High-dose preoperative cholecalciferol to prevent post-thyroidectomy hypocalcaemia: A randomized, double-blinded placebo-controlled trial

Preoperative Vitamin D Supplementation to Reduce Hypocalcemia Following Total Thyroidectomy: Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

This study aims to determine whether preoperative supplementation of vitamin D reduces the incidence of hypocalcemia following total thyroidectomy.

METHODS

Conducted in conformity with the PRISMA statement, a systematic review and meta-analysis of randomized clinical trials (RCT) was performed assessing postoperative hypocalcemia and postoperative symptomatic hypocalcemia.

RESULTS

The search strategy yielded 3808 potentially relevant publications, with eight RCTs ultimately included. These eight trials included a total of 902 patients (22.73% male, n = 205/902), with a median age of 48.9 years (95% CI, 43.5-53.5). Four trials administered only vitamin D in the interventional arm, three trials administered both calcium and vitamin D in the interventional arm, and one trial administered vitamin D in the interventional arm and calcium in both arms. Pooled results from the eight included trials showed a reduced risk of postoperative hypocalcemia in the intervention arm (RR, 0.77; 95% CI, 0.62-0.96; p = 0.02). When excluding the studies that administered calcium supplements in addition to vitamin D, the pooled results showed a similar reduced risk of postoperative hypocalcemia (RR, 0.74; 95% CI, 0.57-0.96; p = 0.03). Analysis of six trials reporting the incidence of postoperative symptomatic hypocalcemia (n = 564) showed a reduced risk in the vitamin D arm, with or without calcium, compared to the control arm (RR, 0.56; 95% CI, 0.34-0.93; p = 0.023).

CONCLUSIONS

Our findings suggest that preoperative vitamin D administration, with or without calcium carbonate, significantly reduces the risk of postoperative hypocalcemia and symptomatic hypocalcemia in patients undergoing total thyroidectomy.

LEVEL OF EVIDENCE: 1

Preoperative Calcium or Vitamin D Supplement in Thyroidectomy: A Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to assess the role of preoperative calcium and vitamin D supplementation in patients who underwent total thyroidectomy.

DATA SOURCES

The search for randomized controlled trials was performed in the OVID Medline and Embase databases.

REVIEW METHODS

The last search was made on September 16, 2024. Three independent reviewers evaluated full-text articles from relevant reports based on eligibility criteria. The quality of the included studies was assessed by two reviewers according to the ROB 2 tool.

RESULTS

This systematic review and meta-analysis considered 13 studies with 1504 participants. There were positive results in treatment outcomes including the mean postoperative calcium level (MD, 0.30 mg/dL: 95% CI, 0.15 to 0.44); the 48 h of postoperative hypocalcemia (OR, 0.41; 95% CI, 0.27 to 0.62); the postoperative symptomatic hypocalcemia (OR, 0.38; 95% CI, 0.24 to 0.62); the IV calcium supplementation (OR, 0.32; 95% CI, 0.18 to 0.58); and length of hospital stays (MD, -0.29; 95% CI, -0.51 to -0.07) as compared to the control group. Readmission rates showed no significant differences between the groups (OR, 0.15; 95% CI, 0.01 to 3.08).

CONCLUSIONS

Preoperative calcium and vitamin D supplementation in patients who underwent total thyroidectomy results in reduction of postoperative symptomatic hypocalcemia. The finding is critical because it offers a feasible and effective solution that could improve patient care while potentially reducing the burden of numerous blood tests during the postoperative period.

REGISTRATION

This systematic review protocol was registered with PROSPERO (registration number CRD42021278859).

LEVEL OF EVIDENCE

1 Laryngoscope, 135:1267-1277, 2025.

Guideline From the Brazilian Society of Surgical Oncology and Brazilian College of Surgeons in Preventing and Managing Acute Hypoparathyroidism After Thyroid Surgery

The risk of hypoparathyroidism and hypocalcemia is a critical concern in thyroid surgery. Preserving parathyroid gland vascularization during surgery is essential for effective prevention. Preoperative and postoperative management, including calcium and Vitamin D supplementation, is paramount. Measurement of parathyroid hormone levels after surgery is the best predictor of hypoparathyroidism. This guideline offers recommendations for the prevention, diagnosis, and treatment of acute hypoparathyroidism and hypocalcemia after thyroid surgery.

Does preoperative calcium and 1, 25 OH vitamin D supplementation impact postoperative hypocalcemia and length of stay following pediatric thyroidectomy?

