Parathyroid hormone-based algorithm reduces complications after total thyroidectomy.

Hypocalcemia after total thyroidectomy is a frequent complication that can be predicted and best managed by the postoperative measurement of parathyroid hormone levels. This study included consecutive patients who underwent total thyroidectomy between 2017 and 2022. Hypocalcemia was defined as serum calcium <8.0 mg/dL and hypoparathyroidism as parathyroid hormone <15 pg/mL. After comparing serum calcium levels on postoperative day 1 and intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy in the first period, an algorithm involving routine postoperative oral calcium and alfacalcidol administration in patients with intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy <20 pg/mL was developed and tested during the second period. The rates of symptomatic hypocalcemia, readmission for hypocalcemia, and permanent hypoparathyroidism were compared between the 2 periods. In the first period, 1,965 total thyroidectomies (1,548 women; mean age, 51 years) were performed, including 617 patients (31%) with central neck dissection for thyroid carcinoma. Of 314 patients (16%) who experienced symptomatic hypocalcemia, only 183 (58%) could be predicted using serum calcium levels on postoperative day 1 <8.0 mg/dL. This rate increased to 96% (301 patients) when using intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy and serum calcium levels on postoperative day 1 (P < .001). Intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy alone could predict symptomatic hypocalcemia in 90% (282) of patients. Hypoparathyroidism was permanent in 20 patients (1%), with a greater predictive value of intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy over serum calcium levels on postoperative day 1 (18/20 [90%] vs 8/20 [40%], P < .01). Using the intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy-based algorithm and preventive calcium supplementation in the second period of the study, 1,420 total thyroidectomies (1,106 women; mean age, 50 years) were performed, including 392 (28%) cases with central neck dissection for thyroid carcinoma. Only 2.3% (32) patients developed a symptomatic hypocalcemia compared with 16% during the first period (P < .001). Thirty-eight patients (2.7%) experienced readmission after total thyroidectomy before implementation of the supplementation protocol in our study compared with 2 patients (0.01%) after we began using the protocol (P < .001). There was no significant difference in permanent hypoparathyroidism between the 2 periods (1.3% vs 1%) (P = .8). The parathyroid hormone-based algorithm determined by intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy and routine preventive administration of oral calcium/calcitriol reduced the risk of symptomatic hypocalcemia and readmission after total thyroidectomy.

Chereau N ，Gaujoux S ，Ghander C ，Bertocchio JP ，Buffet C ，Menegaux F ... -  《-》

Impact of Intraoperative Nanocarbon Staining and parathyroid autotransplantation on parathyroid injury and recovery in adult thyroidectomy: a retrospective cohort study.

Thyroid surgeries are intricate operations that carry the risk of damaging the parathyroid glands, which can result in hypocalcemia and potential long-term hypoparathyroidism. Innovative surgical techniques including Intraoperative Nanocarbon Staining (INS), aim to enhance the preservation of parathyroid glands. This study assesses the effectiveness of INS combined with parathyroid autotransplantation in reducing postoperative complications and preserving parathyroid function. This retrospective cohort study assessed patients aged ≥ 18 who underwent thyroid surgery at a tertiary care hospital from January 2017 to December 2022. We compared the incidence of postoperative parathyroid injury, recovery rates of parathyroid function, and the incidence of permanent hypoparathyroidism between groups. Data on patient demographics, diagnosis, surgical details, parathyroid hormone levels, and calcium levels were collected and analyzed using chi-square tests, t-tests, and logistic regression. The study included 198 patients, with 101 in the intervention group and 97 in the control group. Baseline characteristics such as sex ratio, age, BMI, and preoperative calcium levels showed no significant differences between groups. The intervention group demonstrated a significantly shorter duration of intravenous calcium supplementation (median 2 vs. 3 days, p < 0.001) and higher calcium nadir levels (median 8.36 vs. 7.85 mg/dL, p < 0.001) compared to controls. Furthermore, the incidence of postoperative parathyroid injury and permanent hypoparathyroidism was lower in the intervention group (15.84% vs. 20.62%, p = 0.045 and 4.95% vs. 15.46%, p = 0.003, respectively). Multivariate analysis revealed factors such as Blood iPTH monitoring level (OR 1.053, 95% CI 1.009-1.099, P = 0.018) and surgery type (Near Total Thyroidectomy) (OR 0.447, 95% CI 0.202-0.990, P = 0.047) were positively associated with surgical success. The intervention group also showed higher surgery success rates (OR 2.054, 95% CI 1.017-4.150, P = 0.045). The application of INS and parathyroid autotransplantation during thyroidectomy significantly improves postoperative parathyroid gland function, reducing the incidence of permanent hypoparathyroidism. These findings support the incorporation of these techniques into standard surgical practice for thyroidectomy.

