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Fields T, Ramonell K, Fazendin J, Gillis A, Buczek E, Porterfield J, Chen H, Lindeman B. The Obesity Paradox in Thyroid Surgery: Is Higher BMI Protective Against Hypoparathyroidism? Am Surg 2024; 90:9-14. [PMID: 37497666 DOI: 10.1177/00031348231192065] [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] [Indexed: 07/28/2023]
Abstract
BACKGROUND With a demonstrated association between adiposity and parathyroid hormone (PTH) levels, we hypothesized that patients with a higher body mass index (BMI) would have lower rates of postoperative hypoparathyroidism following total thyroidectomy. METHODS retrospective review of patients undergoing total thyroidectomy from 2015 to 2021. Demographics, BMI, surgical indications, and laboratory data including pre- and postoperative PTH values were examined. RESULTS Of the 352 patients with complete clinicopathologic data, most were female (n = 272, 77.3%) with an average age of 42.7 (SD+/-19.4). Obese (BMI 30-39.99) was most common BMI group (n = 108, 30.8%), with 11.7% (n = 41) morbidly obese (BMI > 40). Morbidly obese patients had significantly higher postoperative PTH levels than BMI < 18.5 (46.0 vs 19.3 pg/mL, P = .004). Patient race was significantly associated with pre- and postoperative PTH (P = .03, P = .004.) On multivariable analysis, preoperative PTH, race, and BMI were independent predictors of higher postoperative PTH (P < .05 for all). DISCUSSION Patients with higher BMI and non-white race have relative protection from postoperative hypoparathyroidism.
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Affiliation(s)
- Tyler Fields
- Department of Surgery, Wellstar Atlanta Medical Center, Atlanta, GA, USA
| | - Kimberly Ramonell
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica Fazendin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrea Gillis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Erin Buczek
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Porterfield
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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A Parathyroid Hormone-guided Calcium and Calcitriol Supplementation Protocol Reduces Hypocalcemia-related Readmissions Following Total Thyroidectomy. Endocr Pract 2023; 29:260-265. [PMID: 36682414 DOI: 10.1016/j.eprac.2023.01.009] [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: 11/15/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine the effect of a 4 hour postoperative serum parathyroid hormone (PTH) guided calcium and calcitriol supplementation protocol on the incidence of hypocalcemia and hospital readmissions in patients undergoing total thyroidectomy. METHODS This was a single institution, retrospective chart review of patients who underwent total thyroidectomy, 148 had been operated on prior to the protocol implementation and 389 after. Hypocalcemia risk was stratified as low (PTH >30 pg/ml), medium (15-30 pg/ml), and high (<15 pg/ml), using serum PTH values obtained 4 hours postoperatively. Hypocalcemia was defined as a total serum calcium level <8 mg/dl. Baseline demographic and operative characteristics, and postoperative outcome were recorded for both groups. Fisher's exact test or Wilcoxon rank sum test were used to compare the characteristics of the two groups. A multivariable logistic regression model was applied to account for potentially confounding variables. RESULTS Postoperative hypocalcemia occurred significantly less frequently in the protocol group compared to the preprotocol group (10.3% vs. 20.9%, P=.002). The reduction in hypocalcemia in the protocol group was observed both in patients with (16.3% vs. 25.6%) and without (8.4% vs. 19.3%) cervical lymph node dissection. There was a significantly lower incidence of hospital readmission events in the protocol group compared to the preprotocol group (1.0% vs. 4.7%, P=.013). CONCLUSIONS Compared to a historical cohort, a PTH-guided protocol for calcium and calcitriol supplementation significantly reduces postoperative hypocalcemia and hospital readmission rates, in patients undergoing total thyroidectomy.
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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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de Carvalho GB, Diamantino LR, Schiaveto LF, Forster CHQ, Shiguemori ÉH, Hirata D, Kohler HF, Lira RB, Vartanian JG, Matieli JE, Kowalski LP. Identification of secondary predictive factors for acute hypocalcemia following thyroidectomy in patients with low postoperative parathyroid hormone levels without overt calcium deficiency: A cohort study. Am J Otolaryngol 2021; 42:103115. [PMID: 34214713 DOI: 10.1016/j.amjoto.2021.103115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 05/15/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The transient acute hypocalcemia (HypoCa) is the most prevalent complication after total thyroidectomy, detected primarily by subnormal intact parathyroid hormone (iPTH) and calcium levels. However, the need for calcium supplementation is ambiguous in patients who exhibit low iPTH with normal calcium levels. The aim of this study was to evaluate complementary predictors of HypoCa in this scenario. METHODS A retrospective cohort study with of 1597 consecutive patients undergoing total thyroidectomy, with or without neck dissection, from January 2014 to December 2018 at a single institution. Patients with an iPTH <12 pg/mL and a total calcium level ≥8 mg/dL in the first 8 h after surgery were included. RESULTS 1597 patients identified with low postoperative iPTH without overt calcium deficiency was diagnosed. The transient HypoCa in that specific subgroup was 509 (31.9%). Multivariate analysis indicated that HYPOCA was associated with bilateral level VI neck dissection and pre- to postoperative calcium reduction >38 pg/mL. To better illustrate the model, we plotted a nomogram with the variables selected for the final model. CONCLUSION Total thyroidectomy patients who exhibit low postoperative iPTH levels without overt calcium deficiency should be considered for calcium replacement therapy when they a marked drop in iPTH postoperatively and underwent bilateral level VI neck dissection.
