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Chen C, Gao D, Luo L, Qu R, Hu X, Wang Y, Guo Y. Parathyroid preservation in total endoscopic thyroid surgeries via the mammary areolas approach: Real-world data from a single center. Asian J Surg 2023; 46:5421-5428. [PMID: 37344318 DOI: 10.1016/j.asjsur.2023.05.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/22/2023] [Accepted: 05/31/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Preserving parathyroid glands in situ is crucial to avoid surgical hypoparathyroidism, but it is also one of the greatest challenges during thyroid surgery. Magnified endoscopic imaging has been proposed as a way to improve parathyroid preservation. METHODS 2,603 consecutive patients who underwent thyroid surgery at the First People's Hospital of Zunyi from January 2018 to July 2022 were screened. 1,355 patients were eligible, including 965 endoscopic and 390 open cases. Parathyroid hormone (PTH) loss levels and severe parathyroid injury rates were compared between endoscopic and open cases. Meanwhile, factors that contribute to parathyroid injuries were assessed, including surgical extent, tumor size, carbon nanoparticle guidance, and surgical proficiency. RESULTS PTH loss levels were similar between endoscopic and open cases (P = 0.440). The incidence of severe parathyroid injuries was also comparable (7.8% for endoscopic vs. 6.9% for open, P = 0.592). The endoscopic group had higher rates of autologous parathyroid transplantation (39.5% vs. 24.4%, P = 0.000), while accidental parathyroidectomy rates were similar (11.4% vs. 10.8%, P = 0.739). Among patients who received the same extent of thyroid surgeries, no significant difference was found in PTH loss levels and severe parathyroid injury rates, except for a higher risk of severe parathyroid injuries in endoscopic bilateral thyroidectomy (18.52% vs. 11.52%, P = 0.033). CONCLUSIONS Despite the magnified endoscopic imaging facilitating the identification of parathyroid tissues, endoscopic approaches are not superior to open ones for the in-situ preservation of parathyroid glands. For a bilateral thyroidectomy, open approaches are safer for parathyroid preservation.
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Affiliation(s)
- Chen Chen
- Breast and Thyroid Center, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Fenghuang N Rd, 563000, Zunyi, Guizhou, China.
| | - Dan Gao
- Breast and Thyroid Center, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Fenghuang N Rd, 563000, Zunyi, Guizhou, China.
| | - Libo Luo
- Breast and Thyroid Center, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Fenghuang N Rd, 563000, Zunyi, Guizhou, China.
| | - Rui Qu
- Breast and Thyroid Center, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Fenghuang N Rd, 563000, Zunyi, Guizhou, China.
| | - Xiaochi Hu
- Breast and Thyroid Center, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Fenghuang N Rd, 563000, Zunyi, Guizhou, China.
| | - Yixiao Wang
- Department of Surgery, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Fenghuang N Rd, 563000, Zunyi, Guizhou, China.
| | - Youming Guo
- Breast and Thyroid Center, The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University), Fenghuang N Rd, 563000, Zunyi, Guizhou, China.
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Patient outcomes following thyroid surgery for thyrotoxicosis. J Laryngol Otol 2023; 137:308-311. [PMID: 35282842 DOI: 10.1017/s0022215122000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Total thyroidectomy can be used as a definitive treatment modality for thyrotoxicosis. This study assessed the outcomes of patients treated with surgery at a single secondary care site. METHOD A retrospective cohort study was conducted analysing consecutive patients who underwent thyroid surgery for thyrotoxicosis between 24 November 2000 and 26 April 2019 (n = 595). RESULTS Total thyroidectomy was performed in 95.4 per cent of patients. Two-thirds of patients had Graves' disease histology. Of patients, 22.8 per cent became transiently hypothyroid whilst on levothyroxine (thyroid hormone replacement therapy). Transient and persistent hypocalcaemia was present in 23.3 per cent and 2.8 per cent of patients respectively. Recurrent laryngeal nerve palsy was transient and persistent in 3.6 per cent and 0.3 per cent respectively. Of patients, 2.5 per cent developed post-operative haematomas that required surgical evacuation in the operating theatre. CONCLUSION The overall complication rate for thyroid surgery is higher in thyrotoxic than in euthyroid patients. Compared to other treatment modalities, total thyroidectomy appears to be the most effective, definitive means of managing Graves' disease.
