Prognostic significance of intraoperative PTH test for the development of post-thyroidectomy hypocalcaemia
Department of Special Surgery, Medical University, Plovdiv, Bulgaria.Folia medica 10/2011; 53(4):15-20. DOI: 10.2478/v10153-011-0062-1
The high incidence of postoperative hypoparathyroidism after total thyroidectomy and the significant morbidity associated with it can account for the sustained efforts to find reliable, affordable markers for the prognosis of this condition. Therefore, a lot of attention has been paid recently to the perioperative measurement of the parathyroid hormone (PTH) as an immediate indicator showing the parathyroid glands functional status. There are a lot of studies in the relevant literature demonstrating that PTH is a highly sensitive marker, with high specificity to predict development of postoperative hypocalcemia. Recent studies analyze in-depth not only the absolute values of PTH, but also the dynamics of its levels during surgery. The number and timing of sampling for testing is a matter of discussion. Importance is attached also to the hormone testing methods. Research results determine intraoperative PTH (IOPTH) as a valuable additional test for early risk assessment of hypocalcaemia allowing prevention and timely treatment of patients at risk. Early identification of risk groups of patients creates a real opportunity to reduce the incidence of this complication by autotransplantation of parathyroid glands. Despite the encouraging results the predictive accuracy of this indicator is not 100%, which requires careful result interpretation. The findings of researchers are not uniform, probably due to differences in study design, the methods used in PTH testing, and the accepted reference range of serum calcium. This impedes comparison of data and highlights the need for similar analyzes in each specialized center.
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ABSTRACT: The management of hypocalcemia (HC) after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of parathyroid hormone (PTH) level after TTx may allow for prediction of postoperative HC and lead to shorter hospital stays. A prospective database was queried between January 2010 and June 2012 with 95 patients who had undergone TTx identified. Patient demographics; preoperative diagnosis; laboratory values and cost; complications; intravenous calcium supplementation; and length of stay (LOS) were analyzed. A PTH-based algorithm was retrospectively applied and theoretical cost savings were analyzed in terms of laboratory cost, LOS, and total cost. Ninety-five patients underwent TTx: 37 patients (38.9%) had cancer, whereas 27 (28.4%) had Graves' disease and the remaining 31 (32.6%) had a benign multinodular goiter. Postoperative PTH was recorded in 72 patients (74.4%); 46 (63.8%) had PTH greater than 10 pg/mL and 26 (36.9%) had PTH less than 10 pg/mL. Transient HC occurred in 10 patients (38.4%) with PTH less than 10 pg/mL (relative risk, 17.69; P = 0.0001). Patients with PTH less than 10 pg/mL incurred a 14.9 per cent higher hospital cost compared with those with PTH greater than 10 pg/mL. With retrospective implementation of the algorithm, there is a potential 46.4 per cent cost savings for the PTH less than 10 pg/mL group, 67.3 per cent savings for the PTH greater than 10 pg/mL group, and 46.7 per cent savings when taken altogether. Algorithmic risk stratification based on postoperative PTH less than 10 pg/mL serves as both a sensitive (100%) and specific (76.7%) predictor of postoperative HC. Such risk stratification may allow for same-day discharge in a number of patients, and even in patients requiring an overnight stay, result in cost savings as a result of a reduction in laboratory expenditures.