Postoperative Hypocalcemia Research Articles

Preoperative prophylactic active vitamin D to streamline total thyroidectomy.

BackgroundHypocalcaemia is a common complication after total thyroidectomy (TT). Treatment consists of calcium and active vitamin D supplementation. Low levels of vitamin D before surgery have been shown to be a risk factor for postoperative hypocalcaemia, yet studies examining routine preoperative vitamin D supplementation have shown conflicting results. This retrospective cohort study aims to investigate the potential benefit of preoperative active vitamin D supplementation on hypocalcaemia and its symptoms after TT.MethodsThis study included patients undergoing TT at Uppsala University Hospital from January 2013 to December 2020, resulting in a total of 401 patients after exclusion. Routine preoperative alfacalcidol treatment was initiated for all TT patients in January 2017 resulting in two groups for comparison: one group (pre-January 2017) that was prescribed preoperative alfacalcidol and one that was not. Propensity score matching was used to reduce bias. The primary outcome was early postoperative hypocalcaemia (serum calcium, S-Ca less than 2.10 mmol/l); secondary outcomes were symptoms of hypocalcaemia and length of stay.ResultsAfter propensity score matching, there were 108 patients in each group. There were 2 cases with postoperative day one S-Ca less than 2.10 in the treated group and 10 cases in the non-treated group (P < 0.001). No patients in the treated group had a S-Ca below 2.00 mmol/l. Preoperative alfacalcidol was associated with higher mean serum calcium level day one (2.33 versus 2.27, P = 0.022), and reduced duration of hospital stay (P < 0.001). There was also a trend toward fewer symptoms of hypocalcaemia (18.9 per cent versus 30.5 per cent, P = 0.099).ConclusionsProphylactic preoperative alfacalcidol was associated with reduced biochemical hypocalcaemia and duration of hospital stay following TT. Also, with this protocol, it is suggested that routine day 1 postoperative S-Ca measurement is not required.

Abstract #1161627: Hypoparathyroidism Manifesting a Decade After Thyroidectomy

Postoperative hypocalcemia usually occurs in the first days after surgery and can be the result of dynamic changes in electrolytes after interventions. When accompanied by a low parathyroid hormone (PTH) level, it is considered hypoparathyroidism. 41-year-old female with history of hypertension and multinodular goiter status post total thyroidectomy (16 years prior) presented with full body and jaw stiffness of 1-hour duration. She reported perioral tingling for the last 5 years and bilateral forearm tingling in the past week. She recalled taking calcium supplements for a brief period after surgery and then again 5 years after surgery. She had not taken any supplements for the last 9 years. Examination shows no neck masses or lymphadenopathy, no limb deformities, and positive Chvostek sign. Laboratory showed serum calcium of 5.1mg/dL (8.9-10.7), ionized calcium 0.92mmol/L (1.16-1.32), albumin 3.7g/dL (3.7-4.9), phosphorus 6.0mg/dL (2.5-4.6), magnesium 1.2mg/dL (1.8-2.8), intact PTH 15.9pg/mL (8.7-77.1), and 25-OH vitamin D of 6.5ng/mL (30.0-100.0). Pathology report confirmed removal of only 1 parathyroid gland. She was started on intravenous calcium gluconate; followed by calcium carbonate, calcitriol, magnesium, and ergocalciferol. Two months after, while taking only calcium carbonate, she showed persistent hypocalcemia with serum calcium of 7.4mg/dL, PTH of 14pg/mL. Calcium decreased to 5.9mg/dL when supplements were stopped; increased to 9.5mg/dL after resuming calcium carbonate and calcitriol. The literature describes an incidence of 0% to 6% of permanent hypoparathyroidism following complete thyroid resection. The fragile nature of the parathyroid glands leaves them susceptible to injuries after manipulation. The short half-life of the PTH allows for prompt clinical manifestations of hypocalcemia after thyroidectomy. Rarely, the manifestations can take several years to present, which is known as “late-onset” or “delayed” hypoparathyroidism. It has been hypothesized that this phenomenon is the result of progressive atrophy of the parathyroid glands; others suggest that scar tissue in the glands leads to hypo-vascularization and slowly progressive ischemia. There are 5 case reports of delayed presentation of post-surgical hypoparathyroidism described in the literature. Four out of five cases were reported in women; three of these cases underwent thyroidectomy for thyroid cancer and two of them for multinodular goiter. Most of the cases presented 12-14 years after surgery; symptoms range from muscle cramps and paresthesia to seizures. Our patient may have had parathyroid insufficiency since her thyroidectomy with intermittent manifestations of hypocalcemia with unclear triggers. It is possible this admission was exacerbated by severely low vitamin D levels. She requires long term treatment for hypocalcemia now as parathyroid glands have completely failed. This case also illustrates that patients with permanent hypoparathyroidism should be followed on a yearly basis to ensure medication adherence and they should be warned about ominous manifestations of hypocalcemia in the long term.

