Single measurement of intact parathyroid hormone after thyroidectomy can predict transient and permanent hypoparathyroidism: a prospective study

The challenges experienced by patients in the early period after thyroidectomy and the effects on sleep quality

BACKGROUND

Thyroidectomy, a standard surgical procedure, can lead to various postoperative issues that can significantly affect a patient's sleep quality. This study, addressing a topic of significant importance to thyroid surgery and patient care, engages healthcare professionals, researchers, and academics, providing crucial insights into the challenges faced by patients in the early period after thyroidectomy and their effects on sleep quality.

OBJECTIVE

The primary aim of this study was to investigate the prevalence of postoperative issues experienced by patients in the early period after thyroidectomy and their influence on sleep quality.

METHODS

This descriptive and prospective study, conducted with a sample of 104 thyroidectomy patients hospitalized in a university's Ear, Nose, and Throat clinic between 2021 and 2023, employed a comprehensive set of tools for data collection. These tools included a questionnaire, Visual Analog Scale for pain and nausea, Symptom Severity Scale, and Richard Campbell Sleep Scale, ensuring a thorough investigation into the prevalence of postoperative issues and their influence on sleep quality.

RESULTS

The most frequently reported postoperative issues were pain, difficulty swallowing, sore throat, dry mouth, nausea-vomiting, tingling, hoarseness, Chvostek's sign, tremors (tetany), Trousseau's sign, and bleeding. Analysis of the pre-and postoperative Richard Campbell Sleep Scale scores revealed a significant decrease in sleep quality post-surgery, particularly in patients experiencing sore throat, difficulty swallowing, pain, Chvostek's sign, and Trousseau's sign.

CONCLUSIONS

Our study has revealed that patients' three most commonly reported problems after thyroidectomy are pain, difficulty swallowing, and sore throat. Importantly, these issues significantly impact sleep quality, underscoring the need for effective management to improve patient recovery. This study enhances our understanding of postoperative issues after thyroidectomy and inspires improved clinical practices in managing these challenges.

Development and validation of risk prediction models for permanent hypocalcemia after total thyroidectomy in patients with papillary thyroid carcinoma

Hypocalcemia is a common complication and can be permanent in patients following total thyroidectomy (TT). The aim of this study was to identify factors associated with permanent hypocalcemia and to develop a validated risk prediction model for permanent hypocalcemia to assist surgeons in the appropriate follow-up of high-risk patients regarding supplemental therapy. We included data of 92 patients with papillary thyroid carcinoma (PTC) undergoing TT who were randomly allocated in a 7:3 ratio to a training set (n = 65) and validation set (n = 27). Univariate and multivariate logistic regression analyses revealed significant correlations of permanent hypocalcemia with parathyroid hormone (PTH) at postoperative month 1 (IM PTH), IM calcium (Ca), and IM phosphorus (P). These variables were constructed two models. Model 1 used the three indicators listed above; model 2 also included tumor, node, metastasis staging. The receiver operating characteristic (ROC) curve analysis showed that the areas under the curve (AUC) for models 1 and 2 were high for both the training set (0.905/0.913) and the validation set (0.894/0.800). Calibration curves showed good agreement between the incidence of permanent hypocalcemia estimated using the predictive models and the actual incidence. Model 1 may be more concise and convenient for clinical use.

Hypoparathyroidism: Similarities and differences between Western and Eastern countries

BACKGROUD

Hypoparathyroidism (hypoPT) is characterized by acute and chronic complications due to insufficient parathyroid hormone (PTH) production or action. Several management guidelines have been developed, but mostly based on evidence from Western countries. Data from Eastern countries have not been systematically compared with those from Western countries.

METHODS

Literatures regarding to the epidemiology, genetics, risk factors, clinical manifestations and therapies for hypoPT in Easten and Western countries, including China, South Korea, Japan, India, and USA, Canada, Italy, and etc., were searched through PubMed and CNKI. This review was officially endorsed by European Calcified Tissue Society (ECTS) board.

RESULTS

Postoperative hypoPT is the major form of hypoPT in both Western and Eastern countries. The genetic profiles and clinical features of hypoPT are similar in Eastern and Western countries. The most commonly used medications in Eastern countries are calcium and native vitamin D or active vitamin D analogues, similar to their Western counterparts. While PTH replacement therapy is not available and approved to use in most Eastern countries.