OBJECTIVE

To investigate whether perioperative calcium and 1,25 OH vitamin D supplementation (PCDS) influences the rates of postoperative hypocalcemia and length of stay (LOS) following pediatric thyroidectomy.

STUDY DESIGN

Retrospective Cohort Review.

SETTING

Tertiary children's hospital.

METHODS

94 patients who underwent completion or total thyroidectomy with or without concomitant neck dissection from 2010 to 2020 at a single institution were included. Patients with pre-existing hypocalcemia or preoperative vitamin D insufficiency were excluded. Rates of postoperative hypocalcemia and LOS were compared for patients receiving PCDS to those receiving no supplementation.

RESULTS

Thirty percent of patients with PCDS had documented postoperative hypocalcemia compared to 64% of patients without PCDS (p = 0.01). Patients with PCDS had a median LOS of 30 h compared to 36 h (p = 0.002). Multivariable analyses confirmed that patients with PCDS had lower odds of postoperative hypocalcemia (OR: 0.32, CI: 0.11, 0.89) and shorter LOS by 17 h (SE: 8, p = 0.04) after adjustment for confounders.

CONCLUSION

PCDS is associated with significantly lower risk of hypocalcemia and shorter LOS. Standardizing preoperative care for pediatric patients undergoing thyroidectomy may decrease variability and improve outcomes following surgery.

Role of vitamin D supplementation in modifying outcomes after surgery: a systematic review of randomised controlled trials

BACKGROUND

There is increasing evidence to suggest vitamin D plays a role in immune and vascular function; hence, it may be of biological and clinical relevance for patients undergoing major surgery. With a greater number of randomised studies being conducted evaluating the impact of vitamin D supplementation on surgical patients, it is an opportune time to conduct further analysis of the impact of vitamin D on surgical outcomes.

METHODS

MEDLINE, EMBASE and the Cochrane Trials Register were interrogated up to December 2023 to identify randomised controlled trials of vitamin D supplementation in surgery. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. A narrative synthesis was conducted for all studies. The primary outcome assessed was overall postoperative survival.

RESULTS

We screened 4883 unique studies, assessed 236 full-text articles and included 14 articles in the qualitative synthesis, comprising 1982 patients. The included studies were highly heterogeneous with respect to patient conditions, ranging from open heart surgery to cancer operations to orthopaedic conditions, and also with respect to the timing and equivalent daily dose of vitamin D supplementation (range: 0.5-7500 mcg; 20-300 000 IU). No studies reported significant differences in overall survival or postoperative mortality with vitamin D supplementation. There was also no clear evidence of benefit with respect to overall or intensive care unit length of stay.

DISCUSSION

Numerous studies have reported the benefits of vitamin D supplementation in different surgical settings without any consistency. However, this systematic review found no clear evidence of benefit, which warrants the supposition that a single biological effect of vitamin D supplementation does not exist. The observed improvement in outcomes in low vitamin D groups has not been convincingly proven beyond chance findings.

TRIAL REGISTRATION NUMBER

CRD42021232067.

Preoperative Vitamin D and Calcium Administration in Patients Undergoing Thyroidectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Objective

This systematic review and meta-analysis aimed to assess whether preoperative administration of calcium and vitamin D prevents postoperative hypocalcemia.

Data Sources

A computerized search in Medline, Embase, and CENTRAL databases was performed.

Review Methods

Trials comparing preoperative calcium and vitamin D administration with either placebo or nothing were eligible for inclusion. The primary outcomes were the occurrence of laboratory hypocalcemia, mean postoperative calcium level, and symptomatic hypocalcemia. The secondary outcomes were the development of permanent hypoparathyroidism and length of hospitalization. Continuous outcomes were represented as standardized mean difference (SMD), and dichotomous outcomes were represented as risk ratio (RR).

Results

Nine trials that enrolled 1079 patients were found eligible. Postoperative laboratory hypocalcemia occurred less in patients who received preoperative calcium and vitamin D, but it was not statistically significant (RR = 0.77, 95% CI: 0.60-1.00; P = .05). Mean postoperative calcium level was significantly higher in the intervention group (SMD = 0.10, 95% CI: 0.07-0.12; P < .00001). The number of patients with symptomatic hypocalcemia was significantly lower in the intervention group (RR = 0.54, 95% CI: 0.38-0.76; P = .0005). There was no significant difference between the 2 groups in cases of permanent hypoparathyroidism and length of hospitalization.

