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Banks L, Kelly NA, Onwuka A, Althubaiti A, Damilano C, Hoffman RP, Aldrink JH, Jatana KR, Walz P. Does preoperative calcium and 1, 25 OH vitamin D supplementation impact postoperative hypocalcemia and length of stay following pediatric thyroidectomy? Int J Pediatr Otorhinolaryngol 2024; 178:111895. [PMID: 38422761 DOI: 10.1016/j.ijporl.2024.111895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/24/2024] [Accepted: 02/10/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To investigate whether perioperative calcium and 1,25 OH vitamin D supplementation (PCDS) influences the rates of postoperative hypocalcemia and length of stay (LOS) following pediatric thyroidectomy. STUDY DESIGN Retrospective Cohort Review. SETTING Tertiary children's hospital. METHODS 94 patients who underwent completion or total thyroidectomy with or without concomitant neck dissection from 2010 to 2020 at a single institution were included. Patients with pre-existing hypocalcemia or preoperative vitamin D insufficiency were excluded. Rates of postoperative hypocalcemia and LOS were compared for patients receiving PCDS to those receiving no supplementation. RESULTS Thirty percent of patients with PCDS had documented postoperative hypocalcemia compared to 64% of patients without PCDS (p = 0.01). Patients with PCDS had a median LOS of 30 h compared to 36 h (p = 0.002). Multivariable analyses confirmed that patients with PCDS had lower odds of postoperative hypocalcemia (OR: 0.32, CI: 0.11, 0.89) and shorter LOS by 17 h (SE: 8, p = 0.04) after adjustment for confounders. CONCLUSION PCDS is associated with significantly lower risk of hypocalcemia and shorter LOS. Standardizing preoperative care for pediatric patients undergoing thyroidectomy may decrease variability and improve outcomes following surgery.
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Affiliation(s)
- Laura Banks
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Natalie A Kelly
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | | | - Abdulrahman Althubaiti
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Cecilia Damilano
- Divison of Endocrinology, Department of Pediatrics, Nationwide Children's Hosp., Columbus, OH, USA
| | - Robert P Hoffman
- Divison of Endocrinology, Department of Pediatrics, Nationwide Children's Hosp., Columbus, OH, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Head and Neck Surgery, Nationwide Children's Hosp., Columbus, OH, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick Walz
- Department of Pediatric Otolaryngology, Head and Neck Surgery, Nationwide Children's Hosp., Columbus, OH, USA; Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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van Dijk SPJ, van Driel MHE, van Kinschot CMJ, Engel MFM, Franssen GJH, van Noord C, Visser WE, Verhoef C, Peeters RP, van Ginhoven TM. Management of Postthyroidectomy Hypoparathyroidism and Its Effect on Hypocalcemia-Related Complications: A Meta-Analysis. Otolaryngol Head Neck Surg 2024; 170:359-372. [PMID: 38013484 DOI: 10.1002/ohn.594] [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: 08/16/2023] [Revised: 10/12/2023] [Accepted: 11/04/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The aim of this Meta-analysis is to evaluate the impact of different treatment strategies for early postoperative hypoparathyroidism on hypocalcemia-related complications and long-term hypoparathyroidism. DATA SOURCES Embase.com, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched to September 20, 2022. REVIEW METHODS Articles reporting on adult patients who underwent total thyroidectomy which specified a treatment strategy for postthyroidectomy hypoparathyroidism were included. Random effect models were applied to obtain pooled proportions and 95% confidence intervals. Primary outcome was the occurrence of major hypocalcemia-related complications. Secondary outcome was long-term hypoparathyroidism. RESULTS Sixty-six studies comprising 67 treatment protocols and 51,096 patients were included in this Meta-analysis. In 8 protocols (3806 patients), routine calcium and/or active vitamin D medication was given to all patients directly after thyroidectomy. In 49 protocols (44,012 patients), calcium and/or active vitamin D medication was only given to patients with biochemically proven postthyroidectomy hypoparathyroidism. In 10 protocols (3278 patients), calcium and/or active vitamin D supplementation was only initiated in case of clinical symptoms of hypocalcemia. No patient had a major complication due to postoperative hypocalcemia. The pooled proportion of long-term hypoparathyroidism was 2.4% (95% confidence interval, 1.9-3.0). There was no significant difference in the incidence of long-term hypoparathyroidism between the 3 supplementation groups. CONCLUSIONS All treatment strategies for postoperative hypocalcemia prevent major complications of hypocalcemia. The early postoperative treatment protocol for postthyroidectomy hypoparathyroidism does not seem to influence recovery of parathyroid function in the long term.
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Affiliation(s)
- Sam P J van Dijk
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M H Elise van Driel
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caroline M J van Kinschot
- Department of Internal Medicine, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine and Thyroid Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maarten F M Engel
- Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gaston J H Franssen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charlotte van Noord
- Department of Internal Medicine, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
| | - W Edward Visser
- Department of Internal Medicine and Thyroid Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robin P Peeters
- Department of Internal Medicine and Thyroid Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tessa M van Ginhoven
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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A Parathyroid Hormone-guided Calcium and Calcitriol Supplementation Protocol Reduces Hypocalcemia-related Readmissions Following Total Thyroidectomy. Endocr Pract 2023; 29:260-265. [PMID: 36682414 DOI: 10.1016/j.eprac.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine the effect of a 4 hour postoperative serum parathyroid hormone (PTH) guided calcium and calcitriol supplementation protocol on the incidence of hypocalcemia and hospital readmissions in patients undergoing total thyroidectomy. METHODS This was a single institution, retrospective chart review of patients who underwent total thyroidectomy, 148 had been operated on prior to the protocol implementation and 389 after. Hypocalcemia risk was stratified as low (PTH >30 pg/ml), medium (15-30 pg/ml), and high (<15 pg/ml), using serum PTH values obtained 4 hours postoperatively. Hypocalcemia was defined as a total serum calcium level <8 mg/dl. Baseline demographic and operative characteristics, and postoperative outcome were recorded for both groups. Fisher's exact test or Wilcoxon rank sum test were used to compare the characteristics of the two groups. A multivariable logistic regression model was applied to account for potentially confounding variables. RESULTS Postoperative hypocalcemia occurred significantly less frequently in the protocol group compared to the preprotocol group (10.3% vs. 20.9%, P=.002). The reduction in hypocalcemia in the protocol group was observed both in patients with (16.3% vs. 25.6%) and without (8.4% vs. 19.3%) cervical lymph node dissection. There was a significantly lower incidence of hospital readmission events in the protocol group compared to the preprotocol group (1.0% vs. 4.7%, P=.013). CONCLUSIONS Compared to a historical cohort, a PTH-guided protocol for calcium and calcitriol supplementation significantly reduces postoperative hypocalcemia and hospital readmission rates, in patients undergoing total thyroidectomy.