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Hillary SL, Chooi JE, Wadsley J, Newell-Price JD, Brown NJ, Balasubramanian SP. Quality of Life in Post-Surgical Hypoparathyroidism (PoSH) in Thyroid and Parathyroid Surgery. World J Surg 2022; 46:3025-3033. [PMID: 36184675 PMCID: PMC9636109 DOI: 10.1007/s00268-022-06730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Post-surgical hypoparathyroidism (PoSH) is often long term, with significant associated morbidity and ongoing treatment. A recent systematic review found impaired quality of life (QoL) in patients with PoSH, despite stable treatment. Most studies did not include an appropriate control arm and further studies were recommended, taking into account underlying disease and comorbidities. This study aims to compare QoL in patients with PoSH with appropriate control groups. METHODS This was a cross-sectional observational study using the general quality of life SF-36 tool and a hypocalcaemia symptom score (HcSS) to assess QoL in patients with PoSH and controls (who had similar surgery but without PoSH). Participants were identified from two patient groups (the Butterfly Thyroid Cancer Trust and the Association for Multiple Endocrine Neoplasia Disorders) and a single tertiary centre in the UK. RESULTS Four hundred and thirty-nine responses (female n = 379, PoSH n = 89) were included with a median (range) age of 52 (19-92) years. Reported dates of surgery ranged from 1973 to 2019. HcSS scores showed significantly more associated symptoms in patients with PoSH than those without (p < 0.001). Although there was no overall difference in QoL between groups, patients with PoSH consistently had lower scores (p = 0.008) in the energy/fatigue subdomain of the SF-36. CONCLUSION Patients with PoSH reported significantly more fatigue and loss of energy compared to appropriately matched controls, but overall QoL was not significantly different. Standardised QoL measures may not be sensitive enough to highlight the impact on QoL in these patients. A disease-specific tool may be required.
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Affiliation(s)
- Sarah L Hillary
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - Je Ern Chooi
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Jonathan Wadsley
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Weston Park Hospital, Sheffield, UK
| | - John D Newell-Price
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nicola J Brown
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Saba P Balasubramanian
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Bashir AY, Alzubaidi AN, Bashir MA, Obed AH, Zakarneh RK, Ennab HZ, Abu-Hijleh OM, El-Zaheri MM, Bashir AA. The Optimal Parathyroid Hormone Cut-Off Threshold for Early and Safe Management of Hypocalcemia After Total Thyroidectomy. Endocr Pract 2021; 27:925-933. [PMID: 33652107 DOI: 10.1016/j.eprac.2021.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To define optimal intact parathyroid hormone (iPTH) cut-off threshold predictive of hypocalcemia after total thyroidectomy for safe and effective postoperative management. METHODS This prospective single center study was done in 2 phases. In phase I, predictors of symptomatic hypocalcemia were analyzed and the receiver operating characteristic curve was used to define the optimal iPTH cut-off threshold predictive of hypocalcemia. Phase II studied giving prompt prophylactic supplemental calcium and vitamin D to all patients who had iPTH levels below the calculated threshold, while phase I patients were given prompt selective supplementation if they had postoperative hypocalcemia or symptoms. RESULTS Univariate analysis of patients in phase I showed that postoperative iPTH was the only significant variable that can predict symptomatic hypocalcemia. Using receiver operating characteristic curve and Youden index, the confirmed optimal cut-off threshold predictive of hypocalcemia was iPTH 19.95 pg/mL, with area under the curve of 0.903, 100% sensitivity, negative predictive value, and highest Youden index, while iPTH 15 pg/mL and iPTH 10 pg/mL were less optimal. Symptomatic hypocalcemia occurred in 30% of the phase I cohort who received selective supplementation versus 3% of those in the phase II cohort who received prophylactic supplementation. Return to emergency department and need for intravenous calcium were also significantly better in phase II. CONCLUSION iPTH cut-off for post-thyroidectomy hypocalcemia was 19.95 pg/mL. Low-risk patients were discharged with no supplementation while all high-risk patients received prompt calcium and vitamin D supplementation, which led to effective hypocalcemia management and safe 24-hour discharge.
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Affiliation(s)
| | - Ahmad N Alzubaidi
- Department of Surgery, Jordan Hospital, Amman, Jordan; Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Aiman H Obed
- Department of Surgery, Jordan Hospital, Amman, Jordan
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Waseem T, Ahmed SZ, Baig H, Ashraf MH, Azim A, Azim KM. Truncal vs Branch Ligation of Inferior Thyroid Arteries in Total Thyroidectomy: Does It Affect Postoperative Hypoparathyroidism? Otolaryngol Head Neck Surg 2020; 164:759-766. [PMID: 32957817 DOI: 10.1177/0194599820957283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Postthyroidectomy hypoparathyroidism remains a significant challenge. Truncal ligation of the inferior thyroid arteries (ITAs) may lead to an increased risk of hypoparathyroidism; however, dissection along the thyroid capsule with branch ligation of the thyroid arteries could be a safer option. This study's objective was to compare the effect of truncal versus branch ligation of the ITAs on the rate of postoperative hypoparathyroidism. STUDY DESIGN Randomized prospective trial in line with the CONSORT guidelines. SETTING The study was conducted at a high-volume tertiary care setting. METHODS We randomized 319 patients into 2 groups: truncal ITA ligation (n = 157) and branch ITA ligation (n = 162). The primary outcomes were serum calcium and parathormone levels on the second postoperative day, followed by the levels on months 1, 3, 6, and 12. The need for exogenous replacements was noted. The secondary outcomes, such as operative time, blood loss, and other complications, were also recorded. RESULTS Our study revealed a significant difference in the incidence of transient hypocalcemia in patients undergoing truncal ITA ligation and branch ITA ligation (22.9% vs 3.1%, P < .05). The results showed that the levels of serum calcium and parathormone dropped on the second postoperative day and that 36 patients from the truncal ITA ligation group required exogenous calcium and vitamin D replacement. In contrast, only 5 patients from the branch ITA ligation group required the same. CONCLUSIONS This is the largest randomized trial of patients undergoing thyroidectomy, and it shows that dissection along the thyroid capsule with branch ligation of the ITAs is more likely to preserve parathyroid function as opposed to truncal ligation of ITAs.
