Clinicopathological characteristics of incidental parathyroidectomy after total thyroidectomy: the effect on hypocalcemia

[helvella]

Sometimes a paper seems to come under the umbrella of "state the bleeding obvious". However, it is so vitally necessary for people to keep doing so. We should be shocked at the implication that sometimes the procedure might be done in a less than meticulous fashion, and that the parathyroids might not always be preserved. But if that is the case, it is for the best that it is stated and other doctors/surgeons cannot defend themselves by saying that all of them do the same. These ones appear so aware that of course they would do everything properly.

Another Graeco-English - or Anglo-Greek - paper for the delectation of Marz

Int J Surg. 2018 Jun 1. pii: S1743-9191(18)31486-9. doi: 10.1016/j.ijsu.2018.05.737. [Epub ahead of print]

Clinicopathological characteristics of incidental parathyroidectomy after total thyroidectomy: the effect on hypocalcemia. A retrospective cohort study.

Vasileiadis I1, Charitoudis G2, Vasileiadis D2, Stylianos K3, Karatzas T3.

Author information

1 Department of Otolaryngology/Head and Neck Surgery, Venizeleio - Pananeio General Hospital, Herakleion, Greece; Department of Otolaryngology - Head and Neck Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom. Electronic address: [e-mail].

2 Department of Otolaryngology - Head and Neck Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom.

3 Second Department of Propedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece.

Abstract

BACKGROUND:

The reported rate of incidental parathyroidectomy (IP) during total thyroidectomy varies between 6.4 to 31.1%. The aim of this study was to investigate the clinicopathological characteristics associated with IP.

MATERIALS AND METHODS:

This is a retrospective cohort study which included 2556 patients who underwent total thyroidectomy between 2002 and 2012 at a single tertiary institution. Demographics, clinicopathological risk factors, and postoperative calcium levels were compared between IP and control group.

RESULTS:

Incidental parathyroidectomy occurred in 18.3% of patients. IP patients had higher risk of postoperative biochemical (40.3% vs 17.3%, p < 0.001) and symptomatic hypocalcemia (14.3% vs 7.3%, p < 0.001) than no-IP group. Multivariate analysis showed malignancy, tumor size > 10 mm, thyroid capsule invasion, extrathyroidal extension, lymph node metastases and central neck dissection, operation time, RLN injury, thyroid gland dimensions were independent risk factors for IP.

CONCLUSIONS:

Our results indicate that patients with certain preoperative findings such as larger thyroid dimensions, diagnosis of malignancy and especially tumor > 10 mm, extrathyroidal extension, and lymph node metastasis are at higher risk of IP and postoperative symptomatic hypocalcemia and these patients should be adequately informed and treated. Α meticulous intraoperative identification and the preservation of all parathyroid glands results in lower incidence of IP and postoperative hypocalcemia.

Copyright © 2018. Published by Elsevier Ltd.

KEYWORDS:

clinicopathological characteristics; hypocalcemia; incidental parathyroidectomy; total thyroidectomy

PMID: 29864531

DOI: 10.1016/j.ijsu.2018.05.737

ncbi.nlm.nih.gov/pubmed/298...

[Nanaedake]

There doesn't seem to be any research on the result of losing half of your parathyroid glands with partial thyroidectomy. When the patient is handed over to the GP, there are no guidelines given to GP's as to what they should be monitoring or checking. Symptoms of calcium deficiency are often ignored it seems. Over or under activity of parathyroid glands are not monitored. GP's don't seem to consider parathyroid hormone as a possible reason for joint or muscle pain and they don't monitor the possible effect on bone andd skeletal health. Thyroid cancer patients get very poor aftercare compared with patients with breast cancer for example...yet the long term effects of losing thyroid or even partial thyroid can be cataclysmic if not effectively managed.

[helvella Administrator in reply to Nanaedake]

I appreciate that this might not always be feasible, but given the autotransplantation of parathyroids, it seems odd that this is not a pretty standard approach.

There are even papers about doing so - one of which ends with:

Conclusions

Parathyroid gland autotranplantation is a simple safe technique with high success rate in preventing persistent hypoparathyroidism after total thyroidectomy in surgical management of advanced hypopharyngeal and laryngeal carcinomas.

ncbi.nlm.nih.gov/pubmed/298...

[Nanaedake in reply to helvella]

Too many surgeons in small regional hospitals carrying out low volume thyroid surgery who really shouldn't be doing it.

[bantam12 in reply to Nanaedake]

Losing two or even three parathyroids usually has no effect on calcium levels as the remaining gland is capable of maintaining correct levels.

On the parathyroid forum we see many people with one gland including myself.

[Nanaedake in reply to bantam12]

How do you know how many parathyroids you have? It can vary with different people so how does a patient know how many they have left after surgery? Also, where is the research to prove that losing two or three parathyroid makes no difference? Could it cause a calcium deficiency that doesn't show up in the blood? Could there be conditions where it does make a difference such as during menopause or imbalance of thyroid hormone etc???

[bantam12 in reply to Nanaedake]

Are you asking how I know how many parathyroids I have ? If so I know because I had parathyroid surgery, I had hypocalcemia for a couple of weeks afterwards but the remaining one then kicked in.

Long term if calcium levels are maintained and pth is at the correct level in relation to calcium then the remaining parathyroids are doing their job. If calcium and/or pth go out of range then there is a problem.

[Nanaedake in reply to bantam12]

Thyroid cancer patients aren't always told and parathyroids are not always checked out beforehand. Calcium blood levels are not always monitored and calcium levels do not always indicate deficiency I believe since parathyroids will increase release of calcium from bone. Doctors often do not recognise symptoms of low calcium and NHS does not treat low calcium unless blood tests show under lab range.

[Hidden]

Before I had my thyroid removed when chatting to the surgeon he mentioned my parathyroids and where he was re-positioning them too.

The paper is interesting everyone should choose their surgeon carefully and make sure that they are experienced and still do plenty of operation each year.

[TSH110]

I am sure my sister lost all hers with TT for thyroid lymphoma and subsequently became very unwell - luckily the person she saw was on the ball and realised what had happened in the op and how to treat it.