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Vaiman M, Mizrakli Y, Taha A, Gavriel H. An individual approach to intraoperative parathyroid hormone measurement during total thyroidectomy. Am J Otolaryngol 2024; 45:104159. [PMID: 38113776 DOI: 10.1016/j.amjoto.2023.104159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/03/2023] [Accepted: 12/03/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Hypocalcemia is a common complication of thyroidectomy. Measurement of the intraoperative serum parathyroid hormone (PTH) levels became an established technique but it requires further improvements. We aimed to assess intraoperative PTH level testing results against the hypothesis that the PTH assay may be performed almost immediately after thyroid gland removal. METHODS A retrospective cohort study. During total thyroidectomy surgery, the patients had PTH levels measured at the cutting time and again immediately after the thyroid gland is removed. Post-operatively, serial total blood calcium levels were obtained twice daily and recorded. RESULTS Among 63 enrolled patients, 39 had multinodular goiter, 15 thyroid carcinoma, and nine had Graves' disease. The mean age was 59.8 ± 15.3 years, 43 females. The mean PTH level before surgery was 45.8 ± 22.0 pg/mL. Post-operatively, 11/63 patients developed hypocalcemia with serum calcium levels <8 mg/dL. Four patients with ≥50 % decrease in PTH concentration were normocalcemic a day after surgery and were discharged early. Four patients with ≥70 % PTH decrease were treated accordingly during prolonged hospitalization and did not suffer from permanent hypocalcemia. The cut-off value of 70 % decrease after the gland removal was able to predict postoperative hypocalcemia with a sensitivity of 100 %, specificity 82.9 %, PPV 60.0 % and NPV 100 %. CONCLUSION Measurements of intraoperative PTH may not be performed at fixed time intervals but after 1-2 min after removal of the thyroid gland. Defining those not at risk would allow the majority of patients to be waived from post-operative blood calcium testing and safely discharged early after surgery.
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Affiliation(s)
- Michael Vaiman
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yuval Mizrakli
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmed Taha
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Gavriel
- Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Devgan Y, Mayilvaganan S, Mishra A, Chand G, Agarwal G, Agarwal A. Comparison of indocyanine green angiography vs intraoperative parathyroid hormone in early prediction of risk of post-thyroidectomy hypocalcemia: a prospective cohort study. Ann Med Surg (Lond) 2024; 86:678-688. [PMID: 38333253 PMCID: PMC10849419 DOI: 10.1097/ms9.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/22/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction Indocyanine green (ICG) angiography is the 'real-time intraoperative imaging' technique used to reduce the chances of hypoparathyroidism in post-thyroidectomy patients. In our study, the authors predicted the risk of early post-thyroidectomy hypocalcemia by intraoperative evaluation of parathyroid gland perfusion by ICG angiography. Materials and methods In patients who underwent total thyroidectomy, ICG angiography was done using the SPY PHI imaging system (Stryker). Post-thyroid specimen removal, scoring of parathyroids was done in spy contrast mode. All 4 or <4 visualized parathyroids were scored for vascularity with the highest score of 8. Serum ionized calcium was done 6 h postsurgery and on the morning and evening of postoperative days 1 and 2. Calcium supplements were given to only those who developed clinical or severe biochemical hypocalcemia. Results Out of 60, postoperative hypocalcemia was noted in 41 patients. Total ICG score ≤5 was seen in 34 patients, out of which 28 developed postoperative hypocalcemia showing PPV 82.3% and diagnostic accuracy of 68.3% while iPTH (4.28 pmol/l) showed PPV 76.7 and diagnostic accuracy 70 %. In eight patients, none of the glands was scored as 2 (White) and all these patients developed hypocalcemia requiring calcium infusion. Conclusion The absence of visualization of at least 1 well-perfused (score 2) gland on ICG angiography is highly predictive of hypocalcemia and the majority of patients with total ICG score ≤5 developed hypocalcemia in the immediate postoperative period. ICG is a good predictor of the absence of hypoparathyroidism after thyroidectomy and is comparable to iPTH in the prediction of post-thyroidectomy hypocalcemia.
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Affiliation(s)
| | - Sabaretnam Mayilvaganan
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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van Dijk SPJ, van Driel MHE, van Kinschot CMJ, Engel MFM, Franssen GJH, van Noord C, Visser WE, Verhoef C, Peeters RP, van Ginhoven TM. Management of Postthyroidectomy Hypoparathyroidism and Its Effect on Hypocalcemia-Related Complications: A Meta-Analysis. Otolaryngol Head Neck Surg 2024; 170:359-372. [PMID: 38013484 DOI: 10.1002/ohn.594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/12/2023] [Accepted: 11/04/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The aim of this Meta-analysis is to evaluate the impact of different treatment strategies for early postoperative hypoparathyroidism on hypocalcemia-related complications and long-term hypoparathyroidism. DATA SOURCES Embase.com, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched to September 20, 2022. REVIEW METHODS Articles reporting on adult patients who underwent total thyroidectomy which specified a treatment strategy for postthyroidectomy hypoparathyroidism were included. Random effect models were applied to obtain pooled proportions and 95% confidence intervals. Primary outcome was the occurrence of major hypocalcemia-related complications. Secondary outcome was long-term hypoparathyroidism. RESULTS Sixty-six studies comprising 67 treatment protocols and 51,096 patients were included in this Meta-analysis. In 8 protocols (3806 patients), routine calcium and/or active vitamin D medication was given to all patients directly after thyroidectomy. In 49 protocols (44,012 patients), calcium and/or active vitamin D medication was only given to patients with biochemically proven postthyroidectomy hypoparathyroidism. In 10 protocols (3278 patients), calcium and/or active vitamin D supplementation was only initiated in case of clinical symptoms of hypocalcemia. No patient had a major complication due to postoperative hypocalcemia. The pooled proportion of long-term hypoparathyroidism was 2.4% (95% confidence interval, 1.9-3.0). There was no significant difference in the incidence of long-term hypoparathyroidism between the 3 supplementation groups. CONCLUSIONS All treatment strategies for postoperative hypocalcemia prevent major complications of hypocalcemia. The early postoperative treatment protocol for postthyroidectomy hypoparathyroidism does not seem to influence recovery of parathyroid function in the long term.