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Affiliation(s)
- Talat Waseem
- Shalamar Endocrine and Surgical Oncology Center, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Safia Zahir Ahmed
- Shalamar Endocrine and Surgical Oncology Center, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Hadia Baig
- Shalamar Endocrine and Surgical Oncology Center, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Muhammad Hasham Ashraf
- Shalamar Endocrine and Surgical Oncology Center, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Asad Azim
- Shalamar Endocrine and Surgical Oncology Center, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Khawaja M Azim
- Shalamar Endocrine and Surgical Oncology Center, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Shalamar Medical and Dental College, Lahore, Pakistan
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Panuganti BA, Weissbrod PA, Somal J. Critical Care and Postoperative Management of the Head and Neck Patient. Otolaryngol Clin North Am 2020; 52:1141-1156. [PMID: 31677648 DOI: 10.1016/j.otc.2019.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.
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Affiliation(s)
- Bharat Akhanda Panuganti
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, 200 West Arbor Drive, MC# 8895, San Diego, CA 92103, USA
| | - Philip A Weissbrod
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, 200 West Arbor Drive, MC# 8895, San Diego, CA 92103, USA
| | - Jaspreet Somal
- Department of Anesthesiology and Critical Care, University of California San Diego, San Diego, CA, USA.
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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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8
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Taye A, Inabnet WB, Pan S, Carty SE, Cotton T, Czako P, Doherty G, Gauger P, Hanks J, McAneny D, Milas M, Perrier N, Rosen J, Schneider DF, Sharma J, Siperstein A, Sosa JA. Post-thyroidectomy emergency room visits and readmissions: Assessment from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP). Am J Surg 2020; 220:813-820. [PMID: 32115176 DOI: 10.1016/j.amjsurg.2020.02.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 02/07/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study analyzed independent factors associated with post-thyroidectomy Emergency Room (ER) visits and Hospital Readmissions (HR). METHODS This is a retrospective review from the CESQIP registry of 8381 thyroidectomy patients by 173 surgeons at 46 institutions. A total of 7142 ER visits and 7265 HR were analyzed. Multivariable logistic regression analysis was performed to determine the risk factors for an ER visit or HR. RESULTS Within 30-days of surgery, rates of all ER visits were 3.4% (n = 250) and all HR were 2.3% (n = 170). Hypocalcemia was the reason for 21.9% of ER encounters and 36.4% of HR. BMI >40 kg/m2 was a risk factor for both ER visit (OR1.86) and HR (OR1.94). Surgical duration >3 h (OR2.63), and transection of recurrent laryngeal nerve (OR4.58) were risk factors for HR. CONCLUSIONS Strategies to decrease hypocalcemia and improve perioperative care of patients with BMI >40 kg/m2 may improve post-thyroidectomy outcome.
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Affiliation(s)
- Aida Taye
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | | | - Stephanie Pan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh School of Medicine at University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Travis Cotton
- Department of Surgery, Brown University Warren Alpert School of Medicine at University Surgical Associates, Providence, RI, USA.
| | - Peter Czako
- Department of Surgery, Oakland University William Beaumont School of Medicine at Royal Oak Surgical Associates, Royal Oak, MI, USA.
| | - Gerard Doherty
- Department of Surgery, Harvard Medical School at Brigham and Women's Hospital, Boston, MA, USA.
| | - Paul Gauger
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA.
| | - John Hanks
- Department of Surgery, University of Virginia School of Medicine at University of Virginia Health Systems, Charlottesville, VA, USA.
| | - David McAneny
- Department of Surgery, Boston University School of Medicine at Boston Medical Center, Boston, MA, USA.
| | - Mira Milas
- Department of Surgery, University of Arizona College of Medicine at Banner-University Medical Center, Phoenix, AZ, USA.
| | - Nancy Perrier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jennifer Rosen
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.
| | - David F Schneider
- Department of Surgery, University of Wisconsin School of Medicine, Madison, WI, USA.
| | - Jyotirmay Sharma
- Department of Surgery, Emory University School of Medicine at Emory University Hospital, Atlanta, USA.
| | | | - Julie Ann Sosa
- Department of Surgery, University of California San Francisco-UCSF, San Francisco, CA, USA.