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Moon H, Seok JW, Kim K, Kim HY, Park MK, Kim IJ, Pak K, Suh S. Effectiveness of prophylactic calcium and vitamin D supplementation for preventing post-thyroidectomy hypocalcemia: a meta-analysis. KOSIN MEDICAL JOURNAL 2022. [DOI: 10.7180/kmj.22.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Postsurgical hypocalcemia is the most common and troublesome consequence of thyroidectomy. We investigated the potential role of routine calcium or vitamin D supplementation in preventing postsurgical hypocalcemia. Methods: We searched MEDLINE and Embase for English-language publications using the keywords “calcium,” “vitamin D,” and “thyroid cancer.” The primary outcome was any postoperative hypocalcemia, and the secondary outcome was symptomatic hypocalcemia. Results: Four studies that included 381 patients were eligible for this meta-analysis. A random-effects model showed no significant difference in the occurrence of hypocalcemia between calcium/vitamin D treatment and placebo/no treatment. However, the occurrence of symptomatic hypocalcemia was lower in patients with calcium/vitamin D treatment. In the combined results, preoperative calcium and vitamin D supplementation were associated with a reduced incidence of symptomatic hypocalcemia. Conclusions: Our findings support the use of preoperative calcium and vitamin D supplementation in conjunction with routine postsurgical supplementation for patients after total thyroidectomy.
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PTH after Thyroidectomy as a Predictor of Post-Operative Hypocalcemia. Diagnostics (Basel) 2021; 11:diagnostics11091733. [PMID: 34574074 PMCID: PMC8467686 DOI: 10.3390/diagnostics11091733] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 12/22/2022] Open
Abstract
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.
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Shonka DC, Maxwell AK, Petroni GR, Jameson MJ. Phase II randomized study of preoperative calcitriol to prevent hypocalcemia following thyroidectomy. Head Neck 2021; 43:2935-2945. [PMID: 34076308 DOI: 10.1002/hed.26775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/07/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND A prospective, stratified, randomized, double-blind, placebo-controlled study was conducted to observe the impact of preoperative calcitriol supplementation on serum calcium levels following total thyroidectomy. METHODS Subjects were randomized 1:1 to receive 1 μg calcitriol or placebo for 1 week preceding thyroidectomy. The primary outcome measure was change in serum calcium from baseline to 18 h post-thyroidectomy. Subjects were also assessed for incidence of symptomatic hypocalcemia, length of stay, readmission for hypocalcemia, and intravenous calcium supplementation. RESULTS Forty-seven patients underwent thyroidectomy; 23 received preoperative calcitriol supplementation, and 24 received placebo. Repeated measures regression demonstrated no difference in postoperative serum calcium over time (p = 0.22). There were no occurrences of hypocalcemia, intravenous calcium supplementation, or readmission in either group. No difference was observed in length of stay (p = 0.38). One patient in the calcitriol group developed Grade 3 hypercalcemia. CONCLUSIONS Preoperative calcitriol supplementation had no impact on postoperative serum calcium levels compared to placebo.
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Affiliation(s)
- David C Shonka
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Anne K Maxwell
- University of Virginia School of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Gina R Petroni
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark J Jameson
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Compton RA, Simmonds JC, Dhingra JK. Total Thyroidectomy as an Ambulatory Procedure in Community Practice. OTO Open 2020; 4:2473974X20957324. [PMID: 33062910 PMCID: PMC7534086 DOI: 10.1177/2473974x20957324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/27/2020] [Indexed: 11/16/2022] Open
Abstract
Objective Increasingly, total thyroidectomy is offered as an ambulatory procedure. Most of the relevant outcomes research derives from academic centers, but most thyroid surgeries are performed in the community. The goal of this study is to evaluate the safety of total thyroidectomy performed as an ambulatory procedure in a community otolaryngology practice. Study Design Retrospective review and national database analysis. Setting A single community otolaryngology practice. Methods Adult patients undergoing total thyroidectomy by a single otolaryngologist between 2013 and 2019 were divided into 2 cohorts: planned ambulatory and planned admission. Charts were reviewed for demographics and surgical outcomes in the 2 groups. The Healthcare Cost and Utilization Project databases for New York and Florida between 2015 and 2016 were also analyzed to compare outcomes of thyroidectomy as an ambulatory surgery between different practice settings. Results A total of 99 total thyroidectomies were performed during the study time period; 66 of 99 (67%) were planned as ambulatory procedures and 33 of 99 (33%) were planned admissions. Five of the 66 (8%) planned outpatient surgeries required admission. Complications of vocal fold dysfunction, symptomatic hypocalcemia, and seroma formation were more commonly seen in the inpatient cohort. Only 2 ambulatory patients required admission after discharge. Nationally, odds of complication were higher for ambulatory total thyroidectomy at nonteaching practice sites, which is not duplicated in our study. Conclusions Ambulatory total thyroidectomy can be undertaken safely in the community in carefully selected cases.