Factors associated with thyroidectomy complications in resource-limited settings: An observational study

Background: Even though thyroidectomy outcomes and their predictive factors are various and widely studied, the data from our country and other African countries where the disease burden is high are limited. The main aim of this study was to evaluate the incidence and factors associated with thyroidectomies complication in a resource limited setting where the procedures were performed by general surgeons/general surgery residents. MethodsThis is an observational study of one hundred ninety-nine patients undergoing elective thyroidectomy from September 1, 2020, to August 30, 2021. The primary outcomes are the incidence and types of complications observed during and after surgery. The secondary outcomes are identifying risk factors associated with complications. Bivariate and multivariate logistic regressions were used to identify risk factors. P-value < 0.05 was considered statistically significant. ResultThe incidence of complications after thyroid surgeries was 18.6%. The two commonest complications were an external branch of the superior laryngeal nerve (EBSLNI) injury and hypocalcemia. Thyroidectomy performed by residents and patients who underwent total thyroidectomy, the independent risk factor of the EBSLN injury [AOR = 8.015; 95%CI (1.402–45.807); P = 0.019 and postoperative hypocalcemia [AOR = 17.797; 95%CI (3.799–83.374); P < 0.001, resulted in an incidence of 7.54% and 5.53% respectively. ConclusionThe incidence of thyroidectomy complications is relatively similar to other studies. However, the provision of special training for residents on surgical techniques to prevent EBSLN injury and performing non-total thyroidectomies for benign thyroid diseases are recommended to reduce complications.

Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia.

Background. Postoperative hypocalcemia is one of the most common complications after total thyroidectomy. Parathormone (PTH) and calcium levels, measured several hours after surgery, have been suggested as valuable markers for detecting patients at risk for post-thyroidectomy hypocalcemia. We aimed to determine if early post-surgery PTH and calcium levels can be used for the early identification of patients at risk for symptomatic hypocalcemia. Methods. PTH and calcium were measured before surgery and at 10 min and 4 h post-thyroidectomy, in 77 patients. Performance characteristics of PTH and calcium levels and their post/pre-surgery ratios were calculated. Results. Four-hour calcium was a sensitive (93.75%) but not specific (67.61%) indicator of patients at risk for symptomatic hypocalcemia. The 4-h/pre-surgery PTH ratio was the most accurate (90.81%) and the most specific (94.37%) test to identify patients at risk. Serum calcium at 4-h, 4-h/pre-surgery PTH ratio, and PTH at 10 min post-surgery had the higher diagnostic odds ratios (50.86, 32.85, and 29.04, respectively). The 4-h/pre-surgery PTH ratio also had the highest (0.694) Youden’s J statistic. Conclusions. Low serum calcium levels 4 h after thyroidectomy and the 4-h/pre-surgery PTH ratio could be valuable additions to everyday clinical practice in post-thyroidectomy patients.

