Postoperative Hypocalcemia Research Articles

Intraoperative strategies in identification and functional protection of parathyroid glands for patients with thyroidectomy: a systematic review and network meta-analysis.

This study aimed to assess the benefits and limitations of four intraoperative visualization of parathyroid gland (IVPG) strategies in the identification and functional protection of parathyroid glands (PGs). We searched PubMed, the Cochrane Central Register of Controlled Trials, CNKI, EMBASE, Web of Science and Google Scholar databases until 30 June 2023. Four IVPG strategies were composed of the naked eyes (NE) and three imaging strategies: autofluorescence (AF), indocyanine green fluorescence (ICGF), and carbon nanoparticles (CN). We performed a pairwise meta-analysis (PMA) for direct comparisons and a Bayesian network meta-analysis (NMA) for indirect comparisons. A total of 29 eligible studies were included. According to NMA and PMA, AF had significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, PG inadvertent resection, and PG auto-transplantation compared to NE, while had significantly higher rate of PG identification. CN showed significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, and PG inadvertent resection compared to NE in PMA and NMA. ICGF showed a significantly higher rate of PG auto-transplantation compared to NE in PMA and AF in NMA. According to SUCRA values, AF showed the best advantage in reducing the rate of postoperative hypocalcemia (0.85) and PG inadvertent resection (0.89), and increasing the rate of PG identification (0.80). CN had the greatest advantage in reducing the rate of postoperative hypoparathyroidism (0.95). ICGF ranked the highest in the rate of PG auto-transplantation (0.98). Three imaging strategies demonstrate significant superiority over NE in the intraoperative PG identification and functional protection. AF is the best strategy in reducing the incidence of postoperative hypocalcemia, increasing the rate of PG identification, and reducing the rate of PG inadvertent resection and auto-transplantation. ICGF has great value in assessing PG viability, leading to the trend towards PG auto-transplantation. CN is the best strategy in reducing the incidence of postoperative hypoparathyroidism.

An individual approach to intraoperative parathyroid hormone measurement during total thyroidectomy

PurposeHypocalcemia is a common complication of thyroidectomy. Measurement of the intraoperative serum parathyroid hormone (PTH) levels became an established technique but it requires further improvements. We aimed to assess intraoperative PTH level testing results against the hypothesis that the PTH assay may be performed almost immediately after thyroid gland removal. MethodsA retrospective cohort study. During total thyroidectomy surgery, the patients had PTH levels measured at the cutting time and again immediately after the thyroid gland is removed. Post-operatively, serial total blood calcium levels were obtained twice daily and recorded. ResultsAmong 63 enrolled patients, 39 had multinodular goiter, 15 thyroid carcinoma, and nine had Graves' disease. The mean age was 59.8 ± 15.3 years, 43 females. The mean PTH level before surgery was 45.8 ± 22.0 pg/mL. Post-operatively, 11/63 patients developed hypocalcemia with serum calcium levels <8 mg/dL. Four patients with ≥50 % decrease in PTH concentration were normocalcemic a day after surgery and were discharged early. Four patients with ≥70 % PTH decrease were treated accordingly during prolonged hospitalization and did not suffer from permanent hypocalcemia. The cut-off value of 70 % decrease after the gland removal was able to predict postoperative hypocalcemia with a sensitivity of 100 %, specificity 82.9 %, PPV 60.0 % and NPV 100 %. ConclusionMeasurements of intraoperative PTH may not be performed at fixed time intervals but after 1–2 min after removal of the thyroid gland. Defining those not at risk would allow the majority of patients to be waived from post-operative blood calcium testing and safely discharged early after surgery.

Factors influencing serum calcium levels and the incidence of hypocalcemia after parathyroidectomy in primary hyperparathyroidism patients.

