Advances in Clinical and Experimental Medicine

Adv Clin Exp Med
Impact Factor (IF) – 1.514
Index Copernicus (ICV 2018) – 157.72
MNiSW – 40
Average rejection rate – 84.38%
ISSN 1899–5276 (print)
ISSN 2451-2680 (online)
Periodicity – monthly

Download PDF

Advances in Clinical and Experimental Medicine

2013, vol. 22, nr 5, September-October, p. 675–682

Publication type: original article

Language: English

Clinical and Biochemical Factors Affecting Postoperative Hypocalcemia After Near-Total Thyroidectomy

Czynniki kliniczne oraz biochemiczne wpływające na pooperacyjną hipokalcemię po prawie całkowitej tyroidektomii

Maciej Sebastian1,A,B,C,D,E,F,G, Jerzy Rudnicki1,A,B,C,D,E,F,G, Witold Jakubaszko1,A,B,C,D,E,F,G, Dorota Zyśko2,A,B,C,D,E,F,G, Anil Kumar Agrawal3,A,B,C,D,E,F,G, Agata Sebastian4,A,B,C,D,E,F,G

1 Department of Minimally Invasive Surgery and Proctology, Wroclaw Medical University, Poland

2 Teaching Department for Emergency Medical Services, Wroclaw Medical University, Poland

3 2nd Department and Clinic of General and Oncological Surgery, Wroclaw Medical University, Poland

4 Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland

Abstract

Background. The most common complication which occurs after thyroidectomy is postoperative hypocalcemia due to parathyroid gland damage. It usually appears 24–48 hours postoperatively, but there are clinical and biochemical factors which may contribute to its earlier diagnosis.
Objectives. The aim of this study was to assess clinical and biochemical factors which can influence postoperative hypocalcemia after near-total thyroidectomy.
Material and Methods. The material consisted of 103 patients with benign nodular goiter. In all patients the blood samples were taken 4 times and levels of total calcium, magnesium, inorganic phosphorus, parathormone and thyroid-stimulating hormone were measured. One day before surgery and during the first three days postoperatively patients were asked about symptoms of hypocalcemia and the presence or absence of a Trousseau sign was observed.
Results. There was no statistically significant connection between the symptoms of hypocalcemia and the age of patients and preoperative hyperthyroidism. Patients with symptomatic hypocalcemia had longer operating time, resected tissue weighed more and hospitalization time was longer than in patients without symptoms of hypocalcemia. Concomitant occurrence of hypocalcemia and hypomagnesemia postoperatively was found in 16% of patients. Changes in parathyroid hormone concentration measured 10 min after thyroid excision were more sensitive and specific for detecting patients with symptomatic hypocalcemia after surgery than total calcium concentration.
Conclusion. Measurement of intraoperative parathormone level 10 min after thyroidectomy is a highly sensitive and specific factor for detecting postoperative hypocalcemia. If we connect this parameter with some other clinical features, it will be possible to predict postoperative hypocalcemia more accurately and introduce supplementation as early as possible.

Streszczenie

Wprowadzenie.Najczęściej występującym powikłaniem po tyroidektomii jest pooperacyjna hipokalcemia wskutek zniszczenia gruczołów przytarczycznych. Pojawia się zwykle 24–48 godzin po zabiegu chirurgicznym, istnieją jednak kliniczne oraz biochemiczne czynniki mogące prowadzić do jej wcześniejszego rozpoznania.
Cel pracy. Określenie czynników klinicznych oraz biochemicznych mających wpływ na pojawienie się hipokalcemii po prawie całkowitej tyroidektomii.
Materiał i metody. Analizie poddano 103 pacjentów z łagodnym wolem guzkowym. U wszystkich badanych osób pobrano 4-krotnie krew i oznaczono stężenie wapnia całkowitego, magnezu, fosforu nieorganicznego, parathormonu oraz hormonu tyreotropowego. Jeden dzień przed zabiegiem chirurgicznym oraz przez 3 kolejne dni po zabiegu pacjenci byli pytani o obecność objawów hipokalcemii oraz wykonano próbę Trousseau.
Wyniki. Nie stwierdzono statystycznie istotnej zależności między wystąpieniem objawów hipokalcemii a wiekiem pacjentów i przedoperacyjnie rozpoznaną nadczynnością tarczycy. U pacjentów z objawową hipokalcemią zabieg chirurgiczny trwał dłużej, usunięta tkanka ważyła więcej i czas hospitalizacji był dłuższy niż u pacjentów bez objawów hipokalcemii. Jednoczesne występowanie hipokalcemii i hipomagnezemii w okresie pooperacyjnym stwierdzono u 16% pacjentów. Zmiany w stężeniu parathormonu, stwierdzone 10 min po usunięciu tarczycy, były bardziej czułe i swoiste dla wykrycia pacjentów z objawową hipokalcemią niż zmiany w stężeniu wapnia całkowitego.
Wnioski. Śródoperacyjne oznaczanie parathormonu 10 min po usunięciu tarczycy jest wysoce czułym i swoistym czynnikiem dla wykrycia pooperacyjnej hipokalcemii. Jeśli połączy się to oznaczenie z innymi czynnikami klinicznymi, będzie możliwe dokładniejsze przewidywanie wystąpienia pooperacyjnej hipokalcemii i jak najszybsze włączenie suplementacji.

