Predictors of postoperative hypocalcemia occurring after a total thyroidectomy: results of prospective multicenter study

Vitalijus Eismontas, Algirdas Slepavicius, Vinsas Janusonis, Paulius Zeromskas, Virgilijus Beisa, Kestutis Strupas, Zilvinas Dambrauskas, Antanas Gulbinas, Arvydas Martinkenas, Vitalijus Eismontas, Algirdas Slepavicius, Vinsas Janusonis, Paulius Zeromskas, Virgilijus Beisa, Kestutis Strupas, Zilvinas Dambrauskas, Antanas Gulbinas, Arvydas Martinkenas

Abstract

Background: Thyroid surgeries are among the most common operations performed in the world. Hypocalcemia following total thyroidectomy is a common complication that is sometimes difficult to correct. The aim of this study is to determine the risk factors for hypocalcemia following total thyroidectomy and their clinical value.

Methods: From January 2015 through to April 2017, 400 patients were included in this prospective multicenter study. All patients underwent total thyroidectomy due to various thyroid diseases. The following risk factors were analyzed: pre-operative and post-operative biochemical blood parameters, clinical effects and factors related to surgery, the patient, and the disease.

Results: Post-operative hypocalcemia developed in 257 patients (64.2%). Of them, 197 patients (76.7%) were diagnosed with asymptomatic hypocalcemia. Clinical symptoms were present in 60 of the 257 patients with hypocalcemia (23.3%). The statistically significant predictors of hypocalcemia were decreased calcium and ionized calcium pre-operatively (p < 0.001), parathyroid hormone on day one following surgery (p < 0.001), thyrotoxicosis <10 years before surgery (odds ratio 1.65, 95% CI 1.01-2.70, p = 0.046), the number of parathyroid glands found during surgery (odds ratio 0.52, 95% CI 0.38-0.70, p < 0.001), ligation of the trunk of the left inferior thyroid artery (odds ratio 2.04, 95% CI 1.27-3.29, p = 0.003), ligation of the trunk of the right inferior thyroid artery (odds ratio 2.37, 95% CI 1.47-3.81, p < 0.001), and the number of transplanted parathyroid glands (odds ratio 1.87, 95% CI 1.12-2.97, p = 0.015). In the multivariate analysis, age (odds ratio 1.05, 95% CI 1.01-1.09, p = 0.029) and gender (odds ratio 5.94, 95% CI 1.13-31.26, p = 0.035) were statistically significant predictors.

Conclusions: This study demonstrates that there is a number of different patient (gender, age, and duration of thyrotoxicosis <10 years before surgery) and surgical (number of parathyroid glands found during surgery, decreased calcium and ionized calcium before surgery, parathyroid hormone on day one following surgery, and ligation of the trunk of the left and right inferior thyroid artery) risk factors predictive of hypocalcemia following total thyroidectomy. Optimization of the surgical technique could possibly prevent the occurrence of hypocalcemia after total thyroidectomy in some cases; in other cases, identification of known risk factors post-operatively could permit early detection and effective treatment of these patients.

Keywords: Hypocalcemia; Predictors; Thyroid surgery; Total thyroidectomy.

Conflict of interest statement

This study was approved by Lithuanian Bioethics Committee (2014-12-02 No.: L-14-09/1, No.: L-14-09/2). Informed consent was obtained from all individual participants included in the study. The informed consent was in written.

Consent for publication was obtained from all individual participants included in the study. Consent for publication was in written.