Parathyroidectomy (PTX) is an effective treatment for primary hyperparathyroidism (PHPT) patients. Postoperative hypocalcemia is a common complication after PTX. This study aimed to analyze the factors influencing serum calcium levels and the incidence of hypocalcemia after parathyroidectomy in primary hyperparathyroidism patients. The retrospective study included 270 PHPT patients treated with PTX and collected their demographic and clinical information and their laboratory indices. Factors influencing serum calcium levels and hypocalcemia after PTX in PHPT patients were analyzed using univariate and multifactorial analyses. First, in patients with normal preoperative serum calcium levels (2.20-2.74 mmol/L), the higher the preoperative alkaline phosphatase and serum phosphorus levels, the lower the postoperative serum calcium levels. Furthermore, the higher the preoperative serum calcium levels and the accompanying clinical symptoms, the higher the postoperative serum calcium levels. Low preoperative serum calcium levels were shown to be a risk factor for postoperative hypocalcemia (OR=0.022), and the optimal preoperative serum calcium threshold was 2.625 mmol/L (sensitivity and specificity were 0.587 and 0.712, respectively). Second, in the mild preoperative hypercalcemia group (2.75-3.00 mmol/L), the older the patient, the higher the preoperative and postoperative serum calcium levels, the higher the postoperative serum calcium; the lower the alkaline phosphatase and calcitonin levels, the higher the postoperative serum calcium levels. On the other hand, the younger the patient was, the more likely hypocalcemia blood was (OR=0.947), with an optimal age threshold of 47.5 years (sensitivity and specificity were 0.543 and 0.754, respectively). Third, in the preoperative moderate to severe hypercalcemia group (>3.0mmol/L), patients undergoing a combined contralateral thyroidectomy and a total thyroidectomy had low postoperative serum calcium levels. Patients with different preoperative serum calcium levels had various factors influencing their postoperative serum calcium levels and postoperative hypocalcemia, which facilitated the assessment of their prognosis.

History of Bariatric Surgery Before Thyroid Surgery: Recommendations for Prevention and Management of Postoperative Hypocalcemia.

Hypocalcemia following thyroidectomy is a common and potentially life-threatening complication. It is caused by intraoperative injury to the parathyroid glands or their blood supply. Although several studies have shown that patients with a prior history of bariatric surgery may be at an increased risk for hypocalcemia after thyroidectomy, no clear recommendations exist for preventing and managing this condition in this population. This paper highlights the significance of understanding this risk and of obtaining a history of prior bariatric surgery before thyroidectomy. We propose concise recommendations for preventing and managing hypocalcemia following thyroidectomy in patients with a history of bariatric surgery.

Low serum iPTH at the end of surgery is the earliest predictor of postoperative hypocalcemia after total thyroidectomy

BackgroundThe most frequent complication of total thyroidectomy remains hypocalcemia due to low postoperative levels of serum intact parathyroid hormone (iPTH). The purpose of this study was to investigate the role of decreased iPTH at the end of surgery in predicting hypocalcemia. In addition, we examined the percentage decrease of iPTH as potential indicator of hypocalcemia.MethodsWe retrospectively collected the data of patients who underwent total thyroidectomy for benign and malignant diseases at our institution between 2010 and 2022. The iPTH level was measured before and at the end of surgery, and serum calcium levels on the first postoperative day. Demographic, clinical, and biochemical characteristics of patients with low iPTH were compared with patients with normal iPTH levels using ANOVA for continuous variables and χ2-tests for categorical variables. Multivariable logistic regression analysis evaluated the association of iPTH at the end of surgery and the relative reduction of iPTH with postoperative hypocalcemia.ResultsThe mean age of the 607 patients in this study was 55.6 years, and the female-to-male ratio was 5:1. Goiter was the most common indication for surgery (N = 382, 62.9%), followed by Graves’ disease (N = 135, 22.2%). The mean preoperative iPTH was 49.0 pg/ml, while the mean postoperative iPTH was 29.3 pg/ml. A total of 197 patients (32.5%) had an iPTH level below normal, 77 patients (39%), had iPTH levels of 10–15.0 pg/ml and 120 patients (61%) of < 10.0 pg/ml at the end of surgery. Among all patients, 124 (20.4%) developed hypocalcemia on the first postoperative day. The mean percentage of decrease of iPTH was highest among patients with iPTH < 10 pg/ml (76.9%, p < 0.01); this group of patients had also the highest rate of postoperative hypocalcemia on day one (45.0% vs. 26.0% vs 12.2%, p < 0.01).ConclusionsMeasurement of iPTH at the end of total thyroidectomy predicts patients who are at risk for postoperative hypocalcemia. The combination of low serum iPTH with a decrease in iPTH level of ≥ 50% may improve prediction of hypocalcemia compared to iPTH levels alone allowing for early calcium substitution in these patients at high risk of developing postoperative hypocalcemia.