CONCLUSION

Physicians and surgeons should follow the guidelines on the management of thyroid nodules, taking more care of protecting parathyroid glands during surgery. The cross-talk between East and West in the management of hypoPT should be continued. Direct comparisons of the management strategies in patients with hypoPT between Eastern and Wester countries regarding to the morbidity, mortality, quality of life, optimal dosage, efficacies and side-effects of conventional therapies or newer medications, as well as pharmacogenetics and pharmacoeconomics, would be valuable.

Incidence of transient and chronic hypoparathyroidism after total thyroidectomy - the experience of a tertiary center

BACKGROUND

The most common cause of hypoparathyroidism (hypoPT) in adults is iatrogenic due to total thyroidectomy, while the ideal moment for considering it chronic is still under debate. Our study aims at reporting the prevalence of transient and permanent hypoPT following thyroid surgery in a tertiary surgical center, as well as serum Parathormone (PTH) variation up to 12 months after surgery stratified according to the type of thyroid disease.

MATERIAL AND METHODS

519 patients who underwent total thyroidectomy in a tertiary surgical center from 2018 to 2023 were analyzed. Postoperative hypoPT was defined as low PTH (less than 15 pg/ml) and/or hypocalcemia (albumin-corrected levels less than 8.5 mg/dl) on day 1 after surgery. Patients were considered to have permanent hypoPT if they had not recovered completely within 1 year after total thyroidectomy. PTH levels were compared according to the underlying thyroid disease.

RESULTS

140 patients (26.97%) had postoperative hypoPT. Twenty-two patients (4.23%) were considered to have permanent hypoPT 12 months after surgery. Approximately half of the patients recovered between 3 months and 12 months after surgery. HypoPT thyroiditis patients had higher PTH levels 3 months after surgery compared to papillary/follicular cancer and multinodular goiter, respectively, and all recovered 1 year after surgery. Papillary/follicular carcinoma was associated with a 29.4% rate of transient and 8.5% rate of chronic hypoPT, respectively.

CONCLUSION

Most patients without incidental parathyroidectomy that still develop postoperative hypoPT will eventually recover; nevertheless, it can take up to 1 year for full resolution. Measuring serum PTH 3 months postoperative may be of interest.

Risk factors of transient and permanent hypoparathyroidism after thyroidectomy: a systematic review and meta-analysis

BACKGROUND

Postoperative hypoparathyroidism (hypoPT) is a common complication following thyroid surgery. However, current research findings on the risk factors for post-thyroid surgery hypoPT are not entirely consistent, and the same risk factors may have different impacts on transient and permanent hypoPT. Therefore, there is a need for a comprehensive study to summarize and explore the risk factors for both transient and permanent hypoPT after thyroid surgery.

MATERIALS AND METHODS

Two databases (PubMed and Embase) were searched from inception to 2024. The Newcastle-Ottawa Scale was used to rate study quality. Pooled odds ratios were used to calculate the relationship of each risk factor with transient and permanent hypoPT. Subgroup analyses were conducted for hypoPT with different definition-time (6 or 12 months). Publication bias was assessed using Begg's test and Egger's test.

RESULTS

A total of 19 risk factors from the 93 studies were included in the analysis. Among them, sex and parathyroid autotransplantation were the most frequently reported risk factors. Meta-analysis demonstrated that sex (female vs. male), cN stage, central neck dissection, lateral neck dissection, extent of central neck dissection (bilateral vs. unilateral), surgery [total thyroidectomy (TT) vs. lobectomy], surgery type (TT vs. sub-TT), incidental parathyroidectomy, and pathology (cancer vs. benign) were significantly associated with transient and permanent hypoPT. Preoperative calcium and parathyroid autotransplantation were only identified as risk factors for transient hypoPT, while preoperative PTH was a protective factor. Additionally, node metastasis and parathyroid in specimen were associated with permanent hypoPT.

CONCLUSION

The highest risk of hypoPT occurs in female thyroid cancer patients with lymph node metastasis undergoing TT combined with neck dissection. The key to preventing postoperative hypoPT lies in the selection of surgical approach and intraoperative protection.

