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

5-year Follow-up of Reimplanted Parathyroid Glands in Forearm Subcutaneous Tissue During Thyroidectomy. A Confirmation of Graft Vitality in a Large Series of Patients

INTRODUCTION

The aim of this study is to assess the outcomes of parathyroid gland reimplantation with PR-FaST technique in patients undergoing thyroid surgery, focusing on graft functionality over a 5-year follow-up period.

MATERIALS AND METHODS

We analyzed data from 131 patients who underwent parathyroid reimplantation using the PR-FaST technique during thyroid surgery due to inadvertent parathyroid removal or evident vascular damage. Postoperative evaluations included serum calcium (Ca), magnesium (Mg), and phosphorus (P) analyses on the 1st and 2nd postoperative days, at 10 days, and at 1, 3, 6 months, 1 year, and 5 years of follow-up. Additionally, the mean values of serum intact parathyroid hormone (iPTH) concentration were measured from blood samples collected from both the reimplanted arm (iPTH RA) and non-reimplanted arm (iPTH NRA) within the same period.

RESULTS

Among 131 patients, at 10 days post-surgery, only 46 patients (35.1%) out of 131 exhibited graft viability (iPTH ratio >1.5). This percentage increased to 72.8% (94 patients) after 1 month and further to 87.8% (108 patients) after 3 months post-surgery. At 1 year, 84.7% of patients showed good graft functionality. After 5 years, the percentage remained stable, with graft viability observed in 81.3% of patients. Only 91 of the initial 131 patients completed follow-up up to 5 years, with a dropout rate of 30.5 %.

CONCLUSIONS

Parathyroid reimplantation using the PR-FaST technique is a viable option for patients undergoing thyroidectomy and has been shown to be a reproducible and effective technique in most patients, with sustained graft functionality and parathyroid hormone production over a 5-year follow-up period.

Investigating the optimal parathyroid autotransplantation strategy in transareolar endoscopic thyroidectomy: A retrospective cohort study

BACKGROUND

There is ongoing debate about whether intraoperative parathyroid autotransplantation effectively prevents permanent hypoparathyroidism after thyroidectomy. This study aims to examine its impact on postoperative parathyroid function and determine the best autotransplantation strategy.

METHODS

A retrospective analysis was conducted on 194 patients who underwent total thyroidectomy with central lymph node dissection (CLND) for papillary thyroid carcinoma (PTC). Patients were divided into four groups based on the number of parathyroid autotransplants during surgery: Group 1 (none, n = 43), Group 2 (1 transplant, n = 60), Group 3 (2 transplants, n = 67), and Group 4 (3 transplants, n = 24). Various clinical parameters were collected and compared among the groups.

RESULTS

Parathyroid autotransplantation was identified as a risk factor for temporary hypoparathyroidism (OR: 1.74; 95% CI: 1.27-2.39, P = 0.001) and a protective factor for permanent hypoparathyroidism (OR: 0.27; 95% CI: 0.14-0.55, P < 0.001). At 12 months postoperative, systemic parathyroid hormone (PTH) levels increased progressively from Groups 1 to 4, with significant differences observed only between Group 1 and Group 2 (P < 0.02). Difference values in systemic PTH levels between Month 1 and Day 1 postoperative increased progressively from Groups 1 to 4, with statistically significant differences observed between adjacent groups (P < 0.02). The number of dissected positive lymph nodes increased progressively across the four groups, showing statistical differences (P < 0.02).

CONCLUSION

Parathyroid autotransplantation can prevent permanent hypoparathyroidism. Additionally, we recommend preserving parathyroids in situ whenever possible. If autotransplantation is required, it should involve no more than two glands.

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

BACKGROUND

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

DESIGN

Retrospective.

SETTING

Multiple centers in the Makkah region of Saudi Arabia.

PATIENTS AND METHODS

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

MAIN OUTCOME MEASURES

Distinguish independent risk factors for postoperative hypocalcemia after thyroidectomy.

SAMPLE SIZE

215 patients.

RESULTS

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

CONCLUSION

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

LIMITATIONS

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

Total Number of Identified Parathyroid Glands During Total Thyroidectomy and Its Relation to Postoperative Hypoparathyroidism

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.

Converting a probe-based fluorescence system into an easy-to-use adjunct for the detection of parathyroid glands accidentally resected intraoperatively

PURPOSE

The reported threshold of a near-infrared fluorescence detection probe (FDP) for judging parathyroid glands (PGs) is based on the autofluorescence intensity relative to other non-PG tissues, making it unreliable when not enough reference tissues are measured. We aim to convert FDP into a more convenient tool for identifying accidentally resected PGs by quantitative measurements of autofluorescence in resected tissues.

METHODS

It was a prospective study approved by the Institutional Review Board. The research was divided into two stages: (1) In order to calibrate the novel FDP system, autofluorescence intensity of different in / ex vivo tissues was measured and the optimal threshold was obtained using receiver operating characteristic (ROC) curve. (2) To further validate the effectiveness of the new system, detection rates of incidental resected PGs by pathology in the control group and by FDP in the experimental group were compared.

RESULTS

Autofluorescence of PGs was significantly higher than that of non-PG tissue (43 patients, Mann-Whitney U test, p < 0.0001). An optimal threshold of sensitivity / specificity (78.8% and 85.1%) for discriminating PGs was obtained. The detection rates of experimental group (20 patients) and control group (33 patients) are 5.0% and 6.1% respectively (one-tailed Fisher's exact test, p = 0.6837), indicating the novel FDP system can achieve a similar proportion of PG detection compared with pathological examinations.

