Rate Of Parathyroidectomy Research Articles

Application of carbon nanoparticles in endoscopic thyroid cancer surgery: a systematic review and meta-analysis.

There has been a substantial increase in incidence of thyroid cancer globally over the past three decades, emphasizing the necessity for efficient surgical management. Surgical intervention requires meticulous lymphatic dissection; however, it is challenging to both accurately identify lymph nodes and preserve the surrounding structures. We investigated the role of carbon nanoparticles in endoscopic thyroid cancer surgery to improve surgical effects and reduce postoperative complications. Chinese and English literature databases from inception to May 2023 were searched based on inclusion criteria, and data were extracted independently by two investigators. STATA software was used for data analysis. A comprehensive systematic review and meta-analysis were conducted with 13 publications (9 randomized and 4 non-randomized controlled trials). The results demonstrated that the application of carbon nanoparticles in thyroid surgery led to an increase in the number of retrieved lymph nodes and identification of metastatic lymph nodes. Furthermore, it considerably reduced the rate of improper parathyroidectomy and the incidence of postoperative hypocalcemia. The application of carbon nanoparticles can effectively improve the effects of surgical treatment, can enhance the identification of intraoperative lymph nodes, reduce postoperative complications, and protect the integrity and function of the parathyroid gland. www.crd.york.ac.uk/PROSPERO, identifier, CRD42023420504.

Comparison of Perioperative Outcomes in Patients with Graves' Disease Undergoing Total Thyroidectomy With or Without Near Infrared Autofluorescence Imaging.

Background: The impact of near-infrared autofluorescence (NIRAF) imaging on postthyroidectomy hypocalcemia is controversial. As patients with Graves' disease are at increased risk, our aim was to compare postoperative parathyroid function in these patients undergoing total thyroidectomy (TT) with or without NIRAF imaging. Methods: This was a retrospective "before and after" study, comparing outcomes of patients who underwent TT without or with NIRAF imaging at a single center. Primary outcome was the incidence of temporary hypocalcemia and secondary outcomes, rates of incidental parathyroidectomy on final specimens and permanent hypocalcemia. Analyses were performed using Mann-Whitney U and chi-Square tests. Continuous data are expressed as median (interquartile range). Results: There were 85 patients in NIRAF and 100 patients in non-NIRAF group. Groups were comparable regarding age, gender, body-mass index, and thyroid weight. Number of parathyroid glands identified intraoperatively was 3 in both groups (p = 0.47). Intraoperative parathyroid implantation rate was 16.5% in NIRAF and 6% in non-NIRAF group (p = 0.02). Incidental parathyroidectomy rate on final pathology was 12.9% in NIRAF and 32% in non-NIRAF group (p = 0.002). The rates of temporary (11.7% vs. 16%) and permanent hypocalcemia (2.4% vs. 2%) were similar between the two groups, respectively (p = 0.66). Conclusion: To our knowledge, this is the first comparative study investigating the impact of NIRAF on postoperative parathyroid function after thyroidectomy for Graves' disease. The rate of incidental parathyroidectomy on final pathology was lower with use of NIRAF, without an impact on temporary or permanent hypocalcemia rates compared to conventional technique.

Incidental parathyroidectomy during total thyroidectomy and functional parathyroid preservation: a retrospective cohort study