Efficacy and safety of total parathyroidectomy with autotransplantation vs. subtotal parathyroidectomy for secondary hyperparathyroidism: A retrospective study

Background

No consensus has been reached on the best surgical approach for secondary hyperparathyroidism (SHPT). We evaluated the short-term and long-term efficacy and safety of total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX).

Methods

We retrospectively analyzed the data of 140 patients undergoing TPTX + AT and 64 undergoing SPTX between 2010 and 2021 in Second Affiliated Hospital of Soochow University, and carried out follow-up. We compared the differences in symptoms, serological examinations, complications and mortality between the two methods, and explored the independent risk factors of secondary hyperparathyroidism recurrence.

Results

In short time after surgery, serum intact parathyroid hormone and calcium level was lower in TPTX + AT group than that in SPTX group (both P < 0.05). Severe hypocalcemia was more common in TPTX group (P = 0.003). The recurrent rate was 17.1% for TPTX + AT and 34.4% for SPTX (P = 0.006). There was no statistical difference in all-cause mortality, cardiovascular events, cardiovascular mortality between the two methods. Higher preoperative serum phosphorus level (HR: 1.929 95% CI 1.045-3.563, P = 0.011) and the SPTX surgical method (HR: 2.309, 95% CI 1.276-4.176, P = 0.006) were found to be independent risk factors for SHPT recurrence.

Conclusions

Compared with SPTX, TPTX + AT is more effective in reducing the recurrent risk of SHPT without increasing the risk of all-cause mortality and cardiovascular events.

Complications, Symptoms, Presurgical Predictors in Patients With Chronic Hypoparathyroidism: A Systematic Review

The complications and symptoms of hypoparathyroidism remain incompletely defined. Measuring serum parathyroid hormone (PTH) and calcium levels early after total thyroidectomy may predict the development of chronic hypoparathyroidism. The study aimed (i) to identify symptoms and complications associated with chronic hypoparathyroidism and determine the prevalence of those symptoms and complications (Part I), and (ii) to examine the utility of early postoperative measurements of PTH and calcium in predicting chronic hypoparathyroidism (Part II). We searched Medline, Medline In-Process, EMBASE, and Cochrane CENTRAL to identify complications and symptoms associated with chronic hypoparathyroidism. We used two predefined criteria (at least three studies reported the complication and symptom and had statistically significantly greater pooled relative estimates). To estimate prevalence, we used the median and interquartile range (IQR) of the studies reporting complications and symptoms. For testing the predictive values of early postoperative measurements of PTH and calcium, we used a bivariate model to perform diagnostic test meta-analysis. In Part I, the 93 eligible studies enrolled a total of 18,973 patients and reported on 170 complications and symptoms. We identified nine most common complications or symptoms probably associated with chronic hypoparathyroidism. The complications or symptoms and the prevalence are as follows: nephrocalcinosis/nephrolithiasis (median prevalence among all studies 15%), renal insufficiency (12%), cataract (17%), seizures (11%), arrhythmia (7%), ischemic heart disease (7%), depression (9%), infection (11%), and all-cause mortality (6%). In Part II, 18 studies with 4325 patients proved eligible. For PTH measurement, regarding the posttest probability, PTH values above 10 pg/mL 12-24 hours postsurgery virtually exclude chronic hypoparathyroidism irrespective of pretest probability (100%). When PTH values are below 10 pg/mL, posttest probabilities range from 3% to 64%. Nine complications and symptoms are probably associated with chronic hypoparathyroidism. A PTH value above a threshold of 10 pg/mL 12-24 hours after total thyroidectomy is a strong predictor that the patients will not develop chronic hypoparathyroidism. Patients with PTH values below the threshold need careful monitoring as some will develop chronic hypoparathyroidism. © 2022 American Society for Bone and Mineral Research (ASBMR).

Definition and diagnosis of postsurgical hypoparathyroidism after thyroid surgery: meta-analysis

BACKGROUND

Postsurgical hypoparathyroidism (PH) is the most frequent complication after thyroid surgery. The aim of this systematic review and meta-analysis is to summarize a unifying definition of PH and to elucidate the best possible approach for early detection of PH.