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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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Abstract
OBJECTIVE The aim of the study was to determine severe hypocalcemia rate following thyroidectomy and factors associated with its occurrence. BACKGROUND Hypocalcemia is the most common complication after thyroidectomy. Severe post-thyroidectomy hypocalcemia can be life-threatening; data on this specific complication are scarce. METHODS Patients who underwent thyroidectomy in the American College of Surgeons-National Surgical Quality Improvement Program thyroidectomy-targeted database (2016-2017) were abstracted. A severe hypocalcemic event was defined as hypocalcemia requiring intravenous calcium, emergent clinic/hospital visit, or a readmission for hypocalcemia. Multivariable regression was used to identify factors independently associated with occurrence of severe hypocalcemia. RESULTS Severe hypocalcemia occurred in 5.8% (n = 428) of 7366 thyroidectomy patients, with 83.2% necessitating intravenous calcium treatment. Rate of severe hypocalcemia varied by diagnosis and procedure (0.5% for subtotal thyroidectomy to 12.5% for thyroidectomy involving neck dissections). Overall, 38.3% of severe hypocalcemic events occurred after discharge; in this subset, 59.1% experienced severe hypocalcemia despite being discharged with calcium and vitamin D. Severe hypocalcemia patients had higher rates of recurrent laryngeal nerve injury (13.4% vs 6.6%), unplanned reoperations (4.4% vs 1.3%), and longer hospital stay (30.4% vs 6.2% ≥3 days (all P < 0.01). After multivariate adjustment, severe hypocalcemia was associated with multiple factors including Graves disease [odds ratio (OR) = 2.06], lateral neck dissections (OR: 3.10), and unexpected reoperations (OR = 3.55); all P values less than 0.01. CONCLUSIONS Severe hypocalcemia and suboptimal hypocalcemia management after thyroidectomy are common. Patients who experienced severe hypocalcemia had higher rates of nerve injury and unexpected reoperations, indicating surgical complexity and provider inexperience. More biochemical surveillance particularly a parathyroid hormone-based protocol, fine-tuned supplementation, and selective referral could reduce occurrence of this morbid complication.
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Karatzanis AD, Ierodiakonou DP, Fountakis ES, Velegrakis SG, Doulaptsi MV, Prokopakis EP, Daraki VN, Velegrakis GA. Postoperative day 1 levels of parathyroid as predictor of occurrence and severity of hypocalcaemia after total thyroidectomy. Head Neck 2018; 40:1040-1045. [DOI: 10.1002/hed.25081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/06/2017] [Accepted: 12/06/2017] [Indexed: 11/08/2022] Open
Affiliation(s)
- Alexander D. Karatzanis
- Department of Otorhinolaryngology; University of Crete Medical School; Heraklion Crete Greece
| | - Despo P. Ierodiakonou
- Division of Social and Public Medicine; University of Crete Medical School; Heraklion Crete Greece
| | - Emmanuel S. Fountakis
- Department of Otorhinolaryngology; University of Crete Medical School; Heraklion Crete Greece
| | - Stylianos G. Velegrakis
- Department of Otolaryngology - Head and Neck Surgery; University of Erlangen; Erlangen Germany
| | - Maria V. Doulaptsi
- Department of Otorhinolaryngology; University of Crete Medical School; Heraklion Crete Greece
| | - Emmanuel P. Prokopakis
- Department of Otorhinolaryngology; University of Crete Medical School; Heraklion Crete Greece
| | - Vasiliki N. Daraki
- Department of Endocrinology; University of Crete Medical School; Heraklion Crete Greece
| | - George A. Velegrakis
- Department of Otorhinolaryngology; University of Crete Medical School; Heraklion Crete Greece
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Liu JB, Sosa JA, Grogan RH, Liu Y, Cohen ME, Ko CY, Hall BL. Variation of Thyroidectomy-Specific Outcomes Among Hospitals and Their Association With Risk Adjustment and Hospital Performance. JAMA Surg 2018; 153:e174593. [PMID: 29188293 DOI: 10.1001/jamasurg.2017.4593] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Current surgical quality metrics might be insufficient to fully judge the quality of certain operations because they are not procedure specific. Hypocalcemia, recurrent laryngeal nerve (RLN) injury, and hematoma are considered to be the most relevant outcomes to measure after thyroidectomy. Whether these outcomes can be used as hospital quality metrics is unknown. Objectives To evaluate whether thyroidectomy-specific outcomes vary among hospitals, whether the addition of thyroidectomy-specific variables affects risk adjustment, and whether differences in hospital performance are associated with thyroidectomy-specific care processes. Design, Setting, and Participants In this retrospective cohort study, patients undergoing thyroidectomies from January 1, 2013, through December 31, 2015, at hospitals participating in the American College of Surgeons' National Surgical Quality Improvement Program were studied. Exposure Thyroidectomy-related care. Main Outcomes and Measures Clinically severe hypocalcemia, RLN injury, and clinically significant hematoma within 30 days of thyroid surgery and hospital-level performance variation, change in risk adjustment, and association with processes. Results Overall, 14 540 patients (mean [SD] age, 52.1 [15.0] years; 11 499 [79.1%] female) underwent operations at 98 hospitals. Because operations missing thyroidectomy-specific outcomes were excluded, the numbers of operations and hospitals analyzed differed by outcome. Of 14 540 operations included, clinically severe hypocalcemia occurred in 450 patients (3.3% overall, 0.6% after partial, and 4.7% after subtotal or total thyroidectomy), RLN injury in 755 patients (5.7% overall, 4.2% after partial, and 6.6% after subtotal or total thyroidectomy), and hematoma in 175 patients (1.3%). Hospital performance varied for hypocalcemia and RLN injury but not for hematoma. Hospital performance rankings were largely unaffected by the inclusion of thyroidectomy-specific data in risk adjustment. With regard to processes, patients undergoing thyroidectomies at the best-performing vs worst-performing hospitals less frequently had their postoperative parathyroid hormone level measured (593 [19.9%] vs 457 [31.7%], P < .001) and more often were prescribed oral calcium, vitamin D, or both (2281 [76.6%] vs 962 [66.8%], P < .001). When profiled by RLN injury, use of energy devices (1517 [69.1%] vs 507 [55.2%], P < .001) and intraoperative nerve monitoring (1223 [55.7%] vs 346 [37.7%], P < .001) were more prevalent at the best- compared with the worst-performing hospitals. Conclusions and Relevance Postoperative hypocalcemia and RLN injury, but not hematoma, potentially could be used as thyroidectomy-specific national hospital quality improvement metrics. Strategies aimed at reducing these complications after thyroidectomy may improve the care of these patients.
