Parathyroid Injury Research Articles

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

BackgroundThyroid 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.MethodsThis 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.ResultsThe 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).ConclusionThe 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.

Dual-branch feature Reinforcement Transformer for preoperative parathyroid gland segmentation

The parathyroid glands are easily injured or accidentally removed during thyroid surgery, causing temporary or even permanent hypocalcemia. Thus, accurate preoperative identification and localization of the parathyroid glands by ultrasound is crucial in protecting the parathyroid glands and preventing parathyroid injury during thyroid surgery. However, there are only a few methods used for highlighting the parathyroid gland in ultrasound images before thyroid surgery. In this study, we propose a Dual-branch feature Reinforcement Transformer Network (DRT-Net) for preoperative parathyroid gland segmentation. DRT-Net incorporates a dual-branch structure, consisting of a devised convolution network (CNN) backbone called Feature Reinforcement subnet (FR-subnet) and a Transformer branch capturing detailed features and context information from the confused ultrasound image. Furthermore, we design a Margin Tracking Attention (MTA) that optimizes the ability of FR-subnet to process margin information by tracking margin pixels of feature map. Finally, we employ a Cross-channel Feature Reinforcement Module (CFRM) to fuse the extracted detailed features from the CNN branch with the global context information from the Transformer branch. We trained and evaluated the DRT-Net on the self-built parathyroid gland segmentation dataset and an open-access Kvasir-SEG dataset. Extensive experiments have been carried out to validate the efficiency of our method.

The impact of gasless insufflation transaxillary endoscopic thyroidectomy on the parathyroid gland injury in patients with thyroid cancer: a retrospective analysis.

Recently, endoscope has been widely used in thyroid surgery and gasless insufflation transaxillary endoscopic thyroidectomy (GTET) has been the mainstay of thyroid surgery. Parathyroid gland (PG) damage is a common complication of thyroid surgery. Therefore, the aim of this study was to investigate the effect of GTET on hypoparathyroidism (HPT) in patients with thyroid cancer. According to the surgical approach, the patients were divided into a GTET group and a conventional open thyroidectomy (COT) group. Univariate analysis and logistic regression were used to identify factors associated with PG injury. The odds ratio (OR) and 95% confidence interval (CI) for each independent variable were calculated. A retrospective analysis was conducted on 405 patients diagnosed with papillary thyroid cancer (PTC). A total of 51 patients experienced PG injury, including 7 cases (5%) of GTET group and 44 cases (16.5%) of COT group (P<0.001). Among them, the incidence of GTET group injury with one PG was 50.4%, two were 2.9%, and COT group were 59.8% and 7.9%, respectively (P=0.006). Univariate and multivariate analysis revealed that GTET was a protective factor for PG injury (OR, 0.251; 95% CI, 0.110-0.576; P=0.001), while Hashimoto's thyroiditis (HT) was identified as a risk factor for PG injury (OR, 2.722; 95% CI, 1.114-6.654; P=0.02). GTET reduces the incidence of PG injury and nerve injury, when PTC is combined with HT, it increases the risk of PG injury.

Infiltration of nanocarbon into the trachea during thyroidectomy surgery: case series and literature review.

The presence of metastatic disease in the cervical lymph nodes can affect the recurrence and survival of patients with thyroid cancer. Parathyroid gland injury during surgery can result in hypoparathyroidism, particularly with total thyroidectomy. Injection of carbon nanoparticles into the thyroid will label draining lymph nodes and aid in the visualization of metastatic cervical lymph nodes during a radical operation, sparing accidental damage to the parathyroid glands. Although reported to be useful during surgery, the safety of nanocarbon particles has rarely been investigated, and adverse side effects need to be studied. The author describes five patients with thyroid cancer who had carbon secretions in the trachea or mucosa after carbon nanoparticles were injected into the thyroid. A patient with carbon secretions in the trachea mucosa recovered but had progressive dyspnoea. Surgical treatment was performed, and a mass was found in the trachea mucosa. After excluding all other possibilities, the author concluded that the mass was caused by nanocarbon suspension. To the author's knowledge, there are no reports on nanocarbon suspension into the mucosa and no consensus has yet been reached on the precise injection site, depth, or dose for injecting carbon nanoparticles before thyroidectomy. The author suggests that the most appropriate injection depth of nanocarbon suspensions should be no more than 3mm of the thyroid gland thickness to avoid deep injection into the trachea.

