The Step Wise Effect of Vessel Ligation Method on Intra and Postoperative Hypoparathyroidism in the Total Thyroidectomy

Abstract Objective Total thyroidectomy represents the gold standard surgical procedure for patients with malignant thyroid disease. Over the past decades, the total thyroidectomy gradually replaced the subtotal thyroidectomy for benign thyroid disorders as well. Postoperative hypocalcemia remains the most frequent complication. The close proximity of parathyroid glands to the thyroid capsule leads often to devascularization or adventitious removal of parathyroid tissue. Clinical symptoms like paresthesia, tingling, muscle cramps or seizures often occur. Combined measurement of intact parathyroid hormone (iPTH) and calcium after the operation are used worldwide to predict postoperative hypoparathyroidism. The purpose of this study was to find out the incidence of decreased iPTH at the end of surgery and its reliability in predicting hypocalcemia. Methods We performed a retrospective analysis of 534 patients who underwent total thyroidectomy at our institution between 2000 and 2019. Medical records were reviewed to analyze the patient characteristics, indication of the procedure, laboratory and histological results, postoperative management and complications. The iPTH was measured before and at the end of the surgery, while the calcium was measured at the first postoperative day. The iPTH assay at our hospital has a normal range between 15.0 and 80.0 pg/ml. Meanwhile hypocalcemia was defined as a calcium measurement < 2.2 mmol/l. Results The mean age of the patients was 55.34 years. The female to male ratio was 4.6:1. The mean preoperative iPTH of our cohort was 48.35 pg/ml, while the postoperative iPTH was 31.74 pg/ml, indicating a mean reduction of 35.75%. A total of 174 patients (32.6%) had a iPTH < 15.0 pg/ml at the end of the surgery, indicating a reduction of 75.6%. 22 of these 174 patients (12.6%) developed clinical symptoms of hypocalcemia. In contrast only 3 patients (0.08%) with normal iPTH developed symptoms. Whole parathyroid glands were identified in 95/534 (17.8%), whereas from the 174 patients with iPTH < 15.0 pg/ml, 56 (32.2%) had at least one parathyroid gland in the operative specimens. Conclusion Measurement of iPTH at the end of total thyroidectomy is a good predictor to detect patient who are at risk for developing symptomatic hypocalcemia and calcium substitution can be started at the same day. A normal iPTH almost excludes symptomatic hypocalcemia.

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ES17ï¿½*RESULTS OF SUTURELESS TECHNIQUES VS CONVENTIONAL VESSEL LIGATION FOR TOTAL THYROIDECTOMY

ANZ Journal of Surgery ◽

10.1111/j.1445-2197.2009.04916_17.x ◽

2009 ◽

Vol 79 ◽

pp. A22-A22

Author(s):

L.-Y. Chang ◽

J. Suliburk ◽

S. Sidhu ◽

L. Delbridge ◽

M. Sywak

Keyword(s):

Total Thyroidectomy ◽

Vessel Ligation

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Association between number of parathyroid glands identified during total thyroidectomy and functional parathyroid preservation

Langenbeck s Archives of Surgery ◽

10.1007/s00423-021-02287-6 ◽

2021 ◽

Author(s):

Fiona Riordan ◽

Matthew S. Murphy ◽

Linda Feeley ◽

Patrick Sheahan

Keyword(s):

