Risk Factors of Hypoparathyroidism Following Total Thyroidectomy for Thyroid Cancer

Background

The risk factors responsible for hypoparathyroidism after total thyroidectomy have not been completely defined. The present study evaluated one surgeon’s personal experience of postoperative hypoparathyroidism after total thyroidectomy for thyroid cancer and predisposing risk factors of postoperative hypoparathyroidism.

Methods

We performed a retrospective analysis of 531 consecutive total thyroidectomy cases for thyroid cancer operated by single surgeon at the Center for Thyroid Cancer, National Cancer Center, Korea, from March 2003 to August 2006.

Results

Postoperative hypoparathyroidism occurred in 135 patients (25.4 %), 19 of whom (3.6 % of total patients) experienced permanent hypoparathyroidism. Parathyroid autotransplantation, bilateral central lymph node dissection, gross extrathyroidal extension, and the presence of parathyroid gland in the pathologic specimen were associated with postoperative hypoparathyroidism in multivariate analysis (p < 0.05, respectively). The presence of parathyroid gland in the pathologic specimen and the early period of surgeon’s practice were statistically significant risk factors for permanent hypoparathyroidism in multivariate analysis (p < 0.05, respectively).

Conclusions

Careful surgical technique for in situ preservation of parathyroid gland and autotransplantation of inadvertently removed parathyroid gland are important, especially in case of gross extrathyroidal extension. Adequate surgical experience is also an important factor. And routine bilateral central lymph node dissection should be done thoughtfully for its effect on postoperative hypoparathyroidism.     

Autotransplantation of at least one parathyroid gland during thyroidectomy in benign thyroid disease minimizes the risk of permanent hypoparathyroidism

OBJECTIVE:Permanent hypoparathyroidism is a distressing complication of thyroid surgery. The reported incidence varies between 0.4 and 13.8 % and is directly correlated to the extent of thyroidectomy. The aim of this retrospective study was to analyze whether simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease could reduce the risk of permanent hypoparathyroidism. METHODS: Since 01/1999 all thyroid operations are prospectively recorded. Beside daily postoperative measurement of serum calcium level, iPTH is routinely determined on the third post op day. Patients with complications are followed closely. Postoperative hypoparathyroidism persisting for more than 6 months is defined permanent. RESULTS: Between 01/1999 and 02/2001 146 total thyroidectomies for benign thyroid disease have been performed (81 pat. with Graves disease, 62 with nodular goiter, 3 with thyroiditis de Quervain/Hashimoto). In 37 pat. (25 %) at least one parathyroid gland was simultaneously autotransplanted into the ipsilateral sternocleidomastoid muscle. Group I (no parathyroid autotransplantation, n = 109) and group II (parathyroid autotransplantation, n = 37) were comparable concerning patient age, thyroid disease and lowest post op calcium level (2.07 versus 2.05 mmol/l). The incidence of postoperative symptomatic hypocalcemia (14.7 % versus 21.6 %) and temporary hypoparathyroidism (15.6 % versus 18.9 %) was higher in group II patients (n. s.). Conversely, permanent hypoparathyroidism occurred exclusively in group I patients (2.75 %), patients with parathyroid autotransplantation (group II) did not develop this complication. CONCLUSIONS: Simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease seems to minimize the risk of permanent hypoparathyroidism. The potential of routine autotransplantation in this setting has to be evaluated. The incidence of postoperative temporary hypocalcemia may be elevated with this policy.     

