Management of Postthyroidectomy Hypoparathyroidism and Its Effect on Hypocalcemia-Related Complications:A Meta-Analysis

Objective: The aim of this Meta-analysis is to evaluate the impact of different treatment strategies for early postoperative hypoparathyroidism on hypocalcemia-related complications and long-term hypoparathyroidism. Data Sources: Embase.com, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched to September 20, 2022. Review Methods: Articles reporting on adult patients who underwent total thyroidectomy which specified a treatment strategy for postthyroidectomy hypoparathyroidism were included. Random effect models were applied to obtain pooled proportions and 95% confidence intervals. Primary outcome was the occurrence of major hypocalcemia-related complications. Secondary outcome was long-term hypoparathyroidism. Results: Sixty-six studies comprising 67 treatment protocols and 51,096 patients were included in this Meta-analysis. In 8 protocols (3806 patients), routine calcium and/or active vitamin D medication was given to all patients directly after thyroidectomy. In 49 protocols (44,012 patients), calcium and/or active vitamin D medication was only given to patients with biochemically proven postthyroidectomy hypoparathyroidism. In 10 protocols (3278 patients), calcium and/or active vitamin D supplementation was only initiated in case of clinical symptoms of hypocalcemia. No patient had a major complication due to postoperative hypocalcemia. The pooled proportion of long-term hypoparathyroidism was 2.4% (95% confidence interval, 1.9-3.0). There was no significant difference in the incidence of long-term hypoparathyroidism between the 3 supplementation groups. Conclusions: All treatment strategies for postoperative hypocalcemia prevent major complications of hypocalcemia. The early postoperative treatment protocol for postthyroidectomy hypoparathyroidism does not seem to influence recovery of parathyroid function in the long term.</p

Management of Postthyroidectomy Hypoparathyroidism and Its Effect on Hypocalcemia-Related Complications:A Meta-Analysis

Objective: The aim of this Meta-analysis is to evaluate the impact of different treatment strategies for early postoperative hypoparathyroidism on hypocalcemia-related complications and long-term hypoparathyroidism. Data Sources: Embase.com, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched to September 20, 2022. Review Methods: Articles reporting on adult patients who underwent total thyroidectomy which specified a treatment strategy for postthyroidectomy hypoparathyroidism were included. Random effect models were applied to obtain pooled proportions and 95% confidence intervals. Primary outcome was the occurrence of major hypocalcemia-related complications. Secondary outcome was long-term hypoparathyroidism. Results: Sixty-six studies comprising 67 treatment protocols and 51,096 patients were included in this Meta-analysis. In 8 protocols (3806 patients), routine calcium and/or active vitamin D medication was given to all patients directly after thyroidectomy. In 49 protocols (44,012 patients), calcium and/or active vitamin D medication was only given to patients with biochemically proven postthyroidectomy hypoparathyroidism. In 10 protocols (3278 patients), calcium and/or active vitamin D supplementation was only initiated in case of clinical symptoms of hypocalcemia. No patient had a major complication due to postoperative hypocalcemia. The pooled proportion of long-term hypoparathyroidism was 2.4% (95% confidence interval, 1.9-3.0). There was no significant difference in the incidence of long-term hypoparathyroidism between the 3 supplementation groups. Conclusions: All treatment strategies for postoperative hypocalcemia prevent major complications of hypocalcemia. The early postoperative treatment protocol for postthyroidectomy hypoparathyroidism does not seem to influence recovery of parathyroid function in the long term.</p