Diagnostic Accuracy of Ultrasonography in Revision Thyroid Surgery: Can It Predict Disease Outcomes?

Revision thyroid surgery for residual/recurrent disease is known to have higher complication rates because of parathyroid injury and recurrent laryngeal nerve (RLN) damage. The aim of this study is to evaluate the accuracy of USG in predicting recurrent disease and disease outcomes in patients undergoing reoperation for recurrent/residual thyroid cancer. We performed a retrospective analysis of all thyroid reoperations from 2015 to 2017. Preoperative USG findings were categorized as per prespecified disease stations in the neck and compared with histopathology to calculate sensitivity, specificity, positive predictive value, and negative predictive value of USG. Survival analysis was performed using Kaplan–Meier curves. Two hundred fifty patients were included in the analysis. In a reoperative setting, USG had an overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 89%, 77%, 89%, 94%, and 60%, respectively. We found a significantly lower disease-free survival in patients who had radiologically detected recurrent disease as compared to disease detected only on histopathology. USG has a reasonable accuracy in determining status of lesions in patients undergoing revision thyroid surgeries.

Evaluation of Hypocalcemia Following Total Laryngectomy With and Without Thyroidectomy.

Hypoparathyroidism and associated hypocalcemia are well-established complications following laryngectomy. This study further characterizes the rates of hypocalcemia in patients undergoing total laryngectomy (TL) with and without thyroidectomy and hemithyroidectomy. Retrospective cohort study. TriNetX. We queried TriNetX, a deidentified patient database, to identify patients who underwent TL with and without thyroidectomy and hemithyroidectomy. Rates of hypocalcemia, low parathyroid hormone (PTH), calcium, and calcitriol supplementation were compared between groups with multivariable repeated measures logistic regression. We identified 870 patients in the TL without thyroidectomy cohort, 158 patients in the hemithyroidectomy cohort, and 123 in the total thyroidectomy cohort. Rates of hypocalcemia differed between patients receiving total thyroidectomy versus TL alone for 0 to 1 month (odds ratio [OR]: 2.88 [1.95-4.26]) 1 to 6 months (OR: 5.08 [2.29-11.3]), and 6 to 12 months (OR: 2.63 [1.003-6.88]) postoperatively, with adjustment for age at laryngectomy, race, ethnicity, and gender. Results were similar among those who received calcium supplementation. The rate of low PTH levels differed in these groups for 0 to 1 month (OR: 5.13 [3.10-8.51]), 1 to 6 months (OR: 3.47 [1.46-8.22]), and 6 to 12 months (OR: 3.63 [1.40-9.38]) following surgery. Rates of postoperative calcium supplementation were increased for patients receiving total thyroidectomy versus TL for 1 to 6 months (OR: 2.44 [1.62-3.68]), and 6 to 12 months following surgery (OR: 1.79 [1.18-2.72]). Patients undergoing TL with total thyroidectomy have a higher risk of postoperative hypocalcemia compared to patients receiving TL alone. Risk of parathyroid injury in these patients may warrant further emphasis on PTH measurement after surgery and a multidisciplinary approach to management.