Parathyroid gland preservation in laryngectomy patients with total thyroidectomy

BackgroundPostoperative hypocalcemia in laryngectomy patients can occur when part or whole of the thyroid gland has been removed. Preservation of the parathyroid glands in situ is considered one of the initial measures to prevent postoperative hypocalcemia even if all thyroid gland is removed. Our study aims to assess the efficacy of parathyroid gland preservation in situ to prevent postoperative hypocalcemia in cases where total laryngectomy is done with total thyroidectomy.MethodsThe study included all laryngectomy patients done during a period from April 2020 to May 2021. Parathyroid gland preservation was done in both primary (12 cases) and salvage (16 cases). Both PTH and corrected calcium level were measured at different time points and used as a guide for further replacement.ResultsWe studied the association between outcome including recovery from transient hypocalcemia and certain variables like age, type of surgery, stage of tumor, and extent of neck dissection. Regarding type of surgery, all patients that underwent primary laryngectomy were totally recovered (n = 12, 100%); however, salvage cases were partially recovered (n = 10, 62.5%).ConclusionParathyroid preservation is achievable in cases of salvage laryngectomy in addition to primary laryngectomy with total thyroidectomy. Early monitoring of the patients PTH and Ca during their hospital stay is a good indicator of successful preservation. Long-term follow-up is advised for potential recovery from transient hypoparathyroidism.

Outcomes and predictors of complications of thyroidectomy in a scarce resource setting: Retrospective cross-sectional study

BackgroundOutcomes and predictors of complications of thyroidectomy are diverse and have been extensively studied, but data from our country and other African countries with high disease burdens are limited. ObjectiveTo evaluate the outcomes and predictors of complications of thyroidectomy among operated patients. MethodSingle institution retrospective cross-sectional study was conducted by reviewing charts from 365 patients who had undergone thyroidectomy on an elective basis between March 2018–February 2022. All patients who were admitted and underwent thyroidectomy were included in this study. Bivariate and multivariate logistic regressions were used to identify risk factors. P-value <0.05 was considered statistically significant. ResultOverall, post-thyroidectomy complications occurred in 17 % of the cases. The two most common complications were hypocalcemia and voice change; the latter being due to injury of either external branch of superior laryngeal nerve or recurrent laryngeal nerve with an incidence of 4.9 % and 2.5 % respectively. Thyroidectomy performed by surgical residents and having total thyroidectomy were significantly associated with overall complications of thyroidectomy. Total thyroidectomy was found to be a risk factor for postoperative hypocalcemia (AOR = 12.24 (95%CI: 4.53, 19.65); P = 0.02). Younger age of the patient (AOR =0.3(95%CI, 0.12,0.51)) and prolonged duration of presentation (AOR = 2.53(95%CI, 1.17,7.76)) were detected predictors of voice change due to injury of either external branch of superior laryngeal nerve or recurrent laryngeal nerve. ConclusionThe rate of thyroidectomy complications is relatively similar to other studies. In this study demographic and clinical factors associated with increased risk of complications after thyroid surgery were identified. This information will be useful for educating patients about the risks of thyroid surgery.

Management of Postthyroidectomy Hypoparathyroidism and Its Effect on Hypocalcemia-Related Complications: A Meta-Analysis.

The aim of this Meta-analysis is to evaluate the impact of different treatment strategies for early postoperative hypoparathyroidism on hypocalcemia-related complications and long-term hypoparathyroidism. Embase.com, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched to September 20, 2022. Articles reporting on adult patients who underwent total thyroidectomy which specified a treatment strategy for postthyroidectomy hypoparathyroidism were included. Random effect models were applied to obtain pooled proportions and 95% confidence intervals. Primary outcome was the occurrence of major hypocalcemia-related complications. Secondary outcome was long-term hypoparathyroidism. Sixty-six studies comprising 67 treatment protocols and 51,096 patients were included in this Meta-analysis. In 8 protocols (3806 patients), routine calcium and/or active vitamin D medication was given to all patients directly after thyroidectomy. In 49 protocols (44,012 patients), calcium and/or active vitamin D medication was only given to patients with biochemically proven postthyroidectomy hypoparathyroidism. In 10 protocols (3278 patients), calcium and/or active vitamin D supplementation was only initiated in case of clinical symptoms of hypocalcemia. No patient had a major complication due to postoperative hypocalcemia. The pooled proportion of long-term hypoparathyroidism was 2.4% (95% confidence interval, 1.9-3.0). There was no significant difference in the incidence of long-term hypoparathyroidism between the 3 supplementation groups. All treatment strategies for postoperative hypocalcemia prevent major complications of hypocalcemia. The early postoperative treatment protocol for postthyroidectomy hypoparathyroidism does not seem to influence recovery of parathyroid function in the long term.