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Affiliation(s)
- Sam P J van Dijk
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M H Elise van Driel
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caroline M J van Kinschot
- Department of Internal Medicine, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine and Thyroid Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maarten F M Engel
- Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gaston J H Franssen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charlotte van Noord
- Department of Internal Medicine, Maasstad Hospital Rotterdam, Rotterdam, The Netherlands
| | - W Edward Visser
- Department of Internal Medicine and Thyroid Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robin P Peeters
- Department of Internal Medicine and Thyroid Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tessa M van Ginhoven
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Frey S, Van Den Heede K, Triponez F, Bizard JP, Godiris-Petit G, Pattou F. Prevention of hypocalcemia and hypoparathyroidism after total thyroidectomy. Recommendations of the Francophone Association of Endocrine Surgery (AFCE) with the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine (SFMN). J Visc Surg 2023:S1878-7886(23)00084-X. [PMID: 37211443 DOI: 10.1016/j.jviscsurg.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Postoperative hypoparathyroidism, resulting from removal and/or devascularization of one or more parathyroid glands, is a feared complication of total thyroidectomy. Two forms, which are distinguished by their frequency, their time to onset and their duration as well as by their presentation, must be individualized: early postoperative hypocalcemia, often secondary to early hypoparathyroidism is a frequent and often transient situation occurring within the first days after surgery; permanent hypoparathyroidism, which is rarer, manifests when parathyroid function remains impaired for more than six months after surgery. Because of their severity, these conditions must be known and ideally prevented during total thyroidectomy. The objective of this article is to provide surgeons with practical recommendations for the prevention, diagnosis, and treatment of hypoparathyroidism after total thyroidectomy. These recommendations, which are the fruit of a medico-surgical consensus, were developed by the Francophone Association of Endocrine Surgery (AFCE), the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine and Molecular Imaging. (SFMN). The content, grade and level of evidence for each recommendation was decided after consultation within a panel of experts, based on an analysis of recent literature.
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Affiliation(s)
- Samuel Frey
- Digestif Cancer, Digestive and Endocrine Surgery, Institute of Digestive Tract Diseases, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Klaas Van Den Heede
- Visceral and Endocrine General Surgery Department, Pitié-Salpêtrière Hospital, Pierre-et-Marie-Curie-Sorbonne University (Paris 6), 75013 Paris, France
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospitals (HUG), Faculty of Medicine of Geneva, 1211 Genève, Switzerland
| | - Jean-Pierre Bizard
- Endocrine and Visceral Surgery, Hospital of Arras-lès-Bonnettes Hospital, 62000 Arras, France
| | - Gaëlle Godiris-Petit
- Visceral and Endocrine General Surgery Department, Pitié-Salpêtrière Hospital, Pierre-et-Marie-Curie-Sorbonne University (Paris 6), 75013 Paris, France
| | - François Pattou
- General and Endocrine Surgery, University Hospital of Lille, 59000 Lille, France.
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5
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Krumeich LN, Finn CB, Fraker DL, Kelz RR, Wachtel H. How low is too low? Intraoperative parathyroid hormone decline in normohormonal primary hyperparathyroidism. Surgery 2023; 173:166-172. [PMID: 36266124 DOI: 10.1016/j.surg.2022.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/20/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In normohormonal primary hyperparathyroidism, parathyroid hormone levels are normal but inappropriately elevated for the degree of hypercalcemia. The study goals were to determine intraoperative parathyroid hormone parameters predictive of (1) cure and (2) hypocalcemia in this subgroup. METHODS We performed a retrospective cohort study comparing patients who underwent parathyroidectomy (2002-2019) for normohormonal and classic primary hyperparathyroidism. The primary outcomes were cure (calcium <10.3 mg/dL) and hypocalcemia (≤8.4 mg/dL) ≥6 months postoperatively. RESULTS In the study, 127 of 1,087 patients (11.7%) had normohormonal primary hyperparathyroidism. The groups experienced similar rates of cure (91.3% vs 94.1%, P = .23) and hypocalcemia (3.9% vs 2.9%, P = .53). However, intraoperative parathyroid hormone decline in cured patients was lower in those with normohormonal primary hyperparathyroidism (66.4% vs 84.5%, P < .0001). Receiver operating characteristic curves provided Youden's indices of 52% and 75% (cure) and 75% and 88% (hypocalcemia) for patients with normohormonal and classic primary hyperparathyroidism, respectively. Cure rates with ≥50% intraoperative parathyroid hormone decline were similar (94.1% vs 95.0%, P = .72), but hypocalcemia was more prevalent in patients with normohormonal primary hyperparathyroidism and ≥70% intraoperative parathyroid hormone decline (10.4% vs 3.3%, P = .01). CONCLUSION In patients with normohormonal primary hyperparathyroidism, intraoperative parathyroid hormone declines of ≥50% and ≥70% were predictive of postoperative cure and hypocalcemia, respectively. These parameters may inform intraoperative decision making and postoperative management.
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Affiliation(s)
- Lauren N Krumeich
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA.
| | - Caitlin B Finn
- Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
| | - Heather Wachtel
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA
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6
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Yao L, Hui X, Li M, Li J, Ahmed MM, Lin C, Kandi M, Sreekanta A, Makhdami N, Tamilselvan D, Ali DS, Dandurand K, Yang K, Bilezikian JP, Brandi ML, Clarke BL, Mannstadt M, Rejnmark L, Khan AA, Guyatt G. Complications, Symptoms, Presurgical Predictors in Patients With Chronic Hypoparathyroidism: A Systematic Review. J Bone Miner Res 2022; 37:2642-2653. [PMID: 36375810 DOI: 10.1002/jbmr.4673] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/22/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022]
Abstract
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).
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Affiliation(s)
- Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Xu Hui
- Evidence-Based Social Sciences Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Jing Li
- Evidence-Based Social Sciences Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Muhammad Muneeb Ahmed
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Clement Lin
- Faculty of Health Sciences, McMaster University, Canada
| | - Maryam Kandi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ashwini Sreekanta
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nima Makhdami
- Internal Medicine Resident, Department of Internal Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Divya Tamilselvan
- Faculty of Health Sciences and Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Karel Dandurand
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Kehu Yang
- Evidence-Based Social Sciences Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Maria Luisa Brandi
- Fondazione Italiana sulla Ricerca sulle Malattie dell'Osso (F.I.R.M.O. Foundation), Florence, Italy
| | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lars Rejnmark
- Dept of Endocrinology and Internal Medicine, Aarhus University hospital, Aarhus, Denmark
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Nagel K, Hendricks A, Lenschow C, Meir M, Hahner S, Fassnacht M, Wiegering A, Germer CT, Schlegel N. Definition and diagnosis of postsurgical hypoparathyroidism after thyroid surgery: meta-analysis. BJS Open 2022; 6:6683841. [PMID: 36050906 PMCID: PMC9437325 DOI: 10.1093/bjsopen/zrac102] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Kathrin Nagel
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Anne Hendricks
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Christina Lenschow
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Michael Meir
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Stefanie Hahner
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg , Würzburg , Germany
| | - Martin Fassnacht
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg , Würzburg , Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Würzburg , Würzburg , Germany
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Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia. J Clin Med 2022; 11:jcm11092389. [PMID: 35566513 PMCID: PMC9105462 DOI: 10.3390/jcm11092389] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Postoperative hypocalcemia is one of the most common complications after total thyroidectomy. Parathormone (PTH) and calcium levels, measured several hours after surgery, have been suggested as valuable markers for detecting patients at risk for post-thyroidectomy hypocalcemia. We aimed to determine if early post-surgery PTH and calcium levels can be used for the early identification of patients at risk for symptomatic hypocalcemia. METHODS PTH and calcium were measured before surgery and at 10 min and 4 h post-thyroidectomy, in 77 patients. Performance characteristics of PTH and calcium levels and their post/pre-surgery ratios were calculated. RESULTS Four-hour calcium was a sensitive (93.75%) but not specific (67.61%) indicator of patients at risk for symptomatic hypocalcemia. The 4-h/pre-surgery PTH ratio was the most accurate (90.81%) and the most specific (94.37%) test to identify patients at risk. Serum calcium at 4-h, 4-h/pre-surgery PTH ratio, and PTH at 10 min post-surgery had the higher diagnostic odds ratios (50.86, 32.85, and 29.04, respectively). The 4-h/pre-surgery PTH ratio also had the highest (0.694) Youden's J statistic. CONCLUSIONS Low serum calcium levels 4 h after thyroidectomy and the 4-h/pre-surgery PTH ratio could be valuable additions to everyday clinical practice in post-thyroidectomy patients.
