Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up.

SUMMARY BACKGROUND DATA: Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy. METHODS: An analysis of 194 patients having thyroidectomy and simultaneous parathyroid autotransplantation at Barnes Hospital from 1990 to 1994 was performed. Data were collected regarding patient demographics, indication for thyroidectomy, operative procedure, pathologic diagnoses, and postoperative course, including biochemical assessment of parathyroid autograft function. RESULTS: Of 194 patients having either total, subtotal, or completion thyroidectomy, 104 (54%) experienced a [Ca(+2)]nadir less than or equal to 8.0 mg/dL and had symptoms and signs of hypocalcemia. Parathyroid autotransplantation was successful in 103 (99%) of these 104 cases and resulted in a 1.0% incidence of hypoparathyroidism in this series. CONCLUSIONS: Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.     

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.     

Routine parathyroid autotransplantation during thyroidectomy

BACKGROUND: Parathyroid autotransplantation (PTHAT) during thyroidectomy has been shown to reduce the incidence of permanent hypoparathyroidism. Although selective PTHAT is most commonly adopted, the value of routine PTHAT has not been well documented. METHODS: From January, 1998 to March, 1999, an operative strategy incorporating routine autotransplantation of at least 1 parathyroid gland was used during thyroidectomy. The postoperative outcome of patients (n = 118) was evaluated and compared with patients (n = 271) operated during a policy of selective PTHAT (January, 1995 to October, 1997). RESULTS: Two or more parathyroid glands were autotransplanted in 26 patients (22%) while 92 patients (78%) received autotransplantation of 1 parathyroid gland. Postoperative hypocalcemia occurred in 29 patients (25%) and 2 patients (1.7%) had permanent hypocalcemia develop. When a policy of selective PTHAT was adopted, 98 patients (36%) underwent PTHAT, and 5 patients developed permanent hypocalcemia (1.8%). The incidence of postoperative hypocalcemia was higher in patients who underwent routine PTHAT (25%) compared with that in patients who underwent selective PTHAT (15%) (P =.014). In addition, the operating time was significantly longer when routine PTHAT was adopted (153 minutes vs 130 minutes; P <.001). CONCLUSIONS: A low incidence of permanent hypoparathyroidism can be achieved by either routine or selective PTHAT during thyroidectomy but routine PTHAT is associated with a high incidence of postoperative 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.     

Does autoimmune thyroid disease affect parathyroid autotransplantation and survival?

Background: While the increased risk to parathyroid gland preservation has long been recognized during surgery for thyroid cancer, the effect of different benign pathological conditions on parathyroid preservation has not previously been reported. The aim of this study was to examine parathyroid viability in relation to autoimmune thyroid disease. Methods: This is a retrospective cohort study including all patients having an initial total thyroidectomy (TT) performed by this unit during the period 2004–2005. Results: A total of 628 patients underwent TT in the study period. For the Graves' disease cases, 45 (62.5%) required the autotransplantation of one or less parathyroid gland, whereas 27 (37.5%) required two or more glands to be autotransplanted. This was significantly higher than for the benign thyroid disease group in which the respective figures were 242 (77.6%) and 70 (22.4%) (P= 0.01). Of the lymphocytic thyroiditis cases, 61 (65.5%) required the autotransplantation of one or less gland, whereas 32 (34.4%) required the autotransplantation of two or more glands. This was also significantly higher (P= 0.03). Temporary hypocalcaemia was significantly higher when two or more glands were autotransplanted (23 out of 177, 13.2%) than one or less gland autotransplanted (18 out of 451, 4.0%, P < 0.01). However, the overall incidence of permanent hypoparathyroidism was 1.0%, and there was no significant difference between the groups. Conclusion: TT performed for Graves' disease and lymphocytic thyroiditis results in the autotransplantation of more parathyroid glands, leading to a higher incidence of temporary hypocalcaemia post‐operatively. Despite this, the incidence of permanent hypoparathyroidism remains low at 1%.     