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A Randomized Controlled Clinical Trial: No Clear Benefit to Prophylactic Central Neck Dissection in Patients With Clinically Node Negative Papillary Thyroid Cancer. Ann Surg 2021; 272:496-503. [PMID: 33759836 DOI: 10.1097/sla.0000000000004345] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this prospective randomized-controlled trial was to evaluate the risks/benefits of prophylactic central neck dissection (pCND) in patients with clinically node negative (cN0) papillary thyroid cancer (PTC). BACKGROUND Microscopic lymph node involvement in patients with PTC is common, but the optimal management is unclear. METHODS Sixty patients with cN0 PTC were randomized to a total thyroidectomy (TT) or a TT+ pCND. All patients received postoperative laryngoscopies and standardized radioiodine treatment. Thyroglobulin (Tg) levels and/or neck ultrasounds were performed at 6 weeks, 6 months, and 1 year. RESULTS Tumors averaged 2.2 ± 0.2 cm and 11.9% had extra-thyroidal extension. Thirty patients underwent a pCND and 27.6% had positive nodes (all ≤6 mm). Rates of postoperative PTH < 10 (33.3% vs 24.1%, P = 0.57) and transient nerve dysfunction (13.3% vs 10.3%, P = 1.00) were not significantly different between groups. Six weeks after surgery, both TT and TT + pCND were equally likely to achieve a Tg < 0.2 (54.5% vs 66.7%, P = 0.54) and/or a stimulated Tg (sTg) <1 (59.3% vs 64.0%, P = 0.78). At 1 year, rates of Tg < 0.2 (88.9% vs 90.0%, P = 1.00) and sTg < 1 (93.8% vs 92.3%, P = 1.00) remained similar between groups. Neck ultrasounds at 1 year were equally likely to be read as normal (85.7% in TT vs 85.1% in pCND, P = 1.00). CONCLUSIONS cN0 PTC patients treated either with TT or TT + pCND had similar complication rates after surgery. Although microscopic nodes were discovered in 27.6% of pCND patients, oncologic outcomes were comparable at 1 year.
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Abstract
Parathyroid glands are critical for calcium and phosphate homeostasis. Parathyroid disease is relatively rare in the pediatric population, but there are some important pediatric-specific considerations and conditions. This article reviews parathyroid physiology, disorders of hyper- and hypo- function, operative management, and uniquely pediatric diagnoses such as neonatal severe hyperparathyroidism. Advances in preoperative imaging, intra-operative gland identification, and management of post-thyroidectomy hypocalcemia are also presented in detail. This article combines a review of fundamentals with recent advances in care, emphasizing pediatric-specific publications.
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Nicholson KJ, Smith KJ, McCoy KL, Carty SE, Yip L. A comparative cost-utility analysis of postoperative calcium supplementation strategies used in the current management of hypocalcemia. Surgery 2019; 167:137-143. [PMID: 31515122 DOI: 10.1016/j.surg.2019.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/24/2019] [Accepted: 05/01/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Symptomatic hypocalcemia is a common complication of total thyroidectomy. Management strategies include responsive treatment initiation for symptoms or prevention by routine or parathyroid hormone-directed calcium supplementation. The comparative cost-effectiveness of even the most often utilized strategies is unclear. METHODS A Markov cohort model was created to compare routine supplementation with calcium alone (RS), postoperative parathyroid hormone-based selective supplementation with calcium and calcitriol (SS), and no supplementation (NS) in asymptomatic patients. Patients could remain asymptomatic or develop symptomatic hypocalcemia, managed with outpatient oral supplementation or intravenous calcium infusion and administered either inpatient or outpatient. Effectiveness was measured in quality-adjusted life years. Sensitivity analyses were performed to test model parameter assumptions. RESULTS RS was the preferred strategy, costing $329/patient and resulting in 0.497 quality-adjusted life years, which was only marginally better compared to SS ($373 for 0.495 quality-adjusted life years). NS was most costly at $4,955 for 0.491 quality-adjusted life years. Preference for RS over SS was sensitive to the probability of developing symptoms and the probability of symptom treatment with intravenous supplementation. On probabilistic sensitivity analysis, RS was preferred in 75.4% of scenarios. CONCLUSION After total thyroidectomy, a preventative calcium supplementation strategy should be strongly considered. In this data-driven theoretical model, RS was the least costly option and resulted in an incremental gain in quality-adjusted life years.