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Affiliation(s)
- Jason B Liu
- American College of Surgeons, Chicago, Illinois.,Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Julie A Sosa
- Surgical Center for Outcomes Research, Section of Endocrine Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Raymon H Grogan
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Yaoming Liu
- American College of Surgeons, Chicago, Illinois
| | | | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois.,Department of Surgery, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Bruce L Hall
- American College of Surgeons, Chicago, Illinois.,Center for Health Policy and the Olin Business School, Department of Surgery, Washington University at St Louis, St Louis, Missouri.,St Louis Veterans Affairs Medical Center, St Louis, Missouri.,BJC Healthcare, St Louis, Missouri
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13
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Al Khadem MG, Rettig EM, Dhillon VK, Russell JO, Tufano RP. Postoperative IPTH compared with IPTH gradient as predictors of post-thyroidectomy hypocalcemia. Laryngoscope 2017; 128:769-774. [PMID: 28842998 DOI: 10.1002/lary.26805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/24/2017] [Accepted: 06/26/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Predicting patients' risk for hypocalcemia after thyroidectomy may allow for same-day discharge. This study was designed to compare postoperative intact parathyroid hormone (IPTH) alone with percentage change in IPTH (IPTH gradient) in predicting post-thyroidectomy hypocalcemia. STUDY DESIGN Retrospective cohort study. METHODS Patients undergoing total thyroidectomy by the senior author from May 2015 to May 2016 were included. Serum IPTH was measured preoperatively and 1 hour postoperatively, and IPTH gradient was calculated. Postoperative hypocalcemia was mild (≥8.0, <8.4) or severe (<8.0 and/or hypocalcemic symptoms). Postoperative IPTH and IPTH gradient were compared with hypocalcemia using logistic regression. Receiver operating characteristic analysis of IPTH measures as predictors of hypocalcemia was performed, and the area under the curve (AUC) was calculated. RESULTS Overall, 119 patients were included. Forty-seven percent of the patients developed postoperative hypocalcemia, including 26 (22%) with mild and 30 (25%) with severe hypocalcemia. Thirteen patients had hypocalcemic symptoms. Median IPTH gradient and postoperative IPTH each differed significantly by category of hypocalcemia (P < .001). Higher IPTH gradient was significantly associated with odds of severe and symptomatic hypocalcemia (adjusted odds ratio [aOR]: 1.21, 95% confidence interval [CI]: 1.06-1.39 and aOR: 1.34, 95% CI: 1.05-1.71 per 10% increase), whereas lower postoperative IPTH was not (aOR: 1.27, 95% CI: 0.95-1.68 and aOR: 1.44, 95% CI: 0.90-2.31 per 10 pg/mL decrease). The AUC for predicting severe hypocalcemia was nonsignificantly higher for IPTH gradient than postoperative IPTH (AUC = 0.77 vs. 0.69, P = .10). The AUC for predicting symptomatic hypocalcemia was significantly higher for IPTH gradient (AUC = 0.75 vs. 0.72, P = .03). CONCLUSIONS Our results suggest that the IPTH gradient may be more useful than postoperative IPTH alone in predicting risk of post-thyroidectomy hypocalcemia. LEVEL OF EVIDENCE 4. Laryngoscope, 128:769-774, 2018.
