Hypoparathyroidism after thyroidectomy: prevention, assessment and management

Iatrogenic Hypoparathyroidism Development After Thyroidectomy: A Retrospective Cohort Study

BACKGROUND

Iatrogenic hypoparathyroidism is a common cause of postthyroidectomy hypocalcaemia. It has varying incidence rates after neck surgery in Saudi Arabia, ranging from 0.07% to 65.30%. Hypoparathyroidism can manifest with a spectrum of symptoms, ranging from mild to severe and life-threatening. This study aimed to assess the rate and predictors of iatrogenic hypoparathyroidism after thyroid surgery and its natural course.

METHODS

This retrospective cohort study used a data collection form to extract patient information from the electronic healthcare system (Best-Care) for patients treated from 2017 to 2022. Patients' demographics, surgical specifics and biochemical profiles were recorded for subsequent analysis.

RESULTS

Among the 343 patients who underwent thyroidectomy, 130 (37.9%) developed hypoparathyroidism, primarily within the first day after surgery. Calcium or vitamin D supplementation before surgery did not significantly influence hypoparathyroidism development. Notably, extensive combined lymph node dissection was significantly associated with postoperative hypoparathyroidism development (p = 0.0004). More patients who underwent central and lateral lymph node dissection (n = 19, 79.17%) developed hypoparathyroidism than patients who underwent central (n = 18, 40.91%) or lateral (n = 8, 38.10%) dissection alone. Permanent hypoparathyroidism was observed in 40 patients (11.66%).

CONCLUSION

This study revealed a high incidence of iatrogenic hypoparathyroidism and high rates of permanent hypoparathyroidism. Further research is warranted to better comprehend the risk factors and optimise management strategies for iatrogenic hypoparathyroidism. Overall, our findings emphasise the need for vigilant monitoring and effective management of patients undergoing thyroidectomy and the significance of postoperative replacement therapies.

Three-year follow-up results of radiofrequency ablation for low-risk papillary thyroid microcarcinomas: Systematic review and meta-analysis

OBJECTIVES

Confidence in long-term treatment results of radiofrequency ablation (RFA) for papillary thyroid microcarcinoma (PTMC) is required in comparison with surgery and active surveillance (AS). The objective of this meta-analysis is to report more than three years of follow-up results of radiofrequency ablation for PTMCs.

METHODS

Ovid PUBMED, COCHRANE, and EMBASE databases were searched through Nov 19, 2023, for studies reporting outcomes in patients with PTMC treated with radiofrequency ablation and followed up for more than 3 years. The standard mean difference of the tumor volume before and after therapy, tumor recurrence, lymph node (LN) metastasis, distant metastasis, complications, and the pooled volume reduction rates (VRRs) at 1, 3, 6, 12, 24, 36, and 48 months after radiofrequency ablation were assessed. Data were extracted and methodological quality was assessed independently by two radiologists according to the PRISMA guidelines.

RESULTS

Eight studies, involving 2131 patients, met the inclusion criteria through database searches. The overall VRR was 99.81 % (95 % CI: 99.68, 99.95) in the last follow-up. During a mean pooled follow-up of 46.59 months, 69 patients experienced local PTMC recurrence, with 8 cases within the ablation area. Additionally, 44 patients were diagnosed with newly discovered PTMC, and 17 patients exhibited lymph node metastases. Among the patients with PTMC recurrence, 3 were under active surveillance while 59 underwent additional RFA. The pooled mean complication rate was 2.80 %, with no instances of life-threatening or delayed complications.

CONCLUSIONS

Radiofrequency ablation proves to be an effective local tumor control method for low-risk PTMC patients, resulting in clinically significant and enduring volume reduction. The rate of regrowth and retreatment requirement post-RFA was notably lower, positioning RFA as a compelling alternative to existing treatment options.

Management of patients with extensive locally advanced thyroid cancer: results of multimodal treatments

PURPOSE

Surgery plays a key role in the treatment of thyroid cancer (TC) patients. Locally advanced cases, however, can require an extensive surgical approach with technical issues and a high risk of complications. In these cases, a multidisciplinary evaluation should be carried out to evaluate pros and cons. The aim of this study was to share our experience, as a multidisciplinary team, in the management of patients with locally advanced TC with a particularly extensive local disease, whose surgical approach could be challenging and part of a multimodal treatment.

METHODS

We retrospectively evaluated clinical, surgical, and oncologic features of all patients with locally advanced TC who had undergone multidisciplinary surgery from January 2019 to June 2020.

RESULTS

Six patients (two cases each of poorly differentiated, papillary, and medullary TC) were included. Four out of six were suffering from symptoms related to the advanced disease. At pre-surgical evaluation, a multidisciplinary team proposed extended surgery with radical intent via cervicotomy and sternotomy, considering other therapies not feasible or probably ineffective without it. No one passed away in intra- or perioperative time. At the end of follow-up (median 2.6 years), all patients presented a remission of symptoms due to the advanced disease, four patients were submitted to adjuvant therapies and only one patient died for a cause unrelated to the disease.

CONCLUSION

This series of very advanced TCs shows the effectiveness of a surgery performed by a multidisciplinary team in controlling symptoms, allowing adjuvant therapies, and improving the survival of patients whose cases would otherwise be very difficult to manage.

Early parathyroid hormone (PTH) level as a predictor of post-surgical hypoparathyroidism

INTRODUCTION

Post-operative hypocalcemia and postoperative persistent hypoparathyroidism remain the most common complications after thyroidectomy. Many approaches have been developed to prevent them, but actually, a common protocol is not yet individuated.

MATERIALS AND METHODS

We retrospectively analyzed the results of a prospectively collected database. We dosed PTH preoperatively and 4 h after surgery (PTH_4); calcium was evaluated preoperatively, on the first (I_POD) and on the second postoperative day (II_POD). Hypocalcemia was defined when calcium <8 mg/dl. PTH_4 and I_POD calcium serum levels are identified to predict postoperative hypocalcemia.

RESULTS

Three hundred and forty-eight patients were enrolled, 37 patients resulted as hypocalcemic on I_POD and 41 on the II_POD. PTH_4 is related to I_POD (p < 0.001, r = 0.45) and II_POD (p < 0.001, r = 0.44) calcemia. PTH_4-cut-off predicting I_POD hypocalcemia was 10.50 pg/ml (sensitivity: 78.7%, specificity: 72.7%). A PTH_4 value of 11.5 pg/ml is able to predict hypocalcemia during II_POD (sensitivity: 76.5%, specificity: 69.2%). We set up a combined test to predict II_POD hypocalcemia, using PTH_4 and I_POD calcium (sensitivity: 77.8%, specificity: 89.9%).

CONCLUSION

This research shows the association between PTH_4 and postoperative hypocalcemia. The PTH_4 cut-off to predict I_POD-hypocalcemia was 10.5 pg/ml. We analyzed the calcemia trend during the postoperative period and we realized a combined test using PTH_4 and I_POD-calcemia. This test improves the accuracy of the previous test. Further studies, in particular multicentric, with a larger sample are necessary to validate the combined model.

The application of autofluorescence system contributes to the preservation of parathyroid function during thyroid surgery

PURPOSE

The purpose of this study was to investigate the impact of autofluorescence technology on postoperative parathyroid function and short-term outcomes in patients undergoing thyroid surgery.

METHODS

A total of 546 patients were included in the study, with 287 in the conventional treatment group and 259 in the autofluorescence group. Both groups underwent central lymph node dissection, which is known to affect parathyroid function. Short-term outcomes, including rates of postoperative hypocalcemia and parathyroid dysfunction, serum calcium and PTH levels on the first postoperative day, as well as the need for calcium supplementation, were analyzed. A multivariable analysis was also conducted to assess the impact of autofluorescence on postoperative parathyroid dysfunction, considering factors such as age, BMI, and preoperative calcium levels.

RESULTS

The autofluorescence group demonstrated significantly lower rates of postoperative hypocalcemia and parathyroid dysfunction compared to the conventional treatment group. The autofluorescence group also had better serum calcium and PTH levels on the first postoperative day, and a reduced need for calcium supplementation. Surprisingly, the use of autofluorescence technology did not prolong surgical time; instead, it led to a shorter hospitalization duration. The multivariable analysis showed that autofluorescence significantly reduced the risk of postoperative parathyroid dysfunction, while factors such as age, BMI, and preoperative calcium levels did not show a significant correlation.

CONCLUSION

This study provides evidence that autofluorescence technology can improve the preservation of parathyroid function during thyroid surgery, leading to better short-term outcomes and reduced postoperative complications. The findings highlight the potential of autofluorescence as a valuable tool in the management of parathyroid hypofunction. Further research and validation are needed to establish the routine use of autofluorescence technology in the thyroid.

Incidence of Post-Thyroidectomy Hypoparathyroidism and Associated Preoperative and Intraoperative Risk Factors

INTRODUCTION

Thyroidectomy technique and extent are related to parathyroid injury and hypoparathyroidism. Total thyroidectomy is one of the most commonly performed endocrine surgeries, and the majority of patients recover completely without any complications. However, persistent hypoparathyroidism is the most prevalent long-term consequence following total thyroidectomy. While it is seldom deadly, it can cause severe morbidity for the patient and raise healthcare expenses.