BackgroundThe published rate of incidental parathyroidectomy (IP) during thyroid surgery varies between 5.8% and 29%. The risk factors and clinical significance of postoperative transient hypocalcemia and permanent hypoparathyroidism are still debated. The aims of this study were to assess the clinical relevance of avoidable IP for transient hypocalcemia and permanent hypoparathyroidism, and to describe the risk factors for IP.MethodsThis retrospective cohort study included 1,537 patients who had a one-step total thyroidectomy in a high-volume endocrine surgery center between 2018 and 2019. Pathology reports were reviewed for incidentally removed parathyroid glands. Intrathyroidal parathyroid glands were excluded from the study. Demographic characteristics, potential risk factors, and postoperative calcium and PTH levels were compared between IP and control groups.ResultsAvoidable IP occurred in 234 (15.2%) patients. Patients with IP had a higher risk of transient hypocalcemia (17.9% vs. 11.5%, p = 0.006; odds ratio [OR] 1.68, 95% confidence interval [95% CI]1.16–2.45) and permanent hypoparathyroidism (4.7% vs. 1.6%, p = 0.002; OR 3.01, 95% CI 1.29–6.63) than patients without IP. Multivariate analysis showed that central lymph node dissection (CLND) and incidental removal of thymus tissue were independent risk factors for IP (OR 4.83, 95% CI 2.71–8.86, p < 0.001 and OR 1.72, 95% CI 1.02–2.82, p = 0.038).ConclusionsPatients with IP were more likely to develop transient hypocalcemia and permanent hypoparathyroidism, indicating the clinical significance of avoidable IP for patients and the need for raising awareness among surgeons. Patients undergoing CLND are at a higher risk for IP, and should be adequately informed and treated. Any removal of thymus tissue should be avoided during CLND.

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Pre-Operative Evaluation.

Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2-22%, and the rate of recHPT is 1-15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.

Hypercalcemia with a parathyroid hormone level of ≤50 pg/mL: Is this primary hyperparathyroidism?

BackgroundPrimary hyperparathyroidism is characterized by hypercalcemia with inappropriately normal or elevated parathyroid hormone. However, the absolute parathyroid hormone value that is defined as inappropriately normal is unclear. We reviewed our experience with parathyroidectomy in patients with hypercalcemia and parathyroid hormone of ≤50.0 pg/mL (normal range 12.0–88.0 pg/mL). MethodsA total of 2,349 patients underwent parathyroidectomy for primary hyperparathyroidism between 2000 and 2021. Of these, 149 patients had preoperative parathyroid hormone ≤50.0 pg/mL (parathyroid hormone ≤50). The biology and outcomes were compared to patients with parathyroid hormone >50.0 pg/mL (parathyroid hormone >50). ResultsOf the parathyroid hormone ≤50 patients, the median parathyroid hormone was 40.0 pg/mL (range 11.6–50.0 pg/mL). All patients were found to have abnormal hypercellular parathyroid glands with a cure rate of 96.7%. When compared to the parathyroid hormone >50 group, the parathyroid hormone ≤50 group was younger (56 ± 15 vs 60 ± 14 years, P < .001) with a lower body mass index (28.7 ± 7.0 kg/m2 vs 31.2 ± 7.9 kg/m2, P < .001), higher rate of fatigue (73.2% vs 63.0%, P = .033), and higher rate of multiglandular disease (58.9% vs 31.9%, P < .001). There was no difference between the groups with respect to patient demographics, rate of previous parathyroidectomy, surgical cure, or postoperative complications (persistent or recurrent hyperparathyroidism and hypocalcemia). ConclusionPatients with hypercalcemia and parathyroid hormone ≤50 pg/mL have a similar clinical presentation and rate of surgical cure to other primary hyperparathyroidism patients and should be considered for parathyroidectomy. Most of these patients have multiglandular disease and thus should be considered for bilateral parathyroid exploration.

Parathyroidectomy and Cinacalcet Use in Medicare-Insured Kidney Transplant Recipients