The authors declare that they have no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Karamanakos SN, Markuo KB, Panagoppulos K, Karavias D, Vagianos CE, Scopa CD, et al. Complications and risk factors related to the extent of surgery in thyroidectomy-results from 2,043 procedures. Hormones. 2010;9:318–325. doi: 10.14310/horm.2002.1283.
    1. Ho TW, Shaheen AA, Dixon E, Harvey A. Utilization of thyroidectomy for benign disease in the United States: a 15-year population-based study. Am J Surg. 2011;201:570–574. doi: 10.1016/j.amjsurg.2010.12.006.
    1. Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, et al. 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. doi: 10.1007/s00268-003-6903-1.
    1. Wilson RB, Erskine C, Crowe PJ. Hypomagnesemia and hypocalcemia after thyroidectomy: a prospective study. World J Surg. 2000;24:722–726. doi: 10.1007/s002689910116.
    1. Jacobs JK, Aland JW, Jr, Ballinger JF. Total thyroidectomy. A review of 213 patients. Ann Surg. 1983;197:542–549. doi: 10.1097/00000658-198305000-00007.
    1. Reeve T, Thompson NW. Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg. 2000;24:971–975. doi: 10.1007/s002680010160.
    1. D’Ajello F, Cirocchi R, Docimo G, Catania A, Ardito G, Rosato L, et al. Thyroidectomy with ultrasonic dissector: a multicentric experience. G Chir. 2010;31(6–7):289–292.
    1. Stack BC, Bimston DN, Bodenner DL, Brett EM, Dralle H, Orloff LA, et al. AACE/ACE disease state clinical review: postoperative hypoparathyroidism - definitions and management. Endocr Pract. 2015;21(6):674–685. doi: 10.4158/EP14462.DSC.
    1. Edafe O, Antakis R, Laskar N, Uttley L, Balasubramanian SP. Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. Br J Surg. 2014;101(4):307–320. doi: 10.1002/bjs.9384.
    1. Demeester-Mirkine N, Hooghe L, Van Geertruyden J, De Maetelaer V. Hypocalcemia after thyroidectomy. Arch Surg. 1992;127:854–858. doi: 10.1001/archsurg.1992.01420070118021.
    1. Lemaire FX, Debruyne F, Delaere P, Vander Porten V. Parathyroid function in the early postoperative period after thyroidectomy. Acta Otorhinolaryngol Belg. 2001;55:187–197.
    1. Lang BH, Yih PC, Ng KK. A prospective evaluation of quick intraoperative parathyroid hormone assay at the time of skin closure in predicting clinically relevant hypocalcemia after thyroidectomy. World J Surg. 2012;36:1300–1306. doi: 10.1007/s00268-012-1561-9.
    1. Ali S, Yu C, Palmer FL, Ganly I, Shaha A, Shah JP, et al. Nomogram to aid selection of patients for short-stay thyroidectomy based on risk of postoperative hypocalcemia. Arch Otolaryngol Head Neck Surg. 2011;137:1154–1160. doi: 10.1001/archoto.2011.189.
    1. Amir A, Sands NB, Tamilia M, Hier MP, Black MJ, Payne RJ. Preoperative serum calcium levels as an indicator of postthyroidectomy hypocalcemia. J Otolaryngol Head Neck Surg. 2010;39:654–658.
    1. Yamashita H, Noguchi S, Tahara K, Watanabe S, Uchino S, Kawamoto H, et al. Postoperative tetany in patients with graves’ disease: a risk factor analysis. Clin Endocrinol. 1997;47:71–77. doi: 10.1046/j.1365-2265.1997.2201033.x.
    1. Gentileschi P, Gacek IA, Manzelli A, Cascarella G, Sileri P, Lirosi F, et al. Early (1 hour) post-operative parathyroid hormone (PTH) measurement predicts hypocalcaemia after thyroidectomy: a prospective case-control single-institution study. Chir Ital. 2008;60:519–528.
    1. Moriyama T, Yamashita H, Noguchi S, Takamatsu Y, Ogawa T, Watanabe S, et al. Intraoperative parathyroid hormone assay in patients with graves’ disease for prediction of postoperative tetany. World J Surg. 2005;29:1282–1287. doi: 10.1007/s00268-005-7880-3.