甲状腺手术中甲状旁腺误切的危险因素分析

目的探讨甲状腺手术中甲状旁腺误切的危险因素。方法回顾性分析2013年1月至2016年6月期间在四川大学华西医院甲状(旁)腺疾病外科诊疗中心因甲状腺良恶性结节至少行甲状腺全切除的983例患者的临床资料。依据术后病理学检查结果所示的切除标本是否存在整枚或大部分甲状旁腺,将患者分为误切组和非误切组。比较2组患者的临床资料数据,并采用单因素及多因素方法探索甲状旁腺误切的危险因素。结果983例甲状腺疾病患者中,发生甲状旁腺误切50例(误切组),未发生甲状旁腺误切933例(非误切组)。术后暂时性甲状旁腺功能低下发生率:误切组为66.0%(33/50),非误切组为36.2%(338/933),2组比较差异有统计学意义,误切组较高(χ~2=19.903,P<0.05);术后永久性甲状旁腺功能低下发生率:误切组为2.0%(1/50),非误切组为0.4%(4/933),2组比较差异无统计学意义(χ!2=2.315,P=0.128)。单因素分析结果表明,双侧中央区淋巴结清扫(P=0.004)和术中辨认甲状旁腺总数≤2枚(P=0.002)是甲状腺手术中甲状旁腺误切的危险因素;多因素分析结果表明,双侧中央区淋巴结清扫[OR=2.553,95%CI为(1.236,5.277),P=0.011]和术中辨认甲状旁腺总数≤2枚[OR=2.819,95%CI为(1.423,5.581),P=0.003]是甲状腺手术中甲状旁腺误切的独立危险因素。结论甲状腺手术应充分评估患者的获益与风险,合理施行双侧中央区淋巴结清扫。甲状腺手术医师应努力提高对甲状旁腺的辨认能力,从而降低手术中甲状旁腺误切的发生率。     

Extensive thyroidectomy in Graves' disease

BACKGROUND: The best surgical treatment for hyperthyroidism caused by Graves' disease remains a controversial subject. METHODS: Seven hundred fourteen consecutive patients underwent total or near-total thyroidectomy for Graves' disease in a 13-year period. In a first analysis, postoperative rates of suffocating hematoma, wound infection, recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, and persistence or recurrence of hyperthyroidism, were studied and compared with the same parameters in 4,426 patients who underwent bilateral thyroid gland resection for other conditions. A second analysis identified factors associated with postoperative complications among Graves' disease patients. RESULTS: Comparing Graves' disease patients with patients who had bilateral thyroid resection for other conditions, the transient morbidity rate was 13.3% versus 8.2% (p < 0.0001), with 10.2% versus 5.0% (p < 0.0001) hypoparathyroidism, 2.2% versus 1.7% (p = 0.35) RLN palsy, 1.7% versus 0.9% (p < 0.05) suffocating hematoma, and 0.3% versus 0.4% (p = 0.67) wound infection, respectively. Permanent morbidity rate was 2% versus 2.2% (p = 0.72), including 0.4% versus 0.6% RLN palsy and 1.5% versus 1.7% hypoparathyroidism. Among the Graves' disease patients, univariate analysis revealed that those who experienced postoperative complications had a higher weight resected thyroid gland (odds ratio = 1.5; 95% CI, 1.0-2.3) and a higher rate of total thyroidectomy (24.4% versus 19.5%, odds ratio = 2.2; 95% CI, 1.4-3.4) than patients without complications. In the multivariable model, these two factors remained independent. There was no recurrence of hyperthyroidism with a median followup of 6.7 years (interquartile range 4.1 to 10.1 years). Persistent hyperthyroidism developed in three patients. CONCLUSIONS: Total or near-total thyroidectomy is an effective and safe treatment for Graves' disease when performed by an experienced surgeon.     

Reoperative surgery for thyroid disease

Background and aims Reoperative surgery for thyroid disease is rare. However, it is sometimes indicated for nodular recurrence after partial surgery for initially benign thyroid disease or for a completion total thyroidectomy when a final diagnosis of well-differentiated thyroid cancer (WDTC) is confirmed on a permanent section of a partially removed thyroid gland. This surgery can expose the patient to postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. The aims of our study were to describe the population subjected to reoperative thyroid surgery and to evaluate postoperative morbidity to find the risk factor. Patients and methods The present study is a retrospective analysis of our experience with completion thyroidectomy: 685 consecutive patients underwent this procedure in a 14-year period, for a recurrent uninodular (85 patients) or multinodular (333 patients) goiter, recurrent thyrotoxicosis (42 patients), or a completion thyroidectomy for WDTC after partial resection of the thyroid gland (225 patients). The operative technique was standardized with identification of the RLN and parathyroid glands before removal of the thyroid gland. l-Thyroxin treatment was started the day after surgery. Postoperative rates of suffocating hematoma, wound infection, RLN palsy, hypoparathyroidism, and persistence or recurrence of hyperthyroidism were studied and compared to the same parameters in patients who underwent primary bilateral thyroid gland resection during the same period. Results The transient morbidity rate was 8%, with 5% hypoparathyroidism, 1.2% RLN palsy, 0.9% suffocating hematoma, and 0.2% wound infection. These results were higher than those from cases of primary thyroid resection for bilateral disease. Within the secondary surgery group, postoperative complications depended on the mean weight of the resected thyroid gland, hyperthyroidism, and the bilaterality of thyroid exploration during the previous surgery. The permanent morbidity rate was 3.8%, including 1.5% RLN palsy and 2.5% hypoparathyroidism. Permanent complication rates were higher than those for primary thyroid resection. Incidental carcinoma was found in 92 patients (13%): 10% (42 of 418) in patients with recurrent euthyroid nodular disease, 7% (3 of 42) in patients with recurrent hyperthyroidism, and 21% (47 of 225) in patients who underwent a completion thyroidectomy for cancer. Conclusion Because reoperative thyroid surgery can lead to potential complications, especially permanent RLN palsy or hypoparathyroidism, it should be reserved for patients who need it. The importance of respecting specific technical rules should be emphasized.     