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Affiliation(s)
- Rebecca A Compton
- Tufts Medical Center, Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Jonathan C Simmonds
- Tufts Medical Center, Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA
| | - Jagdish K Dhingra
- Tufts Medical Center, Department of Otolaryngology-Head & Neck Surgery, Boston, Massachusetts, USA.,ENT Specialists, Inc, Brockton, Massachusetts, USA
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Cao WH, Su YJ, Liu NQ, Peng Y, Diao C, Cheng RC. Role of Ca²⁺ in Inhibiting Ischemia-Induced Apoptosis of Parathyroid Gland Cells in New Zealand White Rabbits. Med Sci Monit 2020; 26:e920546. [PMID: 32071284 PMCID: PMC7043353 DOI: 10.12659/msm.920546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Hypoparathyroidism is a common complication after thyroidectomy. Calcium supplementation can relieve these symptoms, but it is not clear whether it can protect the parathyroid glands. This study aimed to verify whether Ca2+ inhibits the apoptosis of parathyroid cells following ischemic injury. Material/Methods A rabbit model of parathyroid gland ischemic injury was established. The blood calcium concentrations were measured by colorimetry. The parathyroid hormone (PTH) levels were measured by enzyme-linked immunosorbent assay (ELISA). The parathyroid tissues were observed by hematoxylin and eosin (H&E) staining and the TdT-mediated dUTP nick-end labeling (TUNEL) assay. Western blotting was used to quantify the levels of the following proteins: caspase-3 and p38 MAP Kinase (p38 MAPK). Results This study demonstrates that apoptosis can be a part of the pathological changes associated with parathyroid ischemic injury. Calcium supplementation inhibited the apoptosis of parathyroid cells following ischemic injury. There were no significant differences among the serum calcium levels from the Sham operation (Sham), the Control group (CG), or the Calcium supplementation group (CSG) after 24 h, 72 h, and 168 h of treatment. PTH levels in the CG were significantly higher than in the CSG at 24 h and 72 h after treatments. The apoptosis rate of parathyroid cells from rabbits in the CSG was significantly lower than that of those from rabbits in the CG at 24 h and 72 h after the treatment. Calcium supplementation inhibited p38 MAPK and caspase-3 expression. Conclusions This study demonstrates that calcium supplementation inhibited the apoptosis of parathyroid cells following ischemic injury.
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Affiliation(s)
- Wei-Han Cao
- Department of Ultrasound, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Yan-Jun Su
- Department of Thyroid Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Nian-Qiu Liu
- Department of Breast Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Ying Peng
- Department of Thyroid Sugery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Chang Diao
- Department of Thyroid Sugery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Ruo-Chuan Cheng
- Department of Thyroid Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
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Ma JM, Wu LF, Hu JS, Zhu ZW, Li GZ, Li GQ, Sun B, Wang G. Evaluation of surgical risk and prognosis between thyroid nodules of size <1 and ≥1 cm. Gland Surg 2019; 8:674-682. [PMID: 32042675 DOI: 10.21037/gs.2019.11.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background The objective of this study was to evaluate the surgical risk and prognosis between thyroid nodules of size <1 and ≥1 cm and to explore whether it is reasonable generally to ignore the diagnosis and treatment of thyroid nodules and thyroid carcinoma <1 cm in wide areas of China. Methods A retrospective observational study included all first-time thyroid surgery patients between January 2005 and December 2016 of the First Affiliated Hospital of Harbin Medical University. All patients were divided into two groups (group A: <1 cm, group B: ≥1 cm) according to the maximum diameter of the nodules and demographics, surgery procedure, pathology, postoperative complications, morbidity, and mortality were analyzed. Results A total of 6,317 patients were reviewed and 3,424 (54.20%) of them were malignant; 2,128 patients in group A and 4,189 in group B. Patients in group A had better pathological diagnosis, inferior extent of lymph node metastasis, less surgical complexity, fewer postoperative complications, and longer disease-free survival (DFS). Conclusions Thyroid operations were safer and involved fewer postoperative complications when thyroid nodules were <1 cm and patients who were diagnosed with malignant thyroid disease had superior prognoses. Underdeveloped regions of China should diagnose and treat thyroid nodules <1 cm early.
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Affiliation(s)
- Jia-Min Ma
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Lin-Feng Wu
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Ji-Sheng Hu
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Zong-Wen Zhu
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Guang-Zhou Li
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Guo-Qing Li
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Bei Sun
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Gang Wang
- Ward Two of Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Minuto MN, Reina S, Monti E, Ansaldo GL, Varaldo E. Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients. J Endocrinol Invest 2019; 42:1291-1297. [PMID: 31124043 DOI: 10.1007/s40618-019-01064-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/14/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE The endocrine surgeon and the endocrinologist should standardize how they deal with patients with an indication for thyroidectomy, as the road to surgery starts well before the operation itself. The patient should be thoroughly informed about where and how surgery will be performed, the postoperative improvements that can be expected, and the possibility and incidence of relevant complications. This short review aims at identifying the most common postoperative issues after thyroidectomy, with the relevant therapeutic suggestions. METHODS A revision of studies reporting the morbidity of thyroid surgery, involving the largest numbers of patients. RESULTS It has been clearly demonstrated that the outcome of thyroid surgery is significantly better when the procedure is performed by an experienced surgeon. Thus, the number of thyroidectomies performed by a surgeon should drive the endocrinologist when referring a patient. CONCLUSIONS Despite the surgeon's experience, thyroidectomy is burdened by a relatively high rate of postoperative issues ranging from less severe ones to others causing significant changes in the patient's quality of life. Minor, non-invalidating symptoms have been described in 40% of patients after thyroidectomy (e.g. hoarseness, mild dysphagia, some degree of voice alteration); however, these symptoms usually resolve within a few months of surgery, with or without early treatment. On the other hand, major postoperative complications are observed in a limited number of patients, but in these cases early diagnosis is important to provide the most appropriate postoperative treatment, and thus hasten full recovery or at least achieve the greatest possible improvement.
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Affiliation(s)
- M N Minuto
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy.