Key words

hypocalcemia, hypomagnesemia, parathyroid glands, thyroidectomy, hypoparathyroidism.

Słowa kluczowe

hipokalcemia, hipomagnezemia, gruczoły przytarczyczne, tyroidektomia, niedoczynność gruczołów przytarczycznych.

References (30)

  1. Nahas ZS, Farrag TY, Lin FR, Belin RM, Tufano RP: A safe and cost-effective short hospital stay protocol to identify patients at low risk for the development of significant hypocalcemia after total thyroidectomy. Laryngoscope 2006, 116, 906–910.
  2. Lindblom P, Westerdahl J, Bergenfelz A: Low parathyroid hormone levels after thyroid surgery: a feasible predictor of hypocalcemia. Surgery 2002, 131, 515–520.
  3. AES Guidelines 06/01 Group: Australian Endocrine Surgeons Guidelines AES06/01. Postoperative parathyroid hormone measurement and early discharge after total thyroidectomy: analysis of Australian data and management recommendations. ANZ J Surg 2007, 77, 199–202.
  4. Erbil Y, Barbaros U, Salmaslioğlu A, Yanik BT, Bozbora A, Ozarmağan S: The advantage of near-total thyroidectomy to avoid postoperative hypoparathyroidism in benign multinodular goiter. Langenbecks Arch Surg 2006, 391, 567–573.
  5. Bradley TJ, Metzger DL, Sanatani S: Long on Q–T and low on calcium. Cardiol Young 2004, 14, 667–670.
  6. Güllüoğlu BM, Manukyan MN, Cingi A, Yeğen C, Yalin R, Aktan AO: Early prediction of normocalcemia after thyroid surgery. World J Surg 2005, 29, 1288–1293.
  7. Moore FD Jr: Oral calcium supplements to enhance early hospital discharge after bilateral surgical treatment of the thyroid gland or exploration of the parathyroid glands. J Am Coll Surg 1994, 178, 11–16.
  8. Kihara M, Yokomise H, Miyauchi A, Matsusaka K: Recovery of parathyroid function after total thyroidectomy. Surg Today 2000, 30, 333–338.
  9. Payne RJ, Hier MP, Tamilia M, Mac Namara E, Young J, Black MJ: Same-day discharge after total thyroidectomy: the value of 6-hour serum parathyroid hormone and calcium levels. Head Neck 2005, 27, 1–7.
  10. Erbil Y, Barbaros U, Temel B, Turkoglu U, Işsever H, Bozbora A, Ozarmağan S, Tezelman S: The impact of age, vitamin D3 level and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy. Am J Surg 2009, 197, 439–446.
  11. Acun Z, Comert M, Cihan A, Ulukent SC, Ucan B, Cakmak GK: Near-total thyroidectomy could be the best treatment for thyroid disease in endemic regions. Arch Surg 2004, 139, 444–447.
  12. Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, Pelizzo MR, Pezzullo L: Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg 2004, 28, 271–276.
  13. Järhult J, Andersson PO, Duncker L: Alternating from subtotal thyroid resection to total thyroidectomy in the treatment of Graves’ disease prevents recurrences but increases the frequency of permanent hypoparathyroidism. Langenbecks Arch Surg 2006, 391, 567–573.
  14. Kara M, Tellioglu G, Krand O, Fersahoglu T, Berber I, Erdogdu E, Ozel L, Titiz MI: Predictors of hypocalcemia occurring after a total/near total thyroidectomy. Surg Today 2009, 39, 752–757.
