Postoperative Hypocalcemia Research Articles

Selective Parathyroid Autotransplantation During Total Thyroidectomy for Papillary Thyroid Carcinoma: A Cohort Study.

Purpose: The relationship between the selective parathyroid gland (PG) autotransplantation and hypoparathyroidism is still not completely clear. The aim was to ascertain whether the number of autotransplanted PGs affected the incidence of hypoparathyroidism and recovery of parathyroid function in the long-term for patients with papillary thyroid carcinoma (PTC).Methods: A retrospective cohort study included all patients with PTC who had underwent primary total thyroidectomy with central neck dissection between January 2013 and December 2017. The patients were divided into three groups (0, 1, and 2 PGs autotransplanted, respectively).Results: Of the 2,477 patients, 634 (25.6%) received no PG autotransplantation, 1,078 (43.5%) and 765 (30.9%) were autotransplanted 1 and 2 PGs, respectively, and the incidence of permanent hypoparathyroidism (>1 year) was 1.7%, 0.7%, and 0.4% (P = 0.0228). Both 1 or 2 PGs autotransplanted increased the incidence of transient biochemical hypoparathyroidism (odds ratio [OR], 1.567; 95% confidence interval [CI], 1.258–1.953; P < 0.0001; OR, 2.983; 95% CI, 2.336–3.810; P < 0.0001, respectively) but reduced the incidence of permanent hypoparathyroidism (OR, 0.373; 95% CI, 0.145–0.958; P = 0.0404; OR, 0.144; 95% CI, 0.037–0.560; P = 0.0052, respectively). Both 1 or 2 PGs autotransplanted did not independently influence the occurrence of hypocalcemia symptoms.Conclusion: Selective parathyroid autotransplantation is less likely to lead to post-operative symptomatic hypocalcemia, although it could lead to a transient decrease in parathyroid hormone. However, in the long run, it is still an effective strategy to preserve parathyroid function.

Use of pre-operative calcium and vitamin D supplementation to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy: a systematic review

This systematic review aimed to establish the evidence behind the use of pre-operative calcium, vitamin D or both calcium and vitamin D to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy. This review included prospective clinical trials on adult human patients that were published in English and which studied the effects of pre-operative supplementation with calcium, vitamin D or both calcium and vitamin D on the rate of post-operative hypocalcaemia following total thyroidectomy. Seven out of the nine trials included reported statistically significantly reduced rates of post-operative laboratory hypocalcaemia (absolute risk reduction, 13-59 per cent) and symptomatic hypocalcaemia (absolute reduction, 11-40 per cent) following pre-operative supplementation. Pre-operative treatment with calcium, vitamin D or both calcium and vitamin D reduces the risk of post-operative hypocalcaemia and should be considered in patients undergoing total thyroidectomy.

Thyroidectomy for Graves' Disease Predicts Postoperative Neck Hematoma and Hypocalcemia: A North American cohort study.

Objective:Examine the association of Graves’ disease with the development of postoperative neck hematoma.Design:A cohort of patients participating in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016 to December 31, 2018.Setting:A North American surgical cohort study.Methods:17 906 patients who underwent thyroidectomy were included. Propensity score matching was performed to adjust for differences in baseline covariates. Multivariate logistic regression was used to ascertain the association between thyroidectomy for Graves’ disease and risk of postoperative adverse events within 30 days of surgery. The primary outcome was postoperative hematoma. Secondary outcomes were postoperative hypocalcemia and recurrent laryngeal nerve injury.Results:One-to-three propensity score matching yielded 1207 patients with mean age (SD) of 42.6 (14.9) years and 1017 (84.3%) female in the group with Graves’ disease and 3621 patients with mean age (SD) of 46.7 (15.0%) years and 2998 (82.8%) female in the group with indications other than Graves’ disease for thyroidectomy. The cumulative 30-day incidence of postoperative hematoma was 3.1% (38/1207) in the Graves’ disease group and 1.9% (70/3621) in other patients. The matched cohort showed that Graves’ disease was associated with higher odds of postoperative hematoma (OR 1.65, 95% CI 1.10-2.46) and hypocalcemia (OR 2.04, 95% CI 1.66-2.50) compared with other indications for thyroid surgery. There was no difference in recurrent laryngeal nerve injury among the 2 groups.Conclusions:Patients with Graves’ disease undergoing thyroidectomy are more likely to suffer from postoperative hematoma and hypocalcemia compared to patients undergoing surgery for other indications.