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - S Reina
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - E Monti
- Dipartimento di Medicina Interna (DIMI), Università degli Studi di Genova, Genoa, Italy
| | - G L Ansaldo
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - E Varaldo
- Dipartimento di Scienze Chirurgiche (DISC), Università degli Studi di Genova, V.le Benedetto XV 6, 16132, Genoa, Italy
- U.O. Chirurgia 1, Dipartimento di Chirurgia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Abstract
The incidence of thyroid cancer is increasing, largely attributable to overdetection related to prevalent diagnostic and radiologic imaging modalities. Papillary thyroid cancer remains the most common thyroid malignancy. It has a high tendency for regional metastasis to the cervical lymph nodes. The optimal management of the neck in patients with thyroid carcinoma has long been an important topic of debate. This article addresses central and lateral neck dissection, providing a simplified guide to the most up-to-date and evidence-based practices.
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Affiliation(s)
- Ahmad M Eltelety
- Endocrine Head and Neck Surgery, Otolaryngology Department, Medical College of Georgia, Augusta University, 1120 Fifteenth Street, BP-4109, Augusta, GA 30912-4060, USA; Otolaryngology Department, Cairo University, ElManial, Cairo 11562, Arab Republic of Egypt
| | - David J Terris
- Otolaryngology Department, Augusta University, Thyroid and Parathyroid Center, 1120 Fifteenth Street, BP-4109, Augusta, GA 30912-4060, USA.
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12
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Xing T, Hu Y, Wang B, Zhu J. Role of oral calcium supplementation alone or with vitamin D in preventing post-thyroidectomy hypocalcaemia: A meta-analysis. Medicine (Baltimore) 2019; 98:e14455. [PMID: 30813146 PMCID: PMC6407934 DOI: 10.1097/md.0000000000014455] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Thyroidectomy is the main intervention for thyroid malignancies and some benign thyroid diseases. Its most common complication is hypocalcaemia, which requires oral or intravenous calcium therapy. The aim of this meta-analysis was to assess the efficacy of routine calcium supplementation with or without vitamin D in preventing hypocalcaemia post-thyroidectomy. METHODS Systematic searches of the PubMed, EMBASE, and Cochrane Library databases were performed. The qualities of the included articles were assessed using the Cochrane risk of bias tool. The studies' qualities of outcomes and strengths of evidence were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Data analysis was performed using Review Manager 5.3, and odds ratio (ORs) with their 95% confidence intervals (CIs) were computed for dichotomous data. RESULTS Ten randomized controlled trials (RCTs) were included. The combined study recruited 1620 patients (343 men and 1277 women) who underwent total thyroidectomy alone or with neck dissection. Calcium supplementation decreased the risk of transient postoperative hypocalcaemia (OR 0.48 [95% CI, 0.31-0.74]; P < .001) but did not decrease the demand for intravenous supplementation or the rate of permanent hypocalcaemia compared to no treatment. Calcium and vitamin D supplementation significantly reduced the rate of transient hypocalcaemia and the demand for intravenous supplementation compared to either no treatment (OR 0.21 [95% CI, 0.11-0.40]; P < .001 and OR 0.26 [95% CI, 0.10-0.69]; P = .007, respectively) or calcium alone (OR 0.39 [95% CI, 0.18-0.84]; P = .02 and OR 0.18 [95% CI, 0.07-0.47]; P < .001, respectively), but did not decrease the rate of permanent hypocalcaemia. GRADE-based confidence was moderate. CONCLUSION Postoperative calcium supplementation is effective for preventing post-thyroidectomy hypocalcaemia. Calcium plus vitamin D was more effective than calcium alone in preventing postoperative hypocalcaemia and decreasing the demand for intravenous calcium supplementation. Further, well-designed RCTs with larger sample sizes are required to validate our findings.
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Affiliation(s)
| | - Yiyi Hu
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chendu
| | - Bin Wang
- Department of Thyroid Surgery
- The Third People' s Hospital of Chengdu, China
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Echanique KA, Govindan A, Mohamed OM, Sylvester M, Baredes S, Yu-Lan Ying M, Kalyoussef E. Age-Related Trends of Patients Undergoing Thyroidectomy: Analysis of US Inpatient Data from 2005 to 2013. Otolaryngol Head Neck Surg 2019; 160:457-464. [PMID: 30829140 DOI: 10.1177/0194599818825455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES As the country ages, thyroidectomies can be expected to be performed more frequently among the elderly. In this study, we stratified patients by age to explore demographics and complications of patients undergoing thyroidectomy. STUDY DESIGN Retrospective study with a national database. SETTING Nationwide Inpatient Sample. SUBJECTS AND METHODS A total of 414,079 thyroidectomy cases from 2005 to 2013 were identified. Complications, outcomes, demographics, length of stay, and hospital charges were evaluated among patients and stratified by age into 4 cohorts: younger (<65 years), advanced age (65-74 years), elderly (75-84 years), and superelderly (≥85 years). RESULTS Of 414,079 thyroidectomy cases identified, patients aged <65 years accounted for 75.6% of cases, while those aged 65-74, 75-84, and ≥85 years accounted for 16.3%, 7.2%, and 0.9%, respectively ( P < .001). There was a significant difference in length of stay, total hospital charges, and mortality throughout the different age groups ( P < .001), all trending upward with advancing age. In the aging population, incidence of recurrent laryngeal nerve injury, transfusion of erythrocytes, and acute cardiac complications increased with increasing age ( P < .001), while hypoparathyroidism decreased with age ≥65 but ≤85 years ( P < .001). Patients aged ≥75 years had increased odds of mortality as compared with their younger counterparts ( P < .001). CONCLUSION This study utilized a national database to describe and elucidate trends in older populations undergoing thyroidectomy. Thyroid-related complications, including blood transfusion and recurrent laryngeal nerve injury, increased with increasing patient age. This information will help to guide pre- and postoperative care for aging patients undergoing thyroidectomy.