Real-time imaging of ipsilateral parathyroid glands by retrograde injection of methylene blue into the superior thyroid artery: a new intraoperative parathyroid protection method

BackgroundPostoperative hypoparathyroidism caused by parathyroid injury is a problem faced by thyroid surgeons. The current technologies for parathyroid imaging all have some defects.MethodsPatients with differentiated thyroid carcinoma (DTC) who underwent unilateral thyroidectomy plus ipsilateral central lymph node dissection were recruited. We dissected the main trunk of the superior thyroid artery entering the thyroid gland and placed the venous indwelling tube into the artery. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were calculated.ResultsA total of 132 patients enrolled in this single-arm clinical trial, 105 of them completed retrograde catheterization via the superior artery. The sensitivity was 69.23 and 83.33% respectively. The specificity was 72.91 and 64.89%. The accuracy was 72.91 and 64.89%. The PPV was 85.71 and 81.08%. The NPV was 22.58 and 45.45%. There were no patients with allergic reactions to the methylene blue, or methylene blue toxicity.ConclusionsRetrograde injection of methylene blue via the superior thyroid artery is an effective and safe method to visualize parathyroid glands. This method can accurately locate the target organ by ultraselecting the blood vessel and injecting the contrast agent while avoiding background contamination and reducing the amount of contrast agent.Trial registrationClinical trial registration numbers and date of registration: ChiCTR2300077263、02/11/2023.

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

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. 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 dissectionbetween 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. 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*). 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.

Total thyroidectomy versus unilateral lobectomy for unilateral multifocal papillary thyroid carcinoma: systematic review and meta‑analysis.

The optimal surgical procedure(s) for unilateral multifocal papillary thyroid carcinomas is currently controversial. As such, the present study aimed to compare the efficacies of total thyroidectomy and lobectomy in patients with unilateral multifocal papillary thyroid carcinoma. A literature search of the PubMed/Medline, Embase, Web of Science, Cochrane Library, Wan Fang, and Zhi Wang databases for relevant studies, published from inception to October 31, 2022, was performed. Two researchers independently extracted data from the included studies. Lymph node metastasis, vocal fold paralysis, parathyroid injury, postoperative recurrence, and disease-free survival were evaluated. The meta-analysis included 7 studies comprising 1540 patients, of whom 496 and 1044 underwent lobectomy and total thyroidectomy, respectively. Compared with lobectomy, total thyroidectomy resulted in more vocal cord paralysis (odds ratio [OR] 0.35 [95% confidence interval (CI) 0.13 to 0.96]; P = 0.04) and parathyroid injury (OR 0.11 [95% CI 0.03-0.39]; P = 0.001) but with better disease-free survival (OR 0.21 [95% CI 0.09-0.49]; P = 0.000), although vocal cord paralysis and parathyroid injury, in large part, resolved within 1year after surgery. In addition, there was no difference in postoperative lymph nodes metastasis (OR 0.74 [95% CI 0.13-4.21]; P = 0.737) and postoperative recurrence (OR 2.37 [95% CI 0.42-13.38]; P = 0.33). Excluding studies that deviated from the general trend, total thyroidectomy was beneficial in reducing recurrence. Compared with lobectomy, total thyroidectomy was beneficial in reducing recurrence and disease-free survival and may be considered a more optimal approach for unilateral multifocal papillary thyroid carcinoma.

Unexpected mapping of recurrent laryngeal nerve by fluorescence-guided surgery using near-infrared indocyanine green angiography

Background. The recurrent laryngeal nerve (RLN) damage and parathyroid gland injury are the most severe complications of thyroid surgery. The possibility of RLN confirmation in the near-infrared spectrum after the injection of indocyanine green (ICG) was not yet been studied. Aim: to evaluate the ICG angiography for the identification of RLN during thyroid and parathyroid surgery. Materials and methods. ICG angiography of RLN was performed in 7 patients. An intraoperative neuromonitoring was applied as a method of controlling RLN. During the operation, parathyroid glands and RLN were identified by visual inspection (naked eye). To further confirm the location of the parathyroid glands by autofluorescence, an intravenous injection of ICG was performed with a concentration of 0.25 mg/kg followed by the application of the image-based system. Results. A good signal was achieved in the near-infrared spectrum from the RLN in all cases after the ICG injection. Sufficient blood perfusion of the RLN could be considered as a reasonable explanation for the exhibition of a good ICG near-infrared signal. Conclusions. ICG use might be a helpful approach for the confirmation of the RLN in addition to routine visual identification. Such function could be applied during fluorescence-guided surgery to evaluate the parathyroid gland autofluorescence. Visualization of RLN by ICG angiography is considered as an additional useful feature to prevent RLN injury.

