Prevention, Identification and Management of Postoperative Hypoparathyroidism

Salvatore Lazzara; Alberto Barbera; Guido Nicola Zanghì; Francesco Freni; Grazia Pagano; Andrea Cogliandolo; Ozer Makay; Gianlorenzo Dionigi

doi:10.16956/jes.2018.18.2.121

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Lazzara, Barbera, Zanghì, Freni, Pagano, Cogliandolo, Makay, and Dionigi: Prevention, Identification and Management of Postoperative Hypoparathyroidism

Review Article

J Endocr Surg. 2018;18(2):121-131.

Published online: 5 June 2018

DOI: https://doi.org/10.16956/jes.2018.18.2.121

Prevention, Identification and Management of Postoperative Hypoparathyroidism

Salvatore Lazzara¹, Alberto Barbera¹, Guido Nicola Zanghì², Francesco Freni³, Grazia Pagano¹, Andrea Cogliandolo¹, Ozer Makay⁴, Gianlorenzo Dionigi⁵

¹Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy

²Department of Surgery, Policlinico Vittorio Emanuele University Hospital - General Surgery and Oncology Unit, University of Catania, Catania, Italy

³Division of ENT Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy

⁴Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Izmir, Turkey

⁵Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Messina, Italy

Correspondence to Gianlorenzo Dionigi Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University Hospital G. Martino, University of Messina, Via C. Valeria 1, Messina 98125, Italy. E-mail: gdionigi@unime.it

No potential conflict of interest relevant to this article was reported

Received 25 February 20181 April 2018 Accepted 14 April 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

초록

The objective of this article is to detail and present our experience on the incidence and management of parathyroid dysfunction after thyroid surgery. Selective evaluation of original articles and reviews that were retrieved by a PubMed search over the years 1990 to 2018, as well as of the recommendations of medical societies including the American, European and Asian Thyroid/Endocrine Associations. The literature presents several contributions, with controversial results. The recommended management for the diagnosis and treatment of parathyroid dysfunction after bilateral thyroid surgery or recurrent surgery consists of an intact parathyroid hormone (iPTH) determination 12–24 hours after surgery and calcium substitution in iPTH <15 pg/mL, no substitution with iPTH ≥15 pg/mL. This procedure is safe for the patient and is accepted by patients and social insurances (for short hospital stay).

Keywords: Thyroid gland, Thyroid disease, Parathyroid glands, Parathyroid hormone

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Fig. 1.

The terms “superior” and “inferior” refer to a gland's embryologic origin. (A) The superior parathyroid glands are usually one to 2 centimeters cranial to the junction of the RLN with the inferior thyroid artery and within 1 cm of the entry point for the RLN into the ligament of Berry and the cricoid cartilage. Superior parathyroid glands can be undescended, or can be parapharyngeal, retropharyngeal, or retrotracheal within the middle cervical/mediastinal compartment. (B) The 2 inferior parathyroid glands reside in the anterior mediastinal compartment, anterior to the RLN. They are most often found in the thyrothymic tract, or just inside the thyroid capsule on the inferior portion of the thyroid lobes. The parathyroid glands are variable in number: 3 or more small glands. Occasionally, some individuals may have 6, 8, or even more parathyroid glands. RLN = recurrent laryngeal nerve.

Fig. 2.

The superior parathyroid glands receive their blood and drainage from the inferior thyroid vessels in more than 90% of cases, rarely from the superior ones. The inferior parathyroid glands receive a variable blood supply, from either the ascending branch of the inferior thyroid arteries or the thyroid ima artery. The inferior thyroid artery arises from the subclavian arteries. Each parathyroid vein drains into the superior, middle and inferior thyroid veins. The superior and middle thyroid veins drain into the internal jugular vein, and the inferior thyroid vein drains into the brachiocephalic vein.

Fig. 3.

Identification and preservation of parathyroid gland. (A) Transoral endoscopic thyroidectomy vestibular approach. (B) Open conventional thyroidectomy.

Fig. 4.

ICG as near-infrared fluorescent dye for real-time in situ parathyroid glands perfusion monitoring. ICG = indocyanine green.

Table 1.

Frequency of parathyroid gland autographs, temporary and permanent hypothyroidism after thyroidectomy with and without CND, level 6 and 7

Thyroidectomy	No.	Gland autographs	Temporary hypoparathyroidism	Permanent hypoparathyroidism
Without CND	298	15 (5)	56 (18.7)	3 (1)
Unilateral CND	21	2 (9.5)	5 (23)	0 (0)
Bilateral CND	100	7 (7)	22 (22)	2 (2)
Total	419	24 (5.7)	83 (19.8)	5 (1.1)

Values are presented as number (%). No statistical significance differences are found when comparing between groups (P>0.05).

CND = central neck dissection.

Table 2.

PTH and Ca levels on the 1st postoperative day after bilateral thyroidectomy

iPTH (pg/mL)	No. (%)	Serum Ca (mmol/L)
		<1.8	1.8–2.0	>2.0
>15	233 (78)	1 (0.3)	11 (3.6)	221 (74)
10–15	44 (14)	2 (0.6)	19 (6.3)	23 (7)
<10	21 (7)	4 (1.3)	16 (5.3)	1 (0.3)
Total	298	7 (2.3)	46 (15.4)	245 (82)

Values are presented as number (%). Normal range: serum Ca: 2.0–2.6 mmol/L, iPTH: 15–65 pg/mL. Central lymph node dissection cases are excluded from the analysis.

PTH= parathyroid hormone; Ca = calcium; iPTH = intact parathyroid hormone.

Table 3.

Ca/vitamin D substitution as a function of iPTH levels 12–24 hours postoperatively and in the course of (almost total) thyroidectomy (with/without CND, level 6–7)

Variables	Laboratory (iPTH, [total Ca])
12–24 hours postoperative
iPTH (pg/mL)	>15	10–15	<10
Parathyroid function	Normal	Questionable normal hypofunction	Underactive
Substitution “standard dose”	None	Yes	Yes
Ca in mg/cholecalciferol in I.E. p.o.		2×1,000/880	3×1,000/880
Calcitriol in µg [1,25(OH)2D3]		2×0.25	3×0.25
Reduction 1 week postoperatively “maintenance dose”		No	Yes
Ca in mg/cholecalciferol in I.E. p.o.			2×1,000/880
Calcitriol in µg [1,25(OH)2D3]			2×0.25
Laboratory (iPTH) 2 weeks postoperatively		Yes	Yes
iPTH (pg/mL)		>15	<15
Substitution		Finish	Continue
Laboratory (iPTH) 6–8 weeks postoperatively			Yes
iPTH (pg/mL)			>15
Substitution			Finish

Modified from references 2 and 30.

Ca = calcium; iPTH = intact parathyroid hormon; CND = central neck dissection; I.E. = International Units; p.o. = per os.

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