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Affiliation(s)
- Kristen A Echanique
- 1 Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Aparna Govindan
- 1 Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Omar M Mohamed
- 1 Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Michael Sylvester
- 1 Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Soly Baredes
- 1 Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,2 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Mary Yu-Lan Ying
- 1 Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Evelyne Kalyoussef
- 1 Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Bollig CA, Jorgensen JB, Zitsch RP, Dooley LM. Utility of Intraoperative Frozen Section in Large Thyroid Nodules. Otolaryngol Head Neck Surg 2018; 160:49-56. [PMID: 30322356 DOI: 10.1177/0194599818802183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine if the routine use of intraoperative frozen section (iFS) results in cost savings among patients with nodules >4 cm with nonmalignant cytology undergoing a thyroid lobectomy. STUDY DESIGN Case series with chart review; cost minimization analysis. SETTING Single academic center. SUBJECTS AND METHODS Records were reviewed on a consecutive sample of 48 patients with thyroid nodules >4 cm and nonmalignant cytology who were undergoing thyroid lobectomy in which iFS was performed between 2010 and 2015. A decision tree model of thyroid lobectomy with iFS was created. Comparative parameters were obtained from the literature. A cost minimization analysis was performed comparing lobectomy with and without iFS and the need for completion thyroidectomy with costs estimated according to 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. RESULTS The overall malignancy rate was 25%, and 33% of these malignancies were identified intraoperatively. When the malignancy rates obtained from our cohort were applied, performing routine iFS was the less costly scenario, resulting in a savings of $486 per case. When the rate of malignancy identified on iFS was adjusted, obtaining iFS remained the less costly scenario as long as the rate of malignancies identified on iFS exceeded 12%. If patients with follicular lesions on cytology were excluded, 50% of malignancies were identified intraoperatively, resulting in a savings of $768 per case. CONCLUSIONS For patients with nodules >4 cm who are undergoing a diagnostic lobectomy, the routine use of iFS may result in decreased health care utilization. Additional cost savings could be obtained if iFS is avoided among patients with follicular lesions.
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Affiliation(s)
- Craig A Bollig
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Jeffrey B Jorgensen
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Robert P Zitsch
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Laura M Dooley
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
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Orloff LA, Wiseman SM, Bernet VJ, Fahey TJ, Shaha AR, Shindo ML, Snyder SK, Stack BC, Sunwoo JB, Wang MB. American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults. Thyroid 2018; 28:830-841. [PMID: 29848235 DOI: 10.1089/thy.2017.0309] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment. SUMMARY HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.
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Affiliation(s)
- Lisa A Orloff
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Sam M Wiseman
- 2 Department of Surgery, University of British Columbia , Vancouver, Canada
| | - Victor J Bernet
- 3 Division of Endocrinology, Mayo Clinic College of Medicine , Jacksonville, Florida
| | - Thomas J Fahey
- 4 Department of Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center , New York, New York
| | - Ashok R Shaha
- 5 Head and Neck Service, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Maisie L Shindo
- 6 Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University , Portland, Oregon
| | - Samuel K Snyder
- 7 Department of Surgery, University of Texas Rio Grande Valley School of Medicine , Harlingen, Texas
| | - Brendan C Stack
- 8 Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - John B Sunwoo
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Marilene B Wang
- 9 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA , Los Angeles, California
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Margolick J, Chen W, Wiseman SM. Systematic Review and Meta-Analysis of Unplanned Reoperations, Emergency Department Visits and Hospital Readmission After Thyroidectomy. Thyroid 2018; 28:624-638. [PMID: 29587583 DOI: 10.1089/thy.2017.0543] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Unplanned reoperation, emergency department (ED) visits, and hospital readmission following thyroid operations usually arise due to complications and are a source of frustration for both surgeons and patients. With the aim of providing insight important for the development of patient quality care improvement initiatives, the primary objective of this review was to evaluate the available literature systematically in order to determine the contemporary rates of reoperation, readmission, and ED visits following thyroid operations. A secondary study objective was to determine if there were any practices that showed promise in reducing the occurrence of these undesirable postoperative events. METHODS This systematic review was conducted in accordance with the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses protocols. Twenty-two studies were included in the systematic review. Meta-analysis was performed to obtain the weighted-pooled summary estimates of rates of reoperations, ED visits, and unplanned hospital readmission. Jackknife sensitivity analyses were performed for each data set. Finally, in order to detect the risk of publication bias and the small-study effect, funnel plot analysis was performed. RESULTS The pooled rate estimate for reoperation was very low (0.6% [confidence interval (CI) 0.3-1.1%]). This was subject to publication bias because smaller studies tended to report lower rates of reoperation. The pooled rate of ED visits was 8.1% [CI 6.5-9.8%], while the pooled rate of hospital readmission from 19 studies was 2.7% [CI 2.1-3.4%]. Neck hematoma was the most common reason for reoperation, while postoperative hypocalcemia was the most common reason for hospital readmission. CONCLUSIONS ED visits and hospital readmission after thyroidectomy are common, and there are several practices that can reduce their occurrence. Routine postoperative calcium and vitamin D supplementation may reduce rates of postoperative hypocalcemia, and avoiding postoperative hypertension may decrease the risk of neck hematoma development and the need for reoperation. Older age, thyroid cancer, dependent functional status, higher ASA score, diabetes, chronic obstructive pulmonary disease, steroid use, hemodialysis, and recent weight loss increase the risk of hospital readmission after thyroid surgery. By further identifying risk factors for reoperation, ED visits, and readmission, this review may assist practitioners in optimizing perioperative care and therefore reducing patient morbidity and mortality after thyroid operations.
