Postoperative hypocalcemia: analysis of factors influencing early hypocalcemia development following thyroid surgery

Early parathyroid hormone (PTH) level as a predictor of post-surgical hypoparathyroidism

INTRODUCTION

Post-operative hypocalcemia and postoperative persistent hypoparathyroidism remain the most common complications after thyroidectomy. Many approaches have been developed to prevent them, but actually, a common protocol is not yet individuated.

MATERIALS AND METHODS

We retrospectively analyzed the results of a prospectively collected database. We dosed PTH preoperatively and 4 h after surgery (PTH_4); calcium was evaluated preoperatively, on the first (I_POD) and on the second postoperative day (II_POD). Hypocalcemia was defined when calcium <8 mg/dl. PTH_4 and I_POD calcium serum levels are identified to predict postoperative hypocalcemia.

RESULTS

Three hundred and forty-eight patients were enrolled, 37 patients resulted as hypocalcemic on I_POD and 41 on the II_POD. PTH_4 is related to I_POD (p < 0.001, r = 0.45) and II_POD (p < 0.001, r = 0.44) calcemia. PTH_4-cut-off predicting I_POD hypocalcemia was 10.50 pg/ml (sensitivity: 78.7%, specificity: 72.7%). A PTH_4 value of 11.5 pg/ml is able to predict hypocalcemia during II_POD (sensitivity: 76.5%, specificity: 69.2%). We set up a combined test to predict II_POD hypocalcemia, using PTH_4 and I_POD calcium (sensitivity: 77.8%, specificity: 89.9%).

CONCLUSION

This research shows the association between PTH_4 and postoperative hypocalcemia. The PTH_4 cut-off to predict I_POD-hypocalcemia was 10.5 pg/ml. We analyzed the calcemia trend during the postoperative period and we realized a combined test using PTH_4 and I_POD-calcemia. This test improves the accuracy of the previous test. Further studies, in particular multicentric, with a larger sample are necessary to validate the combined model.

Modern internet search analytics and thyroidectomy: What are patients asking?

Objectives

Thyroidectomy is among the most commonly performed head and neck surgeries, however, limited existing information is available on topics of interest and concern to patients.

Study Design

Observational.

Setting

Online.

Methods

A search engine optimization tool was utilized to extract metadata on Google-suggested questions that "People Also Ask" (PAA) pertaining to "thyroidectomy" and "thyroid surgery." These questions were categorized by Rothwell criteria and topics of interest. The Journal of the American Medical Association (JAMA) benchmark criteria enabled quality assessment.

Results

A total of 250 PAA questions were analyzed. Future-oriented PAA questions describing what to expect during and after the surgery on topics such as postoperative management, risks or complications of surgery, and technical details were significantly less popular among the "thyroid surgery" group (P < 0.001, P = 0.005, and P < 0.001, respectively). PAA questions about scarring and hypocalcemia were nearly threefold more popular than those related to pain (335 and 319 vs. 113 combined search engine response page count, respectively). The overall JAMA quality score remained low (2.50 ± 1.07), despite an increasing number of patients searching for "thyroidectomy" (r(77) = 0.30, P = 0.007).

Conclusions

Patients searching for the nonspecific term "thyroid surgery" received a curated collection of PAA questions that were significantly less likely to educate them on what to expect during and after surgery, as compared to patients with higher health literacy who search with the term "thyroidectomy." This suggests that the content of PAA questions differs based on the presumed health literacy of the internet user.

Incidence of Post-Thyroidectomy Hypoparathyroidism and Associated Preoperative and Intraoperative Risk Factors

INTRODUCTION

Thyroidectomy technique and extent are related to parathyroid injury and hypoparathyroidism. Total thyroidectomy is one of the most commonly performed endocrine surgeries, and the majority of patients recover completely without any complications. However, persistent hypoparathyroidism is the most prevalent long-term consequence following total thyroidectomy. While it is seldom deadly, it can cause severe morbidity for the patient and raise healthcare expenses.

METHODS

This retrospective cohort study was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia. We included all confirmed thyroid cancer cases that underwent thyroidectomy with or without neck dissection between July 2016 and August 2022. The data was collected from a chart review of the electronic medical record system (BEST-care), and a data collection sheet was utilized. SPSS version 26 was used to analyze the data.

RESULTS

A total of 192 patients undergoing thyroid surgery were enrolled. One hundred forty-three (74.5%) were females and the mean age of participants was 45.29 ± 16.88 years. Most patients, 170 (88.5%), had a papillary histological type, and total thyroidectomy was performed in 150 (78.1%). A significant association was found between the type of surgery and postoperative hypoparathyroidism (p=<0.05*). In addition, hypocalcemia was seen in 147 (76.6%) of the patients. Postoperative hypoparathyroidism was significantly higher among patients who had asymptomatic postoperative hypocalcemia and those who received IV calcium gluconate (p=<0.05*). Moreover, postoperative hypocalcemia, hypomagnesemia, and hyperphosphatemia were significantly associated with postoperative hypoparathyroidism (p=<0.05*).

CONCLUSION

The incidence of postoperative hypoparathyroidism is significantly higher among patients who underwent total thyroidectomy and had a normal level of preoperative parathyroid hormone (PTH) and magnesium (Mg) levels. Identifying these factors is a crucial step to minimize the occurrence of such complications.

How to Manage Advanced Differentiated Thyroid Cancer: Step-by-Step Analysis from Two Italian Tertiary Referral Centers

BACKGROUND

Differentiated thyroid carcinoma (DTC) has an excellent prognosis; however, advanced disease is associated with a worse prognosis and is relatively common. Surgery followed by RAI treatment remains the mainstream treatment for a large majority of patients with high- and intermediate-risk DTC, but its benefits should be carefully weighed against the potential for harm. The aim of this paper is to critically review the experience in treating advanced DTC at two tertiary referral centers in Italy.

METHODS

Retrospective analysis of 300 patients who underwent surgery for ADTC over 30 years.

RESULTS

The complication rate was 50.33%. A total of 135 patients (45%) remained at regular follow-up, 118 (87.4%) were alive, while 17 (12.6%) were deceased. The mean overall survival at 12 years was 84.8% with a mean of 238 months. Eleven patients (8.1%) experienced a relapse after a median of 13 months.

CONCLUSIONS

ADTC patients adequately treated can achieve prolonged survival even in the case of metastasis or disease relapse. Patients with ADTC should be referred to high-volume centers with the availability of an extended multidisciplinary team to receive tailored treatment.

A Comparison of Harmonic Scalpel and Conventional Techniques for Thyroidectomy

Thyroidectomy is one of the most frequently performed surgeries. Conventional techniques using electrocautery carry the risk of tissue injury. Recently, there has been increased use of harmonic scalpels in thyroid surgery. The harmonic scalpel utilizes ultrasonic shears for cutting and coagulation, thus minimizing thermal injury. The objective of our study was to determine differences in operative duration, hypocalcemia, and RLN palsy. This single-center retrospective comparative study included consecutive patients undergoing hemithyroidectomies using the harmonic scalpel and conventional technique in the past one year (n = 64, harmonic group = 28 and conventional group = 36). The mean operative duration for the harmonic scalpel group was 70.4 min, vs. 81.31 min for the conventional technique group, and the difference in mean duration was found to be 10.84 min (p = 0.027). There was no statistically significant difference in the rates of hypocalcemia (p = 0.751) or RLN palsy (p = 0.121). None of the patients in either group developed permanent hypocalcemia or RLN palsy. The use of a harmonic scalpel during thyroidectomy is safe. The overall surgical duration was reduced when the harmonic scalpel was used, and the complication rates were comparable to those of the conventional technique, making it a non-inferior technique for surgical intervention in thyroidectomy and warranting harmonic scalpel consideration as a valuable addition to the armamentarium of thyroid surgeons.

