Risk factors for hypocalcaemia after completion hemithyroidectomy in thyroid cancer
Hypocalcaemia (HC) is the most common complication after thyroid surgery in differentiated thyroid cancer and leads to a prolongation of the hospital stay. While risk factors for HC after total thyroidectomy (TE) are well investigated, only few studies have been published about HC risk factors after completion of thyroidectomy. Our aim was to identify potential risk factors for HC after completion of TE and to compare these incidences with figures from primary total TE.
MATERIALS AND METHODS
A retrospective cohort study was undertaken including patients undergoing completion of TE between 2002 and 2013 in our tertiary care centre. Patients with hypocalcaemia (group 1) after undergoing second surgery were compared to normocalcaemia patients (group 2) with respect to gender, age, type of thyroid cancer, time interval between surgeries, pre/postoperative calcium and parathyroid hormone (PTH) levels, clinical hypocalcaemia signs and calcium substitution (intravenous, oral). Hypocalcaemia was defined as <2.10 mmol/l, hypoparathyroidism as <15pg/ml.
34 (25 female, 9 male) patients were included. A total of 12 patients (33%) developed a hypocalcaemia (group 1). Three patients out of these also presented with hypoparathyroidism. One patient in each group showed clinical signs of hypocalcaemia. Calcium substitution was necessary in six cases in group 1 and in one case in group 2. There was a significant difference between the groups concerning postoperative PTH (25.1 vs 37.6 pg/ml) and calcium levels (1.87 vs 2.27 mmol/l) (p <0.05). Group comparison shows no significant relationships between all other parameters (age, gender, type of thyroid cancer and duration of interval between surgeries). Logistic regression analysis identified a low preoperative serum calcium level as the only dominant factor indicating postoperative hypocalcaemia.
A hypocalcaemia rate of 33% (12/34) and a hypoparathyroidism rate of 9% (3/34) after completion of thyroidectomy in our cohort is comparable to primary total thyroidectomy. A low preoperative calcium level is a significant risk factor for postoperative hypocalcaemia after completion of thyroidectomy. The prediction of hypocalcaemia still remains difficult since it has multifactorial causes.
- Agate L, Lorusso L, Elisei R. New and old knowledge on differentiated thyroid cancer epidemiology and risk factors. J Endocrinol Invest. 2012;35(6, Suppl):3–9.
- krebsliga.ch. [internet]. Bern: Schweizer Krebsliga (swiss cancer league) [updated 2015 October 9]. Available from: https://www.krebsliga.ch
- Puzziello A, Rosato L, Innaro N, Orlando G, Avenia N, Perigli G, et al. Hypocalcemia following thyroid surgery: incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients. Endocrine. 2014;47(2):537–42; epub ahead of print. doi:.https://doi.org/10.1007/s12020-014-0209-y
- Gulcelik MA, Kuru B, Dincer H, Camlibel M, Yuksel UM, Yenidogan E, et al. Complications of completion versus total thyroidectomy. Asian Pac J Cancer Prev. 2012;13(10):5225–8. doi:.https://doi.org/10.7314/APJCP.2012.13.10.5225
- 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(4):592–7. doi:.https://doi.org/10.1309/J357LMD66E9X2505
- Erdem E, Gülçelik MA, Kuru B, Alagöl H. Comparison of completion thyroidectomy and primary surgery for differentiated thyroid carcinoma. Eur J Surg Oncol. 2003;29(9):747–9. doi:.https://doi.org/10.1016/j.ejso.2003.08.006
