Clinical analysis of 7 cases of parathyroid insufficiency after total thyroidectomy_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

DONG Zhizhong , LIU Wen , SU Yanjun , ZHAN Xiangxiang , DIAO Chang ,  CHENG Ruochuan

Center for Diagnosis and Treatment of Thyroid Disease, the First Affiliated Hospital of Kunming Medical University, Kunming 650032, P. R. China;

Corresponding?author：

CHENG Ruochuan, Email: cruochuan@foxmail.com

Keywords：

total thyroidectomy; hypoparathyroidism; parathyroid hormone; hypocalcemia; vitamin D

DOI：

10.7507/1007-9424.202202016

Video：

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Objective To introduce patients with long-term hypocalcemia and normal parathyroid hormone (PTH) values after total thyroidectomy, and to analyze the possible causes of this phenomenon. Methods The medical records of 1 010 consecutive patients with total thyroidectomy treated in the Center for Diagnosis and Treatment of Thyroid Disease, the First Affiliated Hospital of Kunming Medical University from January 2019 to December 2020 were collected. Seven patients with normal PTH and blood calcium before operation and at least 2 times of PTH with hypocalcemia detected more than 6 months after operation were followed-up to understand the symptoms of hypocalcemia, vitamin D level and calcium consumption. Results Seven patients with thyroid papillary carcinoma underwent total thyroidectomy without parathyroid autotransplantation, and there were 6 cases with mild deficiency or insufficient of vitamin D before operation. The follow-up time was 12–28 months, and the median follow-up time was 19 months. Seven patients developed hypocalcemia after continuous administration of calcium and calcitriol, and vitamin D levels remained mild deficiency or insufficient, PTH decreased by more than 50% in 6 patients one year after operation compared with that before operation. Conclusions Patients with long-term normal PTH values and hypocalcemia after total thyroidectomy have obviously lower PTH levels than those before operation. The possible factors are parathyroid damage during operation and vitamin D deficiency. Such these patients should be more properly referred to as “parathyroid insufficiency”.

Citation： DONG Zhizhong, LIU Wen, SU Yanjun, ZHAN Xiangxiang, DIAO Chang, CHENG Ruochuan. Clinical analysis of 7 cases of parathyroid insufficiency after total thyroidectomy. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(10): 1334-1338. doi: 10.7507/1007-9424.202202016 Copy