Conclusion

Administration of calcium and vitamin D preoperatively achieves lower rates of postthyroidectomy symptomatic hypocalcemia in comparison with no intervention.

Prevention of hypocalcemia and hypoparathyroidism after total thyroidectomy. Recommendations of the Francophone Association of Endocrine Surgery (AFCE) with the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine (SFMN)

Postoperative hypoparathyroidism, resulting from removal and/or devascularization of one or more parathyroid glands, is a feared complication of total thyroidectomy. Two forms, which are distinguished by their frequency, their time to onset and their duration as well as by their presentation, must be individualized: early postoperative hypocalcemia, often secondary to early hypoparathyroidism is a frequent and often transient situation occurring within the first days after surgery; permanent hypoparathyroidism, which is rarer, manifests when parathyroid function remains impaired for more than six months after surgery. Because of their severity, these conditions must be known and ideally prevented during total thyroidectomy. The objective of this article is to provide surgeons with practical recommendations for the prevention, diagnosis, and treatment of hypoparathyroidism after total thyroidectomy. These recommendations, which are the fruit of a medico-surgical consensus, were developed by the Francophone Association of Endocrine Surgery (AFCE), the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine and Molecular Imaging. (SFMN). The content, grade and level of evidence for each recommendation was decided after consultation within a panel of experts, based on an analysis of recent literature.

The role of preoperative vitamin D and calcium in preventing post-thyroidectomy hypocalcaemia: a systematic review

BACKGROUND

The thyroid gland plays an important endocrine function regulating metabolism, growth and development. A variety of benign and malignant conditions necessitate surgical removal of the thyroid gland, either in its entirety, or partially. Thyroidectomy is the most commonly undertaken endocrine surgery. Hypocalcaemia, occurring at a rate of approximately 25%, is the most common complication following total thyroidectomy. Hypocalcaemia can increase healthcare costs requiring further investigations, treatment and delaying discharge. Severe hypocalcaemia can be potentially life threatening. It has been demonstrated that routine post-operative supplementation with Vitamin D and calcium, can reduce post-operative hypocalcaemia, at present it is unclear whether preoperative supplementation has a similar effect.

METHODS

This systematic review includes randomised controlled trials on human adult subjects, who received preoperative Vitamin D and/or calcium, and which studied the effect on post-operative hypocalcaemia following total or near total thyroidectomy. There were no restrictions in respect of post-operative supplementation regimen. Studies were limited to those published in English.

RESULT

Seven of the eleven trials demonstrated a reduction in either laboratory or clinical hypocalcaemia with preoperative supplementation. This benefit was most likely to be seen when postoperative supplementation was performed on an as needed basis. IV calcium was required to treat resistant or severe hypocalcaemia, in five of the eleven trials, in each of these five trials, rates of IV replacement were lower in the preoperative supplementation group.

CONCLUSION

The use of preoperative Vitamin D, with or without calcium, may provide a modest reduction in the incidence of laboratory and clinic hypocalcaemia following total or near total thyroidectomy. There is a trend toward a reduced requirement for IV calcium with preoperative supplementation. Larger robust randomised trials are needed to provide a definitive answer. Preoperative supplementation can be considered in patients undergoing total or near total thyroidectomy.

Perioperative versus postoperative calcium and vitamin D supplementation to prevent symptomatic hypocalcemia after total thyroidectomy: a randomized placebo controlled trial

BACKGROUND

Hypocalcemia is the most common complication following total thyroidectomy. This study aimed to evaluate the efficacy of perioperative combined calcium and vitamin D supplementation compared to postoperative combined calcium and vitamin D supplementation in reducing symptomatic hypocalcemia.

MATERIALS AND METHODS

A prospective randomized placebo-controlled trial was carried out in patients undergoing total or completion thyroidectomy from June 2017 to May 2022. Eligible patients were assigned to receive either calcium carbonate and alfacalcidol or placebo 3 days before surgery, and both groups were given calcium carbonate and alfacalcidol for 14 days after surgery. Clinical outcomes (signs and symptoms of hypocalcemia, requirement of intravenous calcium, and medication-induced hypercalcemia) and laboratory results (calcium and parathyroid hormone levels) were compared between the two groups.