- Rafferty MA, Goldstein DP, Rotstein L, Asa SL, Panzarella T, Gullane P, et al. Completion thyroidectomy versus total thyroidectomy: is there a difference in complication rates? An analysis of 350 patients. J Am Coll Surg. 2007;205(4):602–7. doi:.https://doi.org/10.1016/j.jamcollsurg.2007.05.030
- Swiss society of otolaryngology, head- and neck-surgery. Guidelines for management and therapy of head- and neck-cancer. 2011. pp 62–6
- Tartaglia F, Giuliani A, Sgueglia M, Biancari F, Juvonen T, Campana FP. Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy. Am J Surg. 2005;190(3):424–9. doi:.https://doi.org/10.1016/j.amjsurg.2005.04.017
- Joosen DA, van de Laar RJ, Koopmans RP, Stassen PM. Acute dyspnea caused by hypocalcemia-related laryngospasm. J Emerg Med. 2015;48(1):29–30. doi:.https://doi.org/10.1016/j.jemermed.2014.09.034
- Chow TL, Choi CY, Chiu AN. Postoperative PTH monitoring of hypocalcemia expedites discharge after thyroidectomy. Am J Otolaryngol. 2014;35(6):736–40. doi:.https://doi.org/10.1016/j.amjoto.2014.07.006
- Bähler S, Müller W, Linder T, Frotzler A, Aqtashi B, Elmas F, et al. [Hypocalcemia after total thyroidectomy- A analysis of riskfactors]. Hypocalcämie nach totaler Thyroidektomie - Eine Analyse von Risikofaktoren. Submitted 2016 August. German
- Tietz N. Clinical guide to laboratory tests. 4th ed. Wu AHB, editor. St. Louis (MO): Sanders Elsevier; 2006. 202–7
- Swiss Federal Statistical Office (SFSO). Neuchâtel (Switzerland). 2015 March 17. https://www.bfs.admin.ch/bfs/en/home.html
- Agarwal G, Aggarwal V. Is total thyroidectomy the surgical procedure of choice for benign multinodular goiter? An evidence-based review. World J Surg. 2008;32(7):1313–24. doi:.https://doi.org/10.1007/s00268-008-9579-8
- Feroci F, Rettori M, Borrelli A, Coppola A, Castagnoli A, Perigli G, et al. A systematic review and meta-analysis of total thyroidectomy versus bilateral subtotal thyroidectomy for Graves’ disease. Surgery. 2014;155(3):529–40. doi:.https://doi.org/10.1016/j.surg.2013.10.017
- Yano Y, Sugino K, Akaishi J, Uruno T, Okuwa K, Shibuya H, et al. Treatment of autonomously functioning thyroid nodules at a single institution: radioiodine therapy, surgery, and ethanol injection therapy. Ann Nucl Med. 2011;25(10):749–54. doi:.https://doi.org/10.1007/s12149-011-0526-7
- Liao S, Shindo M. Management of well-differentiated thyroid cancer. Otolaryngol Clin North Am. 2012;45(5):1163–79. doi:.https://doi.org/10.1016/j.otc.2012.06.015
- Erbil Y, Barbaros U, Işsever H, Borucu I, Salmaslioğlu A, Mete O, et al. Predictive factors for recurrent laryngeal nerve palsy and hypoparathyroidism after thyroid surgery. Clin Otolaryngol. 2007;32(1):32–7. doi:.https://doi.org/10.1111/j.1365-2273.2007.01383.x
- Kim ES, Kim TY, Koh JM, Kim YI, Hong SJ, Kim WB, et al. Completion thyroidectomy in patients with thyroid cancer who initially underwent unilateral operation. Clin Endocrinol (Oxf). 2004;61(1):145–8. doi:.https://doi.org/10.1111/j.1365-2265.2004.02065.x
- Dequanter D, Charara F, Shahla M, Lothaire P. Usefulness of neuromonitoring in thyroid surgery. Eur Arch Otorhinolaryngol. 2015;272(10):3039–43. doi:.https://doi.org/10.1007/s00405-014-3293-y