Relationship of Post-Thyroidectomy Hypocalcemia to Surgeon’s Experience in a Private Tertiary Hospital

Objective:To determine the association of surgeon’s experience based on years of practice and incidence of post thyroidectomy hypocalcemia. Methods: Design: Retrospective cohort studySetting: Tertiary Private Training HospitalParticipants: Records of patients who underwent total thyroidectomy in a private tertiary hospital from January 2003 to December 2018 were retrospectively reviewed. Medical information obtained were patient demographics, surgeon’s years of practice, thyroid specimen weight, technique of surgery, histopathologic findings and calcium assay values. Chi square test and Odds Ratio analysis were used to determine the relationship between the surgeon’s experience and post-thyroidectomy hypocalcemia. Results:Three hundred fourteen (314) patients who underwent total thyroidectomy from 2003 to 2018 were included in the study. Overall rate of post-operative hypocalcemia was 41%. On multivariate analysis, no significant odds ratio was found between surgeons with 5 to 19 years of experience and those with more than 19 years of experience in relation to post-operative hypocalcemia [Odds Ratio 1.4 (95% Confidence Interval 0.7 to 2.6)]. Odds ratios for other variables may be interpreted, however, they could not be generalized over the population where data was gathered since the 95% Confidence Interval includes 1. Conclusion: The results of this retrospective cohort study suggest that post-thyroidectomy hypocalcemia is not associated with surgeon’s experience based on years of practice. Further studies are recommended in a multicenter approach to better generalize to the whole population.

Surgical Management of Goiter with Intrathoracic Extension at the Philippine General Hospital Department of Otolaryngology Head and Neck Surgery

Objective: To describe the demographic and clinical characteristics of patients diagnosed with intrathoracic thyroid masses managed surgically in our institution, determine associated factors affecting eventual operative approaches for these patients, and assess postoperative outcomes and complications associated with surgical intervention. Methods: Design: Retrospective descriptive case series Setting:Tertiary National University Hospital Participants: 24 patients Results: The mean age of patients diagnosed with intrathoracic goiters was 55.71 years old, with a 1:1.4 male to female ratio; with most having an intrathoracic extent of Huins Grade 1 (67%) compared to others having Huins Grade 2-3. Majority of patients pre-operatively had a Fine Needle Aspiration (FNA) Bethesda Thyroid Nodule Classification of Category II (benign); 79% of total patients underwent excision of thyroid mass utilizing a transcervical approach alone. As Intrathoracic Extension (ITE) grade increased, additional transthoracic approaches were performed; duration of operation, average estimated blood loss, length of hospital stay was also noted to increase. Majority of post operative surgical histopathology results revealed malignant thyroid masses, in contrast to pre-operative FNA. Post-operative transient hypocalcemia was the most reported immediate complication. Conclusions: Management of intrathoracic goiter is often multidisciplinary. Referral to the thoracic vascular service is warranted for access to the thoracic inlet. Classification by grade of intrathoracic goiters is helpful to determine the most appropriate operative approach and maybe predictive of intraoperative and postoperative outcomes. Postoperative histopathology across all ITE grades mostly yield malignant results; hence, preoperative FNA results should be used with caution.

The significance of short-term preoperative calcium and activated vitamin D3 supplementation in thyroidectomy: a randomized trial and prospective study.

The aim was to explore the effects of preoperative calcium and activated vitamin D3 supplementation on post-thyroidectomy hypocalcemia and hypo-parathyroid hormone-emia (hypo-PTHemia). A total of 209 patients were randomly divided into control group (CG) and experimental group (EG). Oral calcium and activated vitamin D3 supplementation were preoperatively administered to EG, whereas a placebo was administered to CG. Data on serum calcium, phosphorus, and PTH concentrations before operation, on postoperative day 1 (POPD1), at postoperative week 3 (POPW3), and on the length of postoperative hospitalization were collected. The serum calcium, phosphorus, and PTH concentrations, as well as the incidence of postoperative hypocalcemia and hypo-PTHemia, did not significantly differ between EG and CG. Subgroup analysis revealed that the serum calcium concentrations of the experimental bilateral thyroidectomy subgroup (eBTS) on POPD1 and POPW3 were higher than that of the control bilateral thyroidectomy subgroup (cBTS) (P < 0.05); the reduction of serum calcium in eBTS on POPD1 and POPW3 was less than those in cBTS (P < 0.05). However, significant differences were not observed between the unilateral thyroidectomy subgroups (UTS) (P > 0.05). Moreover, the incidence of postoperative hypocalcemia in cBTS on POPD1 was significantly higher than that in eBTS (65.9% vs 41.7%) (P < 0.05). The length of hospitalization in cBTS (3.55 ± 1.89 days) was significantly longer than that (2.79 ± 1.15 days) in eBTS (P < 0.05). Short-term preoperative prophylactic oral calcium and activated vitamin D3 supplementation could effectively reduce the incidence of postoperative hypocalcemia and decrease the length of postoperative hospitalization in patients who have undergone bilateral thyroidectomy.

Intraoperative prevention of postoperative hypoparathyroidism.

