Parathyroid autotransplantation in patients undergoing a total thyroidectomy: a review of 261 patients

Rat thyroid graft transplantation after cryopreservation with scintigraphic standardization for an experimental study

PURPOSE

Budget cuts among other factors undermine the use of state-of-the-art equipment by many research groups. This doesn't mean that their scientific data are not reliable or top-notch. Resort to adaptations is a recurrent need in their reality. The aim of this study was to assess whether scintigraphy with ^99mTcO₄ is effective in evaluating the functionality of thyroid grafts after cryopreservation in rats.

MATERIAL AND METHODS

24 rats were randomly distributed into 3 groups: Control Group (CG), without surgical procedure, Hypothyroidism Group (HTG), submitted to total thyroidectomy, and Transplanted Group (TG), with total thyroidectomy and cryopreservation of the thyroid gland for 7 days followed by grafting of a thyroid lobe. A protocol using a gamma camera imaging was conducted fourteen weeks after transplantation, and the whole body ^99mTc, focusing on the topic of heterotopic thyroid uptake was evaluated.

RESULTS

The images acquired had good quality with no noise and artifacts that could jeopardize its analysis. On the 14th day, HTG displayed no thyroid uptake, and the TG had a clear uptake of the thyroid graft in the topography of the biceps femoris muscle. Presented data also showed that both equipment spatial resolution and alignment (4.375 mm) did not interfere with the physiological uptake of ^99mTc by the thyroid graft.

CONCLUSION

The viability and functionality of cryopreserved thyroid autotransplantation in rats who underwent total thyroidectomy were successfully accessed by the scintigraphy protocol developed.

TOTAL THYROIDECTOMY FOR MALIGNANCY - IS CENTRAL NECK DISSECTION A RISK FACTOR FOR RECURRENT NERVE INJURY AND POSTOPERATIVE HYPOCALCEMIA? A TERTIARY CENTER EXPERIENCE IN ROMANIA

Introduction

Surgery for thyroid cancer carries a higher risk of morbidity given the region's complicated anatomy, the setting of malignancy and extent of the surgery.

Aim

To investigate the rate of complications related to the recurrent nerve and parathyroid glands lesions in patients with thyroid carcinoma that undergo thyroid surgery and lymph node dissection.

Patients and Methods

The data of 71 patients who underwent total thyroidectomy and 19 patients who underwent total thyroidectomy and central neck dissection with various associated neck dissection techniques were investigated using appropriate statistical tests.

Results

As expected, the rate of recurrent nerve injury observed in the neck dissection group was higher than in the total thyroidectomy group (15.7% vs. 2.8%, p=0.05). As for postoperative hypocalcemia, the rate observed in the neck dissection group, both for postoperative day 1 (p<0.0001) and day 30 (p=0.0003) was higher than in the total thyroidectomy group (68.4% vs. 19.7% postoperative day 1, 31.5% vs. 4.2% postoperative day 30).

Conclusions

The risk of morbidity concerning the recurrent nerve injury and postoperative hypoparathyroidism increases with the extent of surgery. Extensive surgery may achieve proper oncologic outcomes but increases the risk of postoperative morbidity and decreases quality of life. In deciding for extensive surgery, both patient and medical team need to understand these risks.

Parathyroid Autotransplantation During thyroid Surgery. Where we are? A Systematic Review on Indications and Results

Introduction: Hypoparathyroidism still represents an important concern in thyroid surgery. Careful dissection with identification and preservation of parathyroid glands in situ remains the best way to maintain gland vitality and avoid post-operative failure. Nevertheless, parathyroid glands are still inadvertently removed in up to 11% of cases. Parathyroid autotransplantation may represent the only way to restore parathyroid gland functionality in case of inadvertent removal or devascularization during thyroid surgery. Despite this, there is still no agreement on the effectiveness of this procedure. The present systematic review is focused on the mainly debated matters regarding the procedure, indications, technique and results. Methods: This review has been carried out according to PRISMA statement and checklist. The research item was: (((parathyroid autotransplantation[Title]) OR parathyroid reimplantation[Title]) NOT hyperparathyroidism[Title]) AND english[Language]. Results: A total of 31 studies have been found according to limitations already described, reporting from 4 to 890 procedures, with a total amount of 4088 PA. Among these studies, there are only 7 prospective case-series evaluations, 2 prospective randomized trials, while the other 22 studies are retrospective evaluations. The main concerns are: when and how to perform autotransplantation; in which anatomical site; which result to be expected, and how to manage and control the graft. Conslusions: Parathyroid autotransplantatin is an important tool to avoid or minimize the risk for hypoparathyroidism following thyroid surgery in selected cases. Parathormone assay can help the surgeon to determine when reimplantation is indicated or not. Further studies could theoretically give definitive results.

