Transient Hypocalcemia Research Articles

Total thyroidectomy: Safe and curative treatment option for hyperthyroidism.

While use of total thyroidectomy has increased in management of hyperthyroidism, concerns exist about increased surgical complication rates; most notably, hematoma, recurrent laryngeal nerve (RLN) injury, and hypocalcemia. Retrospective cohort study of 454 patients undergoing total thyroidectomy between 2003 and 2015. All patients had surgery for hyperthyroidism, benign euthyroid disease, or thyroid malignancy. Total thyroidectomy for hyperthyroidism was not associated with an increased risk for any postoperative complication. Transient hypocalcemia, temporary dysphonia, and postoperative hematoma rates were not significantly different for patients with hyperthyroid (n = 91), euthyroid benign (n = 237), and malignant (n = 126) disease. Permanent hypocalcemia and recurrent laryngeal nerve injury were not noted in any hyperthyroid patients. Complication rates were similar for hyperthyroid patients with Graves' disease vs toxic multinodular goiter. This study affirms safety and efficacy of total thyroidectomy as standard treatment for hyperthyroidism.

Comparison of total endoscopic thyroidectomy with conventional open thyroidectomy for treatment of papillary thyroid cancer: a systematic review and meta-analysis.

Despite the fact that thyroid surgery has evolved towards minimal incisions and endoscopic approaches, the role of total endoscopic thyroidectomy (TET) in thyroid cancer has been highly disputed. We performed a systematic review and meta-analyses of peer reviewed studies in order to evaluate the safety and effectiveness of TET compared with conventional open thyroidectomy (COT) in papillary thyroid cancer (PTC). Medical literature databases such as PubMed, Embase, the Cochrane Library, and Web of science were systematically searched for articles that compared TET and COT in PTC treatment from database inception until March 2019. The quality of the studies included in the review was evaluated using the Downs and Black scale using Review Manager software Stata V.13.0 for the meta-analysis. The systematic review and meta-analysis were based on 5664 cases selected from twenty publications. Criteria used to determine surgical completeness included postoperative thyroglobulin (TG) levels, recurrence of the tumor after long-term follow-up. Adverse event and complication rate scores included transient recurrent laryngeal nerve (RLN) palsy, permanent RLN palsy, transient hypocalcaemia, permanent hypocalcaemia, operative time, number of removed lymph nodes, length of hospital stay and patient cosmetic satisfaction. TET was found to be generally equivalent to COT in terms of surgical completeness and adverse event rate, although TET resulted in lower levels of transient hypocalcemia (OR 1.66; p < 0.05), a smaller number of the retrieved lymph nodes (WMD 0.46; p < 0.05), and better cosmetic satisfaction (WMD 1.73; p < 0.05). COT was associated with a shorter operation time (WMD - 50.28; p < 0.05) and lower rates of transient RLN palsy (OR 0.41; p < 0.05). The results show that in terms of safety and efficacy, TET was similar to COT for the treatment of thyroid cancer. Indeed, the tumor recurrence rates and the level of surgical completeness in TET are similar to those obtained for COT. TET was associated with significantly lower levels of transient hypocalcemia and better cosmetic satisfaction, and thus is the better option for patients with cosmetic concerns. Overall, randomized clinical trials and studies with larger patient cohorts and long-term follow-up data are required to further demonstrate the value of the TET.

Clinical Presentation and Surgical Treatment of Retrosternal Goiter: A Case Series Study.

