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Alharbi BA, Alareek LA, Aldhahri S, Alqaryan S, Al Essa M, Al-Qahtani K. Total Number of Identified Parathyroid Glands During Total Thyroidectomy and Its Relation to Postoperative Hypoparathyroidism. Cureus 2023; 15:e50597. [PMID: 38107216 PMCID: PMC10723786 DOI: 10.7759/cureus.50597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES To evaluate the correlation between the intraoperative number of identified parathyroid glands (PGs) and the risk of developing hypoparathyroidism postoperatively. Also, to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism. METHODS A retrospective study of 499 patients who underwent total thyroidectomy at two tertiary care institutions, King Saud University Medical City (KSUMC) and King Fahad Medical City (KFMC) in Riyadh, Saudi Arabia was included. Individual demographic characteristics with detailed clinical information were recorded, focusing mainly on operative reports for a total number of identified PGs intraoperatively and investigating the risk of developing hypoparathyroidism postoperatively. Factors such as age, gender, comorbidity, and number of excised and reimplanted parathyroid glands were investigated to determine the risks and prognostic factors in patients with postoperative hypoparathyroidism. RESULTS The findings from the analysis showed that the number of identified PGs intraoperatively had a positive correlation with a higher postoperative risk of developing hypoparathyroidism. For zero, one, two, three, and four identified PGs, the risk of hypoparathyroidism in one-hour parathyroid hormone level postoperative was 6.6%, 7.3%, 34.4%, 34.4%, and 17.2% respectively. CONCLUSION The greater the number of identified PGs intraoperatively, the less likely it was to prevent inadvertent hypoparathyroidism post-total thyroidectomy.
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Affiliation(s)
- Bushra A Alharbi
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Latefa A Alareek
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Saleh Aldhahri
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Saleh Alqaryan
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Mohammed Al Essa
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
| | - Khalid Al-Qahtani
- Otolaryngology - Head and Neck Surgery, Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical College, Riyadh, SAU
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Grubnik VV, Parfentiev RS, Grubnik YV, Grubnyk VV. Intraoperative indocyanine green angiography for predicting postoperative hypoparathyroidism. Surg Endosc 2023; 37:9540-9545. [PMID: 37721589 DOI: 10.1007/s00464-023-10466-3] [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: 06/23/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Postoperative hypocalcemia is a common complication of thyroidectomy. This problem is most often associated with accidental devascularization or excision of the parathyroid glands (PG). AIM Aim was to study near-infrared (NIR) fluorescent imaging with intraoperative PG indocyanine green (ICG) angiography to help identify and preserve PG during total thyroidectomy in order to avoid postoperative hypocalcemia. MATERIAL AND METHODS From 2017 to 2022, a total of 92 patients underwent total thyroidectomy at Odessa Regional Hospital. Indications for surgery were multinodular goiter (n = 42), thyroid cancer (n = 43), and Graves' disease (n = 7). By randomization all patients were divided into two groups: in the control group, 48 patients underwent standard total thyroidectomy, and in the main group, 44 patients underwent NIR-assisted total thyroidectomy with ICG angiography. Serum calcium and parathyroid hormone levels were compared between the two groups of patients in 1, 7-15 days after surgery and then 3, 6 months later. RESULTS In the control group, based on a visual assessment of the PG, autotransplantation of the PG was conducted in only five cases. In the second group, autotransplantation was performed in 16 patients. The transient postoperative hypocalcemia was observed in 8 patients of the control group (16, 70%) and in the 2 patients of ICG group (4, 50%) on 5-10 postoperative days. In the first group, 2 patients at 3 months after surgery had permanent hypocalcaemia. CONCLUSION NIR fluorescent imaging with intraoperative PG ICG angiography is a safe and an easily repeatable method. This technique provides improved detecting and assessment of the perfusion of the PG. The need for autotransplantation of the PG can be determined more objectively using ICG imaging than simple visualization.
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Affiliation(s)
- Volodymyr V Grubnik
- Odessa National Medical University, Dobrovolskoho Avenue 90, App. 78, Odesa, Ukraine
| | - Roman S Parfentiev
- Odessa National Medical University, Dobrovolskoho Avenue 90, App. 78, Odesa, Ukraine
| | - Yurii V Grubnik
- Odessa National Medical University, Dobrovolskoho Avenue 90, App. 78, Odesa, Ukraine
| | - Viktor V Grubnyk
- Odessa National Medical University, Dobrovolskoho Avenue 90, App. 78, Odesa, Ukraine.
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Rao SS, Rao H, Moinuddin Z, Rozario AP, Augustine T. Preservation of parathyroid glands during thyroid and neck surgery. Front Endocrinol (Lausanne) 2023; 14:1173950. [PMID: 37324265 PMCID: PMC10266226 DOI: 10.3389/fendo.2023.1173950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/13/2023] [Indexed: 06/17/2023] Open
Abstract
The parathyroid glands are situated in close proximity to the thyroid gland. They have an important endocrine function maintaining calcium and phosphate homeostasis in the body by the secretion of parathormone (PTH), which is responsible for this function. The parathyroid glands are commonly damaged during thyroid surgeries. This could lead to transient or permanent hypoparathyroidism in 30% of cases. Preservation of the parathyroid glands, is an important and integral part of thyroidectomy and other surgical interventions in the neck. The main principle underlying this is a thorough understanding of parathyroid anatomy in relation to the thyroid gland and other important structures in the area. There can also be significant variation in the anatomical location of the glands. Various techniques and methods have been described for parathyroid preservation. They include intraoperative identification utilizing indocyanine green (ICG) fluorescence, carbon nanoparticles, loupes, and microscopes. The techniques of surgery (meticulous capsular dissection), expertise, central compartment neck dissection, preoperative vitamin D deficiency, extent and type of thyroidectomy are the risk factors associated with damaged thyroids, inadvertent parathyroidectomy and subsequent hypoparathyroidism. Parathyroid Autotransplantation is a treatment option for inadvertent parathyroidectomy. Ultimately, the best way to assure normal parathyroid function is to preserve them in situ intraoperatively undamaged.
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Affiliation(s)
- Smitha S. Rao
- Department of Endocrine and Breast Surgery, Oncology, K.S. Hegde Medical Academy, Nitte University, Mangalore, India
| | - Himagirish Rao
- Department of Endocrine and General Surgery, St. John's National Academy of Health Sciences, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Zia Moinuddin
- Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Anthony P. Rozario
- Department of Endocrine and General Surgery, St. John's National Academy of Health Sciences, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Titus Augustine
- Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Dong Z, Liu W, Peng Y, Zhan X, Su Y, Diao C, Cheng R. Single inferior parathyroid autotransplantation during total thyroidectomy with bilateral central lymph node dissection for papillary thyroid carcinoma: a retrospective cohort study. World J Surg Oncol 2023; 21:102. [PMID: 36959661 PMCID: PMC10035247 DOI: 10.1186/s12957-023-02886-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/09/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Management of the inferior parathyroid gland using total thyroidectomy (TT) with central lymph node dissection (CLND) is still controversial. Therefore, we evaluated the safety and effectiveness of single inferior parathyroid autotransplantation. METHODS The clinical data of patients with papillary thyroid carcinoma (PTC) who underwent TT with bilateral CLND from January 2018 to December 2020 were collected. Quality of life (QoL) was assessed using the Chinese version of the EORTC QLQ-C30 and THYCA-QOL. The patients were divided into an autotransplantation group and a preservation group according to whether a single inferior parathyroid gland was transplanted. The incidence of permanent hypoparathyroidism, the number of resected central lymph nodes (CLNs), the rate of recurrence reoperation, the rate of radioactive iodine (RAI) treatment, and the QoL score were compared between the two groups. RESULTS A total of 296 patients were included in the study; there were 99 patients in the autotransplantation group and 197 in the preservation group. The incidence of permanent hypoparathyroidism was 3.0% (3/99) and 4.6% (9/197) in the autotransplantation and preservation groups, respectively (P = 0.532). The median number of resected CLNs was 12 (8-17) and 10 (6-14) in the autotransplantation and preservation groups, respectively (P = 0.015). No reoperations were performed for patients with CLN recurrence, and the rates of lateral lymph node (LLN) recurrence reoperation were 2.0% (2/99) and 3.6% (7/197) in the autotransplantation and preservation groups, respectively (P = 0.473). The RAI treatment rates were 12.1% (12/99) and 22.3% (44/197) in the autotransplantation and preservation groups, respectively (P = 0.034). A total of 276 questionnaires were recovered, including 84 in the autotransplantation group and 192 in the preservation group. The QoL of the two groups of patients is similar (P > 0.05). CONCLUSION Single inferior parathyroid autotransplantation during thyroidectomy can be used to prevent permanent hypoparathyroidism and can enable more extensive CLND.
