Fatores preditores para hipocalcemia pós-tireoidectomia

No Change in Complications Following Thyroidectomy Despite Increase in Thyroid Cancer Surgeries: A Meta-Regression Analysis

PURPOSE

The increase in thyroid cancer incidence has inevitably led to an increase in thyroid cancer surgeries. This meta-regression analysis aimed to determine if the rate of post-thyroidectomy complications changes by year.

MATERIALS AND METHODS

PubMed and Embase databases were used to perform a systematic literature search of studies published from January 1, 2005, using the keywords "thyroidectomy" and "complication." A meta-regression was performed for post-thyroidectomy hypocalcemia and bleeding.

RESULTS

This meta-analysis included 25 studies involving 927751 individuals. Through the years of publications in this study, there was no significant difference in the proportion of post-thyroidectomy hypocalcemia and bleeding (p=0.9978, 0.6393).

CONCLUSION

Although the number of thyroid surgeries has recently increased, the incidence of post-thyroidectomy hypocalcemia and bleeding did not significantly increase.

Management of Postthyroidectomy Hypoparathyroidism and Its Effect on Hypocalcemia-Related Complications: A Meta-Analysis

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.

Risk factors for postoperative hypocalcemia following total thyroidectomy: a retrospective study

BACKGROUND

and Objectives: Hypocalcemia is a commonly reported complication after thyroid surgery. Many possible risk factors have been identified. The purpose of this study is to analyze various risk factors possibly associated with development of postoperative hypocalcemia after thyroid surgery by dividing the sample population into postoperative hypocalcemia and normal calcium groups.

DESIGN

Retrospective.

SETTING

Multiple centers in the Makkah region of Saudi Arabia.

PATIENTS AND METHODS

Risk factors for postoperative hypocalcemia that were obtained for analysis include patient factors, perioperative blood parameters factors, disease-related factors, and surgical factors. Postoperative hypocalcemia was defined as a reduction of the total calcium level to <8.0 mg/dL. Hypocalcemic and normocalcemic patients were compared by multivariate logistic regression.

MAIN OUTCOME MEASURES

Distinguish independent risk factors for postoperative hypocalcemia after thyroidectomy.

SAMPLE SIZE

215 patients.

RESULTS

The incidence of hypocalcemia was 52.1% (112 of 215 patients). According to multivariate analysis, statistically significant risk factors for predicting postoperative hypocalcemia included postoperative parathyroid hormone level <10 pg/dL, inadvertent parathyroid gland resection, and neck dissection surgeries.

CONCLUSION

The causes of postoperative hypocalcemia are multi-factorial. Because many of these factors are modifiable, they should be identified postoperatively to distinguish high-risk groups and implement early preventive measures.

LIMITATIONS

Retrospective with a relatively small size. We encourage additional prospective studies with a larger sample size in multiple regions of the country, which might reveal further significant results.

Intact Parathyroid Hormone Levels in Predicting Postoperative Hypocalcaemia After Total Thyroidectomy in South Indian Population: Cross Sectional Study

Hypocalcaemia being one of the most common complications after total thyroidectomy may not be avoidable in all cases. This study evaluated the effectiveness of intact Parathyroid hormone (iPTH) measured at 1-h after total thyroidectomy in predicting postoperative hypocalcaemia in early postoperative period in South Indian population. Patients who underwent total thyroidectomy in our institute from 2016 to 2018 were included. Preoperative calcium and iPTH levels were measured. Patients' iPTH level was measured 1 h after surgery and serum calcium level was measured at 24 h after surgery. Patients were also monitored clinically for any symptoms and signs of hypocalcaemia. A total of 57 patients were studied. The malignant causes accounted for 75.4% with papillary carcinoma thyroid being the most common cause. 65.7% of patients who underwent total thyroidectomy and 100% of patients who underwent total thyroidectomy with neck dissection developed hypocalcaemia. 70% of patients with low iPTH developed hypocalcaemia and none of the patients who had normal iPTH developed hypocalcaemia. This relation was statistically significant with p value of 0.018 (< 0.05). The positive predictive value is 70% and negative predictive value is 100%. Though our study supports the hypothesis that iPTH is effective in predicting hypocalcaemia after total thyroidectomy in the early postoperative period, a larger sample study is needed to further support this. It can be used to consider patients for early discharge or to prophylactically start oral calcium and Vitamin D supplementation based on iPTH levels at 1 h after surgery.

Hypocalcemia following total and subtotal thyroidectomy and associated factors

BACKGROUND

Thyroidectomy is one of the common endocrinological surgeries for the treatment of thyroid disorders. Hypocalcemia is the potential complication after thyroidectomy, where is persistency can lead to serious systemic effects. The aim of this study is to evaluate the incidence of hypocalcemia in thyroidectomy patients.