Background: The retrosternal goiter (RSG) is a slow-growing mass often benign in nature; thyroidectomy remains the preferred standard curative treatment. This study aimed to explore the local experience of RSG with respect to the clinical presentation, classifications, management, and outcomes. Method: A retrospective chart review was conducted to include all cases diagnosed with RSG and underwent thyroidectomy between January 1998 and December 2013. Results: A total of 1210 patients underwent thyroidectomy; of which 30 (2.5%) patients were diagnosed to have RSG. The commonly reported symptoms were dyspnea (40%), pain and discomfort (30%), dysphagia (26.7%), and hoarseness (20%). Thirteen patients (43.3%) were completely asymptomatic. The fine-needle aspiration cytology was performed in 22 (73.3%) patients, of whom the majority was benign (77.3%). The grading classification showed that grade 1 is the most frequent (73.3%). Total bilateral thyroidectomy was the most prevailing procedure in 57% cases followed by partial thyroidectomy. All patients underwent retrosternal thyroidectomy through a cervical incision except for one case. Postoperative histopathology showed frequent benign multinodular goiter (83.3%), followed by papillary thyroid cancer (10%) and thyroiditis (6.7%). The most common complication after thyroidectomy was tracheomalacia (13.4%), transient hypocalcemia (10%), and hypoparathyroidism (6.7%). There was no intraoperative or perioperative mortality. Conclusion: RSG is a rare entity often presented with pressure symptoms, mostly involving anterior mediastinum and had a challenging surgical procedure. A large multicenter study is needed to include more cases in order to have a consensus on the definition and classification system for such important clinical goiter presentation.

Quality of life is not affected by thyroid surgery in nontoxic benign goitre in long-term surveillance-A prospective observational study.

ObjectiveQuality of life (QoL) has so far seldom been taken into account by default in decision‐making for surgical indication in thyroid surgery. Therefore, we compared pre‐ and postoperative QoL of patients using the EuroQoL‐5D (EQ‐5D) questionnaire. The influence of certain socio‐economic factors on QoL as a second end‐point was considered.DesignProspective cohort study.PatientsAbout 153 patients with euthyroid symptomatic benign goitre after hemi‐ and total thyroidectomy (follow‐up 83.6%) have been included.MeasurementsThe EQ‐5D questionnaire was used prior to and 1 year after surgery. In addition, a questionnaire for assessment of socio‐economic status was collected.ResultsFor n = 90 (n = 67 female, n = 23 male), total thyroidectomy (TT) and, for n = 63 (n = 45 female, n = 18 male), hemithyroidectomy (HT) were performed. None permanent dysfunction of the vocal cord was recorded. Transient symptomatic hypocalcaemia was detected in 9% of the thyroidectomy group (8/90 patients). At follow‐up, 86% of patients showed either no change or improved QoL. About 14% of patients complained of deteriorated QoL, regardless of the extent of surgery. Socio‐economic factors did not influence postoperative QoL.ConclusionsResults indicate that in pre‐operative consultation of patients with benign goitre, the improvement of QoL should be taken into account for decision‐making in cases of ambiguous surgical indication. Contrary to current discussions that too much thyroid surgery is performed in Germany, we can recommend presenting surgery as an equivalent option to watchful waiting as QoL is at least preserved or improved. The extension of the resection should, however, be decided individually.

Preventative and management strategies of hypocalcemia after thyroidectomy among surgeons: An international survey study

To determine international surgeon practice patterns for transient postoperative hypocalcemia in patients undergoing total thyroidectomy. All member surgeons of the American Thyroid Association and the International Association of Thyroid Surgeons were contacted via email to complete a 20-question survey which included both questions about demographic information and preventing and managing postoperative hypocalcemia after thyroidectomy. Univariate analysis was performed to determine whether providers check preoperative vitamin D levels, postoperative calcium trends and/or PTH to assess for postoperative hypocalcemia. A total of 332 surgeons responded to the survey with 72.26% in practice for >10years and 82.18% performing >50 total thyroidectomies per year. 13.29% of surgeon's surveyed reported that they routinely check preoperative vitamin D levels. Surgeon case volume, type of practice (academic vs non-academic practice), and geographic location in the US were significant predictors of whether surgeons check preoperative Vitamin D levels. International surgeons were significantly more likely to check both postoperative serum Ca and PTH compared to US based surgeons (p<.01). There was no significance difference in practice patterns based on whether the surgeon was a General Surgeon or an Otolaryngologist. Using a questionnaire distributed to both General Surgeons and Otolaryngologists, we demonstrated that there is significant variation in practice patterns between surgeons practicing in the United States and surgeons practicing in other countries, and practice often differs from recommended guidelines.

Anorexia Nervosa with Markedly High Bone Turnover and Hyperphosphatemia During Refeeding Rectified by Denosumab.

