Is Decline Rate of Intact Parathyroid Hormone Level a Reliable Criterion for Early Discharge of Patients after Total Thyroidectomy?

Document Type: Original

Authors

Department of Surgery, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Abstract

Introduction:
Parathyroid dysfunction leading to symptomatic hypocalcemia is not uncommon following a total thyroidectomy and is often associated with significant patient morbidity and a prolonged hospital stay. The current study aimed at evaluating the comparative predictive role of serum calcium and intact parathyroid hormone (iPTH) for post-thyroidectomy hypocalcemia.
 
Materials and Methods:
This prospective study was performed in 83 consecutive patients undergoing total thyroidectomy. Laboratory data such as serum calcium, vitamin D level, serum iPTH and serum phosphorus levels before surgery, postoperative calcium, and PTH levels measured after 1 and 6 hours and on the first postoperative day (1POD) were recorded.
 
Results:
Among the 83 patients, the mean (SD) age was 45.87 (12.57) years (range, 21–72 years); 70 (84.3%) patients were female. Final pathology was benign for 47 (56.6%) patients and malignant for 36 (43.4%) patients. In total, lymph node dissections were performed in 19 subjects (22.9%). On histological examination of the specimens, the parathyroid gland was found to have been removed inadvertently in 13 (15.7%) cases. In total, 35 (40.9%) patients developed hypocalcemia after thyroidectomy; receiver operating characteristic (ROC) analysis showed that a cut-off value of 15.39 pg/ml for iPTH, with a decline rate of 73% 1 hour after thyroidectomy is a significant predictor of hypocalcemia (area under the curve [AUC], 0.878; 95% confidence interval [CI], 0.79–0.96, P<0.0001) compared with calcium  
Conclusion:
The current study showed that the decline rate in iPTH is a more reliable factor for hypocalcemia after total thyroidectomy than serum calcium. Patients with a decline rate <73% in iPTH could be discharged at 1POD without supplementation.

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Main Subjects


2. Cayo AK, Yen TW, Misustin SM, Wall K, Wilson SD, et al. Predicting the need for calcium and calcitriol supplementation after total thyroidectomy: results of a prospective, randomized study. Surgery 2012;152:1059.

3. Carter Y, Chen H, Sippel RS. An intact parathyroid hormone-based protocol for the prevention and treatment of symptomatic hypocalcemia after thyroidectomy. J Surg Res 2014;186:23.

4. Alonso M, Sanchez Lopez JD, Sanchez MI, Ratia Jimenez T, Arribas Gomez I, Rodrıguez Pascual A, et al. Serum PTH levels as a predictive factor of hypocalcaemia after total thyroidectomy. Cir Esp 2009; 85:96–102.

5. 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(6):654–8.

6. Noordzij JP, Lee SL, Bernet VJ, Payne RJ, Cohen SM, McLeod IK, et al. Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies. J Am Coll Surg 2007; 205:748–54.

7. Grodski S, Serpell J. Evidence for the role of perioperative PTH measurement after total thyroidectomy as a predictor of hypocalcemia. World J Surg 2008;32(7):1367–73.

8. Del Rio P, Iapichino G, De Simone B, Bezer L, Arcuri M, Sianesi M. Is it possible to identify a risk factor condition of hypocalcemia in patients candidates to thyroidectomy for benign disease? Ann Ital Chir 2010;81: 397–401.

9. Dedivitis RA, Pfuetzenreiter EG Jr, Nardi CEM. Barbara ECD de. Prospective study of clinical and laboratorial hypocalcemia after thyroid surgery. Braz J Otorhinolaryngol 2010;76:71–7.

10. Nair CG, Babu MJ, Menon R, Jacob P. Hypocalcaemia following total thyroidectomy: an analysis of 806 patients. Indian J Endocrinol Metab 2013;17(2):298-303.

11. Tredici P, Grosso E, Gibelli B, Massaro MA, Arrigoni C, Tradati N. Identification of patients at high risk for hypocalcemia after total thyroidectomy. Acta Otorhinolaryngol Ital 2011;31:144–8.

12. 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: 841–4.

13. Falcone TE, Stein DJ, Jumaily JS, Pearce EN, Holick MF, McAneny DB, et al. Correlating preoperative vitamin D status with post thyroidectomy hypocalcemia. Endocr Pract 2015; 21(4):348-58.

14. Mirnezami R, Sahai A, Symes A, Jeddy T. Day-case and short stay surgery: the future for thyroidectomy? Int J Clin Pract 2007;61:1216–22.

