Early Predictors of Post – Thyroidectomy Hypoparathyroidism

Open access


Thyroid surgery is the most commonly performed procedure in the field of endocrine surgery. Studies are still ongoing on the development of a single algorithm for diagnosis and care of patients at risk of postoperative hypoparathyroidism.

The aim of the study was to determine the biochemical marker that would allow the most accurate diagnosis of patient groups at risk of developing hypoparathyroidism and to identify risk factors for this disorder.

Material and methods. The prospective study included 142 consecutive patients undergoing total thyroidectomy for benign goiter from January 1st 2014 to December 31st 2015. Serum intact parathyroid hormone (iPTH), total calcium (Ca), phosphate (P), and magnesium (Mg) levels have been measured preoperatively and at 1, 6, 24, and 48 h postoperatively.

Results. Clinical symptoms of hypoparathyroidism developed in 25 (17.6%) of 142 patients. The best diagnostic accuracy for hypoparathyroidism based on ROC curves was obtained for iPTH at 6h (AUC 0.942; 95% CI: 0.866-1.000, p<0.001) and its percentage change from baseline ΔiPTH at 6h (AUC 0.930; 95% CI: 0.858-1.000, p<0.001). In an multivariate analysis, the preoperative Ca level higher by 0.1 mmol/l, and iPTH level higher by 0.1 pmol/l were associated with a lower risk of hypoparathyroidism, by 68% (p=0.012) and 61% (p=0.007), respectively. A 1% decline in iPTH from baseline increased the risk of hypoparathyroidism by 15% (p<0.001).

Conclusions. The most reliable markers indicating a high risk of postoperative hypoparathyroidism are the decline in ΔiPTH at 6h by > 65% or iPTH level at 6h <1.57 pmol /l. A postoperative decline in iPTH levels is an independent risk factor for the development of hypoparathyroidism. Preoperative higher concentrations of Ca and iPTH are protective factors for the development of this disorder.

1. Rosato L, Avenia N, Bernante P et al.: Complications of thyroid surgery: Analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years World J Surg 2004; 28: 271-76.

2. Grodski S, Serpell J. Evidence for the role of perioperative PTH measurement after total thyroidectomy as a predictor of hypocalcemia. World J Surg 2008; 32.

3. Stack BC, Bimston DN, Bodenner DL et al.: American association of clinical endocrinologists and american college of endocrinology disease state clinical review: postoperative hypoparathyrodism – definitions and management. Endocrine Practice 2015; 21: 674-85.

4. Jumaily JS, Noordzij JP, Dukas AG et al.: Prediction of hypocalcemia after using 1-to 6-hour postoperative parathyroid hormone and calcium levels: an analysis of pooled individual patient data from 3 observational studies. Head and Neck-Journal for the Sciences and Specialties of the Head and Neck 2010: 32: 427-34.

5. Lecerf P, Orry D, Perrodeau E et al.: Parathyroid hormone decline 4 hours after total thyroidectomy accurately predicts hypocalcemia. Surgery 2012: 152.

6. Bergamaschi R, Becouarn G, Ronceray J et al.: Morbidity of thyroid surgery Amer J Surg 1998: 176; 71-75.

7. Puzziello A, Rosato L, Innaro N et al.: Hypocalcemia following thyroid surgery: incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients. Endocrine 2014; 47: 537-42.

8. Pattou F, Combemale F, Fabre S et al.: Hypocalcemia following thyroid surgery: Incidence and prediction of outcome. World J Surg 1998; 22.

9. Rutledge J, Siegel E, Belcher R et al.: Barriers to Same-Day Discharge of Patients Undergoing Total and Completion Thyroidectomy Otolaryngology. Head and Neck Surg 2014; 150: 770-74.

10. Mazeh H, Khan Q, Ms DFS et al.: Same-day thyroidectomy program: Eligibility and safety evaluation Surgery 2012: 152; 1133-39

11. Asari R, Passler C, Kaczirek K et al.: Hypoparathyroidism after total thyroidectomy – A prospective study. Archives of Surg 2008; 143.

12. Payne RJ, Hier MP, Tamilia M et al.: Same-day discharge after total thyroidectomy: The value of 6-hour serum parathyroid hormone and calcium levels. Head and Neck – Journal for the Sciences and Specialties of the Head and Neck 2005; 27.