A Rare Case of Thyroidea Ima Arising From the Internal Thoracic Artery and Reaching Up to the Parathyroid Gland

The thyroidea ima artery (TIA), also known as the Neubauer artery, is a variable artery that takes part in the blood supply of the thyroid gland. The overall prevalence rate of the thyroidea ima artery is 3.3%. Though it most commonly branches off the brachiocephalic trunk or the arch of the aorta, the artery has a highly variable origin point. Herein, we present a rare case of a thyroidea ima originating from the left internal thoracic artery, found during routine dissection of a Caucasian, 76-year-old, male, formalin-fixed cadaver. The artery is a normal finding during embryological development as a part of a more extensive network of vessels supplying the thyroid gland. The latter undergoes significant remodeling, and only four superior and inferior thyroid arteries remain. Thus, the presence of the thyroidea ima is considered to be due to changes in the said remodeling process. Due to its course, anteriorly to the trachea, the thyroidea ima artery might pose problems during different surgical procedures regarding the inner anterior region of the neck, such as tracheotomy, thyroidectomy, laryngeal transplantation, and selective embolization of the thyroid arteries (SETA). Furthermore, complications during the operative treatment of parathyroid conditions and mediastinal bleeding are to be expected. The variable presence and origin of the thyroidea ima have clear and significant clinical and surgical implications. They must be considered when procedures in the neck's anterior region occur.

Incidence and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy

PURPOSE

The incidence and risk factors for hypoparathyroidism after total thyroidectomy is well-known. However, the characteristics of hypoparathyroidism and hypocalcemia after hemithyroidectomy have not been investigated well. In this study, we aimed to evaluate the incidence, characteristics, and risk factors of hypoparathyroidism and hypocalcemia after hemithyroidectomy.

METHOD

We retrospectively analyzed the medical data of 321 patients who underwent hemithyroidectomy, with or without central neck dissection, from January 2012 to April 2019. We analyzed the serum intact parathyroid hormone (iPTH), calcium, and ionized calcium (iCa) levels serially (preoperatively and postoperatively on the operation day; days 1 and 3; and months 1, 3, 6, and 12) and evaluated risk factors for postoperative hypoparathyroidism and hypocalcemia.

RESULTS

The mean iPTH and calcium levels decreased significantly after hemithyroidectomy on the operation day and postoperative days 1 and 3, and returned to the preoperative level at the postoperative 1-month follow-up. The mean iCa level decreased significantly on the operation day and postoperative day 1. Transient hypoparathyroidism and transient hypocalcemia occurred in 16 (5%) and 250 (78%) participants, and they recovered to normal levels postoperatively by 1 month. Eight (2.5%) patients had mild symptoms of hypocalcemia necessitating oral calcium supplementation. No permanent hypoparathyroidism or hypocalcemia was observed. Preoperatively low serum iPTH and calcium levels were associated with transient hypoparathyroidism and hypocalcemia after hemithyroidectomy.

CONCLUSION

Approximately 5% and 2.5% of participants showed transient hypoparathyroidism and mild symptomatic hypocalcemia after hemithyroidectomy. The risk factors for transient hypoparathyroidism and hypocalcemia include preoperative low serum iPTH and calcium levels.

Increased Risk of Complications Associated With Concurrent Parathyroidectomy in Patients Undergoing Total Thyroidectomy

INTRODUCTION

We sought to investigate the association of concurrent parathyroidectomy (PTX) with risks of total thyroidectomy (TTX) through analysis of Collaborative Endocrine Surgery Quality Improvement Program data. TTXis a common operation with complications including recurrent laryngeal nerve injury, neck hematoma, and hypoparathyroidism. A subset of patients undergoing thyroidectomy undergoes planned concurrent PTX for treatment of primary hyperparathyroidism. There are limited data on the risk profile of TTX with concurrent PTX (TTX + PTX).

METHODS

We queried the Collaborative Endocrine Surgery Quality Improvement Program database for patients who underwent TTX or TTX + PTX from January 2014 through April 2020. Multivariable logistic regression was performed to predict hypoparathyroidism, vocal cord dysfunction, neck hematoma, and postoperative emergency department visit. Covariates included patient demographics, patient body mass index, indication for surgery, central neck dissection, anticoagulation use, and surgeon volume.

RESULTS

Thirteen thousand six hundred forty seven patients underwent TTX and 654 patients underwent TTX + PTX. Unadjusted rates of hypoparathyroidism were higher in TTX + PTX patients at 30 d (9.6% versus 7.4%, P = 0.04) and 6 mo (7.9% versus 3.1%, P < 0.001). On multivariable regression, TTX + PTX was associated with an increased risk of hypoparathyroidism at 30 d (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.57-2.79) and 6 mo (OR 4.63, 95% CI 3.06-7.00) and an increased risk of postoperative emergency department visit (OR 1.66, 95% CI 1.20-2.31). TTX + PTX was not associated with recurrent laryngeal nerve injury or neck hematoma.

CONCLUSIONS

Concurrent PTX in patients undergoing TTX is associated with increased risk of immediate and long-term hypoparathyroidism, which should be considered in informed consent discussions and operative decision-making.

Severe hypocalcemia as a cause of transient ischemic attack? A debatable case and evidence from literature

Hypocalcemia and transient ischemic attack (TIA) are different medical disorders; however, limited evidence suggests a possible link between the two. The underlying pathomechanisms by which hypocalcemia may cause cerebrovascular damage are difficult to comprehend. The aim of the study was to present an individual experiencing TIA that possibly due to severe hypocalcemia that associated with hypoparathyroidism after total thyroidectomy; and to explore the available evidence of its cause-effect relationship through available literature. A 68-year-old man presented to Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with complaints of weakness, especially in the right limbs that had worsened in the last week. The patient experienced unconsciousness for an hour before the admission; disorientation and anterograde amnesia over the time of recovering of consciousness. Other complaints included frequent muscle cramps, numbness in both arms and legs, dizziness, swallowing difficulty, nausea, and vomiting. The patient had a history of total thyroidectomy for a large struma diffuse 18 years ago and was prescribed several medications. However, the patient was overwhelmed by forgetfulness which had become more frequent in recent months resulting in medication nonadherence. The vital sign was stable and Chovsteck's sign was positive. The Montreal Cognitive Assessment (MoCA) revealed impairment in the visuospatial/executive component and delayed memory. Laboratory tests revealed severe hypocalcemia, altered thyroid function, hypomagnesemia, elevated D-dimer and fibrinogen, and vitamin D deficiency. TIA and severe hypocalcemia were proposed as the diagnosis. Prompt initiation of appropriate treatment, including calcium supplementation, anticoagulation, and neuroprotective agents, led to significant clinical improvement. Evidence from available literature suggests that there is a possible link between severe hypocalcemia and TIA that occurred in this patient. However, more studies are warrant to establish this cause-effect relationship.

Postoperative Serum Parathyroid Hormone Levels as a Predictor of Hypocalcemia in Patients Undergoing Total Thyroidectomy

Postoperative hypocalcemia is a common complication of total thyroidectomy; the onset and severity of post-operative hypocalcemia is unpredictable. Various attempts have been made to identify predictors of hypocalcemia. There has been an increasing interest in serum levels of parathyroid hormone (PTH) as an early predictor of the development of hypocalcemia after total thyroidectomy. However, there is no consensus on the time intervals and cut-off levels of serum PTH to predict hypocalcemia. In this study, we intend to use serum PTH levels at 4th and 12th hour after total thyroidectomy to identify patients at risk of developing Postoperative hypocalcemia and to evaluate the role of PTH in predicting hypocalcemia. A Cross sectional analytical study conducted in 33 patients undergoing total/completion thyroidectomy from December 2018 to May 2020. Serum total calcium, Serum ionized calcium and Serum intact PTH levels were measured on three occasions (Preoperative and 4th and 12th hour Postoperative). Between both Postoperative levels of PTH, the one with better predictability of hypocalcemia was determined. Postoperative 4th hour PTH is a better predictor of transient hypocalcemia than Postoperative 12th hour PTH, as the association of the former with serum ionized calcium level was statistically highly significant with p value 0.005 and 0.021 respectively. Serum PTH determination after four hours of total thyroidectomy is a relatively better predictor of transient hypocalcemia, and can guide calcium supplementation for those at high risk in the Postoperative period. However, to determine the risk of hypocalcemia at the end of 1 month of follow-up, both the Postoperative 4th and post-operative 12th hour PTH have similar diagnostic accuracy.

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.