We describe a unique case of hyperphosphatemia associated with a very high bone turnover rate in a 51-year-old postmenopausal woman with undiagnosed anorexia nervosa (AN) who presented with a low-trauma hip fracture. In view of her severely malnourished state, she was not fit for surgery. She was treated according to a refeeding protocol that mandated bed rest. Contrary to expectation, she developed sustained hyperphosphatemia and borderline hypercalcemia. Bone remodelling markers, both resorption and formation, were markedly elevated. Parathyroid hormone (PTH) was low-normal at 1.7pmol/L, C-terminal fibroblast growth factor 23 (FGF23) was high at 293RU/ml, but tubular maximum reabsorption of phosphate (TmPO4/GFR) was elevated at 1.93mmol/L. Denosumab 60mg was administered that was followed by: rapid normalisation of serum phosphate; normalisation of resorption markers, transient hypocalcaemia with secondary hyperparathyroidism, and normalisation of both TmPO4/GFR and C-terminal FGF23. We speculate that prolonged immobilization as part of AN management led to a high remodelling state followed by hyperphosphatemia and high-normal calcium with appropriate suppression of PTH and that marked hyperphosphatemia and high TmP/GFR despite high FGF23 indicates the necessity of PTH adequacy for excess FGF23 to lower TmP/GFR.

The Effect of Hypomagnesemia on Refractory Hypocalcemia after Total Thyroidectomy: A Single-Center Prospective Cohort Study.

Background:Hypomagnesemia is known to impede hypocalcemia correction. This prospective observational study aimed to evaluate the impact of serum magnesium levels on the development of refractory hypocalcemia, which remains a concerning problem after total thyroidectomy (TT).Subjects and Methods:Consecutive subjects (n = 312; mean age = 38.4 [range: 13–83] years; M:F = 62:250) undergoing TT for benign or malignant thyroid diseases were evaluated for serum corrected-calcium (8.4–10.4 mg/dL), magnesium (1.7–2.4 mg/dL), intact parathormone (iPTH), and 25-hydroxycholecalciferol (25OHD) levels preoperatively, at 48-h and 6-month post-TT.Results:Postoperatively, 98 subjects (31.4%) exhibited transient hypocalcemia, 96 (30.8%) had hypomagnesemia, and 52 (16.7%) had refractory hypocalcemia. Preoperatively, 38 subjects (12.2%) had asymptomatic hypocalcemia and 77 (24.7%) had hypomagnesemia. In multivariate logistic regression analysis, independent risk factors of transient hypocalcemia were hyperthyroidism (odd's ratio [OR]: 5.6), 48-h iPTH (OR: 3.2), 48-h magnesium (OR: 2.7), preoperative 25OHD (OR: 0.96), and preoperative calcium (OR: 0.5; each P < 0.01). In receiver-operating characteristic analysis, percent calcium decline and 48-h magnesium reliably predicted transient hypocalcemia with a threshold of 10.5% and 1.9 mg/dL, respectively. Area under curve, sensitivity, and specificity were 0.822, 82.7%, and 72.9%; and 0.649 (each P < 0.001), 68.4%, and 63.1%, respectively.Conclusion:Serum magnesium below 1.9 mg/dL had 2.7 times higher odds of developing transient hypocalcemia post-TT. Hypomagnesemia and percent calcium decline >10.5% within 48-h post-TT are associated with refractory hypocalcemia, which necessitates correction of both the deficiencies for prompt resolution of symptoms.

Minimally Invasive Treatment for Benign Parathyroid Lesions: Treatment Efficacy and Safety Based on Nodule Characteristics.