METHODS

In this cross-sectional study, patients referred to (XXX) for thyroidectomy from 2019 to 2020 were enrolled. Preoperative serum calcium and postoperative 24- and 48-h calcium levels were evaluated in these patients. Demographic data (sex and gender), calcium levels, type of thyroidectomy and duration of surgery was recorded for all the patients. SPSS v22 was used for statistical analysis. P < 0.05 was considered as statistically significant.

RESULTS

Of 143 patients included in the study, the mean age was 49.7 ± 10.9 years and 61.5% were females and 38.5% were males. 49% patients had hypocalcemia in the first 24 hours after surgery and 63.6% following 48 hours of the surgery. The difference in calcium levels at three intervals were statistically significant, p = 0.001. The incidence of hypocalcemia was significantly more in women at 48 postoperative hours, p = 0.025. The age and duration of surgery was not significantly correlated with hypocalcemia, p > 0.05, whereas, patients who underwent total thyroidectomy had greater incidence of hypocalcemia 24 hours after the surgery, p = 0.021.

CONCLUSIONS

The incidence of hypocalcemia is greater in total thyroidectomy and female patients. Our study did not report significant correlation between duration of the surgery and age of the patients.

Role of Preoperative Administration of Vitamin D and Calcium in Postoperative Transient Hypocalcemia after Total Thyroidectomy

Introduction Thyroid surgery is one of the most frequently performed surgical procedures worldwide. Total thyroidectomy is a recommended procedure for most of the thyroid diseases. The most common complication resulting after this surgery is transient hypocalcemia - the incidence is 24% - which increases the morbidity rate and increases the length of stay in the hospital. The objective of our study was to compare the frequency of transient hypocalcemia after vitamin D and calcium supplementation with the control group for patients undergoing total thyroidectomy. Patients and methods It was a randomized controlled trial conducted at Department of Surgery, Pakistan Atomic Energy Commission General Hospital, Islamabad, Pakistan from January 2017 to July 2017. A total of 92 patients of both genders undergoing total thyroidectomy were included in the study. Patients undergoing reoperation for thyroid disease, American Society of Anesthesiologists (ASA) grade 3 or above, patients with chronic renal failure, preoperative hypocalcemia or hypercalcemia were excluded. The patients were sorted into two groups by lottery method; Group 1 in which Vitamin D (2,00,000 IU) and calcium (1 gm) was given 24 hours preoperatively. Group 2 was the control group. Total thyroidectomy was done and serum calcium levels were evaluated immediately after surgery on day two, seven and on the 30th day. The final outcome was measured at one month. Data was analyzed via the Statistical Package for Social Sciences version 22.0 (IBM Corp, Armonk, NY, USA). P value ≤ 0.05 was considered significant. Results The age ranged from 18 to 65 years with the mean age of 38.673 ± 8.63 years in group 1 while 41.217 ± 9.52 years in group 2, mean preoperative calcium level was 9.482 ± 0.49 mg/dl in group 1 and 9.678 ± 0.54 mg/dl in group 2. Hypocalcemia was seen in 3 (6.5%) in group 1 as compared to 12 (26.1%) patients in group 2 (p = 0.011). Conclusion Preoperative oral calcium and vitamin D supplements may prevent postoperative hypocalcemia, allowing a safe and early discharge. This will ultimately lead to improved patient satisfaction and significant cost savings.

Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review

PURPOSE

The reported incidence of post surgical hypoparathyroidism (HypoPT) varies greatly. Previous research suggests that the definition of HypoPT is not consistent in the literature. We therefore conducted a systematic review to investigate how HypoPT is defined and whether this definition, as well as the selected threshold for hypocalcemia affects the incidence.

METHODS

Using a predefined search string we identified all articles in PubMed reporting on the incidence of postsurgical HypoPT from 1st January 2010 to January 2017.

RESULTS

We identified 89 articles that employed 20 different definition of HypoPT. The incidence of HypoPT varied from 0.0% to 20.2%. The definitions were not associated with incidence of HypoPT. Use of prophylactic post-operative calcium supplements, however decreased the risk of HypoPT (p = 0.03), and there was a trend towards a lower risk of HypoPT when using a definition of hypocalcemia below lower limit of the reference range (p = 0.09).

CONCLUSION

The large number of definitions of HypoPT, as well as the huge variation in incidence point to a problem suggests that the awareness of HypoPT should be raised. Use of prophylactic post-operative calcium supplements may decrease risk of HypoPT. This, however, may be due to reverse causality as awareness of the risk of HypoPT may promote the use of calcium supplementation.