Posttransplant hyperparathyroidism is common, and treatment practices are poorly characterized. The goal of this study was to examine the incidence, associations, and outcomes of posttransplant parathyroidectomy and calcimimetic use in a cohort of Medicare-insured US kidney transplant recipients. Retrospective observational cohort study. We used the US Renal Data System to extract demographic, clinical, and prescription data from Medicare Parts A, B, and D-insured patients who received their first kidney transplant in 2007-2013. We excluded patients with pretransplant parathyroidectomy. Calendar year of transplantation and pretransplant patient characteristics. (1) Incidence of and secular trends in parathyroidectomy and cinacalcet use in the 3 years after transplant; (2) 90-day outcomes after posttransplant parathyroidectomy and cinacalcet initiation. Temporal trends and pretransplant correlates of parathyroidectomy and cinacalcet use were assessed using proportional hazards models and multivariable Poisson regression, respectively. The inclusion criteria were met by 30,127 patients, of whom 10,707 used cinacalcet before transplant, 551 underwent posttransplant parathyroidectomy, and 5,413 filled≥1 prescription for cinacalcet. The rate of posttransplant parathyroidectomy was stable over time. By contrast, cinacalcet use increased during the period studied. Long dialysis vintage and pretransplant cinacalcet use were strongly associated with posttransplant parathyroidectomy and cinacalcet use. Roughly 1 in 4 patients were hospitalized within 90 days of posttransplant parathyroidectomy, with hypocalcemia-related diagnoses being the most common complication. Parathyroidectomy (vs cinacalcet initiation) was not associated with an increase in acute kidney injury. We lacked access to laboratory data to help assess the severity of secondary/tertiary hyperparathyroidism. The cohort was limited to Medicare beneficiaries. Almost one-fifth of our study cohort was treated with parathyroidectomy and/or cinacalcet. Further studies are needed to establish the optimal treatment for posttransplant hyperparathyroidism.

461 A Retrospective Audit of the Success Rate and Complications of Parathyroidectomy in Primary Hyperparathyroidism

Abstract Aim Primary hyperparathyroidism (pHPT) is a clinical disorder which presents with hypercalcaemia. The definitive management for such cases is a Parathyroidectomy. Few centres have reported their success rate for this procedure. We conducted a retrospective review to compare the success rate and complications in Parathyroidectomy at our centre. Method After approval from the ethical committee, data was collected from the case files of the patients. Inclusion criteria was a Parathyroidectomy performed for pHPT between 2013 and 2020 at our institute. The Data included the demographics with pre- and post-operative Calcium / Parathyroid hormone levels to calculate the success rate. The procedure was defined as successful if the calcium levels returned to normal ranges (&amp;lt;2.6 mmol/L) according to NICE guidelines. Results 246 pHPT patients with a mean age of 61 years were included. 222 patients (90.24%) had their calcium level return to normal indicating a successful procedure. 24 cases (9.75%) had persistence or recurrence of hypercalcaemia indicating a failure of the surgery. The rate of success was significantly higher (96.84%) in the last 2 years (2019 – 2020) of the audit suggesting an improvement in outcomes. Five patients (2.03%) out of the 246 had complications related to the surgery. Two patients reported post-operative cord paresis, two had a post-operative neck haematoma and one experienced hypocalcaemia from hungry bone syndrome. Conclusions The surgical outcomes especially in the last 2 years are comparable to other specialized centres mentioned in the review. This Audit helps us demonstrate the improvement in the surgical results over the years at our centre.

The rate, cost and outcomes of parathyroidectomy in the united states dialysis population from 2016–2018

BackgroundIn end-stage kidney disease, patients may undergo parathyroidectomy if secondary hyperparathyroidism cannot be managed medically. This study was designed to estimate the parathyroidectomy rate in the United States (US) and to quantify changes in costs and other outcomes after parathyroidectomy.MethodsThis was a retrospective observational cohort study using US Renal Data System data for 2015–2018. Parathyroidectomy rates were estimated for adult hemodialysis and peritoneal dialysis patients alive at the beginning of 2016, 2017, and 2018 who were followed for a year or until parathyroidectomy, death, or transplant. Incremental differences in economic and clinical outcomes were compared before and after parathyroidectomy in adult hemodialysis and peritoneal dialysis patients who received a parathyroidectomy in 2016 and 2017.ResultsThe rate of parathyroidectomy per 1,000person-years decreased from 6.5 (95% CI 6.2-6.8) in 2016 to 5.3 (95% CI5.0-5.6) in 2018. The incrementalincrease in 12-month cost after versus before parathyroidectomy was $25,314(95% CI $23,777-$27,078). By the secondmonth after parathyroidectomy, 58% of patients had a corrected calcium level< 8.5 mg/dL. In the year afterparathyroidectomy (versus before), hospitalizations increased by 1.4 perperson-year (95% CI 1.3-1.5), hospital days increased by 12.1 per person-year(95% CI 11.2-13.0), dialysis visits decreased by 5.2 per person-year (95% CI4.4-5.9), and office visits declined by 1.3 per person-year (95% CI1.0-1.5). The incremental rate per 1,000person years for hematoma/bleed was 224.4 (95% CI 152.5-303.1), for vocal cordparalysis was 124.6 (95% CI 59.1-232.1), and for seroma was 27.4 (95% CI0.4-59.0).ConclusionsParathyroidectomy was a relatively uncommon event in the hemodialysis and peritoneal dialysis populations. The incremental cost of parathyroidectomy was mostly attributable to the cost of the parathyroidectomy hospitalization. Hypocalcemia occurred in over half of patients, and calcium and phosphate levels were reduced. Clinicians, payers, and patients should understand the potential clinical and economic outcomes when considering parathyroidectomy.

