Prospective Study of Perioperative Factors Predicting Hypocalcemia After Thyroid and Parathyroid Surgery
To identify whether perioperative 1,25-dihydroxyvitamin D or parathyroid hormone (PTH) levels will predict the development of hypocalcemia after thyroid and parathyroid surgery.
The study included 103 patients who underwent thyroid or parathyroid surgery between 2002 and 2004, with a comparison of the patients who underwent thyroid lobectomy (TL; n = 34), total thyroidectomy (TT; n = 27), parathyroid adenoma excision (PAE; n = 34), and subtotal parathyroidectomy for hyperplasia (SP; n = 8).
Preoperative 1,25-dihydroxyvitamin D levels, number of patients requiring calcium replacement, and postoperative PTH and calcium levels.
No patients in the TL or PAE group developed postoperative hypocalcemia that required calcium replacement. Six patients (22%) in the TT group and 3 patients (38%) in the SP group required calcium replacement for clinically significant hypocalcemia (P<.001). All patients who required calcium replacement had PTH levels of less than 15 pg/mL (1.6 pmol/L) 8 hours after surgery. Among the patients with postoperative PTH levels of less than 15 pg/mL (1.6 pmol/L) 8 hours after surgery, no patients in the PAE group required calcium replacement, compared with 75% of patients in the TT and SP groups (P<.001). The patients in the TT group had significantly lower postoperative calcium levels than those in the TL (P<.001) or the PAE (P<.005) group. The patients in the TL group reached stable calcium levels significantly earlier than those in the other groups (15.8 hours after surgery; P<.05). There was no relationship between preoperative 1,25-dihydroxyvitamin D levels and postoperative calcium levels.
Preoperative 1,25-dihydroxyvitamin D levels were not predictive of postoperative calcium levels. Patients who undergo PAE or TL are at extremely low risk for requiring calcium replacement. Patients who undergo TT or SP with 8-hour postoperative PTH levels greater than or equal to 15 pg/mL (1.6 pmol/L) are at low risk for developing postoperative hypocalcemia, whereas those with PTH levels less than 15 pg/mL (1.6 pmol/L) have a high risk of developing hypocalcemia.
Available from: Domenico Parmeggiani
- "Recently, there has been a great deal of interest in identifying perioperative factors that can predict the development of hypocalcemia after thyroidectomy [30,31]. The drive towards a shorter hospital stay following total thyroidectomy has led to a number of studies evaluating the use of plasma biochemical markers to predict the development of hypocalcaemia. "
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Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after total thyroidectomy (TT). We aimed to compare the impact of age and the clinical usefulness of oral calcium and vitamin D supplements on postoperative hypocalcemia after TT, and to determine which risk factors are important for hypocalcemia incidence.
Two hundred consecutive patients treated by TT were included prospectively in the present study. All patients supplemented oral calcium and vitamin D in the post-operative time. The data concerning symptomatic and laboratoristichypocalcemia were collected.
Symptomatic hypocalcemia developed only in 19 patients (9.5%), whereas laboratory hypocalcemia developed in 36 patients (18%). The risk for postoperative hypocalcemia was increate 20-fold for patients older than 50 years.
Age is significantly associated with postoperative hypocalcemia. Implementing oral calcium and vitamin D after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.
BMC Surgery 10/2013; 13(2). DOI:10.1186/1471-2482-13-S2-S11 · 1.40 Impact Factor
Available from: Kai Pun Wong
- "Postoperative hypoparathyroidism leading to hypocalcemia is the one of the most frequent morbidities after total thyroidectomy with a reported incidence ranging 3–40 %.[1,2] Because potentially life-threatening hypocalcemia does not usually develop until 24–48 h after surgery, hypoparathyroidism is one of the major reasons for delaying hospital discharge and dissuading surgeons from ambulatory thyroid surgery.[3,4] To safely manage postoperative hypoparathyroidism/hypocalcemia and potentially shorten hospital stay, previous authors have suggested the use of single postoperative quick parathyroid hormone (qPTH) testing for predicting of postthyroidectomy hypocalcemia.[3–7] "
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Although some studies have suggested that low preoperative 25-hydroxyvitamin D (25-OHD) levels may increase the risk of hypocalcemia and decrease the accuracy of single quick parathyroid hormone in predicting hypocalcemia after total thyroidectomy, the literature remains scarce and inconsistent. Our study aimed to address these issues.