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Abdelrahim HS, Amer AF, Mikhael Nageeb R. Indocyanine Green Angiography of Parathyroid Glands versus Intraoperative Parathyroid Hormone Assay as a Reliable Predictor for Post Thyroidectomy Transient Hypocalcemia. J INVEST SURG 2022; 35:1484-1491. [PMID: 35450501 DOI: 10.1080/08941939.2022.2066229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Prediction of postoperative hypocalcemia is a fundamental issue in thyroidectomy. Indocyanine green (ICG) angiography of parathyroid glands is a feasible method to detect the perfusion of parathyroid glands and predict postoperative hypocalcemia. MATERIALS AND METHODS A prospective observational study was conducted at Ain Shams University Hospitals between April 2018 and April 2021. The included cases of total thyroidectomy underwent intraoperative ICG fluorescence angiography to identify the four parathyroid glands and score each gland according to the viability. Patients in which less than four glands were identified were excluded. Intraoperative intact parathyroid hormone (ioPTH) level assay was also measured to compare with ICG in predicting postoperative transient hypocalcemia. RESULTS A total of 134 cases underwent total thyroidectomy during the study period. We could identify the four parathyroid glands in 90 patients, including them in the study. We had postoperative hypocalcemia in 28 cases (31.1%). The diagnostic accuracy of ICG angiography and ioPTH level assay was high and almost similar (82.22% versus 87.78%). Both were higher than the surgeons' diagnostic accuracy of visual inspection (62.22%). CONCLUSIONS ICG angiography of the parathyroid gland is a safe, reliable predictor for postoperative transient hypocalcemia with a high and almost similar accuracy compared to intraoperative parathyroid hormone level.
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Affiliation(s)
- Hossam S Abdelrahim
- Faculty of Medicine, General Surgery Department, Ain Shams University, Cairo, Egypt
| | - Ahmed F Amer
- Faculty of Medicine, General Surgery Department, Ain Shams University, Cairo, Egypt
| | - Ramy Mikhael Nageeb
- Faculty of Medicine, General Surgery Department, Ain Shams University, Cairo, Egypt
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10
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Elhady HA, Abd Elghany RAE, Zarad MS. Parathyroid hormone level after total thyroidectomy using conventional versus harmonic focus technique: Prospective randomized study. Ann Med Surg (Lond) 2022; 73:103176. [PMID: 34987791 PMCID: PMC8693406 DOI: 10.1016/j.amsu.2021.103176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/07/2021] [Accepted: 12/11/2021] [Indexed: 11/04/2022] Open
Abstract
Background Total thyroidectomy is a common procedure, we wish to examine the effects of utilizing a harmonic scalpel with traditional procedures on parathyroid hormone levels. Patients and methods 100 patients who underwent total thyroidectomy at the Department of General Surgery, were enrolled in this prospective randomized study, were randomly allocated into two equal groups: Group I: total thyroidectomy using a harmonic scalpel (HS) and Group II: total thyroidectomy using conventional technique. Results There is a significant association between the technique of surgery and the decrease in Postoperative PTH, Mean Difference, Pre and Postoperative and the change Pre PTH (p-value <0.001). Conclusion The postoperative serum level of parathyroid hormone declined significantly after thyroidectomy if the conventional method was used. Using HS during thyroidectomy is safe and effective with low rates of hypoparathyroidism. In treatment of many thyroid disease, total thyroidectomy is a viable option. The biggest disadvantage is the potential for complications, but it also avoids recurrence. Hypoparathyroidism after thyroid surgery is a common problem. Using a harmonic scalpel may help to decrease the reduction in parathyroid hormone levels after surgery.
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Wu YJ, Wang JB, Li FB, Jin L, Zhou L, Xie L. Fine-Needle Pricking Test of the Parathyroid Gland during Thyroid Surgery in Predicting Parathyroid Function. Int J Endocrinol 2022; 2022:8747680. [PMID: 35795846 PMCID: PMC9252692 DOI: 10.1155/2022/8747680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Permanent hypoparathyroidism is a serious complication following total thyroidectomy plus central neck dissection (CND). How to evaluate the vascularization of the parathyroid gland in real time is a major concern of thyroid surgeons. This study aimed to evaluate the fine-needle pricking (FNP) test in predicting parathyroid gland function. METHODS The FNP test was performed in patients undergoing total thyroidectomy plus CND between January 1, 2014, and December 31, 2019, to visualize the vascularization of the parathyroid glands. Patients were classified according to the number of parathyroid glands preserved in situ with excellent vascularity (PGPIEV) demonstrated by FNP: group 0 (without PGPIEV), group 1 (with one PGPIEV), group 2 (with two PGPIEV), group 3 (with three PGPIEV), and group 4 (with four PGPIEV). RESULTS A total of 608 patients with four parathyroid glands underwent FNP testing during thyroidectomy. At least one PGPIEV was demonstrated by FNP testing in 581 patients who had intact parathyroid hormone (iPTH) levels in the normal range after the operation. The prevalence of hypocalcemia decreased from 77.8% in group 0 to 9.8% in group 4 (P < 0.001), and the incidence of hypoparathyroidism decreased from 44.4% in group 0 to 0% in groups 1-4 (P < 0.001). iPTH concentrations on postoperative day 1 were positively correlated with PGPIEV groups (increased from 14.58 ng/l in group 0 to 45.22 ng/l in group 4, P < 0.001). CONCLUSIONS The FNP test is a safe and reliable method to predict parathyroid function. One PGPIEV demonstrated by the FNP test rules out the possibility of patients developing hypoparathyroidism.