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.

Outcome of Parathyroidectomy for Renal Hyperparathyroidism: A Single Center Experience

Background: Renal hyperparathyroidism (HPTH) is a common complication of chronic kidney disease and is known to cause significant morbidity in these patients. There has been substantial debate on the best possible treatment of this condition. Surgical treatment is now considered to be of vital importance as its efficacy is well documented. The present study reported the outcome of parathyroidectomy in King Chulalongkorn Memorial Hospital, a university hospital in Bangkok, Thailand. Objective: To determine surgical outcomes, including success rate and perioperative complications of parathyroidectomy in patients with renal HPTH. Materials and Methods: The data was collected by retrospective review of patients’ records between June 2014 and May 2019. One hundred ten patients were enrolled. Their demographic data, laboratory results, and outcomes were collected and categorized. Results: Among 110 patients, men accounted for 48.6%. The mean age was 49.5 years (SD 13.3). The most frequent operation was total parathyroidectomy with autotransplantation (TPTX+AT). All four glands were identified and excised in 84.5% of all patients. The mean preoperative serum intact parathyroid hormone (iPTH) level was 1,938 pg per dL with a range of 171 to 5,000 pg per dL. Postoperative hypocalcemia requiring intravenous calcium supplement was present in 70%. Postoperative cardiovascular complication occurrences were 16.4%, with one mortality due to myocardial infarction. In addition, one patient suffered unilateral recurrent laryngeal nerve injury, while two had stroke. The overall success rate of treatment was 81.1%, with 7.3% and 8.2% of patients that had persistently high PTH and recurrence of HPTH, respectively. Conclusion: Parathyroidectomy is an essential choice of treatment in patients with renal HPTH. Further validation of correlations with other factors is now being processed, and more data are needed. Keywords: Secondary hyperparathyroidism; Tertiary hyperparathyroidism; Chronic kidney disease mineral bone disease; Parathyroidectomy

Rate of Incidental Parathyroidectomy in a Pediatric Population.

ObjectiveIncidental parathyroidectomy is a relatively common occurrence in thyroid surgery, which may lead to hypoparathyroidism and postoperative hypocalcemia, but it is not well studied in children. The objectives of this study were to determine the rate of incidental parathyroidectomy, identify potential risk factors, and investigate postoperative complications in children undergoing thyroidectomy.Study DesignRetrospective cohort study.SettingPatients who underwent thyroidectomy over a 10-year period at a tertiary children’s hospital.MethodsPathology reports were reviewed to determine incidental parathyroid gland tissue. Additional data collected included patient demographics, type of procedure, underlying thyroid pathology, as well as immediate and long-term postoperative clinical outcomes.ResultsOf 209 patients, 65 (31%) had incidental parathyroidectomy. Several variables were associated with incidental parathyroidectomy on univariable analysis. However, in the final multivariable model, only thyroidectomy with lymph node dissection was associated with increased odds of having incidental parathyroidectomy (odds ratio, 3.3; P = .04; 95% CI, 1.1-9.8). After a median follow up of 1 year, a significantly higher percentage of patients with incidental parathyroidectomy had evidence of long-term hypoparathyroidism (9/62 [15%] vs 3/144 [2%], P = .001).ConclusionIncidental parathyroidectomy was relatively common in our pediatric thyroidectomy population, which may be a result of several anatomic, clinical, and surgeon-related factors. Close attention to parathyroid preservation with meticulous surgical technique is the most practical method of preventing long-term hypoparathyroidism and hypocalcemia.