The Timing of Parathyroid Hormone Measurement as an Early Predictor of Postoperative Hypocalcemia Post Total Thyroidectomy: A Prospective Study

Abstract Background: Serum intact parathyroid hormone (iPTH) level is an early marker of post-thyroidectomy hypocalcemia. However, lack of methodological standardization to define timing and cut-off points of iPTH measurement limit its clinical applicability. Here, we evaluated the relationship between two distinct postoperative time sampling and iPTH accuracy on predicting hypocalcemia. Aim of Study: This study was aimed to evaluate the accuracy of iPTH measured after total thyroidectomy to predict postoperative hypocalcemia and to identify patients at risk of postoperative hypocalcaemia who require supplementation treatment, and those not at risk who can be safely discharged without any supplementation treatment. Moreover, combining postoperative PTH and serum calcium levels could result in an accurate prediction of the risk of postoperative hypocal-caemia. Patients and Methods: iPTH was measured within 24h after surgery (iPTH 24h) and on the morning of the 3rd postoperative day (iPTH 3rd PO). Hypocalcemia was defined by levels of total calcium corrected by serum albumin £8.0mg/dL and/or by the presence of symptoms or signs. The most accurate iPTH cut-off point for hypocalcemia prediction was established from a ROC curve comparing both time-points. Results: The study included 40 patients. The mean age was 46.23±9.03 years, 34 were women (85%) and all patients underwent total thyroidectomy. Hypocalcemia occurred in 8 patients (20%), of whom 5 were symptomatic. Lower levels of iPTH 24h and iPTH 3rd PO were associated with postop-erative hypocalcaemia (p < 0.05). Using the ROC curve, the optimal cut-off points were 14.8pg/mL and 14pg/mL for iPTH 24h and iPTH 3rd PO, respectively. The comparison of the AUC showed no significant difference between these two points of evaluation with 98% accuracy for both time points. Conclusions: Serum iPTH levels measured within 24h or on the 3rd morning after surgery are predictors of postoperative hypocalcemia. Notably, both time-points have the same accuracy to predict postoperative hypocalcemia (with different cutoff points).

Retrospective Comparative Study of the Incidence of Hypocalcaemia in Total Thyroidectomy between Ain-Shams University as a Referral Center and Damanhour Medical National Institute

Abstract Background: Post-operative hypocalcaemia is one of the most serious complications of total thyroidectomy with variable degrees of morbidity. Aim of Study: The aim of this study was to to compare the incidenceandto examine several preoperative and imme-diate post-operative factorsfor development of hypocalcaemia after total thyroidectomy in patients who underwent total thyroidectomy in Ain-Shams University and Damanhour Medical National Institute. Patients and Methods: This retrospective study was conducted in Ain-Shams University Hospital and Damanhour Medical National Institute in the period between December 2015 and December 2019. It included 62 patients who under-went total thyroidectomy. The data was collected from patients' files in the Record Department. Results: There were 52 female and 10 male patients. The mean age was 38 years. Multi-nodular goiter was the most common indication of total thyroidectomy. The mean pre-operative serum Ca was 8.1mg/dl in group A and 8.3mg/dl in group B. 3 (9.7%) patients in group A and 7 (22.5%) in group B developed post-operative hypocalcemia. The highest fre-quency of transient hypocalcaemia was on 2nd post-operative day in group A and on 0 day in group B. There was only one patient 3.2% who required calcium and vitamin D supplement for more than six months. Conclusion: Hypocalcaemia is one of the major concerns following total thyroidectomy that can be prevented by me-ticulous surgical technique, identification and preservation of parathyroid glands and its vascularity. Post-operative monitoring of serum calcium & early treatment can prevent significant morbidity.

Discrepancies in Thyroidectomy Outcomes Between General Surgeons and Otolaryngologists.