RESULTS

One hundred and thirty-four patients were included in the analysis, 68 were in perioperative oral calcium and vitamin D supplementation group, and 66 were in postoperative oral calcium and vitamin D supplementation group. Symptomatic hypocalcemia rates were significantly lower in the perioperative group than in the postoperative group (8.8 and 22.7%, respectively, P=0.033). All symptomatic hypocalcemia cases in the perioperative group occurred in the first 24 hours after surgery. Mean calcium levels were significantly higher in the perioperative group at 24 and 48 hours after surgery. Intravenous calcium requirement rate was lower in the perioperative group but the difference was insignificant (2.9 and 12.1%, P=0.053). Mean parathyroid hormone levels were within the normal range and did not differ between groups. No medication-induced hypercalcemia was detected in either group.

CONCLUSION

Perioperative oral calcium and vitamin D supplementation significantly decreased the risks of symptomatic and biochemical hypocalcemia compared to postoperative oral calcium and vitamin D supplementation. The perioperative supplementation also shortened the recovery period of symptomatic hypocalcemia to within 24 hours.

Effectiveness of prophylactic calcium and vitamin D supplementation for preventing post-thyroidectomy hypocalcemia: a meta-analysis

Background: Postsurgical hypocalcemia is the most common and troublesome consequence of thyroidectomy. We investigated the potential role of routine calcium or vitamin D supplementation in preventing postsurgical hypocalcemia. Methods: We searched MEDLINE and Embase for English-language publications using the keywords “calcium,” “vitamin D,” and “thyroid cancer.” The primary outcome was any postoperative hypocalcemia, and the secondary outcome was symptomatic hypocalcemia. Results: Four studies that included 381 patients were eligible for this meta-analysis. A random-effects model showed no significant difference in the occurrence of hypocalcemia between calcium/vitamin D treatment and placebo/no treatment. However, the occurrence of symptomatic hypocalcemia was lower in patients with calcium/vitamin D treatment. In the combined results, preoperative calcium and vitamin D supplementation were associated with a reduced incidence of symptomatic hypocalcemia. Conclusions: Our findings support the use of preoperative calcium and vitamin D supplementation in conjunction with routine postsurgical supplementation for patients after total thyroidectomy.

Post-thyroidectomy hypocalcemia: Is a routine preferable over a selective supplementation?

BACKGROUND

Comparative studies among protocols for the management of post-total thyroidectomy (TT) hypocalcemia are lacking. We compared the effectiveness of PTH-driven selective supplementation (PD-SS) and routine calcium and calcitriol supplementation with preoperative calcitriol administration in preventing symptomatic hypocalcemia (SH) and readmission.

METHODS

Three-hundred consecutive patients undergoing TT were assigned to 3 groups: the PD-SS group, the high-dose routine supplementation (HD-RS) group and the low-dose routine supplementation (LD-RS) group.

RESULTS

Mean post-operative stay was shorter in HD-RS patients when compared to PD-SS and LD-RS (p < 0.001). Significantly more patients in the PD-SS group experienced SH (p = 0.042). The rate of post-operative hypocalcemia was not significantly different among the groups (p = 0.063). No readmission for SH or hypercalcemia occurred.

CONCLUSIONS

HD-RS emerged as the most effective treatment to prevent SH, without increasing the risk of readmission for calcitriol-related hypercalcemia. Basing on the present results, HD-RS should be recommended as the preferable protocol.

Use of pre-operative calcium and vitamin D supplementation to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy: a systematic review

OBJECTIVE

This systematic review aimed to establish the evidence behind the use of pre-operative calcium, vitamin D or both calcium and vitamin D to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy.

METHOD

This review included prospective clinical trials on adult human patients that were published in English and which studied the effects of pre-operative supplementation with calcium, vitamin D or both calcium and vitamin D on the rate of post-operative hypocalcaemia following total thyroidectomy.

RESULTS

Seven out of the nine trials included reported statistically significantly reduced rates of post-operative laboratory hypocalcaemia (absolute risk reduction, 13-59 per cent) and symptomatic hypocalcaemia (absolute reduction, 11-40 per cent) following pre-operative supplementation.

CONCLUSION

Pre-operative treatment with calcium, vitamin D or both calcium and vitamin D reduces the risk of post-operative hypocalcaemia and should be considered in patients undergoing total thyroidectomy.

Phase II randomized study of preoperative calcitriol to prevent hypocalcemia following thyroidectomy

BACKGROUND

A prospective, stratified, randomized, double-blind, placebo-controlled study was conducted to observe the impact of preoperative calcitriol supplementation on serum calcium levels following total thyroidectomy.