METHODS

A systematic review of the literature according to the PICO framework using Embase, PUBMED and the Cochrane library was carried out on 1 December 2021 followed by analysis for risk of bias, data extraction and meta-analysis. All studies addressing the definition of postoperative hypoparathyroidism and/or diagnostic approaches for early detection and diagnosis were included. Case reports, commentaries, non-English articles, book chapters and pilot studies and reviews were excluded.

RESULTS

From 13 704 articles, 188 articles were eligible for inclusion and further analysis. These articles provided heterogeneous definitions of PH. Meta-analysis revealed that postoperative measurements of parathormone (PTH) levels have a higher sensitivity and specificity than intraoperative PTH measurements to predict PH after thyroid surgery. None of the timeframes analysed after surgery within the first postoperative day (POD1) was superior to predict the onset of PH. PTH levels of less than 15 pg/ml and less than 10 pg/ml are both reliable threshold levels to predict the postoperative onset of PH. A relative reduction of mean(s.d.) PTH levels from pre- to postoperative values of 73 (standard deviation 11) per cent may also be predictive for the development of PH. The estimation of calcium levels on POD1 are recommended.

CONCLUSION

PH is best defined as an undetectable or inappropriately low postoperative PTH level in the context of hypocalcaemia with or without hypocalcaemic symptoms. PTH levels should be measured after surgery within 24 h. Both threshold levels below 10 and 15 pg/ml or relative loss of PTH before/after thyroid surgery are reliable to predict the onset of PH.

How Long Does It Take to Regain Normocalcaemia in the Event of Postsurgical Hypoparathyroidism? A Detailed Time Course Analysis

Background: Postsurgical hypoparathyroidism (PH) is the most common side effect of bilateral thyroid resections. Data regarding the time course of recovery from PH are currently unavailable. Therefore, a detailed analysis of the time course of PH recovery and conditions associated with rapid recovery was conducted. Methods: This is a retrospective analysis of prospectively documented data. Patients with biochemical signs of PH or need for calcium supplementation were followed-up for 12 months. Logistic regression analyses were used to identify covariates of early as opposed to late recovery from PH. Results: There were 1097 thyroid resections performed from 06/2015 to 07/2016 with n = 143 PH. Median recovery time was 8 weeks and six patients (1.1% of total thyroid resections) required calcium supplementation > 12 months. Recovery of PH within 4 and 12 weeks was characterized by high PTH levels on the first postoperative day (4 weeks: OR 1.13, 95% CI 1.06−1.20; 12 weeks: OR 1.08, 95%CI 1.01−1.16). Visualization of all PTGs emerged as an independent predictor of recovery within 12 months (OR 2.32, 95% CI 1.01−4.93) and 24 weeks (OR 2.69, 95% CI 1.08−6.69). Conclusion: In the setting of specialized high-volume endocrine surgery, permanent PH is rare. However, every second patient will require more than 2 months of continued medical surveillance. Early recovery was associated with only moderately decreased postsurgical PTH-levels. Successful late recovery appeared to be associated with the number of parathyroid glands visualized during surgery.

European Expert Consensus on Practical Management of Specific Aspects of Parathyroid Disorders in Adults and in Pregnancy: Recommendations of the ESE Educational Program of Parathyroid Disorders

This European expert consensus statement provides recommendations for the diagnosis and management of primary hyperparathyroidism (PHPT), chronic hypoparathyroidism in adults (HypoPT), and parathyroid disorders in relation to pregnancy and lactation. Specified areas of interest and unmet needs identified by experts at the second ESE Educational Program of Parathyroid Disorders (PARAT) in 2019, were discussed during two virtual workshops in 2021, and subsequently developed by working groups with interest in the specified areas. PHPT is a common endocrine disease. However, its differential diagnosing to familial hypocalciuric hypercalcemia (FHH), the definition and clinical course of normocalcemic PHPT, and the optimal management of its recurrence after surgery represent areas of uncertainty requiring clarifications. HypoPT is an orphan disease characterized by low calcium concentrations due to insufficient PTH secretion, most often secondary to neck surgery. Prevention and prediction of surgical injury to the parathyroid glands are essential to limit the disease-related burden. Long-term treatment modalities including the place for PTH replacement therapy and the optimal biochemical monitoring and imaging surveillance for complications to treatment in chronic HypoPT, need to be refined. The physiological changes in calcium metabolism occurring during pregnancy and lactation modify the clinical presentation and management of parathyroid disorders in these periods of life. Modern interdisciplinary approaches to PHPT and HypoPT in pregnant and lactating women and their newborns children are proposed. The recommendations on clinical management presented here will serve as background for further educational material aimed for a broader clinical audience, and were developed with focus on endocrinologists in training.