CONCLUSIONS

The novel FDP system can be used as an easy-to-use adjunct for detecting PG accidentally resected intraoperatively before the tissues are sent for frozen sections during thyroidectomy surgeries.

TRIAL REGISTRATION

Registration number: ChiCTR2200057957.

Preservation of parathyroid glands during thyroid and neck surgery

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.

Risk factors for hypocalcemia and correlation between thyroid volume and incidental parathyroidectomy after total thyroidectomy: single center experience

Aim: We aimed to investigate correlation between the effects of age, sex, disease, pathologic diagnosis, parathyroid autotransplantation, presence of parathyroid in the pathology specimen and clinicopathological variables and thyroid volume, postoperative hypocalcemia after bilateral total thyroidectomy. Material and Method: A retrospective study planned in tertiary university hospital on patients undergone bilateral total thyroidectomy and neck dissection when necessary surgery for thyroid pathologies. Minimum calcium values in the postoperative period were recorded as transient or permanent hypocalcemia. The cases were statistically analyzed for the relationship between the volume of the thyroid gland removed and hypocalcemia. The effects of sex, pathological diagnosis, preoperative hyperthyroidism, anatomical retrosternal extension, number of parathyroid glands seen and preserved intraoperatively, parathyroid gland autoimplantation, parathyroid gland removal in the pathological specimen, nerve monitoring, bilateral total thyroidectomy and central and lateral neck dissection were analyzed for postoperative hypocalcemia. Results: Totally 763 patients were included in the study. The mean age of the patients was 50.6 years (SD:12.8) and the sex of 575 (75.4%) patients was female. Hypocalcemia was more common in women than in men (31% vs 17%; p

Does the Risk of Hypocalcemia Increase in Complementary Thyroidectomy Performed in Papillary Thyroid Cancer?

Objectives

Papillary thyroid cancer (PTC) is the most common type of thyroid cancers. In some patients, due to the histopathological features of PTC, complementary thyroidectomy (CT) may be needed to contralateral thyroid lobe after lobectomy. Hypocalcemia is the most common complication after thyroidectomy and its etiology is multifactorial. It is still controversial whether the CT increases the risk of hypocalcemia or not. In this study, we aimed to evaluate whether CT procedure increases the risk of hypocalcemia compared to total thyroidectomy (TT) in PTC patients.

Methods

The data of the patients who were operated between 2015 and 2018 and diagnosed with PTC in the pre-operative or post-operative period were evaluated retrospectively, and two patient groups were formed. Group 1 included 19 patients who were diagnosed with PTC in the pathological examination after lobectomy was performed in the first operation, and after that CT was performed to the contralateral lobe. Among the patients who were diagnosed with pre-operative or post-operative PTC in the same period, 53 patients with characteristics similar to the 1^st group in terms of age and gender were selected for Group 2. Biochemical parameters related to calcium metabolism in the pre-operative and post-operative periods, parathyroid autotransplantation and unintentional parathyroid gland removal, post-operative hypocalcemia, and treatment rates were compared between the two groups.

Results

There were 19 patients (13 F and 6 M) with a mean age of 48.3±12.1 years and 53 patients with a mean age of 46.3±9 (40 F and 13 M) in Groups 1 and 2, respectively, and there was no significant difference between the groups in terms of age and gender. There was no significant difference in terms of pre-operative parathormone (PTH), phosphorus (P), magnesium (Mg), Vitamin D deficiency rate, parathyroid autotransplantation, and presence of parathyroid gland in thyroid specimen. Pre-operative calcium (Ca) value was 9.33±0.46 in Group 1 and lower than Group 2 (9.65±0.41) (p=0.012). There was no significant difference between the groups in terms of post-operative day 0 Ca, P, Mg, and PTH and post-operative day 1 Ca, Mg, and PTH. Post-operative day 1 P level was significantly lower in Group 1 (2.86±0.72) compared to Group 2 (3.6±0.83). Post-operative hypocalcemia rates were 21.1% and 30.2% in Groups 1 and 2, respectively, and the difference was not significant (p=0.558). In both groups, hypocalcemia was transient and permanent hypoparathyroidism was not detected. Parathyroid autotransplantation rates (10.5% vs. 3.8%; p=0.283) and the rate of unintentionally removed parathyroid gland (0 vs. 15.1; p=0.185) were similar in Groups 1 and 2, respectively. Ca and active Vitamin D administration rates in the post-operative period were similar in Group 1 and Group 2 (10.5% vs. 22.6%; respectively), and there was no significant difference between the groups in terms of receiving treatment (p=0.327).

Conclusion

CT can be necessary in some patients with post-operative diagnose of PTC. CT can be performed without increased risk of hypocalcemia compared to TT.

Etiology and Pathophysiology of Hypoparathyroidism: A Narrative Review

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).

Clinical application of parathyroid autotransplantation in endoscopic radical resection of thyroid carcinoma

Purpose

This study aimed to examine the effect of selective inferior parathyroid gland autotransplantation on central lymph node dissection(CLND) and incidence of postoperative hypoparathyroidism in patients undergoing endoscopic radical resection of thyroid carcinoma.

Methods

The data of 310 patients undergoing endoscopic radical resection of thyroid carcinoma will be retrospectively analyzed. The patients will be divided into the experimental group and the control group according to whether they combined with parathyroid autotransplantation. Statistics of the incidence rate of postoperative hypoparathyroidism, the concentration of PTH and Calcium in the systemic circulation at different time points in the two groups, the concentration of PTH in the cubital fossa vein in the transplantation region in the experimental group, and the number of central lymph nodes and positive lymph nodes dissection will be carried out.