More than 30,000 thyroid surgeries are performed annually in the Russian Federation. The surgeries are relatively safe because of the prevention methods for postoperative complications. Currently, there is no single effective method of postoperative hypoparathyroidism prevention. This complication is frequently reported and may be health and life-threatening. We aimed to estimate the effectiveness of the intraoperative ICG-angiography and intrathyroid injection of Brilliant Green for the prevention of postoperative hypoparathyroidism. One hundred and forty-three thyroidectomies were performed. Patients were divided into three groups: intraoperative angiography was used in 24 cases; Brilliant Green was injected in 58 cases to identify parathyroid glands; the visual estimation of the parathyroid preservation was used in 61 cases. Calcium level was measured in all patients before and after surgery. Calcium level in the serum before and after surgery was 2.37±0.14 and 2.27±0.17 in Group 1, 2.38±0.16 and 2.21±0.16 in Group 2, and 2.39±0.17 and 2.18±0.19 in Group 3. Postoperative hypocalcemia was more prominent in the group with the visually estimated PTG than in the two other groups. The differences in postoperative calcium levels in Groups 1 and 3 were statistically different. Pre- and postoperative Parathormone levels were 6.2±0.4 in Group 1, 5.6±0.57 in Group 2, and 3.5±0.32 in Group 3. Postoperative levels significantly differed in Groups 1 and 3 (p<0.01) and in Groups 2 and 3 (p<0.05). ICG-angiography and intrathyroid injection of the Brilliant Green are safe methods of identification and sparing of the parathyroid glands. The severity of hypocalcemia and hypoparathormonemia in Group 3 shows the necessity of finding new methods in endocrine surgery to improve patient outcomes.

Outcome Analysis of Total Thyroidectomy: Conventional Suture Ligation Technique vs Sutureless Technique.

Total thyroidectomy is a common surgical procedure in endocrine surgery. However, it carries potential complications such as damage to the recurrent laryngeal nerve, permanent hypoparathyroidism, and bleeding. Methods: A prospective study was conducted at the Professorial Surgical Unit, Jaffna Teaching Hospital, involving consecutive patients who underwent total thyroidectomy. Patients with certain conditions were excluded from the study. The data collected were analyzed using IBMSPSSStatistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). This study included 59 patients who had total thyroidectomy from January 2018 to January 2021 at the Professorial Surgical Unit, Jaffna Teaching Hospital. Of these, 45 underwent conventional suture ligation (CSL), and 17 had a sutureless (SL) technique. Mean ages were 44±12.47 years (range: 23 to 68) for CSL and 47.63±13.37 years (range: 27 to 73) for SL. Operative time was 2.16 ± 0.32 hours for CSL and 1.56 ± 0.49 hours for SL. Intraoperative and postoperative bleeding occurred in 2.38% of CSL cases but not in SL. Postoperative hypocalcemia was 7.14% for CSL and 5.88% for SL. Postoperative stays averaged 3.83 ± 1.56 days for CSL and 3.41 ± 1.62 days for SL. The study found that the operative time differed significantly between the suture and SL techniques. However, there was no statistically significant difference in postoperative drainage volume or postoperative complications. The SL technique was shown to be superior to the conventional suture ligation technique for total thyroidectomy. It resulted in shorter operative time, reduced intraoperative bleeding, lower incidence of postoperative drainage, fewer postoperative voice changes, and shorter hospital stays. Therefore, the SL technique was deemed safe, efficient, and effective for total thyroidectomy compared to the conventional suture ligation technique.

Quality of life in patients with hyperparathyroidism before and after surgical treatment

BACKGROUND: Hyperparathyroidism (HPT) is a syndrome characterized by excessive synthesis of parathyroid hormone (PTH), an imbalance of phosphorus-calcium metabolism, and damage to target organs. Radical treatment of any clinical variant of HPT is surgical. In this regard, the assessment of the quality of life (QoL) of patients before and after surgery is an indicator that reflects the impact of the disease on the patient’s health and the effectiveness of the treatment.AIM: To study QoL of patients with various clinical variants of HPT before and after surgical treatment.MATERIALS AND METHODS: The single-center prospective study included patients operated on for primary (PHPT), secondary (SHPT) and tertiary HPT in 2019–2021. A comparison was made of preand postoperative QoL indicators with a sample comparable in sex and age from residents of the Irkutsk region.RESULTS: The study included 100 patients, of which 13 had multiple lesions of the parathyroid glands (PTG) and 51 with solitary lesions in PHPT, 34 with SHPT and 2 with SHPT. Indicators QoL of patients with HPT before surgery is statistically significantly lower than in the region. The greatest decrease in QoL was found in the group of patients with multiple PTG lesions in PHPT. Improvement in QoL was achieved in 90% of the studied patients. Despite the identified complications, there was an improvement in QoL after surgery in case of achieving remission of the disease. Persistence of the disease is an outcome that does not allow for a statistically significant improvement in QoL after surgery for any type of HPT. Deterioration of QoL according to some indicators was found in 10% of patients. In patients with solitary PTG lesions in PHPT, deterioration in QoL is associated with postoperative hypocalcemia against the background of the «hungry bones» syndrome, and in patients with SHPT with a decrease in parathyroid hormone below population indicators.CONCLUSION: The study demonstrates QoL of patients with various clinical variants of hyperparathyroidism before and after surgical treatment. The dynamics of QoL indicators depending on the nosology, volume, duration, outcome and complications of operations is shown.