ObjectiveThis study aimed to evaluate the efficacy and safety of ultrasound (US)-guided minimally invasive treatment in patients with parathyroid lesions.Materials and MethodsThis study included 27 patients who had undergone US-guided radiofrequency ablation (RFA) or ethanol ablation (EA) for parathyroid lesions between January 2010 and 2018. RFA was performed in 19 patients with primary hyperparathyroidism (PHPT, n = 11) or secondary hyperparathyroidism (SHPT, n = 8), and EA was performed in eight patients with symptomatic nonfunctioning parathyroid cysts (SNPCs). Nodule size, volume, serum parathyroid hormone (PTH) and calcium levels were recorded before and after treatment. Complications were evaluated during and after treatment.ResultsIn patients with PHPT, significant reductions in size and volume were noted after RFA at 6- and 12-month follow-up (all, p < 0.05). Seven nodules nearly completely disappeared (residual volume < 0.1 mL); serum PTH and calcium levels were reduced to normal ranges (7/11, 63.6%). Four patients experienced partial reductions of serum PTH and calcium levels (4/11, 36.4%). In patients with SHPT, three experienced therapeutic response of serum PTH (3/8, 37.5%), while five showed persistent hyperparathyroidism (5/8, 62.5%) within 6 months after RFA. In patients with SNPCs, EA resulted in significant reductions in cyst size and volume (all, p < 0.05) at the last follow-up. A total of four complications (two transient hypocalcemia [RFA], one permanent [RFA], and one transient [EA] hoarseness) were observed.ConclusionMinimally invasive treatments, such as RFA and EA, may serve as therapeutic alternatives for patients with PHPT or SNPCs; they may have limited usefulness in patients with SHPT.

A comparative study of thyroid surgery with and without a microscope

Introduction: The purpose of this prospective study was to evaluate microsurgical thyroidectomy by comparing it with traditional thyroidectomy. Material and Method: Before surgery, patients were assigned either to the microscopic thyroidectomy group (MT group), with the use of the surgical microscope, or the traditional thyroidectomy group (TT group), without the use of visual magnification. Aims and Objective: Outcome measures were operative time, intraoperative bleeding, and complication rates including injury to the recurrent laryngeal nerve (RLN), the external branch of the superior laryngeal nerve (EBSLN), or the parathyroid glands. Result: Sixty patients underwent thyroid surgery (30 patients in the MT group and 30 patients in the TT group). The two groups were almost similar in age, sex, surgical procedures, and histological findings. There was no difference between the two techniques regarding the operative time and the amount of blood loss. Neither permanent nerve palsy nor persistent hypocalcemia occurred in either group. Transient nerve palsies (RLN and EBSLN) were lower in the MT group (3.3%) compared to the TT group (6.6%). Overall transient hypocalcemia was significantly lower in the MT group (3.3%) compared with the TT group (13.3%). If the population was restricted to total thyroidectomy, the rate of transient hypocalcemia was 1% in the MT group and 1% in the TT group, respectively. Conclusion: In conclusion, thyroid surgery with a microscope is significantly reduced the complication without increasing the operative time compare to without microscope.

Calcium and Vitamin D supplementation in the prevention of post-operative hypocalcaemia in thyroidectomy

Introduction: The incidence of transient hypocalcaemia after thyroidectomy varies in centres. It increases morbidity and delays discharge. This randomised controlled trial aimed to ascertain the usefulness of calcium and Vitamin D supplementation for 1 week pre-operatively in the prevention of hypocalcaemia in patients undergoing total thyroidectomy (TT) for multi-nodular goitre. Methodology: Patients undergoing TT for multi-nodular goitre from January 2019 to August 2019 were included in the study. They were randomly divided into two groups by block randomisation. Group A received oral calcium (500 mg every 6 h) and Vitamin D (calcitriol 0.25 mg every 6 h) 7 days before surgery and Group B did not receive supplementation. Symptoms and signs of hypocalcaemia were monitored. Calcium profile was measured pre-operatively and post-operatively at 6 h, 24 h, 72 h and 14th day. Serum calcium level ≤8.5 mg/dl was considered as hypocalcaemia. Results: 8/62 patients in Group A and 26/62 in Group B had symptoms of hypocalcaemia. 11/62 patients in Group A and 34/62 in Group B developed signs of hypocalcaemia. 15/62 patients in Group A and 36/62 in Group B had biochemical hypocalcaemia. 9/62 patients in Group A and 25/62 in Group B developed post-operative hypocalcaemia, which required post-operative oral supplementation. 3/62 patients in Group A and 16/62 in Group B needed post-operative intravenous calcium supplementation. Conclusions: It is concluded that post-operative hypocalcaemia which manifested as signs and symptoms and correlated with biochemical values was lower after receiving pre-operative oral calcium and Vitamin D3 supplement for 7 days. The need for post-operative supplementation was lower in this group.