1.	Stevenson A, Mihai R. Patients’ views about parathyroid transplantation for post-thyroidectomy hypoparathyroidism. Langenbecks Arch Surg, 2018, 403(5): 623-629.
2.	Harsl?f T, Rolighed L, Rejnmark L. Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review. Endocrine, 2019, 64(1): 176-183.
3.	Shoback DM, Bilezikian JP, Costa AG, et al. Presentation of hypoparathyroidism: etiologies and clinical features. J Clin Endocrinol Metab, 2016, 101(6): 2300-2312.
4.	Carty SE, Cooper DS, Doherty GM, et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid, 2009, 19(11): 1153-1158.
5.	Orloff LA, Wiseman SM, Bernet VJ, et al. American Thyroid Association Statement on postoperative hypoparathyroidism: diagnosis, prevention, and management in adults. Thyroid, 2018, 28(7): 830-841.
6.	Promberger R, Ott J, Kober F, et al. Normal parathyroid hormone levels do not exclude permanent hypoparathyroidism after thyroidectomy. Thyroid, 2011, 21(2): 145-150.
7.	Prichard RS, Edhouse PJ, Sidhu SB, et al. Post-operative partial hypoparathyroidism: an under-recognized disorder. ANZ J Surg, 2011, 81(7-8): 524-527.
8.	Philips R, Nulty P, Seim N, et al. Predicting transient hypocalcemia in patients with unplanned parathyroidectomy after thyroidectomy. Am J Otolaryngol, 2019, 40(4): 504-508.
9.	Lo CY, Tam SC. Parathyroid autotransplantation during thyroidectomy: documentation of graft function. Arch Surg, 2001, 136(12): 1381-1385.
10.	El-Sharaky MI, Kahalil MR, Sharaky O, et al. Assessment of parathyroid autotransplantation for preservation of parathyroid function after total thyroidectomy. Head Neck, 2003, 25(10): 799-807.
11.	Unsal IO, Calapkulu M, Sencar ME, et al. Preoperative vitamin d levels as a predictor of transient hypocalcemia and hypoparathyroidism after parathyroidectomy. Sci Rep, 2020, 10(1): 9895. doi: 10.1038/s41598-020-66889-8.
12.	Godlewska P, Benke M, Stachlewska-Nasfeter E, et al. Risk factors of permanent hypoparathyroidism after total thyroidectomy and central neck dissection for papillary thyroid cancer: a prospective study. Endokrynol Pol, 2020, 71(2): 126-133.
13.	郝軍生. 甲狀腺全切術后甲狀旁腺功能減退的恢復時間分析(附13例). 現代腫瘤醫學, 2020, 28(11): 1867-1869.
14.	Matikainen N, Pekkarinen T, Ryh?nen EM, et al. Physiology of calcium homeostasis: an overview. Endocrinol Metab Clin North Am, 2021, 50(4): 575-590.
15.	Al-Khatib T, Althubaiti AM, Althubaiti A, et al. Severe vitamin D deficiency: a significant predictor of early hypocalcemia after total thyroidectomy. Otolaryngol Head Neck Surg, 2015, 152(3): 424-431.
16.	Lotito A, Teramoto M, Cheung M, et al. Serum parathyroid hormone responses to vitamin D supplementation in overweight/obese adults: a systematic review and meta-analysis of randomized clinical trials. Nutrients, 2017, 9(3): 241. doi: 10.3390/nu9030241.
17.	Vibhatavata P, Pisarnturakit P, Boonsripitayanon M, et al. Effect of preoperative vitamin D deficiency on hypocalcemia in patients with acute hypoparathyroidism after thyroidectomy. Int J Endocrinol, 2020, 2020: 5162496. doi: 10.1155/2020/5162496.
18.	Saliba W, Barnett O, Rennert HS, et al. The relationship between serum 25(OH) D and parathyroid hormone levels. Am J Med, 2011, 124(12): 1165-1170.
19.	Wijewickrama PSA, Rajaratnam HN. Delayed hypoparathyroidism following thyroidectomy, a diagnostic conundrum: a report of three cases from Sri Lanka. Case Rep Endocrinol, 2020, 2020: 1735351. doi: 10.1155/2020/1735351.
20.	程少浩, 蘇艷軍, 程若川. 術后甲狀旁腺功能減退癥危害研究進展. 中國實用外科雜志, 2021, 41(9): 1049-1055.
21.	陳曦, 陳海珍. 甲狀腺術后甲狀旁腺功能減退的藥物治療. 中國實用外科雜志, 2018, 38(6): 619-624.
22.	Landry CS, Grubbs EG, Hernandez M, et al. Predictable criteria for selective, rather than routine, calcium supplementation following thyroidectomy. Arch Surg, 2012, 147(4): 338-344.
23.	Carvalho G, Giraldo L R, Lira R B, et al. Preoperative vitamin D deficiency is a risk factor for postoperative hypocalcemia in patients undergoing total thyroidectomy: retrospective cohort study: Sao Paulo Med J, 2019, 137: 241-247.
24.	何領, 徐鯤, 任明, 等. 甲狀腺乳頭狀癌術后甲狀旁腺功能減退的預測因素分析. 臨床外科雜志, 2020, 28(9): 853-856.
25.	Quiros RM, Pesce CE, Wilhelm SM, et al. Intraoperative parathyroid hormone levels in thyroid surgery are predictive of postoperative hypoparathyroidism and need for vitamin D supplementation. Am J Surg, 2005, 189(3): 306-309.
26.	Huang R, Wang Q, Zhang W, et al. The predictive factors for postoperative hypoparathyroidism and its severity on the first postoperative day after papillary thyroid carcinoma surgery. Eur Arch Otorhinolaryngol, 2021, 278(4): 1189-1198.