达芬奇机器人甲状腺手术中甲状旁腺的损伤因素及保护

目的分析达芬奇机器人甲状腺手术中甲状旁腺损伤的相关因素,探讨甲状旁腺保护的方法,避免永久性甲状旁腺功能减退的发生。 方法回顾性分析2014年1月至2016年5月在济南军区总医院甲状腺乳腺外科行达芬奇机器人甲状腺手术的190例患者的临床资料,统计术后患者出现低甲状旁腺激素(PTH)及低血钙的发生率,分析术后发生甲状旁腺功能减退的相关因素,探讨术中如何保护甲状旁腺及其功能。 结果患者术后暂时性低PTH的发生率为20.53%(39/190),暂时性低血钙的发生率为23.68%(45/190),术后随访无永久性甲状旁腺功能减退发生。甲状腺全切术后低PTH、低血钙的发生率高于腺叶 ＋ 峡部切除术者(χ²＝14.789,11.604;P＝0.000,0.001)。行中央区淋巴结清扫的患者术后低PTH、低血钙的发生率高于未清扫者(χ²＝11.200,17.771;P＝0.001,0.000)。甲状旁腺原位保留者术后低PTH、低血钙的发生率低于切除后自体移植者(χ²＝5.536,4.851,6.140,5.453;P＝0.019,0.028,0.013,0.020)。 结论在达芬奇机器人甲状腺手术中,甲状腺全切除、中央区淋巴结清扫、甲状旁腺切除后自体移植是造成患者术后暂时性甲状旁腺功能减退的重要影响因素。在达芬奇机器人手术系统下,准确识别甲状旁腺,精细化手术操作,原位保护甲状旁腺及血供,是预防永久性甲状旁腺功能减退的有效方法。     

Assessment of parathyroid autotransplantation for preservation of parathyroid function after total thyroidectomy

BACKGROUND: Hypoparathyroidism with permanent hypocalcemia is a well-recognized complication after thyroid surgery. AIM: This study was conducted to assess the role of immediate parathyroid autotransplantation in the preservation of parathyroid function after total thyroidectomy. PATIENTS AND METHODS: Twenty-eight patients had autotransplantation of parathyroid glands resected or devascularized during total thyroidectomy. Data were collected prospectively regarding demographics, indication for surgery, operative procedure, pathologic diagnosis, number of glands transplanted, and subsequent course. Thyroid nodules were evaluated by ultrasonography, radionuclide scanning, and/or fine-needle aspiration cytology. All patients had serum ionized calcium, phosphorus, and intact parathyroid hormone (PTH) levels measured preoperatively and monitored regularly postoperatively for a period of 14 weeks and again at 6 months after operation. Patients were categorized into three groups according to the number of glands transplanted: one (group 1, n = 6), two (group 2, n = 14), or three glands (group 3, n = 8). In three other volunteers, one parathyroid gland was transplanted in the brachioradialis and subjected to electron microscopy 1, 2, and 4 weeks after transplantation. RESULTS: Total thyroidectomy was performed for malignant disease in 16 patients (57.1%) and for benign disease in 12 (42.9%) patients. All patients reverted to asymptomatic normocalcemia without the need for any medications within 4 to 14 weeks. Normal levels of serum markers were regained slower when one gland was transplanted compared with two or three glands (P <.01). Electron microscopic examination showed evidence of ischemic degeneration in the transplanted tissues 1 week postoperatively. Regeneration started by the second week and coincided with normalization of PTH levels. Optimum resting and nearly normal status of parathyroid tissue was achieved by the fourth week. CONCLUSIONS: This study showed that active PTH production coincides with regeneration of parathyroid cells and that autotransplantation of at least two resected or devascularized glands during total thyroidectomy nearly eliminates permanent postoperative hypoparathyroidism, thus improving the safety of total thyroidectomy performed for malignant or benign disease.     

Parathyroid Autotransplantation during Total Thyroidectomy—Does the Number of Glands Transplanted Affect Outcome?

Parathyroid autotransplantation is a technique for ensuring the continued function of parathyroid tissue at the time of total thyroidectomy (TT). The aim of this study was to ascertain whether the number of parathyroids transplanted affects the incidence of temporary and permanent hypoparathyroidism. A retrospective cohort study included all patients undergoing a TT in a single unit between July 1998 and June 2003. The number of parathyroids transplanted, the final pathology, and the incidence of temporary and permanent hypoparathyroidism were documented. Fisher’s exact test was used for statistical analysis. A total of 1196 patients underwent a TT during the 5 years studied. Of these, 306 (25.6%) had no parathyroids transplanted, 650 (54.3%), 206 (17.2%), 34 (2.8%) had 1,2, or 3 glands autotransplanted, respectively. The incidence of temporary hypoparathyroidism was 9.8% for no gland transplants, 11.9%, 15.1%, and 31.4% for 1,2,and 3 gland transplants, respectively (p < 0.05). The incidence of permanent hypoparathyroidism was 0.98%, 0.77%, 0.97%, and 0%, respectively (p = NS). The incidence of temporary hypoparathyroidism was higher when surgery was performed for Graves’ disease. Temporary hypocalcemia is closely related to the number of autotransplanted parathyroids during TT. The long-term outcome is not affected by the number of parathyroids autotransplanted. A “ready selective” approach to parathyroid autotransplantation is an effective strategy for minimizing the rate of permanent hypoparathyroidism.     