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Affiliation(s)
- Joseph Margolick
- 1 Department of Surgery, University of British Columbia and St. Paul's Hospital , Vancouver, Canada
| | - Wenjia Chen
- 2 Department of Pharmaceutical Science, University of British Columbia , Vancouver, Canada
| | - Sam M Wiseman
- 1 Department of Surgery, University of British Columbia and St. Paul's Hospital , Vancouver, Canada
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Bollig CA, Gilley D, Lesko D, Jorgensen JB, Galloway TL, Zitsch RP, Dooley LM. Economic Impact of Frozen Section for Thyroid Nodules with "Suspicious for Malignancy" Cytology. Otolaryngol Head Neck Surg 2018; 158:257-264. [PMID: 29292662 DOI: 10.1177/0194599817740328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To perform a cost analysis of the routine use of intraoperative frozen section (iFS) among patients undergoing a thyroid lobectomy with "suspicious for malignancy" (SUSP) cytology in the context of the 2015 American Thyroid Association guidelines. Study Design Case series with chart review; cost minimization analysis. Setting Academic. Subjects and Methods Records were reviewed for patients with SUSP cytology who underwent thyroid surgery between 2010 and 2015 in which iFS was utilized. The diagnostic test performance of iFS and the frequency of indicated completion/total thyroidectomies based on the 2015 guidelines were calculated. A cost minimization analysis was performed comparing lobectomy, with and without iFS, and the need for completion thyroidectomy according to costs estimated from 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Results Sixty-five patients met inclusion criteria. The malignancy rate was 61.5%, 45% of which was identified intraoperatively. The specificity and positive predictive value were 100%. The negative predictive value and sensitivity were 83% and 95%, respectively. Completion/total thyroidectomy was indicated for 9% of patients; 83% of these individuals had findings on iFS that would have changed management intraoperatively. Application of the new guidelines would have resulted in a significant reduction in the frequency of conversion to a total thyroidectomy when compared with the actual management (26.1% vs 7.7%, P = .005). Performing routine iFS was the less costly scenario, resulting in a savings of $474 per case. Conclusion For patients with SUSP cytology undergoing lobectomy, routine use of iFS would result in decreased health care utilization.
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Affiliation(s)
- Craig A Bollig
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - David Gilley
- 2 School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - David Lesko
- 2 School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Jeffrey B Jorgensen
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Tabitha L Galloway
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Robert P Zitsch
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Laura M Dooley
- 1 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri, USA
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Langner E, Tincani AJ, del Negro A. Use of prophylactic oral calcium after total thyroidectomy: a prospective study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2017; 61:447-454. [PMID: 28977158 PMCID: PMC10522254 DOI: 10.1590/2359-3997000000286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 10/10/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the use of prophylactic oral calcium after total thyroidectomy in the prevention of symptomatic hypocalcemia, and to develop a rational strategy of oral calcium supplementation following this type of surgery. SUBJECTS AND METHODS Prospective study including 47 patients undergoing total thyroidectomy from January 2007 to February 2012. The patients were allocated to one of the following groups: I (no postoperative calcium) or II (oral calcium 3 g per day). Oral calcium was started at the first postoperative day and administered until the sixth postoperative day. The patients were followed up for a minimum of 6 months and evaluated with a minimum of five measurements of ionized calcium: preoperative, 16 hours after surgery, seventh postoperative day, and at postoperative days 90 (PO90) and 180 (PO180). The cohort included three men and 44 women, of whom 24 (51.9%) had benign thyroid disease, and 23 had suspected or confirmed malignant disease. RESULTS When compared with Group II, Group I had significantly higher rates of postoperative biochemical hypocalcemia at PO1 and PO180, and of symptomatic hypocalcemia at PO1, PO7, and PO90. Other data were not significantly different between the groups. CONCLUSION We conclude that postoperative calcium supplementation effectively prevents symptomatic and biochemical hypocalcemia after total thyroidectomy, and can be safely used after this procedure. The presented strategy of oral calcium supplementation may be implemented in a viable manner.
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Affiliation(s)
| | - Alfio José Tincani
- Universidade Estadual de CampinasSPBrasilUniversidade Estadual de Campinas (Unicamp), SP, Brasil
| | - André del Negro
- Universidade Estadual de CampinasSPBrasilUniversidade Estadual de Campinas (Unicamp), SP, Brasil
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Castro A, del Rio L, Gavilan J. Stratifying the Risk of Developing Clinical Hypocalcemia after Thyroidectomy with Parathyroid Hormone. Otolaryngol Head Neck Surg 2017; 158:76-82. [DOI: 10.1177/0194599817730334] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective To identify the risk of clinical hypocalcemia in the first hours after thyroidectomy. Study Design Prospective observational study. Setting Single-institution tertiary hospital in Madrid, Spain. Subjects and Methods A total of 123 patients who underwent total or completion thyroidectomy between June 2010 and March 2012 were included. Pre- and postoperative intact parathyroid hormone (iPTH) levels were obtained. Patients remain hospitalized a minimum of 48 hours until blood calcium stabilized. Calcium and/or vitamin D supplements were prescribed only when signs or symptoms of hypocalcemia developed. Receiver operating characteristic curve analysis was employed to evaluate the postoperative iPTH level and the pre- to postoperative decrease in iPTH levels. Two cutoff values were determined to stratify the risk of developing clinical hypocalcemia into 3 groups. Results The areas under the receiver operating characteristic curve were 0.991 for the postoperative iPTH and 0.998 for the decrease in iPTH. An iPTH decrease of 80% had 100% sensitivity to detect patients who developed clinical hypocalcemia, while a postoperative iPTH <3 pg/mL had 100% specificity. Thus, patients with an iPTH decrease ≤80% are at a very low risk of clinical hypocalcemia, and patients with a postoperative iPTH <3 pg/mL are at a very high risk. Patients with an iPTH decrease >80% and a postoperative iPTH ≥3 pg/mL are at intermediate risk. No significant correlation was found between the time when the sample was obtained and iPTH values. Conclusion This study stablishes a very accurate test to stratify the risk of clinical postthyroidectomy hypocalcemia based on pre- and postoperative iPTH levels.