1. Stevenson A, Mihai R. Patients’ views about parathyroid transplantation for post-thyroidectomy hypoparathyroidism. Langenbecks Arch Surg, 2018, 403(5): 623-629.
2. Harsl?f T, Rolighed L, Rejnmark L. Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review. Endocrine, 2019, 64(1): 176-183.
3. Shoback DM, Bilezikian JP, Costa AG, et al. Presentation of hypoparathyroidism: etiologies and clinical features. J Clin Endocrinol Metab, 2016, 101(6): 2300-2312.
4. Carty SE, Cooper DS, Doherty GM, et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid, 2009, 19(11): 1153-1158.
5. Orloff LA, Wiseman SM, Bernet VJ, et al. American Thyroid Association Statement on postoperative hypoparathyroidism: diagnosis, prevention, and management in adults. Thyroid, 2018, 28(7): 830-841.
6. Promberger R, Ott J, Kober F, et al. Normal parathyroid hormone levels do not exclude permanent hypoparathyroidism after thyroidectomy. Thyroid, 2011, 21(2): 145-150.
7. Prichard RS, Edhouse PJ, Sidhu SB, et al. Post-operative partial hypoparathyroidism: an under-recognized disorder. ANZ J Surg, 2011, 81(7-8): 524-527.
8. Philips R, Nulty P, Seim N, et al. Predicting transient hypocalcemia in patients with unplanned parathyroidectomy after thyroidectomy. Am J Otolaryngol, 2019, 40(4): 504-508.
9. Lo CY, Tam SC. Parathyroid autotransplantation during thyroidectomy: documentation of graft function. Arch Surg, 2001, 136(12): 1381-1385.
10. El-Sharaky MI, Kahalil MR, Sharaky O, et al. Assessment of parathyroid autotransplantation for preservation of parathyroid function after total thyroidectomy. Head Neck, 2003, 25(10): 799-807.
11. Unsal IO, Calapkulu M, Sencar ME, et al. Preoperative vitamin d levels as a predictor of transient hypocalcemia and hypoparathyroidism after parathyroidectomy. Sci Rep, 2020, 10(1): 9895. doi: 10.1038/s41598-020-66889-8.
12. Godlewska P, Benke M, Stachlewska-Nasfeter E, et al. Risk factors of permanent hypoparathyroidism after total thyroidectomy and central neck dissection for papillary thyroid cancer: a prospective study. Endokrynol Pol, 2020, 71(2): 126-133.
13. 郝軍生. 甲狀腺全切術后甲狀旁腺功能減退的恢復時間分析(附13例). 現代腫瘤醫學, 2020, 28(11): 1867-1869.
14. Matikainen N, Pekkarinen T, Ryh?nen EM, et al. Physiology of calcium homeostasis: an overview. Endocrinol Metab Clin North Am, 2021, 50(4): 575-590.
15. Al-Khatib T, Althubaiti AM, Althubaiti A, et al. Severe vitamin D deficiency: a significant predictor of early hypocalcemia after total thyroidectomy. Otolaryngol Head Neck Surg, 2015, 152(3): 424-431.
16. Lotito A, Teramoto M, Cheung M, et al. Serum parathyroid hormone responses to vitamin D supplementation in overweight/obese adults: a systematic review and meta-analysis of randomized clinical trials. Nutrients, 2017, 9(3): 241. doi: 10.3390/nu9030241.
17. Vibhatavata P, Pisarnturakit P, Boonsripitayanon M, et al. Effect of preoperative vitamin D deficiency on hypocalcemia in patients with acute hypoparathyroidism after thyroidectomy. Int J Endocrinol, 2020, 2020: 5162496. doi: 10.1155/2020/5162496.
18. Saliba W, Barnett O, Rennert HS, et al. The relationship between serum 25(OH) D and parathyroid hormone levels. Am J Med, 2011, 124(12): 1165-1170.
19. Wijewickrama PSA, Rajaratnam HN. Delayed hypoparathyroidism following thyroidectomy, a diagnostic conundrum: a report of three cases from Sri Lanka. Case Rep Endocrinol, 2020, 2020: 1735351. doi: 10.1155/2020/1735351.
20. 程少浩, 蘇艷軍, 程若川. 術后甲狀旁腺功能減退癥危害研究進展. 中國實用外科雜志, 2021, 41(9): 1049-1055.
21. 陳曦, 陳海珍. 甲狀腺術后甲狀旁腺功能減退的藥物治療. 中國實用外科雜志, 2018, 38(6): 619-624.
22. Landry CS, Grubbs EG, Hernandez M, et al. Predictable criteria for selective, rather than routine, calcium supplementation following thyroidectomy. Arch Surg, 2012, 147(4): 338-344.
23. Carvalho G, Giraldo L R, Lira R B, et al. Preoperative vitamin D deficiency is a risk factor for postoperative hypocalcemia in patients undergoing total thyroidectomy: retrospective cohort study: Sao Paulo Med J, 2019, 137: 241-247.
24. 何領, 徐鯤, 任明, 等. 甲狀腺乳頭狀癌術后甲狀旁腺功能減退的預測因素分析. 臨床外科雜志, 2020, 28(9): 853-856.
25. Quiros RM, Pesce CE, Wilhelm SM, et al. Intraoperative parathyroid hormone levels in thyroid surgery are predictive of postoperative hypoparathyroidism and need for vitamin D supplementation. Am J Surg, 2005, 189(3): 306-309.
26. Huang R, Wang Q, Zhang W, et al. The predictive factors for postoperative hypoparathyroidism and its severity on the first postoperative day after papillary thyroid carcinoma surgery. Eur Arch Otorhinolaryngol, 2021, 278(4): 1189-1198.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Clinical analysis of 7 cases of parathyroid insufficiency after total thyroidectomy

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