TOETVA parathyroid autofluorescence detection: hANDY-i endoscopy attachment.

Treatment options for thyroid pathologies have expanded to include scarless and remote access methods such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Currently, no standardized methods exist for locating parathyroid glands (PGs) in patients undergoing TOETVA, which can lead to parathyroid injury and subsequent hypocalcemia. This early feasibility study describes and evaluates the hANDY-i endoscopic attachment for detecting PGs in transoral thyroidectomy. We used a prototype parathyroid autofluorescence imager (hANDY-i) that was mounted to a 10-mm 0-degree endoscope. The device delivers a split screen view of Red-green-blue (RGB) and near-infrared autofluorescence (NIRAF) which allows for simultaneous anatomical localization and fluorescence visualization of PGs during endoscopic thyroid dissection. One cadaveric case and two patient cases were included in this study. The endoscopic hANDY-i imaging system successfully visualized PGs during all procedures. The ability to leverage parathyroid autofluorescence during TOETVA may lead to improved PG localization and preservation. Further human studies are needed to assess its effect on postoperative hypocalcemia and hypoparathyroidism.

Parathyroid preservation in total endoscopic thyroid surgeries via the mammary areolas approach: Real-world data from a single center

BackgroundPreserving parathyroid glands in situ is crucial to avoid surgical hypoparathyroidism, but it is also one of the greatest challenges during thyroid surgery. Magnified endoscopic imaging has been proposed as a way to improve parathyroid preservation. Methods2,603 consecutive patients who underwent thyroid surgery at the First People’s Hospital of Zunyi from January 2018 to July 2022 were screened. 1,355 patients were eligible, including 965 endoscopic and 390 open cases. Parathyroid hormone (PTH) loss levels and severe parathyroid injury rates were compared between endoscopic and open cases. Meanwhile, factors that contribute to parathyroid injuries were assessed, including surgical extent, tumor size, carbon nanoparticle guidance, and surgical proficiency. ResultsPTH loss levels were similar between endoscopic and open cases (P = 0.440). The incidence of severe parathyroid injuries was also comparable (7.8% for endoscopic vs. 6.9% for open, P = 0.592). The endoscopic group had higher rates of autologous parathyroid transplantation (39.5% vs. 24.4%, P = 0.000), while accidental parathyroidectomy rates were similar (11.4% vs. 10.8%, P = 0.739). Among patients who received the same extent of thyroid surgeries, no significant difference was found in PTH loss levels and severe parathyroid injury rates, except for a higher risk of severe parathyroid injuries in endoscopic bilateral thyroidectomy (18.52% vs. 11.52%, P = 0.033). ConclusionsDespite the magnified endoscopic imaging facilitating the identification of parathyroid tissues, endoscopic approaches are not superior to open ones for the in-situ preservation of parathyroid glands. For a bilateral thyroidectomy, open approaches are safer for parathyroid preservation.

Application of carbon nanoparticles combined with refined extracapsular anatomy in endoscopic thyroidectomy.