소아 갑상선암 환자에서 갑상선 전절제술 후 발생한 저칼슘혈증의 위험요인

학위논문(석사) -- 서울대학교대학원 : 의과대학 의학과, 2023. 2. 신충호.Purpose: Hypocalcemia is the most common complication following thyroidectomy. We investigated the frequency and risk factors of hypocalcemia after total thyroidectomy in pediatric patients with thyroid cancer. Methods: This retrospective study included 98 patients, diagnosed with thyroid cancer after total thyroidectomy <20 years of age during 1990―2018 and followed up more than 2 years at Seoul National University Hospital. Oral calcium and active vitamin D (1-hydroxycholecalciferol or 1,25-dihydroxycholecalciferol) were prescribed when postoperative calcium level was lower than 8.0 mg/dL and when a patient complained of hypocalcemic symptoms. Postoperative hypocalcemia was defined as requiring active vitamin D supplementation to maintain blood calcium levels above 8.5 mg/dL following surgery. Results: The study included 27 boys (27.6%) and 71 girls (72.4%). The mean age at diagnosis was 14.9 ± 3.7 years. Hypocalcemia occurred in 43 (43.9%) patients. Twenty-one (21.4%) patients discontinued active vitamin D less than 6 months, and 14 (14.3%) continued active vitamin D for more than 2 years. Tumor multifocality (Odds ratio (OR) 3.7 vs. single tumor, P=0.013) and preoperative calcium levels (OR 0.2, P=0.028) were independent predictors for developing hypocalcemia immediately after total thyroidectomy. In addition, age (OR 0.8, P=0.011) and preoperative calcium levels (OR 0.04, P=0.014) significantly decreased the risk for persistent hypocalcemia requiring active vitamin D for more than 2 years. Conclusion: Hypocalcemia occurred in about two-fifth after total thyroidectomy in pediatric thyroid cancer. Among them, one-third of patients continued active vitamin D medication for more than 2 years, which was predicted by young age and low preoperative calcium levels.목적: 저칼슘혈증은 갑상선절제술 후 발생할 수 있는 가장 흔한 합병증이다. 이 논문에서는 소아 갑상선암 환자에서 갑상선 전절제술 후 저칼슘혈증의 발생 빈도와 위험인자를 확인하고자 하였다. 방법: 본 연구에서는 1990년부터 2018년 사이 서울대병원에서 20세 미만에 갑상선 전절제술을 시행하고 갑상선암으로 진단된 뒤 2년 이상 추적관찰한 98명의 환자에 대하여 후향적으로 조사하였다. 수술 후 칼슘 농도가 8.0 mg/dL 미만이고 저칼슘혈증 증상이 있는 경우 경구 칼슘과 활성 비타민 D (1-하이드록시콜레칼시페롤 또는 1,25-디하이드록시콜레칼시페롤) 제제를 투약하였다. 수술 후 저칼슘혈증은 칼슘 농도를 8.5 mg/dL 이상으로 유지하기 위하여 활성 비타민 D 투약이 지속적으로 필요한 경우로 정의하였다. 결과: 연구에는 남자 27명 (27.6%)과 여자 71명 (72.4%)이 포함되었다. 진단 당시 평균 연령은 14.9 ± 3.7세였다. 저칼슘혈증은 43명 (43.9%)의 환자에서 발생하였다. 21명 (2.4%)의 환자는 6개월 이내에 활성 비타민 D를 중단하였고, 14명 (14.3%)은 2년 이상 활성 비타민 D 복용을 지속하였다. 다발성 종양 (odds ratio [OR] = 3.7 vs. 단일종양, P=0.013)과 수술 전 칼슘 수치 (OR 0.2, P=0.028) 는 갑상선 전절제술 직후 저칼슘혈증 발병을 예측할 수 있는 인자로 확인되었다. 또한, 연령 (OR 0.8, P=0.011)과 수술 전 칼슘수치 (OR 0.04, P=0.014)가 2년 이상 활성 비타민 D 복용을 필요로 하는 지속적인 저칼슘혈증의 위험을 유의하게 예측하는 인자로 확인되었다. 결론: 소아 갑상선암에서 갑상선 전절제술 후 약 2/5에서 저칼슘혈증이 발생하였다. 그 중 1/3이 2년 이상 활성 비타민 D 투약을 지속하였으며, 진단시 연령이 어릴수록 그리고 수술 전 칼슘 수치가 낮을수록 2년 이상 투약을 필요로 하는 저칼슘혈증이 발생할 가능성이 높다.Introduction 1 Materials and Methods 2 Results 7 Discussion 19 References 25 Abstract in Korean 31석

A cost-utility analysis for prophylactic central neck dissection in clinically nodal-negative papillary thyroid carcinoma

Background: Although prophylactic central neck dissection (pCND) may reduce future locoregional recurrence after total thyroidectomy (TT) for low-risk papillary thyroid carcinoma (PTC), it is associated with a higher initial morbidity. We aimed to compare the long-term cost-effectiveness between TT with pCND (TT+pCND) and TT alone in the institution's perspective. Methods: Our case definition was a hypothetical cohort of 100,000 nonpregnant female patients aged 50 years with a 1.5-cm cN0 PTC within one lobe. A Markov decision tree model was constructed to compare the estimated cost-effectiveness between TT+pCND and TT alone after a 20-year period. Outcome probabilities, utilities, and costs were estimated from the literature. The threshold for cost-effectiveness was set at US$50,000 per quality-adjusted life year (QALY). Sensitivity and threshold analyses were used to examine model uncertainty. Results: Each patient who underwent TT+pCND instead of TT alone cost an extra US$34.52 but gained an additional 0.323 QALY. In fact, in the sensitivity analysis, TT+pCND became cost-effective 9 years after the initial operation. In the threshold analysis, none of the scenarios that could change this conclusion appeared clinically possible or likely. However, TT+pCND became cost-saving (i.e., less costly and more cost-effective) at 20 years if associated permanent vocal cord palsy was kept ≤1.37 %, permanent hypoparathyroidism was ≤1.20 %, and/or postoperative radioiodine ablation use was ≤73.64 %. Conclusions: In the institution's perspective, routine pCND for low-risk PTC began to become cost-effective 9 years after initial surgery and became cost-saving at 20 years if postoperative radioiodine use and/or permanent surgical complications were kept to a minimum. © 2013 Society of Surgical Oncology.postprin