Results

The incidence rate of temporary and permanent hypoparathyroidism in the experimental group was 33.75% and 0.625%, respectively, and in the control group was 22% and 5%, respectively; its difference was statistically significant (X^{2 =} 10.255, P=0.006). Parathyroid autotransplantation increased incidence of transient hypoparathyroidism (OR, 1.806; Cl, 1.088-2.998; P=0.022), and lower incidence of permanent hypoparathyroidism (OR, 0.112; Cl, 0.014-0.904; P=0.040). The diameters of thyroid cancer nodules was not associated with the occurrence of transient hypoparathyroidism (OR, 0.769; Cl, 0.467-1.265; P=0.301) or permanent hypoparathyroidism (OR, 1.434; Cl, 0.316-6.515; P=0.641). Comparison of systemic circulation PTH, between the two groups showed that the PTH of patients in the experimental group was higher than that in the control group from 1 week to 12 months after the operation, and the difference was statistically significant (P<0.05). In the experimental group, from 1 week to 12 months after surgery, PTH concentrations was significantly higher in the cubital fossa of the transplantation side than in the contralateral side, and the differences were statistically significant (P<0.05). The mean number of central lymph node dissected per patient was significantly higher in the experimental group (7.94 ± 3.03 vs. 6.99 ± 2.86; P <0.05); The mean number of positive nodes per patient was significantly higher in the experimental group (3.16 ± 1.86 vs. 2.53 ± 1.59; P <0.05).

Conclusions

In endoscopic radical resection of thyroid carcinoma, parathyroid autotransplantation is more beneficial to postoperative parathyroid glands function recovery, effectively preventing postoperative permanent hypoparathyroidism and realizing more thorough CLND.

Thyroidectomy in Australia 2022: lessons from 21,000 consecutive cases

In this article, we aim to describe our modern-day approach to total thyroidectomy, detailing the subtle refinements of our technique, as it has evolved over three decades and 21 000 cases. Since Delbridge's seminal paper in 2003, the major changes to our approach include a retrograde approach to the recurrent laryngeal nerve that allows dissection of the distal RLN from fascial bands within the ligament of Berry before medialisation of the thyroid lobe. Routine use of intraoperative nerve monitoring systems has increased our awareness of temporary neuropraxia, facilitated a reduction in the risk of bilateral RLN palsy and improved our identification and preservation of the external branch of the superior laryngeal nerve. The increasing use of advanced energy devices has been associated with a reduction in post-operative haematoma rates. We adopt a low threshold to parathyroid auto-transplantation, unless all glands are assessed to be clearly not at risk, and routinely supplement patients with Caltrate in the immediate post-operative period to minimize the risk of symptomatic hypocalcaemia. Ultimately, when we reflect on the subtle refinements that have contributed to improved outcomes, the fundamental principles of exposure and dissection that have evolved over decades remain the basis of our surgical approach and must continue to do so.

Parathyroid Allotransplantation: A Systematic Review

Background: To date, there is no satisfactory treatment for patients with calcium and vitamin D supplementation refractive hypoparathyroidism. Parathyroid allotransplantation by design is a one-time cure through its restoration of the parathyroid function and, therefore, could be the solution. A systematic literature review is conducted in the present paper, with the aim of outlining the possibilities of parathyroid allotransplantation and to calculate its efficacy. Additionally, various transplantation characteristics are linked to success. Methods: This review is carried out according to the PRISMA statement and checklist. Relevant articles were searched for in medical databases with the most recent literature search performed on 9 December 2021. Results: In total, 24 articles involving 22 unique patient cohorts were identified with 203 transplantations performed on 148 patients. Numerous types of (exploratory) interventions were carried out with virtually no protocols that were alike: there was the use of (non-) cryopreserved parathyroid tissue combined with direct transplantation or pretreatment using in vitro techniques, such as culturing cells and macro-/microencapsulation. The variability increased further when considering immunosuppression, graft histology, and donor–recipient compatibility, but this was found to be reported in its entirety by exception. As a result of the large heterogeneity among studies, we constructed our own criterium for transplantation success. With only the studies eligible for our assessment, the pooled success rate for parathyroid allotransplantation emerged to be 46% (13/28 transplantations) with a median follow-up duration of 12 months (Q1–Q3: 8–24 months). Conclusions: Manifold possibilities have been explored around parathyroid allotransplantation but are presented as a double-edged sword due to high clinical diverseness, low expertise in carrying out the procedure, and unsatisfactory study quality. Transplantations carried out with permanent immunosuppression seem to be the most promising, but, in its current state, little could be said about the treatment efficacy with a high quality of evidence. Of foremost importance in pursuing the answer whether parathyroid allotransplantation is a suitable treatment for hypoparathyroidism, a standardized definition of transplantation success must be established with a high-quality trial.

Accumulation of Experience and Newly Developed Devices Can Improve the Safety and Voice Outcome of Total Thyroidectomy for Graves’ Disease

Total thyroidectomy (TT) in patients with Graves’ disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves’ disease who received TT. Forty-six patients received surgery during 1990–1999 (Group A), and 44 patients received surgery during 2010–2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range (p = 0.015) and jitter (p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves’ disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.