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Affiliation(s)
- Ying-Jun Wu
- Department of Operation Room Nursing, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Jian-Biao Wang
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Fei-Bo Li
- Second Department of General Surgery, Zhejiang Putuo Hospital, Zhoushan, Zhejiang 316100, China
| | - Lei Jin
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Liang Zhou
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Lei Xie
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
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Wang JB, Su R, Jin L, Zhou L, Jiang XF, Xiao GZ, Chu YY, Li FB, Feng YB, Xie L. The Clinical Significance of Detecting Blood Supply to the Inferior Parathyroid Gland Based on the "Layer of Thymus-Blood Vessel-Inferior Parathyroid Gland" Concept. Int J Endocrinol 2022; 2022:6556252. [PMID: 35465074 PMCID: PMC9020968 DOI: 10.1155/2022/6556252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE How to preserve the inferior parathyroid gland (IPTG) in situ during central neck dissection (CND) is the major concern of thyroid surgeons. The "layer of thymus-blood vessel-IPTG" (TBP layer) concept showed to be effective in preserving IPTG. The objective of this study was to identify the origin and course of blood supply to IPTG (IPBS) within the TBP layer and to take key points of operation during CND. DESIGN This is a retrospective control study. Participants. Patients who underwent thyroidectomy plus CND using the TBP layer concept and conventional technique between 2017 and 2019 were enrolled. Measurements. The origin and course of IPBS in relation to recurrent laryngeal nerve (RLN) and thymus and prevalence of hypoparathyroidism were detected. RESULTS A total of 71.3% of IPTGs (251 of 352) were supplied by ITA branches, defined as type A. Type A was further divided into Types A1 (branches of ITA, coursing laterally to the RLN (53.1%, 187 of 352)) and A2 (branches of ITA, traversing medially to the RLN (18.2%, 64 of 352)). Type A2 was more common on the right side than on the left side (P < 0.001). Fifty-five (15.6%) IPTG feeding vessels originated from the thymus or mediastinum. Nineteen (5.4%) IPTGs were supplied by branches of the superior thyroid artery. The incidence of transient hypoparathyroidism decreased from 45.7% to 3.6% (P < 0.001), in the TBP layer group compared with the conventional technique group. CONCLUSION The origin and course of IPBS follow a definite pattern. This mapping and precautions help surgeons optimize intraoperative manipulations for better preservation of IPBS during CND.
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Affiliation(s)
- Jian-Biao Wang
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Rong Su
- Department of Operation Room Nursing, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Lei Jin
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Liang Zhou
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Xian-Feng Jiang
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Gui-Zhou Xiao
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Ye-Yuan Chu
- Department of Operation Room Nursing, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Fei-Bo Li
- Second Department of General Surgery, Zhejiang Putuo Hospital, Zhoushan, Zhejiang 316100, China
| | - Yi-Bing Feng
- Second Department of General Surgery, Longyou People's Hospital, Quzhou, Zhejiang 324400, China
| | - Lei Xie
- Department of Head and Neck Surgery, The Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
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Loncar I, Noltes ME, Dickhoff C, Engelsman AF, Schepers A, Vriens MR, Bouvy ND, Kruijff S, van Ginhoven TM. Persistent Postthyroidectomy Hypoparathyroidism in the Netherlands. JAMA Otolaryngol Head Neck Surg 2021; 147:959-965. [PMID: 34617977 DOI: 10.1001/jamaoto.2021.2475] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hypoparathyroidism is one of the most common complications after total or completion thyroidectomy. The reported incidence rate of hypoparathyroidism in the literature is highly variable. Data that provide a better understanding of the magnitude of this postoperative complication are warranted and can provide a stepping stone for further collaborations that aim to reduce complication rates and establish uniform treatment protocols. Objective To evaluate the incidence of postoperative, persistent hypoparathyroidism after total or completion thyroidectomy in patients who were referred to university hospital centers and assess the association of different definitions with the incidence of hypoparathyroidism. Design, Setting, and Participants This retrospective multicenter cohort study conducted throughout 2016 in 7 Dutch university hospital centers included 200 patients who were undergoing a total or completion thyroidectomy. Data analysis was conducted in January 2021. Main Outcomes and Measures We report on the incidence of persistent hypoparathyroidism, defined as the need for active vitamin D with or without calcium supplementation longer than 1 year after surgery. Results A total of 200 patients (143 women [71.5%]; mean [IQR] age, 49.0 [37.0-62.0] years) were included and 30 patients (15.0%) developed persistent hypoparathyroidism. The incidence of persistent hypoparathyroidism varied between 14.5% (calcium and active vitamin D 1 year postsurgery) to 28.5% (calcium and/or active vitamin D 6 months postsurgery) depending on the definition used. Conclusions and Relevance In this cohort study, the risk of persistent hypoparathyroidism after total or completion thyroidectomy was 15% in patients who were referred to university hospital centers. The high rate of persistent hypoparathyroidism warrants efforts to reduce this complication rate. There is discrepancy in the definition and treatment of persistent hypoparathyroidism, and use of uniform evidence-based treatment guidelines enables comparison of interventions.
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Affiliation(s)
- Ivona Loncar
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
| | - Milou E Noltes
- University of Groningen, University Medical Center Groningen, Department of Surgical Oncology, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Nuclear Medicine and Molecular Imaging, Groningen, the Netherlands
| | - Chris Dickhoff
- Amsterdam UMC, location VUmc, Department of Surgery, Amsterdam, the Netherlands
| | - Anton F Engelsman
- Amsterdam UMC, location AMC, Department of Surgery, Amsterdam, the Netherlands
| | - Abbey Schepers
- Leiden University Medical Center, Department of Surgery, Leiden, the Netherlands
| | - Menno R Vriens
- University Medical Center Utrecht, Department of Surgery, Utrecht, the Netherlands
| | - Nicole D Bouvy
- Maastricht University Medical Center, Department of Surgery, Maastricht, the Netherlands
| | - Schelto Kruijff
- University of Groningen, University Medical Center Groningen, Department of Surgical Oncology, Groningen, the Netherlands
| | - Tessa M van Ginhoven
- Erasmus MC Cancer Institute, Department of Surgical Oncology and Gastrointestinal Surgery, Rotterdam, the Netherlands
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Ernst H, Sowerby L, Sahovaler A, Macneil D, Nichols A, Yoo J, Hilsden R, Strychowsky J, Fung K. Rapid standardized operating rooms (RAPSTOR) in thyroid and parathyroid surgery. J Otolaryngol Head Neck Surg 2021; 50:44. [PMID: 34238389 PMCID: PMC8265141 DOI: 10.1186/s40463-021-00525-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/13/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the impact of a high efficiency rapid standardized OR (RAPSTOR) for hemithyroid/parathyroid surgery using standardized equipment sets (SES) and consecutive case scheduling (CCS) on turnover times (TOT), average case volumes, patient outcomes, hospital costs and OR efficiency/stress. METHODS Patients requiring hemithyroidectomy (primary or completion) or unilateral parathyroidectomy in a single surgeon's practice were scheduled consecutively with SES. Retrospective control groups were classified as sequential (CS) or non-sequential (CNS). A survey regarding OR efficiency/stress was administered. Phenomenography and descriptive statistics were conducted for time points, cost and patient outcome variables. Hospital cost minimization analysis was performed. RESULTS The mean TOT of RAPSTOR procedures (16 min; n = 27) was not significantly different than CS (14 min, n = 14) or CNS (17 min, n = 6). Mean case number per hour was significantly increased in RAPSTOR (1.2) compared to both CS (0.9; p < 0.05) and CNS (0.7; p < 0.05). Average operative time was significantly reduced in RAPSTOR (32 min; n = 28) compared to CNS (48 min; p < 0.05) but not CS (33 min; p = 0.06). Time to discharge was reduced in RAPSTOR (595 min) compared to CNS (1210 min, p < 0.05). There was no difference in complication rate between all groups (p = 0.27). Survey responses suggested improved efficiency, teamwork and workflow. Furthermore, there is associated decrease in direct operative costs for RAPSTOR vs. CS. CONCLUSION A high efficiency standardized OR for hemithyroid and parathyroid surgery using SES and CCS is associated with improved efficiency and, in this study, led to increased capacity at reduced cost without compromising patient safety. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Hannah Ernst
- Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Leigh Sowerby
- Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Axel Sahovaler
- Department of Head and Neck Surgery Unit, General Surgery Department, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
- Department of Otolaryngology- Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Macneil
- Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Anthony Nichols
- Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada
| | - John Yoo
- Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Richard Hilsden
- Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada
| | - Julie Strychowsky
- Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Kevin Fung
- Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada.