甲状旁腺的术中观察及术后甲状旁腺功能减退的探讨

目的在甲状腺手术中认识甲状旁腺的局部解剖及甲状腺手术切除范围和甲状旁腺功能减退的关系,探讨术后甲状旁腺功能减退的原因及预防治疗措施。方法回顾2582例甲状腺手术患者的临床资料并术后随访。结果其中对721例双侧甲状腺侧叶全切者行术中探察,发现甲状腺病理状态下甲状旁腺的局部解剖位置及数量变异大,探察到的每种情况术后暂时性甲状旁腺功能减退发生率各不相同,其中上下甲状旁腺双侧均不明显组永久性甲状旁腺功能减退发生1例。2453例手术中行甲状腺部分切除、单侧叶次全切除、单侧叶全切除、双侧叶全切除、双侧叶全切及颈淋巴结清扫者（即甲状腺癌根治）暂时性甲状旁腺功能减退发生率依次增高,其中以双侧叶次全切除暂时性甲状旁腺功能减退发生率最高。且又因甲状腺疾病病种各不相同,甲状旁腺功能减退发生率亦各不相同。结论术后甲状旁腺功能减退的发生与手术操作、甲状旁腺的局部解剖及其变异、甲状腺手术切除范围、巨大甲状腺及其内巨大包块对双侧甲状腺后被膜深面组织的压迫,甲状腺疾病病种不同而手术难度各异等皆有关系。     

内镜甲状腺手术对甲状旁腺的辨别与保护研究

目的探讨在内镜甲状腺手术中辨别和保护甲状旁腺的方法。方法回顾性分析2006年10月至2010年7月160例行颈前小切口内镜辅助甲状腺手术患者的临床资料,其中甲状腺瘤58例,结节性甲状腺肿82例,原发性甲状腺功能亢进16例,甲状腺乳头状癌4例。行一侧甲状腺次全切除术90例,双侧甲状腺次全切除术46例,甲状腺全切术20例,甲状腺全切术＋中央组淋巴结清扫4例,术中均对甲状旁腺进行精确辨认及有效保护。结果 160例均成功完成手术,术后暂时性甲状旁腺功能减退4例（2.5%）,未出现永久性甲状旁腺功能减退。结论内镜辅助甲状腺手术在术中可通过内镜放大作用对甲状旁腺进行精确辨认,并在内镜视野下完成对甲状旁腺血供的精细解剖和分离,有效的保护了甲状旁腺及其血供,明显降低了术后甲状旁腺功能减退并发症的发生率。     