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Affiliation(s)
- Zhizhong Dong
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wen Liu
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ying Peng
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiangxiang Zhan
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanjun Su
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Chang Diao
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ruochuan Cheng
- Department of Thyroid Surgery, Clinical Research Center for Thyroid Diseases of Yunnan Province, The First Affiliated Hospital of Kunming Medical University, Kunming, China.
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Pasieka JL, Wentworth K, Yeo CT, Cremers S, Dempster D, Fukumoto S, Goswami R, Houillier P, Levine MA, Pasternak JD, Perrier ND, Sitges-Serra A, Shoback DM. Etiology and Pathophysiology of Hypoparathyroidism: A Narrative Review. J Bone Miner Res 2022; 37:2586-2601. [PMID: 36153665 PMCID: PMC10364481 DOI: 10.1002/jbmr.4714] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/29/2022] [Accepted: 09/22/2022] [Indexed: 01/19/2023]
Abstract
The approach utilized a systematic review of the medical literature executed with specifically designed criteria that focused on the etiologies and pathogenesis of hypoparathyroidism. Enhanced attention by endocrine surgeons to new knowledge about parathyroid gland viability are reviewed along with the role of intraoperative parathyroid hormone (ioPTH) monitoring during and after neck surgery. Nonsurgical etiologies account for a significant proportion of cases of hypoparathyroidism (~25%), and among them, genetic etiologies are key. Given the pervasive nature of PTH deficiency across multiple organ systems, a detailed review of the skeletal, renal, neuromuscular, and ocular complications is provided. The burden of illness on affected patients and their caregivers contributes to reduced quality of life and social costs for this chronic endocrinopathy. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Janice L Pasieka
- Clinical Professor of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kelly Wentworth
- Assistant Adjunct Professor of Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Caitlin T Yeo
- Clinical Lecturer of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Serge Cremers
- Associate Professor of Pathology and Cell Biology and Medicine, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - David Dempster
- Professor of Clinical Pathology and Cell Biology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Seiji Fukumoto
- Specially Appointed Professor, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Ravinder Goswami
- Professor, Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Pascal Houillier
- Département de Physiologie, Professor of Physiology, Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Michael A Levine
- Professor Emeritus of Pediatrics and Medicine, University of Pennsylvania, Director, Center for Bone Health, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse D Pasternak
- Endocrine Surgery Section Head, Division of General Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nancy D Perrier
- Professor of Surgery, University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Section of Surgical Endocrinology, Houston, TX, USA
| | - Antonio Sitges-Serra
- Emeritus Professor, Universitat Autònoma de Barcelona, Endocrine Surgery, Hospital del Mar, Barcelona, Spain
| | - Dolores M Shoback
- Professor of Medicine, University of California, San Francisco, Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Hypoparathyroidism: State of the Art on Cell and Tissue Therapies. Int J Mol Sci 2021; 22:ijms221910272. [PMID: 34638612 PMCID: PMC8508771 DOI: 10.3390/ijms221910272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/16/2021] [Accepted: 09/22/2021] [Indexed: 12/12/2022] Open
Abstract
Hypoparathyroidism is an endocrine disorder characterized by low serum calcium levels, high serum phosphorus levels, and by inappropriate or absent secretion of the parathyroid hormone (PTH). The most common therapeutic strategy to treat this condition is hormone replacement therapy with calcium and vitamin D but, unfortunately, in the long term this treatment may not be sufficient to compensate for the loss of endocrine function. Glandular autotransplantation is considered the most effective technique in place of replacement therapy. Although it leads to excellent results in most cases, autotransplantation is not always possible. Allograft is a good way to treat patients who have not been able to undergo autograft, but this technique has limited success due to side effects related to tissue rejection. This therapy is supported by systemic immunosuppression, which leads to the onset of serious side effects in patients, with a risk of endocrine toxicity. Today, research on endocrine disorders is focused on discovering alternative graft therapies that can allow optimal results with the fewest possible side effects. In this review, we will make an update on the current state of the art about the cell and tissue therapy as treatment for hypoparathyroidism, to identify which type of therapeutic strategy could be valid for a future clinical use.
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Avgeri TC, Sideris G, Maragoudakis P, Papadopoulos I, Nikolopoulos T, Delides A. The long-term need for calcium supplementation after incidental parathyroidectomy. J Taibah Univ Med Sci 2021; 17:214-219. [PMID: 35592801 PMCID: PMC9073881 DOI: 10.1016/j.jtumed.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/22/2021] [Accepted: 08/02/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives Methods Results Conclusion
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Affiliation(s)
- Theodora-Carolina Avgeri
- National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 2nd Otolaryngology Department, Athens, Greece
- Corresponding address: National & Kapodistrian University of Athens, “Attikon” University Hospital, 2nd Otolaryngology Department, Rimini 1 Chaidari, Athens, 124 62, Greece.
| | - Giorgos Sideris
- National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 2nd Otolaryngology Department, Athens, Greece
| | - Pavlos Maragoudakis
- National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 2nd Otolaryngology Department, Athens, Greece
| | - Iordanis Papadopoulos
- National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 4th Department of Surgery, Athens, Greece
| | - Thomas Nikolopoulos
- National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 2nd Otolaryngology Department, Athens, Greece
| | - Alexander Delides
- National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 2nd Otolaryngology Department, Athens, Greece
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Qiu Y, Xing Z, Qian Y, Fei Y, Luo Y, Su A. Selective Parathyroid Autotransplantation During Total Thyroidectomy for Papillary Thyroid Carcinoma: A Cohort Study. Front Surg 2021; 8:683041. [PMID: 34262932 PMCID: PMC8274712 DOI: 10.3389/fsurg.2021.683041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/07/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose: The relationship between the selective parathyroid gland (PG) autotransplantation and hypoparathyroidism is still not completely clear. The aim was to ascertain whether the number of autotransplanted PGs affected the incidence of hypoparathyroidism and recovery of parathyroid function in the long-term for patients with papillary thyroid carcinoma (PTC). Methods: A retrospective cohort study included all patients with PTC who had underwent primary total thyroidectomy with central neck dissection between January 2013 and December 2017. The patients were divided into three groups (0, 1, and 2 PGs autotransplanted, respectively). Results: Of the 2,477 patients, 634 (25.6%) received no PG autotransplantation, 1,078 (43.5%) and 765 (30.9%) were autotransplanted 1 and 2 PGs, respectively, and the incidence of permanent hypoparathyroidism (>1 year) was 1.7%, 0.7%, and 0.4% (P = 0.0228). Both 1 or 2 PGs autotransplanted increased the incidence of transient biochemical hypoparathyroidism (odds ratio [OR], 1.567; 95% confidence interval [CI], 1.258-1.953; P < 0.0001; OR, 2.983; 95% CI, 2.336-3.810; P < 0.0001, respectively) but reduced the incidence of permanent hypoparathyroidism (OR, 0.373; 95% CI, 0.145-0.958; P = 0.0404; OR, 0.144; 95% CI, 0.037-0.560; P = 0.0052, respectively). Both 1 or 2 PGs autotransplanted did not independently influence the occurrence of hypocalcemia symptoms. Conclusion: Selective parathyroid autotransplantation is less likely to lead to post-operative symptomatic hypocalcemia, although it could lead to a transient decrease in parathyroid hormone. However, in the long run, it is still an effective strategy to preserve parathyroid function.
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Affiliation(s)
- Yuxuan Qiu
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China.,Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhichao Xing
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanfan Qian
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Fei
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Luo
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Anping Su
- Center of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
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Does number of autotransplanted parathyroid glands affects postoperative hypoparathyroidism and serum parathyroid hormone levels? Asian J Surg 2021; 45:117-124. [PMID: 33863630 DOI: 10.1016/j.asjsur.2021.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/09/2021] [Accepted: 03/24/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To investigate how number of autotransplanted parathyroid glands (PGs) affects the incidence of postoperative hypoparathyroidism and the recovery of parathyroid function. METHODS A systematic search was performed in the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. The evaluated indices included the incidence of postoperative transient and permanent hypoparathyroidism and parathyroid hormone (PTH) levels during follow-up. RESULTS Twenty articles with 7291 patients were included. A higher incidence of transient hypoparathyroidism was found in the PG autotransplantation group than in the preservation group (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.90, 2.96). However, there was no significant difference between the two groups regarding permanent hypoparathyroidism (OR: 1.17; 95% CI: 0.71, 1.91). Parathyroid hormone (PTH) levels in the PG autotransplantation group changed significantly more than the preservation group at postoperative 1-day and 1-month, but became similar at the 6-month, 1-year and 2-year follow-up. Autotransplantation of 2 and 3 PGs demonstrated a higher incidence of transient hypoparathyroidism than 1 PG (OR: 2.09; 95% CI: 1.41, 3.11 and OR: 9.70; 95% CI: 2.11, 44.39, respectively), but no significant difference was observed between the autotransplantation of 3 and 2 PGs (OR: 0.99; 95% CI: 0.03, 29.06). Additionally, the incidence of permanent hypoparathyroidism was not significantly different when different number of PGs was autotransplanted. CONCLUSIONS PG autotransplantation is an effective mid- and long-term strategy for the preservation of parathyroid function. Although transient hypoparathyroidism was positively correlated with the number of autotransplanted PGs, no remarkable correlation was observed for permanent hypoparathyroidism.