To evaluate the value of refined extracapsular anatomy combined with carbon nanoparticle suspension tracing technology for protecting parathyroid function and the thoroughness of lymph node dissection in the central region during endoscopic thyroid cancer surgery. Retrospective clinical data analysis was performed on 108 patients who underwent endoscopic thyroid cancer surgery at the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital) from November 2019 to November 2022. Before surgery, thyroid function tests, color Doppler ultrasounds and neck-enhanced CT scans were performed on all patients. Cytopathological diagnosis obtained via ultrasound-guided fine-needle aspiration served as confirmation for the primary diagnosis. It was determined whether to perform a total thyroidectomy or a hemithyroidectomy (HT) together with preventive unilateral (ipsilateral) central neck dissection. Follow-up times were 1 to 34 months. Transient neuromuscular symptoms were present in 3.70% (4/108) cases, with no permanent neuromuscular symptoms or permanent hypoparathyroidism. Regarding transient hypoparathyroidism, the patients recovered after three months and did not need long-term calcium supplementation. The number of harvested LNs (mean± SD) was 5.54 ± 3.84, with ≤5 in 57.41% (62/108) and >5 in 42.59% (46/108) cases. The number of patients with metastatic LNs was 37.96% (41/108), with ≤2 in 65.85% (27/41) and >2 in 34.15% (14/41) cases. Fine extracapsular anatomy combined with carbon nanoparticle suspension tracing is effective in endoscopic thyroid cancer surgery. It can improve the thoroughness of prophylactic central neck dissection and recognition of the parathyroid gland and avoid parathyroid injury and other complications to effectively protect parathyroid function.

The Utility of Near-Infrared Autofluorescence for Parathyroid Gland Identification During Thyroid Surgery: A Single-Center Experience.

Parathyroid gland injury during thyroid surgery is common and can lead to postoperative hypocalcemia. This study aims to determine the utility of near-infrared autofluorescence (NIRAF) technology for parathyroid gland identification in thyroid surgery. A prospective case series of patients who underwent thyroid surgery between March and June 2021 were examined. Following intra-operative visualisation, parathyroid glands and surrounding tissues were exposed to near-infrared light with a wavelength of approximately 800nm using the Storz® Near-Infrared Range/Indocyanine Green (NIR/ICG) endoscopic system. Parathyroid glands were expected to show autofluorescence following exposure. Twenty patients who underwent thyroid surgery were included. Eighteen patients (90%) were female, with a median age of 50.0 (IQR 41.0 - 62.5). Surgeries performed include hemithyroidectomy (9 patients; 45.0%), total thyroidectomy (8 patients; 40.0%), completion thyroidectomy (2 patients; 10.0%) and right inferior parathyroidectomy (1 patient; 5.0%). Attempts were made to identify 56 parathyroid glands in this case series. There were 46/56 (82.1%) surgeon-identified parathyroid glands through direct visualisation. Using NIRAF technology, 39/46 (84.8%) were identified as parathyroid glands. There was no inadvertent resection of parathyroid glands or post-operative hypocalcaemia. NIRAF technology has the potential to be a useful tool in confirming the presence of parathyroid glands following direct visualisation intra-operatively.

Use of fluorescence imaging and indocyanine green during thyroid and parathyroid surgery: Results of an intercontinental, multidisciplinary Delphi survey

BackgroundIn recent years, fluorescence imaging—relying both on parathyroid gland autofluorescence under near-infrared light and angiography using the fluorescent dye indocyanine green—has been used to reduce risk of iatrogenic parathyroid injury during thyroid and parathyroid resections, but no published guidelines exist regarding its use. In this study, orchestrated by the International Society for Fluorescence Guided Surgery, areas of consensus and nonconsensus were examined among international experts to facilitate future drafting of such guidelines. MethodsA 2-round, online Delphi survey was conducted of 10 international experts in fluorescence imaging use during endocrine surgery, asking them to vote on 75 statements divided into 5 modules: 1 = patient preparation and contraindications to fluorescence imaging (n = 11 statements); 2 = technical logistics (n = 16); 3 = indications (n = 21); 4 = potential advantages and disadvantages of fluorescence imaging (n = 20); and 5 = training and research (n = 7). Several methodological steps were taken to minimize voter bias. ResultsOverall, parathyroid autofluorescence was considered better than indocyanine green angiography for localizing parathyroid glands, whereas indocyanine green angiography was deemed superior assessing parathyroid perfusion. Additional surgical scenarios where indocyanine green angiography was thought to facilitate surgery are (1) when >1 parathyroid gland requires resection; (2) during redo surgeries, (3) facilitating parathyroid autoimplantation; and (4) for the predissection visualization of abnormal glands. Both parathyroid autofluorescence and indocyanine green angiography can be used during the same procedure and employing the same imaging equipment. However, further research is needed to optimize the dose and timing of indocyanine green administration. ConclusionThough further research remains necessary, using fluorescence imaging appears to have uses during thyroid and parathyroid surgery.