METHODS

This retrospective cohort study was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia. We included all confirmed thyroid cancer cases that underwent thyroidectomy with or without neck dissection between July 2016 and August 2022. The data was collected from a chart review of the electronic medical record system (BEST-care), and a data collection sheet was utilized. SPSS version 26 was used to analyze the data.

RESULTS

A total of 192 patients undergoing thyroid surgery were enrolled. One hundred forty-three (74.5%) were females and the mean age of participants was 45.29 ± 16.88 years. Most patients, 170 (88.5%), had a papillary histological type, and total thyroidectomy was performed in 150 (78.1%). A significant association was found between the type of surgery and postoperative hypoparathyroidism (p=<0.05*). In addition, hypocalcemia was seen in 147 (76.6%) of the patients. Postoperative hypoparathyroidism was significantly higher among patients who had asymptomatic postoperative hypocalcemia and those who received IV calcium gluconate (p=<0.05*). Moreover, postoperative hypocalcemia, hypomagnesemia, and hyperphosphatemia were significantly associated with postoperative hypoparathyroidism (p=<0.05*).

CONCLUSION

The incidence of postoperative hypoparathyroidism is significantly higher among patients who underwent total thyroidectomy and had a normal level of preoperative parathyroid hormone (PTH) and magnesium (Mg) levels. Identifying these factors is a crucial step to minimize the occurrence of such complications.

Development of a tool to calculate the probability of hypocalcemia after total thyroidectomy: a prospective study

PURPOSE

This study aimed to evaluate the ability of the percentage of decrease in serum PTH level in the first 8 h after total thyroidectomy (TT) to predict hypocalcemia requiring Ca supplementation and develop a tool to predict it.

METHODS

97 patients who underwent TT with measurement of preoperative parathyroid hormone (PTH) levels were prospectively evaluated 1 and 8 h after TT; postoperative magnesium (Mg2PO) and phosphorus levels were evaluated on the 2nd day after surgery. The percentage of decrease in PTH level 1 h (%dPTH1h) and 8 h (%dPTH8h) postoperatively and predictors of hypocalcemia requiring Ca supplementation were evaluated and an equation was developed to predict this outcome.

RESULTS

%dPTH1h (p = 0.002), %dPTH8h (p = 0.001) and (Mg2PO) (p < 0.01) were isolated predictors of postoperative hypocalcemia requiring Ca supplementation. The data obtained led to the development of two tools to predict this complication.

CONCLUSIONS

The percentage of decrease in PTH level 1 h and 8 h postoperatively and the magnesium level on the 2nd day after surgery were predictors of more severe hypocalcemia, and an auxiliary tool for predicting this complication was developed.

C-Cell Hyperplasia and Cystic Papillary Thyroid Carcinoma in a Patient with Type 1B Pseudohypoparathyroidism and Hypercalcitoninaemia: Case Report and Review of the Literature

Hypercalcitoninaemia has been described in patients with pseudohypoparathyroidism (PHP) type 1A and 1B. Elevated calcitonin levels are thought to result from impaired Gsα receptor signaling, leading to multiple hormone resistance. Evidence on the risk of medullary thyroid carcinoma (MTC) or C-cell hyperplasia in PHP patients with hypercalcitoninaemia is lacking. A 43-year-old Caucasian man was referred to our endocrinology clinic for chronic hypocalcemia associated with elevated serum parathormone levels and a single cystic thyroid nodule. The patient did not show skeletal deformities, and screening for concomitant hormone resistances was negative, except for the presence of elevated serum calcitonin levels. The workup led to a molecular diagnosis of sporadic PHP1B. Fine needle aspiration of the thyroid nodule was not diagnostic. The calcium stimulation test yielded an abnormal calcitonin response. Given the scarcity of data on the risk of thyroid malignancy in PHP and calcium stimulation test results, total thyroidectomy was performed. Histological examination revealed cystic papillary thyroid cancer in a background of diffuse C-cell hyperplasia. To our knowledge, we are the first to describe a rare form of thyroid cancer combined with C-cell hyperplasia in a patient with PHP and hypercalcitoninaemia. In the present case, a mere receptor resistance might not fully explain the elevated calcitonin levels, suggesting that hypercalcitoninaemia should be carefully evaluated in PHP patients, especially in the case of concomitant thyroid nodules. Further studies on larger cohorts are needed to elucidate this topic.

Endoscopic thyroidectomy via areola approach for stage T1 papillary thyroid carcinoma: feasibility, safety, and oncologic outcomes

Purpose

To evaluate the feasibility, safety, and oncologic outcomes associated with endoscopic thyroidectomy via the areolar approach (ETAA), compared with conventional open thyroidectomy (COT) for the treatment of stage T1 papillary thyroid carcinoma (PTC).

Methods

Between January 2021 and June 2022, a total of 1204 patients diagnosed with PTC underwent screening, out of which 138 patients were selected for inclusion in the study population after propensity score matching (92 patients in the ETAA group and 46 patients in the COT group). The study included the collection and analysis of clinicopathologic characteristics, intraoperative outcomes, postoperative outcomes, complications, and follow-up data using R software.

Results

The operative time for the ETAA group was longer than that for the COT group (160.42 ± 32.21 min vs. 121.93 ± 29.78 min, p < 0.0001). However, there were no significant differences between the two groups in terms of intraoperative blood loss, the extent of surgical resection, the number of dissected lymph nodes, the number of metastatic lymph nodes, and the rate of parathyroid autotransplantation. Postoperative drainage and C-reactive protein levels were higher in the ETAA group than in the COT group, but there were no significant differences in 24-hour visual analogue scale scores, white blood cell counts, drainage duration, or postoperative hospital stay. Complication rates were similar between the two groups, and no permanent recurrent laryngeal nerve palsy or hypoparathyroidism was observed. Patients who underwent ETAA reported greater cosmetic satisfaction and quality of life than those who underwent COT. During the follow-up phase, only one patient in the COT group developed lateral cervical lymph node involvement requiring reoperation.

Conclusion

ETAA is a safe and feasible surgical method for patients with stage T1 PTC, providing results similar to COT in terms of oncologic completeness, while avoiding neck scars, with excellent cosmetic effects.

Clinical trial registration

Chinese Clinical Trial Registry center, identifier ChiCTR2300077109.

Risk Factors for Calcium-Phosphate Disorders after Thyroid Surgery

INTRODUCTION

Iatrogenic hypoparathyroidism following thyroidectomy is one of the most common complications significantly reducing patients' quality of life.

OBJECTIVES

This study aimed to analyze the risk factors for calcium-phosphate disorders following thyroidectomy.

PATIENTS AND METHODS

The study group consisted of 211 patients who underwent thyroidectomy for different conditions in 2018-2020. Demographic, clinical and surgical risk factors were analyzed against hypoparathyroidism and hypocalcemia.

RESULTS

Hypoparathyroidism occurred in 15.63% of patients, and hypocalcemia occurred in 45% of those operated on. There was statistical significance between hypoparathyroidism and the extent of thyroid surgery: thyroidectomy vs. lobectomy (p = 0.02, OR = 4.5) and surgeon experience (p = 0.016, OR = 6.9). Low preoperative PTH levels were associated with a higher incidence of hypoparathyroidism (p = 0.055, OR = 0.9). There was a statistically significant correlation between the occurrence of hypocalcemia and preoperative vitamin D deficiency (p = 0.04, OR = 3.5). Low calcium levels before surgery were associated with a higher incidence of hypocalcemia (p = 0.051, OR = 0.5). Meta-analyses of selected risk factors confirmed that the most significant factor in the incidence of hypocalcemia was a decrease in PTH levels (p < 0.001).

CONCLUSIONS

The extent of thyroid surgery and the experience of the surgeon are the most significant risk factors for hypoparathyroidism. Hypocalcemia is much more common than hypoparathyroidism. Among the risk factors for hypocalcemia, in addition to the decrease in parathormone levels due to iatrogenic parathyroid damage, we should mention vitamin D deficiency in the preoperative period.

Effect of near infrared autofluorescence guided total thyroidectomy on postoperative hypoparathyroidism: a randomized clinical trial

PURPOSE

The purpose of this single-blinded, 2-centre, randomized controlled trial was to test if near-infrared (NIR) autofluorescence image guidance for parathyroid gland (PG) detection during total thyroidectomy can reduce the incidence of hypoparathyroidism in both malignant and benign cases.

METHOD

Patients admitted for primary or completion total thyroidectomy were randomized to either the NIR intervention group or the standard care NONIR (no near infrared) group. The primary endpoint was the rate of hypoparathyroidism at the 3-month follow-up, defined as hypocalcemia and inappropriately low parathyroid hormone levels and/or continuous treatment with active vitamin D. The secondary endpoint was the PG identification rate.