Study of complications following various thyroidectomy procedures: a tertiary care centre experience in South India

Introduction: Thyroid surgeries comprise one of the more commonly performed procedures by a general surgeon. Today most of the complications of thyroid surgery are related to either metabolic derangements or injury to the recurrent laryngeal nerve injury. Other complications include superior laryngeal nerve injury, infection, airway compromise, and bleeding. At present, mortality for this procedure approaches 0% and overall complication rate is less than 3%. Nonetheless, major complications of thyroidectomy (i.e. compressive hematoma, recurrent laryngeal nerve palsy and hypoparathyroidism) are still fearful complications and account for a significant percentage of medico-legal claims. Patients volume and surgical skill play an important role in reducing the risk of complications. Knowledge about the clinical profiles of thryoidectomy cases and understanding the post thyroidectomy complications are an important milestone in public health. Aims & Objectives: This study intends to identify the incidence of the complications following various thyroidectomy surgeries performed at JSS Hospital, Mysuru and the effect of timely and prompt recognition and intervention in minimizing morbidity. Methodology: This clinical study was conducted between October 2017 and September 2019 and included 70 consecutive patients undergoing various thyroidectomy procedures, at JSS Hospital, Mysuru. All cases were followed up for a period of 6 months. Results: In our prospective observational study 70 cases of patients with thyroid swellings underwent various thyroidectomy procedures. The incidence of thyroid diseases is more common in females than in males.The peak age group in which patients presented to the hospital was in the 4thdecade .The most common histopathological diagnosis was Nodular Colloid Goitre.The most common surgery performed in was Total thyroidectomy in 45 cases out of 70. Transient hypocalcemia was the most common post- operative complication occurring in about 13 out of 70 cases.

Better Outcomes With Minimally Invasive Thyroidectomy Than Conventional Thyroidectomy

Introduction&#x0D; Aim of this study was to evaluate our results from conventional and minimally invasive thyroidectomy and compare their outcomes.&#x0D; Materials and Methods&#x0D; 137 patients undergone conventional and minimally invasive thyroidectomy (video-assisted and open technique with mini-cervicotomy) were reviewed. Demographic data, blood loss, operative time, postoperative pain, cosmetic outcome and complications were examined and compared.&#x0D; Results&#x0D; Minimally invasive group consists of 53 cases(39%) and conventional group is composed of 84 cases(61%). No conversion from minimally invasive to conventional techniques was observed. In minimally invasive group, 25 patients(47%) had differantiated thyroid carcinoma and 28 patients(53%) had benign pathologies. Postoperative complications include transient hypocalcemia in 5 patients(3.6%) (4 in conventional, 1 in minimally invasive group), permanent hypocalcemia in 4 patients(3%) (3 in conventional, 1 in minimally invasive group), unilateral vocal cord paralysis in 2 patients(2%) (1 in conventional, 1 in minimally invasive group). Operative time was similar in both groups; however blood loss during surgery, postoperative pain was significantly lower in minimally invasive group.&#x0D; Conclusion&#x0D; Minimally invasive techniques could be implemented on selected carcinoma patients and results in equal safety and less surgical morbidity.&#x0D; Keywords: minimally invasive thyroidectomy, thyroid cancer, MIVAT

Merits of harmonic scalpel over conventional hemostasis in open thyroid surgery: a randomised controlled trial

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The pioneers of thyroid surgery, Theodor Kocher and Theodor Billroth, developed an acceptable technique of standardized thyroid surgery between 1873 and 1883. The aim of this prospective randomized trial was to evaluate the efficacy and safety of harmonic scalpel use compared with conventional haemostasis in open thyroid surgery.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total of 60 consecutive patients underwent open total thyroidectomy were randomized into two groups. Group A with harmonic scalpel and Group B with electrocautery with 30 patients each. Factors including age, sex, pathology, thyroid volume, haemostatic technique, operative time, drainage volume, thyroid weight, postoperative pain, postoperative complications and hospital stay. The results were analysed using the students t-test and x&lt;sup&gt;2&lt;/sup&gt;.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; No significant difference was found between the two groups concerning mean thyroid weight and mean hospital stay. The mean operative time was shorter in the harmonic scalpel group. The total fluid drainage fluid volume was lower in Harmonic scalpel group shorter in. Harmonic scalpel group experienced significantly less post-operative pain at 24 and 48 hours.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; In patients undergoing thyroidectomy, harmonic scalpel is a reliable and safe tool. AS compared with conventional haemostasis techniques, its use reduces operative times, post-operative pain, drainage volume and transient hypocalcemia.&lt;/p&gt;