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

Risk Factors for Hypoparathyroidism after Thyroid Surgery: A Single-Center Study

BACKGROUND

Hypoparathyroidism is one of the most common complications after thyroidectomy. This study evaluated the incidence and potential risk factors for postoperative hypoparathyroidism after thyroid surgical procedures in a single high-volume center.

METHODS

In this retrospective study, in all patients undergoing thyroid surgery from 2018 to 2021, a 6 h postoperative parathyroid hormone level (PTH) was evaluated. Patients were divided into two groups based on 6 h postoperative PTH levels (≤12 and >12 pg/mL).

RESULTS

A total of 734 patients were enrolled in this study. Most patients (702, 95.6%) underwent a total thyroidectomy, while 32 patients underwent a lobectomy (4.4%). A total of 230 patients (31.3%) had a postoperative PTH level of <12 pg/mL. Postoperative temporary hypoparathyroidism was more frequently associated with female sex, age < 40 y, neck dissection, the yield of lymph node dissection, and incidental parathyroidectomy. Incidental parathyroidectomy was reported in 122 patients (16.6%) and was correlated with thyroid cancer and neck dissection.

CONCLUSIONS

Young patients undergoing neck dissection and with incidental parathyroidectomy have the highest risk of postoperative hypoparathyroidism after thyroid surgery. However, incidental parathyroidectomy did not necessarily correlate with postoperative hypocalcemia, suggesting that the pathogenesis of this complication is multifactorial and may include an impaired blood supply to parathyroid glands during thyroid surgery.

American Thyroid Association Guidelines and National Trends in Management of Papillary Thyroid Carcinoma

Importance

Over time, the American Thyroid Association (ATA) guidelines have increasingly promoted more limited treatments for well-differentiated thyroid cancers.

Objective

To determine whether the 2009 and 2015 ATA guidelines were associated with changes in the management of low-risk papillary thyroid carcinomas on a national scale.

Design, Setting, and Participants

This historical cohort study used the National Cancer Database. All papillary thyroid carcinomas diagnosed from 2004 to 2019 in the National Cancer Database were selected. Patients with tumors of greater than 4 cm, metastases, or clinical evidence of nodal disease were excluded. Data were analyzed from August 1, 2021, to September 1, 2022.

Main Outcomes and Measures

The primary aim was to tabulate changes in the rates of thyroid lobectomy (TL), total thyroidectomy (TT), and TT plus radioactive iodine (RAI) therapy after the 2009 and 2015 ATA guidelines. The secondary aim was to determine in which settings (eg, academic vs community) the practice patterns changed the most.

Results

A total of 194 254 patients (155 796 [80.2%] female patients; median [range] age at diagnosis, 51 [18-90] years) who underwent treatment during the study period were identified. Among patients who underwent surgery, rates of TL decreased from 15.1% to 13.7% after the 2009 guidelines but subsequently increased to 22.9% after the 2015 changes. Among patients undergoing TT, rates of adjuvant RAI decreased from 48.7% to 37.1% after 2009 and to 19.3% after the 2015 guidelines. Trends were similar for subgroups based on sex and race and ethnicity. However, academic institutions saw larger increases in TL rates (14.9% to 25.7%) than community hospitals (16.3% to 19.5%). Additionally, greater increases in TL rates were observed for tumors 1 to 2 cm (6.8% to 18.9%) and 2 to 4 cm (6.6% to 16.0%) than tumors less than 1 cm (22.8% to 29.2%).

Conclusions and Relevance

In this cohort study among patients with papillary thyroid carcinomas up to 4 cm, ATA guideline changes corresponded with increased TL and reduced adjuvant RAI. These changes were primarily seen in academic institutions, suggesting an opportunity to expand guideline-based care in the community setting.

Effect of gasless endoscopic thyroidectomy through an axillary approach on the recurrent laryngeal nerve injury in patients with thyroid cancer

OBJECTIVE

To observe the effect of gasless endoscopic thyroidectomy through an axillary approach (GETAN) on the recurrent laryngeal nerve in patients with thyroid cancer.

METHODS

One hundred and ten patients with thyroid cancer admitted to the department of general surgery, the First Affiliated Hospital of Xiamen University were retrospectively selected as the research subjects. They were divided into an observation group (OG, 55 patients, treated with GETAN) and a control group (CG, 55 patients, treated with conventional radical resection for papillary thyroid cancer). Clinical indicators, pain degree, negative emotions, recurrent laryngeal nerve injury, vocal and swallowing function, and the incidence of complications were compared between the two groups.

RESULTS

In terms of clinical indicators, the operation time, intraoperative blood loss, extubation time, and hospitalization time in the OG were shorter than those of the CG (all P<0.05). The scores of Visual Analogue Scale (VAS) at one, two, and three days after surgery in the OG were lower than those in the CG (all P<0.001). As for the negative emotions, the Self-Rating Anxiety Scale score, and Self-Rating Depression Scale score in the OG were lower than those in the CG (both P<0.001). The incidence of postoperative recurrent laryngeal nerve injury in the OG was lower than that of the CG (P<0.001). Another analysis showed that GETAN was a protective factor against recurrent laryngeal nerve injury in patients with thyroid cancer (P<0.05). The Voice Handicap Index and Swallowing impairment score one week and one month after surgery were lower in the OG than in the CG (all P<0.001). The incidence of postoperative complications such as hypocalcemia, wound infection, and numbness of hands and feet in the OG was lower than that in the CG (all P<0.001).

CONCLUSION

The GETAN approach is able to relieve postoperative pain, anxiety, and depression; reduce the laryngeal recurrent nerve injury; promote the recovery of laryngeal recurrent nerve; and decrease the incidence of vocal and swallowing dysfunction It is worthy of clinical promotion.

Indocyanine Green Angiography of Parathyroid Glands versus Intraoperative Parathyroid Hormone Assay as a Reliable Predictor for Post Thyroidectomy Transient Hypocalcemia

BACKGROUND

Prediction of postoperative hypocalcemia is a fundamental issue in thyroidectomy. Indocyanine green (ICG) angiography of parathyroid glands is a feasible method to detect the perfusion of parathyroid glands and predict postoperative hypocalcemia.

MATERIALS AND METHODS

A prospective observational study was conducted at Ain Shams University Hospitals between April 2018 and April 2021. The included cases of total thyroidectomy underwent intraoperative ICG fluorescence angiography to identify the four parathyroid glands and score each gland according to the viability. Patients in which less than four glands were identified were excluded. Intraoperative intact parathyroid hormone (ioPTH) level assay was also measured to compare with ICG in predicting postoperative transient hypocalcemia.

RESULTS

A total of 134 cases underwent total thyroidectomy during the study period. We could identify the four parathyroid glands in 90 patients, including them in the study. We had postoperative hypocalcemia in 28 cases (31.1%). The diagnostic accuracy of ICG angiography and ioPTH level assay was high and almost similar (82.22% versus 87.78%). Both were higher than the surgeons' diagnostic accuracy of visual inspection (62.22%).

CONCLUSIONS

ICG angiography of the parathyroid gland is a safe, reliable predictor for postoperative transient hypocalcemia with a high and almost similar accuracy compared to intraoperative parathyroid hormone level.

Carbon Nanoparticles for Thyroidectomy and Central Lymph Node Dissection for Thyroid Cancer

PURPOSE

To evaluate whether the application of carbon nanoparticles (CNs) in total or near-total thyroidectomy combined with central lymph node dissection (CLND) for thyroid cancer (TC) is beneficial to lymph node dissection, parathyroid, and recurrent laryngeal nerve (RLN) protection.

METHODS

Relevant literatures were systematically searched on PubMed, EMBASE, and Cochrane Library Databases until March 31, 2021. All analyses were performed using Revman Manager 5.3 software. The main results were the number of central lymph nodes, the number of central metastatic lymph nodes, accidental parathyroidectomy, postoperative hypoparathyroidism, postoperative hypocalcemia, and postoperative transient RLN paralysis.