15. Sam AH, Dhillo WS, Donaldson M, Meeran K, Tolley NS, Palazzo FF. Serum parathyroid hormone is not an accurate predictor of postthyroidectomy hypocalcemia in vitamin D deficient patients: a pilot study. Clin Chem 2011;57:1206–7.

16. Falcone T, Stein D, Jumaily J, Pearce E, Holick M, McAneny D, et al. Correlating preoperative vitamin d status with post thyroidectomy hypocalcemia. Endocr Pract 2015;21(4):348–54.

17. Mehanna HM, Jain A, Randeva H, Watkinson J, Shaha A. Postoperative hypocalcemia--the difference a definition makes Head Neck. 2010;32(3):279–83.

18. Trung N, Kerr P, Sutherland D, Lambert P. Validation of 1-hour post-thyroidectomy parathyroid hormone level in predicting hypocalcemia. J Otolaryngol Head Neck Surg 2014;43:5.

19. Selberherr A, Scheuba C, Riss P, and Niederle B. Postoperative hypoparathyroidism after thyroidectomy: Efficient and cost-effective diagnosis and treatment. Surgery 2015;157:349–53.

20. 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;152:863–8.

21. Puzziello A, Gervasi R, Orlando G, Innaro N, Vitale M, Sacco R. Hypocalcaemia after total thyroidectomy: Could intact parathyroid hormone be a predictive factor for transient postoperative hypocalcemia? Surgery 2015;157:344–8.

22. Nhan C, Dolev Y, Mijovic T, Rivera JA, Kallai-Sanfac¸on M-A, Mlynarek AM, et al. Vitamin D deficiency and the risk of hypocalcemia following total thyroidectomy. J Otolaryngol Head Neck Surg J 2012; 41:401–6.

23. Nhan C, Dolev Y, Mijovic T, Rivera JA, Mlynarek AM, Kallai- Sanfac¸on M-A, et al. Low Vitamin D and Risk of Postthyroidectomy Hypocalcemia. Otolaryngol Head Neck Surg 2012; 41(6):401–6.

24. Pradeep PV, Ramalingam K. Postoperative PTH measurement is not a reliable predictor for hypocalcemia after total thyroidectomy in vitamin D deficiency: prospective study of 203 cases. World J Surg 2014;38:564–7.

25. Tripathi M, Karwasra RK, Parshad S. Effect of preoperative vitamin D deficiency on postoperative hypocalcemia after thyroid surgery. Thyroid Res 2014; 7:8.

26. Al-Khatib T, Althubaiti AM, Althubaiti A, Mosli HH, Alwasiah RO, Badawood LM. Severe Vitamin D Deficiency A Significant Predictor of Early Hypocalcemia after Total Thyroidectomy. Otolaryngol Head Neck Surg 2015;152(3):424–31.

27. Kirkby-Bott J, Markogiannakis H, Skandarajah A, Cowan M, Fleming B, Palazzo F. Preoperative vitamin D deficiency predicts postoperative hypocalcemia after total thyroidectomy. World J Surg 2011; 35:324–30.

28. Cherian AJ, Ponraj S, Gowris, Ramakant P, Thomas P, Abraham T, et al. The role of vitamin D in post-thyroidectomy hypocalcemia: Still an enigma. Surgery 159; 2:532–38.

29. Griffin TP, Murphy MS, Sheahan P. Vitamin D and risk of postoperative hypocalcemia after total thyroidectomy. JAMA Otolaryngol Head Neck Surg 2014; 140:346–51.

30.  Lin Y, Ross HL, Raeburn CD, DeWitt PE, Albuja-Cruz M, Jones EL, et al. Vitamin D deficiency does not increase the rate of postoperative
hypocalcemia after thyroidectomy. Am J Surg 2012; 204:888–93.

31. White ML, Gauger PG, Doherty GM. Central lymph node dissection in differentiated thyroid cancer. World J Surg 2007; 31:895–904.

32. Shen WT, Ogawa L, Ruan D, Suh I, Kebebew E, Duh QY, et al. Central neck lymph node dissection for papillary thyroid cancer: the reliability of surgeon judgment in predicting which patients will benefit. Surgery 2010; 148:398–403.

33. Park I, Rhu J, Woo JW, Choi JH, Kim JS, Kim JH. Preserving Parathyroid Gland Vasculature to Reduce Post-thyroidectomy Hypocalcemia. World J Surg 2016;40(6):1382–9.