Surgical aspects and controversies in the management of medullary thyroid cancer

Medullary thyroid cancer (MTC) accounts for only 4% of thyroid carcinomas but 15% of thyroid cancer deaths. MTC is a tumour of the calcitonin secreting parafollicular C cells in the thyroid which can occur sporadically or be hereditary in multiple endocrine neoplasias type 2 syndromes due to germline RET mutations. Sporadic forms of MTC can also be caused by mutations in the RET protooncogene. MTC commonly presents in a late stage, with 70% of patients presenting with local nodal metastasis. Currently, the only curative treatment for MTC is surgical removal. The aim of this paper is to describe the current guidelines and progressions of the surgical management of MTC and to highlight up-and-coming chemotherapies. A database literature review was completed utilizing PubMed to cumulate the extant literature, screening for most recent guidelines and publications regarding the management of MTC. Current guidelines were described by the American Thyroid Association in 2015. Controversial publications continue to present supporting evidence for varying degrees of thyroidectomy and neck dissections. Recently, researchers have been exploring non-surgical options including external beam radiotherapy and multikinase inhibitors such as vandetanib and cabozantinib for the treatment of MTC. Surgical management of MTC remains controversial and varies significantly dependent on the extent of disease. Chemotherapeutic options have undetermined effects on survival to date.

Fine-Needle Pricking Test of the Parathyroid Gland during Thyroid Surgery in Predicting Parathyroid Function

BACKGROUND

Permanent hypoparathyroidism is a serious complication following total thyroidectomy plus central neck dissection (CND). How to evaluate the vascularization of the parathyroid gland in real time is a major concern of thyroid surgeons. This study aimed to evaluate the fine-needle pricking (FNP) test in predicting parathyroid gland function.

METHODS

The FNP test was performed in patients undergoing total thyroidectomy plus CND between January 1, 2014, and December 31, 2019, to visualize the vascularization of the parathyroid glands. Patients were classified according to the number of parathyroid glands preserved in situ with excellent vascularity (PGPIEV) demonstrated by FNP: group 0 (without PGPIEV), group 1 (with one PGPIEV), group 2 (with two PGPIEV), group 3 (with three PGPIEV), and group 4 (with four PGPIEV).

RESULTS

A total of 608 patients with four parathyroid glands underwent FNP testing during thyroidectomy. At least one PGPIEV was demonstrated by FNP testing in 581 patients who had intact parathyroid hormone (iPTH) levels in the normal range after the operation. The prevalence of hypocalcemia decreased from 77.8% in group 0 to 9.8% in group 4 (P < 0.001), and the incidence of hypoparathyroidism decreased from 44.4% in group 0 to 0% in groups 1-4 (P < 0.001). iPTH concentrations on postoperative day 1 were positively correlated with PGPIEV groups (increased from 14.58 ng/l in group 0 to 45.22 ng/l in group 4, P < 0.001).

CONCLUSIONS

The FNP test is a safe and reliable method to predict parathyroid function. One PGPIEV demonstrated by the FNP test rules out the possibility of patients developing hypoparathyroidism.

The effectiveness and safety of prophylactic central neck dissection in clinically node-negative papillary thyroid carcinoma patients: A meta-analysis

OBJECTIVE

This meta-analysis was performed to evaluate the effectiveness and safety of prophylactic central neck dissection (PCND) in patients with clinically node-negative (cN0) papillary thyroid carcinoma.

MATERIALS AND METHODS

A meta-analysis of the literature was performed using the key words "papillary thyroid carcinomas" and "lymph node ecisions" for searches of electronic databases. Complications such as transient hypocalcemia, permanent hypocalcemia, transient and permanent hypoparathyroidism, transient and permanent vocal cord paralysis, transient recurrent and permanent recurrent laryngeal nerve injury, and local recurrence were pooled by meta-analysis. Stata17.0 was used to carry out the meta-analysis.

RESULTS

Data were extracted from 15 studies. In the present review, the group of patients who had total thyroidectomy (TT) with PCND had a lower local recurrence than the group with TT alone (OR 0.22, 95% CI 0.10-0.45, P = 0.000), whereas the incidence of permanent hypocalcemia (OR 4.24, 95% CI 1.05-17.22, P = 0.043) and transient hypoparathyroidism (OR 2.14, 95% CI 1.34-3.42, P =0.001) were higher. No significant differences were recorded in the incidence of other complications: transient hypocalcemia (OR 2.24, 95% CI 0.77-6.51, P = 0.138), permanent hypoparathyroidism (OR 1.70, 95% CI 0.89-3.27, P = 0.111), transient vocal cord paralysis (OR 1.48, 95% CI 0.78-2.83, P = 0.231), permanent vocal cord paralysis (OR 1.44, 95% CI 0.53-3.94, P = 0.477), transient recurrent laryngeal nerve injury (OR 1.47, 95% CI 0.93-2.32, P = 0.102) and permanent recurrent laryngeal nerve injury (OR 1.24, 95% CI 0.56-2.74, P = 0.587) between the two groups.

CONCLUSION

Compared with TT alone, TT with PCND was more effective in reducing local recurrence without increasing the risk of recurrent laryngeal nerve, thyroid and vocal cord, except for hypocalcemia and transient hypoparathyroidism. Therefore, we believe that TT with PCND should be recommended for patients with cN0 PTC.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD4202 2355078.

Hypoparathyroidism: State of the Art on Cell and Tissue Therapies

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.

Endocrine Surgery: Management of Postoperative Complications Following Endocrine Surgery of the Neck

Cervical endocrine operations include parathyroidectomy, thyroid lobectomy, thyroidectomy, central neck dissection, and lateral neck dissection. The vital structures at risk include the recurrent laryngeal nerves to the intrinsic muscles of the larynx, additional cranial nerves, parathyroid glands essential for calcium homeostasis, aerodigestive structures, and great vessels. Here, the authors discuss complications of endocrine neck surgery, including cervical hematoma and other fluid collections, hypocalcemia from hypoparathyroidism, and nerve injuries, along with their prevention, mitigation, and management. Significant and permanent morbidity can result, but fortunately the overall rate of complications remains low, especially when surgery is performed by high-volume surgeons.