Vitamin D ◽

Multivariate Analysis ◽

Total Thyroidectomy ◽

Parathyroid Glands ◽

Graves Disease ◽

Permanent Hypoparathyroidism ◽

Academic Teaching ◽

Postoperative Hypoparathyroidism ◽

Academic Teaching Hospital ◽

Systematic Identification

Abstract Purpose Systematic identification of all 4 parathyroid glands has been recommended during total thyroidectomy (TT); however, it is unclear whether this strategy necessarily translates into optimized functional parathyroid preservation. We wished to investigate the association between number of parathyroids identified intraoperatively during TT, and incidence of incidental parathyroidectomy, and postoperative hypoparathyroidism. Methods Retrospective review of prospectively maintained database of 511 consecutive patients undergoing TT at an academic teaching hospital. The association between number of parathyroid glands identified intraoperatively and incidence of biochemical hypocalcaemia (defined as any calcium < 2 mmol/L n first 48 h after surgery), symptomatic hypocalcaemia; permanent hypoparathyroidism (defined as any hypocalcaemia or need for calcium or vitamin D > 6 months after surgery), and incidental parathyroidectomy, was investigated. The association between number of parathyroid glands visualized and postoperative parathyroid hormone (PTH) levels was investigated in a subset of 454 patients. Results Patients in whom a greater number of parathyroids had been identified had a significantly higher incidence of biochemical and symptomatic hypocalcaemia, and significantly lower postoperative PTH levels, than patients with fewer glands identified. There were no significant differences in incidence of permanent hypoparathyroidism or incidental parathyroidectomy. On multivariate analysis, malignancy, Graves disease, and identification of 3–4 parathyroids were independent predictors of biochemical hypocalcaemia. For symptomatic hypocalcaemia, identification of 2–4 parathyroids, and identification of 3–4 parathyroids, were significant. Conclusions Systematic identification of as many parathyroid glands as possible during TT is not necessary for functional parathyroid preservation.

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Postoperative hypoparathyroidism after total thyroidectomy for thyroid cancer

Nippon Jibiinkoka Gakkai Kaiho ◽

10.3950/jibiinkoka.122.1561 ◽

2019 ◽

Vol 122 (12) ◽

pp. 1561-1562

Author(s):

Masanori Teshima ◽

Naoki Otsuki ◽

Hikari Shimoda ◽

Naruhiko Morita ◽

Tatsuya Furukawa ◽

...

Keyword(s):

Thyroid Cancer ◽

Total Thyroidectomy ◽

Postoperative Hypoparathyroidism

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Postoperative hypoparathyroidism after total thyroidectomy for thyroid cancer

JOURNAL OF JAPAN SOCIETY FOR HEAD AND NECK SURGERY ◽

10.5106/jjshns.29.259 ◽

2020 ◽

Vol 29 (3) ◽

pp. 259-265

Author(s):

Naoki Otsuki ◽

Hikari Shimoda ◽

Tatsuya Furukaw ◽

Hirotaka Shinomiya ◽

Masanori Teshima ◽

...

Keyword(s):

Thyroid Cancer ◽

Total Thyroidectomy ◽

Postoperative Hypoparathyroidism

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Use of parathyroid hormone analog (Teriparatide) in patients with chronic hypoparathyroidism after total thyroidectomy: a case report

Journal of Diabetes and Endocrine Association of Nepal ◽

10.3126/jdean.v4i2.34603 ◽

2020 ◽

Vol 4 (2) ◽

pp. 29-35

Author(s):

Avinash Rai ◽

P Karki ◽

D Paudel ◽

R Maskey

Keyword(s):