甲状腺癌根治术致甲状旁腺功能减退的危险因素及预防

目的:探讨甲状腺癌根治术中可能导致甲状旁腺功能减退的危险因素及预防措施。方法:回顾性分析首都医科大学附属北京同仁医院普通外科2014年全年由同一外科医师实施的75例甲状腺癌手术的临床资料。结果:全组术后发生甲状旁腺功能减退20例(26.67%),其中暂时性甲状旁腺功能减退19例(25.33%),永久性甲状旁腺功能减退1例(1.33%)。甲状腺全切术患者甲状旁腺功能减退发生率明显高于甲状腺近全切除术患者(46.88%vs.11.63%,P0.05);行VI区淋巴结清扫患者甲状旁腺功能减退发生率明显高于未行VI区淋巴结清扫患者(45.71%vs.10.00%,P0.05);同时行自体甲状旁腺移植术患者甲状旁腺功能减退发生率高于未行甲状旁腺移植患者,但差异无统计学意义(50.00%vs.22.22%,P0.05)。结论:甲状腺全切和Ⅵ区淋巴结清扫是导致甲状旁腺功能减退的危险因素。术中精细解剖甲状腺后被膜,尤其是尽可能保留下甲状旁腺血运,术后应用预防性药物可能有助于甲状旁腺功能的保护。     

Multivariate Analysis of Risk Factors for Postoperative Complications in Benign Goiter Surgery: Prospective Multicenter Study in Germany

Risk factors for postoperative complications of benign goiter surgery have not been investigated systematically. To this end, a prospective multicenter study (January 1 through December 31, 1998) was conducted involving 7266 patients with surgery for benign goiter from 45 East German hospitals. High-volume providers (>150 operations per year) performed 69% (5042/7266), intermediate-volume providers 27% (50–150), and low-volume providers 4% (258/7266) of operations. Among the hospital groups, the pattern of thyroid disease did not vary significantly, but there was a trend that small-volume providers tended to perform more operations for uninodular goiter and high-volume providers treated more patients with Graves' disease and recurrent goiter. Extent of resection (p < 0.0001) and remnant size (multinodular goiter and recurrent goiter, p < 0.001), differed significantly, with total thyroidectomy being performed more often in hospitals with more than 150 operations compared to hospitals with an operative volume of less than 150 procedures per year. Despite the larger extent of resection and smaller remnant size, rates of recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism were not increased. When the logistic regression analyses were fitted to evaluate the impact of risk factors on transient and permanent RLN palsy and hypoparathyroidism, larger extent of resection [relative risk (RR) 1.5–2.1] and recurrent goiter (RR 1.8–3.4) consistently evolved as independent risk factors. With hypoparathyroidism, additional significant factors included patient gender (RR 2.1–2.4), hospital operative volume (RR 0.8–1.5), and Graves' disease (RR 2.8). Unlike parathyroid gland identification during hypoparathyroidism, RLN identification (RR 1.6) significantly (p= 0.01) reduced permanent RLN palsy rates. The multivariate analyses clearly confirmed the pivotal role of routine RLN identification, independent of the extent of the thyroid resection. These findings might help hospitals with lower operative volumes to identify patients at increased risk whom they might consider for specialist care.     

Dysfunction of calcium metabolism following resection of the thyroid gland. An analysis of important risk factors

PURPOSE: Dysfunction of the parathyroid glands is a typical complication following thyroid surgery. Risk factors for the development of postoperative symptomatic hypocalcemia were retrospectively analyzed. METHODS: 308 consecutive thyroid resections (women n = 236, men n = 72, mean age 53 years) performed in 1996 and 1997 were evaluated. Main diagnosis was non-toxic nodular goiter (n = 234, 76 %), 28 patients (9 %) had thyroid carcinoma. The most common operation performed was bilateral functional thyroid resection (n = 116, 38 %), the proportion of thyroidectomies was 14 % (n = 44). The patients with postoperative symptomatic hypocalcemia were followed for a median of 32 months. RESULTS: Clinical symptoms of hypocalcemia were observed in 18 patients (6 %) postoperatively. Three patients developed transient (n = 1) or permanent hypothyroidism (n = 2). In univariate analysis, the underlying thyroid disease, the method of operative therapy, removal, identification and autotransplantation of parathyroid glands, in multivariate analysis, thyroidectomy (relative risk 6.9) and removal of parathyroid glands (relative risk 23.9) were proved to be significant risk factors for the development of postoperative symptomatic hypocalcemia (p < 0.05). CONCLUSIONS: Patients with thyroidectomy, operation for thyroid carcinoma and intraoperative removal of parathyroid glands should be closely followed for postoperative hypocalcemia. Exact surgical technique provided, permanent hypoparathyroidism is rare, particularly if several parathyroid glands were identified intraoperatively and autotransplanted, if necessary.     