In Situ Preservation of Parathyroid Gland With Vasculature for Papillary Thyroid Carcinoma Is Associated With Higher PTH Levels After Total Thyroidectomy

PURPOSE

To evaluate the impact of parathyroid gland vasculature preservation in-situ technique (PGVPIST) on postoperative parathyroid hormone (PTH) and calcium plasma levels in thyroid patients undergoing total thyroidectomy for papillary thyroid carcinoma (PTC).

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients with PTC who underwent total thyroidectomy by either the conventional technique (group 1, January 2019 to January 2020) or PGVPIST (group 2, January 2020 to January 2021) were compared. Postoperative blood calcium levels and PTH levels were assessed in these groups.

RESULTS

Totally 149 patients with consecutive PTC underwent total thyroidectomy, including 60 patients in group 1 and 89 patients in group 2. Postoperative serum calcium levels in group 1 were insignificantly lower than in group 2 at day 1 (2.18 ± 0.02 vs 2.15 ± 0.01 mmol/L) and day 30 (2.27 ± 0.02 vs 2.38 ± 0.11) after surgery. But postoperative serum PTH levels in group 1 were significantly lower than that in group 2 at day 1 (23.68 ± 2.54 vs 31.46 ± 2.11 pg/mL) and day 30 (45.63 ± 3.21 vs 55.65 ± 2.89 pg/mL) after surgery.

CONCLUSION

Parathyroid gland vasculature preservation in-situ technique for PTC is associated with higher PTH level after total thyroidectomy. The parathyroid gland vasculature mostly strongly adheres with adjacent thyroid parenchyma. Therefore, deferred processing of tiny thyroid parenchyma of parathyroid gland vessels is essential to prevent devascularization.

Selective Parathyroid Autotransplantation During Total Thyroidectomy for Papillary Thyroid Carcinoma: A Cohort Study

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.

Does number of autotransplanted parathyroid glands affects postoperative hypoparathyroidism and serum parathyroid hormone levels?

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.

Etiology and Diagnosis of Permanent Hypoparathyroidism after Total Thyroidectomy

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.

Microscopic Thyroidectomy: The Way We Do It

The present study was conducted with an intent to document the reduced morbidity in terms of postoperative hypocalcemia, injury to recurrent laryngeal and external branch of superior laryngeal nerve, in patients undergoing microscope assisted thyroidectomy. The present study enrolled a total of 878 patrients who underwent hemi, total and completion thyroidectomies, over a period of 3 years at Jain ENT Hospital, Jaipur. In the present study, out of 1118 RL nerves dissected temporary paresis was found in 1.52% and permanent palsy in only 0.36%. Temporary hypocalcemia was seen in 8.12% while permanent hypocalcemia in 0.6% patients. EBSLN could be identified in 1082 of the 1118 nerves dissected. We recommend the use microscope routinely for all thyroid surgeries, starting from the very first step in view of the reduced morbidity that it offers.

Parathormone decline levels are better markers of symptomatic hypocalcemia following total thyroidectomy than parathormone alone

Background: We aimed to assess the predictive value of the absolute and relative intact parathormone (iPTH) decline levels as reliable markers of postoperative hypocalcemia. Materials & methods: iPTH levels were measured 4 h after surgery and the following morning after surgery (postoperative day 1). iPTH, absolute iPTH decline (ΔPTH) and relative iPTH decline (ΔPTH%) were calculated and correlated with symptomatic hypocalcemia. Results: Of the 95 patients, 20% of patients (n = 19) developed symptomatic hypocalcemia. The ΔPTH (U = 206; p < 0.001) and ΔPTH% (U = 127; p < 0.001) were significantly higher in patients with symptomatic hypocalcemia. A ΔPTH% of 20% (sensitivity of 84%; specificity of 91%); and an absolute iPTH decline of 3.75 pg/ml (sensitivity of 74%; specificity of 87%) were highly predictive of symptomatic hypocalcemia. Conclusion: Postoperative ΔPTH and ΔPTH% have the potential to be predictors of symptomatic hypocalcemia following thyroidectomy and could facilitate a safe early discharge.

[Complications of lymph node dissection in thyroid cancer]

Cervical lymphadenectomy in thyroid cancer is a frequent intervention with around 20,000 operations per year in Germany. Some of the complications are identical with those in thyroid surgery, such as recurrent laryngeal nerve palsy and hypoparathyroidism as well as postoperative bleeding and wound infection. Specific complications of lateral lymphadenectomy are lesions of the accessory, phrenic and hypoglossal nerves, the sympathetic trunk and cervical plexus as well as lesions of the salivary glands and lymphatic vessels, in particular the thoracic duct. Most of these complications are rare with a frequency of less than 1%. Profound knowledge of the anatomy and a meticulous dissection technique make a decisive contribution to minimizing these complications.

A comparison of the quantitative evaluation of in situ parathyroid gland perfusion by indocyanine green fluorescence angiography and by visual examination in thyroid surgery

Objective The most vital complications of thyroidectomy are recurrent nerve damage and hypocalcaemia. We aimed to compare the tissue perfusion scores (PS) of IG fluorescence angiography (IGFA) and visual examination by the surgeon after total thyroidectomy. Subjects and methods Forty-three patients were accepted into the study. Localisation of the parathyroid gland (PG) was determined by the naked eye and scored in terms of tissue perfusion. The averages of fluorescent light intensities for each IGFA were calculated, the perfusions were scored and compared with the PS given by the surgeon. Biochemical parameters were noted. Results 37.2% of patients had autotransplanted PGs, according to their visual scores. The means of IGFA-PS for PGs scored as 0, 1 or 2 on visual inspection were 48.58 ± 4.49 [30-70], 89.65 ± 8.93 [36-144] and 158.76 ± 8.93 [70-253], respectively, which correlated with the visual PSs in a statistically significant manner (P < 0.0001). The predictive cut-off value for IGFA-PS was determined to be 70, given a visual PS of 0 (95% CI [0.72-0.85]), and this was interpreted to be a candidate cut-off point for the autotransplantation of PGs. Conclusion IGFA scoring may be considered as an operative predictor, providing objective criteria to evaluate the tissue and blood perfusion of PGs after thyroidectomy. IGFA scoring may be considered to have value in minimising postoperative permanent hypoparathyroidism in patients.