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Koimtzis GD, Stefanopoulos L, Giannoulis K, Papavramidis TS. What are the real rates of temporary hypoparathyroidism following thyroidectomy? It is a matter of definition: a systematic review. Endocrine 2021; 73:1-7. [PMID: 33651345 DOI: 10.1007/s12020-021-02663-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/10/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Georgios D Koimtzis
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Heath Park Way, Cardiff, CF14 4XW, UK.
| | - Leandros Stefanopoulos
- Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | - Kleanthis Giannoulis
- 1st Surgical Department, Papageorgiou General Hospital of Thessaloniki, Taskou Papageorgiou, 54631, Thessaloniki, Greece
| | - Theodosios S Papavramidis
- 1st Propaedeutic Surgical Department, University Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki (AUTH), 1st St. Kiriakidi Street, 54621, Thessaloniki, Greece
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16
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Su D, Xia F, Huang W, Zhang Z, Bai N, Wang D, Liao X, Li X. Short-term recovery in patients suffering hypoparathyroid after thyroidectomy: a case control study. BMC Surg 2021; 21:204. [PMID: 33882915 PMCID: PMC8059228 DOI: 10.1186/s12893-021-01173-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 03/23/2021] [Indexed: 08/30/2023] Open
Abstract
Background Postoperative hypoparathyroidism is the main reason for outpatient follow-up and long-term oral calcium and calcitriol treatment. Our study investigated the influencing factors and powerful predictors of short-term postoperative parathyroid function recovery. Methods Logistic regression was used to compare the clinicopathological characteristics; surgical details; and serum calcium (Ca), magnesium (Mg), and phosphorus (P) concentrations of patients. A receiver operating characteristic (ROC) curve was used to analyze the predictors of normal parathyroid hormone (PTH). Results Among the 111 patients with PTH < 10 pg/mL on the first postoperative day, most patients experienced a return to normal PTH (PTH > 15 pg/mL) within 30 days postoperatively. Univariate analysis showed that Pod (postoperative day) 1 PTH, Pod3 PTH, Pod7 Ca, Pod7 Mg, and Pod7 P (P < 0.05) were associated with parathyroid function recovery to normal on the seventh postoperative day. Multivariate logistic regression analysis revealed the following independent risk factors for normal PTH levels at Pod7 after thyroidectomy: Pod3 PTH (P = 0.038), Pod1 PTH (P = 0.056), Pod7 Mg (P = 0.001), Pod7 P (P = 0.020), and the number of parathyroid glands in situ intraoperatively. The combined sensitivity of serum magnesium concentration and phosphorus concentration to predict parathyroid function recover to normal on the seventh postoperative day was 82.76%, with a sensitivity of 76.83%. Conclusion Serum magnesium, phosphorus and PTH concentrations are important influencing factors and effective predictors of short-term postoperative parathyroid function recovery to normal. Serum ion is an effective auxiliary diagnostic method for hypoparathyroidism after thyroidectomy.
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Affiliation(s)
- Duntao Su
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Fada Xia
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Wanze Huang
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Zhejia Zhang
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Ning Bai
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Di Wang
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Xin Liao
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China
| | - Xinying Li
- Department of General Surgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, China.
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Gan X, Feng J, Deng X, Shen F, Lu J, Liu Q, Cai W, Chen Z, Guo M, Xu B. The significance of Hashimoto's thyroiditis for postoperative complications of thyroid surgery: a systematic review and meta-analysis. Ann R Coll Surg Engl 2021; 103:223-230. [PMID: 33645288 DOI: 10.1308/rcsann.2020.7013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Hashimoto's thyroiditis (HT) is one of the most common immune-mediated diseases. It makes thyroid surgery more complicated and difficult because there may be adhesions between the thyroid gland and surrounding structures. However, it is still controversial whether HT patients carry a high risk for postoperative complications of thyroid surgery. The purpose of this study was to investigate the significance of HT for the postoperative complications of thyroid surgery. METHODS A search for studies assessing the postoperative complication risks of HT patients compared with that of patients with benign nodules (BNs) was performed in PubMed, EMBASE and Web of Science. Nine studies (20,118 cases, 1,582 cases of HT and 18,536 cases of BN) were identified, and the data from the relevant outcomes were extracted and analysed. RESULTS There were no significant differences between the HT group and BN group in recurrent laryngeal nerve palsy (RLNP) and permanent hypoparathyroidism (PHP). The rate of transient hypocalcaemia (THC) was significantly higher in the HT group (16.85%) than in the BN group (13.20%). CONCLUSIONS The meta-analysis showed that HT only increased the risk of the postoperative complication THC compared to BN. Understanding the significance of HT in postoperative hypoparathyroidism after thyroid surgery would help clinicians perform sufficient preoperative (and postoperative) assessments and to optimise surgical planning.
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Affiliation(s)
- X Gan
- Department of Thyroid Surgery, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - J Feng
- Department of Thyroid Surgery, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - X Deng
- Department of Thyroid Surgery, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - F Shen
- Department of Thyroid Surgery, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - J Lu
- Department of Colorectal and Anal Surgery, Guangzhou Digestive Disease Center, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Q Liu
- Department of Oncology, Guangzhou First People's Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - W Cai
- Department of Thyroid Surgery, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Z Chen
- Department of Thyroid Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - M Guo
- Department of Thyroid Surgery, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - B Xu
- Department of Thyroid Surgery, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
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Lagos J, Herrera JA, Lagos D, Merchán Galvis AM. Tiempo óptimo para medición de paratohormona como predictor de hipocalcemia en pacientes posterior a tiroidectomía total. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La hipocalcemia posterior a tiroidectomía total es una complicación frecuente en la cirugía de tiroides. La hormona paratiroidea ha demostrado ser un predictor confiable para detectar los pacientes con alto riesgo de hipocalcemia significativa y la consecuente necesidad de administrar suplemento de calcio. El objetivo de este estudio fue determinar el tiempo óptimo de medición de la paratohormona para dicho fin.