Post-thyroidectomy hypocalcemia. Incidence and risk factors

Two hundred twenty-one patients undergoing thyroidectomy were analyzed for factors increasing the risk of postoperative hypocalcemia. Eighty-three percent of all patients experienced hypocalcemia postoperatively, with 13 percent requiring some treatment for symptoms. Patients with advanced thyroid cancer, Graves' disease, or other manifestations of preoperative hyperthyroidism had significantly increased rates of hypocalcemia compared with patients with small cancers or benign euthyroid disease. Total thyroidectomy, repeat thyroidectomy, and thyroidectomy plus neck dissection all significantly increased the incidence of permanent hypocalcemia, whereas lobectomy or subtotal thyroidectomy for benign euthyroid disease were low risk operations. Inadvertent excision of more than one parathyroid gland during thyroidectomy also significantly increased the rate of permanent hypocalcemia.     

Parathyroid autotransplantation during thyroidectomy: is frozen section necessary?

OBJECTIVE: To evaluate the accuracy of parathyroid gland identification and the need for routine frozen section examination before parathyroid autotransplantation during thyroidectomy. DESIGN: A prospective case series. SETTING: An endocrine surgical unit. PATIENTS: From January 1, 1995, to December 31, 1997, parathyroid autotransplantation was attempted for devascularized or inadvertently removed glands in 152 (33.7%) of 450 patients during thyroidectomy. Before autotransplantation, a biopsy specimen of the transplanted tissue was sent for histological examination without frozen section confirmation. MAIN OUTCOME MEASURES: Positive identification of parathyroid tissue in microscopic examination. RESULTS: Of 179 attempted autotransplantations of parathyroid glands, parathyroid tissue was confirmed in 167 biopsy specimens (93.3%). Incorrect identification of parathyroid gland occurred in 12 instances. The tissue mistaken as parathyroid gland included fat in 6 cases, thyroid tissue in 4 cases, lymph node in 1 case, and thymus in 1 case. Transplantation of at least 1 parathyroid gland (range, 1-3) was confirmed in 144 patients. For patients with confirmed parathyroid autotransplantation at risk of hypoparathyroidism (n = 112), postoperative transient hypocalcemia occurred in 22 (19.6%), while no patient developed any permanent hypocalcemia during a median follow-up of 6 months. CONCLUSIONS: Devascularized or inadvertently removed parathyroid glands can be identified expeditiously without routine frozen section during thyroid surgery. Immediate autotransplantation should be performed and permanent hypoparathyroidism can be avoided with this measure.     

Rolle der totalen Thyreoidektomie im primären Therapiekonzept der benignen Knotenstruma

INTRODUCTION: After subtotal resection of multinodular goiter, rates of up to 40% are reported for recurrent goiter in the long-term follow-up. Because of the increased morbidity of surgery for recurrent goiter, this study evaluated the preconditions that would justify total thyroidectomy as part of the primary therapy concept for benign multinodular goiter. MATERIAL AND METHODS: The Quality Assurance Study of Benign and Malignant Goiter covering the period from 1 January to 31 December 1998 assessed 5195 patients treated for benign goiter by primary bilateral resection. With respect to the extent of resection three groups were analyzed: bilateral subtotal resection (ST+ST, n=4580), subtotal resection with contralateral lobectomy (ST+HT, n=527), and total thyroidectomy (TT, n=88). RESULTS: The age of the patients was significantly higher (60.3 years) in the TT group than in the ST+ST (52.5 years) and ST+HT (55.6 years) groups. ASA classification grades III and IV were significantly more frequent in the TT group. The postoperative morbidity increased with the extent of resection. The rate of permanent recurrent laryngeal nerve (RLN) palsy was 0.8% for ST+ST, 1.4% for ST+HT, and 2.3% for TT and of permanent hypoparathyroidism 1.5% for ST+ST, 2.8% for ST+HT, and 12.5% for TT. Multivariate analysis showed that the extent of resection significantly increased the risk of RLN palsy (transient RR 0.5, permanent RR 0.4) and hypoparathyroidism (transient RR 0.2,permanent RR 0.08). The surgeon's experience (RR 0.6) and identification of the RLN (RR 0.5) reduced the risk of permanent RLN palsy. Additionally, the development of permanent hypoparathyroidism was reduced if at least two parathyroid glands (RR 0.4) were identified. CONCLUSION: Total thyroidectomy is associated with an increased rate of RLN palsies and hypoparathyroidism in comparison to less extensive thyroid surgery. In the hands of well-trained surgeons using an appropriate intraoperative technique, primary thyroidectomy is justified if the patient has an increased risk of recurrent goiter. Due to the increased postoperative morbidity after total thyroidectomy, subtotal thyroid resection based on the morphologic changes in the thyroid gland is still recommended as the standard treatment regimen for multinodular goiter.     