Trastornos posoperatorios del metabolismo del calcio postiroidectomía

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

Identification of secondary predictive factors for acute hypocalcemia following thyroidectomy in patients with low postoperative parathyroid hormone levels without overt calcium deficiency: A cohort study

BACKGROUND

The transient acute hypocalcemia (HypoCa) is the most prevalent complication after total thyroidectomy, detected primarily by subnormal intact parathyroid hormone (iPTH) and calcium levels. However, the need for calcium supplementation is ambiguous in patients who exhibit low iPTH with normal calcium levels. The aim of this study was to evaluate complementary predictors of HypoCa in this scenario.

METHODS

A retrospective cohort study with of 1597 consecutive patients undergoing total thyroidectomy, with or without neck dissection, from January 2014 to December 2018 at a single institution. Patients with an iPTH <12 pg/mL and a total calcium level ≥8 mg/dL in the first 8 h after surgery were included.

RESULTS

1597 patients identified with low postoperative iPTH without overt calcium deficiency was diagnosed. The transient HypoCa in that specific subgroup was 509 (31.9%). Multivariate analysis indicated that HYPOCA was associated with bilateral level VI neck dissection and pre- to postoperative calcium reduction >38 pg/mL. To better illustrate the model, we plotted a nomogram with the variables selected for the final model.

CONCLUSION

Total thyroidectomy patients who exhibit low postoperative iPTH levels without overt calcium deficiency should be considered for calcium replacement therapy when they a marked drop in iPTH postoperatively and underwent bilateral level VI neck dissection.

Role of perioperative parathormone hormone level assay after total thyroidectomy as a predictor of transient and permanent hypocalcemia: Prospective study

BACKGROUND

The researchers are trying to evaluate the measurement of: Intact parathyroid hormone (iPTH) and serum total calcium (sCa) levels for predicting hypocalcemia after total thyroidectomy (TT).

METHODS

The sample of this single center prospective study consists of (100) patients, where (77) females and (23) males with an age range between (28) and (65) (the mean level is, 48.17 ± 6.54). These selected patients underwent total thyroidectomy (TT) in the general surgery department, Benha university hospital from the period of June 2019 to February 2020. Levels of sCa and iPTH were measured aat several times preoperatively, 10 min, 48 h, 3, 6, 9 months, and 1 year after being after gone TT.

RESULTS

Among the entire study sample, 23 patients (23%) developed transient hypoparathyroidism and hypocalcemia (˂8.5 mg/dl), none of them developed permanent hypoparathyroidism and hypocalcemia. The cut-off point of PTH has been 10 min after TT was at 23 pg/mL as it was the best compromise between sensitivity and specificity for predicting hypocalcaemia. It has been found that Patients who have a PTH greater than 23 pg/mL can be discharged safely after 24 h. Patients who have PTH of less than 23 pg/mL were observed for an additional 24 h, and the study found that timely treatment initiation is recommended. A PTH ˂ 10 pg/mL measured at 48 h after surgery had a sensitivity, specificity as well as an accuracy of 100%, for predicting hypocalcemia after TT. The accuracy of a single PTH concentration at 48 h was useful for predicting hypocalcemia [Area under receiver-operator characteristic curve (AUC) 1; confidence interval (CI), 95%, 0.85-0.94].

CONCLUSION

Patients with iPTH ˂ 10 pg/mL, and sCa levels ˂ 7.4 mg/dL are at higher risk of developing hypoparathyroidism and hypocalcemia after TT.

Role of postoperative intact serum PTH as an early predictor of severe post-thyroidectomy hypocalcemia: a prospective study

BACKGROUND

Post thyroidectomy hypocalcemia is a major sequel of thyroidectomy and continues to trouble the endocrinologists and the endocrine surgeons as there is no ideal predictive marker of hypocalcemia which has the potential to develop into a life-threatening complication. The role of early serum intact parathormone (iPTH) to predict post thyroidectomy hypocalcemia is becoming useful but the literature is still unclear regarding the optimal time of testing and the optimal cut-off value of serum iPTH.