RESULTS

A total of 147 patients were included of whom 73 were allocated to NIR. Primary or completion thyroidectomy was conducted in 84 and 63 cases, respectively. A total of 130 completed 3 months follow-up. Postoperative hypoparathyroidism in the NIR group at 12 h, 1 month and 3 months was, respectively, 31.8, 14.1, 6.5% compared with 35.9, 18.9, 11.8% in the NONIR group (all p > 0.46). In the NIR group, the identification rate of PGs was 69.5% (146 of 210 PGs), and 9% (19 of 210 PGs) were identified only due to additional use of NIR. For 15 out of 69 patients (21.7%) additionally PGs was found.

CONCLUSION

Hypoparathyroidism was nominally less frequent in the NIR group, although not statistically significant. Further studies are needed to confirm if NIR may be a supportive PG identification tool to minimize the number of PG which would have been otherwise missed, especially during more complicated thyroid procedures.

TRIAL REGISTRY

ClinicalTrials.gov: NCT04193332. Registration date: 16.08.2019.

Preoperative ultrasound identification and localization of the inferior parathyroid glands in thyroid surgery

INTRODUCTION

The parathyroid glands are important endocrine glands for maintaining calcium and phosphorus metabolism, and they are vulnerable to accidental injuries during thyroid cancer surgery. The aim of this retrospective study was to investigate the application of high-frequency ultrasound imaging for preoperative anatomical localization of the parathyroid glands in patients with thyroid cancer and to analyze the protective effect of this technique on the parathyroid glands and its effect on reducing postoperative complications.

MATERIALS AND METHODS

A total of 165 patients who were operated for thyroid cancer in our hospital were included. The patients were assigned into two groups according to the time period of surgery: Control group, May 2018 to February 2021 (before the application of ultrasound localization of parathyroid in our hospital); PUS group, March 2021 to May 2022. In PUS group, preoperative ultrasound was used to determine the size and location of bilateral inferior parathyroid glands to help surgeons identify and protect the parathyroid glands during operation. We compared the preoperative ultrasound results with the intraoperative observations. Preoperative and first day postoperative serum calcium and PTH were measured in both groups.

RESULTS

Our preoperative parathyroid ultrasound identification technique has more than 90% accuracy (true positive rate) to confirm the location of parathyroid gland compared to intraoperative observations. Postoperative biochemical results showed a better Ca²⁺ [2.12(0.17) vs. 2.05(0.31), P=0.03] and PTH [27.48(14.88) vs. 23.27(16.58), P=0.005] levels at first day post-operation in PUS group compared to control group. We also found a reduced risk of at least one type of hypoparathyroidism after surgery in control group:26 cases (31.0%) vs. 41 cases (50.6%), p=0.016.

CONCLUSION

Ultrasound localization of the parathyroid glands can help in the localization, identification and in situ preservation of the parathyroid glands during thyroidectomy. It can effectively reduce the risk of hypoparathyroidism after thyroid surgery.

Effects of Intraoperative Nerve Monitoring Techniques on Voice and Swallowing Disorders after Uncomplicated Thyroidectomy: Preliminary Report of a Bi-Institutional Prospective Study

Background: Voice and swallowing problems are frequently associated with thyroidectomy. Intermittent nerve monitoring (i-IONM) seems to provide a positive effect in reducing its prevalence. The aim of this study was to test the hypothesis that continuous intraoperative nerve monitoring (c-IONM) may reduce the prevalence of these disorders even further than i-IONM. Methods: This 3-arm prospective bi-institutional study compared 179 consecutive patients that underwent thyroidectomy: 56 without IONM, 55 with i-IONM and 67 with c-IONM. Neck dissections and laryngeal nerve palsies were excluded. Two questionnaires (VHI-10 for voice disorders and EAT-10 for swallowing disorders; both validated for Italian language use) were administered before and 1 month after surgery. Statistical significance was analyzed by the chi-squared test. Results: After thyroidectomy, no statistically significant differences were found in the three groups concerning EAT-10. although these symptoms seemed to be influenced by gastro-esophageal reflux. VHI-10 worsened in the “no-IONM” group compared with both i-IONM (p < 0.09, not quite statistically significant) and c-IONM (p < 0.04). Conclusion: Both i- and c-IONM improve voice quality independently of laryngeal nerve integrity. Reduced dissection and particularly restrained manipulation could explain these results, being particularly favorable for c-IONM.

Prevalence and Risk Factors for Hypoparathyroidism Following Total Thyroidectomy in Taif City

Background Postoperative hypoparathyroidism has been investigated in health records and surgical cohorts, but the results have been highly variable and imprecise. It is not clear how often endocrinologists encounter this hormone deficit in clinical practice. Thus, the aim of this study is to determine the incidence of permanent hypoparathyroidism and the factors associated with it in a group of post-thyroidectomy patients followed at three tertiary care institutions in Taif city. Materials and Methods A retrospective cohort analysis was done to examine patients who had a total thyroidectomy in the city of Taif between January 1, 2015, and December 31, 2019. Patients were eligible for the study if they received total thyroidectomy, were above the age of 18 years, had surgical and pathological data available, and had been monitored in the same institution for at least a year after their thyroidectomy. Patients who did not return for follow-up care following surgery were excluded from the study. Results The incidence of hypoparathyroidism was 10.3%, and females had a higher prevalence (12.1%) than males (3.2%). In patients with two and three parathyroid glands, hypoparathyroidism was found to be more prevalent (33.3% and 25.5%) in permanent histological sections. There was no single independent risk factor for hypoparathyroidism according to a logistic regression model. Conclusion The incidence rate of hypoparathyroidism following total thyroidectomy was about 10.3%. There were no independent risk factors identified for hypoparathyroidism after total thyroidectomy. Permanent hypoparathyroidism severely affects the quality of life, and research should be done to prevent its incidence after thyroidectomy.

Surgical tips and techniques to avoid complications of thyroid surgery

Objectives

Surgery of the thyroid takes place in a body part with complicated anatomy and several vital physiologic functions. Thyroidectomy is rarely associated with mortality but can be followed by significant complications, (i.e. hypoparathyroidism, hemorrhage, upper airway obstruction, laryngeal nerve injuries and thyrotoxic storm). This review aims to indicate surgical tips and techniques to sustain a low level of complications.

Content

MEDLINE database (PubMed) platform was used as a search engine and the articles related to the topic were selected using the keywords combination "thyroid surgery and complications".

Summary and Outlook

The most common complication of total thyroidectomy with an occurrence ranging between 0.5 and 65% is hypoparathyroidism. Damage to recurrent laryngeal nerves can be temporary or permanent, unilateral or bilateral; bilateral lesion is associated with severe episodes of breathlessness. Thus, intraoperative monitoring of nerve function is essential to prevent damage. Ιn addition, hematoma formation can lead to breathing difficulties due to airway obstruction; preventive hemostasis during surgery is essential. The surgeon must have a complete anatomical understanding of not only the normal anatomy of the central visceral compartment of the neck, but also the common variations of the laryngeal nerves and parathyroid glands in order to keep the complication rate at a very low level.

Effectiveness of prophylactic calcium and vitamin D supplementation for preventing post-thyroidectomy hypocalcemia: a meta-analysis

Background: Postsurgical hypocalcemia is the most common and troublesome consequence of thyroidectomy. We investigated the potential role of routine calcium or vitamin D supplementation in preventing postsurgical hypocalcemia. Methods: We searched MEDLINE and Embase for English-language publications using the keywords “calcium,” “vitamin D,” and “thyroid cancer.” The primary outcome was any postoperative hypocalcemia, and the secondary outcome was symptomatic hypocalcemia. Results: Four studies that included 381 patients were eligible for this meta-analysis. A random-effects model showed no significant difference in the occurrence of hypocalcemia between calcium/vitamin D treatment and placebo/no treatment. However, the occurrence of symptomatic hypocalcemia was lower in patients with calcium/vitamin D treatment. In the combined results, preoperative calcium and vitamin D supplementation were associated with a reduced incidence of symptomatic hypocalcemia. Conclusions: Our findings support the use of preoperative calcium and vitamin D supplementation in conjunction with routine postsurgical supplementation for patients after total thyroidectomy.

Autologous parathyroid gland left brachioradialis transplantation: A single-center study and long-term follow-up

Parathyroid gland transplantation into the sternocleidomastoid muscle is effective, but it is not possible to confirm transplant survival with this method. In this study, we evaluated parathyroid autotransplantation into the brachioradialis muscle and its survival rate.

OBJECTIVES

To evaluate autologous parathyroid gland left forearm brachioradial muscle transplantation and its survival rate.

SUMMARY BACKGROUND DATA

The most commonly used transplantation site is the sternocleidomastoid muscle, but transplant survival cannot be confirmed using this method. Autologous parathyroid gland left forearm brachioradial muscle transplantation solves this problem, and we evaluate the transplant survival using this method.

METHODS

We followed-up patients who underwent thyroidectomy and autologous parathyroid left forearm brachioradial muscle transplantation in our center from September 2013 to January 2018. The last follow-up date was January 2021; all enrolled patients underwent at least 3 years of follow-up. We calculated the transplant survival rate at several time points.

RESULTS

We evaluated 238 transplanted cases, for which the long-term survival rate was 85.7% (204/238), and the short-term survival rate was 86.1% (205/238). Sixty-five cases had two parathyroid glands transplanted into the left forearm brachioradialis muscle. The long-term survival rate was 92.3% (60/65), and the short-term survival rate was 95.4% (62/65).