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Affiliation(s)
- Mai G Al Khadem
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Eleni M Rettig
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Vaninder K Dhillon
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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Judge PD, Menousek J, Schramm JC, Cusick R, Lydiatt W. Does Surgical Volume Influence the Need for Second Surgery? A Pilot Study. OTO Open 2017; 1:2473974X17728257. [PMID: 30480193 PMCID: PMC6239034 DOI: 10.1177/2473974x17728257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/11/2017] [Accepted: 08/04/2017] [Indexed: 11/15/2022] Open
Abstract
Objective To examine outcomes of pediatric thyroidectomy in the context of training
background, institution, and experience of the surgeon. Study Design Case series with chart review. Setting A tertiary academic medical center and a pediatric hospital. Subjects and Methods Eighty-one thyroidectomy patients younger than 18 years. Outcomes were major
complications (recurrent laryngeal nerve injury, permanent hypocalcemia, and
wound infection), length of stay (LOS), and need for repeat surgery. Results Eighty-one patients, 39 from the University of Nebraska Medical Center and 42
from the Children’s Hospital and Medical Center–Omaha, were identified over
a 12-year time period. No difference was found in surgeon training
(otolaryngology/head and neck surgery vs general/pediatric surgery) for
complications (1 vs 1, odds ratio [OR] = 0.76, 95% confidence interval [CI]
= [0.05, 13.1]), LOS >1 day (5 vs 13, OR = 0.39, 95% CI = [0.13, 1.24]),
or need for second surgery (4 vs 7, OR = 1.47, 95% CI = [0.39, 5.49]).
Higher surgeon volume (≥12 surgeries) was found to be significant for
decreased need for second surgery (3 vs 8, OR = 6.67, 95% CI = [1.57,
27.17]). Patients of higher-volume surgeons were 4.2 times more likely to
stay in the hospital 1 day or less compared with those patients operated on
by surgeons with less experience (7 vs 11, 95% CI = [1.59, 15.0]). Conclusions Need for second surgery in pediatric thyroidectomy may be predicted by
surgical volume.
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Affiliation(s)
- Paul D Judge
- Otolaryngology/Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Joseph Menousek
- University of Nebraska Medical Center School of Medicine, Omaha, Nebraska, USA
| | - Jordan C Schramm
- Pediatric Otolaryngology, University of Utah, Primary Children's Hospital, Utah Valley Hospital, Provo, Utah, USA
| | - Robert Cusick
- Pediatric Surgery, Children's Hospital and Medical Center-Omaha, Omaha, Nebraska, USA
| | - William Lydiatt
- Head and Neck Surgical Oncology, Methodist Estabrook Cancer Center, Nebraska Methodist Health System, Omaha, Nebraska, USA
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15
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Inversini D, Rausei S, Ferrari CC, Frattini F, Anuwong A, Kim HY, Liu X, Wu CW, Tian W, Liu R, Dionigi G. Early intact PTH (iPTH) is an early predictor of postoperative hypocalcemia for a safer and earlier hospital discharge: an analysis on 260 total thyroidectomies. Gland Surg 2016; 5:522-528. [PMID: 27867867 DOI: 10.21037/gs.2016.09.08] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hypocalcemia is the most frequent complication after thyroidectomy. Serum calcium levels are reliable only 48-72 hours postoperatively. Early intact PTH (iPTH) has been proposed as early predictor of postoperative hypocalcemia. Our aim is to assess the ability of iPTH in predicting postoperative hypocalcemia. METHODS Two hundred and sixty patients underwent thyroidectomy with postoperative iPTH evaluation. The iPTH samplings were early performed after thyroidectomy. The calcium levels were dosed postoperatively. Age, sex, clinical diagnosis, obesity, comorbidities, previous neck surgery, preoperative therapy, type of surgery, dissectors used, lymphadenectomy, post-operative complications, reoperation and histological diagnosis were considered. The primary end-point was the postoperative hospital stay. The secondary end-points were serum calcium and iPTH. Three iPTH cut-offs were tested to assess which was the best value (10.0, 15.0, and 20.0 pg/mL). RESULTS The iPTH cut-off value of 10.0 pg/mL was the most accurate and specific for hypocalcemia. Comparing the iPTH value with the different values of calcium respectively 24 and 48 hours after surgery, a statistically stronger association with the serum calcium levels 48 hours postoperatively has been shown. iPTH ≥10 pg/mL 3-6 hours after surgery was strongly correlated to early discharge. CONCLUSIONS The correlation of iPTH with hypocalcemia is significant since a few hours after surgery and the value of iPTH ≥10 pg/mL is able to select those patients for a safe and early discharge. The use of the iPTH might avoid unnecessary extensions of hospitalization.