MODERN SURGICAL INTERVENTIONS IN PATIENTS WITH THYROID DISEASES

The study is based on the analysis of the results of surgical treatment of 298 patients with various diseases of the thyroid gland, who were examined and treated in the department of endocrine surgery of the City Clinical Hospital named after S. P. Botkin from 2012 to 2016. 147 (49.3%) patients of the I group were operated on using extrafascial technique with intersection of the prelaryngeal muscles and visualization of the recurrent laryngeal nerve. 151 (51.7%) patients of group II underwent extrafascial surgical interventions from reduced migratory approaches using modern, including original, methodological approaches. For the prevention of paresis of the larynx in the allocation of recurrent laryngeal nerves, microsurgical instruments and magnifying devices were used. For the prevention of postoperative hypoparathyroidism, in addition to carefully accounting for anatomical and topographic-anatomical features, a «stress-test» and a method of double visual-instrumental recording of the parathyroid gland-induced fluorescence were used. In the first group of patients with surgical treatment, the following complications were recorded: in 2 (1.4%) patients developed permanent, in 8 (5.4%) transient postoperative hypoparathyroidism, and in 3 (2.0%) - temporary unilateral laryngeal paresis. The overall incidence of operative complications was 8.8% (13 patients). In the postoperative period, the following complications were recorded in group II: 2 (1.3%) patients developed transient hypocalcemia, and 1 (0.7%) patient had unilateral laryngeal paresis. The overall incidence of operative complications was 1.99% (3 patients). Analysis of the cosmetic result of the intervention, assessed on the POSAS scale, showed that cosmetic effect was better in group II (p 0.05). Thus, modern surgical interventions in patients with thyroid diseases, including new methodological approaches, have improved the results of surgical treatment with a decrease of the number of complications and achieving a better cosmetic effect of the surgical intervention.

Safety and Cost-effectiveness of LigaSure® in Total Thyroidectomy in Comparison with Conventional Suture Tie Technique.

Introduction: Total thyroidectomy has been considered to be a treatment of choice for thyroid malignancies. It has recently gained popularity as gold standard for benign thyroid disorders requiring surgical treatment. Because of higher number of complications associated with total thyroidectomy, it is still considered an adventurous endeavor. Most important improvements in thyroid surgery include laparoscopic thyroidectomy, energy based devices (EBD) like Harmonic Focus® and LigaSure® for dissection and hemostasis, intraoperative neuromonitoring, and parathyroid hormone (PTH) assay technology.Aim of Study: Recent studies have suggested that despite lesser complication rates with LigaSure dissection method in total thyroidectomy, it is associated with prolonged operation time. Aim of our study was to compare conventional suture tie technique and LigaSure thyroidectomy, in terms of perioperative complications including bleeding, recurrent laryngeal nerve (RLN) injury, postoperative hematoma, hypocalcemia, operation time, and cost-effectiveness. Results: This is a retrospective descriptive study done at Shifa Internationall Hospital/Shifa College of Medicine/Shifa Tameer e’ Millat University, Islamabad, Pakistan from 1st of June 2016 to 1st of June 2018. One hundred and two (102) patients who underwent surgical treatment for benign thyroid diseases were included in the study. Study was done after approval from ethical committee of Shifa International Hospital/Shifa Tameer e’ Millat University. Group A included patients in whom LigaSure was used for hemostasis and dissection during total thyroidectomy. Group B included patients who underwent total thyroidectomy by traditional clamp, tie, and electrocautery method for hemostasis and dissection. Frequency of female patients in group A was 45 (88.2%) and in group B was 41 (80.3%). In group A frequency of male patients was 9 (17.6%) and in group B it was 7 (13.7%). Mean operative time in group A was significantly lower (92 ± 9.61 min) than group B (123 ± 7.96 min). Mean intraoperative blood loss in group A was estimated to be 51.73 ± 5.65 mL and 139.42 ± 7.31 mL in group B. Transient hypocalcemia was the most common complication in both the groups. In group A 6.8% (n=7) patients developed transient postoperative hypocalcemia. Three patients in group B (2.9%) had transient hypocalcemia.Conclusion: LigaSure was significantly advantageous over conventional technique in reducing risk of complications and operation time as well as perioperative and postoperative blood loss. The reduction of operative times resulted in decreased operating room occupancy costs but the overall cost of surgery was significantly higher in LigaSure group.