- Contin P, Gooßen K, Grummich K, Jensen K, Schmitz-Winnenthal H, Büchler MW, et al. ENERgized vessel sealing systems versus CONventional hemostasis techniques in thyroid surgery--the ENERCON systematic review and network meta-analysis. Langenbecks Arch Surg. 2013;398(8):1039–56. doi:.https://doi.org/10.1007/s00423-013-1137-7
- Zanghì A, Cavallaro A, Di Vita M, Cardì F, Di Mattia P, Piccolo G, et al. The safety of the Harmonic® FOCUS in open thyroidectomy: a prospective, randomized study comparing the Harmonic® FOCUS and traditional suture ligation (knot and tie) technique. Int J Surg. 2014;12(Suppl 1):S132–5. doi:.https://doi.org/10.1016/j.ijsu.2014.05.028
- Pisanu A, Podda M, Reccia I, Porceddu G, Uccheddu A. Systematic review with meta-analysis of prospective randomized trials comparing minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT). Langenbecks Arch Surg. 2013;398(8):1057–68. doi:.https://doi.org/10.1007/s00423-013-1125-y
- Sun GH, Peress L, Pynnonen MA. Systematic review and meta-analysis of robotic vs conventional thyroidectomy approaches for thyroid disease. Otolaryngol Head Neck Surg. 2014;150(4):520–32. doi:.https://doi.org/10.1177/0194599814521779
- Noureldine SI, Genther DJ, Lopez M, Agrawal N, Tufano RP. Early predictors of hypocalcemia after total thyroidectomy: an analysis of 304 patients using a short-stay monitoring protocol. JAMA Otolaryngol Head Neck Surg. 2014;140(11):1006–13. doi:.https://doi.org/10.1001/jamaoto.2014.2435
- Pradeep PV, Ramalingam K, Jayashree B. Post total thyroidectomy hypocalcemia: a novel multi-factorial scoring system to enable its predictions to facilitate an early discharge. J Postgrad Med. 2013;59(1):4–8.
- Lo CY. Parathyroid autotransplantation during thyroidectomy. ANZ J Surg. 2002;72(12):902–7. doi:.https://doi.org/10.1046/j.1445-2197.2002.02580.x
- Song CM, Jung JH, Ji YB, Min HJ, Ahn YH, Tae K. Relationship between hypoparathyroidism and the number of parathyroid glands preserved during thyroidectomy. World J Surg Oncol. 2014;12(1):200. doi:.https://doi.org/10.1186/1477-7819-12-200
- Vaiman M, Nagibin A, Olevson J. Complications in primary and completed thyroidectomy. Surg Today. 2010;40(2):114–8. doi:.https://doi.org/10.1007/s00595-008-4027-9
- Edafe O, Antakia R, Laskar N, Uttley L, Balasubramanian SP. Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. Br J Surg. 2014;101(4):307–20. doi:.https://doi.org/10.1002/bjs.9384
- Alhefdhi A, Mazeh H, Chen H. Role of postoperative vitamin D and/or calcium routine supplementation in preventing hypocalcemia after thyroidectomy: a systematic review and meta-analysis. Oncologist. 2013;18(5):533–42. doi:.https://doi.org/10.1634/theoncologist.2012-0283
- 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(6):888–93, discussion 893–4. doi:.https://doi.org/10.1016/j.amjsurg.2012.10.001
- Wang TS, Cheung K, Roman SA, Sosa JA. To supplement or not to supplement: a cost-utility analysis of calcium and vitamin D repletion in patients after thyroidectomy. Ann Surg Oncol. 2011;18(5):1293–9. doi:.https://doi.org/10.1245/s10434-010-1437-x
- Huang SM. Do we overtreat post-thyroidectomy hypocalcemia? World J Surg. 2012;36(7):1503–8. doi:.https://doi.org/10.1007/s00268-012-1580-6
- Griffin TP, Murphy MS, Sheahan P. Vitamin D and risk of postoperative hypocalcemia after total thyroidectomy. JAMA Otolaryngol Head Neck Surg. 2014;140(4):346–51. doi:.https://doi.org/10.1001/jamaoto.2014.25