The incidence of post-thyroidectomy hypocalcaemia: a retrospective single-centre audit

INTRODUCTION

The aim of this single centre retrospective observational record-based audit was to assess the incidence of post-thyroidectomy hypocalcaemia. The setting was a district general hospital in Hertfordshire covering a population of 500,000 people. A total of 196 patients who had had total or completion thyroidectomy during a five-year period were included in the study.

MATERIALS AND METHODS

The primary outcome measure was to determine the rate of biochemical and symptomatic hypocalcaemia in patients undergoing total or completion thyroidectomy. Secondary outcome measures assessed time taken for biochemical and clinical hypocalcaemia to resolve, whether malignancy affected the rate of hypocalcaemia and if removal of parathyroid glands during surgery were a predictor of hypocalcaemia.

RESULTS

The overall incidence of post-thyroidectomy hypocalcaemia (PTHC) within 24 hours was 21.4%. The incidence increased from 6 hours (13.8%) to 24 hours post-thyroidectomy (15.8%) and there was evidence of both transient and delayed PTHC within the first 24 hours. By 6 months post-surgery, 3.6% remained hypocalcaemic and required continual oral supplementation. Patients with benign thyroid disease had a higher risk of PTHC (P = 0.04) and patients younger than 50 years of age had a higher risk of symptomatic hypocalcaemia (P = 0.016). Other clinical factors including sex, type of surgery, neck dissection, oral calcium and/or vitamin D supplementation and inadvertent histological parathyroid gland excision were not associated with an increased incidence of PTHC or symptomatic hypocalcaemia.

CONCLUSIONS

Our audit shows that the rate of PTHC within our population was below the national average with higher risk in benign thyroid disease.

Association of Hypomagnesemia with Hypocalcemia after Thyroidectomy

BACKGROUND

Hypocalcemia is one of the most common acceptable complications in postoperative period after thyroidectomy. Hypomagnesemia has been recognized after parathyroid surgery, and it has not been studied extensively after thyroidectomy. The aim of this study was to estimate magnesium and calcium ion levels in patients undergoing thyroidectomy and to evaluate the association of hypomagnesemia with hypocalcemia after thyroidectomy. A prospective study was conducted in Government Medical College, Calicut, from December 2012 to November 2013.

MATERIALS AND METHODS

all patients had undergone total/near-total/subtotal thyroidectomy. Pre- and postoperative at 24 h and serum calcium and magnesium were measured by automate electrolyte analyzer. Clinical findings of hypocalcemia were recorded. Statistical analysis was done using SPSS software, version 17.0. Unpaired student t-test was used. Pearson Chi-square test or Fisher's exact test was used to compare the percentage for categorical variables.

RESULTS

In our study, 58% of the patients developed hypocalcemia, biochemical and/or symptomatic (S. Ca <8.5). About 34% of patients developed hypomagnesemia, biochemical and/or symptomatic (S. Mg <1.7). About 30% of patients developed both hypocalcemia and hypomagnesemia. About 24% of patients developed symptoms of both hypocalcemia and hypomagnesemia.

DISCUSSION

Thyroidectomy patients were at a risk of transient and permanent hypoparathyroidism because of chances of parathyroid resection during operation. Transient hypocalcemia and hypomagnesemia occur frequently after total thyroidectomy. It is important to monitor both calcium and magnesium levels after total thyroidectomy and to correct deficiencies to facilitate prompt resolution of symptoms.

CONCLUSION

There is an association of hypomagnesemia with hypocalcemia after thyroidectomy.

Outcome of Treatment for Medullary Thyroid Carcinoma-a Single Centre Experience

We conducted this study to evaluate the demography, clinical presentation, management and outcomes of medullary thyroid carcinoma (MTC) from the Indian context. This was a retrospective study of patients with MTC managed between January 2008 and December 2016. All pertinent data was collected and the results were analysed using STATA (v.13.1). MTC accounted for 90/2022 (4.45%) patients managed with thyroid cancer during the study period. The mean age of presentation was 40 years (range 14-70 years) with 47 males and 43 females. The most common presentation included goitre with cervical lymphadenopathy seen in 60 patients (66.7%). There were 11 patients (12.2%) with systemic metastasis at presentation. Rearranged during transfection (RET) testing was performed in 71 patients and was positive in 25 (35.2%). The mutations among these patients were seen in the following codons: 634 (12), 804 (8), 790 (3) and 618 (2). Persistent hypercalcitoninemia (calcitonin > 50 pg/ml) was observed in 62/80 (77.5%) patients. Forty patients underwent a meta-iodo-benzyl-guanidine (MIBG) scan in the postoperative period, 10 were positive. The mean duration of follow-up was 32 months and 10 patients defaulted from follow-up. Sixteen patients developed metastasis during the period of follow-up while eight patients expired. The mean survival was 85.75 months (95% CI 78.7-92.7). MTC accounted for 4.5% of thyroid carcinomas in this cohort among which 35% were hereditary. Persistent hypercalcitoninemia following surgery is seen in more than 70% of patients but this does not affect survival. RET screening should be performed for all patients with MTC as curative surgery can be offered for mutation positive offspring.