    1. Sitges-Serra A, Ruiz S, Girvent M, Manjón H, Dueñas JP, Sancho JJ. Outcome of protracted hypoparathyroidism after total thyroidectomy. Br J Surg. 2010;97:1687–1695. doi: 10.1002/bjs.7219.
    1. Kamer E, Unalp HR, Erbil Y, Akguner T, Issever H, Tarcan E. Early prediction of hypocalcemia after thyroidectomy by parathormone measurement in surgical site irrigation fluid. Int J Surg. 2009;7:466–471. doi: 10.1016/j.ijsu.2009.07.006.
    1. Erbil Y, Barbaros U, Temel B, Turkoglu U, Issever H, Bozbora A, et al. The impact of age, vitamin D(3) level, and incidental parathyroidectomy on. Am J Surg. 2009;197:439–446. doi: 10.1016/j.amjsurg.2008.01.032.
    1. Erbil Y, Bozbora A, Ozbey N, Issever H, Aral F, Ozarmagan S, et al. Predictive value of age and serum parathormone and vitamin D3 levels for postoperative hypocalcemia after total thyroidectomy for nontoxic multinodular goiter. Arch Surg. 2007;142:1182–1187. doi: 10.1001/archsurg.142.12.1182.
    1. Walsh SR, Kumar B, Coveney EC. Serum calcium slope predicts hypocalcaemia following thyroid surgery. Int J Surg. 2007;5:41–44. doi: 10.1016/j.ijsu.2006.03.006.
    1. Yamashita H, Murakami T, Noguchi S, Shiiba M, Watanabe S, Uchino S, et al. Postoperative tetany in graves disease: important role of vitamin D metabolites. Ann Surg. 1999;229:237–245. doi: 10.1097/00000658-199902000-00012.
    1. Luu Q, Andersen PE, Adams J, Wax MK, Cohen JI. The predictive value of perioperative calcium levels after thyroid/parathyroid surgery. Head Neck. 2002;24:63–67. doi: 10.1002/hed.10013.
    1. Hallgrimsson P, Nordenström E, Almquist M, Bergenfelz AO. Risk factors for medically treated hypocalcemia after surgery for graves’ disease: a Swedish multicenter study of 1,157 patients. World J Surg. 2012;36:1933–1942. doi: 10.1007/s00268-012-1574-4.
    1. Díez Alonso M, Sánchez López JD, Sánchez-Seco Peña MI, Ratia Jimenez T, Arribas Gomez I, Rodriguez Pascual A, et al. Serum PTH levels as a predictive factor of hypocalcaemia after total thyroidectomy. Cir Esp. 2009;85:96–102. doi: 10.1016/j.ciresp.2008.09.006.
    1. Graff AT, Miller FR, Roehm CE, Prihoda TJ. Predicting hypocalcemia after total thyroidectomy: parathyroid hormone level vs. serial calcium levels. Ear Nose Throat J. 2010;89:462–465.
    1. Alia P, Moreno P, Rigo R, Francos JM, Navarro MA. Postresection parathyroid hormone and parathyroid hormone decline accurately predict hypocalcemia after thyroidectomy. Am J Clin Pathol. 2007;127:592–597. doi: 10.1309/J357LMD66E9X2505.
    1. Wong C, Price S, Scott-Coombes D. Hypocalcaemia and parathyroid hormone assay following total thyroidectomy: predicting the future. World J Surg. 2006;30:825–832. doi: 10.1007/s00268-005-0478-y.
    1. Roh JL, Park CI. Intraoperative parathyroid hormone assay for management of patients undergoing total thyroidectomy. Head Neck. 2006;28:990–997. doi: 10.1002/hed.20444.
    1. Aluffi P, Aina E, Bagnati T, Toso A, Pia F. Prognostic factors for definitive hypoparathyroidism following total thyroidectomy. Acta Otorrinolaringol Esp. 2008;59:321–324. doi: 10.1016/S0001-6519(08)75550-X.
    1. Pisanu A, Cois A, Piu S, Altana ML, Uccheddu A. Factors predicting outcome of hypocalcaemia following total thyroidectomy. Chir Ital. 2003;55:35–40.
    1. Pattou F, Combemale F, Fabre S, Carnaille B, Decoulx M, Wemeau JL, et al. Hypocalcemia following thyroid surgery: incidence and prediction of outcome. World J Surg. 1998;22:718–724. doi: 10.1007/s002689900459.