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Affiliation(s)
- Kristina J Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | | | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, PA.
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8
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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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Akram S, Elfenbein DM, Chen H, Schneider DF, Sippel RS. Assessing American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease. J Surg Res 2019; 245:64-71. [PMID: 31401249 DOI: 10.1016/j.jss.2019.07.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/30/2019] [Accepted: 07/12/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND The American Thyroid Association (ATA) issued specific preoperative preparatory guidelines for patients undergoing thyroidectomy for treatment of Graves' disease. Our goal is to determine if compliance with these guidelines is associated with better outcomes. METHODS A retrospective review of a prospectively maintained database identified 228 patients with Graves' disease who underwent total thyroidectomy between August 2007 and May 2015. Patients treated in compliance with ATA guidelines were compared with those not in full compliance with the current preparatory guidelines. RESULTS At the time of surgery, 52% of all patients followed ATA guidelines. Patients who were prepped per ATA guidelines had fewer episodes of intraoperative tachycardia (0.3 versus 4.5, P = 0.04) but had no difference in peak systolic blood pressure or in number of episodes of systolic blood pressure > 180 mmHg. ATA prepped and nonprepped patients had similar mean operating room time and length of stay. ATA prepped and nonprepped patients had similar complication rates, including transient hypocalcemia (30.4% versus 25.5%, P = 0.45), prolonged hypoparathyroidism (0.98% versus 4.3%, P = 0.15), hoarse voice (10.8% versus 7.5%, P = 0.42), permanent recurrent laryngeal nerve paralysis (2.9% versus 2.1%, P = 0.71), and hematoma (2.9% versus 0%, P = 0.09). CONCLUSIONS Our data suggest that compliance with ATA guidelines for thyroidectomy preparation is not essential for a successful surgical outcome. Although preparation per the guidelines decreased the frequency of intraoperative tachycardia, it did not impact intraoperative hypertension, operating room time, or postoperative complications.
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Affiliation(s)
- Siddique Akram
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dawn M Elfenbein
- Division of Endocrine Surgery, Department of Surgery, University of California - Irvine Health, Irvine, California
| | - Herbert Chen
- Department of Surgery, University of Alabama - Birmingham, Birmingham, Alabama
| | - David F Schneider
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rebecca S Sippel
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Smithson M, Asban A, Miller J, Chen H. Considerations for Thyroidectomy as Treatment for Graves Disease. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2019; 12:1179551419844523. [PMID: 31040734 PMCID: PMC6482648 DOI: 10.1177/1179551419844523] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/26/2019] [Indexed: 11/16/2022]
Abstract
Hyperthyroidism is a clinical state that results from abnormally elevated thyroid hormones. Thyroid gland affects many organ systems; therefore, patients usually present with multiple clinical manifestations that involve many organ systems such as the nervous, cardiovascular, muscular, and endocrine system as well as skin manifestations. Hyperthyroidism is most commonly caused by Graves disease, which is caused by autoantibodies to the thyrotropin receptor (TRAb). Other causes of hyperthyroidism include toxic multinodular goiter, toxic single adenoma, and thyroiditis. Diagnosis of hyperthyroidism can be established by measurement of thyroid-stimulating hormone (TSH), which will be suppressed with either elevated free T4 and/or T3 (overt hyperthyroidism) or normal free T3 and T4 (subclinical hyperthyroidism). Hyperthyroidism can be treated with antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy. ATDs have a higher replacement rate when compared with RAI or thyroidectomy. Recent evidence has shown that thyroidectomy is a very effective, safe treatment modality for hyperthyroidism and can be performed as an outpatient procedure. This review article provides some of the most recent evidence on diagnosing and treating patients with hyperthyroidism.