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Affiliation(s)
- Alejandro Castro
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
| | - Laura del Rio
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
| | - Javier Gavilan
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
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Arer IM, Kus M, Akkapulu N, Aytac HO, Yabanoglu H, Caliskan K, Tarim MA. Prophylactic oral calcium supplementation therapy to prevent early post thyroidectomy hypocalcemia and evaluation of postoperative parathyroid hormone levels to detect hypocalcemia: A prospective randomized study. Int J Surg 2016; 38:9-14. [PMID: 28039060 DOI: 10.1016/j.ijsu.2016.12.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/08/2016] [Accepted: 12/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative hypocalcemia is the most common complication after total thyroidectomy. Postoperative parathyroid hormone (PTH) measurement is one of the methods to detect or prevent postoperative hypocalcemia. Prophylactic oral calcium supplementation is another method to prevent early postoperative hypocalcemia. The aim of this study is to detect the accurate timing of PTH and evaluate efficacy of routine oral calcium supplementation for postoperative hypocalcemia. METHODS A total of 106 patients were performed total thyroidectomy. Rotuine oral calcium supplementation was given to group 1 and no treatment to group 2 according to randomization. Serum calcium and PTH level of patients in group 2 at postoperative 6, 12 and 24 h and patients in both groups at postoperative day 7 were evaluated. Patients were compared according to age, sex, operation findings, serum calcium and PTH levels and symptomatic hypocalcemia. RESULTS Half of the patients (50%) were in group 1. Most of the patients were female (83%). The most common etiology of thyroid disease was multinodular goiter (64.1%). Oral calcium supplementation was given to 18 (33.9%) patients in group 2. Symptomatic hypocalcemia for group 1 and 2 was found to be 1.9 and 33.9% respectively (p < 0.05). No statistical difference can be observed regarding the timing of serum biomarkers. CONCLUSION Serum PTH levels at postoperative 12 and 24 h can predict early post-thyroidectomy hypocalcemia. Prophylactic oral calcium supplementation therapy can prevent early post-thyroidectomy hypocalcemia with advantages of being cost effective and safe.
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Affiliation(s)
- Ilker Murat Arer
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Murat Kus
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Nezih Akkapulu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Huseyin Ozgur Aytac
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Hakan Yabanoglu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Kenan Caliskan
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Mehmet Akin Tarim
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
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Hu J, Zhao N, Kong R, Wang D, Sun B, Wu L. Total thyroidectomy as primary surgical management for thyroid disease: surgical therapy experience from 5559 thyroidectomies in a less-developed region. World J Surg Oncol 2016; 14:20. [PMID: 26801233 PMCID: PMC4722660 DOI: 10.1186/s12957-016-0772-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/11/2016] [Indexed: 11/30/2022] Open
Abstract
Background The objective of this study was to evaluate the safety of total thyroidectomy for thyroid disorders and summarise the treatment experience in a less-developed region. Methods This was a retrospective observational cohort study using the computerised database of the First Affiliated Hospital of Harbin Medical University. All consecutive thyroidectomy patients from 2003 to 2014 were included in this study. Demographics, surgical procedure, diagnoses, morbidity and mortality were retrospectively reviewed. Results There were a total of 714 men and 4845 women in this study, with a mean age of 55 (range 9–87) years. A total of 4632 patients underwent total thyroidectomy for primary surgical treatment, and 189 patients previously underwent partial thyroidectomy. A total of 56.2 % of the patients had multinodular goitre, including 12.23 % who were thyrotoxic. Graves’ disease and Hashimoto’s disease were diagnosed in 2.82 and 7.23 % of the patients, respectively. Papillary thyroid cancer was identified in 1336 patients, 44.99 % of whom had papillary microcarcinoma. The total prevalence of permanent complications of first-time and secondary surgeries was 0.35 and 7.41 %, respectively. During thyroid surgery, 945 patients underwent parathyroid autotransplantation. Conclusions Initial total thyroidectomy can be safely performed for both benign and malignant thyroid diseases in a less-developed region. The morbidity of a secondary surgical procedure after subtotal thyroidectomy is significantly high compared to first-time surgery.
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Affiliation(s)
- Jisheng Hu
- Department of Pancreatic and Biliary Surgery, First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China.
| | - Nan Zhao
- Department of Respiratory Medicine, First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China.
| | - Rui Kong
- Department of Pancreatic and Biliary Surgery, First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China.
| | - Dawei Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, 150 Haping Street, Nangang District, Harbin, 150081, Heilongjiang Province, China.
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China.
| | - Lifeng Wu
- Department of Pancreatic and Biliary Surgery, First Affiliated Hospital of Harbin Medical University, 23 Youzheng Street, Nangang District, Harbin, 150001, Heilongjiang Province, China.
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Segel JM, Duke WS, White JR, Waller JL, Terris DJ. Outpatient thyroid surgery: Safety of an optimized protocol in more than 1,000 patients. Surgery 2015; 159:518-23. [PMID: 26471720 DOI: 10.1016/j.surg.2015.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/30/2015] [Accepted: 08/05/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Outpatient thyroid surgery is becoming increasingly common. The aim of this study was to clarify the principles for safe outpatient thyroid surgery and review our outcomes with the use of a protocol for outpatient thyroidectomy in a large patient cohort. STUDY DESIGN A systematic analysis of a prospectively maintained database of outcomes of thyroidectomy in a tertiary endocrine surgery practice. SETTING Academic medical center. SUBJECTS AND METHODS A protocol for outpatient thyroidectomy was conceived and refined over 3 years. A prospective analysis of all thyroidectomies accomplished by a single surgeon who used this protocol from May 2006 to November 2013 was then undertaken. Patient demographics, operative and pathologic data, admission status, complications, and readmission rates were recorded. RESULTS A total of 1,311 thyroidectomy procedures were performed during the study period, of which 1,026 (78.3 %) were conducted on an outpatient basis. The readmission rate for outpatients was 0.9%, with only 1 readmission in the last 200 procedures. Inpatients (which included patients in the 23-hour "observation" category) were readmitted more often than outpatients (3.5% vs 0.9%, P < .01). Outpatient management increased steadily throughout the study period (from 59.7% to 92.3%, P < .01), despite a larger mean nodule size and a greater rate of malignancy over time. There were no changes in the complication rate across the study timeframe except for the incidence of temporary hypocalcemia, which decreased over time (P < .01). CONCLUSION Outpatient thyroid surgery is safe in appropriately selected patients using an optimized and systematic protocol.