Chen C ，Wang X ，Liu G ，Huang Y ... -  《BMC Surgery》

The predictive role of intraoperative parathyroid hormone measurement on postoperative parathyroid function in patients undergoing total thyroidectomy.

Hypocalcemia is a common complication of thyroidectomy, particularly total thyroidectomy. The higher incidence of hypocalcemia following total thyroidectomy is primarily due to inadvertent damage to the parathyroid glands during surgery. This study aims to investigate the predictive value of intraoperative parathyroid hormone (IOPTH) in determining hypocalcemia during hospitalization and the recovery of parathyroid function after total thyroidectomy, as well as the factors that may influence IOPTH. In this retrospective study, we analyzed a cohort of 164 patients who underwent total thyroidectomy at our institution between 2018 and 2019. IOPTH was measured either 15 min after bilateral thyroidectomy combined with area VI lymph node dissection, or 15 min after bilateral thyroidectomy alone. We plotted ROC curves for IOPTH and ΔPTH% in relation to hypocalcemia during hospitalization and recovery of parathyroid function. Additionally, we explored risk factors for the development of hypocalcemia during hospitalization and factors that may influence IOPTH. IOPTH and ΔPTH% demonstrated good specificity and sensitivity for predicting hypocalcemia during hospitalization and for assessing recovery of parathyroid function. Lower preoperative PTH levels, chronic lymphocytic thyroiditis, and intraoperative parathyroid auto-transplantation were identified as risk factors for IOPTH < 15 pg/mL. IOPTH and ΔPTH% are predictive of hypocalcemia during the postoperative hospital stay and recovery of parathyroid function. Patients with chronic lymphocytic thyroiditis, intraoperative parathyroid auto-transplantation, and low preoperative PTH levels should be closely monitored for the recovery of parathyroid function after surgery.

Zhang Y ，Zhao Y ，Tang H ，Zou H ，Li Y ，Bian X ，Tan J ，Wang Y ... -  《Scientific Reports》

An intact parathyroid hormone-based protocol for the prevention and treatment of symptomatic hypocalcemia after thyroidectomy.

Symptomatic (SX) hypocalcemia after thyroidectomy is a barrier to same day surgery and the cause of emergency room visits. A standard protocol of calcium and vitamin D supplementation, dependent on intact parathyroid hormone (iPTH) levels, can address this issue. How effective is it? When does it fail? We performed a retrospective review of the prospective Thyroid database from January 2006 to December 2010. Six hundred twenty patients underwent completion thyroidectomy or total thyroidectomy and followed our postoperative protocol of calcium carbonate administration for iPTH levels ≥10 pg/mL and calcium carbonate and 0.25 μg calcitriol twice a day for iPTH <10 pg/mL. Calcium and iPTH values, pathology, and medication were compared to evaluate protocol efficacy. A P value <0.05 was considered statistically significant. Using the protocol, sixty-one (10.2%) patients were chemically hypocalcemic but never developed symptoms and 24 (3.9%) patients developed breakthrough SX hypocalcemia. The SX and asymptomatic groups were similar with regard to gender, cancer diagnosis, and preoperative calcium and iPTH. The SX group was significantly younger (39.6 ± 2.8 versus 49 ± 0.6 y, P = 0.01), with lower postoperative iPTH levels. Thirty-three percent (n = 8) of SX patients had an iPTH ≤5 pg/mL versus only 6% (n = 37) of ASX patients. Although the majority of patients with a iPTH ≤5 pg/mL were asymptomatic, 62.5% (n = 5) of SX patients with iPTH levels ≤5 pg/mL required an increase in calcitriol dose to achieve both biochemical correction and symptom relief. Prophylactic calcium and vitamin D supplementation based on postoperative iPTH levels can minimize SX hypocalcemia after thyroidectomy. An iPTH ≤5 pg/mL may warrant higher initial doses of calcitriol to prevent symptoms.