CONCLUSIONS

Autologous parathyroid gland left brachioradialis transplantation is a reliable, measurable method with good survival rate, and we recommend this method for consideration for transplanting parathyroid glands in thyroidectomy.

Hypoparathyroidism Risk After Total Endoscopic Thyroidectomy for Papillary Thyroid Cancer: A Comparison of the Transoral Vestibular and Breast Approaches

Background

This study aimed to compare the risk of hypoparathyroidism between the transoral vestibular approach (TOVA) and the breast approach (BA) in patients undergoing total endoscopic thyroidectomy (TET) for papillary thyroid carcinoma (PTC).

Methods

The medical records of 121 PTC patients (all women) who underwent total TET from January 2015 to January 2021 were retrospectively analyzed. Patients were grouped according to surgical approach (BA or TOVA). Clinical status and concentrations of parathyroid hormone (PTH) and calcium were monitored in the perioperative period and 1, 6, and 12 months after surgery.

Results

The BA and TOVA groups comprised 101 and 20 patients, respectively. Clinicopathologic and characteristics and surgical data were comparable between the groups. Incidence of transient hypoparathyroidism was significantly lower in the TOVA group than the BA group (10% vs 63.4%; p <0.01). Incidence of permanent hypoparathyroidism was comparable (5% vs 6.9%). Two days after TET, mean PTH concentration was significantly higher and incidence of abnormal PTH was significantly lower in the TOVA group. The incidence of abnormal calcium concentration 2 days after surgery was significantly lower in the TOVA group. One month after surgery, the mean calcium concentration was significantly higher in the TOVA group. Univariate and multivariate Cox regression analysis suggested that patients who underwent TOVA had a lower risk of transient hypoparathyroidism (hazard ratio 0.05, 95% confidence interval, 0.01–0.23; p<0.01). No clinicopathological factors examined were significantly associated with permanent hypoparathyroidism.

Conclusion

In patients undergoing TET for PTC, the incidence of transient hypoparathyroidism may be lower with the TOVA than the BA. Surgeons should be aware of the relatively high risk of transient hypoparathyroidism when performing the BA.

Near-Infrared Autofluorescence Imaging in Thyroid Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis aimed to assess the position of near-infrared autofluorescence (NIRAF) imaging in the recognition and protection of the parathyroid gland (PG) during thyroidectomy.

METHODS

The PubMed, MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were searched up to June 2021. The primary outcome was to evaluate the rates of postoperative hypocalcemia, inadvertent PG resection, and autotransplantation of PG when adopting NIRAF imaging compared with standard naked-eye (N-E) surgery.

RESULTS

Eight studies with 2,889 patients were enrolled in the analysis. Our analysis showed that the incidence of transient hypocalcemia was 7.11% (60/844) in the NIRAF group and 22.40% (458/2045) in the N-E group (p < 0.0001) and the rate of transient hypoparathyroidism was 28.31% (126/445) and 33.36% (496/1487) in the NIRAF and N-E groups (p = 0.0008). The rate of inadvertent resection of PGs was 7.65% (55/719) in the NIRAF group and 14.39% (132/917) in the N-E group (p < 0.0001). No significant difference was observed in other indexes including the pooled proportion of permanent hypocalcemia and rate of PG autotransplantation.

CONCLUSIONS

The application of NIRAF imaging in thyroidectomy can help lower the incidence of inadvertent PG resection and reduce the risk of postoperative hypocalcemia and hypoparathyroidism compared with N-E recognition.

Establishing a predictive model of hypoparathyroidism after total thyroidectomy and central lymph node dissection for postoperative calcium supplementation selectively

Background

The core goal of this article is to find some meaningful risk factors that can affect the postoperative hypoparathyroidism of thyroid cancer, create an effective prediction model on this basis, and use it to selectively implement routine prophylactic calcium supplementation for patients after thyroid carcinoma surgery.

Methods

The clinicopathological characteristics of patients with papillary thyroid carcinoma (PTC) who underwent conventional bilateral total thyroidectomy (TT) + bilateral central lymph node dissection from January 2020 to August 2021 in the Affiliated Hospital of Nantong University were retrospectively analyzed. Firstly, this study analyzed the relationship between postoperative hypocalcemia and hypoparathyroidism. Then, we included many potential risk factors such as gender, age, body mass index (BMI), lateral lymph node dissection (LLND) and so on and also performed univariate and multivariate analysis of the independent risk factors for postoperative hypoparathyroidism in patients, and established a predictive scoring model.

Results

Among the 401 patients with PTC, 50.1% developed postoperative hypoparathyroidism. There was significant difference in serum calcium concentration between normal parathyroid group and hypoparathyroidism group after thyroid carcinoma surgery. BMI <24 kg/m², lateral lymph node dissection, multifocality, and extrathyroidal extension (ETE) were all identified as independent risk factors for postoperative hypoparathyroidism. Based on these independent risk factors, a nine-point risk scoring model was created to firstly assess the postoperative parathyroid function status of patients and then to determine whether routine prophylactic calcium supplementation is needed. Importantly, the area under the curve (AUC) of the risk scoring model is equal to 0.979.

Conclusions

At present, prophylactic calcium supplementation after thyroid carcinoma surgery is a controversial postoperative treatment. It should be selectively implemented for high-risk patients with hypoparathyroidism after surgery. Routine prophylactic calcium supplementation is recommended for PTC patients with a score greater than or equal to 5, although there are no clinical symptoms of postoperative hypocalcemia caused by hypoparathyroidism. However, prophylactic calcium supplementation is not recommended for patients with PTC with a score of less than 5; if the patient develops hypocalcemia at the later stage, therapeutic calcium supplementation can then be implemented.

Clinical Efficacy of Modified Small Incision Thyroidectomy and Analysis of Influencing Factors of Postoperative Hypocalcemia

Objective

Analyze the clinical effect of modified small incision thyroidectomy and evaluate the influencing factors of hypocalcemia (EH) in patients after operation.

Methods

A total of 220 patients with thyroid cancer in our hospital from October 2019 to October 2021 were selected. The patients were randomly divided into a control group and an observation group, with 110 patients in each group. The control group were treated with traditional thyroidectomy, while the observation group were treated with modified small incision surgery. The perioperative indicators of the two groups were compared. The thyroid hormone indexes of the two groups were meansured before operation and 7 days after operation, and the incidence of complications was compared between the two groups. Serum calcium was detected 7 days after operation in both groups. According to the level of blood calcium, patients were divided into EH group and normal group. The data of two groups were compared, and the related factors affecting the occurrence of EH after operation were analyzed.

Results

The operation time, incision length and intraoperative bleeding volume of patients in the observation group were significantly lower than those of patients in the control group (p < 0.05). There was no significant difference in drainage time and postoperative drainage volume between the two groups (p > 0.05). The postoperative PTH level of patients in the observation group was significantly higher than that in the control group (p < 0.05), but there was no significant difference in FT3, FT4 and TSH levels (p > 0.05). The incidence of postoperative complications in the observation group (11.82%) was significantly lower than that in the control group (34.55%). Logistic regression analysis showed that bilateral lymph node dissection, parathyroidectomy and decreased PTH were the independent risk factors for EH in our patient after operation (p < 0.05).

Conclusion

The modified small incision operation can effectively reduce the occurrence of surgical trauma and related complications. Bilateral lymph node dissection, parathyroidectomy and PTH decrease are the risk factors for postoperative EH in patients with thyroid cancer. Taking corresponding measures to improve the metabolic function of patients during perioperative period will help to reduce the incidence of postoperative EH in patients with thyroid cancer.

Does Time Matter in Deficit of Calcium after Total Thyroidectomy in Subjects with Previous Bariatric Surgery?

Background: Hypoparathyroidism-related hypocalcemia is a common complication after total thyroidectomy (TT), particularly if there is a history of prior bariatric surgery. However, it is still unknown if it is the surgery timing or the type of bariatric intervention that increases the risk of developing this complication. Methods: We compared the risk of hypocalcemia (serum calcium levels < 8 mg/dL) and hypoparathyroidism (both transient and permanent) between patients with restrictive procedures (LSG and GB) and patients without a history of obesity surgery in the immediate post-operative period and after 12 months. Hypoparathyroidism was considered permanent if the plasma parathyroid hormone (PTH) levels at 6 months were less than 15 pg/mL and the patient still required oral calcium (calcium carbonate) and vitamin D supplementation, in addition to the supplements that were taken routinely before thyroidectomy. Results: From the 96 patients who underwent TT, 50% had a history of bariatric surgery: 36 LSG and 12 GB. The risk of hypocalcemia was similar in patients with a history of restrictive procedures (31.35%) and in controls (25%) (p = 0.49). Furthermore, hypocalcemia risk was similar between patients with a history of LSG (30.5%) and GB (33%) (p = 0.85). The prevalences of transient and permanent hypoparathyroidism were similar between patients with a history of restrictive procedures and in controls; similarly, no differences were detected between subjects undergoing LSG and GB. Conclusions: Restrictive bariatric surgery (LSG and GB) is not a risk factor for post-thyroidectomy hypocalcemia and hypoparathyroidism and thus did not require a different perioperative supplementation protocol compared to subjects without history of bariatric surgery undergoing TT.