Thyroidectomy is a common operation, performed by general surgeons and otolaryngologists. Few studies compare complication rates between these two specialties. We hypothesized that there would be no difference in the incidence of postoperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, or hematoma based on the surgical specialty performing the thyroidectomy. The 2016-2017 National Surgical Quality Improvement Program Targeted Thyroidectomy database was queried for patients who underwent thyroidectomy for both benign and malignant thyroid diseases. Thyroidectomies performed by general surgeons were compared to those performed by otolaryngologists. Multivariate logistic regression was used to identify risk factors associated with RLN injury, hematoma, and hypocalcemia. From 11,595 patients, 6313 (54.4%) were performed by general surgeons and 5282 (45.6%) by otolaryngologists. Goiter (43.7%) and nodule/neoplasm (40.8%) were the most common indications for the general surgery and otolaryngology cohorts respectively. General surgeons used an energy vessel sealant device more frequently (77.7% vs. 51.5%, p < 0.001), whereas RLN monitoring (67.4% vs. 58.3%, p < 0.001) and drain placement (44.3% vs. 14.8%, p < 0.001) were utilized more often by otolaryngology. After controlling for covariates, thyroidectomy by general surgeons had an increased associated risk of RLN injury (OR = 1.26, CI = 1.07-1.48, p = 0.006) and post-operative hypocalcemia (OR = 1.17, CI = 1.00-1.37, p = 0.046). Thyroidectomy volume is relatively equally distributed among general surgeons and otolaryngologists. Operation by a general surgeon is associated with an increased risk for RLN injury and postoperative hypocalcemia. This discrepancy may be explained by case volume, training, and/or completion of an endocrine surgery fellowship; however, this discrepancy still merits ongoing attention.

Measurement of serum intact parathyroid hormone (iPTH) at the end of total thyroidectomy: A reliable parameter for hypocalcemia?

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 &amp;lt; 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 &amp;lt; 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 &amp;lt; 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.

Improving the Management of Post-Operative Hypocalcaemia in Thyroid Surgery.

Hypocalcaemia is a frequent, and potentially dangerous complication of total thyroidectomy occurring secondary to devascularisation of the parathyroid glands. This quality improvement (QI) project was undertaken in a large Ear, Nose and Throat (ENT) department in the East of England over a one year period. The project aimed to improve postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, prophylactic calcium prescribing and the subsequent monitoring and management of hypocalcaemia.A baseline audit was conducted to determine the initial guideline compliance. The QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover.The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%. The measurement of PTH at four hours improved from 42.5% to 52.2%. By optimising postoperative care, this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.

Association of preoperative factors and postoperative hypocalcemia after parathyroidectomy for primary hyperparathyroidism

Association of preoperative factors and postoperative hypocalcemia after parathyroidectomy for primary hyperparathyroidism

Intact Parathyroid Hormone Levels in Predicting Postoperative Hypocalcaemia After Total Thyroidectomy in South Indian Population: Cross Sectional Study.

Hypocalcaemia being one of the most common complications after total thyroidectomy may not be avoidable in all cases. This study evaluated the effectiveness of intact Parathyroid hormone (iPTH) measured at 1-h after total thyroidectomy in predicting postoperative hypocalcaemia in early postoperative period in South Indian population. Patients who underwent total thyroidectomy in our institute from 2016 to 2018 were included. Preoperative calcium and iPTH levels were measured. Patients' iPTH level was measured 1h after surgery and serum calcium level was measured at 24h after surgery. Patients were also monitored clinically for any symptoms and signs of hypocalcaemia. A total of 57 patients were studied. The malignant causes accounted for 75.4% with papillary carcinoma thyroid being the most common cause. 65.7% of patients who underwent total thyroidectomy and 100% of patients who underwent total thyroidectomy with neck dissection developed hypocalcaemia. 70% of patients with low iPTH developed hypocalcaemia and none of the patients who had normal iPTH developed hypocalcaemia. This relation was statistically significant with p value of 0.018 (< 0.05). The positive predictive value is 70% and negative predictive value is 100%. Though our study supports the hypothesis that iPTH is effective in predicting hypocalcaemia after total thyroidectomy in the early postoperative period, a larger sample study is needed to further support this. It can be used to consider patients for early discharge or to prophylactically start oral calcium and Vitamin D supplementation based on iPTH levels at 1h after surgery.

37 Improving the Management of Post-Operative Hypocalcaemia in Thyroid Surgery

Abstract Introduction Hypocalcaemia is a frequent, and potentially dangerous, complication of total thyroidectomy [1, 2]. This quality improvement (QI) project was undertaken in a large ENT department in the East of England over a year. The project improved postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, appropriate prescribing and the monitoring and management of hypocalcaemia. Method Following a baseline audit the QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover. Results The measurement of PTH at four hours improved from 42.5% to 52.2%. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%. Conclusions By optimising postoperative care this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.