How many parathyroid glands can be identified during thyroidectomy?: Evidence-based data for medical experts

Background

The purpose of this study is to provide guidance for medical experts regarding malpractice claims on permanent hypoparathyroidism by analyzing the number of parathyroid glands (PGs) identified during thyroidectomy and the clinical outcome.

Methods

Parathyroid findings were documented in a standardized protocol for 357 patients undergoing thyroidectomy and treated by a single specialized surgeon. The resected thyroid was routinely dissected for accidentally removed PGs with consecutive autotransplantation and the pathological report also described unintentionally resected PGs. Follow-up was performed for 6 months.

Results

The mean number of identified PGs was 2.28. No PGs were found in 20 (5.6%), one in 56 (15.7%), two in 126 (35.3%), three in 114 (31.9%), and four in 41 (11.5%) cases. One patient (0.28%) had manifest permanent hypoparathyroidism, while ten patients (2.8%) had latent permanent hypoparathyroidism (hypocalcemia and normoparathyroidism). The risk factors identified for postoperative hypoparathyroidism were an increasing number of visualized PGs, autotransplantation, central neck dissection, and PGs in the histopathological work-up. For permanent hypoparathyroidism, PGs in the histology examination and neck dissection were significant, but the number of identified PGs was not.

Conclusion

Even an experienced surgeon is not always able to find all four PGs during thyroidectomy and occasionally identifies none. Rather than focusing on identifying a minimum number of PGs, it is more important not to miss them in risky positions. A documented awareness of PGs, i. e., knowledge of variable parathyroid positions and their saving, is a prerequisite for surgical quality and to protect surgeons from claims.

Review of Heterotopic Thyroid Autotransplantation

Total thyroidectomy is increasingly accepted for the management of bilateral benign thyroid disorders. Postoperatively, patients require lifelong levothyroxine replacement therapy to avoid postoperative hypothyroidism, which besides the burden of compliance, has been proven to be associated with several long-term side effects. Heterotopic thyroid autotransplantation was proposed several decades ago to avoid the need for life-long postoperative replacement therapy with maintaining the autoregulatory mechanism of thyroxin production inside the body according to its needs. Available data regarding this topic in literature is relatively poor. Before applying thyroid autotransplantation on humans, several studies have been done on animals, where the autologous transplantations were found to be successful in almost all the cases, proved by follow up postoperative 8-week measurements of thyroid hormones and histopathological examination of the removed autografts. Regarding the clinical application, few trials have been done using cryopreserved in vivo, in vitro or immediately autotransplanted thyroid autografts. Satisfactory results were obtained, however, the number of these studies and the number of patients per each study was very low. Besides the study methodologies were not so consistent.

Parathyroid Hormone: A Sensitive Predictor of Hypocalcemia Following Total Thyroidectomy

OBJECTIVE: To investigate whether monitoring parathyroid hormone (PTH) could predict hypocalcemia following total thyroidectomy or other bilateral thyroid manipulations.

STUDY DESIGN AND SETTING: Forty patients undergoing total thyroidectomy as well as other bilateral thyroid procedures were prospectively enrolled. PTH levels were measured preoperatively and 30 minutes postoperatively. Calcium levels were measured preoperatively and every 8–12 hours for the first 72 postoperative hours. Changes in PTH levels as well as symptoms of hypocalcemia were correlated with postoperative hypocalcemia.

RESULTS: Hypocalcemia developed in 13/40 patients (32.5%), mainly those patients undergoing total thyroidectomy in conjunction with paratracheal neck dissections. The respective sensitivity and specificity of a drop in PTH for detecting hypocalcemia was 92% and 66% (50% drop), 23% and 75% (75% drop), and 46% and 100% (drop below normal range).

CONCLUSIONS: A 50% drop in PTH levels 30 minutes following bilateral thyroid procedures is a sensitive predictor of hypocalcemia. A drop of 75% is a highly specific indicator of postoperative hypocalcemia, though not highly sensitive.

Parathyroid Reimplantation in Forearm Subcutaneous Tissue During Thyroidectomy: A Simple and Effective Way to Avoid Hypoparathyroidism

INTRODUCTION

Parathyroid autotransplantation plays an important role in preventing hypoparathyroidism following thyroidectomy. The preferred reimplantation site is still the sternocleidomastoid muscle, but this approach does not permit to check graft vitality postoperatively. The authors report the first prospective evaluation of normal parathyroid gland reimplantation in forearm subcutaneous tissue (using the same technique proposed during parathyroidectomy for hyperplasia) in case of devascularized or inadvertently removed glands during thyroid surgery.

