Chereau Nathalie, Gaujoux Sebastien, Ghander Cecile, Bertocchio Jean Philippe, Buffet Camille, Menegaux Fabrice
Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, Paris, France; Groupe de Recherche Clinique No. 16 Thyroid Tumors, Sorbonne University, Paris, France.
Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, Paris, France; Groupe de Recherche Clinique No. 16 Thyroid Tumors, Sorbonne University, Paris, France.
Surgery. 2025 Feb;178:108933. doi: 10.1016/j.surg.2024.10.024. Epub 2024 Nov 29.
Hypocalcemia after total thyroidectomy is a frequent complication that can be predicted and best managed by the postoperative measurement of parathyroid hormone levels.
This study included consecutive patients who underwent total thyroidectomy between 2017 and 2022. Hypocalcemia was defined as serum calcium <8.0 mg/dL and hypoparathyroidism as parathyroid hormone <15 pg/mL. After comparing serum calcium levels on postoperative day 1 and intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy in the first period, an algorithm involving routine postoperative oral calcium and alfacalcidol administration in patients with intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy <20 pg/mL was developed and tested during the second period. The rates of symptomatic hypocalcemia, readmission for hypocalcemia, and permanent hypoparathyroidism were compared between the 2 periods.
In the first period, 1,965 total thyroidectomies (1,548 women; mean age, 51 years) were performed, including 617 patients (31%) with central neck dissection for thyroid carcinoma. Of 314 patients (16%) who experienced symptomatic hypocalcemia, only 183 (58%) could be predicted using serum calcium levels on postoperative day 1 <8.0 mg/dL. This rate increased to 96% (301 patients) when using intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy and serum calcium levels on postoperative day 1 (P < .001). Intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy alone could predict symptomatic hypocalcemia in 90% (282) of patients. Hypoparathyroidism was permanent in 20 patients (1%), with a greater predictive value of intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy over serum calcium levels on postoperative day 1 (18/20 [90%] vs 8/20 [40%], P < .01). Using the intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy-based algorithm and preventive calcium supplementation in the second period of the study, 1,420 total thyroidectomies (1,106 women; mean age, 50 years) were performed, including 392 (28%) cases with central neck dissection for thyroid carcinoma. Only 2.3% (32) patients developed a symptomatic hypocalcemia compared with 16% during the first period (P < .001). Thirty-eight patients (2.7%) experienced readmission after total thyroidectomy before implementation of the supplementation protocol in our study compared with 2 patients (0.01%) after we began using the protocol (P < .001). There was no significant difference in permanent hypoparathyroidism between the 2 periods (1.3% vs 1%) (P = .8).
The parathyroid hormone-based algorithm determined by intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy and routine preventive administration of oral calcium/calcitriol reduced the risk of symptomatic hypocalcemia and readmission after total thyroidectomy.
全甲状腺切除术后低钙血症是一种常见并发症，可通过术后测量甲状旁腺激素水平进行预测并得到最佳管理。
本研究纳入了2017年至2022年间连续接受全甲状腺切除术的患者。低钙血症定义为血清钙<8.0mg/dL，甲状旁腺功能减退定义为甲状旁腺激素<15pg/mL。在第一阶段比较术后第1天的血清钙水平和全甲状腺切除术后20分钟的术中甲状旁腺激素水平后，制定了一种算法，即在全甲状腺切除术后20分钟术中甲状旁腺激素水平<20pg/mL的患者中常规术后口服钙剂和阿法骨化醇，并在第二阶段进行测试。比较两个阶段有症状性低钙血症、因低钙血症再次入院和永久性甲状旁腺功能减退的发生率。
在第一阶段，共进行了1965例全甲状腺切除术（1548例女性；平均年龄51岁），其中617例（31%）因甲状腺癌行中央区颈淋巴结清扫术。在314例（16%）发生有症状性低钙血症的患者中，仅183例（58%）可通过术后第1天血清钙水平<8.0mg/dL预测。当使用全甲状腺切除术后20分钟的术中甲状旁腺激素水平和术后第1天的血清钙水平时，这一比例增至96%（301例患者）（P<0.001）。仅全甲状腺切除术后20分钟的术中甲状旁腺激素水平就能预测90%（282例）患者的有症状性低钙血症。20例患者（1%）发生永久性甲状旁腺功能减退，全甲状腺切除术后20分钟的术中甲状旁腺激素水平对其预测价值高于术后第1天的血清钙水平（20例中有18例[90%]对20例中有8例[40%]，P<0.01）。在研究的第二阶段，使用基于全甲状腺切除术后20分钟术中甲状旁腺激素水平的算法并进行预防性补钙，共进行了1420例全甲状腺切除术（1106例女性；平均年龄50岁），其中392例（28%）因甲状腺癌行中央区颈淋巴结清扫术。与第一阶段的16%相比，仅2.3%（32例）患者发生有症状性低钙血症（P<0.001）。在我们的研究中，在实施补充方案前，38例患者（2.7%）全甲状腺切除术后再次入院，而开始使用该方案后为2例患者（0.01%）（P<0.001）。两个阶段永久性甲状旁腺功能减退无显著差异（1.3%对1%）（P=0.8）。
由全甲状腺切除术后20分钟的术中甲状旁腺激素水平确定的基于甲状旁腺激素的算法以及常规预防性口服钙剂/骨化三醇可降低全甲状腺切除术后有症状性低钙血症和再次入院的风险。