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Affiliation(s)
- Davide Inversini
- Division of General Surgery, Ospedale di Circolo, University of Insubria, Varese, Italy
| | - Stefano Rausei
- Division of General Surgery, Ospedale di Circolo, University of Insubria, Varese, Italy
| | - Cesare Carlo Ferrari
- Division of General Surgery, Ospedale di Circolo, University of Insubria, Varese, Italy
| | - Francesco Frattini
- Division of General Surgery, Ospedale di Circolo, University of Insubria, Varese, Italy
| | - Angkoon Anuwong
- Department of Surgery, Police General Hospital, Faculty of Medicine, Siam University, Bangkok, Thailand
| | - Hoon Yub Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Minimally Invasive Surgery and Robotic Surgery Center, KUMC Thyroid Center, Korea University, Anam Hospital, Seoul, Korea
| | - Xiaoli Liu
- Division of Thyroid Surgery, China-Japan Union Hospital, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin University, Changchun 130033, China
| | - Chei-Wei Wu
- Department of Otolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen Tian
- Department of General Surgery, the Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Renbin Liu
- Breast Cancer Center, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Gianlorenzo Dionigi
- Division of General Surgery, Ospedale di Circolo, University of Insubria, Varese, Italy
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Albuja-Cruz MB, Pozdeyev N, Robbins S, Chandramouli R, Raeburn CD, Klopper J, Haugen BR, McIntyre R. A “safe and effective” protocol for management of post-thyroidectomy hypocalcemia. Am J Surg 2015; 210:1162-8; discussion 1168-9. [DOI: 10.1016/j.amjsurg.2015.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/08/2015] [Accepted: 07/16/2015] [Indexed: 11/27/2022]
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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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18
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Finnerty BM, Brunaud L, Mirallie E, McIntyre C, Aronova A, Fahey TJ, Zarnegar R. Cost disparity between health care systems--it's not the surgeons: A cost analysis of thyroid cancer care between the United States and France. Surgery 2015; 159:132-40. [PMID: 26435427 DOI: 10.1016/j.surg.2015.06.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/04/2015] [Accepted: 06/03/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND The cost disparity between the United States and other advanced health care systems, including France, is expanding. In this report we identified the management of papillary thyroid cancer (PTC) that contribute to reimbursement disparity. METHODS A tri-institutional, retrospective review included 200 patients with PTC (100 from the United States, 100 from France) treated by total thyroidectomy with/without central neck dissection. A cost model was generated incorporating perioperative management variables (within 1 year) and their reimbursement rates according to the 2014 US Medicare and French government fee-schedules. RESULTS In the United States, total thyroidectomy with central neck dissection was more frequent (92% vs 35%, P < .001), median duration of stay was less (1 vs 3 days, P < .001), and use of radioactive iodine was less (66% vs 93%, P < .001), although Thyrogen stimulation was more prevalent (100% vs 43%, P < .001). Overall, the median cost per patient was greater in the United States ($14,069 vs $4,590, P < .001). Reimbursements to the hospital facility accounted for 70% of the disparity, despite lesser durations of stay. Nuclear medicine accounted for 19%, mostly from Thyrogen reimbursement despite less use of radioactive iodine. Surgeon fees accounted for 6%, followed by office visits, laboratory/imaging, anesthesia/pathology fees, and medications. CONCLUSION The costs of management of PTC are substantially greater in the US compared with France. Efforts to decrease this disparity should focus on reimbursements for hospital facility and use of nuclear medicine imaging.
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Affiliation(s)
- Brendan M Finnerty
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY.
| | - Laurent Brunaud
- Department of Digestive, Hepato-Biliary and Endocrine Surgery, Universit de Lorraine, CHU Nancy - Hospital Brabois Adultes, Nancy, France
| | - Eric Mirallie
- Department of Digestive and Endocrine Surgery, CCDE, IMAD, CHU Nantes, Nantes, France
| | - Caitlin McIntyre
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY
| | - Anna Aronova
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY
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19
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Importance of the intraoperative appearance of preserved parathyroid glands after total thyroidectomy. Surg Today 2015; 46:356-62. [DOI: 10.1007/s00595-015-1216-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/30/2015] [Indexed: 11/26/2022]
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20
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Schneider DF, Mazeh H, Oltmann SC, Chen H, Sippel RS. Novel thyroidectomy difficulty scale correlates with operative times. World J Surg 2015; 38:1984-9. [PMID: 24615607 DOI: 10.1007/s00268-014-2489-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate a new thyroidectomy difficulty scale (TDS) for its inter-rater agreement, correspondence with operative times, and correlation with complications. METHODS We developed a four item, 20-point TDS. Following cases where two board-certified surgeons participated, each surgeon completed a TDS, blinded to the other's responses. Paired sets of TDS scores were compared. The relationship between operative time and TDS scores was analyzed with linear regression. Multiple regression evaluated the association of TDS scores and other clinical data with operative times. RESULTS A total of 119 patients were scored using TDS. In this cohort, 22.7% suffered from hyperthyroidism, 37.8% experienced compressive symptoms, and 58.8% had cancer. The median total TDS score was 8, and both surgeons' total scores exhibited a high degree of correlation. Overall, 87.4% of the two raters' total scores were within one point of each other. Patients with hyperthyroidism received higher median scores than euthyroid patients (10 vs. 8, p < 0.01). Similarly, patients who suffered a complication had higher scores than those without complications (10 vs. 8, p = 0.04). TDS scores demonstrated a linear relation with operative times (R2 = 0.36, p < 0.01). Cases with a score of ≥14 took 41.0% longer compared to cases with scores of ≤5 (p < 0.01). In the multiple regression analysis, TDS scores independently predicted the operative time (p < 0.01). CONCLUSION The TDS is an accurate tool whose scores correlate with more difficult thyroidectomies as measured by complications and operative times.