Hypocalcemia After Completion Thyroidectomy for Papillary Thyroid Carcinoma

Surgical management of papillary thyroid carcinoma (PTC) includes total thyroidectomy and lobectomy. After lobectomy, a reoperation called completion thyroidectomy is occasionally required. Postoperative hypocalcemia is the most common complication associated with thyroid surgery. Our main goal was to determine if there is a significant difference between the incidence rate of postoperative hypocalcemia in patients who underwent total thyroidectomy for PTC compared with patients who underwent completion thyroidectomy for PTC. Apart from that, we analyzed the following potential predictive factors for the occurrence of hypocalcemia: sex, age, size of tumor, side of tumor, maximum diameter of individual lobe, occult metastasis, and operating surgeon. The study involved 340 patients who underwent surgery for PTC at the Department of ENT and Head and Neck Surgery, Zagreb University Hospital Centre, between February 25, 2013 and January 3, 2016. Postoperative hypocalcemia incidence rates were higher in the total thyroidectomy group than in the completion thyroidectomy group (37.8% and 29.0%, respectively). However, these differences were not statistically significant. Every analyzed potential predictive factor was proven not to have any correlation with postoperative hypocalcemia. This study demonstrated that there was no significant difference between postoperative hypocalcemia rates in patients who underwent completion thyroidectomy compared with patients who underwent total thyroidectomy for PTC.

Ultrasonic scalpel with knot tying protects parathyroid function for total thyroidectomy with central neck dissection

Background

Hypoparathyroidism might be due to collateral thermal injury induced by harmonic scalpel (HS) after total thyroidectomy (TT) with central neck dissection (CND). The current study aimed to evaluate whether a clamp and tie (CAT) technique used to preserve parathyroid glands in situ could reduce damage to parathyroid function in HS patients undergoing TT plus unilateral or bilateral CND.

Methods

Medical records of 537 HS-operated patients with papillary thyroid carcinoma (PTC) undergoing TT plus unilateral or bilateral CND were retrospectively evaluated. Patients were divided into HS and HS-CAT groups based on whether the CAT techniques were used near parathyroid glands. Patients' characteristics such as age, sex, tumour size, operative time, pre- and post-operative levels of parathyroid hormone (PTH) and complications were analysed.

Results

For patients undergoing TT plus unilateral CND, operative time was significantly shorter (P<0.001), but there were significantly higher incidences of transient hypoparathyroidism (P=0.002) on postoperative day 1 and incidental parathyroidectomy (P=0.036) in the HS group. There was no significant difference in permanent hypoparathyroidism. For patients undergoing TT plus bilateral CND, a significantly shorter operative time and sharper postoperative PTH decline was found in the HS group (P=0.029). However, there were no significant differences regarding incidences of incidental parathyroidectomy, transient or permanent hypoparathyroidism.

Conclusions

The CAT technique applied near parathyroid glands was a practical surgical application for decreasing the incidence of postoperative transient hypoparathyroidism for TT plus unilateral CND.

Risk of Permanent Hypoparathyroidism After Total Thyroidectomy for Benign Disease: A Nationwide Population-based Cohort Study From Sweden

OBJECTIVE

To investigate the prevalence and risk factors for permanent hypoparathyroidism after total thyroidectomy for benign disease in a population-based setting with data independent of input of complication data.

SUMMARY OF BACKGROUND DATA

The reported rate of permanent hypoparathyroidism is highly variable and mostly rely on reported complication data from national or institutional registries.

METHODS

All patients who underwent total thyroidectomy in Sweden from 2005 to 2015 were identified through Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery and the Swedish National Patient Register. Patients were matched to outcome data from the Swedish Prescribed Drug Register. Permanent hypoparathyroidism was defined as treatment with calcium and/or active vitamin D more than 1 year after surgery.

RESULTS

Seven thousand eight hundred fifty-two patients were included and 938 (12.5%) developed permanent hypoparathyroidism. The risk was lower in patients registered in the quality register (11.0% vs 16%, P < 0.001). In a multivariable analysis there was a higher risk of permanent hypoparathyroidism in patients with parathyroid autotransplantation [Odds ratio (OR) 1.72; 95% confidence interval 1.47-2.01], center-volume <100 thyroidectomies per year (OR 1.22; 1.03-1.44), age above 60 year (OR 1.64; 1.36-1.98) and female sex (OR 1.27; 1.05-1.54). Reported data from the quality register only identified 178 of all 938 patients with permanent hypoparathyroidism.

CONCLUSION

The risk of permanent hypoparathyroidism after total thyroidectomy was high and associated with parathyroid autotransplantation, higher age, female sex and surgery at a low volume center. Reported follow-up data might underestimate the rate of permanent hypoparathyroidism.

Trauma-induced primary hypoparathyroidism following severe bite wound injury to the neck in a dog

OBJECTIVE

To describe the clinical presentation and outcome of a dog with primary hypoparathyroidism secondary to cervical bite wounds.