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Abstract
Currently, thyroid surgery is the most common and safe operation worldwide. However, thyroidectomy is still not free from the risks of complications and death due to the anatomical structure and physiological function particularity of the thyroid gland. Postoperative complications affect the life quality and life safety of patients after surgery. The common complications include hypoparathyroidism (HP), recurrent laryngeal nerve (RLN) injury, injury to the external branch of the superior laryngeal nerve (EBSLN), postoperative bleeding (PB), thoracic duct injury, laryngeal edema, tracheospasm, tracheal injury, and esophageal injury. A severe complication, such as dyspnea, asphyxia, or thyroid crisis, might cause the death of the patient. Therefore, every thyroid surgeon's responsibility is to remain alert and aware of the occurrence of various intraoperative and postoperative complications and exercise effective prevention and treatment. This is closely related to the advancement in thyroid disease research, the increase in local anatomy knowledge, the standardization of surgical approaches, the improvement in operating skills, the application of new technologies, and the emphasis on specialty training. In addition, many complications that effect patients are much better tolerated if the patient has appropriate expectations of what the complications are and how to treat them. Open communication between surgeon and patient optimizes the potential negative effects that complications may have on patients' quality of life. This paper discusses the prevention, recognition and therapy of intraoperative and postoperative complications in thyroid surgery.
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Affiliation(s)
- Shan Jin
- Department of General Surgery, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China.,Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Iwao Sugitani
- Department of Endocrine Surgery, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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11
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Sitges-Serra A. Etiology and Diagnosis of Permanent Hypoparathyroidism after Total Thyroidectomy. J Clin Med 2021; 10:jcm10030543. [PMID: 33540657 PMCID: PMC7867256 DOI: 10.3390/jcm10030543] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 12/19/2022] Open
Abstract
Postoperative parathyroid failure is the commonest adverse effect of total thyroidectomy, which is a widely used surgical procedure to treat both benign and malignant thyroid disorders. The present review focuses on the scientific gap and lack of data regarding the time period elapsed between the immediate postoperative period, when hypocalcemia is usually detected by the surgeon, and permanent hypoparathyroidism often seen by an endocrinologist months or years later. Parathyroid failure after thyroidectomy results from a combination of trauma, devascularization, inadvertent resection, and/or autotransplantation, all resulting in an early drop of iPTH (intact parathyroid hormone) requiring replacement therapy with calcium and calcitriol. There is very little or no role for other factors such as vitamin D deficiency, calcitonin, or magnesium. Recovery of the parathyroid function is a dynamic process evolving over months and cannot be predicted on the basis of early serum calcium and iPTH measurements; it depends on the number of parathyroid glands remaining in situ (PGRIS)—not autotransplanted nor inadvertently excised—and on early administration of full-dose replacement therapy to avoid hypocalcemia during the first days/weeks after thyroidectomy.
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12
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Zhang Z, Xia F, Wang W, Jiang B, Yao L, Huang Y, Li X. Ambulatory thyroidectomy is safe and beneficial in papillary thyroid carcinoma: Randomized controlled trial. Head Neck 2020; 43:1116-1121. [PMID: 33247492 DOI: 10.1002/hed.26557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/11/2020] [Accepted: 11/20/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Currently, no randomized controlled trial has been performed to investigate the safety profiles, economic benefit and mental health of ambulatory thyroidectomy in patients with papillary thyroid carcinoma (PTC). METHODS Patients diagnosed with PTC were enrolled in this study and were randomly assigned to ambulatory group and control group. The safety profiles, economic benefit and mental health were investigated. RESULTS Four hundred and eleven patients completed the study. There was no significant difference in demographic or tumor index. The incidence of complications was not significantly different (P = .631). The economic cost was significantly lower (P < .001) and hospitalization was significantly shorter (P < .001) in ambulatory group. No significant difference was shown in depression (P = .758) and stress disorder (P = .390). However, the ambulatory group showed a higher point of anxiety (P < .001). CONCLUSION The ambulatory thyroidectomy is safe in patients with PTC, with significant benefits of economic cost and hospitalization.
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Affiliation(s)
- Zeyu Zhang
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Fada Xia
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wenlong Wang
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Bo Jiang
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Lei Yao
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yun Huang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Xinying Li
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
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13
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Tartaglia F, Giuliani A, Sorrenti S, Ulisse S. Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews. J Minim Access Surg 2020; 16:315-322. [PMID: 32978350 PMCID: PMC7597888 DOI: 10.4103/jmas.jmas_123_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: We compared two systematic reviews, one focusing on transoral video-assisted thyroidectomy (TOVAT) and the other on minimally invasive video-assisted thyroidectomy (MIVAT), to highlight the pros and cons that can determine the choice of one or the other procedure. Materials and Methods: PubMed, Scopus and ISI Web of Science databases were searched for relevant articles published from 2000 to June 2018. Both searches were performed using the same keywords. All articles describing human surgical case series of any size were included, while the following were excluded: articles published in languages other than English, case reports, reviews, early cadaver and animal studies and old reports of cases now included in more recent works. Application of the above selection criteria yielded 151 articles on TOVAT and 246 on MIVAT. Of these, 34 articles were selected for inclusion in the present study: 17 for the TOVAT group and 17 for the MIVAT group. The comparison was made considering the most common variables used in evaluating thyroid surgery procedures. The statistical methods used were Cohen's delta, Student's t-test and the non-parametric Mann–Whitney U-test. Results: The variable 'operative time' was found to show a very large effect size, and 'hospital stay' also differed significantly between the MIVAT and TOVAT groups. Conclusions: TOVAT and MIVAT should not be considered in competition with each other, but seen simply as alternative choices. Both appear to be safe methods, comparable in terms of post-operative complications, although the main reason for using TOVAT seems to be purely aesthetic.
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Affiliation(s)
| | - Alessandro Giuliani
- Department of Environment and Health, Superior Institute of Health, Rome, Italy
| | - Salvatore Sorrenti
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Salvatore Ulisse
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
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14
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Melikyan A, Menkov A. Postoperative Hypoparathyroidism: Prognosis, Prevention, and Treatment (Review). Sovrem Tekhnologii Med 2020; 12:101-108. [PMID: 34513060 PMCID: PMC8353683 DOI: 10.17691/stm2020.12.2.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 12/19/2022] Open
Abstract
This review summarizes the results of studies concerning the problem of post-surgical hypoparathyroidism, a common complication of thyroid gland surgery, decreasing the quality of life in patients and, in some cases, leading to disability. A search for publications was carried out in electronic databases Web of Science, Scopus, Academic Search Complete (EBSCO), eLIBRARY, using keywords. The search depth was 7-10 years. Prevalence of post-surgical hypoparathyroidism was evaluated, the pathogenetic causes of the disease development, its clinical forms, methods of diagnosis and treatment were studied. It has been found that there is no single algorithm for analyzing the prognostic factors for the development of this pathological condition. It is emphasized that drug therapy of post-surgical hypoparathyroidism has a number of adverse effects. Therefore, the issues of prevention and surgical correction are of particular relevance. However, controversial opinions of contemporary authors about their clinical effectiveness determine the scientific and practical significance of further research on these issues.
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Affiliation(s)
- A.A. Melikyan
- Surgeon, Nizhny Novgorod Regional Clinical Hospital named after N.A. Semashko, 190 Rodionova St., Nizhny Novgorod, 603126, Russia
| | - A.V. Menkov
- Professor, Department of General, Operative Surgery and Topographic Anatomy named after A.I. Kozhevnikov, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
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Ponce de León-Ballesteros G, Velázquez-Fernández D, Hernández-Calderón FJ, Bonilla-Ramírez C, Pérez-Soto RH, Pantoja JP, Sierra M, Herrera MF. Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands. World J Surg 2019; 43:1728-1735. [PMID: 30919027 DOI: 10.1007/s00268-019-04987-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation. PATIENTS AND METHODS We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05. RESULTS Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02). CONCLUSIONS Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).