O62: INTRA-OPERATIVE ADJUNCTS IN MINIMALLY INVASIVE RADIO-GUIDED PARATHYROIDECTOMY AT A SPECIALIST ENDOCRINE SURGERY CENTRE

Abstract Introduction Primary Hyperparathyroidism (PH) is common cause of hypercalcaemia (0.3% of the population). Minimally invasive radio-guided parathyroidectomy (MIRP) has been made possible due to advancements in pre-operative imaging i.e. sestamibi scans allowing localisation of areas of parathyroid hyperactivity. Method Due to the disagreement in the literature regarding which intra operative adjunct is best used in MIRP surgery to decrease recurrence, the rationale for this study is to examine and compare the performance of these adjuncts in consecutive patients i.e. 1. Intra operative PTH assay (IOPTHA) 2. Tc-99m radio-guidance using a gamma probe and the 20% rule 3. Frozen section analysis. Result 45 MIRP procedures were carried out between 01/07/2018 and 30/10/2019. 77.8% were females; mean age was 62 years (range 30 - 79). Final pathology showed that in 43 of the cases parathyroid tissue was correctly removed; thyroid tissue was identified for the other 2 cases. 20% rule was positive in 43 out of the 45 cases and negative in 2 (sensitivity 100%, specificity 100%). A drop in IOPTHA greater than 50% was found in 41 out of the 45 cases but not in 4 (sensitivity 93.9%, specificity 100%). Frozen section was 100% concordant with final pathology (45/45). AUC analysis showed no significant difference in the performance of these tests (p = 0.15) but was around 1 for 20% rule and Frozen section. Conclusion When radio-guidance and frozen sections are added to IOPTHA, the success rate of parathyroidectomy is markedly improved. Using them together will greatly reduce recurrent hyperparathyroidism. Take-home message When radio-guidance and frozen sections are added to Intra-operative PTH assays in Minimally Invasive Radio-Guided Parathyroidectomy, the success rate of parathyroidectomy is markedly improved. Using them together as in our study will greatly reduce the incidence of recurrent hyperparathyroidism and thus recurrent surgery.

Incidental parathyroidectomy in thyroidectomy and central neck dissection

BackgroundAlthough higher thyroidectomy volume has been linked with lower complication rates, its association with incidental parathyroidectomy remains less studied. The volume relationship is even less clear for central neck dissection, where individual parathyroid glands are at greater risk. MethodsPatients undergoing thyroidectomy with or without central neck dissection were evaluated for incidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Univariate and multivariable analyses were performed using binary logistic regression. ResultsOverall, 1,114 thyroidectomies and 396 concurrent central neck dissections were performed across 7 surgeons. Incidental parathyroidectomy occurred in 22.4% of surgeries (range, 16.9%–43.6%), affecting 7.1% of parathyroids at risk (range, 5.8%–14.5%). When stratified by surgeon, lower incidental parathyroidectomy rates were associated with higher thyroidectomy volumes (R2 = 0.77, P = .008) and higher central neck dissection volumes (R2 = 0.93, P < .001). On multivariable analysis, low-volume surgeon (odds ratio 2.94, 95% confidence interval 2.06–4.19, P < .001), extrathyroidal extension (odds ratio 3.13, 95% confidence interval 1.24–7.87, P = .016), prophylactic central neck dissection (odds ratio 2.68, 95% confidence interval 1.65–4.35, P <.001), and therapeutic central neck dissection (odds ratio 4.44, 95% confidence interval 1.98–9.96, P < .001) were the most significant factors associated with incidental parathyroidectomy. In addition, incidental parathyroidectomy was associated with a higher likelihood of temporary hypoparathyroidism (odds ratio 2.79, 95% confidence interval 1.45–5.38, P = .002) and permanent hypoparathyroidism (odds ratio 4.62, 95% confidence interval 1.41–5.96, P = .025), but not permanent hypocalcemia (odds ratio 1.27, 95% confidence interval 0.48–3.35, P = .63). Higher lymph node yield in central neck dissection was not associated with higher incidental parathyroidectomy rates (odds ratio 1.13, 95% confidence interval 0.85–8.81, P = .82). ConclusionHigher surgical volume conferred a lower rate of incidental parathyroidectomy. Nonetheless, greater lymph node yield in central neck dissections did not result in greater parathyroid-related morbidity. Such findings support the value of leveraging surgical volume to both optimize oncologic resection and minimize complication rates.