Central Compartment Nodal Bulk: A Predictor of Permanent Postoperative Hypocalcaemia.

Central compartment clearance (CCC) for Papillary thyroid cancers (PTC) is one of the factors causing postoperative hypocalcaemia. We aimed to examine determinants of this major sequela. 41 patients treated for PTCs between 2014 and 2016 were studied. Surgical details, tumour and nodal characteristics, incidence of transient, temporary and permanent hypocalcaemia were noted. Central clearance was done bilaterally in 24 (58.5%) cases, ipsilaterally in 17 (41.6%). Central nodes were involved in 26 (63.4%) cases, unilaterally in 15 (36.6%), bilaterally in 11 (26.8%). Transient hypocalcaemia developed in 10 (24.4%) cases, temporary hypocalcaemia in 6 (14.6%) cases, and permanent hypocalcaemia in 2 (4.9%) cases. 17 (41%) patients were symptomatic. 9 (21.9%) patients received intravenous calcium. The only factor consistently associated with development of hypocalcaemia of all patterns, was the presence of matted central compartment nodes (p = 0.021). Matted nodes also related to a longer length of stay (p = 0.04) and requirement of intravenous calcium (p = 0.000). Extent of CCC, nodal yield, nodal positivity, perinodal extension, number of parathyroids identified, gender or pT size were not significantly associated. Symptomatic patients did not necessarily become permanently hypocalcaemic (p = 0.8). Patients requiring intravenous calcium were more likely to take oral calcium after discharge (p = 0.002). Postoperative hypocalcaemia is more likely in cases with bulky involved central nodes where extensive clearance is done. In routine CCC, even if done bilaterally, preservation of parathyroid function is possible. Permanent hypocalcaemia after CCC need not be taken as inevitable.

Repeated epistaxis caused by primary hyperparathyroidism with multiple brown tumors: One case report

To report the clinical, imaging and pathological feature of a case of primary hyperparathyroidism(PHPT) with multiple brown tumors whose complain was repeated epistaxis, and to conduct a retrospective analysis with relevant literatures. A postmenopausal middle-aged woman, with a history of joint pain, fracture, and kidney stone which were neglected due to the lack of specificity of symptoms for years, went to hospital due to repeated epistaxis. Laboratory results showed high blood calcium, hypophosphatemia, alkaline phosphatase(ALP), and parathyroid hormone(PTH) levels, as well as increased urinary calcium. Imaging examination showed systemically multiple brown tumors and extensive osteoporosis. Meanwhile an abnormal mass was found behind the right thyroid. Taking all findings into account, the diagnosis was made with PHPT, and the histopathology further confirmed that the lesion was a parathyroid adenoma. This case seems to be a rare case of multiple brown tumor caused by parathyroid adenoma, which compressed and destructed nasal blood vessels, thus induced a repeated nasal discharge. After resection of parathyroid adenoma, the patient experienced a transient hypocalcemia and PTH level elevation. After 5-month follow up, part of the brown tumors spontaneously regressed, bone density increased, and her clinical symptoms were mostly relieved. Key words: Primary hyperparathyroidism; Parathyroid adenoma; Brown tumor; Epistaxis

Comparison between Magnification Techniques and Direct Vision in Thyroid Surgery: A Systematic Review and Meta-Analysis.