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Affiliation(s)
- Jamie M Segel
- Department of Otolaryngology - Head and Neck Surgery, Georgia Regents University, Augusta, GA
| | - William S Duke
- Department of Otolaryngology - Head and Neck Surgery, Georgia Regents University, Augusta, GA
| | - Jennifer R White
- Department of Otolaryngology - Head and Neck Surgery, Georgia Regents University, Augusta, GA
| | - Jennifer L Waller
- Department of Biostatistics and Epidemiology, Georgia Regents University, Augusta, GA
| | - David J Terris
- Department of Otolaryngology - Head and Neck Surgery, Georgia Regents University, Augusta, GA.
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Stack BC, Bimston DN, Bodenner DL, Brett EM, Dralle H, Orloff LA, Pallota J, Snyder SK, Wong RJ, Randolph GW. American Association of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: Postoperative Hypoparathyroidism - Definitions and Management. Endocr Pract 2015; 21:674-685. [DOI: 10.4158/ep14462.dsc] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Day Case Thyroid and Parathyroid Surgery: Time to Replicate Same in Developing Countries. World J Surg 2015; 39:2102-3. [PMID: 25609119 DOI: 10.1007/s00268-015-2951-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Terkawi AS, Al-Dhahri SF. Perioperative parathyroid hormone measurements in thyroid surgery: one stone to hit three birds. Braz J Otorhinolaryngol 2014; 80:551-3. [PMID: 25457078 PMCID: PMC9442736 DOI: 10.1016/j.bjorl.2014.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 07/22/2014] [Indexed: 11/19/2022] Open
Affiliation(s)
- Abdullah S Terkawi
- Department of Anesthesiology, University of Virginia, Charlottesville, USA.
| | - Saleh F Al-Dhahri
- Department of Otolaryngology - Head, Neck Surgery, King Saud University, King Fahad Medical City, Riyadh, Saudi Arabia
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Changing Trends in Thyroid and Parathyroid Surgery over the Decade: Is Same-day Discharge Feasible in the United Kingdom? World J Surg 2014; 38:2825-30. [DOI: 10.1007/s00268-014-2673-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
INTRODUCTION The main barriers to short stay thyroidectomy are haemorrhage, bilateral recurrent laryngeal nerve palsy causing respiratory compromise and hypocalcaemia. This study assessed the safety and effectiveness of thyroidectomy as a 23-hour stay procedure. METHODS All patients undergoing total or completion thyroidectomy were prescribed calcium and vitamin D3 supplements following surgery. Retrospective analysis identified patients admitted for longer than 23 hours and any readmissions. RESULTS A total of 164 patients were admitted for 23-hour stay thyroid surgery over a 25-month period between 2008 and 2010. Four patients (2%) required admission for longer than 23 hours. No patients required emergency intervention for postoperative haemorrhage or airway compromise. Biochemical hypocalcaemia (despite calcium supplements) was detected in one patient when measured at the outpatient clinic two weeks following surgery. Twelve patients (7.3%) attended the accident and emergency department following discharge; four required admission for intravenous antibiotics for wound infection and one for biochemical hypocalcaemia. CONCLUSIONS This single centre UK experience demonstrates that thyroidectomy can be carried out both safely and effectively as a 23-hour stay procedure. Prophylactic prescription of calcium and vitamin D3 reduces hypocalcaemia, and thereby also prolonged admission and readmission due to hypocalcaemia. Supplements are an acceptable, cost effective method of reducing hypocalcaemia and shortening postoperative length of stay.
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Affiliation(s)
- A H Perera
- Barnet and Chase Farm Hospitals NHS Trust, UK
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Alhefdhi A, Mazeh H, Chen H. Role of postoperative vitamin D and/or calcium routine supplementation in preventing hypocalcemia after thyroidectomy: a systematic review and meta-analysis. Oncologist 2013; 18:533-42. [PMID: 23635556 DOI: 10.1634/theoncologist.2012-0283] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Transient hypocalcemia is a frequent complication after total thyroidectomy. Routine postoperative administration of vitamin D and calcium can reduce the incidence of symptomatic postoperative hypocalcemia. We performed a systematic review to assess the effectiveness of this intervention. The primary aim was to evaluate the efficacy of routine postoperative oral calcium and vitamin D supplementation in preventing symptomatic post-thyroidectomy hypocalcemia. The second aim was to draw clear guidelines regarding prophylactic calcium and/or vitamin D therapy for patients after thyroidectomy. METHODS We identified randomized controlled trials comparing the administration of vitamin D or its metabolites to calcium or no treatment in adult patients after thyroidectomy. The search was performed in PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, and Web of Knowledge databases. Patients with a history of previous neck surgery, calcium supplementation, or renal impairment were excluded. RESULTS Nine studies with 2,285 patients were included: 22 in the vitamin D group, 580 in the calcium group, 792 in the vitamin D and calcium group, and 891 in the no intervention group, with symptomatic hypocalcemia incidences of 4.6%, 14%, 14%, and 20.5%, respectively. Subcomparisons demonstrated that the incidences of postoperative hypocalcemia were 10.1% versus 18.8% for calcium versus no intervention and 6.8% versus 25.9% for vitamin D and calcium versus no intervention. The studies showed a significant range of variability in patients' characteristics. CONCLUSIONS A significant decrease in postoperative hypocalcemia was identified in patients who received routine supplementation of oral calcium or vitamin D. The incidence decreased even more with the combined administration of both supplements. Based on this analysis, we recommend oral calcium for all patients following thyroidectomy, with the addition of vitamin D for high-risk individuals.
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Affiliation(s)
- Amal Alhefdhi
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin 53792, USA
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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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Singer MC, Terris DJ. Cost-Effective by Any Definition: Response to “Cost-Effectiveness in Otolaryngology,” from Mark G. Shrime. Otolaryngol Head Neck Surg 2012. [DOI: 10.1177/0194599812446790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Shrime MG. Cost-effectiveness in otolaryngology. Otolaryngol Head Neck Surg 2012; 147:180-1; author reply 181. [PMID: 22745320 DOI: 10.1177/0194599812446789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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