METHODS

Subjects were randomized 1:1 to receive 1 μg calcitriol or placebo for 1 week preceding thyroidectomy. The primary outcome measure was change in serum calcium from baseline to 18 h post-thyroidectomy. Subjects were also assessed for incidence of symptomatic hypocalcemia, length of stay, readmission for hypocalcemia, and intravenous calcium supplementation.

RESULTS

Forty-seven patients underwent thyroidectomy; 23 received preoperative calcitriol supplementation, and 24 received placebo. Repeated measures regression demonstrated no difference in postoperative serum calcium over time (p = 0.22). There were no occurrences of hypocalcemia, intravenous calcium supplementation, or readmission in either group. No difference was observed in length of stay (p = 0.38). One patient in the calcitriol group developed Grade 3 hypercalcemia.

CONCLUSIONS

Preoperative calcitriol supplementation had no impact on postoperative serum calcium levels compared to placebo.

Does Preoperative Calcium and Calcitriol Decrease Rates of Post-Thyroidectomy Hypocalcemia? A Randomized Clinical Trial

BACKGROUND

Postoperative hypocalcemia is the most common complication after thyroidectomy. Postoperative supplementation with calcium and calcitriol reduces its occurrence; however, prophylactic preoperative supplementation has not been studied systematically. The primary objective of this study was to determine whether pre- and postoperative calcium and calcitriol supplementation reduces postoperative hypocalcemia after total thyroidectomy compared with postoperative supplementation alone.

STUDY DESIGN

We conducted a single-institution prospective randomized trial enrolling 82 patients undergoing total thyroidectomy from July 2017 through May 2019. Those undergoing partial thyroidectomy or concurrent planned parathyroidectomy were excluded. The intervention group started calcitriol 0.25 μg po bid and calcium carbonate 1,500 mg po tid 5 days preoperatively and continued postoperatively. The control group started these medications postoperatively. The primary end point was clinical or biochemical hypocalcemia. Secondary outcomes were postoperative calcium levels, need for intervention, length of stay, and readmission.

RESULTS

Thirty-eight patients were randomized to the intervention group and 44 to the control group. There were 12 episodes of hypocalcemia; 5 (13.2%) in the intervention and 7 (15.9%) in the control group (p = 0.76). No differences were found in secondary outcomes; including postoperative calcium levels at each measured time point, need for intervention (n = 10 [26.3%], n = 15 [34.1%]; p = 0.48), length of stay (mean [SD] 32.3 [15.6] hours, 30.7 [10.5] hours; p = 0.6), or readmissions (n = 0 [0.0%], n = 3 [6.8%]; p = 0.24).

CONCLUSIONS

Starting supplementation with calcium and calcitriol preoperatively does not reduce postoperative hypocalcemia compared with postoperative supplementation alone after total thyroidectomy. These findings do not support the practice of routine calcium and calcitriol supplementation before total thyroidectomy.

Post-Operative Permanent Hypoparathyroidism and Preoperative Vitamin D Prophylaxis

Permanent hypoparathyroidism, a feared thyroidectomy complication, leads to significant patient morbidity, medical treatment, and monitoring. This study explores whether preoperative high-dose vitamin D loading decreases the incidence of permanent hypoparathyroidism. In a subgroup analysis, the study examines the predictive utility of day 1 parathyroid hormone (PTH) in permanent hypoparathyroidism. Patients (n = 150) were previously recruited in the VItamin D In Thyroidectomy (VIDIT) trial, a multicentre, randomised, double blind, placebo-controlled trial evaluating the role of 300,000 IU cholecalciferol administered orally a week before total thyroidectomy. Patients were contacted postoperatively beyond six months through a telephonic questionnaire. The primary outcome was permanent hypoparathyroidism, strictly defined as the need for activated vitamin D six months postoperatively. Out of 150 patients, 130 (86.7%) were contactable. Permanent hypoparathyroidism occurred in 11/130 (8.5%) patients, with a lower incidence of 5.3% (3/57) in the cholecalciferol group compared to 11% (8/73) in the placebo group; however, this was non-significant (p = 0.34). In a subgroup analysis, no relationship between day 1 PTH level and the incidence of permanent hypoparathyroidism was found (p ≥ 0.99). There was a lower rate of permanent hypoparathyroidism in the cholecalciferol group, which was not significant. The predictive utility of day 1 postoperative PTH levels may be limited to transient hypoparathyroidism.