  15. Di Fabio F, Casella C, Bugari G, Iacobello C, Salerni B: Identification of patients at low risk for thyroidectomyrelated hypocalcemia by intraoperative quick PTH. World J Surg 2006, 30, 1428–1433.
  16. Sakorafas GH, Stafyla V, Bramis C, Kotsifopoulos N, Kolettis T, Kassaras G: Incidental parathyroidectomy during thyroid surgery: an underappreciated complication of thyroidectomy. World J Surg 2005, 29, 1539–1543.
  17. McHenry CR, Speroff T, Wentworth D, Murphy T: Risk factors for postthyroidectomy hypocalcemia. Surgery 1994, 116, 641–647.
  18. Barczyński M, Cichoń S, Konturek A: Which criterion of intraoperative iPTH assay is the most accurate in prediction of true serum calcium levels after thyroid surgery? Langenbecks Arch Surg 2007, 392, 693–698.
  19. Simsek Celik A, Erdem H, Guzey D, Celebi F, Celik A, Birol S, Kaplan R: The factors related with postoperative complications in benign nodular thyroid surgery. Indian J Surg 2011, 73, 32–36.
  20. Dogan L, Karaman N, Yilmaz KB, Ozaslan C, Atalay C: Total thyroidectomy for the surgical treatment of multinodular goiter. Surg Today 2011, 41, 323–327.
  21. Proczko-Markuszewska M, Kobiela J, Stefaniak T, Łachiński AJ, Śledziński Z: Postoperative PTH measurement as predictor of hypocalcaemia after thyroidectomy. Pol Przegl Chir 2010, 82, 24–28.
  22. Glinoer D, Andry G, Chantrain G, Samil N: Clinical aspects of early and late hypocalcaemia after thyroid surgery. Eur J Surg Oncol 2000, 26, 71–77.
  23. Higgins KM, Mandell DL, Govindaraj S, Genden EM, Mechanick JI, Bergman DA, Diamond EJ, Urken ML: The role of intraoperative rapid parathyroid hormone monitoring for predicting thyroidectomy-related hypocalcemia. Arch Otolaryngol Head Neck Surg 2004, 130, 63–67.
  24. Kuhel WI, Carew JF: Parathyroid biopsy to facilitate the preservation of functional parathyroid tissue during thyroidectomy. Head Neck 1999, 21, 442–446.
  25. Wiseman JE, Mossanen M, Ituarte PH, Bath JM, Yeh MW: An algorithm informed by the parathyroid hormone level reduces hypocalcemic complications of thyroidectomy. World J Surg 2010, 34, 532–537.
  26. Youngwirth L, Benavidez J, Sippel R, Chen H: Postoperative parathyroid hormone testing decreases symptomatic hypocalcemia and associated emergency room visits after total thyroidectomy. Surgery 2010, 148, 841–844.
  27. Lim JP, Irvine R, Bugis S, Holmes D, Wiseman SM: Intact parathyroid hormone measurement 1 hour after thyroid surgery identifies individuals at high risk for the development of symptomatic hypocalcemia. Am J Surg 2009, 197, 648–653.
  28. Richards ML, Bingener-Casey J, Pierce D, Strodel WE, Sirinek KR: Intraoperative parathyroid hormone assay: an accurate predictor of symptomatic hypocalcemia following thyroidectomy. Arch Surg 2003, 138, 632–635.
  29. Quiros RM, Pesce CE, Wilhelm SM, Djuricin G, Prinz RA: Intraoperative parathyroid hormone levels in thyroid surgery are predictive of postoperative hypoparathyroidism and need for vitamin D supplementation. Am J Surg 2005, 189, 306–309.
  30. Wilson RB, Erskine C, Crowe PJ: Hypomagnesemia and hypocalcemia after thyroidectomy: prospective study. World J Surg 2000, 24, 722–726.