MATERIALS AND METHODS

From January 2013 to August 2014, we performed 348 consecutive thyroidectomies for various disease, both benign and malignant. In 25 cases, due to inadvertent parathyroid removal or evidence of insufficient blood supply, we removed and fragmented the gland into 0.5-1 mm slices (one for frozen section) and reimplanted it into two subcutaneous pockets on the non-dominant forearm. After surgery we checked grafted gland function by evaluation of serum parathormone gradient between reimplanted versus non-reimplanted arm (considering significant a ratio of 1.5 or more), at 1 week, 1 and 3 months after surgery.

RESULTS

We observed recovery of reimplanted graft function in 48, 88 and 96% of patients respectively at 1 week, 1 and 3 months after surgery. All patients showed normal parathormone levels in peripheral blood (non-reimplanted arm). In one case we observed post-operative wound hematoma on graft-site. This patient showed no graft functionality in post-operative period (even at 3 months follow-up).

CONCLUSIONS

Parathyroid gland reimplantation in forearm subcutaneous tissue during thyroid surgery is a safe, easy and effective procedure; furthermore, it allows a good control of graft functionality and would allow an easy grafted gland removal if needed.

Total thyroidectomy as primary surgical management for thyroid disease: surgical therapy experience from 5559 thyroidectomies in a less-developed region

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.

Parathyroid gland autotransplantation after total thyroidectomy in surgical management of hypopharyngeal and laryngeal carcinomas: A case series

BACKGROUND AND OBJECTIVES

Total thyroidectomy is indicated in most cases with postcricoid carcinoma, circumferential hypopharyngeal carcinoma and in advanced laryngeal carcinoma. Persistent hypoparathyroidism is a frequent complication after total thyroidectomy which is difficult to manage unlike hypothyroidism. This study was to assess the feasibility of parathyroid gland autotranplantation after total thyroidectomy in advanced carcinomas and their effectiveness in preventing persistent hypoparathyroidism.

METHODS

This study included 26 patients with hypopharyngeal and laryngeal carcinoma presented to National Cancer Institute, Cairo University. Total thyroidectomy and total parathyroid gland excision were performed as a part of adequate oncologic surgical procedure. The parathyroid glands were identified, resected and stored in iced saline. Histological confirmation was necessary before implantation into separated muscle pockets in the anterior forearm muscles. Regular samples were drawn to assess serum parathormone and calcium levels.

RESULTS

All patients experienced hypocalcaemia within 1-5 days after operation. Only one patient experienced parathyroid graft failure while the remaining patients were normocalcemic during follow up after surgery, indicating functioning parathyroid grafts.

CONCLUSIONS

Parathyroid gland autotranplantation is a simple safe technique with high success rate in preventing persistent hypoparathyroidism after total thyroidectomy in surgical management of advanced hypopharyngeal and laryngeal carcinomas.

Parathyroid hyperplasia of auto-transplanted tissue in forearm skin

Currently, the treatment of choice for refractory tertiary hyperparathyroidism is a total parathyroidectomy with autotransplantation of the parathyroid tissue into the forearm. Recurrent hyperparathyroidism after autotransplantation requiring surgical excision of the autograft is uncommon. We describe a female patient with recurrent hyperplasia who underwent an excision of her parathyroid autograft. The excisional specimen was submitted to pathology with the only provided history of a 'left arm mass'. The lack of clinical history led to a preliminary impression of an adnexal neoplasm by the primary pathologist.

Is therapy with calcium and vitamin D and parathyroid autotransplantation useful in total thyroidectomy for preventing hypocalcemia?

BACKGROUND

Routine calcium and vitamin D administration and routine autotransplantation of parathyroid glands can prevent hypocalcemia after total thyroidectomy.

METHODS

Routine autotransplantation of 1 or more parathyroid glands and oral calcium and vitamin D supplementation was used in 252 patients.

RESULTS

One, 2, or 3 parathyroid glands were autotransplanted in 223, 27, and 2 patients, respectively. Routine oral calcium and vitamin D was administered in postoperative period in all patients. Postoperative hypocalcemia occurred in 17%, of whom 1.6% had minor symptoms related to hypocalcemia. No patient developed permanent hypocalcemia during the follow-up period. The postoperative stay was 1 day in 93.6% of the cases. The incidence of postoperative hypocalcemia and hospital stay was higher in patients who underwent autotransplantation of more than 1 parathyroid gland.