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Affiliation(s)
- David F Schneider
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, K3/738, Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792, USA,
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21
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Al-Dhahri SF, Mubasher M, Al-Muhawas F, Alessa M, Terkawi RS, Terkawi AS. Early prediction of oral calcium and vitamin D requirements in post-thyroidectomy hypocalcaemia. Otolaryngol Head Neck Surg 2014; 151:407-14. [PMID: 24903452 DOI: 10.1177/0194599814536848] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To optimize and individualize post-thyroidectomy hypocalcemia management. STUDY DESIGN A multicenter prospective cohort study. SETTING Two tertiary care hospitals. SUBJECTS AND METHODS parathyroid hormone (PTH) was measured preoperatively, then at 1 and 6 hours after surgery. The required doses of calcium and vitamin D were defined as those maintaining the patients asymptomatic and their cCa ≥ 2 mmol/L. They were used as an endpoint in a generalized linear mixed effect model (GLIMMEX) aiming to identify the best predictors of these optimal required doses. Models were evaluated by goodness of fit and Receiver Operating Characteristic (ROC) curves. RESULTS One hundred and sixty-eight patients were analyzed; 85.1% were female, 49.3% had BMI > 30, and 64% had vitamin D deficiency. Post-thyroidectomy hypocalcemia was found in 25.6%, of whom 18 (41.9%) were symptomatic and received intravenous calcium. First hour percentage of drop in PTH correlated positively with the severity of hypocalcemia (P < .0001). The GLIMMIX prediction model for oral calcium requirement was based on first-hour percentage change from preoperative PTH level, preoperative actual PTH, BMI, and thyroid function. The same predictors were identified for vitamin D, except that thyroid function was replaced with vitamin D status. These factors were used to build predictive equations for calcium and vitamin D doses. CONCLUSION Our findings help to optimize management of post-thyroidectomy hypocalcemia by assisting in the early identification of those who are not at risk of hypocalcaemia and by guiding early effective management of those at risk. This may reduce complications and medical cost.
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Affiliation(s)
- Saleh F Al-Dhahri
- Department of Otolaryngology, Head and Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia Department of Otolaryngology, Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed Mubasher
- Department of Biostatistics, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fida Al-Muhawas
- Department of Otolaryngology, Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Alessa
- Department of Otolaryngology, Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | | | - Abdullah S Terkawi
- Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
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22
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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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Salinger EM, Moore JT. Perioperative indicators of hypocalcemia in total thyroidectomy: the role of vitamin D and parathyroid hormone. Am J Surg 2013; 206:876-81; discussion 881-2. [PMID: 24112673 DOI: 10.1016/j.amjsurg.2013.08.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 06/26/2013] [Accepted: 08/29/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hypocalcemia is a common complication of thyroidectomy. The aim of this study was to identify risk factors for this problem. METHODS This prospective analysis included 111 patients undergoing total or completion thyroidectomy. Preoperative vitamin D levels and postoperative day 1 parathyroid hormone levels were analyzed for their predictive effects on postoperative hypocalcemia. RESULTS Patients with ionized calcium <4.4 mg/dL had significantly lower mean parathyroid hormone levels than normocalcemic patients (13.0 vs 28.4 pg/mL, P < .001). Parathyroid hormone levels were also significantly lower in symptomatic patients (11.0 vs 28.4 pg/mL, P < .001). Preoperative vitamin D level, body mass index, gender, and pathologic findings were not associated with low calcium levels or symptoms of hypocalcemia. CONCLUSIONS Younger age and low postoperative parathyroid hormone levels are predictive of symptomatic hypocalcemia. A parathyroid hormone level outside of the reference range may indicate a need for more aggressive postoperative calcium supplementation and treatment with activated vitamin D. Older patients with normal postoperative parathyroid hormone levels may be safely discharged with appropriate calcium supplementation.
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Affiliation(s)
- Eric M Salinger
- Department of Graduate Medical Education, Exempla Saint Joseph Hospital, 1835 Franklin Street, Denver, CO 80218, USA.
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Díez M, Vera C, Ratia T, Diego L, Mendoza F, Guillamot P, San Román R, Mugüerza JM, Rodríguez Á, Medina C, Gómez B, Granell J. Efecto de la deficiencia de vitamina D sobre la hipocalcemia tras tiroidectomía total por bocio benigno. Cir Esp 2013. [PMID: 23201328 DOI: 10.1016/j.ciresp.2012.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Singer MC, Terris DJ. Parathyroid hormone decline 4 h after total thyroidectomy accurately predicts hypocalcemia. Surgery 2013; 153:437. [PMID: 23415601 DOI: 10.1016/j.surg.2012.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 12/17/2012] [Indexed: 11/25/2022]
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26
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Mazeh H, Khan Q, Schneider DF, Schaefer S, Sippel RS, Chen H. Same-day thyroidectomy program: Eligibility and safety evaluation. Surgery 2012; 152:1133-41. [DOI: 10.1016/j.surg.2012.08.033] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 08/20/2012] [Indexed: 11/29/2022]
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