Indocyanine Green Angiography of Parathyroid Glands versus Intraoperative Parathyroid Hormone Assay as a Reliable Predictor for Post Thyroidectomy Transient Hypocalcemia

Background Prediction of postoperative hypocalcemia is a fundamental issue in thyroidectomy. Indocyanine green (ICG) angiography of parathyroid glands is a feasible method to detect the perfusion of parathyroid glands and predict postoperative hypocalcemia. Materials and Methods A prospective observational study was conducted at Ain Shams University Hospitals between April 2018 and April 2021. The included cases of total thyroidectomy underwent intraoperative ICG fluorescence angiography to identify the four parathyroid glands and score each gland according to the viability. Patients in which less than four glands were identified were excluded. Intraoperative intact parathyroid hormone (ioPTH) level assay was also measured to compare with ICG in predicting postoperative transient hypocalcemia. Results A total of 134 cases underwent total thyroidectomy during the study period. We could identify the four parathyroid glands in 90 patients, including them in the study. We had postoperative hypocalcemia in 28 cases (31.1%). The diagnostic accuracy of ICG angiography and ioPTH level assay was high and almost similar (82.22% versus 87.78%). Both were higher than the surgeons’ diagnostic accuracy of visual inspection (62.22%). Conclusions ICG angiography of the parathyroid gland is a safe, reliable predictor for postoperative transient hypocalcemia with a high and almost similar accuracy compared to intraoperative parathyroid hormone level.

Change in parathyroid hormone levels from baseline predicts hypocalcemia following total or completion thyroidectomy.

This study aims to identify the strongest predictor of postoperative hypocalcemia following thyroid surgery. Study of patients who underwent total/completion thyroidectomy. No patients received postoperative calcium supplementation. Demographic and perioperative data were collected including preoperative baseline parathyroid hormone (PTH) levels, PTH levels at 30 min and 6h post-excision, and 18 h post-excision calcium levels. Of 124 patients studied, 20.2% developed temporary hypocalcemia (Ca <8.5mg/dL at 18 h post-excision). In multivariate analyses, absolute PTH levels at 30 min and 6h post-excision as well as change in PTH from baseline at 30 min and 6h post-excision were statistically significantly associated with postoperative hypocalcemia. Per 10units decrease in PTH from baseline at 30 min post-excision, the risk of developing temporary hypocalcemia increases by 17%. Absolute PTH levels and change in PTH from baseline at 30 min and 6h post-excision predict hypocalcemia after total or completion thyroidectomy.

Carbon Nanoparticles for Thyroidectomy and Central Lymph Node Dissection for Thyroid Cancer.

To evaluate whether the application of carbon nanoparticles (CNs) in total or near-total thyroidectomy combined with central lymph node dissection (CLND) for thyroid cancer (TC) is beneficial to lymph node dissection, parathyroid, and recurrent laryngeal nerve (RLN) protection. Relevant literatures were systematically searched on PubMed, EMBASE, and Cochrane Library Databases until March 31, 2021. All analyses were performed using Revman Manager 5.3 software. The main results were the number of central lymph nodes, the number of central metastatic lymph nodes, accidental parathyroidectomy, postoperative hypoparathyroidism, postoperative hypocalcemia, and postoperative transient RLN paralysis. This meta-analysis identified 4 randomized controlled trials and 8 non-randomized controlled trials comprising 1870 patients. Compared with the control, the use of CNs was helpful to dissect more central lymph nodes (weighted mean difference [WMD]: 3.55, 95% confidence interval [CI]: 2.12-4.98, P < .00001) and central metastatic lymph nodes (WMD: 1.69, 95% CI:1.31-2.08, P < .00001), lower rate of accidental parathyroidectomy (odds ratio [OR]: .33, 95% CI: .23-.47, P < .00001), lower rate of both postoperative transient hypoparathyroidism (OR: .40, 95% CI: .31-.51, P < .00001), and transient hypocalcemia (OR: .37, 95% CI: .27-.51, P < .00001). However, there were no statistical difference between the groups for postoperative permanent hypoparathyroidism (OR: .29, 95% CI: .06-1.28, P = .10), postoperative permanent hypocalcemia (OR: .94, 95% CI: .10-9.16, P = .96), and postoperative transient RLN paralysis (OR: .66, 95% CI: .40-1.12, P = .12). The application of CNs in total or near-total thyroidectomy combined with CLND for TC can better dissect the central lymph nodes and protect parathyroid glands (PGs) and their function.