CONCLUSIONS

Routine oral calcium and vitamin D supplementation and autotransplantation of at least 1 parathyroid gland effectively reduced symptomatic hypocalcemia and permanent hypoparathyroidism in total thyroidectomy.

Incidental Parathyroidectomy during Thyroid Surgery: An Underappreciated Complication of Thyroidectomy

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.

Recovery of parathyroid function after total thyroidectomy: Long-term follow-up study

BACKGROUND

To prevent postoperative hypoparathyroidism following total thyroidectomy, the parathyroid glands are preserved in situ and/or resected or devascularized parathyroid glands are autotransplanted. A retrospective investigation was conducted utilizing biochemical and specific endocrine assessments to evaluate the difference in recovery of parathyroid function in the long term.

METHODS

A total of 103 patients underwent total thyroidectomy at Second Department of Surgery, School of Medicine, Kagawa University between 1990 and 1998. These patients were divided into a preservation group (n = 17), with only preserved glands in situ; a combination group (n = 72), consisting of patients with one or more parathyroid glands preserved in situ and one or more autotransplanted parathyroid glands; and an autotransplantation group (n = 14), with only transplanted glands.

RESULTS

The overall incidence of permanent hypoparathyroidism in the preservation group, the combination group, and the autotransplantation group was 0%, 1.4%, and 21.4%, respectively. The mean levels of intact parathyroid hormone in the preservation group, the combination group, and the autotransplantation group recovered to 102%, 107%, and 50% of the preoperative levels at 5-year follow up.

CONCLUSION

The results of the present study suggest that parathyroid glands should be preserved in situ whenever possible, to promote better recovery of postoperative function, and that only autotransplantation produces inadequate recovery of long-term function.

Total thyroidectomy for clinically benign disease of the thyroid gland

Background

The role of total thyroidectomy in the treatment of patients with benign thyroid disease remains controversial. However, this procedure may be appropriate when both thyroid lobes are involved and when the risk of recurrence is significant. This study is a review of a 15-year experience of total thyroidectomy for benign disease.

Methods

Between 1988 and 2002, 834 patients underwent total thyroidectomy for clinically benign disease at the Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital. There were 128 men and 706 women with a mean age of 52 (range 16–91) years. Indications for surgery were euthyroid multinodular goitre (MNG), toxic MNG and Graves' disease in 730 (87·5 per cent), 57 (6·8 per cent) and 47 (5·6 per cent) respectively. A total of 74 patients had previously undergone partial thyroidectomy.

Results

The incidence of temporary recurrent laryngeal nerve palsy was 2·3 per cent and that of temporary hypoparathyroidism 14·4 per cent. Permanent recurrent laryngeal nerve palsy occurred in 1·1 per cent, and 2·4 per cent of patients had permanent hypoparathyroidism. Neither the initial clinical diagnosis nor a history of previous treatment significantly influenced the rate of complications. The incidence of malignancy, other than incidental microscopic papillary carcinoma, was 4·6 per cent.

Conclusion

Total thyroidectomy has an important role in the management of patients with benign disease when both lobes of the thyroid gland are involved. This approach avoids disease recurrence and the increased risk of morbidity associated with secondary operation.

Assessment of parathyroid autotransplantation for preservation of parathyroid function after total thyroidectomy

BACKGROUND

Hypoparathyroidism with permanent hypocalcemia is a well-recognized complication after thyroid surgery.

AIM

This study was conducted to assess the role of immediate parathyroid autotransplantation in the preservation of parathyroid function after total thyroidectomy.

PATIENTS AND METHODS

Twenty-eight patients had autotransplantation of parathyroid glands resected or devascularized during total thyroidectomy. Data were collected prospectively regarding demographics, indication for surgery, operative procedure, pathologic diagnosis, number of glands transplanted, and subsequent course. Thyroid nodules were evaluated by ultrasonography, radionuclide scanning, and/or fine-needle aspiration cytology. All patients had serum ionized calcium, phosphorus, and intact parathyroid hormone (PTH) levels measured preoperatively and monitored regularly postoperatively for a period of 14 weeks and again at 6 months after operation. Patients were categorized into three groups according to the number of glands transplanted: one (group 1, n = 6), two (group 2, n = 14), or three glands (group 3, n = 8). In three other volunteers, one parathyroid gland was transplanted in the brachioradialis and subjected to electron microscopy 1, 2, and 4 weeks after transplantation.