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Affiliation(s)
- Mary Smithson
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar Asban
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason Miller
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
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11
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Wei H, Huang M, Fan J, Wang T, Ling R. Intraoperative rapid aspiration cytological method for parathyroid glands identification and protection. Endocr J 2019; 66:135-141. [PMID: 30518736 DOI: 10.1507/endocrj.ej18-0363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To explore new methods for intraoperative identification of parathyroid glands, 86 thyroid cancer patients, admitted to Xijing hospital from July 2017 to July 2018, were included. During lymph node dissection, parathyroid glands were firstly judged by clinician eyeballing, based on his clinical experience. Then, cytological detection was used for rapid identification via Diff-quik staining. PTH monitoring was performed by PTH detection kit. Finally, frozen pathology was examined and regarded as the golden standard. In this study, 172 suspicious parathyroid glands were observed. According to frozen pathology outcome, the accuracy, sensitivity and specificity of clinician eyeballing were calculated as 63.3%, 100%, and 13.9%. Kappa test showed poor consistency (kappa = 0.156), AUC area was 0.569 ± 0.045, 95%CI = (0.480-0.658), p = 0.123. For cytological and PTH detection, the accuracy, sensitivity and specificity were 91.7% vs. 92.3%, 93.6% vs. 93.8% and 89.0% vs. 90.3%. Kappa value was 0.829 vs. 0.842, indicating good consistency. AUC area was 0.908 ± 0.027 vs. 0.918 ± 0.025, 95%CI = (0.856-0.960) vs. (0.869-0.966), p < 0.001, indicating higher diagnositic value. Besides, compared with frozen pathology, cytological detection was easily and rapid. The time-taking between frozen pathology and cytological detection or PTH detection were 39.0 ± 6.59 min vs. 5.02 ± 0.78 min and 39.0 ± 6.59 min vs. 6.1 ± 1.23 min, p < 0.001. In conclusion, intra-operative cytological detection maybe potential for in-situ preservation of parathyroid glands.
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Affiliation(s)
- Hongliang Wei
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an 710032, China
| | - Meiling Huang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an 710032, China
| | - Jing Fan
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an 710032, China
| | - Ting Wang
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an 710032, China
| | - Rui Ling
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an 710032, China
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Abstract
Surgical hypoparathyroidism is the most common cause of hypoparathyroidism and the result of intentional or inadvertent extirpation, trauma, or devascularization of the parathyroid glands. Surgical hypoparathyroidism may present as a medical emergency. Pediatric patients, those with Graves disease, and those undergoing extensive neck dissections or reoperative neck surgery are at particular risk for this complication. Extensive surgical expertise, immediate or delayed autotransplantation, and prophylactic and postoperative calcium/vitamin D supplementation in select patients are associated with a reduction in the risk of surgical hypoparathyroidism. Intraoperative parathyroid imaging is among novel strategies being investigated to mitigate surgical hypoparathyroidism in the intraoperative setting.
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Affiliation(s)
- Hadiza S Kazaure
- Section of Endocrine Surgery, Department of Surgery, Duke Cancer Institute, Duke University Medical Center, Box 2945, Durham, NC 27710, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, Suite S320, Box 0104, San Francisco, CA 94143, USA.
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13
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Davis JR, Dackiw AP, Holt SA, Nwariaku FE, Oltmann SC. Rapid Relief: Thyroidectomy is a Quicker Cure than Radioactive Iodine Ablation (RAI) in Patients with Hyperthyroidism. World J Surg 2018; 43:812-817. [PMID: 30483883 DOI: 10.1007/s00268-018-4864-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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14
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Htun HM, Edmiston R, Kaimal K, Kumar BN. Variable management of postoperative hypoparathyroidism at nine NHS trusts in north-west England: The need for a universal protocol. Clin Otolaryngol 2018; 43:1583-1587. [PMID: 30063291 DOI: 10.1111/coa.13205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 05/11/2018] [Accepted: 06/10/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Hay Mar Htun
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Rachel Edmiston
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Krishna Kaimal
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - B N Kumar