Prediction of the development of hypocalcemia in primary hyperparathyroidism patients 1–3 days after radical parathyroidectomy

BACKGROUND: It was impossible to predict the development of hypocalcemia following parathyroidectomy (PTE) in patients with primary hyperparathyroidism (PHPT) until now. Hypocalcemia may be accompanied by myalgia, generalized seizures up to tetany, and arrhythmias. Hypocalcemia following PTE can be prevented by preoperative cholecalciferol supplementation. However, patients with severe hypercalcemia above 3 mmol/L do not receive vitamin D due to the risk of hypercalcemia progression. Despite the existing data showing the safety of cholecalciferol therapy in case of mild elevation of serum calcium, not all patients are prescribed vitamin D supplementation, probably due to the lack of a suitable tool to assess the postoperative hypocalcemia risks.AIM: To design a mathematical model and a software tool for predicting hypocalcemia 1–3 days post-PTE in PHPT patients using the patient’s demographic and clinical data, laboratory test results and preoperative therapy status.MATERIALS AND METHODS: This retrospective study included 478 PHPT patients diagnosed with adenomas and carcinomas of the parathyroid gland (PTG) who underwent radical PTE between 1993–2010 or 2018–2020 at the Endocrinology Research Centre. The following parameters were analyzed: sex; age; laboratory markers prior to calcimimetic and antiresorptive therapy: PTH, total calcium, phosphorus; osteocalcin (OC), alkaline phosphatase (ALP), C-terminal telopeptide of type 1 collagen. Also we analyzed 25-hydroxyvitamin D (25(OH)D); bone mineral density (BMD) measured by X-ray densitometry; medical history of low-energy fractures; preoperative therapy with denosumab, bisphosphonates, cinacalcet, cholecalciferol. Categorical gradient boosting (CatBoost) was built to predict the risk of postoperative hypocalcemia.RESULTS: The prevalence of severe osteoporosis is higher in the postoperative hypocalcemia group compared to the nonhypocalcemia group (27% vs. 15%), wherein the frequency of preoperative administration of cholecalciferol in this group is lower (8% vs. 25%). A CatBoost model was built to predict postoperative hypocalcemia using 13 predictors (sex, age, PTH, serum total calcium, phosphorus, OC, BMD reduction, 25(OH)D, administration of cholecalciferol, bisphosphonates, denosumab, and cinacalcet. The proposed model http://194.87.111.169/hypocalcemia for post-PTE hypocalcemia in PHPT patients achieved the following metrics: positive predictive value 73.3%-86.7%; negative predictive value 74.9%-89.3%.CONCLUSION: The model can be used to choose the appropriate preand postoperative approaches for patients who undergo rPTE.

Accidental parathyroidectomy during total thyroidectomy and hypoparathyroidism in a large series of 766 patients: incidence and consequences in a referral center.

Transient hypoparathyroidism is the most common complication after total thyroidectomy, and accidental parathyroidectomy (AP) may be a cause. The aim of this study was to investigate the incidence of AP and its impact on postoperative calcemia. From February 2016 to May 2018, 766 patients undergoing total thyroidectomy were prospectively included. Surgical indications, hormonal status, definitive histology, and postoperative calcium and PTH levels were analyzed. 578/(75.45%) were women and 188/(24.55%) men with mean age of 53.4years. Parathyroid tissue on the thyroid specimen was observed in 40 (5.2%) patients: 30 APs and 10 parathyroid fragments. Among the 30 APs, 12 glands were intrathyroid and 18 (2.3%) in eutopic location. 97 (12.6%) patients were treated for postoperative hypocalcemia: 90 (11.7%) had transient and 5 (0.6%) definitive hypoparathyroidism; 2 were lost in follow-up. 13/30 (43.3%) with AP had transient hypoparathyroidism. A strong correlation was found (p < 0.0001) between AP and postoperative hypocalcemia. 1/30 (3.3%) patient with APs had definitive hypoparathyroidism. Transient and persistent nerve palsies were found in 10 (1.3%) and 3 (0.4%) patients, respectively. A careful examination of the thyroid gland after resection help to identify an AP that could be autotransplanted. Surgeon and hospital activity volume per years seem to reduce the risk of hypoparathyroidism. Total thyroidectomy and intrathyroid localization of parathyroid glands are risk factors for the AP. The incidence of AP was 2.3%, and this remains low due to our longstanding experience in thyroid and parathyroid surgery.