Of the 281 consecutive patients who underwent a total/completion total thyroidectomy, 244 (86.8 %) did not require any oral calcium and/or calcitriol supplements (group 1), while 37 (13.2 %) did (group 2) at hospital discharge. 25-OHD level was checked 1 day before surgery, and postoperative quick parathyroid hormone (PTH) was checked at skin closure (PTH-SC). Postoperative serum calcium was checked regularly. Hypocalcemia was defined by the presence of symptoms or adjusted calcium of <1.90 mmol/L. Significant factors for hypocalcemia were determined by univariate and multivariate analyses. The accuracy of PTH-SC in predicting hypocalcemia was measured by area under a receiver operating characteristic curve (AUC), and the AUC of PTH-SC was compared between patients with preoperative 25-OHD <15 and ≥15 ng/mL via bootstrapping.
Preoperative 25-OHD level was not significantly different between groups 1 and 2 (13.1 vs. 12.5 ng/mL, p = 0.175). After adjusting for other significant factors, PTH-SC (odds ratio 2.49, 95 % confidence interval 1.52–4.07, p < 0.001) and parathyroid autotransplantation (odds ratio 3.23, 95 % confidence interval 1.22–8.60, p = 0.019) were the two independent factors for hypocalcemia. The AUC of PTH-SC was similar between those with 25-OHD <15 and ≥15 ng/mL (0.880 vs. 0.850, p = 0.61)
Low 25-OHD was not a significant factor for hypocalcemia and did not lower the accuracy of quick PTH in predicting postthyroidectomy hypocalcemia.
Annals of Surgical Oncology 09/2012; 20(3). DOI:10.1245/s10434-012-2666-y · 3.93 Impact Factor
Available from: PubMed Central
- "Transient hypoparathyroidism is a major reason for delayed hospital discharge following a total or completion total thyroidectomy because potentially life-threatening hypocalcemic symptoms may not occur until 24–48 h after surgery [3, 4]. Among the various strategies proposed to optimize the management of postoperative hypocalcemia by shortening hospital stay, PTH-directed selective supplementation is a safe and effective approach [9, 10, 13]. "
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ABSTRACT: Post-thyroidectomy hypocalcemia is a major contributing factor in delayed hospital discharge and dissuading surgeons from ambulatory thyroidectomy. We prospectively evaluated the accuracy and reliability of quick parathyroid hormone level measurement at skin closure (PTH-SC) in predicting clinically relevant hypocalcemia (i.e., patients requiring calcium ± calcitriol supplements on hospital discharge).
Of the 117 patients who underwent a total or completion total thyroidectomy and PTH-SC, 17 (14.5 %) had hypocalcemic symptoms or adjusted calcium <1.90 mmol/L requiring calcium and/or calcitriol supplements on discharge. Serum calcium was checked regularly in the perioperative period until stabilization and an additional quick PTH was checked on the following morning (PTH-D1). Univariate and multivariate analyses were performed to evaluate potential preoperative clinicopathologic factors and postoperative day 0 biochemical indicators. Youden's index and the area under the ROC curve (AUC) were used to determine the best cutoff value and predictability of significant variables or criteria, respectively.
In the multivariate analysis, low preoperative adjusted calcium (p = 0.041) and low PTH-SC (p = 0.001) were the two independent variables associated with hypocalcemia. PTH-SC (≤1 or >1 pmol/L) had a higher specificity (95.0 %) and AUC (0.887) than serial calcium monitoring or PTH-D1 alone. Although 3/98 of patients with PTH-SC >1 pmol/L required calcium supplements on discharge, they required only the minimum amount to maintain normocalcemia.
PTH-SC is an accurate and reliable means of predicting clinically relevant hypocalcemia. It would be reasonable to discharge those with PTH-SC >1 pmol/L on the same operative day as the risk of life-threatening hypocalcemia would seem unlikely.
World Journal of Surgery 03/2012; 36(6):1300-6. DOI:10.1007/s00268-012-1561-9 · 2.64 Impact Factor
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