Background and Objectives: The most common complications after conventional thyroid surgery in adult patients are recurrent laryngeal nerve (RLN) injury and hypocalcemia. Magnification techniques (surgical loupes or surgical microscope) are used for identification of RLN and parathyroid glands to diminish these complications although more evidence is necessary to assess their safety and efficacy in comparison with direct vision. Methods and Materials: Electronic databases (Pubmed, Cochrane Library, Scopus) as well as gray literature sources were searched for randomized controlled trials (RCTs) comparing the frequency of transient/permanent RLN injury and hypocalcemia after thyroid surgery by using magnification techniques and direct vision for identification of RLN and parathyroid glands until October 17, 2019. The main outcomes were transient/permanent RLN injury and hypocalcemia. For all outcomes, 95% confidence intervals (95% CI) were used. Statistical analysis was performed with RevMan 5.3. Results: Systematic review and meta-analysis included 3 RCTs with 437 patients overall. Magnification techniques did not significantly affect the risk of occurrence of transient RLN injury (OR = 0.38, 95% CI (0.11–1.35), I2 = 0%) and transient hypocalcemia (OR = 0.31, 95% CI (0.09–1.09), I2 = 23%) compared with direct vision. Included RCTs demonstrated only two patients with permanent hypocalcemia and another one with permanent RLN injury, who belonged to the direct vision group. Conclusion: The use of magnification techniques for identification of RLN and parathyroid glands seems to be as safe as direct vision. However, they do not decrease the risk of RLN injury and transient hypocalcemia after thyroid surgery compared with direct vision. Finally, further prospective research should be conducted as the sample among the studies was small.

Multidisciplinary Management of Intrathoracic Goiter: A Case Report

Introduction: Intrathoracic goiters are associated with compression of nearby structures, triggering severe compressive symptoms. Total thyroidectomy is the gold standard to treat these cases. Case Presentation: A patient with a huge intrathoracic goiter suffering from compressive symptoms underwent a thorough clinical, functional and imaging assessment and underwent total thyroidectomy in an Endocrino-Metabolic surgical referral center; after the surgery she suffered from transient hypocalcaemia but was discharged without major complications and continued periodical endocrinological follow-up. Conclusion: Management of intra-thoracic goiter requires a multidisciplinary approach of a skilled team both pre, during and after surgery to maximize the safety and efficacy of the procedure and reduce or promptly manage surgical or medical complications.

Role of perioperative calcium and vitamin D supplementation in prevention of hypocalcemia after total thyroidectomy

Background: Thyroid surgery is one of the most frequently performed surgical procedures worldwide. Total thyroidectomy is a recommended procedure for most of the thyroid diseases. The most common complication resulting after this surgery is transient hypocalcemia - the incidence is 24% - which increases the morbidity rate and increases the length of stay in the hospital. Objective: The aim of the present randomized controlled trial was to ascertain the usefulness of pre- and post-operative calcium and Vitamin D supplementation in prevention of hypocalcemia after total thyroidectomy. Materials and Methods: It was a prospective randomized controlled study conducted at Department of Surgery, Derna Teaching Hospital, Libya from February 2018 to august 2019. A total of 100 patients of both genders undergoing total thyroidectomy were included in the study, Patients undergoing reoperation for thyroid disease, American Society of Anesthesiologists (ASA) grade 3 or above, patients with chronic renal failure were excluded. The patients were sorted into two groups by lottery method; Group 1 received oral calcium (500 mg every 6 h) and Vitamin D (calcitriol 0.25 mcg every 6 h) 3 days before and 7 days after the surgery; and Group 2 did not receive supplementation. Total thyroidectomy was done and Calcium profile was measured pre- and post-operatively at 6, 12, 24, 48, 72 h, and on 30th day. Hypocalcemia after surgery was either symptomatic or laboratory documented. Serum calcium level ≤ 8.5 mg/dl was considered as laboratory hypocalcemia. The final outcome was measured at one month. Data was analyzed via the Statistical Package for Social Sciences version 22.0 (IBM Corp, Armonk, NY, USA). P value ≤ 0.05 was considered significant.Results: More patients from Group 2 than patients from Group 1 developed symptomatic hypocalcemia (P < 0.01) clearly at 48h and 72h times. Laboratory hypocalcemia within postoperative 24 h was comparable between two groups, but more patients of Group 2 compared to Group 1 developed hypocalcemia at 48 h (10 and 21 respectively; P = 0.04) and at 72 h after surgery (13 and 23 respectively; P = 0.01). Preoperative serum calcium was only independent variable significantly associated with development of 24 h post-operative hypocalcemia.Conclusion: Routine pre- and post-TT calcium and Vitamin D supplementation can significantly reduce postoperative hypocalcemia. Which ultimately can also decrease prolonged hospitalization of patients and costs associated with multiple blood sampling.