Assessment of Radiofrequency Ablation for Papillary Microcarcinoma of the Thyroid: A Systematic Review and Meta-analysis

IMPORTANCE

Papillary microcarcinomas of the thyroid (mPTCs) account for an increasing proportion of thyroid cancers in past decades. The use of radiofrequency ablation (RFA) has been investigated as an alternative to surgery. The effectiveness and safety of RFA has yet to be determined.

OBJECTIVE

To evaluate the effectiveness and safety of RFA for low-risk mPTC.

DATA SOURCES

Embase, MEDLINE via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched from inception to May 28, 2021.

STUDY SELECTION

Articles reporting on adult patients with mPTC treated with RFA were included. Studies that involved patients with pre-ablation lymph node or distant metastases, recurrence of disease, or extrathyroidal extension were excluded. Final article selection was conducted by multiple reviewers based on consensus. The proportion of eligible articles was 1%.

DATA EXTRACTION AND SYNTHESIS

This meta-analysis was conducted in accordance with the MOOSE guidelines. Random and fixed-effect models were applied to obtain pooled proportions and 95% CIs.

MAIN OUTCOMES AND MEASURES

The primary outcome was the complete disappearance rate of mPTC. Secondary outcomes were tumor progression and complications.

RESULTS

Fifteen studies were included in this meta-analysis. A total of 1770 patients (1379 women [77.9%]; mean [SD] age, 45.4 [11.4] years; age range, 42.5-66.0 years) with 1822 tumors were treated with RFA; 49 tumors underwent 1 additional RFA session and 1 tumor underwent 2 additional RFA sessions. Mean (SD) follow-up time was 33.0 (11.4) months (range, 6-131 months). The pooled complete disappearance rate at the end of follow-up was 79% (95% CI, 65%-94%). The overall tumor progression rate was 1.5% (n = 26 patients), local residual mPTC in the ablation area was found in 7 tumors (0.4%), new mPTC in the thyroid was found in 15 patients (0.9%), and 4 patients (0.2%) developed lymph node metastases during follow-up. No distant metastases were detected. Three major complications occurred (2 voice changes lasting >2 months and 1 cardiac arrhythmia). Minor complications were described in 45 patients.

CONCLUSIONS AND RELEVANCE

The findings of this systematic review and meta-analysis suggest that RFA is a safe and efficient method to treat selected low-risk mPTCs. Radiofrequency ablation could be envisioned as step-up treatment after local tumor growth under active surveillance for an mPTC or initial treatment in patients with mPTCs with anxiety about active surveillance.

Seasonal variation in calcium treatment after thyroidectomy as surrogate for post-operative hypocalcemia: a retrospective register-based national cohort study

Background

Hypocalcemia is one of the most common complications of thyroidectomy, and vitamin D deficiency has been found to be an independent risk factor. Sweden is located north of the 55th latitude, resulting in a significant seasonal variation in sun exposure, thereby large variation in the naturally occurring levels of vitamin D. This study aimed to determine if there is a correlation between season of surgery and post-thyroidectomy hypocalcemia.

Methods

We conducted a retrospective register-based observation study on patients who had undergone total thyroidectomy during 2008–2015. In total, 7125 patients operated in Swedish facilities were identified via the Scandinavian Quality Register for Thyroid, Parathyroid, and Adrenal Surgery (SQRTPA). Patients operated during February–April were included in the dark group and patients operated during August–October were included in the bright group. Further stratification was made on the indication for surgery. The primary outcome was post-operative calcium treatment due to hypocalcemia, defined as having received calcium orally or intravenously before discharge.

Results

The risk of receiving post-operative calcium treatment was significantly lower in the bright group (29.7%) compared to the dark group (35.1%), with a relative risk of 0.846 (P < 0.001). This correlation held true if the indication for surgery was goiter or thyrotoxicosis. For malignancy, there was no significant difference between the groups.

Conclusion

In this cohort, total thyroidectomy performed during August–October was associated with a lower rate of calcium treatment given post-operatively when compared to total thyroidectomy performed during February–April. This would indicate a decreased risk of post-operative hypocalcemia if surgery was carried out after the brighter season.

Hipocalcemia posterior a tiroidectomía total: Análisis de dosis para suplemento rutinario profiláctico

Introducción. La hipocalcemia es la complicación más frecuente de la tiroidectomía. La profilaxis con calcio/ calcitriol es una alternativa costo-efectiva, sencilla y expedita para disminuir esta situación, sin alterar la función paratiroidea residual. Lo que no está claro es si hay superioridad de una dosis frente a otra, por lo que el objetivo de este estudio fue evaluar el comportamiento entre diferentes esquemas de profilaxis para hipocalcemia. Métodos. Estudio de cohorte retrospectivo de adultos operados en un hospital de cuarto nivel, entre febrero de 2017 y diciembre de 2020. Se calculó la tasa de síntomas, la hipocalcemia e hipercalcemia bioquímica en el control postquirúrgico durante las siguientes dos semanas. Se hizo análisis bivariado y multivariado entre dosis de calcio/ calcitriol, otros factores asociados y los desenlaces mencionados. Resultados. Se incluyeron 967 pacientes. El 10 % presentaron síntomas. No hubo diferencias significativas en el calcio sérico del control posquirúrgico entre los grupos con distintas dosis de calcio. La dosis de carbonato de calcio >3600 mg/día y el calcio en las primeras 24 horas de cirugía se asociaron a la presencia de síntomas. La dosis de calcitriol  <1 mcg/día y el bocio aumentaron el riesgo de hipocalcemia bioquímica, mientras que la dosis de 1,5 mcg/día lo disminuyó. Ninguna variable evaluada se asoció a hipercalcemia bioquímica. Conclusiones. Teniendo en cuenta los resultados observados con las dosis de calcio y calcitriol, sugerimos iniciar la profilaxis con un esquema de 3600 mg/día de carbonato de calcio y 1,5 mcg/día de calcitriol. Sin embargo, esta dosis debe modificarse en situaciones como bocio o calcio sérico temprano anormal, que fueron las variables asociadas a mayor riesgo en nuestro estudio.

Outcome of parathyroid function after total thyroidectomy when calcium supplementation is administered routinely versus exclusively to symptomatic patients: A prospective randomized clinical trial

PURPOSE

Current guidelines for calcium supplementation for parathyroid function recovery after thyroidectomy are based on low-quality evidence. The present trial compared the effects of oral calcium and vitamin D supplementation on the recovery of parathyroid function when administered routinely or exclusively to symptomatic patients.

METHODS

This prospective, randomized, open-label clinical trial analyzed 203 patients who underwent total thyroidectomy and developed hypoparathyroidism on postoperative day 1 (POD1) with median age of 41 years and proportion of women of 77.8%. Participants were randomized to group A (calcium and vitamin D supplementation administered only to symptomatic patients) and group B (routine supplementation). The primary outcome was the incidence of protracted hypoparathyroidism in the two groups. Secondary outcomes included risk factors for postoperative protracted hypoparathyroidism and the incidence of symptomatic hypocalcemia.

RESULTS

The incidence of protracted hypoparathyroidism was not significantly different between group A and group B (11 of 99 vs. 17 of 104, P = 0.280). Parathyroid hormone (PTH) in group B exhibited a better recovery tendency. The incidence of postoperative symptomatic hypocalcemia in group B was significantly lower than group A (26.92% vs. 42.42%, P = 0.020). Independent factors predicting protracted hypoparathyroidism included sex, preoperative serum calcium, and POD1 PTH.

CONCLUSION

Calcium and vitamin D supplementation administered exclusively to symptomatic patients achieved the same effect on protracted hypoparathyroidism as routine supplementation. However, routine supplementation significantly reduced postoperative hypocalcemia. Extra attention is necessary in female patients with high preoperative serum calcium and patients with low POD1 PTH.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR), ChiCTR1900022194. Registered March 30, 2019.

Number of cells in parathyroid tissue in primary hyperparathyroidism cases and its relationship with serum calcium value

BACKGROUND

The relationship between serum calcium (Ca) level to serum parathyroid hormone (PTH), phosphorus (P) levels and tissue properties of the parathyroid gland is unknown in primary hyperparathyroidism cases. Revealing this relationship may be useful for understanding the etiopathogenesis of primary hyperparathyroidism and determining the time of treatment.

METHODS

Ninety patients (71 females, 19 males, age range; 27-73 years, average age; 46) who underwent single gland excision with the diagnosis of primary hyperparathyroidism were studied. The patients were divided into 2 groups as serum Ca level <12 and serum Ca level ≥12. Age and sex of the patients, mean cell number of the gland, mean volume of the gland, serum levels of PTH, P, and histopathologic type of hyperplasia were evaluated.

RESULTS

The mean cell number per cubic centimeter is 22.9 (10-220 range) million in all glands. Serum Ca level was <12 in 82 (91.1%) of the patients, and ≥12 in 8 (8.9%) cases. Mean cell number of the gland, mean volume of the gland, existence of cystic hyperplasia of the gland, serum levels of PTH and P were statistically significant between the 2 groups (P < .001, P < .001, P < .05, P < .001, P < .05 respectively).

