Sheetal K, Sooria N Deva, Nikisha G N
Karpaga Vinayaga Institute of Medical Science and Research Center, Chengalpattu, Tamil Nadu India.
Indian J Otolaryngol Head Neck Surg. 2023 Dec;75(4):3402-3409. doi: 10.1007/s12070-023-03949-1. Epub 2023 Jun 24.
Multiple risk factors have been predicted in post operative hypoparathyroidism in total thyroidectomy patients but none have been clearly defined. Present study aims at evaluating the clinic pathological and surgical impact factors in predicting the risk of post operative hypoparathyroidism in thyroidectomy patients. The study was done in Karpaga Vinayaga Institute of Medical Science and Research Centre where Retrospective prospective cohort study who underwent and undergoing total thyroidectomy with or without central neck dissection for both benign and malignant thyroid disorders during 2014 to 2022 was analyzed. The study has analyzed the various risk factors from clinic pathological and surgical skills of identifying the Inferior thyroid artery at its origin and tracing the branches to the parathyroid gland and evaluating the incidence of hypocalcemia in both study and control groups. Two groups were analyzed during the period 2014 to 2022. The study group was included patients with thyroidectomy where ITA were identified and traced up to the parathyroid gland. They were further classified into category A where both sides ITA were identified and saved, category B where only one side was preserved. In control group, the surgery was done only on basis of capsular dissection and peripheral ligation of vessels close to the gland. Total study participants in our study was 416. The overall prevalence of hypocalcemia in our study was 11.4%. The age, gender and pathological variants were comparable between the two groups. Female preponderance (76%) was seen among both the groups. Among total study subjects who underwent total thyroidectomy 44.8% were having multi nodular goitre, 7.3% toxic goitre, 9.8% follicular adenoma, 30.2% papillary carcinoma and 7.9% follicular carcinoma. In our study benign and malignant thyroid disorders had no significant difference. Prevalence of hypocalcemia among control group 14.5% vs study group 3.8%. We found incidence of hypocalcaemia was comparitively lesser among patients with thyroidectomy alone, than those with unilateral or bilateral CND. Prevalence of hypocalcemia among control group was 33% (45/133) and study group 7% (12/153), when thyroidectomy alone was done. However, with neck dissection in bilateral CND, incidence was 41% (23/56) in study group and 61% (11/18) in control group. In unilateral CND, study and control group had 31% (10/32) and 54% (13/24) which was found to be statistically significant. Parathyroid auto transplantation among the control group (29%) compared to the study group (16%). Bilateral neck dissection and gross extrathyroidal extension and cases with PTG inadvertent removal posed significant risk factors for hypoparathyroidism. The prevalence of immediate hypocalcemia among Cat A, Cat B and control group were 14%, 20.3% and 37.5% respectively and was statistically significant ( < .0001). Symptomatic and Biochemical hypocalcemia at the end of 1 week among Cat A, Cat B, and control group was 8%, 12%, and 33.6, & 12.9%, 21% and 30% respectively. Whereas transient hypocalcemia reported among these groups was 1.6%, 5% and 14.6%. Permanent hypocalcemia was < 1% in study group and 4% among control group. We observed that permanent hypocalcemia was high among patients with bilateral neck dissection and auto transplanted PTG. There was no significant statistical difference in hypocalcemia (transient or permanent) among study and control group, but the incidence of hypocalcemia had significantly reduced in both study groups when unilateral or bilateral identification of ITA was done compared to control group. Our hypothesis in this study aims at preserving the branches of ITA supplying PTG distally has greater functional preservation of the parathyroid than conventional technique. This technique also helps us maintaining the plane and capsular dissection if done properly. By trying to preserve the ITA surgeons may acquire better meticulous dissection skills and understanding the anatomical variation of vessels around PTG more precisely which improve the surgical outcome in preventing both transient and permanent hypocalcaemia.
甲状腺全切术后甲状旁腺功能减退的多种风险因素已被预测，但均未明确界定。本研究旨在评估临床病理及手术相关影响因素，以预测甲状腺切除患者术后甲状旁腺功能减退的风险。该研究在卡尔帕加·维奈亚加医学科学与研究中心进行，分析了2014年至2022年间接受或正在接受甲状腺全切术（无论是否行中央区淋巴结清扫）治疗良性及恶性甲状腺疾病的回顾性前瞻性队列研究。该研究分析了来自临床病理及手术操作的各种风险因素，包括在甲状腺下动脉起始处识别并追踪其分支至甲状旁腺，以及评估研究组和对照组低钙血症的发生率。2014年至2022年期间对两组进行了分析。研究组纳入了甲状腺切除术中识别并追踪甲状腺下动脉至甲状旁腺的患者。他们进一步分为A类，即双侧甲状腺下动脉均被识别并保留；B类，即仅保留一侧。对照组仅根据包膜剥离及靠近腺体的血管外周结扎进行手术。本研究的总参与者为416例。本研究中低钙血症的总体患病率为11.4%。两组间年龄、性别及病理类型具有可比性。两组中女性均占多数（76%）。在接受甲状腺全切术的所有研究对象中，44.8%患有多结节性甲状腺肿，7.3%患有毒性甲状腺肿，9.8%患有滤泡性腺瘤，30.2%患有乳头状癌，7.9%患有滤泡癌。在本研究中，良性和恶性甲状腺疾病无显著差异。对照组低钙血症患病率为14.5%，研究组为3.8%。我们发现，单纯甲状腺切除术患者的低钙血症发生率相对低于单侧或双侧中央区淋巴结清扫患者。单纯行甲状腺切除术时，对照组低钙血症患病率为33%（45/133），研究组为7%（12/153）。然而，双侧中央区淋巴结清扫时，研究组发生率为41%（23/56），对照组为61%（11/18）。单侧中央区淋巴结清扫时，则分别为31%（10/32）和54%（13/24），差异具有统计学意义。对照组甲状旁腺自体移植率（29%）高于研究组（16%）。双侧颈部淋巴结清扫、甲状腺外广泛侵犯以及甲状旁腺意外切除的病例是甲状旁腺功能减退的重要危险因素。A类、B类和对照组即刻低钙血症患病率分别为14%、20.3%和37.5%，差异具有统计学意义（<0.0001）。A类、B类和对照组术后1周时症状性及生化性低钙血症发生率分别为8%、12%和33.6%，以及12.9%、21%和30%。而这些组中报告的短暂性低钙血症发生率分别为1.6%、5%和14.6%。研究组永久性低钙血症发生率<1%，对照组为4%。我们观察到双侧颈部淋巴结清扫及甲状旁腺自体移植患者的永久性低钙血症发生率较高。研究组和对照组低钙血症（短暂性或永久性）无显著统计学差异，但与对照组相比，研究组单侧或双侧识别甲状腺下动脉时，低钙血症发生率均显著降低。本研究中的假设旨在保留甲状腺下动脉向甲状旁腺远端供血的分支，比传统技术能更好地保留甲状旁腺功能。如果操作得当，该技术还有助于我们维持手术平面及包膜剥离。通过尝试保留甲状腺下动脉，外科医生可能会获得更好的精细解剖技能，并更精确地了解甲状旁腺周围血管的解剖变异，从而改善手术效果，预防短暂性和永久性低钙血症。