RESULTS

This meta-analysis identified 4 randomized controlled trials and 8 non-randomized controlled trials comprising 1870 patients. Compared with the control, the use of CNs was helpful to dissect more central lymph nodes (weighted mean difference [WMD]: 3.55, 95% confidence interval [CI]: 2.12-4.98, P < .00001) and central metastatic lymph nodes (WMD: 1.69, 95% CI:1.31-2.08, P < .00001), lower rate of accidental parathyroidectomy (odds ratio [OR]: .33, 95% CI: .23-.47, P < .00001), lower rate of both postoperative transient hypoparathyroidism (OR: .40, 95% CI: .31-.51, P < .00001), and transient hypocalcemia (OR: .37, 95% CI: .27-.51, P < .00001). However, there were no statistical difference between the groups for postoperative permanent hypoparathyroidism (OR: .29, 95% CI: .06-1.28, P = .10), postoperative permanent hypocalcemia (OR: .94, 95% CI: .10-9.16, P = .96), and postoperative transient RLN paralysis (OR: .66, 95% CI: .40-1.12, P = .12).

CONCLUSIONS

The application of CNs in total or near-total thyroidectomy combined with CLND for TC can better dissect the central lymph nodes and protect parathyroid glands (PGs) and their function.

Comparison of Transoral Endoscopic Thyroidectomy Vestibular Approach and Conventional Open Thyroidectomy in Benign Thyroid Tumors

Conventional open thyroidectomy remains the standard treatment of surgery for benign thyroid tumors but leaves a permanent scar in the neck. We conducted this study to compare the surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus conventional open thyroidectomy (COT), and thence analyze the safety and viability of this approach. Seventy-eight patients who had undergone either COT or TOETVA from 2020 to 2021 in our institution to treat benign thyroid tumors were prospectively studied. Outcomes between the two groups were analyzed, including time of operation, blood loss, hospital stay, postoperative complications, and level of satisfaction. A total of 78 patients, in which TOETVA was applied to 47 patients and COT thyroid surgery was applied to 31 patients, participated in this study. COT has a shorter operative time (59.8 ± 10.8 min versus 102.3 ± 34.9 min, p < .001). TOETVA is less painful postoperatively (visual analog scale score on day 4 of 1.1 ± 1.2 versus 1.8 ± 0.7, p < .001). There were no significant differences between TOETVA and COT groups regarding incidences of transient recurrent laryngeal nerve (RLN) injury (10.6% and 6.5%, respectively, p = .697) and both transient and permanent hypoparathyroidism (8.5% versus 3.5%, p = .644 with transient and 0% versus 6.7%, p = .166 with permanent). Other complications were comparable between two arms such as bleeding, seroma, and infection. At 3 months after surgery, the TOETVA group had the significantly higher proportion of the very satisfied level than the COT group (80.9% versus 35.4%, p < .001). TOETVA in patients with favorable features is a safe, viable alternative to open thyroidectomy regarding postoperative outcomes and provide higher satisfaction after surgery in the long term.

Hipocalcemia posterior a tiroidectomía total: Análisis de dosis para suplemento rutinario profiláctico

Introducción. La hipocalcemia es la complicación más frecuente de la tiroidectomía. La profilaxis con calcio/ calcitriol es una alternativa costo-efectiva, sencilla y expedita para disminuir esta situación, sin alterar la función paratiroidea residual. Lo que no está claro es si hay superioridad de una dosis frente a otra, por lo que el objetivo de este estudio fue evaluar el comportamiento entre diferentes esquemas de profilaxis para hipocalcemia. Métodos. Estudio de cohorte retrospectivo de adultos operados en un hospital de cuarto nivel, entre febrero de 2017 y diciembre de 2020. Se calculó la tasa de síntomas, la hipocalcemia e hipercalcemia bioquímica en el control postquirúrgico durante las siguientes dos semanas. Se hizo análisis bivariado y multivariado entre dosis de calcio/ calcitriol, otros factores asociados y los desenlaces mencionados. Resultados. Se incluyeron 967 pacientes. El 10 % presentaron síntomas. No hubo diferencias significativas en el calcio sérico del control posquirúrgico entre los grupos con distintas dosis de calcio. La dosis de carbonato de calcio >3600 mg/día y el calcio en las primeras 24 horas de cirugía se asociaron a la presencia de síntomas. La dosis de calcitriol  <1 mcg/día y el bocio aumentaron el riesgo de hipocalcemia bioquímica, mientras que la dosis de 1,5 mcg/día lo disminuyó. Ninguna variable evaluada se asoció a hipercalcemia bioquímica. Conclusiones. Teniendo en cuenta los resultados observados con las dosis de calcio y calcitriol, sugerimos iniciar la profilaxis con un esquema de 3600 mg/día de carbonato de calcio y 1,5 mcg/día de calcitriol. Sin embargo, esta dosis debe modificarse en situaciones como bocio o calcio sérico temprano anormal, que fueron las variables asociadas a mayor riesgo en nuestro estudio.

Risk Benefit Analysis of Routine Thymectomy for Differentiated Thyroid Cancers: A Systematic Review

Background  Central compartment lymph node dissection (CLND) is a part of the surgical management of differentiated thyroid cancer (DTC). Therapeutic CLND is done to address clinically significant central compartment nodes in patients with DTC, while prophylactic CLND is performed in the presence of high-risk features in the absence of clinically significant neck nodes. Removal of thymus—unilateral or bilateral—during CLND to achieve complete clearance of level VI and VII lymph node stations and address thymic metastasis is debatable.

Objective  The present systematic review was conducted to summarize the evidence, delineating the role of thymectomy during CLND in patients with DTC.

Methods  Electronic databases of PubMed, Embase, and Cochrane were searched from their inception to July 2020 using keywords—thyroid neoplasms or tumors, thyroidectomy, and thymectomy—to identify the articles describing the role of thymectomy during CLND in DTC. A pooled analysis of surgicopathological outcomes was performed using metaprop command in STATA software version 16.

Result  A total of three studies and 347 patients—total thyroidectomy (TT) with bilateral thymectomy in 154, TT with unilateral thymectomy in 166, and TT alone in 27 patients with DTC—were included in the systematic review. The pooled frequency of thymic metastasis was a mere 2% in patients undergoing either unilateral or bilateral thymectomy. The routine addition of thymectomy does not result in better lymph node clearance. Unilateral and bilateral thymectomy were associated with high chances of transient hypocalcemia (12.0% and 56.1%, respectively).

Conclusion  Routine thymectomy is not warranted during CLND, considering minimal oncological benefit and high risk of postoperative hypocalcemia.

Post-thyroidectomy complications in southwestern Saudi Arabia: a retrospective study of a 6-year period

BACKGROUND

Thyroidectomy is the surgical removal of all or part of the thyroid gland for non-neoplastic and neoplastic thyroid diseases. Major postoperative complications of thyroidectomy, including recurrent laryngeal nerve injury, hypocalcemia, and hypothyroidism, are not infrequent.

OBJECTIVE

Summarize the frequency of surgical complications of thyroidectomy.

DESIGN

Retrospective.

SETTING

Secondary health facility in southwestern Saudi Arabia.

PATIENTS AND METHODS

We collected data from the records of patients who were managed for thyroid diseases between December 2013 and December 2019.

MAIN OUTCOME MEASURE

Complications following thyroidectomy.

SAMPLE SIZE

339 patients, 280 (82.6%) females and 59 (17.4%) males.

RESULTS

We found 311 (91.7%) benign and 28 (8.3%) malignant thyroid disorders. Definitive management included 129 (38.1%) total thyroidectomies, 70 (20.6%) hemithyroidectomies, 10 (2.9%) subtotal thyroidectomies and 5 (1.5%) near-total thyroidectomies with 125 (36.9%) patients treated non-surgically. The overall complication rate was 11.3%. There were 4 (1.9%) patients with recurrent laryngeal nerve palsy, 16 (7.5%) patients with temporary hypoparathyroidism, 1 (0.5%) patient with paralysis of the external branch of the superior laryngeal nerve and 3 (1.4%) patients with wound hematoma.

CONCLUSION

The rate of complications following thyroidectomy is still high. There is a need for emphasis on comprehensive measures to control the high rate of complications.

LIMITATIONS

Retrospective design and no long-term follow up to monitor late complications.

CONFLICT OF INTEREST

None.