CONCLUSION

In primary hyperparathyroidism cases serum Ca level is not related to age and sex but directly related to proportionals to the cell number and volume of the gland and serum levels of PTH, inversely related to cystic hyperplasia and serum levels of P. Early surgical intervention should be planned since the serum Ca level will be high in large adenomas with a noncystic radiological appearance.

Trastornos posoperatorios del metabolismo del calcio postiroidectomía

Introducción: revisión narrativa que revela como la tiroidectomía ha aumentado en los últimos años y con ella sus complicaciones: la hipocalcemia y el hipoparatiroidismo. Métodos: los motores de búsqueda utilizados fueron PubMed, Clinical Key, Embase, Cochrane y Lilacs, se incluyeron referencias en español e inglés, publicadas entre 2016 y 2020. Los artículos seleccionados se revisaron utilizando CONSORT, STROBE o PRISMA, según el caso. Resultados: fueron seleccionados 35 artículos que tenían relación directa con el tema, entre ellos: metanálisis, revisiones sistemáticas, estudios prospectivos y observacionales, revisiones narrativas y consensos de expertos, procedentes de los cinco continentes. La hipocalcemia y el hipotiroidismo en sus dos formas se relacionan con la afectación de la vascularización de las glándulas paratiroides o su exérecis accidental, existiendo factores predisponentes propios del paciente, derivados de la técnica quirúrgica o la característica patológica de la lesión en el tiroides. Como estrategias de prevención disponemos de herramientas ópticas para definir en el perioperatorio la disposición de las paratiroides; además existe la posibilidad de autotrasplantarlas al identificarlas en la pieza anatómica. El mejor marcador del estado metabólico del calcio es la PTHi. Conclusiones: la preservación de las paratiroides y de su irrigación es la mejor estrategia para prevenir los trastornos posoperatorios del calcio.

Assessing Intraoperative Laser Speckle Contrast Imaging of Parathyroid Glands in Relation to Total Thyroidectomy Patient Outcomes

Background: Accurate assessment of parathyroid gland vascularity is important during thyroidectomy to preserve the function of parathyroid glands and to prevent postoperative hypocalcemia. Laser speckle contrast imaging (LSCI) has been shown to be accurate in detecting differences in parathyroid vascularity. In this surgeon-blinded prognostic study, we evaluate the relationship between intraoperative LSCI measurements and postoperative outcomes of total thyroidectomy patients. Methods: Seventy-two thyroidectomy patients were included in this study. After thyroid resection, an LSCI device was used to image all parathyroid glands identified, and a speckle contrast value was calculated for each. An average value was calculated for each patient, and the data were grouped according to whether the patient had normal (16-77 pg/mL) or low levels of parathyroid hormone (PTH) measured on postoperative day 1 (POD1). The aim of this study was to establish a speckle contrast threshold for classifying a parathyroid gland as adequately perfused and to determine how many such glands are required for normal postoperative parathyroid function. Results: A speckle contrast limit of 0.186 separated the normoparathyroid and hypoparathyroid groups with 87.5% sensitivity and 84.4% specificity: 7 of 8 patients with low PTH on POD1 had an average parathyroid speckle contrast above this limit, while 54 of 64 patients with normal postoperative PTH had an average parathyroid speckle contrast below this limit. Taking this value as the threshold for adequate parathyroid perfusion, it was determined that only one vascularized gland was needed for normal postoperative parathyroid function: 64 of 69 patients (92.8%) with at least one vascularized gland (determined by LSCI) had normal postoperative PTH, while all 3 patients (100%) with no vascularized glands had low postoperative PTH. Overall, the rates of temporary and permanent hypoparathyroidism in this study were 8.3% and 1.4%, respectively. Conclusions: LSCI is a promising technique for assessing parathyroid gland vascularity. It has the potential to help reduce the incidence of hypocalcemia after thyroidectomy by providing surgeons with additional information during surgery to aid in the preservation of parathyroid function.

PTH after Thyroidectomy as a Predictor of Post-Operative Hypocalcemia

Post-thyroidectomy hypocalcemia is a frequent complication with significant morbidity, and has been shown to increase hospital stay and readmission rates. The evaluation of serum parathyroid hormone (PTH) levels after thyroidectomy represents a reliable method to predict post-thyroidectomy hypocalcemia, but it remains infrequently used. This retrospective study investigates serum PTH values 3 h after thyroidectomy as a predictor of hypocalcemia. In this study, we enrolled 141 patients aged between 27 and 71 years eligible for total thyroidectomy who presented with multinodular goiter, suspicious nodule on cytological examination, Graves’ disease, or toxic multinodular goiter. Three hours after total thyroidectomy, 53 patients (37.6%) showed a reduction in serum PTH. Of these patients 75.5% developed hypocalcemia by 24 h after surgery and 100% were hypocalcemic after 48 h (p < 0.001). There was no significant difference attributable to the different thyroid diseases, nor to the age of the patients. PTH at 3 h after total thyroidectomy accurately predicts post-operative hypocalcemia. The early detection of patients at risk of developing post-operative hypocalcemia allows for prompt supplementation of calcium and Vitamin D in order to prevent symptoms and allows for a safe and timely discharge.

Development of an imaging device for label-free parathyroid gland identification and vascularity assessment

During thyroid surgeries, it is important for surgeons to accurately identify healthy parathyroid glands and assess their vascularity to preserve their function postoperatively, thus preventing hypoparathyroidism and hypocalcemia. Near infrared autofluorescence detection enables parathyroid identification, while laser speckle contrast imaging allows assessment of parathyroid vascularity. Here, we present an imaging system combining the two techniques to perform both functions, simultaneously and label-free. An algorithm to automate the segmentation of a parathyroid gland in the fluorescence image to determine its average speckle contrast is also presented, reducing a barrier to clinical translation. Results from imaging ex vivo tissue samples show that the algorithm is equivalent to manual segmentation. Intraoperative images from representative procedures are presented showing successful implementation of the device to identify and assess vascularity of healthy and diseased parathyroid glands.

[Cross-cultural adaptation of the French version of the thyroid cancer-specific quality of life questionnaire: THYCA-QoL]

INTRODUCTION

The aim of this study was to translate into French the 24 items of the THYCA-QoL questionnaire used in thyroid cancers and then to study its psychometric properties.

MATERIALS AND METHODS

The THYCA-QoL is a specific questionnaire for evaluating the quality of life of patients undergoing thyroid cancer surgery. It consists of 24 items and is divided into seven dimensions and six isolated questions. The translation has been carried out according to the recommendations of the EORTC. Validation of the translated version was obtained by finding a consensus of experts for each of the items.

RESULTS

All the original questions of the questionnaire have been adapted into French. The translated questionnaire, named THYCA-CoL-fr, was tested on 60 patients (65 % female), mean age 54.5 years. All questions were well accepted and understood and no missing data were reported. Eight patients (13 %) proposed an item correction to the questionnaire. No attenuation effects (floor or ceiling) were detected. The internal structure was comparable to the original questionnaire: Cronbach α coefficients varied from 0.53 for the oropharyngeal dimension to 0.88 for the voice dimension. The scree-plot highlighted the seven dimensions of the English version.

CONCLUSION

THYCA-QoL-fr is the first specific French language questionnaire to evaluate the quality of life in thyroid cancer patients undergoing surgery. These first exploratory psychometric results confirmed the conceptual similarity of the French translation and the English version.

Parathyroid Hormone Level Changes Following Radioiodine Therapy for Thyroid Cancer: A Prospective Observational Study

OBJECTIVE

Our objective was to analyze the effect of radioiodine (RAI) therapy on parathyroid hormone (PTH) secretion.

METHODS

A total of 137 patients were included and divided into 2 groups based on pretherapy PTH levels. The residual thyroid tissue volume was classified into 4 grades (0-3), and a value of 0 indicated that there was no apparent residual tissue. We analyzed the PTH level changes among different time points in each group and the factors that could predict the PTH level changes.

RESULTS

In 113 patients with normal parathyroid gland function, the PTH level at baseline, 1 day, 7 days, 1 month, 3 months, and 6 months after RAI therapy did not show any significant difference; in 24 patients with decreased parathyroid gland function, the level of PTH immediately decreased after the implementation of RAI therapy but gradually returned to a pre-RAI therapy level within 6 months. On the seventh day after therapy, the mean value of PTH in patients with a residual thyroid tissue volume of extent of 0/1 was 8.0 ± 2.3 pg/mL, which was significantly higher than that in patients with a residual thyroid tissue volume of extent of 2/3 (P = .011). Similar phenomena were observed 1 month, 3 months, and 6 months after therapy.

CONCLUSION

RAI therapy had a significant transient adverse effect on parathyroid gland function in patients with decreased PTH secretion pretherapy, and the extent was associated with the amount of residual thyroid tissue.