Risk factors for hypocalcemia after total thyroidectomy.

Hypocalcemia is a common complication of total thyroidectomy; transient hypocalcemia has been reported in up to 68% of the patients. Chart review of all patients undergoing total thyroidectomy from 2016 to 2020. Clinical, biochemical, and pathological information was registered. We sought correlations between the different variables and the occurrence of post-operative hypocalcemia. This is a retrospective study carried out at a tertiary care teaching hospital. The aim of the study was to ascertain the incidence of hypocalcemia after thyroidectomy and to establish potential clinical and pathological risk factors for its development. Three hundred and thirty-seven patients were included in this study (78% female), with a median age of 47 years. The majority (75%) harbored thyroid neoplasms. Post-operative hypocalcemia developed in 43 patients (12.7%). On bivariate analysis, the most significant risk factor was an intraoperative injury of the parathyroid glands (OR = 2.49, 95% CI = 1.11-5.59), followed by a surgical time > 2.5 h (OR = 2.0, 95% CI = 1.03-4.19), concomitant lymph node dissection (OR = 2.45, 95% CI = 1.2-4.9), and placement of drains (OR = 2.40, 95% CI = 1.19-4.87). Only parathyroid injury remained statistically significant on multivariable analysis. The most significant risk factor for the development of post-operative hypocalcemia after thyroidectomy is injury of the parathyroid glands, which is usually noticed by the surgeon.

Preventing Inadvertent Parathyroidectomy during Thyroid Surgery - A Literature Narrative

Background: Accidental parathyroidectomy during thyroid surgery can lead to temporary or permanent hypocalcemia and serious morbidity. Proper identification of parathyroid glands during surgery can be an effective way to prevent this complication. Methods: The keywords “parathyroid gland,” “preserve,” “protect,” “inadvertent or accidental parathyroidectomy,” “surgery,” and “dissection” were used to search Medline and Embase databases. A total of 133 articles were selected after preliminary review, of which 80 indexed papers were reviewed for subject relevance. Results: Imaging techniques, such as the use of carbon nanoparticles or indocyanine green angiography, and operative techniques, such as meticulous capsular dissection of the thyroid gland, were associated with significantly improved rates of avoidance of inadvertent parathyroidectomy. Conclusion: During thyroid surgery, the use of imaging and careful operative techniques can prevent parathyroid injury. This, in turn, can prevent complications resulting from hypoparathyroidism such as tetany, ECG changes, and neurological sequelae.

Thyroidectomy with and without laryngectomy: Differences in post-operative hypocalcemia and management

BackgroundTotal laryngectomy (TL) with thyroidectomy can pose significant risks to parathyroid function, and variance in rates of post-operative hypocalcemia (POH) based on extent of thyroidectomy have not been previously reported. Our objective is to identify the rates of hypocalcemia and hypoparathyroidism in TL+/−thyroidectomy and compare this to matched thyroidectomy alone cohorts. MethodsMulti-institutional retrospective chart review of patients treated surgically for laryngeal cancer with TL or benign/malignant thyroid disease with thyroidectomy at regional tertiary care centers in New Orleans and Baton Rouge, Louisiana from 2016 to 2019. Cases were evaluated for post-operative and post-discharge calcium and parathyroid hormone levels, post-operative and long-term calcium supplementation, and intraoperative parathyroid identification and management. Results101 TL and 319 thyroidectomy patients' charts were reviewed. Regression analysis revealed increased odds of hypocalcemia and hypoparathyroidism in TL + TT versus TT alone (OR 10.7, OR 16.5, p < 0.001, respectively). TL + HT versus HT alone had increased odds of hypoparathyroidism (OR 1.6, p < 0.001). TL with any thyroidectomy compared to TL alone demonstrated both increased odds of hypocalcemia and hypoparathyroidism (OR 4.4 p = 0.009, and OR 4.5 p = 0.05). Odds of requiring long-term calcium supplementation were significantly increased with the addition of thyroidectomy across all groups. TL + TT was 8 times as likely (p = 0.002) and TL + HT was 5.3 times as likely (p = 0.001) to require long-term calcium supplementation compared to TL alone. ConclusionsThyroidectomy combined with TL demonstrates marked increased risk of parathyroid dysfunction and resultant POH. Despite improved visualization of soft tissue anatomy with TL, risk of parathyroid injury in these settings requires special attention to extent of parathyroid dissection and potential devascularization to reduce long-term sequelae of hyperparathyroidism. Therefore, post-operative calcium monitoring after TL is necessary and should resemble the long-standing stringent protocols that already exist for monitoring in thyroidectomy populations.