Frequency of Hypomagnesaemia following Total and Near-total Thyroidectomy and its relationship with Hypocalcaemia.

To determine the frequency of hypomagnesaemia in patients undergoing thyroidectomy and evaluate its relationship with postoperative hypocalcaemia. Observational, cross-sectional study. Surgical Unit 1, Benazir Bhutto Hospital, Rawalpindi, Pakistan from April 2017 to May 2019. Preoperative and 24-hour postoperative samples for serum calcium and magnesium of 75 patients undergoing total and near-total thyroidectomy were taken. Postoperative signs and symptoms of hypocalcaemia were documented. Data was analysed on SPSS version 22, using independent and paired t-test, Pearson correlation, linear regression, Chi-square test and Fisher's Exact test. Postoperatively 49 (65.3%) patients developed hypocalcaemia and 8 (10.7%) developed hypomagnesaemia. Postoperative hypocalcaemia was significantly associated with hypomagnesaemia (p=0.03) with a significant positive linear correlation. Ten patients (13.3%) developed symptomatic hypocalcaemia; however, it was not associated with postoperative hypomagnesaemia. Postoperative hypocalcaemia and hypomagnesaemia were significantly associated with preoperative calcium level (p = 0.03 and 0.04, respectively). There was significantly lower calcium level in patients with hypomagnesaemia (p = 0.002) and a significant fall in magnesium level in patients developing hypocalcaemia (p = 0.044). Postoperatively hypocalcaemia was prevalent following thyroidectomy, while hypomagnesaemia was not common. Hypomagnesaemia and a fall in magnesium level after surgery was associated with hypocalcaemia; but not with symptomatic hypocalcaemia. Monitoring of magnesium levels in severe or persistent hypocalcaemia is recommended. While this study proves a relationship between calcium and magnesium, its clinical implication must be further studied. Key Words: Calcium, Magnesium, Postoperative, Hypocalcaemia, Hypomagnesaemia, Thyroidectomy.

Predictors of early postoperative hypocalcemia in patients with secondary hyperparathyroidism undergoing total parathyroidectomy.

ObjectiveTo summarize the clinical features of secondary hyperparathyroidism (SHPT) in patients with chronic renal failure and to explore the predictive factors of postoperative hypocalcemia after total parathyroidectomy in these patients.MethodsThe clinical data of 87 patients admitted to Guangdong Electric Power Hospital from May 2013 to February 2020 were reviewed. All patients underwent total parathyroid resection and sternocleidomastoid microtransplantation. Age, sex, and the serum calcium, phosphorus, alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) concentrations were analyzed as predictive factors of postoperative hypocalcemia.ResultsBone pain was the most common clinical manifestation in this study population, and all 87 patients experienced relief from their clinical symptoms after the surgical procedure. Age and the preoperative serum calcium, ALP, and iPTH concentrations were determined to be early predictive factors of postoperative hypocalcemia.ConclusionsAge and the preoperative calcium, ALP, and iPTH concentrations are independent risk factors for postoperative hypocalcemia in patients with SHPT and renal disease who undergo total parathyroidectomy with sternocleidomastoid microtransplantation. These factors can help identify high-risk patients who can be managed by a multidisciplinary team to improve graft survival and quality of life.

The Effect of Incidental Parathyroidectomy on Hypocalcemia in Benign and Malignant Thyroid Patients

Objective: Hypocalcemia is characterized by clinical findings resulting from a decrease in serum calcium (Ca2+) and many etiological factors may cause this condition. The most common cause of postoperative hypocalcemia is hypoparathyroidism and the most frequent complication that occurs after thyroid surgery is hypocalcemia. We aimed to investigate the effect of incidental parathyroidectomy on postoperative early hypocalcemia in patients after thyroid surgery.Methods: Retrospectively analyzed the data of patients who underwent thyroidectomy in General Surgery Department of Abant Izzet Baysal University between January 2009 and December 2018. Age, gender, serum Ca2+ and parathormone (PTH) levels were obtained. The histopathological results of thyroidectomy materials were grouped as benign (Group 1) and malignant (Group 2). Results: The study population was consisted of 3841 patients. 3154 patients were in group 1 and 687 patients were in group 2. The postoperative average serum Ca2+ levels of group 1 and 2 were 8.50 mg/dl (6.80-9.80) and 8,50 mg/dl (6.80-9.80), respectively (p=0.996). Postoperative PTH levels of group 1 and 2 were 44.5 ng/l (0-65) and 44.5 ng/l (0-65), respectively (p=0.979). Overall postoperative hypocalcemia (8.4 mg/dL) was observed in 1742 (45.4%) patients. There was no difference in Ca2+ and PTH levels between group 1 and group 2. Incidental parathyroidectomy (%5.4) was performed in 209 of total study population who underwent thyroidectomy. 155 (4.9%) and 54 (7.9%) of the patients in groups 1 and 2, respectively and the incidental parathyroidectomy rates of the groups were statistically different (p=0.02).Conclusion: We think that incidental parathyroidectomy does not stimulate the development of postoperative hypocalcemia.