Selective parathyroid auto‐transplantation during thyroidectomy

Aim: Permanent hypoparathyroidism is a debilitating morbidity following thyroidectomy and parathyroid auto‐transplantation has been shown to be effective in preventing permanent hypoparathyroidism. Controversy exists regarding the benefit of routine versus selective auto‐transplantation. We evaluate the outcome of selective parathyroid auto‐transplantation in our hospital. Methods: A retrospective study was conducted to assess the incidence of postoperative hypocalcaemia. Indication for parathyroid auto‐transplant was doubtful viability of parathyroid gland during thyroidectomy. From 1 July 2000 to 30 June 2005, all patients who underwent total, subtotal and completion thyroidectomy were included. Other outcome measures including recurrent laryngeal nerve injury and operative time were also analyzed. Results: A total of 170 bilateral or completion thyroidectomies were performed within this period. Total, subtotal, and completion total thyroidectomies were performed in 103 (60.6%), 62 (36.5%), and five (2.9%) patients, respectively. Median age was 45 years (range 19–82). One hundred and twenty‐four patients (73%) had benign thyroid disease, and 46 patients (27%) had thyroid carcinoma. Parathyroid auto‐transplant was performed in 35 patients (20.6%). Mean operation time was 204 min (range 95–510 min). There was no difference in the operation time between the patients with parathyroid auto‐transplant and those without auto‐transplant (217 vs 200 min, P = 0.229). Transient hypocalcaemia occurred in 31 patients (18.2%) whereas two patients had permanent hypocalcaemia (1.2%). Permanent recurrent laryngeal nerve injury occurred in one patient (0.6%). Conclusions: The adoption of selective parathyroid auto‐transplant during thyroidectomy achieves an extremely low incidence of permanent hypoparathyroidism without excessive transient hypoparathyroidism.     

Total thyroidectomy is the preferred treatment for patients with Graves' disease and a thyroid nodule.

OBJECTIVE: To identify the indications and outcomes of total thyroidectomy for Graves' disease in a North American cohort. STUDY DESIGN AND SETTING: Prospective database of 297 patients undergoing total thyroidectomy in a tertiary care center identified 49 patients with Graves'. RESULTS: There were 37 women and 12 men (mean age, 37.9 years). Common indications for surgery were: refusal of radioactive iodine (20%), thyroid storm (18%), a thyroid nodule (16%), failure of I131(14%), and ophthalmopathy (14%). Complications included: symptomatic hypocalcemia (14%), permanent hypoparathyroidism (0%), and symptoms of recurrent laryngeal nerve injury (0%). Graves' patients had more bleeding (117 mL versus 48 mL, P<0.05). Clinical nodules were malignant in 38%. Papillary thyroid carcinoma occurred in 10% of patients, with 60% multifocal, and 60% lymph node metastases. CONCLUSION: Total thyroidectomy for Graves' has minimal morbidity. Patients with Graves' and a thyroid nodule are at an increased risk for malignancy and should be treated with a total thyroidectomy.     

Parathyroid autotransplantation during thyroidectomy

Permanent hypoparathyroidism is a debilitating morbidity following thyroidectomy, with a reported incidence of up to 43%. Apart from meticulous dissection to preserve parathyroid glands and their blood supply, parathyroid autotransplantation (PA) has been increasingly employed to preserve parathyroid function. The adoption of PA during thyroidectomy has been reported to be associated with a low incidence of permanent hypoparathyroidism. Biochemical function of parathyroid autografts can be demonstrated objectively by forearm reimplantation or during long-term follow up. The clearest indication for PA is for inadvertently removed or devascularized parathyroid glands during thyroid surgery. Other strategies, including routine autotransplantation of at least one parathyroid gland, can be considered, but is associated with a high incidence of transient hypocalcaemia. Apart from refinement in technique to facilitate graft success, a reliable way to assess overall parathyroid function or viability of individual parathyroid gland may assist in monitoring parathyroid function and selecting patients requiring this procedure to prevent permanent hypoparathyroidism.     