Narrative review of management of thyroid surgery complications

Currently, thyroid surgery is the most common and safe operation worldwide. However, thyroidectomy is still not free from the risks of complications and death due to the anatomical structure and physiological function particularity of the thyroid gland. Postoperative complications affect the life quality and life safety of patients after surgery. The common complications include hypoparathyroidism (HP), recurrent laryngeal nerve (RLN) injury, injury to the external branch of the superior laryngeal nerve (EBSLN), postoperative bleeding (PB), thoracic duct injury, laryngeal edema, tracheospasm, tracheal injury, and esophageal injury. A severe complication, such as dyspnea, asphyxia, or thyroid crisis, might cause the death of the patient. Therefore, every thyroid surgeon's responsibility is to remain alert and aware of the occurrence of various intraoperative and postoperative complications and exercise effective prevention and treatment. This is closely related to the advancement in thyroid disease research, the increase in local anatomy knowledge, the standardization of surgical approaches, the improvement in operating skills, the application of new technologies, and the emphasis on specialty training. In addition, many complications that effect patients are much better tolerated if the patient has appropriate expectations of what the complications are and how to treat them. Open communication between surgeon and patient optimizes the potential negative effects that complications may have on patients' quality of life. This paper discusses the prevention, recognition and therapy of intraoperative and postoperative complications in thyroid surgery.

Tiempo óptimo para medición de paratohormona como predictor de hipocalcemia en pacientes posterior a tiroidectomía total

Introducción. La hipocalcemia posterior a tiroidectomía total es una complicación frecuente en la cirugía de tiroides. La hormona paratiroidea ha demostrado ser un predictor confiable para detectar los pacientes con alto riesgo de hipocalcemia significativa y la consecuente necesidad de administrar suplemento de calcio. El objetivo de este estudio fue determinar el tiempo óptimo de medición de la paratohormona para dicho fin. Métodos. Estudio prospectivo realizado en dos instituciones de nivel III en Popayán, Colombia, entre abril de 2016 y febrero de 2018, en el cual se midieron niveles de paratohormona prequirúrgico, a las 0, 2, 4 y 12 horas del postoperatorio, y se compararon con los valores obtenidos a los 3 meses de seguimiento en pacientes sometidos a tiroidectomía total. Se consideró como grupos de riesgo y con necesidad de suplemento de calcio un valor de paratohormona menor de 10 pg/ml o una disminución mayor del 80 % con respecto al valor prequirúrgico. Resultados. Se incluyeron 34 pacientes intervenidos. Tomando como umbral un valor menor de 10 pg/ml, la medición de paratohormona a las 4 horas fue sensible y específica (60 y 93,1 % respectivamente). Para una disminución mayor del 80 % con respecto al valor prequirúrgico, la sensibilidad fue del 60 % y la especificidad del 96,5 %, presentando un valor predictivo positivo de 75 % y negativo del 93,3 %, con una p < 0,001. Discusión. Una disminución mayor del 80 % del valor de paratohormona prequirúrgico medida a las 4 horas después de la tiroidectomía total permite identificar aquellos pacientes con alto riesgo de hipocalcemia significativa, que requieren administración temprana de suplementos de calcio, comparado con la determinación de la disminución a las 0, 2 y 12 horas postoperatorias.

Recovery of severely damaged parathyroid function after total thyroidectomy for thyroid cancer

Background

An extremely low parathyroid hormone (PTH) concentration after thyroidectomy may reflect the immediate severely damaged parathyroid function. The current study aimed to examine time-related changes of severely damaged parathyroid function on postoperative day 1 (SDPF-D1), which was here defined as serum PTH ≤1 pg/mL, and the risk factors of SDPF-D1.

Methods

This is a retrospective review of patients with thyroid cancer undergoing total thyroidectomy with or without central neck dissection (CND). The number of parathyroids preserved in situ, autotransplanted, or found in the final pathology was recorded and the corresponding parathyroid glands remaining in situ (PGRIS) score (PGRIS = 4 - parathyroids autotransplanted-parathyroids found in the final pathology) was calculated. Chronological changes of serum levels of PTH and total calcium were investigated for at least one year after surgery.

Results

One hundred and twenty-two of 344 patients included for analysis suffered from SDPF-D1. Patients with SDPF-D1 had a prolonged recovery in comparison with hypoparathyroidism patients without SDPF-D1, who fully recovered within 6 months after thyroidectomy. The PGRIS score in patients with permanent hypoparathyroidism was significantly lower than other patients with SDPF-D1who fully recovered.

Conclusions

Most patients with SDPF-D1 could fully recover within one year after total thyroidectomy. Less parathyroids removed and autotransplanted contributed to a quick recovery of SDPF-D1.

Ambulatory thyroidectomy is safe and beneficial in papillary thyroid carcinoma: Randomized controlled trial

BACKGROUND

Currently, no randomized controlled trial has been performed to investigate the safety profiles, economic benefit and mental health of ambulatory thyroidectomy in patients with papillary thyroid carcinoma (PTC).

METHODS

Patients diagnosed with PTC were enrolled in this study and were randomly assigned to ambulatory group and control group. The safety profiles, economic benefit and mental health were investigated.

RESULTS

Four hundred and eleven patients completed the study. There was no significant difference in demographic or tumor index. The incidence of complications was not significantly different (P = .631). The economic cost was significantly lower (P < .001) and hospitalization was significantly shorter (P < .001) in ambulatory group. No significant difference was shown in depression (P = .758) and stress disorder (P = .390). However, the ambulatory group showed a higher point of anxiety (P < .001).

CONCLUSION

The ambulatory thyroidectomy is safe in patients with PTC, with significant benefits of economic cost and hospitalization.

Efficacy of Fluorescein Green Dye in Assessing Intra-Operative Parathyroid Gland Vascularity and Predicting Post-Thyroidectomy Hypocalcaemia- A Novel Prospective Cohort Study

BACKGROUND

Postoperative hypocalcaemia (POH) after total thyroidectomy (TT) is a common complication. Parathyroid hormone (PTH), an accurate predictor of POH cannot assess intra-operative viability of parathyroid glands (PGs). Different dyes including indocyanine green or carbon nanoparticles have been used, but they are expensive and not widely available. Fluorescein green dye (FD) has been used as a low-cost alternative to study viability of various organs, but seldom tried in visualizing PGs. This novel study aims to assess utility of FD in determining parathyroid viability and predicting POH.

MATERIAL AND METHOD

Total 72 out of 88 patients undergoing TT between January and December 2019 were included. Two ml of 25% FD was given intravenously before wound closure and attempts were made to visualize PGs under blue light. A numerical score was given according to the number of PGs visualized. Intact-PTH and corrected calcium were measured on postoperative day 1 and patients observed for POH.

RESULTS

No PGs were visualized in 6 patients, 1 in 13, 2 in 30, 3 in 16 & 4 in 7 patients. Mean PTH was 6, 16.9, 31.6, 33.2 and 48.5 respectively. Corrected-calcium was 7.08, 7.7, 7.9, 8.5 and 8.5 respectively. All patients with score 0 received supplementary IV calcium, while 53.8% (score-1), 30% (score-2), 0% (scores-3, 4) received the same. Sensitivity, specificity and ROC of PG score of ≥2 on FD in predicting POH were 100%, 44% and 0.83 respectively.

CONCLUSION

FD visualization of parathyroids post TT is feasible and can be used as low cost efficacious method to predict POH.

What is the experience of our patients with transient hypoparathyroidism after total thyroidectomy?

BACKGROUND

We sought to better understand the experience of patients with transient hypoparathyroidism using patient interviews and quality of life surveys.

METHODS

This is a prospective analysis of 62 patients after total thyroidectomy at a high-volume institution. Semistructured patient interviews and quality of life surveys were conducted preoperatively and postoperatively at 2 weeks, 6 weeks, 6 months, and 1 year and compared based on postoperative parathyroid hormone levels.

RESULTS

Postoperative parathyroid hormone levels were <10 pg/mL in 32% of patients (n = 20), 10 to 20 pg/mL in 19% (n = 12), and >20 pg/mL in 48% (n = 30). Hypocalcemic symptoms at 2 weeks were reported in 28 of 55 patients (51%), but patients felt "well prepared" and reported it "wasn't a big deal." If symptoms persisted at 6 weeks, they became more bothersome. At 6 months and 1 year, patients reported calcium supplementation prevented most symptoms and did not interfere with daily activities. Quality of life as measured by the European Organization for Research and Treatment of Cancer and the 12-Item Short Form Survey demonstrated a slight improvement at 1 year postoperatively regardless of parathyroid hormone level.

CONCLUSION

Early postoperative transient hypoparathyroidism is common but when appropriately managed did not have a substantial negative impact on the overall quality of life.