Métodos. Estudio prospectivo realizado en dos instituciones de nivel III en Popayán, Colombia, entre abril de 2016 y febrero de 2018, en el cual se midieron niveles de paratohormona prequirúrgico, a las 0, 2, 4 y 12 horas del postoperatorio, y se compararon con los valores obtenidos a los 3 meses de seguimiento en pacientes sometidos a tiroidectomía total. Se consideró como grupos de riesgo y con necesidad de suplemento de calcio un valor de paratohormona menor de 10 pg/ml o una disminución mayor del 80 % con respecto al valor prequirúrgico.
Resultados. Se incluyeron 34 pacientes intervenidos. Tomando como umbral un valor menor de 10 pg/ml, la medición de paratohormona a las 4 horas fue sensible y específica (60 y 93,1 % respectivamente). Para una disminución mayor del 80 % con respecto al valor prequirúrgico, la sensibilidad fue del 60 % y la especificidad del 96,5 %, presentando un valor predictivo positivo de 75 % y negativo del 93,3 %, con una p < 0,001.
Discusión. Una disminución mayor del 80 % del valor de paratohormona prequirúrgico medida a las 4 horas después de la tiroidectomía total permite identificar aquellos pacientes con alto riesgo de hipocalcemia significativa, que requieren administración temprana de suplementos de calcio, comparado con la determinación de la disminución a las 0, 2 y 12 horas postoperatorias.
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 219] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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20
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Gálvez-Pastor S, Torregrosa NM, Ríos A, Febrero B, González-Costea R, García-López MA, Balsalobre MD, Pastor-Pérez P, Moreno P, Vázquez-Rojas JL, Rodríguez JM. Prediction of hypocalcemia after total thyroidectomy using indocyanine green angiography of parathyroid glands: A simple quantitative scoring system. Am J Surg 2019; 218:993-999. [DOI: 10.1016/j.amjsurg.2018.12.074] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/21/2018] [Accepted: 12/31/2018] [Indexed: 11/12/2022]
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21
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Harsløf T, Rolighed L, Rejnmark L. Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review. Endocrine 2019; 64:176-183. [PMID: 30788669 DOI: 10.1007/s12020-019-01858-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/31/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Torben Harsløf
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Lars Rolighed
- Department of Otorhinolaryngology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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22
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Tsai SD, Mostoufi-Moab S, Bauer S, Kazahaya K, Hawkes CP, Adzick NS, Bauer AJ. Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy. Front Endocrinol (Lausanne) 2019; 10:760. [PMID: 31781035 PMCID: PMC6851192 DOI: 10.3389/fendo.2019.00760] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/21/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Hypoparathyroidism is one of the most common complications for patients undergoing total thyroidectomy. Our study's primary objective was to assess if intraoperative PTH levels correlate with parathyroid gland function recovery time in pediatric patients following total thyroidectomy. Methods: Retrospective review of pediatric patients who underwent thyroid surgery at CHOP for demographics and laboratory test values (calcium, phosphorus, and parathyroid hormone). We defined Time of Recovery (TOR) as the time difference from first intra-operative parathyroid hormone level (ioPTH) timepoint until normalization of PTH (> 10 pg/mL) post-thyroidectomy. Calcium and vitamin D supplements were weaned following normalization of calcium and phosphorous levels postoperatively. Patients were excluded if they lacked three intraoperative PTH timepoints or were missing postoperative follow-up PTH data. Results: 65 patients (54 female), median age 15 (range 5-23 years), underwent thyroid surgery and met study inclusion criteria. The correlations of 2nd and 3rd ioPTHs with TOR were statistically significant (p < 0.05): the lower the ioPTH, the greater the recovery time. Stratifying patients into high-risk (2nd ioPTH ≤ 10 pg/mL), moderate-risk (2nd ioPTH between 10 and 20 pg/mL), and low-risk (2nd ioPTH ≥ 20 pg/mL) tertiles, the TOR decreased by orders of magnitudes from an average of 43.13 ± 76.00 to 6.10 ± 17.44 to 1.85 ± 6.20 days. These differences were statistically significant (p < 0.05). Conclusions: Our study results confirm the usefulness of intraoperative PTH levels to predict pediatric patient recovery post-surgery and provides useful anticipatory guidance to optimize timing and frequency of postoperative laboratory surveillance.
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Affiliation(s)
- Steven D. Tsai
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sogol Mostoufi-Moab
- Division of Pediatric Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Samantha Bauer
- Orthopaedic Institute for Children, Los Angeles, CA, United States
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Colin P. Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - N. Scott Adzick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Andrew J. Bauer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Andrew J. Bauer
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Mazotas IG, Yen TW, Park J, Liu Y, Eastwood DC, Carr AA, Evans DB, Wang TS. A postoperative parathyroid hormone-based algorithm to reduce symptomatic hypocalcemia following completion/total thyroidectomy: A retrospective analysis of 591 patients. Surgery 2018; 164:746-753. [DOI: 10.1016/j.surg.2018.04.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/13/2018] [Accepted: 04/15/2018] [Indexed: 12/12/2022]
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24
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Orloff LA, Wiseman SM, Bernet VJ, Fahey TJ, Shaha AR, Shindo ML, Snyder SK, Stack BC, Sunwoo JB, Wang MB. American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults. Thyroid 2018; 28:830-841. [PMID: 29848235 DOI: 10.1089/thy.2017.0309] [Citation(s) in RCA: 207] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment. SUMMARY HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.
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Affiliation(s)
- Lisa A Orloff
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Sam M Wiseman
- 2 Department of Surgery, University of British Columbia , Vancouver, Canada
| | - Victor J Bernet
- 3 Division of Endocrinology, Mayo Clinic College of Medicine , Jacksonville, Florida
| | - Thomas J Fahey
- 4 Department of Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center , New York, New York
| | - Ashok R Shaha
- 5 Head and Neck Service, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Maisie L Shindo
- 6 Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University , Portland, Oregon
| | - Samuel K Snyder
- 7 Department of Surgery, University of Texas Rio Grande Valley School of Medicine , Harlingen, Texas
| | - Brendan C Stack
- 8 Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences , Little Rock, Arkansas
| | - John B Sunwoo
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine , Stanford, California
| | - Marilene B Wang
- 9 Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA , Los Angeles, California
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25
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Vidal Fortuny J, Sadowski SM, Belfontali V, Guigard S, Poncet A, Ris F, Karenovics W, Triponez F. Randomized clinical trial of intraoperative parathyroid gland angiography with indocyanine green fluorescence predicting parathyroid function after thyroid surgery. Br J Surg 2018; 105:350-357. [PMID: 29405252 PMCID: PMC6084300 DOI: 10.1002/bjs.10783] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/15/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hypoparathyroidism, the most common complication after thyroid surgery, leads to hypocalcaemia and significant medical problems. An RCT was undertaken to determine whether intraoperative parathyroid gland angiography with indocyanine green (ICG) could predict postoperative hypoparathyroidism, and obviate the need for systematic blood tests and oral calcium supplementation. METHODS Between September 2014 and February 2016, patients who had at least one well perfused parathyroid gland on ICG angiography were randomized to receive standard follow-up (measurement of calcium and parathyroid hormone (PTH) on postoperative day (POD) 1 and systematic supplementation with calcium and vitamin D; control group) or no supplementation and no blood test on POD 1 (intervention group). In all patients, calcium and PTH levels were measured 10-15 days after thyroidectomy. The primary endpoint was hypocalcaemia on POD 10-15. RESULTS A total of 196 patients underwent ICG angiography during thyroid surgery, of whom 146 had at least one well perfused parathyroid gland on ICG angiography and were randomized. None of these patients presented with hypoparathyroidism, including those who did not receive calcium supplementation. The intervention group was statistically non-inferior to the control group (exact 95 per cent c.i. of the difference in proportion of patients with hypocalcaemia -0·053 to 0·053; P = 0·012). Eleven of the 50 excluded patients, in whom no well perfused parathyroid gland could be identified by angiography, presented with hypoparathyroidism on POD 1, and six on POD 10-15, which was significantly different from the findings in randomized patients (P = 0·007). CONCLUSION ICG angiography reliably predicts the vascularization of the parathyroid glands and obviates the need for postoperative measurement of calcium and PTH, and supplementation with calcium in patients with at least one well perfused parathyroid gland. Registration number: NCT02249780 (http://www.clinicaltrials.gov).