P32: POST-OPERATIVE RELATIVE PARATHORMONE DECLINE (ΔPTH%) AND ABSOLUTE PARATHORMONE DECLINE (ΔPTH) LEVELS ARE BETTER MARKERS OF SYMPTOMATIC HYPOCALCEMIA FOLLOWING TOTAL THYROIDECTOMY THAN POST-OPERATIVE PTH ALONE

Abstract Introduction Hypocalcemia is a frequent complication following thyroidectomy which can delay discharge and increase overall treatment expenditure. We aimed to assess the predictive value of absolute and relative intact Parathormone(iPTH) decline levels as reliable markers of post-operative hypocalcemia. Method This prospective study included 95 consecutive patients at our tertiary care centre. Patients underwent either Total Thyroidectomy(TT), TT+Central Neck Dissection(CND) or TT+CND+Modified Radical Neck Dissection(MRND). iPTH levels were measured four hours after surgery and the following morning after surgery(POD 1). iPTH, absolute iPTH decline(ΔPTH) and relative iPTH decline(ΔPTH%) were calculated and correlated with hypocalcemia. Comparisons between groups were measured by chi-square test, Fischer's exact test and Mann-Whitney U test. Result Of the 95 patients, 59 had malignant disease, while 36 patients had benign histopathology. TT was performed in 69 patients, TT+CCLND in 7, and TT+CCLND+MRND in 19. 32.6% of patients(n=31) had biochemical hypocalcemia and 20%(n=19) had symptomatic hypocalcemia. The mean calcium of the cohort on Post-operative day(POD)-1 was 8.3±0.66(range=6.5-9.9) and POD-3 was 8.4±0.69(range=6.3–10.7). Median PTH, measured 4 hours after surgery was 24pg/ml(IQR–23.4;range 2.5–85.5), and measured on POD-1 was 28pg/ml(IQR–27.6;range=2-79). The ΔPTH(U=206;p&amp;lt;0.001) &amp; ΔPTH% (U=127;p&amp;lt;0.001) were significantly higher in patients with symptomatic hypocalcemia. A ΔPTH% of 20%(sensitivity=84%;specificity=91%) and ΔPTH of 3.75 pg/ml(sensitivity = 74%; specificity=87%) were good predictors of symptomatic hypocalcemia. Conclusion Post-operative ΔPTH and ΔPTH% are reliable predictors of hypocalcemia following thyroid surgery and have the potential to facilitate a safe early discharge for patients undergoing TT. 20% fall in the PTH level(ΔPTH%) can be useful as a marker of hypocalcemia. Take-home message Post-operative ΔPTH and ΔPTH% are better predictors of hypocalcemia following thyroid surgery than a single value of post-operative PTH alone.

P33: PROPOSAL OF A NEW SCORING TOOL FOR PREDICTION OF HYPOCALCEMIA IN PATIENTS UNDERGOING SURGERY FOR PAPILLARY THYROID CANCER