Effect of Truncal Versus Branch Ligation of Inferior Thyroid Artery on Postoperative Hypocalcemia Patients Undergoing Thyroid Surgery: Rawalpindi

Objective: To investigate the effect of truncal or branch ligation of the inferior thyroid artery on postoperative hypocalcemia. Study Design: Quasi-experimental study.Place and Duration of Study: The study was conducted at the Department of Surgery, Pak Emirates Military Hospital (PEMH), Rawalpindi, Pakistan from July 2021 to June 2022.Methods: For this study, 60 patients were enrolled who underwent total thyroidectomy at the Department of Surgery from July 2021 to June 2022. Patients were divided into Group 'A' and Group 'B', with an equal number of 30 patients in each group. Patients in group 'A' underwent bilateral ITA ligation at the trunk, while patients in group 'B' underwent ligation of terminal branches of ITA on the gland capsule. The primary outcome was postoperative hypocalcemia on 1 postoperative day.Results: Our results showed a significant difference in hypocalcemia in both groups. Decreased incidence of biochemical hypocalcemia was found in branch ligation of ITA (3.33%) than trunk ligation (36.36%) P value 0.025.Conclusion: Branch ligation of ITA decreases the incidence of hypocalcemia after total thyroidectomy.&#x0D; How to cite this: Javed R, Butt MQ, Tariq M, Qamar R, Bukhari ST. Effect of Truncal Versus Branch Ligation of Inferior Thyroid Artery on Postoperative Hypocalcemia Patients Undergoing Thyroid Surgery: Rawalpindi. Life and Science. 2023; 4(4): 452-457. doi: http://doi.org/10.37185/LnS.1.1.366

SAT542 TDC or Not TDC: Isolated Ectopic Papillary Carcinoma in the Midline Neck with a Benign Native Thyroid

Abstract Disclosure: M. Fasen: None. L. Kosmiski: None. Background: Thyroglossal duct carcinoma is a rare entity, occurring in about 1% of all thyroglossal duct cysts (TDC). Several cases have reported PTC within a thyroglossal duct cyst. Initially thought to be a TDC, we present an unusual case of a midline ectopic papillary thyroid carcinoma with absence of features characteristic of a TDC in the context of benign native thyroid tissue. Clinical Case: A 19 year old female presents to the clinic with a progressively growing midline neck mass over the past five years associated with mild dysphagia. Physical exam was notable for 2 x 2 cm mobile nontender midline mass. Neck ultrasound demonstrated a complex cystic lesion measuring 3.8 x 3.4 x 2.5 cm with partial calcification and mildly vascular. The thyroid itself had no nodules. She underwent a Sistrunk procedure with follow-up pathology revealing 1.6 cm classical PTC that extended into surrounding soft tissue and focal invasion into skeletal muscle without a definitive remnant thyroglossal duct lining despite cystic architecture. The differential included PTC completely replacing the thyroglossal duct cyst, PTC arising from ectopic thyroid tissue or metastatic PTC. Due to the unclear origin of the PTC, decision was made to perform total thyroidectomy. Pathology of the thyroid and four lymph nodes were negative for malignancy confirming a PTC origin from an extra-thyroidal remnant. The patient’s course was complicated by post-operative hypocalcemia resolved with calcitriol and calcium carbonate. She is pending discussion with endocrinology regarding adjuvant radioactive iodine. Conclusion: Thyroglossal duct carcinoma, most commonly papillary carcinoma, is a rare condition that should be considered in patients presenting with cystic midline neck masses. Sistrunk surgery should be performed in all cases for tumor removal. Thyroidectomy in individuals with normal thyroid can be considered due to the probability of concomitant intraglandular thyroid cancer and enables management with adjuvant radio-iodine if needed. In this particular case, PTC was found without evidence of a TDC and suggests PTC arose from ectopic thyroid tissue. Ectopic thyroid tissue can undergo malignant transformation along with the native thyroid gland. There are only a few other reports of isolated ectopic thyroid tissue malignancy with a benign thyroid gland. Presentation Date: Saturday, June 17, 2023