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Affiliation(s)
- J. Vidal Fortuny
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - S. M. Sadowski
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - V. Belfontali
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - S. Guigard
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - A. Poncet
- Department of Clinical EpidemiologyUniversity Hospitals of GenevaGenevaSwitzerland
| | - F. Ris
- Department Visceral SurgeryUniversity Hospitals of GenevaGenevaSwitzerland
| | - W. Karenovics
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - F. Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of MedicineUniversity Hospitals of GenevaGenevaSwitzerland
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26
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Sadowski SM, Vidal Fortuny J, Triponez F. A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques. Gland Surg 2017; 6:S30-S37. [PMID: 29322020 DOI: 10.21037/gs.2017.07.10] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Identification of the parathyroid glands (PGs) during thyroid surgery may prevent their inadvertent surgical removal and prevent postoperative hypoparathyroidism. However, identification of the PGs does not guarantee their function, and their vascular supply needs to be preserved as well. The recent introduction of intraoperative indocyanine green (ICG) fluorescent angiography of the PGs during thyroid surgery allows for the appraisal of the vascular anatomy and evaluation of PG function. The use of this tool could lead to a significant reduction in the rate of postoperative hypoparathyroidism, as it allows surgeons to adapt their surgical technique for the preservation of the PGs. ICG fluorescent angiography is currently the only available real-time tool to assess the vascular blood supply of each individual PG intraoperatively and can thus assist surgeons in their decision-making. Herein, we review the relevant literature.
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Affiliation(s)
| | - Jordi Vidal Fortuny
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Frederic Triponez
- Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
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27
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Mazotas IG, Wang TS. The role and timing of parathyroid hormone determination after total thyroidectomy. Gland Surg 2017; 6:S38-S48. [PMID: 29322021 DOI: 10.21037/gs.2017.09.06] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Postoperative hypocalcemia is a common complication of total thyroidectomy resulting from manipulation, resection, or devascularization of the parathyroid glands. Parathyroid hormone (PTH) levels assessed in the perioperative period have been used to predict development of hypocalcemia. Articles examining the role of PTH measurement in the perioperative period following total or completion thyroidectomy are reviewed. Focus is placed on the timing of PTH measurement and the ability to predict which patients will develop hypocalcemia requiring supplementation. Postoperative PTH determination is highly accurate in predicting the development of hypocalcemia. Studies have examined PTH levels drawn at differing time points, ranging from intraoperatively until postoperative day 1 (POD1) with similar accuracy. This data is used to guide postoperative selective calcium and calcitriol supplementation in patients at highest risk for hypocalcemia. When evaluated within the first 4 hours postoperatively, predictive accuracy is maintained but can allow for earlier discharge for those patients at lower risk. Alternatively, some authors argue for routine supplementation, which can reduce the rate of postoperative hypocalcemia but increases the rate of unnecessary supplementation and potential risks associated with hypercalcemia. PTH determination at four hours after total thyroidectomy is an accurate predictor of hypocalcemia and can guide selective calcium supplementation for those at high risk, as well as facilitate a safe earlier hospital discharge for those at low risk of developing postoperative hypocalcemia.
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Affiliation(s)
- Ioanna G Mazotas
- Section of Endocrine Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tracy S Wang
- Section of Endocrine Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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28
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The Impact of Postoperative Percent Change of Parathormone Level From Baseline Value on the Rate of Hypocalcemia After Total Thyroidectomy. Int Surg 2017. [DOI: 10.9738/intsurg-d-16-00249.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
The purpose of this study was to investigate the impact of the percent change of postoperative parathormone (PoPTH) level from baseline value (ΔPTH) on the rate of hypocalcemia after total thyroidectomy.
Methods
Assays of serum PTH and calcium (Ca) were performed preoperatively and at 24 hours postoperatively in 222 consecutive patients who underwent total thyroidectomy. Postoperative hypocalcemia was defined as serum calcium level corrected for albumin concentration (cCa) <8.5 mg/dL. Patients with postoperative hypocalcemia were classified as group 1 (n = 100) and those with normal Ca levels as group 2 (n = 122). The PoPTH levels and ΔPTH were compared between the 2 groups. Receiver operating characteristic analysis was performed to determine the cutoff values for PoPTH and ΔPTH.
Results
The mean PoPTH level was significantly lower in group 1 compared with group 2 (18.6 ± 15.3 versus 32.3 ± 15.6 pg/mL, respectively; P < 0.0001). PoPTH values were within the normal range in 54% of the patients with hypocalcemia and 35% of those with symptomatic hypocalcemia. PoPTH <28 pg/mL or ΔPTH >45 were significantly associated with increased risk of post-thyroidectomy hypocalcemia (P = 0.0001). A ΔPTH >70%, PoPTH ≤15.5 pg/mL, and postoperative serum cCa concentrations<8.0 mg/dL significantly predicted symptomatic hypocalcemia (P = 0.009, P = 0.006, and P = 0.0001, respectively). The sensitivities of ΔPTH, PoPTH level, and postoperative serum cCa concentration to predict symptomatic hypocalcemia were 67%, 64%, and 100%, respectively.
Conclusion
Although PTH decline significantly correlates with symptomatic hypocalcemia, a considerable number of patients may experience hypocalcemic symptoms despite normal PoPTH levels. Analysis of serum Ca concentrations at 24 hours postoperatively help to achieve a more precise prediction of patients who bear a high risk for developing hypocalcemic symptoms.