Analysis of cases with emergency thyroid surgery

Objective: To investigate the clinical features of cases with emergency thyroid surgery. Methods: Nineteen cases treated with emergency thyroid surgery from May 2014 to May 2019 were analysed retrospectively, including 9 males and 10 females, aged from 24-79 years old. Among them, 6 cases had nodular goitres and 13 cases had thyroid malignancies. One case underwent tracheal stenting before operation. Emergency thyroid surgery was due to severe dyspnea in all cases. Treatment outcomes and prognoses of patients were evaluated. Results: All the 19 patients underwent general anesthesia with endotracheal intubation. One patient underwent extracorporeal membrane oxygenation(ECMO) and two patients underwent cardiopulmonary bypass. Six cases of nodular goitres underwent proximal thyroidectomy. Eight cases of malignant tumors underwent total thyroidectomy, six cases with invading the trachea underwent tracheal end-end anastomosis after partial tracheal resection, one case underwent tumor resection with sternal sternum approach, cervical and mediastinal lymph node dissection, total laryngectomy and tracheal low ostomy. Two cases with extensive involvement of malignant tumors were given a definite diagnosis and tracheostomy. Of three cases with malignant lymphoma, one underwent total thyroidectomy, and two were only given a definite diagnosis and tracheostomy. No complications such as hemorrhage, recurrent laryngeal nerve or parathyroid injury occurred after operation in all patients. With followed up for 6-50 months, except 2 cases died due to tumor progression, the rest were alive. Conclusions: Patients with obvious dyspnea caused by thyroid tumors have a high mortality rate and should be treated actively. Emergency surgery not only relieves respiratory obstruction and saves the lives of patients, but some patients can get a radical cure as well.

Parathyroid Hormone as a Predictor of Post Total Thyroidectomy Parathyroid Gland Injury

Background: Post-thyroidectomy hypocalcaemia is one of the most prevalent morbidities. Serum parathormone hormone (PTH) levels before and after the operation have been an area of high interest for detecting the risk of postoperative hypocalcaemia. Aim: This study was conducted to determine the accuracy of perioperative parathormone hormone assessment as a predictor of parathyroid gland injury in total thyroidectomy operations. Methods: Fifty patients presented with goiter indicated for total thyroidectomy operation were evaluated and operated. Routine preoperative labs with measurement of the parathormone hormonal level, thyroid profile, and serum calcium (Ca) were done. Results: The level of postoperative PTH was lower in patients with post-operative manifestations of hypocalcaemia than those without (6.3 ± 5.1 vs. 24.8 ± 6.7), with a 78.9% drop in PTH from the preoperative level in the hypocalcaemia group versus 56.1% drop in the normocalcemia group (P < 0.0001). Percentage changes in PTH had good discriminative power, AUC=0.840 (95% CI: 0.648-1.000), p=0.002. Conclusion: postoperative PTH levels can be a good predictor of hypocalcemia in total thyroidectomies. Patients with a greater than 64.8% decrease in PTH levels were significantly more likely to develop hypocalcemia.