Hypocalcemia After Completion Thyroidectomy for Papillary Thyroid Carcinoma

Surgical management of papillary thyroid carcinoma (PTC) includes total thyroidectomy and lobectomy. After lobectomy, a reoperation called completion thyroidectomy is occasionally required. Postoperative hypocalcemia is the most common complication associated with thyroid surgery. Our main goal was to determine if there is a significant difference between the incidence rate of postoperative hypocalcemia in patients who underwent total thyroidectomy for PTC compared with patients who underwent completion thyroidectomy for PTC. Apart from that, we analyzed the following potential predictive factors for the occurrence of hypocalcemia: sex, age, size of tumor, side of tumor, maximum diameter of individual lobe, occult metastasis, and operating surgeon. The study involved 340 patients who underwent surgery for PTC at the Department of ENT and Head and Neck Surgery, Zagreb University Hospital Centre, between February 25, 2013 and January 3, 2016. Postoperative hypocalcemia incidence rates were higher in the total thyroidectomy group than in the completion thyroidectomy group (37.8% and 29.0%, respectively). However, these differences were not statistically significant. Every analyzed potential predictive factor was proven not to have any correlation with postoperative hypocalcemia. This study demonstrated that there was no significant difference between postoperative hypocalcemia rates in patients who underwent completion thyroidectomy compared with patients who underwent total thyroidectomy for PTC.

Characteristics of hypoparathyroidism in Colombia: data from a single center in the city of Medellín

OBJECTIVE

Hypoparathyroidism is a rare condition, whose most common etiology is complications of neck surgery. The aim of the study was to identify the clinical and biochemical profile of the patients with diagnosis of hypoparathyroidism, including the frequency of symptoms, clinical signs, long-term complications and disease control. Additionally, the study sought to know what the medication profile was, and the doses required by the patients.

SUBJECTS AND METHOD

A retrospective cohort study was conducted wherein all patients with ICD-10 codes associated with hypoparathyroidism between 2011 and 2018 at the Hospital Universitario San Vicente Fundación were included. We investigated the etiology of the disease; biochemical profile including lowest serum calcium, highest serum phosphorus, 25OHD levels, calciuria and calcium/phosphorus product; medication doses, disease control, and presence of complications, especially renal and neurologic complications were also evaluated.

RESULTS

The cohort included 108 patients (99 women/9 men) with a mean age of 51.6 ± 15.6 years. The main etiology was postoperative (93.5%), the dose of elemental calcium received was relatively low (mean 1,164 mg/day), and in only 9.2% of cases more than 2,500 mg/day of elemental calcium was necessary. We were able to evaluate the follow-up in 89 patients, and found that only 57.3% met the criteria for controlled disease.

CONCLUSION

The clinical profile of patients with hypoparathyroidism in our cohort is similar to that described in other international studies, with predominantly postoperative etiology. With standard therapy, only adequate control is achieved in a little more than half of patients. Arch Endocrinol Metab. 2020;64(3):282-9.

Ultrasonic scalpel with knot tying protects parathyroid function for total thyroidectomy with central neck dissection

Background

Hypoparathyroidism might be due to collateral thermal injury induced by harmonic scalpel (HS) after total thyroidectomy (TT) with central neck dissection (CND). The current study aimed to evaluate whether a clamp and tie (CAT) technique used to preserve parathyroid glands in situ could reduce damage to parathyroid function in HS patients undergoing TT plus unilateral or bilateral CND.

Methods

Medical records of 537 HS-operated patients with papillary thyroid carcinoma (PTC) undergoing TT plus unilateral or bilateral CND were retrospectively evaluated. Patients were divided into HS and HS-CAT groups based on whether the CAT techniques were used near parathyroid glands. Patients' characteristics such as age, sex, tumour size, operative time, pre- and post-operative levels of parathyroid hormone (PTH) and complications were analysed.

Results

For patients undergoing TT plus unilateral CND, operative time was significantly shorter (P<0.001), but there were significantly higher incidences of transient hypoparathyroidism (P=0.002) on postoperative day 1 and incidental parathyroidectomy (P=0.036) in the HS group. There was no significant difference in permanent hypoparathyroidism. For patients undergoing TT plus bilateral CND, a significantly shorter operative time and sharper postoperative PTH decline was found in the HS group (P=0.029). However, there were no significant differences regarding incidences of incidental parathyroidectomy, transient or permanent hypoparathyroidism.

Conclusions

The CAT technique applied near parathyroid glands was a practical surgical application for decreasing the incidence of postoperative transient hypoparathyroidism for TT plus unilateral CND.

Outcomes of parathyroid gland identification and autotransplantation during total thyroidectomy

PURPOSE

To report the outcomes of parathyroid gland (PG) identification and autotransplantation (autoT) during thyroidectomy.

METHODS

Consecutive total thyroidectomy cases performed by a single surgeon using extracapsular dissection technique were considered. PGs were not intentionally sought during dissection. PG location, number identified and autoT were prospectively recorded and correlated to postoperative outcomes.

RESULTS

In all, 265 cases were included. The mean number of PGs identified per case was 2.7. The number of PGs identified had no correlation to postoperative hypocalcemia. However, independent risk factors for hypocalcemia were female sex, bilateral central compartment neck dissection (CND) and autoT > 1 PG; and for permanent hypoparathyroidism were female sex and bilateral CND. AutoT did not protect against permanent hypoparathyroidism.

CONCLUSION

The number of PGs identified during the course of a standard extracapsular dissection technique had no correlation to postoperative hypocalcemia. Whenever possible, avoiding bilateral CND and careful techniques to preserve PGs in an in situ and viable state, to obviate the necessity for autoT, are recommended.

African Head and Neck Society Clinical Practice guidelines for thyroid nodules and cancer in developing countries and limited resource settings

BACKGROUND

International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources.

METHODS

Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined.

RESULTS

Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines.

CONCLUSIONS

Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources.

Impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy

OBJECTIVES

To determine the impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy.

MATERIAL AND METHODS

A single-center retrospective study was conducted for a 5-year period in a university hospital center, including 605 patients undergoing total thyroidectomy, 52 of whom had mediastinal-recurrent cellular and lymph-node dissection.

ENDPOINTS

The main endpoint was intraoperative number of parathyroid glands as predictor of parathyroid hormone (PTH) level and postoperative hypocalcemia. The secondary endpoint was the correlation between associated mediastinal-recurrent cellular and lymph-node dissection and incidental parathyroidectomy and its impact on PTH level and calcemia in the immediate postoperative period and at 1 month.

RESULTS

161 patients (26.61%) showed hypocalcemia in the immediate postoperative period and 12 (1.98%) at 1 month. Mediastinal-recurrent cellular and lymph-node dissection increased incidental parathyroidectomy risk 4.6-fold. Mediastinal-recurrent cellular and lymph-node dissection was associated with a statistically "suggestive" decrease in day-1 calcemia (P=0.03), and no significant decrease at 1 month (P=0.52). Incidental parathyroidectomy (6.7% of cases with parathyroidectomy versus 1.3% without) did not significantly increase the rate of early hypocalcemia (P=0.28), but was associated with a "suggestive" worsening at 1 month (P=0.02).

CONCLUSION

Hypocalcemia after total thyroidectomy is a complex, probably multifactorial issue. Systematic parathyroid gland identification is not recommended due to the increased risk of gland lesion, mainly by devascularization. Incidental parathyroidectomy may induce hypocalcemia at 1 month postoperatively (statistically "suggestive" association).

The role of carbon nanoparticle in lymph node detection and parathyroid gland protection during thyroidectomy for non-anaplastic thyroid carcinoma- a meta-analysis

OBJECTIVE

To assess the efficiency of the carbon nanoparticles (CNs) in lymph node identification and parathyroid gland (PG) protection during thyroidectomy for non-anaplastic thyroid carcinoma (N-ATC).

METHODS

A systematic literature search for relevant literatures published up to December 2018 in PubMed, EMBASE, Web of Science and Cochrane Library was performed. Both English and Chinese literatures were retrieved and analyzed. Randomized controlled trials or nonrandomized controlled trials comparing the use of CNs with the use of methylene blue or a blank control in patients undergoing thyroidectomy for N-ATC were enrolled in this study. The primary outcomes included the number of lymph nodes harvested, the rate of lymph nodes involved, and the rates of accidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Weighted mean differences (WMDs), odds ratios (ORs) and risk differences (RDs) were calculated for the dichotomous outcome variables. Between study heterogeneity was tested using the Q tests and the I2 statistics. All analyses were performed using Review Manager (version 5.3.5).

RESULTS

25 studies comprising 3266 patients were included in this analysis. The total number of lymph nodes harvested in the CNs groups was significantly higher than that in the control groups (WMD, 2.36; 95% CI, 1.40 to 3.32; P <0.01). Administrating CNs was associated with a lower incidence of accidental PG removal (OR = 0.28, 95% CI = 0.21 to 0.37, P<0.01) and lower rates of both postoperative transient hypoparathyroidism (OR = 0.46, 95% CI = 0.33 to 0.64, P <0.01) and transient hypocalcemia (OR = 0.46, 95% CI = 0.33 to 0.65, P <0.01). No significant difference was found concerning lymph node metastatic rates between CNs group and control group. Subgroup analysis indicated that the application of CNs in reoperation thyroidectomy reduced both the rate of transient hypoparathyroidism (OR = 0.21, 95% CI = 0.06 to 0.75, P = 0.02) and the possibility of accidental PGs removal (OR = 0.21, 95% CI = 0.07 to 0.62, P = 0.004, P<0.05).

CONCLUSIONS

The application of CNs in thyroidectomy for N-ATC results in higher number of lymph node harvested and better PG protection during both initial and reoperation thyroidectomy.