PATIENTS AND METHODS

This is a prospective cohort study of 111 patients who underwent total thyroidectomy in a tertiary care endocrine surgery referral unit. Serum iPTH was measured after 20 min and 4 h of surgery. Receiver-Operator characteristic Curve (ROC) was used to find out of the best cut-off value of S. iPTH 20 min and 4 h after surgery in predicting hypocalcemia.

RESULTS

Hypocalcemia was noted in 60 (54%) out of 111 subjects who underwent total thyroidectomy. The best cut-off values of Serum iPTH to predict hypocalcemia was found to be 4.28 pmol/l at 20 min post total thyroidectomy with a sensitivity and specificity of 81.7% and 51%, respectively. In addition, patients with malignancy or central lymph nodal dissection were significantly over-represented in the hypocalcemia group with serum iPTH above the threshold level of 4.28 pmol/l. Below the cut off level, parenteral calcium supplementation was required in 23% (17/74) subjects while the rate was only 5.4% (2/37) patients when serum iPTH was above the cut-off level.

CONCLUSIONS

The decline of serum iPTH below a specific level after surgery has predictive value together with other factors strictly related to patient, the thyroid disease itself and surgery. The risk of development of hypocalcemia and consequent need for calcium supplementation should be evaluated by clinical assessment along with serum PTH measurement.

What are the real rates of temporary hypoparathyroidism following thyroidectomy? It is a matter of definition: a systematic review

INTRODUCTION

Post-operative hypoparathyroidism is the most encountered complication of thyroid surgery and is classified as temporary or permanent. However, its incidence varies greatly in the literature ranging from 0.5% to 65%. This can be mainly attributed to the different definition of hypoparathyroidism used in each study and especially to the different time cutoff applied to distinguish temporary from permanent hypoparathyroidism.

METHODS

We conducted a systematic literature search in PubMed, Scopus, Cochrane and GoogleScholar databases, as well as grey literature. Ultimately, 45 articles with 23,164 patients in total were included in this review. These articles used either the cutoff of six or twelve post-operative months to distinguish temporary from permanent hypoparathyroidism.

RESULTS

The overall incidence of permanent hypoparathyroidism diagnosed at 6 months post-operatively was 4.11% and 4.08% at 12 months post-operatively. There was no statistically significant difference between the two groups (p = 0.92).

CONCLUSIONS

We suggest that adhering to the current guidelines that recommend diagnosing temporary hypoparathyroidism when recovery is made within 6 months after surgery is important when conducting future research in order to narrow the gap that exists currently in the literature, as well as when deciding to put patients on long-term calcium supplements.

[Postoperative hypocalcemia - the most common complication of endocrine head and neck surgery: acute management]

BACKGROUND

In Germany, 8000 patients are affected by postoperative hypoparathyroidism per year following surgery of the thyroid gland, parathyroidal glands and the larynx. Patients do not only suffer from paresthesia in the acute phase of this complication, but are also adversely affected by the fear of loss of control following episodes of tetany even years after the first episode.

OBJECTIVES

Discussion of a diagnostic pathway and presentation of a management pathway for postoperative hypocalcemia.

METHODS

Narrative review, analysis and discussion of current literature and expert recommendations.

RESULTS

Early determination of calcium and parathyroid hormone allows timely diagnosis and treatment of postoperative hypoparathyroidism. Active vitamin D is pivotal for the resorption of calcium. Only the combined treatment with active vitamin D and calcium can mitigate or prevent the postoperative drop of calcium levels.

CONCLUSIONS

A standard operating procedure (SOP) for postoperative hypoparathyroidism should be implemented in every surgical department. An SOP for diagnosis and treatment of postoperative hypoparathyroidism is proposed for institutional individualization and implementation.

The predictive factors for postoperative hypoparathyroidism and its severity on the first postoperative day after papillary thyroid carcinoma surgery

PURPOSE

The purpose of the study was to investigate the predictive factors for hypoparathyroidism and its severity on the first postoperative day (POD1) after total thyroidectomy (TT) with or without central neck dissection (CND) in patients with papillary thyroid carcinoma (PTC).