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Karunakaran P, Maharajan C, Ramalingam S, Rachmadugu SV. Is hungry bone syndrome a cause of postoperative hypocalcemia after total thyroidectomy in thyrotoxicosis? A prospective study with bone mineral density correlation. Surgery 2018; 163:367-372. [DOI: 10.1016/j.surg.2017.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/15/2017] [Accepted: 09/03/2017] [Indexed: 10/25/2022]
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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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Sonne-Holm E, Holst Hahn C. Prolonged Duration of Surgery Predicts Postoperative Hypoparathyroidism among Patients Undergoing Total Thyroidectomy in a Tertiary Referral Centre. Eur Thyroid J 2017; 6:255-262. [PMID: 29071238 PMCID: PMC5649273 DOI: 10.1159/000470840] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/11/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative hypoparathyroidism is a common complication following total thyroidectomy. The aim of this study was to investigate the incidence of both transient and permanent hypoparathyroidism in patients undergoing total thyroidectomy in a tertiary referral centre and, furthermore, to identify early predictive risk factors. METHODS Based on a single-institution retrospective review, we identified 582 patients who underwent total thyroidectomy between January 2010 and March 2015. Information on age, gender, pathological diagnosis, duration of surgery, autotransplantation of parathyroid glands, neck dissection, and experience and position of the surgeon was retrieved from the medical records. Furthermore, serum levels of parathyroid hormone and calcium were registered pre- and postoperatively and after 3 and 12 months. RESULTS The incidence of transient hypoparathyroidism during the first 24 h and 3 months after surgery was 47.8 and 17.8%, respectively. Furthermore, the incidence of permanent hypoparathyroidism 1 year after surgery was 10.7%. A prolonged duration of surgery was significantly associated with hypoparathyroidism. Moreover, autotransplantation of parathyroid glands was a significant predictor of transient hypoparathyroidism after 24 h and 3 months, but was not associated with permanent hypoparathyroidism. CONCLUSIONS Transient and permanent hypoparathyroidism is common among patients undergoing total thyroidectomy in a tertiary referral centre. A duration of surgery >120 min constitutes an independent risk factor due to the risk of ischaemic damage. Regain of function of devascularized parathyroid glands must be expected to last at least 1 year postoperatively. Furthermore, the recovery of autotransplanted parathyroid glands should not be evaluated within 1-3 months after surgery.
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Affiliation(s)
- Emilie Sonne-Holm
- *Emilie Sonne-Holm, Schacksgade 11, 4tv, DK–1365 Copenhagen K (Denmark), E-Mail
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Is Decline Rate of Intact Parathyroid Hormone Level a Reliable Criterion for Early Discharge of Patients after Total Thyroidectomy? IRANIAN JOURNAL OF OTORHINOLARYNGOLOGY 2017; 29:239-246. [PMID: 28955671 PMCID: PMC5610371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Parathyroid dysfunction leading to symptomatic hypocalcemia is not uncommon following a total thyroidectomy and is often associated with significant patient morbidity and a prolonged hospital stay. The current study aimed at evaluating the comparative predictive role of serum calcium and intact parathyroid hormone (iPTH) for post-thyroidectomy hypocalcemia. MATERIALS AND METHODS This prospective study was performed in 83 consecutive patients undergoing total thyroidectomy. Laboratory data such as serum calcium, vitamin D level, serum iPTH and serum phosphorus levels before surgery, postoperative calcium, and PTH levels measured after 1 and 6 hours and on the first postoperative day (1POD) were recorded. RESULTS Among the 83 patients, the mean (SD) age was 45.87 (12.57) years (range, 21-72 years); 70 (84.3%) patients were female. Final pathology was benign for 47 (56.6%) patients and malignant for 36 (43.4%) patients. In total, lymph node dissections were performed in 19 subjects (22.9%). On histological examination of the specimens, the parathyroid gland was found to have been removed inadvertently in 13 (15.7%) cases. In total, 35 (40.9%) patients developed hypocalcemia after thyroidectomy; receiver operating characteristic (ROC) analysis showed that a cut-off value of 15.39 pg/ml for iPTH, with a decline rate of 73% 1 hour after thyroidectomy is a significant predictor of hypocalcemia (area under the curve [AUC], 0.878; 95% confidence interval [CI], 0.79-0.96, P<0.0001) compared with calcium <8 mg/dl (2 mmol/L) with AUC=0.639; 95% CI, 0.51-0.76); P=0.067). CONCLUSION The current study showed that the decline rate in iPTH is a more reliable factor for hypocalcemia after total thyroidectomy than serum calcium. Patients with a decline rate <73% in iPTH could be discharged at 1POD without supplementation.