Risk factors for hypocalcemia and hypoparathyroidism following thyroidectomy: a retrospective Chinese population study

Background

Hypocalcemia is one of the most common postoperative complications following thyroid surgery in clinical practice. The occurrence of hypocalcemia is mainly attributed to hypoparathyroidism when parathyroid glands are devascularized, injured, or dissected during the surgery. The aim of this study was to analyze the risk factors for hypocalcemia and hypoparathyroidism following thyroidectomy.

Patients and methods

A total of 278 patients who underwent thyroid surgery were analyzed retrospectively. Univariate analysis and multivariable logistic regression were performed to discover the risk factors for hypocalcemia and hypoparathyroidism.

Results

Postoperative hypocalcemia occurred in 76 (27.3%) patients and hypoparathyroidism occurred in 42 (15.1%) patients. Seven factors were significantly related to the presence of postoperative hypocalcemia, namely, age (P=0.049), gender (P=0.015), lateral lymph node dissection (P=0.017), operation type (P<0.001), preoperative parathyroid hormone (PTH) level (P=0.035), operation time (P=0.001), and applying carbon nanoparticles (CNs; P=0.007). Our result revealed that gender (P=0.014), lateral lymph node dissection (P=0.038), operation type (P<0.001), operative time (P<0.001), and applying CNs (P=0.001) had a significant correlation with postoperative hypoparathyroidism.

Conclusion

These findings were crucial for guiding surgeons to prevent the occurrence of hypocalcemia and hypoparathyroidism.

Hypoparathyroidism following thyroidectomy: Predictive factors

OBJECTIVE

To evaluate the incidence and predictive factors for transient and permanent hypocalcemia and hypoparathyroidism following thyroidectomy.

METHOD

We studied all the 162 patients that underwent thyroid surgery in the ENT department of the Centro Hospitalar Vila Nova Gaia/Espinho from January 2005 to December 2014. We reviewed pre-operative, 6h and 12h after surgery ionized calcium and PTH levels. All patients were reviewed and evaluated according to the following criteria: gender, age, thyroid function, histologic diagnosis of the specimen, surgery extension and presence or absence of hypoparathyroidism.

RESULTS

There were 31 (19.1%) cases of transient hypoparathyroidism and 8 (5%) of permanent hypoparathyroidism. No significant difference was found for transient hypoparathyroidism when patients were analyzed by gender. However, all cases of permanent hypoparathyroidism were observed in female individuals. Comparing hemithyroidectomy with all other surgical procedures, we found that extension of surgery was a great predictor of transient (p=0.0001) and permanent (p=0.001) hypoparathyroidism. Diagnosis of malignancy was a strong predictor of transient hypoparathyroidism (p=0.002). It was also associated with permanent hypoparathyroidism, although differences did not reach statistical significance (p=0.096).

CONCLUSION

Extension of surgery (total thyroidectomy) and diagnosis of malignancy are predictors of transient and permanent hypoparathyroidism.

Bilateral Truncal Ligation of the Inferior Thyroid Artery during Bilateral Subtotal Thyroidectomy Causes a Decrease in Parathormone without Clinically Manifest Hypoparathyroidism: A Randomized Clinical Trial

BACKGROUND

Bilateral truncal ligation (BTL) of the inferior thyroid artery (ITA) is frequently used during subtotal thyroidectomy to reduce the risk of post-operative bleeding as well as to reduce the blood loss intra-operatively. However, its effect on parathyroid function has not been evaluated in relation to age, residual and resected thyroid volume.

METHODS

A total of 83 patients were randomized to receive non-BTL or BTL. After bilateral resection, the residual thyroid tissue on each side was measured by intra-operative ultrasonography. Laboratory and clinical examinations were performed the day before operation, intra-operatively and on post-operative days 2 and 5. The primary outcome measure was the difference in intact parathormone (PTHi) on post-operative day 5. Secondary outcomes were laboratory-diagnosed hypocalcaemia or hypoparathyroidism and clinically manifest hypoparathyroidism, respectively.