Vitamin D ◽

Thyroid Cancer ◽

Parathyroid Hormone ◽

Total Thyroidectomy ◽

Standard Treatment ◽

Hormone Analog ◽

Postoperative Hypoparathyroidism ◽

Treatment Refractory ◽

Chronic Hypoparathyroidism ◽

Intravenous Calcium

Background: Hypoparathyroidism and hypocalcemia is a common postoperative complication, after total thyroidectomy due to thyroid cancer. Standard treatment with supplementation of calcium and vitamin D analogs, usually treat this condition. In some patients, hypoparathyroidism is refractory to standard treatment plus intermittent calcium infusions with persistent low serum calcium levels and associated clinical complications. Attempts have been made to add recombinant human parathormone (rhPTH) to the treatment schedule. To our knowledge, this is the first time that we encounter a patient suffering from treatment-refractory postsurgical hypoparathyroidism who was treated with teriparatide. Case presentation: Male (31 years) with postoperative hypoparathyroidism, after total thyroidectomy due to papillary thyroid cancer, several weeks after the surgery still required intermittent intravenous calcium infusions because of tetany symptoms. He had persistent hypocalcemia despite oral treatment with up to 1 ug calcitriol and 4 g calcium per day necessitating additional intravenous administration of calcium gluconate intermittently. This time, Teriparatide treatment was introduced at once daily 50 micrograms (mcg) subcutaneous injection, while doses of calcium and calcitriol were gradually decreased depending on the response of serum total and ionized calcium taken periodically, which resulted in total resolution of hypocalcemia symptoms and the achievement and maintenance of laboratory normocalcaemia in just 5 days. Conclusion: Treatment refractory chronic hypoparathyroidism may be seen in some cases after total thyroidectomy. Furthermore, the use of recombinant human parathyroid hormone analog (Teriparatide) allows for the control of recurrent hypocalcemia reducing the daily dosage of calcium and vitamin D. Finally, regular intravenous calcium administration was no more needed.

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DO NEAR-INFRARED INTRA-OPERATIVE FINDINGS OBTAINED USING INDOCYANINE GREEN CORRELATE WITH POST-THYROIDECTOMY PARATHYROID FUNCTION? THE ICGPREDICT STUDY

Endocrine Practice ◽

10.4158/ep-2020-0119 ◽

2020 ◽

Vol 26 (9) ◽

pp. 967-973

Author(s):

Theodosios S. Papavramidis ◽

Panagiotis Anagnostis ◽

Angeliki Chorti ◽

Ioannis Pliakos ◽

Stavros Panidis ◽

...

Keyword(s):

Parathyroid Hormone ◽

Indocyanine Green ◽

Total Thyroidectomy ◽

Serum Calcium ◽

Scoring System ◽

Near Infrared ◽

Eligibility Criteria ◽

Hydroxyvitamin D ◽

Postoperative Hypoparathyroidism ◽

Operative Findings

Objective: Postoperative hypoparathyroidism (hypoPT) still remains a significant complication after thyroidectomy. Intra-operative imaging modalities, such as near-infrared fluorescence using indocyanine green (ICG), may assist in identifying and preserving the parathyroid glands (PGs). The purpose of this study was to test the association between the intra-operative ICG staining scoring system and 24-hour postoperative parathyroid hormone (PTH) levels, as well as its capability for intra-operative PG identification. Methods: This was a prospective study, recruiting patients scheduled for total thyroidectomy by the same surgical team, from December 2018 to April 2019. Intra-operative angiography was performed after infusion of ICG solution (5 mg). Two minutes later, images were acquired using the near-infrared system. Results: Sixty patients fulfilled the eligibility criteria. The percentage of temporary postoperative hypoPT (defined as PTH <14 pg/mL) was 11.66%. No association between intra-operative ICG staining score (expressed as the number of PGs scoring <2 per patient) and 24-hour postoperative PTH ( r = 0.011; P = .933) or serum calcium concentrations ( r = 0.127; P = .335) was observed. There was also no correlation between the location of PGs scoring ≤2 and postoperative PTH ( P = .257) or serum calcium levels ( P = .950). Moreover, with regard to secondary endpoint, ICG correctly identified PGs in 98.3% of cases. ICG score was not affected by age, gender, duration of operation, or thyroid gland pathology. No allergic reactions attributed to ICG administration were observed. Conclusion: The intra-operative ICG staining scoring system did not predict 24-hour postoperative PTH and serum calcium levels. However, this modality may assist in intra-operative PG identification during a total thyroidectomy. Abbreviations: 25(OH)D = 25-hydroxyvitamin D; hypoPT = hypoparathyroidism; ICG = indocyanine green; NIR = near-infrared; NIRF = near-infrared autofluorescence; PG = parathyroid gland; PTH = parathyroid hormone

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