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29
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Kim BW, Kim SY, Lee YS, Kim SM, Chang HS, Park CS. Parathyroid score can predict the duration of required calcium supplementation after total thyroidectomy. PLoS One 2017; 12:e0174088. [PMID: 28350886 PMCID: PMC5369690 DOI: 10.1371/journal.pone.0174088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 03/03/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Postoperative hypoparathyroidism is the most common complication after total thyroidectomy, owing to unintentional injury or decreased blood flow to the parathyroid glands. Prediction of postoperative hypoparathyroidism would be helpful for surgeons to manage postoperative hypocalcemia. In this study, we scored the discoloration of the parathyroid glands using a new parathyroid scoring system and evaluated the correlation between the parathyroid score and duration of required calcium supplementation after total thyroidectomy. METHODS A total of 316 patients undergoing total thyroidectomy between November 2009 and April 2010 were enrolled in this retrospective study. Parathyroid scoring was performed by one experienced surgeon. The status of each of the 4 parathyroid glands was classified as normal color (3 points), slightly discolored (2 points), dark discoloration (1 point), or loss of the gland (0 points), resulting in possible total scores of 0-12. Serum parathyroid hormone (PTH), serum calcium, and ionized calcium concentrations were measured at 2 hours, 2 weeks, 3 months, 6 months, and 1 year after surgery. Patients were also divided into three groups based on the duration of required calcium supplementation: no required supplementation (n = 260, 82.3%), required supplementation for <6 months (n = 38, 12%), and required supplementation for ≥6 months (n = 18, 5.75%). RESULTS Parathyroid scores were positively correlated with ionized PTH concentrations at 2 hours (r = 0.053, p < 0.001), 2 weeks (r = 0.056, p < 0.001), 3 months (r = 0.032, p<0.001), 6 months (r = 0.072, p < 0.001), and 1 year (r = 0.071, p < 0.001) after thyroidectomy. Parathyroid scores were significantly and inversely associated with the duration of required calcium supplementation (p = 0.001). CONCLUSIONS Parathyroid scores at the end of surgery might be helpful for predicting the degree of postoperative hypocalcemia after total thyroidetomy.
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Affiliation(s)
- Bup-Woo Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soo Young Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Sang Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Mo Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hang-Seok Chang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
| | - Cheong Soo Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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30
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Arer IM, Kus M, Akkapulu N, Aytac HO, Yabanoglu H, Caliskan K, Tarim MA. Prophylactic oral calcium supplementation therapy to prevent early post thyroidectomy hypocalcemia and evaluation of postoperative parathyroid hormone levels to detect hypocalcemia: A prospective randomized study. Int J Surg 2016; 38:9-14. [PMID: 28039060 DOI: 10.1016/j.ijsu.2016.12.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/08/2016] [Accepted: 12/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative hypocalcemia is the most common complication after total thyroidectomy. Postoperative parathyroid hormone (PTH) measurement is one of the methods to detect or prevent postoperative hypocalcemia. Prophylactic oral calcium supplementation is another method to prevent early postoperative hypocalcemia. The aim of this study is to detect the accurate timing of PTH and evaluate efficacy of routine oral calcium supplementation for postoperative hypocalcemia. METHODS A total of 106 patients were performed total thyroidectomy. Rotuine oral calcium supplementation was given to group 1 and no treatment to group 2 according to randomization. Serum calcium and PTH level of patients in group 2 at postoperative 6, 12 and 24 h and patients in both groups at postoperative day 7 were evaluated. Patients were compared according to age, sex, operation findings, serum calcium and PTH levels and symptomatic hypocalcemia. RESULTS Half of the patients (50%) were in group 1. Most of the patients were female (83%). The most common etiology of thyroid disease was multinodular goiter (64.1%). Oral calcium supplementation was given to 18 (33.9%) patients in group 2. Symptomatic hypocalcemia for group 1 and 2 was found to be 1.9 and 33.9% respectively (p < 0.05). No statistical difference can be observed regarding the timing of serum biomarkers. CONCLUSION Serum PTH levels at postoperative 12 and 24 h can predict early post-thyroidectomy hypocalcemia. Prophylactic oral calcium supplementation therapy can prevent early post-thyroidectomy hypocalcemia with advantages of being cost effective and safe.
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Affiliation(s)
- Ilker Murat Arer
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Murat Kus
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Nezih Akkapulu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Huseyin Ozgur Aytac
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Hakan Yabanoglu
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Kenan Caliskan
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
| | - Mehmet Akin Tarim
- Baskent University Adana Teaching and Research Center, Department of General Surgery, Adana, Turkey.
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Vidal Fortuny J, Belfontali V, Sadowski SM, Karenovics W, Guigard S, Triponez F. Parathyroid gland angiography with indocyanine green fluorescence to predict parathyroid function after thyroid surgery. Br J Surg 2016; 103:537-43. [PMID: 26864909 PMCID: PMC5067567 DOI: 10.1002/bjs.10101] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 11/05/2015] [Accepted: 12/10/2015] [Indexed: 12/02/2022]
Abstract
BACKGROUND Postoperative hypoparathyroidism remains the most common complication following thyroidectomy. The aim of this pilot study was to evaluate the use of intraoperative parathyroid gland angiography in predicting normal parathyroid gland function after thyroid surgery. METHODS Angiography with the fluorescent dye indocyanine green (ICG) was performed in patients undergoing total thyroidectomy, to visualize vascularization of identified parathyroid glands. RESULTS Some 36 patients underwent ICG angiography during thyroidectomy. All patients received standard calcium and vitamin D supplementation. At least one well vascularized parathyroid gland was demonstrated by ICG angiography in 30 patients. All 30 patients had parathyroid hormone (PTH) levels in the normal range on postoperative day (POD) 1 and 10, and only one patient exhibited asymptomatic hypocalcaemia on POD 1. Mean(s.d.) PTH and calcium levels in these patients were 3·3(1·4) pmol/l and 2·27(0·10) mmol/l respectively on POD 1, and 4·0(1.6) pmol/l and 2·32(0·08) mmol/l on POD 10. Two of the six patients in whom no well vascularized parathyroid gland could be demonstrated developed transient hypoparathyroidism. None of the 36 patients presented symptomatic hypocalcaemia, and none received treatment for hypoparathyroidism. CONCLUSION PTH levels on POD 1 were normal in all patients who had at least one well vascularized parathyroid gland demonstrated during surgery by ICG angiography, and none required treatment for hypoparathyroidism.
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Affiliation(s)
- J. Vidal Fortuny
- Thoracic and Endocrine SurgeryUniversity Hospitals of Geneva, 4 Rue Gabrielle Perret‐Gentil, 1211GenevaSwitzerland
| | - V. Belfontali
- Thoracic and Endocrine SurgeryUniversity Hospitals of Geneva, 4 Rue Gabrielle Perret‐Gentil, 1211GenevaSwitzerland
| | - S. M. Sadowski
- Thoracic and Endocrine SurgeryUniversity Hospitals of Geneva, 4 Rue Gabrielle Perret‐Gentil, 1211GenevaSwitzerland
| | - W. Karenovics
- Thoracic and Endocrine SurgeryUniversity Hospitals of Geneva, 4 Rue Gabrielle Perret‐Gentil, 1211GenevaSwitzerland
| | - S. Guigard
- Thoracic and Endocrine SurgeryUniversity Hospitals of Geneva, 4 Rue Gabrielle Perret‐Gentil, 1211GenevaSwitzerland
| | - F. Triponez
- Thoracic and Endocrine SurgeryUniversity Hospitals of Geneva, 4 Rue Gabrielle Perret‐Gentil, 1211GenevaSwitzerland
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