METHODS

From February 2014 to February 2019, 2550 PTC patients were admitted to our department. PTC patients who underwent TT were enrolled in this study. A parathyroid hormone (PTH) level lower than 15 pg/mL on POD1 was defined as hypoparathyroidism, and the severity of hypoparathyroidism was classified into three categories according to the level of PTH on POD1: mild hypoparathyroidism (10 pg/mL ≤ PTH < 15 pg/mL), moderate hypoparathyroidism (5 g/mL ≤ PTH < 10 pg/mL), and severe hypoparathyroidism (PTH < 5 pg/mL). Multiple clinical, pathological and surgical parameters of these two different groups were compared and analyzed to demonstrate the possible causes of hypoparathyroidism. Furthermore, patients who developed postoperative hypoparathyroidism were also included in a subgroup analysis according to the severity of their hypoparathyroidism. The underlying factors affecting different severities of hypoparathyroidism were also illustrated with univariate and multivariate analyses.

RESULTS

Ultimately, 690 patients who underwent TT were enrolled in this retrospective study. Through the univariate analysis, different surgeons (P < 0.001), extent of CND (P = 0.009), prophylactic calcium supplementation (PCS) (P < 0.001), preoperative (pre-op) PTH level (P < 0.001), and pre-op phosphorus concentration (P = 0.022) were found to be significantly correlated with postoperative hypoparathyroidism. According to the multivariate analysis, PCS was the only independent high-risk factor for hypoparathyroidism. In the univariate analysis of patient subgroups with different severities of hypoparathyroidism, we demonstrated that the tumor T stage (P = 0.021) and pre-op PTH level (P < 0.001) were associated with the severity of hypoparathyroidism. Furthermore, after the multivariate analysis, hypertension (P < 0.001) and pre-op PTH (P < 0.001) were the two independent predictive factors for the severity of hypoparathyroidism after surgery.

CONCLUSIONS

Postoperative PCS could increase the risk for PTC patients developing hypoparathyroidism after thyroid surgery. Patients with a history of hypertension and a relatively high pre-op PTH level may not develop severe hypoparathyroidism after TT with CND.

Assessment of the Early and Late Complication after Thyroidectomy

Background

The complications in thyroid surgery have been reported variable in literature. The aim of this study was to evaluate the early and late (3 months after surgery) complication rates of thyroidectomy in a cohort of patients undergoing thyroid surgery at two hospitals of Isfahan University of Medical Science, Iran.

Materials and Methods

This study included 204 patients who candidates for thyroidectomy presenting at Medical Educational Centers of Al-Zahra and Kashani hospitals in Isfahan between March 2016 and March 2017. Clinical data are collected for all patients by continuous enrollment. The patients examined before and after thyroid surgery and the findings were recorded.

Results

The highest prevalence of thyroidectomy was in women (81.9%). The most frequent thyroid surgery was total thyroidectomy and the most common indication for thyroid surgery was suspicious fine-needle aspiration for thyroid malignancy. Hypocalcemia was the most common complication with a frequency of 54.4%. The odds ratios for early complications were 2.375 and 2.542 for intermediate- and low-volume surgeons, respectively, compared to high-volume surgeons.

Conclusions

According to the results of this study, the high level of surgeon's skill is effective to reduce the likelihood of late and early complications; furthermore, the chance of late complications increases with age.

Prediction of permanent hypoparathyroidism by parathyroid hormone and serum calcium 24 h after thyroidectomy

PURPOSE

To assess the value of 24-hour intact parathyroid hormone (iPTH), serum calcium, and decreases in both were evaluated against preoperative values (iPTH and serum calcium decline) and used to determine the existence of permanent hypoparathyroidism (pHPP) after total thyroidectomy (TT).

MATERIALS AND METHODS

The clinical data of patients who underwent total thyroidectomy in our hospital between September 2014 and July 2015 were retrospectively analyzed.

RESULTS

There were 42 cases with normal parathyroid function, 58 cases with temporary HPP, and 10 cases with pHPP. When iPTH and serum calcium were administered at 24 h after surgery, iPTH decline and calcium decline differed significantly among the three groups above (P < .01). The accuracy and positive predictive value of 24 h iPTH for pHPP were higher than any one of the others. The sensitivity, specificity, false positive rate, and accuracy were 100%, 95%, 33.33%, and 94.45%, respectively. The AUC was 0.982 when 24-hour iPTH was equal to or <3.15 pg/mL. The use of blood calcium equal to or <2.03 mmol/L (8.12 mg/dL) pointed to a diagnosis of pHPP, with a sensitivity of 100%, specificity of 63%, false positive rate of 78.72%, and accuracy of 66.36%.