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.     

甲状腺全切除术治疗良性甲状腺疾病128例临床疗效

目的：探讨甲状腺全切除术治疗甲状腺良性疾病的疗效及术后并发症的预防。方法：回顾性分析128例行甲状腺全切除术的甲状腺良性疾病病人的临床资料,其中首次手术者98例,再次手术者30例。分析总结该128例病人的术后并发症。结果：128例病人术后均未发生永久性甲状旁腺功能低下和永久性喉返神经损伤。首次甲状腺全切除组术后暂时性喉返神经损伤和暂时性甲状旁腺功能低下的发生率均为1．02％,再次手术组的发生率明显增高,分别为10．00％和13．33％,两组比较,Fisher精确概率P分别为0．040、0．011。两组暂时性喉上神经损伤发生率均很低,无明显差别。结论：对符合指征的良性甲状腺疾病,甲状腺全切除术是一合适的治疗选择。熟悉甲状腺解剖和精细手术操作,可有效预防并发症发生。     

The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients

BACKGROUND: Limited information exists about risk factors for postoperative hypoparathyroidism after bilateral thyroid surgery. METHODS: Between January 1 and December 31, 1998, bilateral thyroid surgery was performed on 5846 patients for benign and malignant thyroid disease. Data were prospectively collected by questionnaires from 45 hospitals. A logistic regression model was used to determine independent risk factors. RESULTS: The overall incidence of transient and permanent hypoparathyroidism was 7.3% and 1.5%, respectively. On logistic regression analysis, total thyroidectomy (odds ratio [OR], 4.7), female gender (OR, 1.9), Graves' disease (OR, 1.9), recurrent goiter (OR, 1.7), and bilateral central ligation of the inferior thyroid artery (OR, 1.7) constituted independent risk factors for transient hypoparathyroidism. When the multivariate analysis was confined to permanent hypoparathyroidism, total thyroidectomy (OR, 11.4), bilateral central (OR, 5.0) and peripheral (OR, 2.0) ligation of the inferior thyroid artery, identification and preservation of no or only a single parathyroid gland (OR, 4.1), and Graves' disease (OR, 2.4) emerged as independent risk factors. CONCLUSIONS: Extent of resection and surgical technique had a greater impact on the rates of permanent postoperative hypoparathyroidism than thyroid pathologic condition. In bilateral thyroid surgery, peripheral ligation of the inferior thyroid artery at the thyroid capsule should be favored over central ligation, and at least 2 parathyroid glands should be identified and preserved. High-risk procedures, such as total thyroidectomy and Graves' disease, require special surgical training and expertise.     

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.     

Applicability of Intraoperative Parathyroid Hormone Assay During Total Thyroidectomy as a Guide for the Surgeon to Selective Parathyroid Tissue Autotransplantation