Modified thyroidectomy: 4 techniques to prevent recurrent laryngeal nerve injury and postoperative hypocalcaemia

Objective: To share 4 techniques that decrease the rate of postoperative hypocalcaemia and save recurrent laryngeal nerve with a good cosmetic outcome. Method: The research included all consecutive patients of thyroidectomy (hemi and total thyroidectomy) during 4-year practice. The techniques included (1) elevation of a circular flap after 4 cm collar incision. (2) Ligation of the pedicles (middle first-vein, inferior last-artery). (3) Sharp dissection of the parathyroid glands. (4) Sharp and blunt dissection and exposing the nerve in all of the patients. Result: The total numbers of patients were 2399. At least 1 symptom of hyperthyroidism was found in 1271 patients (53%). The main indication for operation was multinodular goiter and compression symptoms in 1331 (55.5%) patients, followed by thyrotoxicosis in 598 (25%) patients and malignancy in 402 (16.8%) patients. The most common operations were total thyroidectomy in 1880 (78.4%) patients, followed by thyroid lobectomy in 495 (20.6%) patients and completion thyroidectomy in 24 (1%) patients. Among all patients, 4 (0.16%) patients developed permanent voice change. Seven (0.3%) patients developed permanent hypocalcemia. Conclusion: This study offers a set of surgical techniques that reduced the risks of complications of thyroidectomy to a minimal range.

A combined nano-carbon tracer and nano-fluorescence assay for parathyroid misresection reduction in thyroid surgery

In recent years, the incidence of nodular goiter and thyroid carcinoma (TC), as well as the amount of surgery, have been increasing simultaneously. To summarize the significance and experience of combined nano-carbon tracer and nano-fluorescence assay for parathyroid misresection reduction in thyroid surgery. The data of patients who underwent thyroid surgery from November 2016 to July 2017 in the Thyroid Disease Diagnosis and Treatment Center of the Tenth People’s Hospital of Tongji University were collected and divided into test group (combined nano-carbon tracer and nano-fluorescence assay method, 80 cases) and a control group (nano carbon tracer method, 80 cases). Comparison of the patient data and preoperative and postoperative blood calcium, blood phosphorus, PTH value in the control and test group was performed. No significant difference was found on gender, age, preoperative Calcium, Phosphorus, Magnesium and PTH, postoperative Calcium, Phosphorus and Magnesium was found in the control and test group (all the p > 0.05), whereas significant difference was found on the postoperative PTH between control and test group (p < 0.001). Moreover, significant reduced number of parathyroid misresection was found in the test group compared to the control group (p = 0.003). Significant difference could be found on pre- and postoperation data of blood Calcium, Phosphorus, Magnesium and PTH in both control and test group (all the p < 0.05). A combined nano-carbon tracer and nano-fluorescence assay can be used in thyroid surgery, which is helpful to distinguish parathyroid tissue, avoid accidental injury or missection of parathyroid gland as much as possible, and reduce the incidence of postoperative hypocalcemia.

Hungry bone syndrome in delay diagnosed primary hyperparathyroidism with fi brocystic osteitis: A case report

Fibrocystic osteitis is a rare but severe primary hyperparathyroidism (PHPT) complication. We describe a 66-year-old female presented with fi brocystic osteitis and nephrocalcinosis with eGFR reduction to CKD stage 4 due to primary hyperparathyroidism. Delayed diagnosis of long-term hypercalcemia, high parathyroid hormone level, unsubstituted 25(OH)D defi ciency, and the use of bisphosphonates in high doses caused development of «hungry bones» syndrome in early postoperative period. Severe hypocalcemia required prescription of active and native vitamin D metabolites, oral calcium supplements as well as intravenous calcium. Delay in diagnosis of PHPT with fi brocystic osteitis formation led to lower well-being, reduced quality of life and also provoked sever postoperative hypocalcemia («hungry bone» syndrome).