RESULTS

Total thyroidectomy was performed for malignant disease in 16 patients (57.1%) and for benign disease in 12 (42.9%) patients. All patients reverted to asymptomatic normocalcemia without the need for any medications within 4 to 14 weeks. Normal levels of serum markers were regained slower when one gland was transplanted compared with two or three glands (P <.01). Electron microscopic examination showed evidence of ischemic degeneration in the transplanted tissues 1 week postoperatively. Regeneration started by the second week and coincided with normalization of PTH levels. Optimum resting and nearly normal status of parathyroid tissue was achieved by the fourth week.

CONCLUSIONS

This study showed that active PTH production coincides with regeneration of parathyroid cells and that autotransplantation of at least two resected or devascularized glands during total thyroidectomy nearly eliminates permanent postoperative hypoparathyroidism, thus improving the safety of total thyroidectomy performed for malignant or benign disease.

Parathyroid autotransplantation during thyroidectomy

Permanent hypoparathyroidism is a debilitating morbidity following thyroidectomy, with a reported incidence of up to 43%. Apart from meticulous dissection to preserve parathyroid glands and their blood supply, parathyroid autotransplantation (PA) has been increasingly employed to preserve parathyroid function. The adoption of PA during thyroidectomy has been reported to be associated with a low incidence of permanent hypoparathyroidism. Biochemical function of parathyroid autografts can be demonstrated objectively by forearm reimplantation or during long-term follow up. The clearest indication for PA is for inadvertently removed or devascularized parathyroid glands during thyroid surgery. Other strategies, including routine autotransplantation of at least one parathyroid gland, can be considered, but is associated with a high incidence of transient hypocalcaemia. Apart from refinement in technique to facilitate graft success, a reliable way to assess overall parathyroid function or viability of individual parathyroid gland may assist in monitoring parathyroid function and selecting patients requiring this procedure to prevent permanent hypoparathyroidism.

Incidence of inadvertent parathyroid removal during thyroidectomy

OBJECTIVES

To assess the incidence of unintentional parathyroid removal during routine thyroidectomy and to identify factors that might predict patients at high risk.

STUDY DESIGN

Retrospective review of case records. Data analyzed for incidental finding of parathyroid gland(s) in the thyroidectomy specimen and postoperative temporary or permanent hypocalcemia.

METHODS

The clinical records of 220 patients undergoing thyroidectomies between January 1997 and October 1999 were reviewed. Pathology reports were screened for information on the presence of parathyroid tissue along with the thyroid specimen. Operative reports were reviewed to exclude the possibility of intentional parathyroid gland removal. Case records were scrutinized to determine whether the patient developed symptomatic hypocalcemia postoperatively.

RESULTS

Nine percent of the 220 patients were found to have had inadvertent removal of parathyroid tissue. The majority of patients (95%) had two or less parathyroid glands in their specimens. The size and histological nature of the thyroid lesion were not predictive of inadvertent parathyroid removal. Of the 25 repeat operations for recurrent or persistent malignancy, 5 (20%) were found to have unintentional parathyroid removal compared with 15 (7.71%) of 195 primary thyroidectomy cases (P <.05). Nineteen percent of patients who had tracheoesophageal groove node dissection had an incidental parathyroid in their specimen compared with 7% who did not undergo tracheoesophageal groove node dissection (P = .04). None of the patients with unintentional parathyroid gland removal developed either temporary or permanent postoperative hypocalcemia.

CONCLUSIONS

Inadvertent excision of a parathyroid gland(s) occurred in 9% of patients undergoing thyroidectomy in our experience. Reoperative thyroid surgery and tracheoesophageal node dissection were associated with a significantly higher risk of inadvertent parathyroid gland excision. Inadvertent parathyroidectomy did not result in symptomatic temporary or permanent hypocalcemia postoperatively.

Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up

SUMMARY BACKGROUND DATA

Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy.

METHODS

An analysis of 194 patients having thyroidectomy and simultaneous parathyroid autotransplantation at Barnes Hospital from 1990 to 1994 was performed. Data were collected regarding patient demographics, indication for thyroidectomy, operative procedure, pathologic diagnoses, and postoperative course, including biochemical assessment of parathyroid autograft function.

RESULTS

Of 194 patients having either total, subtotal, or completion thyroidectomy, 104 (54%) experienced a [Ca(+2)]nadir less than or equal to 8.0 mg/dL and had symptoms and signs of hypocalcemia. Parathyroid autotransplantation was successful in 103 (99%) of these 104 cases and resulted in a 1.0% incidence of hypoparathyroidism in this series.

CONCLUSIONS

Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.