改良Miccoli术式下甲状腺全切除病人甲状旁腺功能保护的研究

目的:探讨甲状腺全切除术后病人甲状旁腺功能减退的影响因素及改良Miccoli术式对于甲状旁腺功能保护的作用。方法:回顾性分析2012年8月至2013年7月在我科行甲状腺全切除的206例病人临床病理资料,根据手术范围分为甲状腺全切除组、全切除+单侧中央区清扫组、全切除+双侧中央区清扫组,对术后甲状旁腺功能减退的可能因素进行分析。结果:206例病人中33例出现甲状旁腺功能减退(16.0%),其中1例为永久性甲状旁腺功能减退(0.5%)。不同年龄、性别、原发灶手术范围的病人术后甲状旁腺功能减退的发生无统计学差异(P0.05)。甲状腺恶性肿瘤(P=0.048)、原位保留甲状旁腺数量减少(P=0.003)、中央区淋巴结转移7枚(P=0.036)的病人,易发生甲状旁腺功能减退。结论:术后甲状旁腺功能减退与原发灶性质、原位保留甲状旁腺数量、中央区淋巴结转移数量有关,改良Miccoli术式在一定程度有利于术中更好地发现和保护甲状旁腺。     

The impact of single parathyroid gland autotransplantation during thyroid surgery on postoperative hypoparathyroidism: a multicenter study

BACKGROUND: We compared the surgical outcomes in patients undergoing bilateral thyroid surgery with or without parathyroid gland autotransplantation (PTAT). METHODS: One thousand three hundred nine patients underwent surgery for treatment of various thyroid diseases at three Academic Departments of General Surgery and one Endocrine-Surgical Unit throughout Italy. A nonviable gland or difficulties in dissection of the parathyroid glands were encountered in 160 (13.7%) patients. The subjects were divided into two groups: (1) patients undergoing PTAT during thyroidectomy (n = 79) versus (2) control group (n = 81), patients not undergoing PTAT. RESULTS: Clinical manifestations occurred in 5.0% of PTAT patients and in 13.6% of control patients (P = NS). Total postoperative hypocalcemia was less among PTAT than control patients (17.7% and 48.1%, respectively; P = .0001). There was no significant difference between the two groups in terms of definitive hypocalcemia (0% vs 2.5% in PTAT and control, respectively). Transient postoperative hypocalcemia was less among PTAT than controls (17.7% vs 45.7%; P = .0002). PTAT was associated with decreased occurrence of hypocalcemia in the two subgroups of patients operated for benign euthyroid disease (P < .0001), as compared with the control group. CONCLUSIONS: PTAT is an effective procedure to reduce the incidence of permanent hypoparathyroidism. Transient hypoparathyroidism appears to not be influenced by PTAT. Moreover, we observed that damage to one parathyroid gland has more side effects (ie, transient hypocalcemia) among patients who were preoperatively at low rather than at high risk of postoperative hypocalcemia.     

Complications and sequelae of benign thyroid surgery]

A series of 640-operations performed on benign thyroid gland during 8 years is presented. The pre and post operative mortality is 0.62 per cent. Late recurrent nerve paralysis occurred in 2.6 per cent. 27 patients had transit hypocalcemia and 8 had permanent hypoparathyroidism or 1.2 per cent. These complications has been studied in relation with patient benign thyroid affection and operation. In case of thyroidectomy without search for recurrent laryngeal nerve, nervous paralysis are frequent when if parathyroid gland are rare, for these lata are protected. Systematic dissection of recurrent nerve reduce nervous sequelae, but increase hypoparathyroidism, mainly by devascularisation of parathyroids glands. Complications and sequelae of thyroid surgery can yet be reduced by a rigorous surgical technic, a most sure experience and a systematic dissection of recurrent nerve and gland parathyroid in case of bilateral operation.