CASE SUMMARY

A 3-year-old male intact Chihuahua presented after being attacked by a large breed dog. The dog sustained severe cervical lacerations, exposing the trachea and jugular veins. A portion of the right thyroid gland was missing. The dog was stabilized before wound debridement and closure. Ionized calcium concentrations were within reference range at the time of presentation. Forty-eight hours after the initial trauma, the dog was presented in lateral recumbency with signs of hypovolemic shock, muscle tremors, and hyperthermia. Bloodwork showed severe ionized hypocalcemia with low normal parathyroid hormone concentration consistent with acute primary hypoparathyroidism. The dog was managed initially with IV calcium gluconate and calcitriol, then long-term oral calcium carbonate and vitamin D3. After 6 months, the dog was successfully weaned off calcium supplementation.

NEW OR UNIQUE INFORMATION PROVIDED

This is the first described case of traumatic primary hypoparathyroidism after a bite injury to the neck in a dog.

Prevalence and risk factors for hypoparathyroidism following total thyroidectomy in Spain: a multicentric and nation-wide retrospective analysis

PURPOSE

The prevalence of postoperative hypoparathyroidism has been studied in registries and in surgical series with highly variable and imprecise results. However, the frequency of this hormonal deficiency in the clinical practice of endocrinologists is not known with accuracy. We aimed to assess the prevalence and risk factors of hypoparathyroidism in patients undergoing total thyroidectomy in Spain.

METHODS

We designed a retrospective, multicentre and nation-wide protocol including all patients with total thyroidectomy who were seen in the endocrinology clinic of the participant centers from January to March 2018. Prevalence of hypoparathyroidism was evaluated at discharge of surgery, 3-6 months after surgery, 12 months after surgery and at last visit. Twenty hospitals participated in the study.

RESULTS

Of 1792 patients undergoing total thyroidectomy, 866 (48.3%) developed postoperative hypoparathyroidism at discharge of surgery. Most of them recover parathyroid function over time. Prevalence of hypoparathyroidism at 3-6 months, 12 months and at last visit was 22.9%, 16.7% and 14.5%, respectively. The risk of developing definitive hypoparathyroidism was related to the presence of parathyroid tissue at histology, lymph node dissection, and two-stage thyroidectomy. Patients with thyroid cancer, with higher postoperative calcium levels and treated by expert surgical teams exhibited lower risk of developing permanent hypoparathyroidism.

CONCLUSIONS

Although most patients with postsurgical hypoparathyroidism recover parathyroid function, the prevalence of permanent disease in clinical practice is non negligible (14.5%). Postoperative calcium, extent and timing of surgery, the presence of cancer, expert surgical team, and parathyroid tissue at histology are predictors of permanent hypoparathyroidism.

Thyroid and Parathyroid Functions After Pharyngo-Laryngo-Esophagectomy for Cervical Esophageal Cancer

BACKGROUND

Cervical esophageal cancer (CEC) patients whose larynx function cannot be preserved often undergo chemoradiotherapy, whereas those with residual or recurrent lesions undergo a pharyngo-laryngo-esophagectomy (PLE); however, some need to undergo a pharyngolaryngectomy with total esophagectomy (PLTE) for synchronous or metachronous esophageal cancer. We retrospectively evaluated the relationship between preoperative irradiation (or the extent of esophageal resection) and postoperative endocrine complications in CEC, including hypothyroidism and hypoparathyroidism.

METHODS

The cancers of 35 (5.4%) of 678 esophageal cancer patients with esophagectomy treated in 2000-2017 were CECs. We also analyzed the 17 cases of CEC patients who underwent PLE with thyroid lobectomy-11 with irradiation before PLE and 6 without irradiation. Seven patients underwent a PLTE.

RESULTS

Hypothyroidism and hypoparathyroidism occurred in 14 and 12 patients, respectively. The hypothyroidism rate was significantly higher in patients with irradiation versus those without irradiation (100% vs. 50%; p = 0.010), and the hypoparathyroidism rate was significantly higher in the PLTE versus non-PLTE patients (100% vs. 50%; p = 0.026). The mean levothyroxine dosage was 1.60 μg/kg/day in the PLE patients post-irradiation.

CONCLUSIONS

Irradiation appears to be a risk factor for hypothyroidism after PLE with thyroid lobectomy, while PLTE might have some effect on hypoparathyroidism. Due to vocal function loss, PLE patients may experience symptoms from endocrine complications. Levothyroxine treatment soon after PLE for post-irradiation patients and patients requiring as-needed calcium or vitamin D supplementation based on biochemical hypocalcemia for PLE (especially PLTE), may be effective in preventing symptomatic endocrine complications.

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

Introduction

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

Aim

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

Patients and Methods

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

Results

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

Conclusions

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

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

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

Clinical Utility of Intraoperative Parathyroid Hormone Measurement in Children and Adolescents Undergoing Total Thyroidectomy

Background: Hypoparathyroidism is one of the most common complications for patients undergoing total thyroidectomy. Our study's primary objective was to assess if intraoperative PTH levels correlate with parathyroid gland function recovery time in pediatric patients following total thyroidectomy. Methods: Retrospective review of pediatric patients who underwent thyroid surgery at CHOP for demographics and laboratory test values (calcium, phosphorus, and parathyroid hormone). We defined Time of Recovery (TOR) as the time difference from first intra-operative parathyroid hormone level (ioPTH) timepoint until normalization of PTH (> 10 pg/mL) post-thyroidectomy. Calcium and vitamin D supplements were weaned following normalization of calcium and phosphorous levels postoperatively. Patients were excluded if they lacked three intraoperative PTH timepoints or were missing postoperative follow-up PTH data. Results: 65 patients (54 female), median age 15 (range 5-23 years), underwent thyroid surgery and met study inclusion criteria. The correlations of 2nd and 3rd ioPTHs with TOR were statistically significant (p < 0.05): the lower the ioPTH, the greater the recovery time. Stratifying patients into high-risk (2nd ioPTH ≤ 10 pg/mL), moderate-risk (2nd ioPTH between 10 and 20 pg/mL), and low-risk (2nd ioPTH ≥ 20 pg/mL) tertiles, the TOR decreased by orders of magnitudes from an average of 43.13 ± 76.00 to 6.10 ± 17.44 to 1.85 ± 6.20 days. These differences were statistically significant (p < 0.05). Conclusions: Our study results confirm the usefulness of intraoperative PTH levels to predict pediatric patient recovery post-surgery and provides useful anticipatory guidance to optimize timing and frequency of postoperative laboratory surveillance.