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Tartaglia F, Giuliani A, Sorrenti S, Tromba L, Carbotta S, Maturo A, Carbotta G, De Anna L, Merola R, Livadoti G, Pelle F, Ulisse S. Early discharge after total thyroidectomy: a retrospective feasibility study. G Chir 2017; 37:250-256. [PMID: 28350971 DOI: 10.11138/gchir/2016.37.6.250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM The continued hospitalization after total thyroidectomy is often due to the onset of hypocalcemic complications more than 24 hours after surgery. So it would be important to predict which patients will not develop the hypocalcemic complication to discharge them early. This was the aim of our study. PATIENTS AND METHODS Our retrospective study was conducted on 327 consecutive thyroidectomized patients, operated on for benign and malignant diseases. We evaluated the values of preoperative serum calcium levels (Cal0) and of the first postoperative day (Cal1) and two new variables were calculated (dCal and dCaln). The same thing was made on a subgroup of 111 patients in whom also parathiroyd hormone (PTH) values were detected. Statistical analysis was performed with the goal of determining if we could establish a safe criterion for discharge at 24 hours after surgery and if there is a correlation between suitability for discharge and diagnosis. RESULTS As to discharge, the predictive power of the discriminant function applied was significant both on the total of patients and in the subgroup of 111 patients, but it was clinically unacceptable because it would expose us to a 21% to 27% error rate. It is not possible to identify a threshold, below which to consider patients surely dischargeable. The diagnosis does not appear correlated with the suitability for discharge. CONCLUSION On the basis of serum calcium and PTH levels in the first postoperative day, it is impossible to predict which patients can be discharged 24 hours after surgery without incurring in hypocalcemic complications.
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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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Brekke A, Elfenbein DM, Madkhali T, Schaefer SC, Shumway C, Chen H, Schneider DF, Sippel RS, Balentine C. When patients call their surgeon's office: an opportunity to improve the quality of surgical care and prevent readmissions. Am J Surg 2015; 211:599-604. [PMID: 26762830 DOI: 10.1016/j.amjsurg.2015.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 11/07/2015] [Accepted: 11/09/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about care coordination and communication with outpatient endocrine surgery patients. This study evaluated phone calls between office nurses and surgical patients to identify common issues addressed and their effect on patient care. METHODS Qualitative analysis of preoperative and postoperative phone conversations between office nurses and endocrine surgery patients. RESULTS We identified 183 thyroidectomy patients with 38% contacting our office before surgery and 54% within 30 days after surgery. Common reasons for preoperative calls included questions about preoperative evaluation (21%), medications (18%), and insurance and/or work paperwork (12%). Postoperatively, common topics included medications (23%), laboratory results (23%), and concerns about wounds (12%). Nursing staff prevented unnecessary readmission in 7 patients (4%) whereas appropriately referring 16 (9%) for early evaluation. CONCLUSIONS Patients frequently contact their surgeons before and after endocrine surgery cases. Our findings suggest several areas for improving communication with patients.
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Affiliation(s)
- Andrew Brekke
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Dawn M Elfenbein
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Tariq Madkhali
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Sarah C Schaefer
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Cindy Shumway
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Herbert Chen
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - David F Schneider
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375
| | - Courtney Balentine
- Department of Surgery, University of Wisconsin, 600 Highland Avenue Madison, WI 53792-7375.
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White MG, James BC, Nocon C, Nagar S, Kaplan EL, Angelos P, Grogan RH. One-hour PTH after thyroidectomy predicts symptomatic hypocalcemia. J Surg Res 2015; 201:473-479. [PMID: 27020834 DOI: 10.1016/j.jss.2015.11.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/12/2015] [Accepted: 11/18/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND A major morbidity after total thyroidectomy is hypocalcemia. Although many clinical factors and laboratory studies have been correlated with both biochemical and symptomatic hypocalcemia, the ideal use and timing of these tests remain unclear. We hypothesize 1-h (PACU) parathyroid hormone (PTH) will identify patients at risk for symptomatic hypocalcemia. METHODS This prospective study evaluated 196 patients undergoing total thyroidectomy. Serum calcium and PTH levels were measured 1 h after surgery and on postoperative day 1 (POD1). Performance of a central compartment lymph node dissection, parathyroid autotransplantation, indication for procedure, pathology, and presence of parathyroid tissue in the pathology specimen were recorded. RESULTS Of 196 patients, nine (4.6%) developed symptomatic hypocalcemia. Thirty four (17.3%) had a 1-h PACU PTH ≤10 pg/dL, whereas 31 (15.8%) had a POD1 PTH of ≤10. Five (56%) of the nine symptomatic patients underwent central compartment lymph node dissection, four (44%) had parathyroid autotransplantation, and four (44%) had a PACU PTH ≤10. PACU and POD1 PTH levels were correlated (R(2) = 0.682). Multivariate regression identified central compartment dissection, autotransplantation, and PACU or POD1 PTH correlated with symptomatic hypocalcemia. PACU PTH, POD1 PTH, PACU Ca, malignant final pathology, and age ≤45 y correlated with biochemical hypocalcemia. CONCLUSIONS A 1-h postoperative PACU PTH is equivalent to POD1 PTH in predicting the development of symptomatic hypocalcemia. Biochemical hypocalcemia was not predictive of symptoms in the immediate postoperative period. Lymph node dissection and parathyroid autotransplantation correlated with symptomatic hypocalcemia and improve the sensitivity of biochemical screening alone.
