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      Protocol for management after thyroidectomy: a retrospective study based on one-center experience

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          Abstract

          Background and aim

          The optimal approach to detect and treat symptomatic hypocalcemia (SxH) after thyroidectomy is still uncertain. In our retrospective study, we sought to set a standardized postoperative management protocol on the basis of relative change of parathyroid hormone (PTH) and absolute value of postoperative day 1 (POD1) PTH.

          Methods

          Patients who underwent thyroidectomy were identified retrospectively in our prospective database. Blood was collected 1 day before surgery and on POD1. Extra calcium and calcitriol supplement was prescribed when necessary. Meanwhile, postoperative signs of SxH were treated and recorded in detail. Patients were followed up for 1 month after surgery and then 3 months thereafter.

          Results

          A total of 744 patients were included in the final analysis. Transient SxH occurred in 86 (11.6%) patients, and persistent SxH occurred in 4 (0.54%) patients in more than half year after surgery. Relative decrease of PTH reached its maximal discriminative effect at 70% (area under the curve [AUC] =0.754), with a sensitivity of 72.1% and a specificity of 75%. In Group 1 (≤70%), 24 (4.67%) patients were interpreted as having SxH, whereas in Group 2, 62 (27.0%) patients had SxH (>70%), P<0.001. Days of symptom relief in Group 1–1 (1, 2) were significantly shorter than those in Group 2–2 (1, 10), P=0.023. In Group 2, 112 (80%) patients with POD1 PTH <1 pmol/L were treated with calcitriol, whereas only 8 (8.89%) patients with POD1 PTH ≥1 pmol/L were treated with calcitriol ( P<0.001). According to relief of SxH and recovery of parathyroid function, treating with and without calcitriol showed no difference in patients with POD1 PTH <1 and ≥1 pmol/L.

          Conclusion

          Relative decrease of PTH >70% is a significant risk factor for SxH in post-thyroidectomy. The decreasing percent of PTH ≤70% ensures discharge on POD1, but longer hospitalization was advocated for patients with decreasing percent of PTH >70%, who needed extra calcitriol supplement when POD1 PTH <1 pmol/L.

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          Most cited references 19

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          Hypocalcemia following thyroid surgery: incidence and prediction of outcome.

          Postoperative hypocalcemia is a common and most often transient event after extensive thyroid surgery. It may reveal iatrogenic injury to the parathyroid glands and permanent hypoparathyroidism. We prospectively evaluated the incidence of hypocalcemia and permanent hypoparathyroidism following total or subtotal thyroidectomy in 1071 consecutive patients operated during 1990-1991. We then determined in a cross-sectional study which early clinical and biochemical characteristics of patients experiencing postoperative hypocalcemia correlated with the long-term outcome. Postoperative calcemia under 2 mmol/l was observed in 58 patients (5. 4%). In 40 patients hypocalcemia was considered severe (confirmed for more than 2 days, symptomatic or both). At 1 year after surgery five patients (0.5%) had persistent hypocalcemia. We found that patients carried a high risk for permanent hypoparathyroidism if fewer than three parathyroid glands were preserved in situ during surgery or the early serum parathyroid hormone level was /= 4 mg/dl under oral calcium therapy. When one or more of these criteria are present, long-term follow-up should be enforced to check for chronic hypocalcemia and to avoid its severe complications by appropriate supplement therapy.
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            Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient.

            Surgery of the thyroid takes place in an area of complicated anatomy and in which a number of vital physiologic functions and special senses are controlled. Thyroidectomy rarely is associated with mortality; but unless the surgeon performing it is well trained in operative surgery and is knowledgeable of the gland and its function, pathology, and anatomy, excellent results cannot be achieved. Failure to observe cardinal surgical principles may result in legal difficulties, which can be avoided. It is well to observe the principles and avoid problems. We address this issue herein.
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              Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies.

              Monitoring for hypocalcemia after thyroidectomy, using only symptoms and serum calcium levels, can delay the discharge of patients who will remain normocalcemic and can delay the treatment of hypocalcemic patients. We conducted a systematic search for articles describing use of parathyroid hormone (PTH) assay, checked within hours of completing thyroidectomy, to predict postoperative symptomatic hypocalcemia. Studies were excluded if all patients were treated with postoperative calcium, or if early PTH values were used to alter management of the patient. Individual patient data (perioperative PTH and calcium levels, development of hypocalcemia) were obtained for 457 patients from the corresponding authors of 9 studies and pooled to yield the following results. PTH, checked at three time periods after removal of the thyroid gland (0 to 20 minutes, 1 to 2 hours, and 6 hours), was substantially lower in patients who became hypocalcemic compared with those who remained normocalcemic. The accuracy of PTH in determining hypocalcemia increased with time and was excellent when checked 1 to 6 hours postoperatively. A single PTH threshold (65% decrease compared with preoperative level), checked 6 hours after completing thyroidectomy, had a sensitivity of 96.4% and specificity of 91.4% in detecting postoperative hypocalcemia. PTH assay, when checked 1 to 6 hours after thyroidectomy, has excellent accuracy in determining which patients will become symptomatically hypocalcemic. Routine use of this assay should be considered because it may allow earlier discharge of the normocalcemic patient and earlier identification of patients requiring treatment of postthyroidectomy hypocalcemia.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2017
                15 May 2017
                : 13
                : 635-641
                Affiliations
                [1 ]Thyroid & Breast Surgery
                [2 ]Nephrology
                [3 ]Biostatistics Center, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
                Author notes
                Correspondence: Jingqiang Zhu, West China Hospital, Guoxue Alley 37≤, Chengdu, Sichuan 610041, People’s Republic of China, Tel/fax +86 28 8542 2467, Email zjq-wkys@ 123456163.com
                Article
                tcrm-13-635
                10.2147/TCRM.S129910
                5437971
                © 2017 Luo et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

                Medicine

                parathyroid hormone, pth, relative change, thyroidectomy, calcitriol, discharge

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