Seasonal variation in calcium treatment after thyroidectomy as surrogate for post-operative hypocalcemia: a retrospective register-based national cohort study

BackgroundHypocalcemia is one of the most common complications of thyroidectomy, and vitamin D deficiency has been found to be an independent risk factor. Sweden is located north of the 55th latitude, resulting in a significant seasonal variation in sun exposure, thereby large variation in the naturally occurring levels of vitamin D. This study aimed to determine if there is a correlation between season of surgery and post-thyroidectomy hypocalcemia.MethodsWe conducted a retrospective register-based observation study on patients who had undergone total thyroidectomy during 2008–2015. In total, 7125 patients operated in Swedish facilities were identified via the Scandinavian Quality Register for Thyroid, Parathyroid, and Adrenal Surgery (SQRTPA). Patients operated during February–April were included in the dark group and patients operated during August–October were included in the bright group. Further stratification was made on the indication for surgery. The primary outcome was post-operative calcium treatment due to hypocalcemia, defined as having received calcium orally or intravenously before discharge.ResultsThe risk of receiving post-operative calcium treatment was significantly lower in the bright group (29.7%) compared to the dark group (35.1%), with a relative risk of 0.846 (P < 0.001). This correlation held true if the indication for surgery was goiter or thyrotoxicosis. For malignancy, there was no significant difference between the groups.ConclusionIn this cohort, total thyroidectomy performed during August–October was associated with a lower rate of calcium treatment given post-operatively when compared to total thyroidectomy performed during February–April. This would indicate a decreased risk of post-operative hypocalcemia if surgery was carried out after the brighter season.

Paediatric thyroidectomy: When and why? A 25-year institutional experience

ObjectiveThyroidectomy in paediatric patients is relatively uncommon. In this study, we reviewed our experience of thyroidectomy in children and identified risk factors associated with postoperative complications. MethodsWe performed a retrospective analysis of paediatric patients who had thyroidectomy in our institution between April 1995 and January 2021. Demographic data, preoperative cytological findings, indications of surgery, surgical complications and histological results were analysed. ResultsA total of 87 paediatric patients with 92 thyroidectomy were identified. The indications for surgery were Graves’ disease refractory to medical treatments (40.2%), benign thyroid nodules or multinodular goitre (26.4%), thyroid carcinoma (23.0%) and multiple endocrine neoplasm type 2A syndrome (10.3%). Patients presented with thyroid nodules or cervical lymph nodes had a 43.9% risk of malignancy.66 total thyroidectomy were done with median operation time of 134 min(102–170), while 26 hemi-thyroidectomy were performed (Right side 12/92, Left side 14/92) with median operation time of 65 min(49–102). The median postoperative hospital stay was 2 days(1–4). Intraoperative neck dissection (p = 0.003), drain insertion (p = 0.001) and hypocalcaemia requiring medical treatment (p = 0.004) were associated with longer hospital stay.The median follow-up was 11.3 years (3.0–16.8). 32% patients had immediate postoperative hypocalcaemia and 8% patients had permanent hypoparathyroidism. Transient vocal cord palsy was found in 3 patients(3%) and all resolved within 5-month time upon reassessment direct laryngoscopy. The use of intraoperative recurrent laryngeal nerve monitoring was associated with less vocal cord palsy (p = 0.022).The median disease-free survival was 13.7 years(7.4–17.7) for patients operated for well-differentiated thyroid carcinoma(WDTC). amongst the 9 patients who had prophylactic total thyroidectomy for MEN2A syndrome, 44% were found to have medullary thyroid microcarcinomas on pathology. ConclusionsSurgical management of paediatric thyroid disease can be complex. Postoperative hypocalcaemia and vocal cord palsy were usually transient after total thyroidectomy. The use of intraoperative recurrent laryngeal nerve monitoring had resulted in less vocal cord palsy. Long-term disease-free survival of patients with thyroid cancer had been achieved with multi-disciplinary management in our centre.Level of Evidence: Retrospective Comparative Study; Level III

Risk factors for hypocalcemia in dialysis patients with refractory secondary hyperparathyroidism after parathyroidectomy: a meta-analysis