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Affiliation(s)
- Michael G White
- Endocrine Surgery Research Group in the Department of Surgery, The University of Chicago Medicine 5841 S. Maryland Ave MC 4052, Chicago IL 60637
| | - Benjamin C James
- Endocrine Surgery Research Group in the Department of Surgery, The University of Chicago Medicine 5841 S. Maryland Ave MC 4052, Chicago IL 60637
| | - Cheryl Nocon
- Section of Otolaryngology in the Department of Surgery, The University of Chicago Medicine 5841 S. Maryland Ave MC 1035, Chicago IL 60637
| | - Sapna Nagar
- Endocrine Surgery Research Group in the Department of Surgery, The University of Chicago Medicine 5841 S. Maryland Ave MC 4052, Chicago IL 60637
| | - Edwin L Kaplan
- Endocrine Surgery Research Group in the Department of Surgery, The University of Chicago Medicine 5841 S. Maryland Ave MC 4052, Chicago IL 60637
| | - Peter Angelos
- Section of Otolaryngology in the Department of Surgery, The University of Chicago Medicine 5841 S. Maryland Ave MC 1035, Chicago IL 60637
| | - Raymon H Grogan
- Endocrine Surgery Research Group in the Department of Surgery, The University of Chicago Medicine 5841 S. Maryland Ave MC 4052, Chicago IL 60637
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Abstract
Outpatient thyroid surgery is controversial because of concerns over life-threatening cervical hematoma. Despite this concern, outpatient thyroidectomy is becoming increasingly common, especially among high-volume endocrine surgeons. Multiple studies have now demonstrated that careful patient selection combined with surgeon experience can result in successful and safe surgery without a full inpatient admission. This article reviews the data on safety and outcomes for outpatient thyroidectomy and discusses several techniques used to minimize risk to patients.
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Affiliation(s)
- Courtney J Balentine
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, K3/704 Clinical Science Center, Madison, WI 53792-7375, USA
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, K3/704 Clinical Science Center, Madison, WI 53792-7375, USA.
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McFadden D, Souba WW. Change is good! The Journal of Surgical Research: 2014-2015. J Surg Res 2015; 197:1-4. [PMID: 25982043 DOI: 10.1016/j.jss.2015.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David McFadden
- Department of Surgery, University of Connecticut Health Center, Hartford, CT.
| | - Wiley W Souba
- Department of Surgery, Dartmouth College of Medicine, Hanover, NH
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Ritter K, Elfenbein D, Schneider DF, Chen H, Sippel RS. Hypoparathyroidism after total thyroidectomy: incidence and resolution. J Surg Res 2015; 197:348-53. [PMID: 25982044 DOI: 10.1016/j.jss.2015.04.059] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/26/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Parathyroid hormone (PTH) levels are often measured after thyroid surgery and are used to detect patients at risk for postoperative hypoparathyroidism. However, there is a lack of consensus in the literature about how to define the recovery of parathyroid gland function and when to classify hypoparathyroidism as permanent. The goals of this study were to determine the incidence of low postoperative PTH in total thyroidectomy patients and to monitor their time course to recovery of parathyroid gland function. METHODS We identified 1054 consecutive patients who underwent a total or completion thyroidectomy from January, 2006-December, 2013. Low PTH was defined as a PTH measurement <10 pg/mL immediately after surgery. Patients were considered to be permanently hypoparathyroid if they had not recovered within 1 y. Recovery of parathyroid gland function was defined as PTH ≥10 pg/mL and no need for therapeutic calcium or activated vitamin D (calcitriol) supplementation to prevent hypocalcemic symptoms. RESULTS Of 1054 total thyroidectomy patients, 189 (18%) had a postoperative PTH <10 pg/mL. Of those 189 patients, 132 (70%) showed resolution within 2 mo of surgery. Notably, 9 (5%) resolved between 6 and 12 mo. At 1 y, 20 (1.9%) were considered to have permanent hypoparathyroidism. Surprisingly, 50% of those patients had recovery of PTH levels yet still required supplementation to avoid symptoms. CONCLUSIONS Most patients with a low postoperative PTH recover function quickly, but it can take up to 1 y for full resolution. Hypoparathyroidism needs to be defined not only by PTH levels but also by medication requirements.