Background Intraoperative parathyroid hormone assay (IOPTH) has been suggested to have value in predicting the development of postoperative hypoparathyroidism after thyroid surgery. IOPTH has been validated in identification of patients at risk of postoperative hypocalcemia requiring early onset of calcium supplementation therapy and in improving selection of patients eligible for a safe early discharge. However, the value of IOPTH has not been assessed in a randomized study as a guide for the surgeon to parathyroid tissue autotransplantation (PA). The objective of this study was to evaluate the applicability of IOPTH in guiding the surgeon to selective parathyroid tissue autotransplantation during total thyroidectomy (TT). Methods Between January 2005 and December 2005, 340 patients qualified for total thyroidectomy (TT) who met the inclusion criteria were randomized to two equal-sized groups (n = 170): group A, in which elective PA of at least one parathyroid gland was performed in all cases without IOPTH as a guide; and group B, in which selective IOPTH-guided PA was performed, if only the iPTH plasma level was <10 ng/L at 10–20 min after TT (before skin closure). The standard technique of PA consisting of implanting the parathyroid tissue into 10–20 sternocleidomastoid muscle pockets was used in both groups. IOPTH measurements were performed by the STAT-Intraoperative-iPTH-Assay. Serum calcium was routinely monitored at 4, 12, 24, 48, and 72 hr postoperatively. The incidence and severity of hypocalcemia and related symptoms were matched with the IOPTH results. On follow-up, serum calcium and plasma iPTH values were measured at 1, 3, and 6 months postoperatively. The primary end point was the success rate in preventing permanent postoperative hypoparathyroidism. The secondary end point was the use of postoperative medication for transient hypocalcemic symptoms. Results Twenty-one group B patients (12.3%) had plasma iPTH levels <10 ng/L at 10–20 min after TT (before skin closure) and they underwent selective IOPTH-guided PA. None of the patients from both groups experienced permanent postoperative hypoparathyroidism. Transient postoperative hypocalcemia occurred in 22.3% vs. 11.2% of patients (group A vs. B, respectively; p < 0.05). The mean cumulated serum calcium values were significantly lower for group A vs. group B patients within the entire 3-month period after TT (2.12 ± 0.09 mmol/L vs. 2.27 ± 0.05 mmol/L, respectively; p < 0.001). The mean oral calcium supplementation was significantly higher for group A vs. group B patients during the 3 months after TT (2.7 ± 0.9 g/day vs. 0.9 ± 0.4 g/day, respectively; p < 0.001). Conclusions IOPTH offers valuable information during TT, correctly identifying patients at risk of postoperative hypocalcemia. Selective IOPTH-guided PA in patients with plasma iPTH levels <10 ng/L at 10–20 min after TT reduces the risk of permanent postoperative hypoparathyroidism to zero, and this approach seems to be as effective as elective PA of at least one parathyroid gland without IOPTH guidance. Moreover, selective IOPTH-guided PA significantly decreases the incidence of transient postoperative hypoparathyroidism and the need for calcium supplementation therapy compared with elective PA without IOPTH. Presented at the 42^nd World Congress of Surgery, Montreal, Canada, August 26 to 30, 2007.     

Risk factors for postthyroidectomy hypocalcemia

BACKGROUND: Hypocalcemia is a common complication of thyroidectomy. The aim of this study was to evaluate the incidence of hypocalcemia after thyroid operation and its relation to clinical, biologic, and surgical factors. STUDY DESIGN: A retrospective study of 265 patients who underwent unilateral (n = 50) or bilateral (n = 215) thyroidectomy between 1996 and 2000 was done to determine incidence and risk factors for hypocalcemia. Free thyroxine and thyrotropin levels were obtained before operation in 254 patients, together with preoperative and postoperative calcium and phosphorus levels. All patients were examined for age, gender, extent of thyroidectomy, initial versus reoperative neck operation, pathologic characteristics of resected thyroid tissue, substernal thyroid extension, and parathyroid resection and autotransplantation. RESULTS: Hypocalcemia, defined as a calcium level less than 2 mmol/L, occurred in 42 of 265 patients (16%), including 11 (4%) symptomatic patients who required vitamin D, calcium, or both for 2 to 6 weeks. Factors significantly predictive of postoperative hypocalcemia in univariate analysis included elevated free thyroxine level (p = 0.0064), bilateral thyroidectomy (p = 0.00064), parathyroid autotransplantation (p = 0.0128), and female gender (p = 0.0028). Independent risk factors on multivariate analysis were elevated free thyroxine level (p = 0.0476), bilateral thyroidectomy (p = 0.0338), and parathyroid autotransplantation (p = 0.0003). CONCLUSIONS: Bilateral thyroidectomy, elevated free thyroxine level, and parathyroid autotransplantation are independent risk factors for postthyroidectomy hypocalcemia. Oral calcium supplements may be of value in this group of patients to enhance early hospital discharge.     

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.     

纳米炭负显影及甲状旁腺自体移植在甲状腺乳头状癌手术中的应用

目的探讨纳米炭混悬注射液负显影联合甲状旁腺自体移植对甲状旁腺保护的临床意义。 方法回顾性分析2014年5月至2017年05月收治的134例甲状腺乳头状癌(TPC)患者临床资料,将67例注射纳米炭混悬注射液行甲状旁腺负显影及自体移植患者作为纳米炭组,67例常规手术患者作为对照组。应用SPSS17.0进行统计学处理,比较两组患者术后甲状旁腺误切率,手术后暂时性及永久性甲状旁腺功能减退的发生率,采用χ²检验,P<0.05差异有统计学意义。 结果纳米炭组甲状旁腺误切率10.44%(7/67)、暂时性甲状旁腺功能减退发生率10.44%(7/67)、永久性甲状旁腺功能减退发生率4.47%(3/67)明显低于对照组31.34%(21/67)、31.34%(21/67)、21.89%(14/67)差异有统计学意义(P<0.05)。 结论TPC根治术中通过纳米炭混悬注射液进行甲状旁腺负显影联合自体移植术,可有效减少甲状旁腺损伤,降低永久性甲状旁腺功能减退的发生率,提高手术安全性。     

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.     