RESULTS

PTHi on post-operative day 5 was significantly lower in the BTL group (29.4 vs. 34.7 ng/l in the non-BTL group, p = 0.033), especially in 61- to 80-year-old patients (0 vs. -7.91 ng/l, p = 0.029). The biggest decline in PTHi was found in the BTL group (-14.067 ng/l PTH, p = 0.018) with a residual thyroid volume of 0.5-1.9 ml. There were two cases of asymptomatic hypoparathyroidism in each group (5.1 vs. 4.8%, respectively, p = 1.000). The only case of clinically manifest hypoparathyroidism was in a BTL group patient aged 64 years (2.4%, p = 1.000).

CONCLUSION

BTL of the ITA during subtotal thyroidectomy causes a larger decrease in PTH but does not lead to a significantly higher rate of clinically manifest hypoparathyroidism. BTL of the ITA, age >61 years, and a very small thyroid remnant (<2 ml) may be risk factors for post-operative hypoparathyroidism.

Perioperative kinetics of parathyroid hormone in unilateral, primary thyroid surgery

Dysfunction of the parathyroid glands is an important cause of complications after thyroid surgery. Intraoperative monitoring of the function of the parathyroid glands can be performed using parathyroid hormone (PTH) kinetics. Unilateral thyroid surgery is associated with a decreased risk for postoperative hypocalcemia (POH) and permanent hypoparathyroidism (PEH). We focused on unilateral thyroid surgery by monitoring the functionality of the parathyroid glands and comparing the perioperative PTH kinetics of patients with and without POH. In a prospective study, 143 patients scheduled for unilateral thyroid surgery underwent monitoring of perioperative changes in serum PTH and serum calcium levels, and of clinical symptoms of hypocalcemia. The rates of POH and PEH were 18.2 and 0%, respectively. In patients without POH, PTH significantly increased from the time of skin incision to the end of the operation and after the operation (20.1 pg/ml, IQR 15.5-26.8 vs. 21.4 pg/ml, IQR 16.4-29.5; p=0.005), which was not the case in patients who developed POH. In a multivariate analysis of predictive factors for POH, two parameters became significant, namely female gender (odds ratio 6.87, 95% confidence interval 0.92-51.01) and lower initial serum calcium levels (odds ratio 3.54*e(-8), 95% confidence interval 3.63*e(-12); 0.00). The rate of POH was unexpectedly high. Rather than intraoperative PTH declines, an unstable balance of factors that influence calcium metabolism likely is the major contributor to POH after unilateral thyroid surgery. There was no case of PEH after unilateral, primary thyroid surgery, which underlines the need for an individualized approach to the extent of resection.

Left-shifted relation between calcium and parathyroid hormone in Graves' disease

BACKGROUND

Patients with Graves' disease (GD) have disturbances in calcium regulation with manifestations such as postoperative hypocalcemia. We have investigated the thyroid as well as the parathyroid function in detail.

MATERIALS AND METHOD

A series of patients undergoing total thyroidectomy for GD (n = 56) or multinodular goiter (MNG; n = 50) were scrutinized for postoperative hypocalcemia and a need for calcium and/or vitamin D substitution. A citrate-calcium (CiCa) clamp was used in 14 patients and 21 controls to quantify the secretion of PTH in relation to the ionized plasma calcium level. The set point, equal to the plasma-ionized calcium concentration at which 50% of the maximal secretion of PTH is inhibited, as well as other CiCa-related parameters were calculated.

RESULTS

Hypocalcemia was present in 48% of GD and 41.2% of patients with MNG postoperatively. Patients with GD had lower calcium levels, 18% had serum Ca less than 2.00 mmol/L compared with 4.0% in the MNG group (P = .02). A higher degree of GD patients were given parenteral calcium substitution during the hospital stay (3.6% vs 0 %) and oral calcium substitution at discharge (48% vs 10%), although they had normal vitamin D3 levels. The GD group showed a significantly left-shifted set point compared with the normal group on the CiCa clamp, 1.16 mmol/L vs 1.20 mmol/L (P < .001) as well as an increased PTH release to hypocalcemic stimulus. GD patients also show an association between degree of subclinical toxicosis at time of surgery and risk for developing postoperative hypocalcemia.

CONCLUSION

Patients with GD demonstrate dysregulation of the calcium homeostasis by several parameters. GD patients have lower postoperative serum calcium compared with patients with MNG, lower calcium/PTH set point, and a significantly increased release of PTH to hypocalcemic stimulus compared with controls. The CiCa clamp response in GD patients with normal 25-hydroxyvitamin D3 levels mimics that of obese patients in which vitamin D insufficiency has been proposed as an underlying cause.