Predictors of graft function after parathyroid autotransplantation during thyroid surgery

BACKGROUND

The purpose of this study was to identify predictors associated with graft function after parathyroid autotransplantation during thyroid surgery.

METHODS

One hundred fifty patients who underwent thyroid surgery with parathyroid autotransplantation were enrolled prospectively. During surgery, the misresected or devascularized parathyroid gland was autografted in the brachioradialis muscle of the forearm. Parathyroid hormone (PTH) levels in both arms were measured regularly after surgery. Patient age, sex, extent of surgery, and postoperative serum calcium levels were recorded.

RESULTS

Graft function was documented in 115 patients (76.7%). Univariate analysis revealed that graft function had a significant association with lower serum calcium level 1 day after surgery. The cutoff point was 2.11 mmol/L, which was confirmed by a receiver-operating characteristic (ROC) curve.

CONCLUSION

Low serum calcium levels in the early postoperative period may stimulate a functional recovery in an autografted parathyroid gland. Therefore, a moderate calcium supplement strategy was recommended for patients who underwent parathyroid autotransplantation during the early stage after total thyroidectomy.

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

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

Parathyroid autotransplantation in thyroid surgery

BACKGROUND

Careful parathyroid gland dissection and in situ preservation was the time-honored approach to prevent parathyroid failure after total thyroidectomy. The relative success of parathyroid autotransplantation of hyperplastic parathyroid tissue in patients with renal or hereditary hyperparathyroidism did popularize the use of normal parathyroid tissue autografts during thyroidectomy to prevent permanent hypoparathyroidism. Proof of autograft function in this setting, however, is controversial.

PURPOSE

This narrative review aims at reviewing critically the current status of parathyroid autotransplantation during total thyroidectomy. It is also meant to analyze from the historical, methodological, and clinical points of view the claimed benefit of normal parathyroid gland autotransplantation. A focus is placed on the prevention of permanent hypoparathyroidism by parathyroid autotransplantation.

CONCLUSIONS

Liberal parathyroid autotransplantation was proposed in the mid 1970s but evidence of function is scarce. Proofs are accumulating that parathyroid autografts not only increase the rate of postoperative hypocalcemia, but may be also contribute to permanent hypoparathyroidism.

Does the number of parathyroid glands autotransplanted affect the incidence of hypoparathyroidism and recovery of parathyroid function?

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.).

In Situ Preservation Fraction of Parathyroid Gland in Thyroidectomy: A Cohort Retrospective Study

BACKGROUND AND OBJECTIVES

Parathyroid failure is the most common symptom after thyroidectomy. To prevent it, a gland was preserved in situ or an ischemic one was autotransplanted. This study explored the relationship between in situ preservation of the parathyroid gland and gland failure.

METHODS

Consecutive patients who underwent initial total thyroidectomy were enrolled retrospectively in a prospectively maintained database. Patients were divided into groups by parathyroid gland remaining in situ fraction (PGRIF) (PGRIF = number of in situ glands/(total number of identified glands - number of glands in specimen). Patients were graded by tertiles and followed at least one year after surgery.

RESULTS

559 patients were included. PGRIF is significantly inversely associated with transient hypoparathyroidism, protracted hypoparathyroidism, and postoperative hypocalcemia. PGRIF was identified as an independent risk factor for transient hypoparathyroidism, protracted hypoparathyroidism, and postoperative hypocalcemia (OR = 0.177, 0.190, and 0.330, resp.). Autotransplantation of parathyroid gland would not affect the calcium level in the long term.

CONCLUSION

In situ preservation of parathyroid gland is crucial for parathyroid function. Less preserved is the independent risk factor for postoperative hypoparathyroidism and hypocalcemia, resulting in a worse function of parathyroid gland in the long term.

Time to parathyroid function recovery in patients with protracted hypoparathyroidism after total thyroidectomy

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

To identify or not to identify parathyroid glands during total thyroidectomy

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.

Short and long-term impact of parathyroid autotransplantation on parathyroid function after total thyroidectomy

The most common complication of total thyroidectomy is parathyroid insufficiency. Acute, transient, post-operative hypoparathyroidism increases length of hospitalization, morbidity and cost associated with total thyroidectomy. While permanent hypoparathyroidism poses a significant medical burden with lifetime medication, regular follow up and considerable disease burden related to chronic renal failure and other sequelae. Parathyroid autotransplantation has been demonstrated to result in biochemically functional grafts, leading to the procedures' common use during total thyroidectomy. The clearest indications for parathyroid auto transplantation are inadvertently removed or devascularized parathyroid glands. Some centers utilize routine autotransplantation to reduce the risk of permanent hypoparathyroidism. Novel fluorescence techniques to aid in parathyroid detection during thyroid surgery are under evaluation. This review aims to define the role and impact of parathyroid autotransplantation undertaken during total thyroidectomy.