Objective Hypocalcemia after parathyroidectomy (PTX) results in tetany, diarrhea, cardiac arrhythmia, and even sudden death. However, a meta-analysis or systematic evaluation of risk factors with the occurrence and development of hypocalcemia in patients with secondary hyperparathyroidism (SHPT) after PTX has never been performed. Methods A thorough search of electronic databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE, was performed to retrieve relevant studies from database inception to June 2021. Quality of the included studies was assessed by two independent reviewers using the Newcastle–Ottawa Scale. Review Manager 5.3 and Stata 16.0 were used for meta-analysis. The random-effects model was adopted to calculate the 95% CIs (I 2> 50% or p < 0.05) of the combined effect size and the corresponding homogeneous data. Otherwise, a fixed-effects model was used. Results Thirteen studies including 2990 participants who met the inclusion criteria were enrolled in the present meta-analysis. The overall quality of the enrolled studies had a score of >7 points. Risk factors significantly related to hypocalcemia in patients with SHPT after PTX were preoperative serum calcium (OR 0.19, 95%CI 0.11–0.31), preoperative alkaline phosphatase (ALP) (OR 1.01, 95% CI 1.01–1.02), and preoperative intact parathyroid hormone (iPTH) (OR 1.38, 95%CI 1.20–1.58). Meanwhile, age (OR 0.97, 95%CI 0.87–1.10) was not significantly correlated with hypocalcemia after PTX. Conclusions Based on the current evidence, preoperative serum calcium, preoperative ALP, and preoperative iPTH were significant predictors of hypocalcemia in patients with SHPT after PTX. More attention should be given to patients with these risk factors for the prevention of postoperative hypocalcemia.

Limited contribution of indocyanine green (ICG) angiography for the detection of parathyroid glands and their vascularization during total thyroidectomy: A STROBE observational study

IntroductionIn total thyroidectomy, indocyanine green (ICG) angiography has mainly been evaluated at end of procedure to predict postoperative hypoparathyroidism. By using it during surgery, we sought to determine whether it could also be an aid to the surgeon. ObjectiveTo determine whether ICG used intraoperatively in total thyroidectomy modified the surgical procedure. Material and methodThirty-two patients who underwent ICG angiography during total thyroidectomy were included in our single-center retrospective study. The number of parathyroid (PT) glands visualized in white light and on ICG angiography was collected, as well as PT vitality of at end of surgery according to these two modalities. Vitality scores were 0 (no vascularity), 1 (moderately vascularized) or 2 (well vascularized). Postoperative calcemia at D1, D2 and D7 was analyzed. ResultsIn the 32 operations, the surgical procedure was modified in 10 cases (31%). The average number of PTs detected was 2.4 (77 PT) on ICG angiography and 2 (65 PT) in white light. Eleven patients (37.5%) had postoperative hypocalcemia. Cumulative vitality scores at end of procedure were 3.75/8 and 3.37/8 in white light and on ICG angiography respectively (P=0.648). The use of the device did not predict the occurrence of postoperative hypocalcemia. ConclusionIndocyanine green angiography used in thyroid surgery could assist the surgeon in the identification of PT glands, sparing them in one third of cases.