Carter Y ，Chen H ，Sippel RS 《-》

Impact of Clinico Pathological and Surgical Related Risk Factor in Post Operative Hypoparathyroidism in Total Thyroidectomy Patients.

Multiple risk factors have been predicted in post operative hypoparathyroidism in total thyroidectomy patients but none have been clearly defined. Present study aims at evaluating the clinic pathological and surgical impact factors in predicting the risk of post operative hypoparathyroidism in thyroidectomy patients. The study was done in Karpaga Vinayaga Institute of Medical Science and Research Centre where Retrospective prospective cohort study who underwent and undergoing total thyroidectomy with or without central neck dissection for both benign and malignant thyroid disorders during 2014 to 2022 was analyzed. The study has analyzed the various risk factors from clinic pathological and surgical skills of identifying the Inferior thyroid artery at its origin and tracing the branches to the parathyroid gland and evaluating the incidence of hypocalcemia in both study and control groups. Two groups were analyzed during the period 2014 to 2022. The study group was included patients with thyroidectomy where ITA were identified and traced up to the parathyroid gland. They were further classified into category A where both sides ITA were identified and saved, category B where only one side was preserved. In control group, the surgery was done only on basis of capsular dissection and peripheral ligation of vessels close to the gland. Total study participants in our study was 416. The overall prevalence of hypocalcemia in our study was 11.4%. The age, gender and pathological variants were comparable between the two groups. Female preponderance (76%) was seen among both the groups. Among total study subjects who underwent total thyroidectomy 44.8% were having multi nodular goitre, 7.3% toxic goitre, 9.8% follicular adenoma, 30.2% papillary carcinoma and 7.9% follicular carcinoma. In our study benign and malignant thyroid disorders had no significant difference. Prevalence of hypocalcemia among control group 14.5% vs study group 3.8%. We found incidence of hypocalcaemia was comparitively lesser among patients with thyroidectomy alone, than those with unilateral or bilateral CND. Prevalence of hypocalcemia among control group was 33% (45/133) and study group 7% (12/153), when thyroidectomy alone was done. However, with neck dissection in bilateral CND, incidence was 41% (23/56) in study group and 61% (11/18) in control group. In unilateral CND, study and control group had 31% (10/32) and 54% (13/24) which was found to be statistically significant. Parathyroid auto transplantation among the control group (29%) compared to the study group (16%). Bilateral neck dissection and gross extrathyroidal extension and cases with PTG inadvertent removal posed significant risk factors for hypoparathyroidism. The prevalence of immediate hypocalcemia among Cat A, Cat B and control group were 14%, 20.3% and 37.5% respectively and was statistically significant (P < .0001). Symptomatic and Biochemical hypocalcemia at the end of 1 week among Cat A, Cat B, and control group was 8%, 12%, and 33.6, & 12.9%, 21% and 30% respectively. Whereas transient hypocalcemia reported among these groups was 1.6%, 5% and 14.6%. Permanent hypocalcemia was < 1% in study group and 4% among control group. We observed that permanent hypocalcemia was high among patients with bilateral neck dissection and auto transplanted PTG. There was no significant statistical difference in hypocalcemia (transient or permanent) among study and control group, but the incidence of hypocalcemia had significantly reduced in both study groups when unilateral or bilateral identification of ITA was done compared to control group. Our hypothesis in this study aims at preserving the branches of ITA supplying PTG distally has greater functional preservation of the parathyroid than conventional technique. This technique also helps us maintaining the plane and capsular dissection if done properly. By trying to preserve the ITA surgeons may acquire better meticulous dissection skills and understanding the anatomical variation of vessels around PTG more precisely which improve the surgical outcome in preventing both transient and permanent hypocalcaemia.

Sheetal K ，Sooria ND ，Nikisha GN 《-》