Variation in surgical management of primary hyperparathyroidism in the US Department of Veterans Affairs healthcare system: A 15-year observational study

BackgroundPrimary hyperparathyroidism is underdiagnosed and undertreated nationally despite the benefits of parathyroidectomy. However, the degree of hospital-level variation in the management of primary hyperparathyroidism is unknown. MethodsWe performed a national, retrospective study of Veterans with primary hyperparathyroidism using the Veterans Affairs Corporate Data Warehouse from January 2000 to September 2015. The objective was to characterize the extent of hospital-level variation in the use of parathyroidectomy for the management of primary hyperparathyroidism within a national, integrated healthcare system. Rate of parathyroidectomy in patients with primary hyperparathyroidism was stratified by (1) geographic region, (2) facility complexity level, (3) volume of parathyroidectomies per facility, and (4) frequency of parathyroid hormone testing in hypercalcemic patients. ResultsAmong 47,158 Veterans with primary hyperparathyroidism, 6,048 (12.8%) underwent parathyroidectomy. Rates of parathyroidectomy were significantly higher in the Continental (17.0%) and Pacific (16.0%) regions than in other areas (11.4%, P < .01). The highest complexity referral centers had the highest rate of parathyroidectomy (13.6%) compared with all other facilities (12.1%, P < .01). Centers that performed the highest volume of parathyroidectomies were more likely to offer surgery (13.3%) than low volume centers (8.9%, P < .01). Facilities with higher frequency of parathyroid hormone testing among hypercalcemic patients were more likely to offer parathyroidectomy (15.2%) than those with the lowest parathyroid hormone testing frequency (12.6%, P < .01). ConclusionAlthough there is notable variation in parathyroidectomy use for definitive treatment of primary hyperparathyroidism between Veterans Affairs facilities, parathyroidectomy rates are low across the entire system. Further research is needed to understand additional local contextual and other patient and clinician-level factors for the undertreatment of primary hyperparathyroidism to subsequently guide corrective interventions.

The impact of near infrared fluorescence imaging on parathyroid function after total thyroidectomy.

Compared withconventional thyroidectomy, hypocalcemia rate was reported to be lower after total thyroidectomy (TT) utilizing near infrared fluorescence imaging (NIFI). The aim of this study is to evaluate the impact of NIFI on postoperative parathyroid function after TT. This was a retrospective institutional review board-approved study comparing 100 patients who underwent TT with NIFI guidance and 200 patients without, by the same surgeon. Clinical parameters were compared using χ2 and t test. Average number of parathyroid glands identified intraoperatively was similar between twogroups. However, rate of incidental parathyroidectomy was higher in conventional (14%) versus NIFI group (6%) (P = .039), despite similar (4% vs 6%, respectively) autotransplantation rates (P = .562). Incidences of transient (6.5% vs 5.0%) and permanent (0.5% vs 0%) hypocalcemia were not statistically different between conventional and NIFI groups (P = NS). The use of NIFI during thyroidectomy may decrease the rate of incidental parathyroidectomy by increasing the ability of the surgeon to recognize parathyroid glands with fluorescent contrast distinction. Nevertheless, in contrary to recent reports in literature, postoperative hypocalcemia rate was not altered compared with conventional technique, suggesting that preservation of parathyroid vasculature, rather than an augmented ability to detect the glands, may dominantly affect postoperative function.