Abstract Introduction Post-operative hypocalcemia occurs more frequently in certain high-risk patients. The aim of our study is to propose a preliminary scoring system to identify patients who are more likely to develop hypocalcemia following surgery for papillary thyroid cancer. Method The study was performed with a retrospective developmental cohort(n=131) and a prospective validation cohort(n=71). Patients underwent either Total Thyroidectomy(TT), TT+Central Neck Dissection(CND) or TT+CND+Modified Radical Neck Dissection(MRND). Significant pre-operative variables and operative findings were converted into categorical variables for analysis. Univariate, multivariate analysis and a logistic regression were used to select significant predictors. The score was constructed by converting into integer, the regression coefficients of independently predictive factors in the logistic regression model. This score was validated prospectively in the validation cohort. Result 24(18%) out of 131 patients in the developmental cohort and 16(22.5%) out of 71 patients in the validation cohort had symptomatic hypocalcemia. Thyroiditis, positive lymph node metastasis, central and lateral compartment dissection, Neutrophil-to-lymphocyte ratio(NLR)&amp;gt;3.35 and platelet-to-lymphocyte ratio(PLR)&amp;gt;135 were selected as significant predictors. A score with a range of 0-11 was created. The cut-off value for the score was 6 points(sensitivity of 92.0% and specificity of 89.0%). Areas under the ROC curve for the scores were 0.926 and 0.901 in the developmental and validation cohorts, respectively. Conclusion This score could be a tool in the prediction of hypocalcemia and could help in identifying patients at a higher risk of post-operative hypocalcemia and guide calcium/Vitamin D treatment, as well as facilitate a safe earlier hospital discharge for low risk patients. Take-home message The proposed scoring system could help in identification of patients at a higher risk of post-operative hypocalcemia.

A Rapid Intraoperative Parathyroid Hormone Assay Based on the Immune Colloidal Gold Technique for Parathyroid Identification in Thyroid Surgery.

ObjectiveA novel immunochromatographic test strip method was developed to detect tissue parathyroid hormone (PTH) using the immune colloidal gold technique (ICGT). The accuracy and application value of this method for intraoperative parathyroid identification were evaluated.MethodsSerum samples were collected to measure PTH by both ICGT and electrochemiluminescence immunoassay (ECLIA). Patients who underwent unilateral and total thyroidectomy were enrolled to evaluate the feasibility and clinical efficacy of rapid intraoperative identification of parathyroid glands via PTH determination using ICGT. Two sample preparation methods, fine needle aspiration (FNA) and tissue block homogenate (TBH), were used for PTH-ICGT analysis.ResultsBablok analysis showed a linear relationship between the serum PTH measurements obtained by ICGT and ECLIA. Non-parathyroid tissues had much lower PTH concentrations (14.8 ± 2.1 pg/ml, n = 97) detected by ICGT, compared to the parathyroid gland tissues (955.3 ± 16.1 pg/ml, n = 79; P < 0.0001), With biopsy results as the standard, ICGT showed higher diagnosis rates as compared with direct visual inspection, for identifying both parathyroid glands (97.4 vs. 78.2%) and non-parathyroid tissues (100 vs. 68.9%). The cut-off values for parathyroid identification by FNA and TBH methods were 63.99 and 136.30 pg/ml, respectively. The detection time was 2 min by TBH method for in vitro tissue detection and 6 min by FNA method for in situ tissue detection, both of which were faster than traditional intraoperative cryopathological examination (usually >30 min). Intraoperative application of ICGT method was associated with higher postoperative serum calcium and blood PTH levels at 1 and 3 months as well as a lower incidence of postoperative transient hypocalcemia, as compared with direct visual inspection.ConclusionPTH-ICGT assay shows high potential as a rapid, novel alternative for intraoperative parathyroid identification.

P5 A Cut Throat approach to post thyroidectomy care

IntroductionAcross the UK, approximately 10,000 elective neck dissection surgeries (thyroidectomy/parathyroidectomy) are performed each year. The recognised post-operative complications of such surgeries range from mild post-operative hypocalcaemia to life threatening wound haematoma .AimThis project aimed to establish the awareness of the British Association of Endocrine and Thyroid Surgeons (BAETS) post thyroidectomy guidelines and provide targeted education in order to improve any identified failings in the management of this patient group.MethodsA nine point questionnaire was generated based on the guidelines published by BAETS. This questionnaire was disseminated to the junior doctors and nurse practitioners based on the surgical unit of North Tees General Hospital.ResultsResults were analysed from twenty respondents. 92% opted to call a registrar or consultant during a critical airway emergency secondary to wound haematoma rather than attempt to open the wound on the ward. Respondents displayed poor understanding of the risks of thyroid surgery (55%) and struggled to identify symptoms of hypocalcaemia (25%).Participants showed good understanding of the need for post-operative thyroxine (100%), the correct dose of calcium gluconate required for treatment of hypocalcaemia (90%) and normal calcium levels (85%).A video was created and distributed which highlighted front of neck anatomy and steps involved in releasing a wound haematoma. This included the ‘SCOOP’ video created by Endocrine Surgery Oxford. Data collected following the session found 93% of respondents would be more confident to intervene in future.ConclusionIt is vital that junior doctors are well educated and equipped to deal with post-operative patients, especially those who may develop imminent airway obstruction. Our “cut throat” approach aims to ensure our first responders are decisive and effective in carrying out life saving interventions.