Use of Prophylactic Steroids to Prevent Hypocalcemia and Voice Dysfunction in Patients Undergoing Thyroidectomy: A Randomized Clinical Trial

Importance

Total thyroidectomy is associated with risks related to temporary hypocalcemia and vocal quality dysfunction. Dexamethasone has been proposed to have a physiological effect on hypocalcemia and voice quality.

Objective

To assess the effect of preoperative dexamethasone used to improve hypocalcemia and postthyroidectomy voice dysfunction.

Design, Setting, and Participants

This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted from January 15, 2014, to December 31, 2019, at the Department of Surgery, Holy Family Hospital in Rawalpindi, Pakistan. All patients with a benign thyroid condition and no preoperative corrected hypocalcemia and voice or vocal quality dysfunction were included. Patients were excluded if they had previous thyroid or neck surgery, known vocal cord dysfunction on laryngoscopy, hearing or voice problems, a history of gastroesophageal reflux, stomach ulcer disease, or contraindications to steroid use.

Interventions

Corrected serum calcium levels and Voice Analog Score defined and measured preoperatively. The dexamethasone group received a 2-mL intravenous dose of 8 mg of dexamethasone 60 minutes before the induction of anesthesia. In contrast, the placebo group received 2 mL of intravenous normal saline (0.9%) 60 minutes before the induction of anesthesia.

Main Outcomes and Measures

Evidence of hypocalcemia and voice dysfunction. Voice dysfunction was defined as a subjective score of less than 50 on a Voice Analog Score scale of 0 to 100 points.

Results

A total of 192 patients (mean [SD] age, 38.9 [12.4] years; 156 women [81.2%]) were included in the study, with 96 patients randomized to each study group (dexamethasone group, mean [SD] age, 39.2 [12.1] years; 75 women [78.1%]; placebo group, mean [SD] age, 38.5 [12.9] years; 81 women [84.5%]). In the first 24 hours after undergoing thyroidectomy, 47 patients (24.4%) developed hypocalcemia and 18 (9.4%) were symptomatic. At 3 days postthyroidectomy, 4 of 96 patients (4.2%) in the placebo group had hypocalcemia compared with no patients in the dexamethasone group. At 24 hours postthyroidectomy, 8 of 96 patients (8.3%) in the dexamethasone group had voice dysfunction compared with 32 of 96 patients (33.3%) in the placebo group. A total of 40 patients (20.8%) reported voice dysfunction. The absolute reduction in the rate of hypocalcemia at 24 hours was 24% (95% CI, 11.9%-35.2%) and at 3 days was 4.2% (-0.44% to 10.0%). The rate of symptomatic hypocalcemia was 19% lower in the dexamethasone group than in the placebo group (95% CI, 11.1%-27.7%). The rate of voice dysfunction was 25% lower in the dexamethasone group than in the placebo group (95% CI, 13.7%-35.7%).

Conclusions and Relevance

In this randomized clinical trial, a single preoperative dose of dexamethasone was safe and effective in reducing postoperative hypocalcemia and voice dysfunction rates in patients undergoing thyroidectomy.

Trial Registration

ClinicalTrials.gov identifier: NCT04752852.

Adverse events in thyroid surgery: observational study in three surgical units with high volume/year

Background

Thyroid surgery, performed for benign or malignant pathologies, is one of the most frequently performed procedures and its frequency has even been increasing in recent years. Postoperative bleeding, recurrent laryngeal nerve (RLN) palsy, associated to dysphonia, dysphagia, dyspnea, and hypoparathyroidism represent the most fearful and common complications. We conducted a multicenter, observational study of retrospectively collected data in three high-volume referral centers, enrolling all patients undergone to thyroid surgery between January 2016 and December 2017 in Parma University Hospital, Cagliari University Hospital and Ferrara University Hospital.

Materials

Patients were divided into five groups, differentiated thyroid carcinoma, medullary thyroid carcinoma, non-toxic benign pathology, hyperfunctioning benign pathology and NIFTP (Non-invasive Follicular Thyroid neoplasm with Papillary-like nuclear features). A follow up at 7 and 30 days was executed, evaluating the onset of paresthesia, dysphonia and dysphagia. A 6-month follow-up was conducted in cases of early complications.

Results

Totally, 1252 patients were eligible for the study: 907 female and 345 male, with a female to male ratio of 2.6:1 and an average age of 53.428. Total thyroidectomy was performed in 1022 cases, lobectomy in 230. After 6 months we recorded paresthesia in 0.5%, dysphonia in 1.8% and dysphagia in 0.5%.

Conclusion

Our study confirms once again that a share of morbidity escapes the possibilities of prediction and control by the operator, depending on patient anamnestic, pathological or anatomical factors.

Risk Factors for Low Levels of Parathyroid Hormone after Surgery for Thyroid Cancer: A Single Center Study

Background: Thyroidectomy is the definitive treatment for most patients with thyroid cancer. Hypoparathyroidism is the most frequent complication of thyroidectomy, and its pathogenesis is multifactorial. The aim of this study is to evaluate the patient- and surgical-related risk factors for hypoparathyroidism after surgery for thyroid cancer. Methods: In this retrospective study, patients referred to surgery for thyroid cancer from 2016 to 2019 were enrolled. Preoperative serum calcium and parathyroid hormone (PTH) and postoperative 24 h PTH and calcium levels were evaluated. Demographic data, type of surgery, incidence of hypoparathyroidism and hypocalcemia were recorded for all the patients. Patients were divided into two groups based on post-operative PTH levels (≤12 and >12 pg/mL). Results: A total of 189 patients were enrolled in this study. There were 146 women (87.3%) and 43 men (22.7%), with a mean age of 51.3 years. A total of 79 patients (41.7%) underwent a neck dissection. A total of 59 patients (31.1%) had a postoperative PTH level < 12 pg/mL. Female sex, neck dissection, the yield of lymph node dissection and incidental parathyroidectomy were significantly associated with postoperative hypoparathyroidism. Incidental parathyroidectomy was reported in 44 (23.2%) patients and was correlated with younger age (<40 years) and neck dissection. There was no difference in the rate of post-operative hypocalcemia between patients with incidental parathyroidectomy and those without. Conclusions: Young patients undergoing neck dissection and with incidental parathyroidectomy have the highest risk of postoperative hypoparathyroidism after surgery for thyroid cancer. However, a large proportion of patients without incidental parathyroidectomy may have temporary hypocalcemia, suggesting that impaired blood supply of parathyroid glands during their identification and dissection may play a relevant role.

Near-Infrared Autofluorescence Imaging May Reduce Temporary Hypoparathyroidism in Patients Undergoing Total Thyroidectomy and Central Neck Dissection

Background: Near-infrared autofluorescence (NIRAF) imaging is known to reduce the incidence of post-thyroidectomy hypocalcemia. However, there are no studies on how much NIRAF imaging affects the serum parathyroid hormone (PTH) level after surgery. We investigated the changes of the serum PTH level and ionized calcium (iCa.) in patients undergoing total thyroidectomy with central neck dissection (CND). Materials and Methods: This retrospective study with historical control enrolled 542 patients who underwent total thyroidectomy with CND. Patients were divided into two groups: the NIRAF group (261 patients) and the control group (281 patients). PTH and iCa. levels were measured at the hospital stay, 1, 3, and 6 months after surgery. In addition, the number of identified parathyroid glands (PGs), autotransplanted PGs, and the inadvertent resection rate of PGs was evaluated. Results: The incidence of postoperative hypoparathyroidism (PTH <15 pg/mL) was significantly lower in the NIRAF group during the hospitalization (88 patients: 33.7% vs. 131 patients: 46.6%; p = 0.002) and at 1 month postoperatively (23 patients: 8.8% vs. 53 patients: 18.9%; p = 0.001). There was no difference in the permanent hypoparathyroidism rate (6 months after surgery) between the NIRAF group and the control group (4.2% vs. 4.6%; p = 0.816). There was no difference in the incidence of hypocalcemia (iCa. <1.09 mmol/L) (during hospitalization: 6.5% vs. 10.0%; 1 month: 2.3% vs. 2.5%; 3 months: 0.8% vs. 0.7%; 6 months after surgery: 1.1% vs. 1.1%) between the two groups. The number of inadvertently resected PGs was significantly lower in the NIRAF group (18:6.9% vs. 36:12.8%; p = 0.021). Conclusions: These results suggest that NIRAF imaging may reduce temporary hypoparathyroidism and the risk of inadvertent resection of PGs in patients undergoing total thyroidectomy with CND.