Clinicopathological characteristics of incidental parathyroidectomy after total thyroidectomy: The effect on hypocalcemia. A retrospective cohort study

BackgroundThe reported rate of incidental parathyroidectomy (IP) during total thyroidectomy varies between 6.4 and 31.1%. The aim of this study was to investigate the clinicopathological characteristics associated with IP. Materials and methodsThis is a retrospective cohort study which included 2556 patients who underwent total thyroidectomy between 2002 and 2012 at a single tertiary institution. Demographics, clinicopathological risk factors, and postoperative calcium levels were compared between IP and control group. ResultsIncidental parathyroidectomy occurred in 18.3% of patients. IP patients had higher risk of postoperative biochemical (40.3% vs 17.3%, p < 0.001) and symptomatic hypocalcemia (14.3% vs 7.3%, p < 0.001) than no-IP group. Multivariate analysis showed malignancy, tumor size >10 mm, thyroid capsule invasion, extrathyroidal extension, lymph node metastases and central neck dissection, operation time, RLN injury, thyroid gland dimensions were independent risk factors for IP. ConclusionsOur results indicate that patients with certain preoperative findings such as larger thyroid dimensions, diagnosis of malignancy and especially tumor >10 mm, extrathyroidal extension, and lymph node metastasis are at higher risk of IP and postoperative symptomatic hypocalcemia and these patients should be adequately informed and treated. Α meticulous intraoperative identification and the preservation of all parathyroid glands results in lower incidence of IP and postoperative hypocalcemia.

Incidence of post-operative hypocalcaemia after thyroidectomy - a retrospective study

Introduction Post-operative hypocalcaemia following thyroidectomy can lead to distressing symptoms and increase the period of hospitalization. Iatrogenic injury to parathyroid glands is the primary cause for hypocalcaemia. Aim This study aims to describe the incidence of postoperative hypocalcaemia and its demographic distribution. Method A retrospective analysis was made in 240 consecutive patients who had undergone total thyroidectomy in the professorial surgical unit, Teaching Hospital Jaffna. The post-operative calcium level, symptoms and signs of hypocalcaemia were considered and correlated with their demographic details and histology report of the specimen. Results The overall incidence of hypocalcaemia was 10.83% (n=26). Among them, 96.15% (n=25) had transient hypocalcaemia and 88.46% had symptomatic hypocalcaemia (n=23) with biochemical evidence of hypocalcaemia. The rate of inadvertent parathyroidectomy was 6.25%. Conclusion Hypocalcaemia is common in the first three days of postoperative period and most of the hypocalcaemic events are transient.

Intraoperative localization of the parathyroid glands with indocyanine green and Firefly(R) technology during BABA robotic thyroidectomy.

It is unclear whether near-infrared (NIR) light-induced indocyanine green (ICG) fluorescence can effectively identify, and thus permit the preservation of, parathyroid glands in bilateral axillo-breast approach (BABA) robotic thyroidectomy. This case-control study with a prospectively recruited consecutive series and a retrospectively selected control group assessed the usefulness of ICG with Firefly(R) technology to identify the parathyroid glands intraoperatively during BABA robotic thyroidectomy. All consecutive patients (N=22) who were scheduled to undergo BABA robotic thyroidectomy for papillary thyroid carcinoma in December 2013-August 2015 and met the study eligibility criteria were recruited prospectively. ICG fluorescence was used with the Firefly system (NIR illuminator: 805nm; filter: 825nm) integrated in the da Vinci Si robot system to identify the lower parathyroid glands. Parathyroid hormone levels were recorded on postoperative days 0, 1, 2, and 14. Propensity score matching was used to identify an age-, gender-, tumor size-, and operation type-matched group of control patients who underwent BABA robotic thyroidectomy without the Firefly system. The two groups were compared in terms of parathyroid-related outcomes. ICG fluorescence-mediated identification of the parathyroid and thyroid glands required on average (range) 203±89 (125-331) and 207±112 (130-356)s, respectively. The mean (range) fluorescence duration in these glands was 20.8±6.0 (16.6-35.8) and 20.1±7.3 (15.5-33.8)min, respectively. The ICG group had a significantly lower rate of incidental parathyroidectomy than the control group (0 vs. 15.9%, P=0.048). ICG with NIR light may feasibly and safely identify the parathyroid glands in BABA robotic thyroidectomy.