Risk Factors for Severe Hypocalcemia in Patients with Secondary Hyperparathyroidism after Total Parathyroidectomy.

Background Hypocalcemia is the most common complication of total parathyroidectomy in secondary hyperparathyroidism (SHPT) and is associated with adverse consequences such as spasms, epilepsy, and arrhythmia and even death if the serum calcium level decreases rapidly. Previous studies have identified several risk factors for postoperative severe hypocalcemia (SH) in patients with SHPT, but the sample sizes were small and thus the results may not be reliable. Objectives This study was performed to investigate the risk factors for SH after total parathyroidectomy without autotransplantation (tPTX) in a large sample of patients with uremic hyperparathyroidism. Methods We retrospectively investigated the records of 1,095 patients with SHPT treated with tPTX between January 2008 and December 2018. Based on the postoperative serum calcium concentration, the patients were grouped into SH and non-SH groups. The clinical characteristics and biochemical results were analyzed, and binary logistic regression analysis was used to identify the risk factors for SH. Results After surgery, 25.9% of the patients developed SH. Age, diastolic blood pressure (DBP), heart rate, frequency of bone pain, weight of resected glands, preoperative serum calcium, intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), and hemoglobin levels differed between the two groups. Binary logistic regression analyses identified preoperative serum calcium, iPTH, and ALP levels as independent predictors of SH after surgery. Conclusions The preoperative serum calcium, iPTH, and ALP levels can be used to assess the risk of postoperative SH in patients with SHPT. Such patients should thus be monitored closely in order to initiate prompt interventions to avoid SH.

Hypocalcemia following thyroid surgery- A prospective study

Introduction: This was a prospective observational study of 18-month duration. The purpose of this study is to compare preoperative serum calcium levels with postoperative serum calcium levels and to analyze postthyroid surgery hypocalcemia with regard to prevalence, clinical presentation, and severity and to treat hypocalcemia if it occurs. In addition, we analyzed the correlation of postoperative hypocalcemia with relation to the type of surgery, diagnosis, duration of surgery, and the quantity of blood loss. This study was conducted on consecutive patients who underwent thyroid surgery in the Department of General Surgery of a tertiary hospital in Puducherry for 18 months from November 2014 to April 2016. The median age of the patients was 40 years. The sex ratio was 17:2 in favor of females. Out of 38 patients, 18 patients were diagnosed with multinodular goiter, 8 were follicular carcinoma thyroid, 5 were papillary carcinoma thyroid, 2 were medullary carcinoma thyroid, 4 were adenomatoid nodule, and 1 patient was diagnosed to have thyroid abscess. In addition, 31 patients underwent total thyroidectomy, 6 patients underwent hemithyroidectomy when 1 patient underwent incision and drainage for thyroid abscess. Results: 39% (n = 15) of the patients developed hypocalcemia postoperatively. 87% (n = 11) of the patients were symptomatic and required calcium correction. Two patients had delayed presentation of hypocalcemia on postoperative day 5. One patient who underwent hemithyroidectomy developed hypocalcemia in the postoperative period. Trousseau's sign was the most typical clinical feature seen in hypocalcemia patients. In the present study, no significant association of hypocalcemia with the female gender was noted, and we did not find any association of hypocalcemia with advancing age. We did not find any association between hypocalcemia and prolonged surgery duration or increased blood loss in the present study. In addition, we did not see any increase in the incidence of hypocalcemia in patients who underwent thyroidectomy combined with lymph node clearance. Conclusion: The rate of postoperative hypocalcemia following thyroid surgery in this study was 39%. It coincides with the incidence reported elsewhere in the world. Although the risk of hypocalcemia was associated with increased blood loss, prolonged surgery, and extent of surgery, it was not statistically significant. If a similar study is conducted on a larger scale, including a broader spectrum of the population, important factors that influence postoperative hypocalcemia may be recognized.