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

Background

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

Methods

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

Results

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

Conclusion

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

•

Incidence of Post-thyroidectomy transient hypoparathyroidism ranges between 0.3 and 49%, while permanent hypoparathyroidism is 13%.

•

Incidence of hypocalcemia following total thyroidectomy ranging between 3% and 40% and is usually transient, while permanent hypocalcemia is ≤ 2%.

•

Post-thyroidectomy PTH accurately predict hypocalcemia.

Identification of Patients at High Risk for Postsurgical Hypoparathyroidism

BACKGROUND/AIM

Postsurgical hypoparathyroidism (PostHypo) is a common complication after total thyroidectomy. We studied the risk factors associated with PostHypo.

PATIENTS AND METHODS

The study included 109 women, (mean age: 50.7±10.75 years), who underwent total thyroidectomy for thyroid diseases.

RESULTS

Based on the development of biochemical hypocalcemia on the first postoperative day following total thyroidectomy, (cCa<8.4 mg/dl), 37 women developed PostHypo and 72 did not. Younger age, a lower preoperative corrected calcium and the presence of parathyroid glands in the specimens were related to the development of PostHypo. Of all patients, 51.4% had a vitamin D deficiency. A parathyroid hormone (PTH) value ≤9.4 pg/ml was 84.9% sensitive and 71.4% specific to predict PostHypo on the 1^st postoperative day. A 50% reduction of the PTH value on the 1^st postoperative day from the preoperative level could identify patients who develop PostHypo with 76% sensitivity and 75% specificity.

CONCLUSION

PTH postoperative measurement and its alteration from the preoperative level can be used to identify patients who are at increased risk to develop PostHypo.

Risk factors for postoperative hypocalcaemia after thyroidectomy: A systematic review and meta-analysis

Objective

A meta-analysis to investigate the risk factors for postoperative hypocalcaemia after thyroidectomy in adult patients.

Methods

A systematic search of publications in the electronic databases (PubMed®, The Cochrane Library, Web of Science, OVID and Embase®) from inception to June 2020 was conducted. Screening of titles, abstracts and full texts and data extraction were independently performed by two authors. The OR was selected as the pooled estimate.

Results

The analysis included 23 studies. Twelve significant risk factors for postoperative hypocalcaemia were identified: hypoparathyroidism, OR 5.58; total thyroidectomy, OR 3.59; hypomagnesaemia, OR 2.85; preoperative vitamin D deficiency, OR 2.32; female sex, OR 1.49; thyroid malignancy, OR 1.85; thyroiditis, OR 1.48; substernal multinodular goitres, OR 1.70; parathyroidectomy, OR 1.58; central compartment neck dissection, OR 1.17; modified radical neck dissection, OR 1.57; and central neck dissection, OR 1.54.

Conclusions

This meta-analysis provides moderate-to-high quality evidence that the 12 risk factors were predictive of postoperative hypocalcaemia, which should be monitored closely before thyroidectomy.

Effect of energy-based devices on post-operative parathyroid function and blood calcium levels after total thyroidectomy

Introduction: Energy-based devices are widely used in thyroid surgery in order to achieve optimal hemostasis, while their role in the incidence of hypocalcemia and hypoparathyroidism comprises a topic evaluated in numerous studies.Areas covered: The aim of this systematic review is to investigate the potential benefit of Ultrasonic Shears and Electrothermal Bipolar (Radiofrequency) System in thyroid surgery regarding the incidence of post-operative hypocalcemia and hypoparathyroidism. A systematic review of the literature in PubMed/Medline and Scopus databases was conducted. Forty-nine studies met the inclusion criteria and were analyzed. A statistically decreased rate of transient hypocalcemia and hypoparathyroidism was reported in 15 studies and 4 studies, respectively, when using energy-based devices. However, 18 and 13 surveys examined transient hypocalcemia and hypoparathyroidism, respectively, and demonstrated no statistical difference between energy-based devices and conventional hemostasis. No difference was observed between the groups concerning permanent hypocalcemia. Out of 13 studies, only 2 showed a significant reduction in the occurrence of permanent hypoparathyroidism in the energy-based device group.Expert opinion: Energy-based devices reduced the rate of transient hypocalcemia and hypoparathyroidism after thyroid surgeries in 42.8% and 23.5% of the included studies, respectively. Further studies are needed to evaluate their impact on permanent post-operative hypocalcemia and hypoparathyroidism.

A Meta-Analysis of Risk Factors for Transient and Permanent Hypocalcemia After Total Thyroidectomy

Background

As hypocalcemia is the most common complication of total thyroidectomy, identifying its risk factors should guide prevention and management. The purpose of this study was to determine the risk factors for postthyroidectomy hypocalcemia.

Methods

We searched PubMed, Web of Science and EMBASE through January 31, 2019, and assessed study quality using the Newcastle–Ottawa Scale.

Results

Fifty studies with 22,940 patients met the inclusion criteria, of which 24.92% (5716/22,940) had transient hypocalcemia and 1.96% (232/11,808) had permanent hypocalcemia. Significant (P < 0.05) predictors of transient hypocalcemia were: younger age, female, parathyroid autotransplantation (PA), inadvertent parathyroid excision (IPE), Graves’ disease (GD), thyroid cancer, central lymph node dissection, preoperative severe Vitamin D deficiency, preoperative Vitamin D deficiency and a lower postoperative 24 h parathyroid hormone (PTH) level. Preoperative magnesium, preoperative PTH and Hashimoto’s thyroiditis were not significant predictors of transient hypocalcemia. IPE, GD, and thyroid cancer were associated with an increased rate of permanent hypocalcemia, but gender and PA did not predict permanent hypocalcemia.

Conclusion

Important risk factors for transient and permanent hypocalcemia were identified. However, given the limited sample size and heterogeneity of this meta-analysis, further studies are required to confirm our preliminary findings.

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.

Intraoperative Nerve Monitoring in Thyroidectomies for Malignancy: Does it Matter?

BACKGROUND

Recurrent laryngeal nerve (RLN) injury and postoperative hypocalcemia are potential complications of thyroidectomy, particularly in malignancy. Intraoperative nerve monitoring (IONM) remains controversial. We sought to evaluate the impact of IONM on these complications using a national data set.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program thyroidectomy-targeted data set was queried for patients who underwent thyroidectomies from 2016 to 2017. Patients were grouped according to IONM use. Logistic regression models were constructed to evaluate associations of variables with 30-day hypocalcemic events (HCEs) and RLN injury. Associations were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). A subgroup analysis was performed of patients with malignancy.

RESULTS

A total of 9527 patients were identified; 5969 (62.7%) underwent thyroidectomy with IONM and 3558 (37.3%) without. By multivariable analysis, IONM had protective associations with HCE (OR = .81, 95% CI = .68-.96; P = .013) and RLN injury (OR = .83, 95% CI = .69-.98; P = .033). Malignancy increased risk of HCE (OR = 1.21, 95% CI=1.01-1.45; P = .038) and RLN injury (OR = 1.22, 95% CI = 1.02-1.46; P = .034). A large proportion (5943/9527, 62.4%) of patients had malignancy; 3646 (61.3%) underwent thyroidectomy with IONM and 2297 (38.7%) without. In the subgroup analysis, IONM had stronger protective associations with HCE (OR = .73, 95% CI = .60-.90; P = .003) and RLN injury (OR = .76, 95% CI = .62-.94; P = .012).

DISCUSSION

Malignancy was associated with increased risk of HCE and RLN injury. Intraoperative nerve monitoring had a protective association with HCE and RLN injury, both overall, and in the malignant subgroup. Intraoperative nerve monitoring was correlated with improved thyroidectomy outcomes, especially if the indication was malignancy. This warrants further study to clarify cause and effect.