Outcomes of Patients with High Risk Thyroid Cancer – T3b to T4

Abstract Aims The aims of this study are to analyse the outcomes of patients with T3b, T4 thyroid cancers (TC) by examining their tumour-node-metastasis (TNM) classification at presentation, the treatments they were offered and any postoperative complications. Methods A retrospective analysis of 41 patients who were diagnosed and treated for T3b and T4 thyroid cancer. Comparison of categorical variables was performed using Chi-square (where n ≥ 5) or Fisher’s exact test (where n &amp;lt; 5). Mann Whitney U tests were used to identify statistical significance between data without normal distribution. Outcome measures included perineural invasion (PNI), lymphovascular invasion (LVI), postoperative hypocalcaemia (2 weeks, 3 months and 6 months), postoperative tri-iodothyronine, postoperative thyroxine and postoperative thyroglobulin. Results Patients with T4 TC were shown to have an increase in risk of PNI (3.23% vs 30.00%, p = 0.013). LVI was similar in both groups (45.16% vs 50.00%, p = 0.790). T4 patients had higher rates of postoperative hypocalcaemia at 2 weeks (10.00% vs 50.00%, p = 0.006). Postoperative hypocalcaemia was similar at 3 months (9.68% vs 10.00%, p = 0.976) and 6 months (6.67% vs 0.00%, p = 0.426). Low postoperative tri-iodothyronine was more frequent in T3b patients (29.03% vs 10.00%, p = 0.376). High postoperative thyroxine was more common in T3b patients (45.16% vs 20.00%, p = 0.069). Conclusion Patients with T4 TC had higher rates of PNI and postoperative hypocalcaemia. Postoperative thyroid markers differed slightly but were not statistically significant. Patient demographics and presentations did not have any significant differences.

Quality outcomes comparison of total thyroidectomy between UKRETS and HES databases

Abstract Aims Hospital Episodes Statistics for England (HES) and UK Registry of Endocrine and Thyroid Surgery (UKRETS) are the largest databases on thyroidectomy within the UK. A validation of UKRETS data accuracy has never occurred. The purpose of this study was to compare quality outcomes in total thyroidectomy (TT) between the UKRETS and HES datasets. Methods A retrospective comparison study between UKRETS and HES for TT from April 2012–March 2018. Vocal cord palsy, hypocalcaemia, mortality &amp; length of stay were the quality outcomes studied. Results The HES and UKRETS databases contained 23,025 and 11,242 patients respectively with UKRETS capturing 48.8% of HES data for TT. 18.8%(42/223) of surgeons performed ≥20 procedures/year in 54.3%(6110/11,242) of UKRETS procedures compared to only 9.7%(72/740) of surgeons from HES performing 44.6%(10,279/23,035) of all TTs. Median length of stay was significantly higher within in HES(2 days, IQR 1-3) versus UKRETS(1 day, IQR 1-2). 30.7%(7,071) of HES patients stayed for &amp;gt;2 days compared to 18.7%(1,837) within the UKRETS registry. Both databases reported a mortality of 0.1%. Post-operative hypocalcaemia was reported higher in UKRETS (21.7%) compared to HES (6.8%), p&amp;lt;0.0001. Rates of voice change were significantly higher in UKRETS (9.4%) compared to those in HES (1.3%), p&amp;lt;0.0001. Conclusions Surgeons contributing to UKRETS had a higher volume practice and shorter stay than those within HES. UKRETS appears to underreport the number of procedures conducted, with less low volume surgery captured. However, recording of hypocalcaemia and voice changes is mandatory in UKRETS, and HES appear to substantially under-report such complications.

An audit of thyroidectomy for Graves’ Disease, in a large UK tertiary centre

Abstract Aims Patients undergoing thyroidectomy for Graves’ disease are at increased risk of post-operative complications and therefore require additional pre-operative preparation and close post-operative assessment. This study aimed to assess the pre- and post-operative management and morbidity in a single UK tertiary centre. Method Retrospective analysis of patients undergoing thyroidectomy for Graves’ between 2014–19. The primary endpoint was thyroid status pre-operatively and post-operative morbidity. Secondary endpoints were administration of potassium iodide, vitamin D and beta blockers and assessment of post-operative parathyroid function. Results Ninety-two thyroidectomies were undertaken for Graves’ in the five-year period. Pre-operatively 98% were successfully rendered euthyroid or hypothyroid and 2% hyperthyroid but required emergency surgery. Post-operative hypocalcaemia occurred in 26% but was temporary in 92%. Vocal cord palsy was found in 11%, but in all cases was temporary (post-operative laryngoscopy was reported in 93%). 49% had received potassium iodide, 53% beta-blockers and 48% vitamin D. Post-operative calcium and PTH estimation was undertaken on day 0 in 99% and 97% respectively and day 1 in 100% and 98%. Conclusion This audit of specialist practice shows a majority of patients rendered eu- or hypothyroid pre-operatively and low complication rates, with the majority being temporary. Pre-operative medical optimization was not undertaken uniformly in all patients and although outcomes were good, a protocol to improve consistency has been developed in response.