Outcomes of Parathyroid Autotransplantation During Total Thyroidectomy: A Comparison with Age- and Sex-Matched Controls

ABSTRACTPurpose: To determine the effect of parathyroid autotransplantation (PA) on postoperative hypocalcemia in cases of total thyroidectomy. Materials and Methods: Cases undergoing total thyroidectomy and PA were compared with age and sex-matched controls who had not undergone PA. The postoperative percentage changes (PC) of parathyroid hormone (PTH) and calcium (Ca+2) in the first 12–24 hours (12–24hr→preop), between the 1st-3rd weeks (1-3wk→preop) and at the 6th month (6mo→preop), the rates of hypocalcemia (Ca+2< 8mg/dL) and low PTH level (PTH< 15 pg/mL), permanent hypocalcemia, inadvertent parathyroidectomy in both groups were compared. Results: The number of patients with PTH12-24hr<15 pg/mL was significantly higher (n:34,(55.7%)) than the number of patients in the control group (n:16(26.2%)), (p=0.001). The rate of decrease in the blood Ca+2 median PC (6mo→preop) was significantly higher in the PA group (4.2%) than the control group (1.1%), (p=0.008). There was no significant difference between the 2 groups in terms of the postoperative frequency of hypocalcemia (p>0.05). In the PA&age≤50 group, the rate of inadvertent parathyroidectomy was higher than that of cases over age 50 (p=0.029). Conclusion: In spite of the presence of an increased postoperative hypocalcemia trend in cases requiring PA during total thyroidectomy, the rates of transient and permanent hypocalcemia were not different to the control cases. But the frequency of cases with low PTH level in cases undergoing PA was higher than that of the control cases. In cases of 50 years of age and under, who had undergone PA, the possibility of inadvertent parathyroidectomy increased.

Incidence, Risk Factors, and Clinical Outcomes of Incidental Parathyroidectomy During Thyroid Surgery.

The reported rate of incidental parathyroidectomy (IP) during thyroid surgery is between 5.2 and 21.6%. Current literature reports wide discrepancy in incidence, risk factors, and outcomes. Thus study was designed to address definitively the topic of IP and identify associated risk factors and clinical outcomes with this multi-institutional study. This retrospective cohort study included 1767 total thyroidectomies that occurred between 1995 and 2014 at two academic centers. Pathologic reports were reviewed for the presence of unintentionally removed parathyroid glands. Demographics, potential risk factors, and postoperative calcium levels were compared with matched control group. Logistic regression, t tests, and Chi squared tests were used when appropriate. IP occurred in 286 (16.2%) of thyroidectomies. Risk factors for IP were: malignancy, neck dissection, and lymph node metastases (p=0.005, <0.001, and <0.001). Fifty-three (19.2%) of IPs were intrathyroidal. Those with IP were more likely to have postoperative biochemical (65.6 vs. 42.0%; p<0.001) and symptomatic (13.4 vs. 8.1%; p=0.044) hypocalcemia than controls. The number of parathyroids identified intraoperatively was inversely correlated with the number of parathyroid glands in the specimen (p<0.001). Our findings indicate that malignancy, lymph node dissection, and metastatic nodal disease are risk factors for IP. Patients with IP were more likely to have postoperative biochemical and symptomatic hypocalcemia than controls, showing that there is a physiologic consequence to IP. Additionally, intraoperative surgeon identification of parathyroid glands results in a lower incidence of IP, highlighting the importance of awareness of parathyroid anatomy during thyroid surgery.