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Affiliation(s)
- Guillermo Ponce de León-Ballesteros
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico
| | - David Velázquez-Fernández
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico
| | - F Javier Hernández-Calderón
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico
| | - Carlos Bonilla-Ramírez
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico
| | - Rafael H Pérez-Soto
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico
| | - Juan Pablo Pantoja
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico
| | - Mauricio Sierra
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico
| | - Miguel F Herrera
- Service of Endocrine and Advanced Laparoscopic Surgery/Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Vasco de Quiroga 15, Seccion XVI, Tlalpan, 14000, Mexico City, Mexico.
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16
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Deffain A, Scipioni F, De Rienzo B, Allal S, Castagnet M, Kraimps JL, Donatini G. Preoperative vitamin D levels do not relate with the risk of hypocalcemia following total thyroidectomy. A cohort study. MINERVA CHIR 2019; 74:14-18. [PMID: 30646675 DOI: 10.23736/s0026-4733.18.07456-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypocalcemia is the most common complication following total thyroidectomy. Few factors may relate with increased risk of postoperative hypocalcemia. Preoperative vitamin D values have been evaluated in few studies, but reports present conflicting data. Aim of our study is to evaluate the association of preoperative vitamin D values and hypocalcemia following total thyroidectomy. METHODS A retrospective analysis of patients undergoing total thyroidectomy in our department of endocrine surgery between November 2012 and November 2015 was performed. RESULTS Mean age of patients was 56.2 years (±14.0) and sex ratio (F:M) was 4.3:1. Sixty-four patients (17.4%) had preoperative vitamin D insufficiency (x<25 nmol/L), 138 patients (37.5%) vitamin D deficiency (25<x<50 nmol/L) and 166 patients (45.1%) vitamin D sufficiency (x>50 nmol/L). Following total thyroidectomy for both benign and malignant pathology, 66 patients (17.9%) had symptomatic hypocalcemia (x<2.0 mmol/L) requiring medical treatment (group 1), 64 patients (17.4%) biochemical hypocalcemia (2<x<2.1 mmol/L) not requiring treatment (group 2) and 238 patients (64.7%) had normal levels (x>2.1 mmol/L, group 3). Mean postoperative PTH value was 25.4 pg/ml (range 2-61). No statistical correlation between postoperative serum calcium and preoperative vitamin D values (R=-0.001, P=0.9849) was found nor associations were found regarding age, sex, type of thyroid disease or BMI. CONCLUSIONS In our cohort of patients, preoperative vitamin D levels were not associated with a higher risk of hypocalcemia following total thyroidectomy. Postoperative PTH appears to be the most sensible item to predict the risk of postoperative symptomatic hypocalcemia.
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Affiliation(s)
- Alexis Deffain
- Department of General and Endocrine Surgery, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Federica Scipioni
- Department of General and Endocrine Surgery, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Beatriz De Rienzo
- Department of General and Endocrine Surgery, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Sana Allal
- Department of General and Endocrine Surgery, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Marion Castagnet
- Department of General and Endocrine Surgery, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Jean-Louis Kraimps
- Department of General and Endocrine Surgery, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Gianluca Donatini
- Department of General and Endocrine Surgery, CHU Poitiers, University of Poitiers, Poitiers, France -
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Wang B, Zhu CR, Liu H, Wu J. The effectiveness of parathyroid gland autotransplantation in preserving parathyroid function during thyroid surgery for thyroid neoplasms: A meta-analysis. PLoS One 2019; 14:e0221173. [PMID: 31412080 PMCID: PMC6693848 DOI: 10.1371/journal.pone.0221173] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/31/2019] [Indexed: 12/13/2022] Open
Abstract
Objective We conducted this meta-analysis to assess the effectiveness of parathyroid gland autotransplantation in preserving parathyroid function during thyroid surgery for thyroid neoplasms. Methods We conducted a search by using PubMed, Embase, and the Cochrane Library electronic databases for studies that were published up to January 2019. The reference lists of the retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the overall combined risk estimates. Publication bias was evaluated with a funnel plot using Egger’s and Begg’s tests. Results A total of 25 independent studies involving 10,531 participants were included in the meta-analysis. Compared with patients who did not undergo parathyroid gland autotransplantation, the overall pooled relative risks for patients who underwent parathyroid gland autotransplantation were 1.75 (95% CI: 1.51–2.02, p<0.001) for postoperative hypoparathyroidism, 1.72 (95% CI: 1.45–2.05, p<0.001) for protracted hypoparathyroidism, 1.06 (95% CI: 0.44–2.58, p = 0.894) and 0.71 (95% CI: 0.22–2.29, p = 0.561) for biochemical hypoparathyroidism and biochemical hypocalcemia at 6 months postoperatively, respectively, and 1.89 (95% CI: 1.33–2.69, p<0.001) and 0.22 (95% CI: 0.09–0.52, p = 0.001) for biochemical hypoparathyroidism and biochemical hypocalcemia at 12 months postoperatively, respectively. The pooled relative risks for patients who underwent one parathyroid gland autotransplantation and patients who underwent two or more parathyroid gland autotransplantations were 1.71 (95% CI: 1.25–2.35, p = 0.001) and 2.22 (95% CI: 1.43–3.45, p<0.001) for postoperative hypoparathyroidism, 1.09 (95% CI: 0.59–2.01, p = 0.781) and 0.55 (95% CI: 0.16–1.87, p = 0.341) for hypoparathyroidism at 6 months postoperatively compared with those of patients who did not undergo parathyroid gland autotransplantation. Conclusions Parathyroid gland autotransplantation is significantly associated with increased risk of postoperative and protracted hypoparathyroidism, and the number of autoplastic parathyroid glands is positively correlated with the incidence of postoperative hypoparathyroidism.
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Affiliation(s)
- Bin Wang
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Chun-Rong Zhu
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
- Department of Chemistry, School of Basic Medical Science, North Sichuan Medical College, Nanchong, China
| | - Hong Liu
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Jian Wu
- Department of Thyroid and Breast Surgery, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
- * E-mail:
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18
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Maturo A, Tromba L, De Anna L, Carbotta G, Livadoti G, Donello C, Falbo F, Galiffa G, Esposito A, Biancucci A, Carbotta S. Incidental thyroid carcinomas. A retrospective study. G Chir 2019; 38:94-101. [PMID: 28691675 DOI: 10.11138/gchir/2017.38.2.094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM The aim of the present study is to report our series of incidental thyroid carcinomas in the last 15 years and their follow-up, discussing therapeutics indications and surgical choices. PATIENTS AND METHODS We have considered 1793 patients operated on Surgical Sciences Department of "Sapienza" University of Rome from January 1, 2001 to December 31, 2015. The study was conducted on 83 totally thyroidectomized patients with a real incidental thyroid carcinoma, by clinical, laboratory and instrumental controls. Whole-body scan was the most important test in postoperative evaluation. RESULTS In our series, the incidence of incidental carcinomas was 4.62%. Compared to the total number of cancer patients, the percentage is 21,9%. In 15.66% of cases there was multifocality and in 7.23% also bilaterality. Regarding the histological type, in all cases they were papillary carcinoma. The size of the neoplastic lesions ranged from a minimum of 3 to a maximum of 10 mm. Whole-body scan revealed lymph node metastasis in 57.69% of patients. DISCUSSION Comparing these data with our previous studies we have seen a significant increase in incidence of incidental thyroid carcinomas over the years. Our therapeutical choice is total thyroidectomy and complection thyroidectomy after lobectomy, because of a relevant percentage of multifocality and/or bilaterality of these tumors. Many Authors on the contrary prefer a more conservative approach invoking the good prognosis of these tumors. The 57.69% of lymph node metastasis at postoperative whole-body scan comfort us in our setting. CONCLUSION Incidental thyroid carcinomas are not uncommon. We consider only tumors until 1 cm in diameter. Multifocality and bilaterality are often present such as occult lymph node metastasis. Our therapeutical choice is total thyroidectomy in order to conduct a proper follow-up.