A Cost-Minimization Analysis Comparing Total Thyroidectomy Alone and Total Thyroidectomy with Prophylactic Central Neck Dissection in Clinically Nodal-Negative Papillary Thyroid Carcinoma

postprin

Clinicopathological Risk Factors and Biochemical Predictors of Safe Discharge after Total Thyroidectomy and Central Compartment Node Dissection for Thyroid Cancer: A Prospective Study

To determine the clinicopathological risk factors and reliable biochemical predictors of the development of hypocalcemic symptoms after total thyroidectomy on the basis of serum calcium and intact parathyroid hormone (PTH) levels measured 1 hour after surgery, a prospective study was performed on 817 patients who underwent a total thyroidectomy with central compartment node dissection (CCND) due to well-differentiated thyroid cancer. We evaluated the correlations between hypocalcemic symptom development and clinicopathological factors. And the predictability for hypocalcemic symptom development of intact PTH cut-offs (<10 pg/mL and <20 pg/mL, resp.) according to serum calcium level subgroup was analyzed. Female gender (P<0.001) was the only independent risk factor for hypocalcemic symptom development in multivariate regression analysis. The negative predictive value (NPV) of intact PTH, signifying nondevelopment of hypocalcemic symptoms, was higher than the positive predictive value (PPV) which signified development of hypocalcemic symptoms. In addition, when we applied the different adoption of the intact PTH cut-off according to serum calcium level, we could obtain more increased NPVs. A female gender and the application of more specific cut-offs for intact PTH according to the serum calcium levels measured 1 hour after surgery may help the patients to be more safely discharged

How Useful Are Perioperative Biochemical Parameters in Predicting the Duration of Calcium and/or Vitamin D Supplementation After Total Thyroidectomy?

postprin

Risk factors of permanent hypoparathyroidism after total thyroidectomy and central neck dissection for papillary thyroid cancer: a prospective study

Introduction: Inadvertent removal of, or damage to the parathyroid glands in the course of operations on the anterior neck compartment are responsible for over 80% of cases of chronic hypoparathyroidism (HypoPT). This study searched for factors related to the development of permanent HypoPT after total thyroidectomy and central neck lymphadenectomy in patients with thyroid carcinoma. Material and methods: In total, 89 of 103 screened patients met the study’s criteria and were put under prospective one-year observation. Demographic and surgical factors as well as the biochemical parameters of mineral homeostasis, controlled both preoperatively and postoperatively, were subject to statistical analysis. In line with contemporary guidelines, postoperative hypocalcaemia, rather than an abnormally low serum parathormone (PTH) concentration, was considered a diagnostic criterion of HypoPT. Results: On postoperative day one (POD1), serum concentration of PTH decreased below the normal range (&lt; 12 pg/mL) in 29 patients and was undetectable in 19 patients (&lt; 6 pg/mL). At one year postoperatively, 12 patients with undetectable POD1 PTH required treatment for hypocalcaemia and were diagnosed with permanent hypoPT. All the other patients regained normocalcaemia. Relative risk of permanent HypoPT associated with undetectable POD1 PTH was 88.75. A significant difference in median POD1 serum calcium concentration between the patients with undetectable POD1 PTH and those with detectable POD1 PTH was found (p &lt; 0.001). The difference between the POD1 serum calcium in patients with permanent or transient HypoPT in the subgroup with undetectable POD1 PTH did not reach the level of statistical significance (median, 1.82 mmol/L vs. 1.96 mmol/L). At one month postoperatively, in patients who later developed permanent HypoPT, serum calcium was lower than it was in all other patients (p = 0.167). At one year postoperatively, serum concentration of PTH was in the normal range in 10 of 12 patients with permanent HypoPT; however, it was significantly lower than it had been before the operation and distinctly lower than it was in patients who regained normocalcaemia. The number of parathyroid glands either dissected or autotransplanted did not affect the development of permanent HypoPT. Conclusions: Undetectable POD1 PTH is an important risk factor of permanent HypoPT. The main cause of permanent HypoPT was irreversible damage to the left in situ parathyroid glands