    1. Tartaglia F, Giuliani A, Sgueglia M, Patrizi G, Di Rocco G, Blasi S, et al. Is ionized calcium a reliable predictor of hypocalcemia after total thyroidectomy? A before and after study. G Chir. 2014;35(1/2):27–35.
    1. Chapman DB, French CC, Leng X, Browne JD, Waltonen JD, Sullivan CA. Parathyroid hormone early percent change: an individualized approach to predict postthyroidectomy hypocalcemia. Am J Otolaryngol. 2012;33:216–220. doi: 10.1016/j.amjoto.2011.06.004.
    1. Kovacevic B, Ignjatovic M, Cuk V, Zivaljevic V, Paunovic I. Early prediction of symptomatic hypocalcemia after total thyroidectomy. Acta Chir Belg. 2011;111:303–7.
    1. Proczko-Markuszewska M, Kobiela J, Stefaniak T, Lachiński AJ, Sledziński Z. Postoperative PTH measurement as a predictor of hypocalcaemia after thyroidectomy. Acta Chir Belg. 2010;110:40–44. doi: 10.1080/00015458.2010.11680563.
    1. Vanderlei FA, Vieira JG, Hojaij FC, Cervantes O, Kunii IS, Ohe MN, et al. Parathyroid hormone: an early predictor of symptomatic hypocalcemia after total thyroidectomy. Arq Bras Endocrinol Metabol. 2012;56:168–172. doi: 10.1590/S0004-27302012000300003.
    1. Lecerf P, Orry D, Perrodeau E, Lhommet C, Charretier C, Mor C, et al. Parathyroid hormone decline 4 hours after total thyroidectomy accurately predicts hypocalcemia. Surgery. 2012;152:863–868. doi: 10.1016/j.surg.2012.03.011.
    1. Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients. Surgery. 2003;133:180–185. doi: 10.1067/msy.2003.61.
    1. Pfleiderer AG, Ahmad N, Draper MR, Vrotsou K, Smith WK. The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies. Ann R Coll Surg Engl. 2009;91:140–146. doi: 10.1308/003588409X359349.
    1. Asari R, Passler C, Kaczirek K, Scheuba C, Niederle B. Hypoparathyroidism after total thyroidectomy: a prospective study. Arch Surg. 2008;143:132–137. doi: 10.1001/archsurg.2007.55.
    1. Promberger R, Ott J, Kober F, Mikola B, Karik M, Freissmuth M, et al. Intra- and postoperative parathyroid hormone-kinetics do not advocate for autotransplantation of discolored parathyroid glands during thyroidectomy. Thyroid. 2010;20:1371–1375. doi: 10.1089/thy.2010.0157.
    1. Serpell JW, Phan D. Safety of total thyroidectomy. ANZ J Surg. 2007;77:15–19. doi: 10.1111/j.1445-2197.2006.03897.x.
    1. Welch KC, McHenry CR. Total thyroidectomy: is morbidity higher for graves’ disease than nontoxic goiter? J Surg Res. 2011;170:96–99. doi: 10.1016/j.jss.2011.03.054.
    1. Chiang FY, Lin JC, Wu CW, Lee KW, Lu SP, Kuo WR, et al. Morbidity after total thyroidectomy for benign thyroid disease: comparison of graves’ disease and non-graves’ disease. Kaohsiung J Med Sci. 2006;22:554–559. doi: 10.1016/S1607-551X(09)70352-3.
    1. Park I, Rhu J, Woo J-W, Choi JH, Kim JS, Kim JH. Preserving parathyroid gland vasculature to reduce post-thyroidectomy hypocalcemia. World J Surg. 2016;40:1382–1389. doi: 10.1007/s00268-016-3423-3.
    1. Lee DY, Cha W, Jeong WJ, Ahn SH. Preservation of the inferior thyroidal vein reduces post-thyroidectomy hypocalcemia. Laryngoscope. 2014;124:1272–1277. doi: 10.1002/lary.24519.
    1. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg. 1998;228(3):320–330. doi: 10.1097/00000658-199809000-00005.
    1. Kandil E, Noureldine SI, Abbas A, Tufano RP. The impact of surgical volume on patient outcomes following thyroid surgery. Surgery. 2013;154(6):1346–1353. doi: 10.1016/j.surg.2013.04.068.
    1. Sands NB, Payne RJ, Cote V, Hier MP, Black MJ, Tamilia M. Female gender as a risk factor for transient post-thyroidectomy hypocalcemia. Otolaryngol Head Neck Surg. 2011;145:561–564. doi: 10.1177/0194599811414511.

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