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19
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Chiang FY, Lee KD, Tae K, Tufano RP, Wu CW, Lu IC, Chang PY, Lin YC, Huang TY. Comparison of hypocalcemia rates between LigaSure and clamp-and-tie hemostatic technique in total thyroidectomies. Head Neck 2019; 41:3677-3683. [PMID: 31347742 DOI: 10.1002/hed.25884] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/10/2019] [Accepted: 07/11/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Postoperative hypocalcemia (PH) is a serious complication after total thyroidectomy. This study aimed to compare PH rates between LigaSure Small Jaw (LSJ) and clamp-and-tie hemostatic technique in patients undergoing total thyroidectomy. METHODS Four hundred twenty patients were divided into two groups: group L (210 patients) performed with LSJ and group C (210 patients) with clamp-and-tie technique. Serum ionized calcium (iCa) was measured before and 12, 24, 48, 72 hours after surgery. PH was defined as iCa lower than 4.2 mg/dL in at least two measurements. RESULTS There was no significant difference between groups in sex, age, extent of surgery, pathology, and the strategy of intraoperative management of parathyroid glands (PG). The PH rate was significantly lower in group L compared to group C (22.9% vs 32.4%, P = .03). CONCLUSIONS Compared to clamp-and-tie technique, LigaSure is superior to decrease PH rate after total thyroidectomy.
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Affiliation(s)
- Feng-Yu Chiang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kang Dae Lee
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Kosin University, Busan, South Korea
| | - Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Ralph P Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Che-Wei Wu
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Cheng Lu
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pi-Ying Chang
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Yen Huang
- Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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20
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Predicting transient hypocalcemia in patients with unplanned parathyroidectomy after thyroidectomy. Am J Otolaryngol 2019; 40:504-508. [PMID: 31027850 DOI: 10.1016/j.amjoto.2019.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/08/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the utility of rapid parathyroid hormone (PTH) values in predicting transient post-operative hypocalcemia in patients with unplanned parathyroidectomy during total or completion thyroidectomy. METHODS All patients who underwent total or completion thyroidectomy between January 2010 and January 2015 were reviewed. Incidences of post-operative hypocalcemia were compared in patients with and without unplanned parathyroidectomy. Unplanned parathyroidectomy was defined as intra-operative incidental or intentional parathyroidectomy. Logistic regression assessed for predictors of hypocalcemia and optimum amount of calcium supplementation. RESULTS Thirty-eight (13.6%) patients had evidence of incidental parathyroidectomy and 39/280 (13.9%) patients had parathyroid autotransplantation intra-operatively. Central neck dissection and malignancy were identified as risk factors for unplanned parathyroidectomy (p = 0.001, p = 0.060). Patients with unplanned parathyroidectomy were more likely to have hypocalcemia (p = 0.002) and hypoparathyroidism (p < 0.0005). PTH value was the only significant predictor of hypocalcemia in these patients. In patients with a post-operative PTH of ≤15, initial calcium supplementation ≥ 1000 mg decreased the risk of hypocalcemia (p < 0.05). CONCLUSION Post-operative PTH value predicts hypocalcemia in patients undergoing total and completion thyroidectomy with unplanned parathyroidectomy. In patients with a post-operative PTH < 15, initial calcium supplementation with ≥1000 mg of elemental calcium is recommended.
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21
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Attard A, Paladino NC, Lo Monte AI, Falco N, Melfa G, Rotolo G, Rizzuto S, Gulotta E, Salamone G, Bonventre S, Scerrino G, Cocorullo G. Skip metastases to lateral cervical lymph nodes in differentiated thyroid cancer: a systematic review. BMC Surg 2019; 18:112. [PMID: 31074393 PMCID: PMC7402576 DOI: 10.1186/s12893-018-0435-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/29/2018] [Indexed: 12/27/2022] Open
Abstract
Papillary thyroid carcinoma is a slow-growing cancer with a generally good prognosis that sometimes have an aggressive behaviour. Metastases to neck lymph nodes is the first step of the diffusion. The central neck compartment is involved most commonly. The ipsilateral lateral neck compartments are usually involved afterwards, and the involvement of the contralateral one is considered a quite rare occurrence. In more rare cases, metastases to lateral neck compartment without central lymph node metastasis (so called “skip metastases”) could be observed. Aim of this literature review study is to analyse the average incidence, pattern and risk factors of this occurrence. This study was performed according to PRISMA criteria. A final selection of 13 articles published in English language from 1997 to 2017 was performed. Any research article, review or meta-analysis was taken into consideration. Research was expanded considering the related references of articles. The incidence of skip metastases ranged from 1.6 to 21.8%. Risk factors such as age > 45 years, size < 5 mm and tumor located in the upper pole or isthmus of thyroid gland were found. Due to the frequency of skip metastases in thyroid cancer, a careful preoperative examination of lateral lymph nodes should be necessary.
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Affiliation(s)
- Andrea Attard
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Nunzia Cinzia Paladino
- Unit of General, Endocrine and Metabolic Surgery, CHU AP-HM Hôpital de la Conception (Marseille), 147 Boulevard Baille, 13385, Marseille cedex, France
| | - Attilio Ignazio Lo Monte
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Nicola Falco
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Giuseppina Melfa
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Giulia Rotolo
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Stefano Rizzuto
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Eliana Gulotta
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Giuseppe Salamone
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Sebastiano Bonventre
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
| | - Gregorio Scerrino
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy.
| | - Gianfranco Cocorullo
- Policlinico "P. Giaccone", Department of general emergency and transplant surgery, Unit of general and emergency surgery, Palermo, Italy
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Kong DD, Wang W, Wang MH. Superior parathyroid blood supply safety in thyroid cancer surgery: A randomized controlled trial. Int J Surg 2019; 64:33-39. [PMID: 30872176 DOI: 10.1016/j.ijsu.2019.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/20/2019] [Accepted: 02/28/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND To evaluate the clinical value of a technique protecting blood supply to the superior parathyroid during surgery for thyroid cancer. MATERIALS AND METHODS The observation group comprised 113 patients admitted to our hospital during the period from January 1, 2016 to December 31, 2016, who were diagnosed with thyroid cancer and treated by surgery using a technique protecting blood supply to the superior parathyroid. The control group comprised 113 patients diagnosed with thyroid cancer who were treated by surgery using the conventional technique. Postoperative parathyroid function damage and blood calcium levels were assessed in both groups. RESULTS The incidences of hypocalcemia and low parathyroid hormone in the observation and control groups were 10.6% and 31.9%, and 14.2% and 35.4%, respectively. The relative risk (RR) of the control group was increased (RR = 3.009 for control; RR = 2.493 for observation). Univariate logistic regression analysis showed that postoperative temporary hypoparathyroidism was associated with lymph node metastasis, use of the above protective technique, and tumor size [(odds ratio, OR = 1.936, 95%CI 1.029-3.643; P = 0.041), (OR = 0.301, 95%CI 0.156-0.579; P = 0.001) and (OR = 2.022, 95%CI 1.089-3.756; P = 0.026), respectively]. Postoperative temporary hypoparathyroidism was also associated with lymph node dissection (Bilateral vs. No, P = 0.003) and T classification (T3 vs. T1, P = 0.034). Multivariate logistic regression analysis showed that, after including significant independent variables of univariate logistic regression analysis (e.g., lymph node metastasis, lymph node resection, protective technique, tumor size, and T classification), the protective technique was a factor supporting reduced incidence of postoperative temporary hypoparathyroidism (OR = 0.325, 95% CI 0.163-0.648; P = 0.001). CONCLUSION Application of a technique protecting blood supply to the superior parathyroid during thyroid cancer surgery effectively reduced the incidence of postoperative temporary hypoparathyroidism. However, because of the imbalance in lymph node dissection between the two groups, confounding factors could not be completely eliminated, and matched pair analysis is needed to eliminate these factors.
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Affiliation(s)
- De-Di Kong
- Department of Thyroid and Breast Surgery, Jining No. 1 People's Hospital, No. 6, Jiankang Road, Jiningy, 272011, Shandong, People's Republic of China.
| | - Wei Wang
- Department of Thyroid and Breast Surgery, Jining No. 1 People's Hospital, No. 6, Jiankang Road, Jiningy, 272011, Shandong, People's Republic of China.
| | - Mei-Hong Wang
- Department of ICU, Jining No. 1 People's Hospital, No. 6, Jiankang Road, Jiningy, 272011, Shandong, People's Republic of China.