13. Pisanu A, Saba A, Coghe F et al.: Early prediction of hypocalcemia following total thyroidectomy using combined intact parathyroid hormone and serum calcium measurement. Langenbecks Archiv of Surg 2013; 398: 423-30.

14. Barczynski M, Cichon S, Konturek A: Which criterion of intraoperative iPTH assay is the most accurate in prediction of true serum calcium levels after thyroid surgery? Langenbecks Archiv of Surg 2007; 392: 693-98.

15. Thomusch O, Machens A, Sekulla C et al.: The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: A multivariate analysis of 5846 consecutive patients. Surgery 2003; 133: 180-85

16. Antakia R, Edafe O, Uttley L et al.: Effectiveness of Preventative and Other Surgical Measures on Hypocalcemia Following Bilateral Thyroid Surgery: A Systematic Review and Meta-Analysis. Thyroid 2015; 25: 95-106.

17. Schietroma M, Cecilia EM, Carlei F et al.: Dexamethasone for the Prevention of Recurrent Laryngeal Nerve Palsy and Other Complications After Thyroid Surgery A Randomized Double-Blind Placebo – Controlled Trial. JAMA Otolaryngology-Head & Neck Surgery 2013; 139: 471-78.

18. Australian Endocrine Surgeons Guidelines AES06/01. Postoperative parathyroid hormone measurement and early discharge after total thyroidectomy: analysis of Australian data and management recommendations. ANZ J Surg 2007; 77: 199-202.

19. Bentrem DJ, Rademaker A, Angelos P: Evaluation of serum calcium levels in predicting hypoparathyroidism after total/near-total thyroidectomy or parathyroidectomy Amer Surg 2001; 67: 249-51.

20. Glinoer D, Andry G, Chantrain G et al.: Clinical aspects of early and late hypocalcaemia after thyroid surgery. Eur J Surg Oncol 2000: 26

21. Reeve T, Thompson NW : Complications of thyroid surgery: How to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg 2000; 24: 971-75.

22. Nahas ZS, Farrag TY, Lin FR et al.: A safe and cost-effective short hospital stay protocol to identify patients at low risk for the development of significant hypocalcemia after total thyroidectomy. Laryngoscope 2006; 116: 906-10.

23. Gulluoglu BM, Manukyan MN, Cingi A et al.: Early prediction of normocalcemia after thyroid surgery World J Surg 2005; 29: 1288-93.

24. Scurry WC, Beus KS, Hollenbeak CS et al.: Perioperative parathyroid hormone assay for diagnosis and management of post-thyroidectomy hypocalcemia. Laryngoscope 2005; 115: 1362-66.

25. Noordzij JP, Lee SL, Bernet VJ et al.: Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: An analysis of pooled individual patient data from nine observational studies. J Amer College of Surg 2007; 205: 748-54.

26. Raffaelli M, De Crea C, D’Amato G et al.: Post-thyroidectomy hypocalcemia is related to parathyroid dysfunction even in patients with normal parathyroid hormone concentrations early after surgery. Surgery 2016; 159: 78-84.

27. Middleton L, Stack BC, Jr., Riggs AT et al.: Vitamin D deficiency: A simple algorithm employing weekly administration of 50,000 IU of vitamin D. Amer J of Otolaryngol 2014; 35: 85-88.

28. Lin YH, Ross HL, Raeburn CD et al.: Vitamin D deficiency does not increase the rate of postoperative hypocalcemia after thyroidectomy. Amer J of Surg 2012; 204: 888-93.

29. Cherian AJ, Ponraj S, Gowri SM et al.: The role of vitamin D in post-thyroidectomy hypocalcemia: Still an enigma. Surgery 2016; 159: 532-38.

30. Xiao Q, Murphy RA, Houston DK et al.: Dietary and Supplemental Calcium Intake and Cardiovascular Disease Mortality. JAMA Internal Med 2013; 173: 639-46.

31. Terris DJ, Snyder S, Carneiro-Pla D et al.: American Thyroid Association Statement on Outpatient Thyroidectomy. Thyroid 2013; 23: 1193-1202.

Polish Journal of Surgery

The Journal of Foundation of the Polish Journal of Surgery

Journal Information

CiteScore 2016: 0.29

SCImago Journal Rank (SJR) 2016: 0.166
Source Normalized Impact per Paper (SNIP) 2016: 0.207


All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 161 161 14
PDF Downloads 71 71 6