Accumulation of Experience and Newly Developed Devices Can Improve the Safety and Voice Outcome of Total Thyroidectomy for Graves’ Disease

Total thyroidectomy (TT) in patients with Graves’ disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves’ disease who received TT. Forty-six patients received surgery during 1990–1999 (Group A), and 44 patients received surgery during 2010–2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range (p = 0.015) and jitter (p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves’ disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.

Frequency of Hypocalcaemia after Thyroid Surgery

Aim: to investigate the frequency of postoperative hypocalcaemia undergoing thyroid surgery. Study design: Cross sectional study Place and duration: Study was conducted at Endocrinology department of general surgery, Bakhtawar Amin Medical and Dental College, Multan, from January 2021 to January 2022. Methodology: Study was conducted on total 115 patients who were admitted for thyroid surgery. Main variables of study were demographics, preoperative diagnosis, calcium level after surgery at 1st, 2nd and 5th day. SPSS version 23 was used for data analysis, test of significant were applied and p value ≤ 0.05 was taken as significant. Results: One hundred and fifteen patients were analyzed in our study, with mean age 38.99±4.63 years. There were 54.8% males and 45.2% females. Total thyroidectomy underwent in 46.1% patients and completion thyroidectomy underwent in 53.9% patients. Furthermore, 84.3% developed malignant and 15.7% developed benign. Hypocalcaemia developed in 9.6% patients. Among these, 54.5% malignant and 36.4% benign and only 9.1% developed permanent hypocalcaemia. On the second day of operation, 7.8% patients developed transient hypocalcaemia. While, on the fifth day of operation, 4.3% patients developed transient hypocalcaemia.2.6% patients required calcium and vitamin D supplements. Conclusion: Following thyroid surgery hypocalcaemia is a major concern that can be prevented by adopting meticulous operative technique and preserving vascularity of parathyroid glands. Continuous monitoring of serum calcium level in postoperative period and early management in cases of hypocalcaemia can significantly reduce the associated morbidity. Keywords: Hypocalcaemia, Frequency, Thyroid surgery, Postoperative period

Incidental Parathyroidectomy Among Pediatric Patients Undergoing Thyroid Surgery.

To evaluate rates of incidental parathyroidectomy(IP) and to determine risk factors among children undergoing thyroid surgery. Retrospective case-control study. Pediatric patients undergoing thyroidectomy with or without neck dissection were included in this retrospective cohort study over a 20year period. Demographics, clinical features, and surgical outcomes were evaluated. The primary outcome was the presence of parathyroid tissue in the surgical specimen. Two hundred and eighty-six patients were included (100 cases with ≥1 parathyroid gland found in the pathology specimen and 186 controls). The most common surgical indication was cancer (49%), followed by benign nodule (25%). Hemithyroidectomy was performed in 119 (42%) patients, total thyroidectomy in 138 (48%), and completion in 29 (10%). Central neck dissection (CND) and lateral neck dissection were performed in 41% and 13%, respectively. 27 (9%) patients had parathyroid reimplantation. On univariable analysis, diagnosis, adenopathy on preoperative ultrasound, extent of thyroidectomy, neck dissection, and parathyroid reimplantation were significant predictors of IP. On multivariate analysis, CND > 5 nodes were the sole predictor of IP. Patients with IP were more likely to require postoperative calcium/vitamin D supplementation compared to those without (44% vs. 16%; P< .001). Incidental parathyroidectomy during pediatric thyroidectomy is relatively common. CND was independently predictive of IP. There were increased rates of postoperative hypocalcemia when 1 or more parathyroid gland was identified in the specimen. Reimplantation of 1 parathyroid gland was predictive of another gland in the specimen. Anticipating outcomes may help optimize patient care by allowing for early supplementation, frequent monitoring, and consideration of ancillary monitoring modalities in high-risk procedures. Level 4 Laryngoscope, 132:2262-2269, 2022.