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Bai B, Chen Z, Chen W. Risk factors and outcomes of incidental parathyroidectomy in thyroidectomy: A systematic review and meta-analysis. PLoS One 2018; 13:e0207088. [PMID: 30412639 PMCID: PMC6226183 DOI: 10.1371/journal.pone.0207088] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 10/24/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction Postoperative hypocalcemia is the most common complication of thyroidectomy. Incidental parathyroidectomy (IP) was thought to be associated with postoperative hypocalcemia. However, according to previous studies, the risk factors and clinical outcomes of IP remain controversial. Methods Eligible studies were searched in databases including PubMed, Web of Science, and EMBASE from January 1990 to September 2017. Articles focusing on the relationship between IP and postoperative hypocalcemia were included. The risk of publication bias was assessed using Begg’s test and Egger’s regression asymmetry test. Pooled analysis was performed to evaluate the effect of IP on postoperative hypocalcemia and related risk factors. Sensitivity analysis was also conducted to test the stability of our results. The effects of hypocalcemia type, permanent definition, IP incidence, total thyroidectomy, and malignancy operation were also examined using a further subgroup analysis. Results Thirty-five studies were finally included in the analysis after an exhaustive literature review. Pathology data demonstrate that incidental parathyroidectomy occurred in various locations: intrathyroidal (2.2–50.0%), intracapsular (16.7–40.0%) and extracapsular (15.7–81.1%) regions. Overall, the analysis found that malignancy (RR = 1.60, 95% CI: 1.27 to 2.02; p< 0.0001), central neck dissection (RR = 2.35, 95% CI: 1.47 to 3.75; p = 0.0004), total thyroidectomy (RR = 1.42, 95% CI: 1.20 to 1.67; p< 0.0001) and reoperation (RR = 1.81, 95% CI: 1.20 to 2.75; p = 0.005) were significant risk factors of IP in thyroid surgery. There was an obvious effect of IP on temporary/permanent (RR = 1.59, 95% CI: 1.37 to 1.84; p< 0.0001) and permanent (RD = 0.0220, 95% CI: 0.0069 to 0.0370; p = 0.0042) postoperative hypocalcemia. Sensitivity analysis showed that these results were robust. The subgroup analysis found that IP played a significant role in both biochemical and clinical hypocalcemia in thyroidectomy (p < 0.0001 and p = 0.0003, separately). The association of IP and permanent hypocalcemia using different definitions (6 months or more than 12 months) was also confirmed by the analysis. IP increased the incidence of temporary/permanent and permanent hypocalcemia for cases undergoing total thyroidectomy (40.4% vs 24.8% and 5.8% vs 1.4%, respectively). Thyroidectomy with IP was associated with more permanent hypocalcemia (RR = 3.10, 95% CI: 2.01 to 4.78; p< 0.0001) in malignant cases but was not associated with temporary/permanent hypocalcemia. Conclusions Malignancy, central neck dissection, total thyroidectomy and reoperation were found to be significant risk factors of IP. IP increases the risk of postoperative hypocalcemia after thyroidectomy. We recommend a more meticulous intraoperative identification of parathyroid gland in thyroidectomy to reduce IP, particularly for total thyroidectomy and malignancy cases.
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Affiliation(s)
- Binglong Bai
- Department of General Surgery (Thyroid Center), Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P. R. China
| | - Zhiye Chen
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China
| | - Wuzhen Chen
- Department of Surgical Oncology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P. R. China
- * E-mail:
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Stevenson A, Mihai R. Patients' views about parathyroid transplantation for post-thyroidectomy hypoparathyroidism. Langenbecks Arch Surg 2018; 403:623-629. [PMID: 29971614 PMCID: PMC6132637 DOI: 10.1007/s00423-018-1693-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/26/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Permanent hypoparathyroidism (hypoPT) represents the most common postoperative complication associated with total thyroidectomy. Current treatment relies on high-dose calcium and/or vitamin D supplementation, but often this is insufficient and some patients remain symptomatic. Parathyroid allotransplantation is a new therapeutic option described recently in the literature. This study aims to investigate the patients' acceptability of parathyroid transplantation as a potential new treatment for hypoPT. METHOD Online survey of members of HypoParaUK, a support group for individuals affected by hypoPT. RESULTS Responses were received from 252 hypoPT patients. Majority declared to experience severe symptoms despite regular medical treatment. On a severity scale of 0-5, symptoms that were most troublesome were fatigue (3.8), low sense of well-being (3.5), and numbness/tingling (2.9). On a scale of 0-10, on average, their current quality of life (QoL) was 5 ± 3 and they expected this would improve to 7 ± 2 with correction of their hypoPT. Forty-four percent of patients were extremely interested in a potential technique involving intramuscular injection of parathyroid cell suspension compared to just 14% who were interested in the more invasive procedure of implantation of a parathyroid allograft into the forearm. The main concerns expressed were related to the possible need for immunosuppressive therapy. CONCLUSION Patients with severe symptomatic hypoPT seem interested to consider participation in a clinical trial exploring the feasibility and success rate of parathyroid transplantation.
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Affiliation(s)
| | - Radu Mihai
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
- Blenheim Head & Neck Unit, Churchill Cancer Centre, Old Road, Headington, Oxford, OX3 7LE, UK.
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Iorio O, Petrozza V, De Gori A, Bononi M, Porta N, De Toma G, Cavallaro G. Parathyroid Autotransplantation During thyroid Surgery. Where we are? A Systematic Review on Indications and Results. J INVEST SURG 2018; 32:594-601. [PMID: 29658811 DOI: 10.1080/08941939.2018.1441344] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Introduction: Hypoparathyroidism still represents an important concern in thyroid surgery. Careful dissection with identification and preservation of parathyroid glands in situ remains the best way to maintain gland vitality and avoid post-operative failure. Nevertheless, parathyroid glands are still inadvertently removed in up to 11% of cases. Parathyroid autotransplantation may represent the only way to restore parathyroid gland functionality in case of inadvertent removal or devascularization during thyroid surgery. Despite this, there is still no agreement on the effectiveness of this procedure. The present systematic review is focused on the mainly debated matters regarding the procedure, indications, technique and results. Methods: This review has been carried out according to PRISMA statement and checklist. The research item was: (((parathyroid autotransplantation[Title]) OR parathyroid reimplantation[Title]) NOT hyperparathyroidism[Title]) AND english[Language]. Results: A total of 31 studies have been found according to limitations already described, reporting from 4 to 890 procedures, with a total amount of 4088 PA. Among these studies, there are only 7 prospective case-series evaluations, 2 prospective randomized trials, while the other 22 studies are retrospective evaluations. The main concerns are: when and how to perform autotransplantation; in which anatomical site; which result to be expected, and how to manage and control the graft. Conslusions: Parathyroid autotransplantatin is an important tool to avoid or minimize the risk for hypoparathyroidism following thyroid surgery in selected cases. Parathormone assay can help the surgeon to determine when reimplantation is indicated or not. Further studies could theoretically give definitive results.
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Affiliation(s)
- Olga Iorio
- Department of Surgery, Casa di Cura "Città di Aprilia" , Aprilia ( LT ), Italy
| | - Vincenzo Petrozza
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University , Rome , Italy.,Pathology Unit, I.C.O.T. Hospital , Latina , Italy
| | | | - Marco Bononi
- Department of Surgery "P. Valdoni", Sapienza University , Rome , Italy
| | - Natale Porta
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University , Rome , Italy.,Pathology Unit, I.C.O.T. Hospital , Latina , Italy
| | - Giorgio De Toma
- Department of Surgery "P. Valdoni", Sapienza University , Rome , Italy
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Su A, Gong Y, Wu W, Gong R, Li Z, Zhu J. Does the number of parathyroid glands autotransplanted affect the incidence of hypoparathyroidism and recovery of parathyroid function? Surgery 2018; 164:S0039-6060(17)30928-5. [PMID: 29398031 DOI: 10.1016/j.surg.2017.12.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/08/2017] [Accepted: 12/23/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The relationship between the number of parathyroid glands autotransplanted and hypoparathyroidism as well as recovery of parathyroid function is not understood fully. The aim was to ascertain whether the number of autotransplanted glands affected the incidence of hypoparathyroidism and recovery of parathyroid function in long-term follow-up after thyroidectomy. METHODS A retrospective cohort study included all patients with papillary thyroid carcinoma who underwent first-time total thyroidectomy with central neck dissection between June 2012 and June 2015. The patients were divided into 4 groups (0, 1, 2, and 3) on the basis of the number of parathyroid glands autotransplanted. RESULTS Of the 766 patients, 283 (36.9%) had no gland autotransplanted, and 373 (48.7%), 97 (12.7%), and 13 (1.7%) had 1, 2, and 3 glands autotransplanted, respectively. More lymph nodes and more metastatic ones in the central compartment were retrieved in groups 2 and 3 (P < .05). With increasing number of autotransplanted glands, the incidence of transient hypoparathyroidism was 26.1%, 36.2%, 52.6%, and 84.6% (P < .05), and the incidence of permanent hypoparathyroidism was 1.8%, 1.1%, 1.0%, and 0% (P > .05). The recovery rates of serum parathyroid hormone concentration were 84.7%, 82.2%, 82.0%, and 79.2% after 2-year follow-up (P > .05). CONCLUSION Autotransplantation is an effective strategy for restoration of parathyroid function. Transient hypoparathyroidism is positively correlated to the number of autotransplanted parathyroid glands during total thyroidectomy with central neck dissection. There is no increase in permanent hypoparathyroidism in patients with a higher number of autotransplanted glands, despite more extensive lymph node disease. (Surgery 2018;161:XXX-XXX.).
