head Neck 2012; 34:805-12. [DOI: 10.1002/hed.21815] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2011] [Indexed: 11/10/2022] Open
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