SAT194 A Rare Case Of Untreated Primary Hyperparathyroidism With Extremely High PTH And Lytic Bone Lesions

Abstract Disclosure: M. Shah: None. K. Akinola: None. M. Bollineni: None. S.A. Milan: None. S. Challagulla: None. Background: Primary hyperparathyroidism (PHPT) typically presents with PTH levels two times above the upper limit of normal. Given the increase in routine calcium measurements, PHPT is usually diagnosed and treated early and skeletal complications are not frequent at presentation. We present a case of PHPT with severely elevated PTH levels and bone lesions mimicking metastatic disease. Clinical Case: A 30-year-old male with a history of untreated primary hyperparathyroidism presented with severe chest wall pain and abdominal pain. Initial laboratory tests revealed a calcium level of 13.3 mg/dL (normal 8.6 to 10.5 mg/dL), alkaline phosphatase (AP) of 747 IU/L (normal 24 to 130 IU/L), and PTH of 2485 pg/mL (normal 9-77 pg/mL). The patient was diagnosed with primary hyperparathyroidism years before this presentation, but was lost to follow up due to lack of insurance. His PTH was first noted to be elevated in 2013 at 266 pg/mL. CT of the chest, abdomen, pelvis showed a 2.8 x 3.0 x 3.3 cm anterior mediastinal mass and diffuse mixed lytic and sclerotic bone lesions consistent with metastatic disease. The patient underwent further imaging with CT 4D parathyroid which revealed a 1.1 cm left inferior thyroid nodule and an anterior mediastinal mass of unclear etiology. Given the high concern for malignancy, a biopsy of the mediastinal mass was performed and returned as hypercellular parathyroid tissue with no atypia. Bone biopsies of the sclerotic lesions of the iliac crest were consistent with osseous tissue with prominent bone remodeling and fibrous tissue; no neoplasm was seen. He was treated with IV fluids and zoledronic acid during this work up which only temporarily improved his high calcium levels. He was then placed on cinacalcet prior to surgery. He ultimately underwent resection of the anterior mediastinal mass and left inferior parathyroid gland via a cervical approach. The patient’s preoperative PTH level was 3455 pg/mL and decreased to 209 pg/mL immediately after resection. Resection of the other parathyroid glands was not done due to the high risk of postoperative hypocalcemia. Pathology of both lesions returned as intrathymic parathyroid adenoma with focal fibrosis. Postoperatively, the patient developed symptomatic hypocalcemia as low as 6.4 mg/dL. He required IV and oral calcium for approximately 3 weeks postoperatively, consistent with hungry bone syndrome. He was discharged on an oral regimen of calcium supplementation. Discussion: Long standing untreated PHPT can present with severely elevated PTH levels and skeletal manifestations commonly mistaken for metastatic lesions. As in this case, parathyroidectomy was the only effective treatment. However, it can be complicated by hungry bone syndrome, especially in a patient with significant bone remodeling as evidenced by high AP and lytic bone lesions. Presentation: Saturday, June 17, 2023

Intraoperative indocyanine green angiography for predicting postoperative hypoparathyroidism.

Postoperative hypocalcemia is a common complication of thyroidectomy. This problem is most often associated with accidental devascularization or excision of the parathyroid glands (PG). Aim was to study near-infrared (NIR) fluorescent imaging with intraoperative PG indocyanine green (ICG) angiography to help identify and preserve PG during total thyroidectomy in order to avoid postoperative hypocalcemia. From 2017 to 2022, a total of 92 patients underwent total thyroidectomy at Odessa Regional Hospital. Indications for surgery were multinodular goiter (n = 42), thyroid cancer (n = 43), and Graves' disease (n = 7). By randomization all patients were divided into two groups: in the control group, 48 patients underwent standard total thyroidectomy, and in the main group, 44 patients underwent NIR-assisted total thyroidectomy with ICG angiography. Serum calcium and parathyroid hormone levels were compared between the two groups of patients in 1, 7-15days after surgery and then 3, 6months later. In the control group, based on a visual assessment of the PG, autotransplantation of the PG was conducted in only five cases. In the second group, autotransplantation was performed in 16 patients. The transient postoperative hypocalcemia was observed in 8 patients of the control group (16, 70%) and in the 2 patients of ICG group (4, 50%) on 5-10 postoperative days. In the first group, 2 patients at 3months after surgery had permanent hypocalcaemia. NIR fluorescent imaging with intraoperative PG ICG angiography is a safe and an easily repeatable method. This technique provides improved detecting and assessment of the perfusion of the PG. The need for autotransplantation of the PG can be determined more objectively using ICG imaging than simple visualization.