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Affiliation(s)
- Anping Su
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yanping Gong
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wenshuang Wu
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Rixiang Gong
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhihui Li
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jingqiang Zhu
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Maeda SS, Moreira CA, Borba VZC, Bandeira F, Farias MLFD, Borges JLC, Paula FJAD, Vanderlei FAB, Montenegro FLDM, Santos RO, Ferraz-de-Souza B, Lazaretti-Castro M. Diagnosis and treatment of hypoparathyroidism: a position statement from the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:106-124. [PMID: 29694629 PMCID: PMC10118685 DOI: 10.20945/2359-3997000000015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/14/2017] [Indexed: 11/23/2022]
Abstract
Objective To present an update on the diagnosis and treatment of hypoparathyroidism based on the most recent scientific evidence. Materials and methods The Department of Bone and Mineral Metabolism of the Sociedade Brasileira de Endocrinologia e Metabologia (SBEM; Brazilian Society of Endocrinology and Metabolism) was invited to prepare a document following the rules set by the Guidelines Program of the Associação Médica Brasileira (AMB; Brazilian Medical Association). Relevant papers were retrieved from the databases MEDLINE/PubMed, LILACS, and SciELO, and the evidence derived from each article was classified into recommendation levels according to scientific strength and study type. Conclusion An update on the recent scientific literature addressing hypoparathyroidism is presented to serve as a basis for the diagnosis and treatment of this condition in Brazil.
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Villarroya-Marquina I, Sancho J, Lorente-Poch L, Gallego-Otaegui L, Sitges-Serra A. Time to parathyroid function recovery in patients with protracted hypoparathyroidism after total thyroidectomy. Eur J Endocrinol 2018; 178:103-111. [PMID: 29066572 DOI: 10.1530/eje-17-0589] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/16/2017] [Accepted: 10/23/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Hypocalcaemia is the most common adverse effect after total thyroidectomy. It recovers in about two-thirds of the patients within the first postoperative month. Little is known, however, about recovery of the parathyroid function (RPF) after this time period. The aim of the present study was to investigate the time to RPF in patients with protracted (>1 month) hypoparathyroidism after total thyroidectomy. DESIGN Cohort prospective observational study. METHODS Adult patients undergoing total thyroidectomy for goitre or thyroid cancer. Cases with protracted hypoparathyroidism were studied for RPF during the following months. Time to RPF and variables associated with RPF or permanent hypoparathyroidism were recorded. RESULTS Out of 854 patients undergoing total thyroidectomy, 142 developed protracted hypoparathyroidism. Of these, 36 (4.2% of the entire cohort) developed permanent hypoparathyroidism and 106 recovered: 73 before 6 months, 21 within 6-12 months and 12 after 1 year follow-up. Variables significantly associated with RPF were the number of parathyroid glands remaining in situ (not autografted nor inadvertently resected) and a serum calcium concentration >2.25 mmol/L at one postoperative month. Late RPF (>6 months) was associated with surgery for thyroid cancer. RPF was still possible after one year in patients with four parathyroid glands preserved in situ and serum calcium concentration at one month >2.25 mmol/L. CONCLUSIONS Permanent hypoparathyroidism should not be diagnosed in patients requiring replacement therapy for more than six months, especially if the four parathyroid glands were preserved.
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Affiliation(s)
- Inés Villarroya-Marquina
- Endocrine Surgery Unit, Hospital del Mar, Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sancho
- Endocrine Surgery Unit, Hospital del Mar, Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Leyre Lorente-Poch
- Endocrine Surgery Unit, Hospital del Mar, Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lander Gallego-Otaegui
- Endocrine Surgery Unit, Hospital del Mar, Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Sitges-Serra
- Endocrine Surgery Unit, Hospital del Mar, Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
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Gschwandtner E, Seemann R, Bures C, Preldzic L, Szucsik E, Hermann M. How many parathyroid glands can be identified during thyroidectomy?: Evidence-based data for medical experts. Eur Surg 2017; 50:14-21. [PMID: 29445392 PMCID: PMC5799329 DOI: 10.1007/s10353-017-0502-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 10/31/2017] [Indexed: 12/17/2022]
Abstract
Background The purpose of this study is to provide guidance for medical experts regarding malpractice claims on permanent hypoparathyroidism by analyzing the number of parathyroid glands (PGs) identified during thyroidectomy and the clinical outcome. Methods Parathyroid findings were documented in a standardized protocol for 357 patients undergoing thyroidectomy and treated by a single specialized surgeon. The resected thyroid was routinely dissected for accidentally removed PGs with consecutive autotransplantation and the pathological report also described unintentionally resected PGs. Follow-up was performed for 6 months. Results The mean number of identified PGs was 2.28. No PGs were found in 20 (5.6%), one in 56 (15.7%), two in 126 (35.3%), three in 114 (31.9%), and four in 41 (11.5%) cases. One patient (0.28%) had manifest permanent hypoparathyroidism, while ten patients (2.8%) had latent permanent hypoparathyroidism (hypocalcemia and normoparathyroidism). The risk factors identified for postoperative hypoparathyroidism were an increasing number of visualized PGs, autotransplantation, central neck dissection, and PGs in the histopathological work-up. For permanent hypoparathyroidism, PGs in the histology examination and neck dissection were significant, but the number of identified PGs was not. Conclusion Even an experienced surgeon is not always able to find all four PGs during thyroidectomy and occasionally identifies none. Rather than focusing on identifying a minimum number of PGs, it is more important not to miss them in risky positions. A documented awareness of PGs, i. e., knowledge of variable parathyroid positions and their saving, is a prerequisite for surgical quality and to protect surgeons from claims.
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Affiliation(s)
- Elisabeth Gschwandtner
- Second Department of Surgery “Kaiserin Elisabeth”, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Vienna, Austria
| | - Rudolf Seemann
- Department of Cranio‑, Maxillofacial and Oral Surgery, Medical University Vienna, Vienna, Austria
| | - Claudia Bures
- Second Department of Surgery “Kaiserin Elisabeth”, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Vienna, Austria
| | - Lejla Preldzic
- Second Department of Surgery “Kaiserin Elisabeth”, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Vienna, Austria
| | - Eduard Szucsik
- Second Department of Surgery “Kaiserin Elisabeth”, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Vienna, Austria
| | - Michael Hermann
- Second Department of Surgery “Kaiserin Elisabeth”, Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Vienna, Austria
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Chang YK, Lang BHH. To identify or not to identify parathyroid glands during total thyroidectomy. Gland Surg 2017; 6:S20-S29. [PMID: 29322019 DOI: 10.21037/gs.2017.06.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hypoparathyroidism is one of the most common complications after total thyroidectomy and may impose a significant burden to both the patient and clinician. The extent of thyroid resection, surgical techniques, concomitant central neck dissection, parathyroid gland (PG) autotransplantation and inadvertent parathyroidectomy have long been some of the risk factors for postoperative hypoparathyroidism. Although routine identification of PGs has traditionally been advocated by surgeons, recent evidence has suggested that perhaps identifying fewer number of in situ PGs during surgery (i.e., selective identification) may further lower the risk of hypoparathyroidism. One explanation is that visual identification may often lead to subtle damages to the nearby blood supply of the in situ PGs and that may increase the risk of hypoparathyroidism. However, it is worth highlighting the current literature supporting either approach (i.e., routine vs. selective) remains scarce and because of the significant differences in study design, inclusions, definitions and management protocol between studies, a pooled analysis on this important but controversial topic remains an impossible task. Furthermore, it is worth nothing that identification of PGs does not equal safe preservation, as some studies demonstrated that it is not the number of PGs identified, but the number of PG preserved in situ that matters. Therefore a non-invasive, objective and reliable way to localize PGs and assess their viability intra-operatively is warranted. In this aspect, modern technology such as the indocyanine green (ICG) as near-infrared fluorescent dye for real-time in situ PG perfusion monitoring may have a potential role in the future.