Hypomagnesemia and Hypocalcemia after Thyroidectomy: Prospective Study

Hypomagnesemia after total thyroidectomy has not been studied extensively. Our anecdotal experience suggests that it may be important in some patients after thyroid excision. The hypomagnesemic hypocalcemic syndrome has been described in other disease states in which a state of functional hypoparathyroidism exists. This study was designed to determine the incidence of hypomagnesemia after total thyroidectomy and relate it to hypocalcemia and symptoms during the postoperative period. A prospective study of all patients undergoing total thyroidectomy between September 1994 and July 1996 was performed. Patient data, thyroid function, retrosternal extension, initial versus reoperative surgery, operative details, parathyroid resection, and pathology were recorded. Calcium, magnesium, electrolytes, blood count, liver function tests, and albumin were measured prior to surgery and twice daily during the postoperative period. Fifty patients underwent total thyroidectomy: 68% were hypocalcemic, 72% were hypomagnesemic, and 36% were symptomatic during the postoperative period. Hypomagnesemia and gender were associated with hypocalcemia. Volume of fluid and neck dissection were associated with low magnesium levels. Hypomagnesemia and parathyroid resection were risk factors for symptoms after thyroidectomy. No patients developed permanent hypoparathyroidism. Transient hypocalcemia and hypomagnesemia occur frequently after total thyroidectomy. The etiology of this phenomenon is probably multifactorial. Patients are more likely to be symptomatic when both cations are low, and attempting to correct only hypocalcemia may prolong symptoms. It is important to monitor both calcium and magnesium levels after total thyroidectomy and to correct deficiencies to facilitate prompt resolution of symptoms.     

LigaSure vs clamp-and-tie technique to achieve hemostasis in total thyroidectomy for benign multinodular goiter: a prospective randomized study

HYPOTHESIS: Occurrence of adverse effects and advantages of the LigaSure diathermy system (or LigaSure vessel sealing system) in total thyroidectomy have not been tested in prospective randomized studies comparing its use with that of the time-saving clamp-and-tie technique to ligate and divide thyroid vessels. The effectiveness of LigaSure in achieving vessel division and hemostasis remains dependent on vessel diameter, and the risk of damage to adjacent structures cannot be completely excluded. We tested the hypothesis that use of LigaSure compared with the clamp-and-tie technique can significantly and conveniently reduce operative time without increasing postoperative complications in patients undergoing total thyroidectomy for benign multinodular goiter. DESIGN: Prospective randomized study. SETTING: Regional hospital. PATIENTS: Two hundred consecutive patients with benign multinodular goiter undergoing total thyroidectomy performed by 1 of 3 surgeons. INTERVENTIONS: According to a randomized sequence, total thyroidectomy was performed in 100 patients using LigaSure and in 100 patients using the clamp-and-tie technique. MAIN OUTCOME MEASURES: End points of the study included the comparative evaluation of postoperative complications, need for parathyroid gland autotransplantation, operative time, and time to hospital discharge. Preoperative, postoperative (24 hours), and 6-week follow-up serum Ca(++) levels are also reported and compared. RESULTS: The postoperative complication rate was 35% overall, including all transient postoperative disturbances. The incidence of cervical hematomas was 2%, but 3 patients (1.5%), 1 in the LigaSure group and 2 in the clamp-and-tie group, required repeat operations because of respiratory tract obstruction. The incidence of permanent complications was 2.5% overall, including 3 patients (1.5%) with permanent hypocalcemia and 2 patients (1%) with permanent recurrent nerve lesions. No statistical difference in the incidence of complications was found between the 2 study groups. Similarly, no difference was found in mean hospitalization time and need for parathyroid gland autotransplantation. Preoperative, postoperative, and 6-week follow-up mean serum Ca(++) levels were not statistically different in the 2 study groups and in the subset of patients undergoing parathyroid gland autotransplantation. Mean operative time was significantly shorter in the LigaSure group, although the mean difference between the 2 study groups was minimal (7.4 minutes). Concomitantly, there was an additional cost of 45euro (US $57.40) per operation using LigaSure. CONCLUSION: The use of LigaSure is equally as safe and effective at vessel division and homeostasis as the clamp-and-tie technique, with a statistically significant (although minimal) decrease in mean operative time. Because of this minimal decrease in operative time, use of LigaSure would allow more patients to undergo total thyroidectomy each year, which would eventually help to offset its higher cost.