VITOM 4K 3D Exoscope: A Preliminary Experience in Thyroid Surgery

Since its introduction in 2008, the Karl Storz 4K 3D VITOM® exoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany) has been successfully used in various surgical disciplines. This paper describes our department’s experience using this technology and its use in the first total thyroidectomy case. The set up of the 3D VITOM exoscope in the operating theatre allows for a user-friendly approach to thyroid surgery with the exoscope placed out of the line of sight of the surgeon with a monitor placed directly ahead. The surgeon has a control panel within reach, which allows for adjustments to image magnification and focus. The use of the 3D VITOM exoscope has the potential to confer significant improvements in patient outcomes by promoting efficient and safer surgery through superior operative visualisation.

The efficacy and safety of microwave ablation versus lobectomy for the treatment of benign thyroid nodules greater than 4 cm

PURPOSE

To evaluate the safety and effectiveness of microwave ablation (MWA) versus lobectomy for the treatment of benign thyroid nodules > 4 cm.

METHODS

We retrospectively analyzed the data of 48 patients who underwent MWA and 53 patients who underwent lobectomy to treat benign thyroid nodules > 4 cm. The patients were followed up for 12 months. The volume reduction ratio (VRR) was calculated. The operation time, incision length, hospitalization time, complications, thyroid function, symptoms, and cosmetic improvement were analyzed and compared between the two groups.

RESULTS

During the 12-month follow-up, the mean nodule volume in the MWA group was reduced from 36.1 ± 23.1 to 4.0 ± 4.1 ml, and the mean VRR of the nodules was 90 ± 5% in the MWA group, which was comparable with that in the surgery group. No significant postoperative change in thyroid function was observed in the MWA group. Compared with the surgery group, the incidence of complications and postoperative pain in the MWA group were lower, the operation time, incision length, and hospitalization time in the MWA group were shorter, and satisfaction with the esthetic results in the MWA group was greater.

CONCLUSION

MWA is safe and effective for the treatment of benign thyroid nodules > 4 cm. Moreover, MWA is associated with a faster recovery, fewer complications, better protection of thyroid function, and superior esthetic results relative to thyroid lobectomy.

Truncal vs Branch Ligation of Inferior Thyroid Arteries in Total Thyroidectomy: Does It Affect Postoperative Hypoparathyroidism?

OBJECTIVE

Postthyroidectomy hypoparathyroidism remains a significant challenge. Truncal ligation of the inferior thyroid arteries (ITAs) may lead to an increased risk of hypoparathyroidism; however, dissection along the thyroid capsule with branch ligation of the thyroid arteries could be a safer option. This study's objective was to compare the effect of truncal versus branch ligation of the ITAs on the rate of postoperative hypoparathyroidism.

STUDY DESIGN

Randomized prospective trial in line with the CONSORT guidelines.

SETTING

The study was conducted at a high-volume tertiary care setting.

METHODS

We randomized 319 patients into 2 groups: truncal ITA ligation (n = 157) and branch ITA ligation (n = 162). The primary outcomes were serum calcium and parathormone levels on the second postoperative day, followed by the levels on months 1, 3, 6, and 12. The need for exogenous replacements was noted. The secondary outcomes, such as operative time, blood loss, and other complications, were also recorded.

RESULTS

Our study revealed a significant difference in the incidence of transient hypocalcemia in patients undergoing truncal ITA ligation and branch ITA ligation (22.9% vs 3.1%, P < .05). The results showed that the levels of serum calcium and parathormone dropped on the second postoperative day and that 36 patients from the truncal ITA ligation group required exogenous calcium and vitamin D replacement. In contrast, only 5 patients from the branch ITA ligation group required the same.

CONCLUSIONS

This is the largest randomized trial of patients undergoing thyroidectomy, and it shows that dissection along the thyroid capsule with branch ligation of the ITAs is more likely to preserve parathyroid function as opposed to truncal ligation of ITAs.

Implications of Postpancreatectomy Hypophosphatemia

BACKGROUND

Electrolyte abnormalities are commonly found after major abdominal surgery for malignancy. We hypothesized that the severity of hypophosphatemia developed in pancreatectomy patients would be associated with the incidence of complications postoperatively.

METHODS

A retrospective analysis of an institutional database was conducted for all pancreatic resections (2009-2017). Patient charts were reviewed for demographics, clinicopathologic factors, and perioperative outcomes.

RESULTS

In a cohort of 283 pancreatectomy patients, 107 (37.8%) and 134 (47.3%) developed mild (2.0-2.5 mg/dL) and moderate/severe hypophosphatemia (<2.0 mg/dL), respectively. Nadir serum phosphate levels were shown to occur on postoperative day (POD) 2 for patients without complications and POD3 for patients who had at least 1 complication. Patients who developed severe hypophosphatemia were significantly more likely to suffer fistula-related complications (P = .0401).

CONCLUSIONS

Assessing the severity and timing of postpancreatectomy hypophosphatemia presents an opportunity for early detection of impending fistula-related complications.

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.

Elective Central Compartment Lymph Node Dissection Does not Increase the Risk of Postoperative Hypoparathyroidism in Patients Treated for Differentiated Thyroid Cancer

Aim

The aim of this study was to compare the incidence of postoperative hypoparathyroidism in two groups of patients who were treated for differentiated thyroid cancer.

Methods

A retrospective analysis of 179 patients who were treated for differentiated thyroid cancer in our institution from January 2011 until December 2018 was performed. Only patients initially treated with total thyroidectomy and those who did not have preoperatively confirmed central compartment and lateral neck lymph node metastases were included in this study. Two main groups of patients were analysed. The patients who were treated with total thyroidectomy and elective central compartment lymph node dissection simultaneously were included in the first group. The patients who were treated only with total thyroidectomy were included in the second group. The rate of transitory and persistent postoperative hypoparathyroidism was compared between the two groups.

Results

A total of 117 patients (65.4%) underwent total thyroidectomy and elective central compartment lymph node dissection simultaneously (TT + CCLNd group). The remaining 62 patients (34.6%) underwent total thyroidectomy only (TT group). A total of 22.6% patients in the TT group developed postoperative hypoparathyroidism compared with 25.6% in the TT + CCLNd group. The rate of persistent hypoparathyroidism in the TT and TT + CCLNd groups was 3.2% and 6.0%, respectively. The difference in the rate of transient and persistent postoperative hypoparathyroidism was not statistically significant between the two groups. Within the TT + CCLNd group, 82.9% of patients underwent ipsilateral paratracheal lymph node dissection and 17.1% underwent bilateral paratracheal lymph node dissection. The rate of postoperative hypoparathyroidism was analysed in those two subgroups of patients and did not prove to be statistically significant.

Discussion

While its impact on the local recurrence rate is still controversial, elective central compartment lymph node dissection could be a great tool for selection of patients who could profit from adjuvant radioiodine treatment. On the other hand, central compartment lymph node dissection could potentially increase the risk of hypoparathyroidism due to involuntary injury to parathyroid glands and/or their blood supply. Our study did not find a statistically significant difference regarding postoperative hypoparathyroidism between patients who underwent central compartment lymph node dissection compared with patients who underwent total thyroidectomy only. Our data are not in accordance with some of the previously published studies.

Conclusion

Our results demonstrated that elective central compartment lymph node dissection is a safe procedure and does not significantly increase the risk of postoperative hypoparathyroidism when it is performed simultaneously with total thyroidectomy.

Mini-invasive thyroidectomy and intraoperative neuromonitoring: a high-volume single-center experience in 215 consecutive cases

BACKGROUND

Endocrine surgery recent evolution has been characterized by introduction of mini-invasive video-assisted technique. When a new technique is introduced in surgical use the rate of adverse events must be the same of previous standardized technique. In MIVAT procedure complication rate and in particular nerve injury risk is associated surgeon's experience. The new approach is the intraoperative neuro-monitoring (IONM) use in MIVAT in order to reduce the laryngeal nerve injury rate in a more technically difficult surgical procedure.