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Affiliation(s)
- Yuk Kwan Chang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Brian H H Lang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
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Sitges-Serra A. The PGRIS and parathyroid splinting concepts for the analysis and prognosis of protracted hypoparathyroidism. Gland Surg 2017; 6:S86-S93. [PMID: 29322026 DOI: 10.21037/gs.2017.07.16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Most patients with hypocalcemia after total thyroidectomy will recover the parathyroid function in a few weeks, but some 20-30% of them will still be in the need for replacement therapy one month after surgery and about 5-10% of those will develop permanent hypoparathyroidism. Although postoperative hypocalcemia has been related to several demographic and metabolic causes, parathyroid hormone (PTH) decline, resulting from autotransplantation, inadvertent excision or devascularization of the parathyroid glands, is the common final pathway. The number of parathyroid glands remaining in situ (PGRIS) is a key variable to understand the pathogenesis of protracted hypoparathyroidism and the chances for restoration of the parathyroid function. Normal-high serum calcium concentration, probably achieved by a more intensive medical treatment at the time of hospital discharge, has been identified as an independent variable favoring recovery of the parathyroid function. This we refer to as parathyroid splinting, a hypothesis holding that putting the injured parathyroid parenchyma at rest after thyroidectomy may improve long-term outcome of protracted hypoparathyroidism.
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Sonne-Holm E, Holst Hahn C. Prolonged Duration of Surgery Predicts Postoperative Hypoparathyroidism among Patients Undergoing Total Thyroidectomy in a Tertiary Referral Centre. Eur Thyroid J 2017; 6:255-262. [PMID: 29071238 PMCID: PMC5649273 DOI: 10.1159/000470840] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/11/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative hypoparathyroidism is a common complication following total thyroidectomy. The aim of this study was to investigate the incidence of both transient and permanent hypoparathyroidism in patients undergoing total thyroidectomy in a tertiary referral centre and, furthermore, to identify early predictive risk factors. METHODS Based on a single-institution retrospective review, we identified 582 patients who underwent total thyroidectomy between January 2010 and March 2015. Information on age, gender, pathological diagnosis, duration of surgery, autotransplantation of parathyroid glands, neck dissection, and experience and position of the surgeon was retrieved from the medical records. Furthermore, serum levels of parathyroid hormone and calcium were registered pre- and postoperatively and after 3 and 12 months. RESULTS The incidence of transient hypoparathyroidism during the first 24 h and 3 months after surgery was 47.8 and 17.8%, respectively. Furthermore, the incidence of permanent hypoparathyroidism 1 year after surgery was 10.7%. A prolonged duration of surgery was significantly associated with hypoparathyroidism. Moreover, autotransplantation of parathyroid glands was a significant predictor of transient hypoparathyroidism after 24 h and 3 months, but was not associated with permanent hypoparathyroidism. CONCLUSIONS Transient and permanent hypoparathyroidism is common among patients undergoing total thyroidectomy in a tertiary referral centre. A duration of surgery >120 min constitutes an independent risk factor due to the risk of ischaemic damage. Regain of function of devascularized parathyroid glands must be expected to last at least 1 year postoperatively. Furthermore, the recovery of autotransplanted parathyroid glands should not be evaluated within 1-3 months after surgery.
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Affiliation(s)
- Emilie Sonne-Holm
- *Emilie Sonne-Holm, Schacksgade 11, 4tv, DK–1365 Copenhagen K (Denmark), E-Mail
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Tartaglia F, Giuliani A, Sorrenti S, Tromba L, Carbotta S, Maturo A, Carbotta G, De Anna L, Merola R, Livadoti G, Pelle F, Ulisse S. Early discharge after total thyroidectomy: a retrospective feasibility study. G Chir 2017; 37:250-256. [PMID: 28350971 DOI: 10.11138/gchir/2016.37.6.250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM The continued hospitalization after total thyroidectomy is often due to the onset of hypocalcemic complications more than 24 hours after surgery. So it would be important to predict which patients will not develop the hypocalcemic complication to discharge them early. This was the aim of our study. PATIENTS AND METHODS Our retrospective study was conducted on 327 consecutive thyroidectomized patients, operated on for benign and malignant diseases. We evaluated the values of preoperative serum calcium levels (Cal0) and of the first postoperative day (Cal1) and two new variables were calculated (dCal and dCaln). The same thing was made on a subgroup of 111 patients in whom also parathiroyd hormone (PTH) values were detected. Statistical analysis was performed with the goal of determining if we could establish a safe criterion for discharge at 24 hours after surgery and if there is a correlation between suitability for discharge and diagnosis. RESULTS As to discharge, the predictive power of the discriminant function applied was significant both on the total of patients and in the subgroup of 111 patients, but it was clinically unacceptable because it would expose us to a 21% to 27% error rate. It is not possible to identify a threshold, below which to consider patients surely dischargeable. The diagnosis does not appear correlated with the suitability for discharge. CONCLUSION On the basis of serum calcium and PTH levels in the first postoperative day, it is impossible to predict which patients can be discharged 24 hours after surgery without incurring in hypocalcemic complications.
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Famà F, Cicciù M, Polito F, Cascio A, Gioffré-Florio M, Piquard A, Saint-Marc O, Sindoni A. Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution. World J Surg 2016; 41:457-463. [PMID: 27734084 DOI: 10.1007/s00268-016-3754-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision. METHODS In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation. RESULTS We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001). CONCLUSIONS We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.
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Affiliation(s)
- Fausto Famà
- Department of Human Pathology, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy. .,Complesso MITO, Residenza Ginestre F/2, 98151, Messina, Italy.
| | - Marco Cicciù
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Francesca Polito
- Department of Clinical and Experimental Medicine, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Antonio Cascio
- Department of Human Pathology, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Maria Gioffré-Florio
- Department of Human Pathology, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
| | - Arnaud Piquard
- Department of General, Endocrine and Thoracic Surgery, Regional Hospital of Orleans, 14, Avenue de l'Hopital, 45067, Orléans (cedex 2), France
| | - Olivier Saint-Marc
- Department of General, Endocrine and Thoracic Surgery, Regional Hospital of Orleans, 14, Avenue de l'Hopital, 45067, Orléans (cedex 2), France
| | - Alessandro Sindoni
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, University Hospital of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
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Kirdak T, Dundar HZ, Uysal E, Ocakoglu G, Korun N. Outcomes of Parathyroid Autotransplantation During Total Thyroidectomy: A Comparison with Age- and Sex-Matched Controls. J INVEST SURG 2016; 30:201-209. [PMID: 27700191 DOI: 10.1080/08941939.2016.1232768] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine the effect of parathyroid autotransplantation (PA) on postoperative hypocalcemia in cases of total thyroidectomy. MATERIALS AND METHODS Cases undergoing total thyroidectomy and PA were compared with age and sex-matched controls who had not undergone PA. The postoperative percentage changes (PC) of parathyroid hormone (PTH) and calcium (Ca+2) in the first 12-24 hours (12-24hr→preop), between the 1st-3rd weeks (1-3wk→preop) and at the 6th month (6mo→preop), the rates of hypocalcemia (Ca+2< 8mg/dL) and low PTH level (PTH< 15 pg/mL), permanent hypocalcemia, inadvertent parathyroidectomy in both groups were compared. RESULTS The number of patients with PTH12-24hr<15 pg/mL was significantly higher (n:34,(55.7%)) than the number of patients in the control group (n:16(26.2%)), (p=0.001). The rate of decrease in the blood Ca+2 median PC (6mo→preop) was significantly higher in the PA group (4.2%) than the control group (1.1%), (p=0.008). There was no significant difference between the 2 groups in terms of the postoperative frequency of hypocalcemia (p>0.05). In the PA&age≤50 group, the rate of inadvertent parathyroidectomy was higher than that of cases over age 50 (p=0.029). CONCLUSION In spite of the presence of an increased postoperative hypocalcemia trend in cases requiring PA during total thyroidectomy, the rates of transient and permanent hypocalcemia were not different to the control cases. But the frequency of cases with low PTH level in cases undergoing PA was higher than that of the control cases. In cases of 50 years of age and under, who had undergone PA, the possibility of inadvertent parathyroidectomy increased.
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Affiliation(s)
- Turkay Kirdak
- a Department of Surgery , Uludag University Faculty of Medicine , Bursa , Turkey
| | - Halit Ziya Dundar
- a Department of Surgery , Uludag University Faculty of Medicine , Bursa , Turkey
| | - Erdal Uysal
- b Department of Surgery , Sanko University School of Medicine , Gaziantep , Turkey
| | - Gokhan Ocakoglu
- c Department of Biostatistics , Uludag University Faculty of Medicine , Bursa , Turkey
| | - Nusret Korun
- a Department of Surgery , Uludag University Faculty of Medicine , Bursa , Turkey
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