CONCLUSIONS

Measurement of the postoperative 24-h intact parathyroid hormone and serum calcium concentration can predict the occurrence of permanent hypoparathyroidism and the former is more advantageous. Postoperative 24-h intact parathyroid hormone equal to or <3.15 pg/mL is a reliable index, and it is suitable for the prediction of postoperative permanent hypoparathyroidism.

Same day discharge after thyroidectomy is safe and effective

Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely.

METHODS

This report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits.

RESULTS

A total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke.

CONCLUSION

Postoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.

Early corrected serum calcium value can predict definitive calcium serum level after total thyroidectomy in asymptomatic patients

INTRODUCTION

Hypocalcemia is the most common complication of thyroidectomy, requiring supplementation as well as prolonged hospitalization. Our study's objective was to determine a corrected calcium (CCa) level on day 1 after thyroidectomy predictive of no calcium and vitamin supplementation.

MATERIALS AND METHODS

A single-center prospective study conducted between January 2012 and July 2015 in 396 patients, consisting of 331 cases of total thyroidectomy, with seven completion surgeries. The data collected were age, sex, type of thyroid surgery, etiology, anatomical pathological analysis, and the need for calcium and vitamin supplementation therapy as well as its duration. CCa levels were analyzed 20 and 30 h after surgery then on days 2 and 3. To determine a cut-off value for CCa, a ROC curve analysis was performed. The population was described in terms of numbers and associated percentages for categorical variables, and mean.

RESULTS

Mean CCa on 20 h after surgery was 2.09 mmol/L (p < 0.001) and 30 h was 2.06 mmol/L p = 0.02. CCa of less than 2.13 mmol/L was predictive of calcium and vitamin supplementation with 56% sensitivity and 97% specificity. On the evening of day 1, the cut-off value for CCa was 2.06 mmol/L with 67% sensitivity and 65% specificity.

CONCLUSION

This prospective study confirms that CCa on the first morning after surgery is reliable when it is more than 2.13 mmol/L. In total, analyzing CCa on day 1 after total thyroidectomy allows the discharge of 70% of patients on the first day after surgery, with no risk of hypocalcemia.

Perioperative determinants of transient hypocalcemia after pediatric total thyroidectomy

PURPOSE

We seek to identify risk factors associated with hypocalcemia after pediatric total thyroidectomy.

METHODS

We retrospectively reviewed patients younger than 21years undergoing total thyroidectomy between January 2002 and January 2016. We defined hypocalcemia as any serum calcium <8mg/dl or ionized calcium <1.0mmol/L. Perioperative risk factors were identified through multivariate logistic regression.

RESULTS

Ninety-one children underwent total thyroidectomy. The average age was 13.7±4.4years, and 77% were female. Transient hypocalcemia was diagnosed in 34% (n=31) of patients. There was one case of permanent hypoparathyroidism. Predictors of transient hypocalcemia included age (OR 0.87, 95% CI 0.8-0.97, p=0.01), lymphadenectomy (OR 6.6, 95% CI 1.7-31.6, p=0.01), and hyperthyroidism (OR 13.3, 95% CI 1.3-1849, p=0.03). Patients with malignancy undergoing central (OR 7.1, 95% CI 1.5-33.4, p=0.01) or central plus lateral lymphadenectomy (OR 6.33, 95% CI 1.0-40.1, p=0.05) had significantly increased risk for transient hypocalcemia. Malignancy, MEN2A/B, goiter, preoperative calcium supplementation, incidental parathyroid removal, and postoperative PTH <15pg/ml were not associated with transient hypocalcemia.

CONCLUSIONS

Younger age, hyperthyroidism, and concomitant lymphadenectomy during total thyroidectomy increase risk of developing transient hypocalcemia. Malignant cases with central or central plus lateral lymphadenectomy are also at increased risk. Aggressive perioperative management of hypocalcemia should be initiated in patients with these risk factors.

LEVEL OF EVIDENCE

2b.