METHODS

We analyzed clinical and surgical data regarding 215 patients treated with MIVAT technique and simultaneous IONM utilization from September 2014 to December 2019 in a single high-volume surgical center. We recorded data regarding age, gender, preoperative diagnosis, surgical time, early postoperative hypocalcemia, hematoma and vocal cord palsy. We compared these data to our first 211 cases of MIVAT (July 2005 to June 2009) at the beginning of the learning curve, performed without using IONM. We tried to highlight the impact of MIVAT and IONM simultaneous use on surgical outcome comparing results to our previous studies, also highlighting the learning curve effect.

RESULTS

We detected a postoperative transitory clinical hypocalcemia in 14 patients (6.5%). No postoperative hematoma was recorded. Using I-IONM during thyroidectomy, we recorded in five cases a loss of signal; in three cases (1.4%) we experienced a temporary postoperative vocal cord palsy, only one case of definitive palsy. We did not observe any significant differences in surgical complications rate between the first 211 cases and these last 215 cases. We have not found any statistically significative difference regarding IONM use during MIVAT procedure related to MIVAT performed without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). Surgical indication has changed.

CONCLUSIONS

In our experience we report that the use of IONM in MIVAT is as helpful to improve the safe of procedure. The risk of nerve palsy in literature associated to MIVAT is the same of the related one to classic technique (CT). We have not found statistical positivity to use IONM in MIVAT related to MIVAT without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). The most important IONM effect, in our opinion is the "safety feeling" experienced by the surgeon using IONM in a more challenging procedure. As a University Hospital, training surgery residents, we also identified the IONM as a very useful teaching support.

The prevalence of hypocalcemia following total thyroidectomy. A retrospective study based at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Objectives:

To estimate the prevalence of hypocalcemia following total thyroidectomy (TT) at a tertiary center.

Methods:

This retrospective study was conducted between 2014 and 2019 at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. The study was based at the Department of General Surgery and was approved by the Research Ethics Committee of KAUH. Medical records of 154 patients who had undergone TT were reviewed. Data such as age, gender, level of postoperative calcium at 24 and 48 hours after surgery, parathyroid hormone (PTH) levels, central neck dissection (CCND), histological diagnosis were entered into Microsoft Excel sheets.

Results:

Hypocalcemia occurred more on the second day after surgery in 67.4% of patients. Among them, 83.9% were female and 16.1% were male. The majority of patients were asymptomatic and benign thyroid disease was the most common. There was a significant association between hypocalcemia and the PTH level (p<0.001).

Conclusion:

There was a high prevalence of hypocalcemia on the second day after surgery. Presence of hypocalcemia association with the PTH level. Meticulous surgical technique and preservation of parathyroid vascularity are important in preventing postoperative hypocalcemia.

A Single Parathyroid Hormone Measurement Two Hours after a Thyroidectomy Reliably Predicts Permanent Hypoparathyroidism

INTRODUCTION

Hypoparathyroidism is the most common complication following thyroidectomy, and various algorithms for early detection have been suggested. The aim of this study was to evaluate the predictive value of measuring the parathyroid hormone level 2 h after thyroidectomy and whether determination of the perioperative decline in parathyroid hormone added diagnostic value.

METHODS

Patients subjected to thyroidectomy for benign thyroid disorders were analyzed in (1) a retrospective register-based study (366 consecutive patients treated during 2015-2016) and (2) a prospective observational study (39 patients treated during 2018). Optimal cut-off values for postoperative parathyroid hormone and perioperative decline (%) in parathyroid hormone were determined by receiver operating characteristics and area under the curve. Sensitivity, specificity, positive and negative predictive values were calculated using cross tabulation.

RESULTS

The prevalence of hypoparathyroidism the first day after thyroidectomy was higher among patients treated for hyperthyroidism (30% vs 20%; P = 0.03). The optimal cut-off level for postoperative parathyroid hormone was 1.1 pmol/L (area under the curve = 0.887, 95% confidence interval: 0.839-0.934; positive predictive value: 88%, negative predictive value: 93%) for the entire cohort. When the groups were analyzed separately, the optimal cut-off was 1.05 for the non-hyperfunctioning group and 1.55 pmol/L for the group with hyperthyroidism. Twelve months after thyroidectomy, 3% were defined as having permanent hypoparathyroidism. Measurement of parathyroid hormone decline added diagnostic value for one patient with preoperative parathyroid-hormone-elevation associated with vitamin D deficiency.

CONCLUSION

For patients with vitamin D sufficiency, the diagnostic accuracy of a single measurement of parathyroid hormone 2 h after thyroidectomy is an excellent indicator for predicting transient hypoparathyroidism.

Severe Hypocalcemia After Thyroidectomy: An Analysis of 7366 Patients

OBJECTIVE

The aim of the study was to determine severe hypocalcemia rate following thyroidectomy and factors associated with its occurrence.

BACKGROUND

Hypocalcemia is the most common complication after thyroidectomy. Severe post-thyroidectomy hypocalcemia can be life-threatening; data on this specific complication are scarce.

METHODS

Patients who underwent thyroidectomy in the American College of Surgeons-National Surgical Quality Improvement Program thyroidectomy-targeted database (2016-2017) were abstracted. A severe hypocalcemic event was defined as hypocalcemia requiring intravenous calcium, emergent clinic/hospital visit, or a readmission for hypocalcemia. Multivariable regression was used to identify factors independently associated with occurrence of severe hypocalcemia.

RESULTS

Severe hypocalcemia occurred in 5.8% (n = 428) of 7366 thyroidectomy patients, with 83.2% necessitating intravenous calcium treatment. Rate of severe hypocalcemia varied by diagnosis and procedure (0.5% for subtotal thyroidectomy to 12.5% for thyroidectomy involving neck dissections). Overall, 38.3% of severe hypocalcemic events occurred after discharge; in this subset, 59.1% experienced severe hypocalcemia despite being discharged with calcium and vitamin D. Severe hypocalcemia patients had higher rates of recurrent laryngeal nerve injury (13.4% vs 6.6%), unplanned reoperations (4.4% vs 1.3%), and longer hospital stay (30.4% vs 6.2% ≥3 days (all P < 0.01). After multivariate adjustment, severe hypocalcemia was associated with multiple factors including Graves disease [odds ratio (OR) = 2.06], lateral neck dissections (OR: 3.10), and unexpected reoperations (OR = 3.55); all P values less than 0.01.

CONCLUSIONS

Severe hypocalcemia and suboptimal hypocalcemia management after thyroidectomy are common. Patients who experienced severe hypocalcemia had higher rates of nerve injury and unexpected reoperations, indicating surgical complexity and provider inexperience. More biochemical surveillance particularly a parathyroid hormone-based protocol, fine-tuned supplementation, and selective referral could reduce occurrence of this morbid complication.

The injury of recurrent laryngeal nerve and thyroid regeneration after irreversible electroporation ablation of most part of thyroid gland-an experimental study on swine model

To study the thyroid regeneration and injury of recurrent laryngeal nerve after irreversible electroporation (IRE). 12 pigs were divided into three groups: six pigs underwent IRE, other pigs were used as controls. IRE was performed near tracheoesophageal groove, to ablate most part of thyroid gland. Parathyroid and thyroid function, recurrent laryngeal nerve injury and thyroid computed tomography (CT) imaging were regularly investigated. The histopathology results were analyzed to detect thyroid regeneration. Masson's trichrome method for collagen and immunohistochemistry were performed for Soluble protein-100 (S100) and neurofilaments on nerve section. In IRE group, there were no symptoms of recurrent laryngeal nerve-related injury. No abnormalities of recurrent laryngeal nerve were shown on hematoxylin-eosin (HE) staining, Masson's trichrome staining, Neurofilament (NF) staining and S100 staining. There were no significant changes for thyroid and parathyroid function in all pigs. Immediately after IRE, CT showed hypoattenuation in the ablated thyroid gland and it became swelling. 14 days after IRE, thyroid CT showed hetergenous attenuation in the electroporation zone, and the size and attenuation of thyroid gland were normal after two months. There was cell apoptosis in the thyroid gland after IRE. Seven and 14 days after IRE, there was fragmentation of nucleus within the follicle, and some follicles were empty. Two months later, complete regeneration of thyroid tissue was shown. IRE was shown to be both effective and safe with complete regeneration of thyroid tissue and preservation of the function and structure of the recurrent laryngeal nerve.