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Affiliation(s)
- Kathryn Ritter
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dawn Elfenbein
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David F Schneider
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Herbert Chen
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rebecca S Sippel
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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26
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Aggeli C, Zografos G, Nixon A, Tsipras I. Postoperative hypoparathyroidism after thyroid surgery. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13126-015-0193-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Oltmann SC, Brekke AV, Schneider DF, Schaefer SC, Chen H, Sippel RS. Preventing postoperative hypocalcemia in patients with Graves disease: a prospective study. Ann Surg Oncol 2014; 22:952-8. [PMID: 25212835 DOI: 10.1245/s10434-014-4077-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypocalcemia occurs after total thyroidectomy (TT) for Graves disease via parathyroid injury and/or from increased bone turnover. Current management is to supplement calcium after surgery. This study evaluates the impact of preoperative calcium supplementation on hypocalcemia after Graves TT. METHODS A prospective study of patients with Graves disease undergoing TT was performed. Patients with Graves disease managed over a 9-month period took 1 g of calcium carbonate (CC) three times a day for 2 weeks before TT. Those managed the previous year without supplementation served as historic controls. Age-, gender-, and thyroid weight-matched, non-Graves TT patients were procedure controls. Patient demographics, postoperative laboratory values, complaints, and medications were reviewed. Parathyroid hormone (PTH)-based postoperative protocols dictated postoperative CC and calcitriol use. RESULTS Forty-five patients with Graves disease were treated with CC before TT, and 38 patients with Graves disease were not. Forty control subjects without Graves disease were identified. Age, gender, and thyroid weight were comparable. Preoperative calcium and PTH levels were equivalent. PTH values immediately after surgery, at postoperative day 1, and at 2-week follow-up were equivalent. Postoperative use of scheduled CC (p = 0.10) and calcitriol (p = 0.60) was similar. Postoperatively, patients with untreated Graves disease had lower serum calcium levels than pretreated patients with Graves disease or control subjects without Graves disease (8.3 mg/dL vs. 8.6 vs. 8.6, p = 0.05). Complaints of numbness and tingling were more common in nontreated Graves disease (26%) than in pretreated Graves disease (9%) or in control subjects without Graves disease (10%, p < 0.05). CONCLUSIONS Calcium supplementation before TT for Graves disease significantly reduced biochemical and symptomatic postoperative hypocalcemia. Preoperative calcium supplementation is a simple treatment that can reduce symptoms of hypocalcemia after Graves TT.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, Madison, WI, USA
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Rivere AE, Brooks AJ, Hayek GA, Wang H, Corsetti RL, Fuhrman GM. Parathyroid Hormone Levels Predict Posttotal Thyroidectomy Hypoparathyroidism. Am Surg 2014. [DOI: 10.1177/000313481408000835] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We hypothesized that parathyroid hormone (PTH) determination would be the most effective strategy to identify posttotal thyroidectomy hypoparathyroidism (PTTHP) compared with other clinical and laboratory parameters. We retrospectively reviewed our recent experience with total thyroidectomy. We recorded demographics, malignancy, thyroid weight, parathyroid autotransplantation, hospital stay, use of postoperative calcium and hormonally active vitamin D3 (calcitriol), and postoperative serum calcium and PTH levels. Patients were divided into two groups depending on whether supplemental calcitriol was required to maintain eucalcemia and therefore reflecting the diagnosis of PTTHP. From October 2010 to June 2013, a total of 202 total thyroidectomies were performed. Twenty-four patients (12%) developed PTTHP and required calcitriol replacement. Logistic regression analysis revealed that only postoperative calcium levels ( P = 0.02) and PTH levels ( P < 0.0001) statistically significantly predicted PTTHP. Twenty-two of 29 patients with PTH 13 pg/mL or less had PTTHP. Only two of 173 patients with a PTH level greater than 13 pg/mL were diagnosed with PTTHP. We recommend using PTH levels after total thyroidectomy to determine which patients will have hypoparathyroidism requiring calcitriol therapy. An early determination of PTTHP allows for prompt management that can shorten hospital stay and improve outcomes.
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Affiliation(s)
- Amy E. Rivere
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Ashton J. Brooks
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana; and
| | - Genevieve A. Hayek
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana; and
| | - Heng Wang
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Ralph L. Corsetti
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana; and
| | - George M. Fuhrman
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
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Mok VM, Oltmann SC, Chen H, Sippel RS, Schneider DF. Identifying predictors of a difficult thyroidectomy. J Surg Res 2014; 190:157-63. [PMID: 24750986 DOI: 10.1016/j.jss.2014.03.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/05/2014] [Accepted: 03/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS. METHODS A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P<0.05) variables from a univariate analysis. RESULTS A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P=0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P=0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P=0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23-15.36, P=0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28-9.66, P=0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06-6.42, P=0.037) were independently associated with DT. CONCLUSIONS Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.
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Affiliation(s)
- Valerie M Mok
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Sarah C Oltmann
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Herbert Chen
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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