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Research Article | DOI: https://doi.org/10.31579/2768-2757/115
1Consultant Surgeon, Department of General Surgery, Prime Hospital, Dubai, UAE.
2Specialist ENT Surgeon, Department of ENT Surgery, Prime Hospital, Dubai, UAE.
3Specialist ENT Surgeon, Department of General Surgery, Prime Hospital, Dubai, UAE.
4Specialist General Surgeon, Department of General Surgery, Prime Hospital, Dubai, UAE.
5Consultant General Surgeon, Department of General Surgery, Gladstone Queensland Hospital, Perth, Australia.
6Consultant Surgeon, Department of General Surgery, American Hospital, Dubai, UAE.
7Undergraduate Student UCL, London, UK.
8Specialist General Surgeon, Department of General Surgery, Prime Hospital, Dubai, UAE.
9Specialist General Surgeon, Department of General Surgery, Prime Hospital, Dubai, UAE.
*Corresponding Author: Vinod Kumar Singha, Consultant Surgeon, Department of General Surgery, Prime Hospital, Dubai, UAE.
Citation: Vinod K Singhal., Sharma P., Senofer N., Suleman A., Faris D Alaswad., et al. (2024), Postoperative hypo parathyroid in patient with total thyroidectomy; a multi-center study, Journal of Clinical Surgery and Research, 5(2); DOI:10.31579/2768-2757/115
Copyright: © 2024, Vinod Kumar Singha. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 09 February 2024 | Accepted: 19 February 2024 | Published: 26 February 2024
Keywords: postoperative, hypo parathyroid, total thyroidectomy and management protocols
Background: Thyroidectomy complications include nerve damage, hypoparathyroidism, and bleeding. Hypoparathyroidism, marked by reduced parathyroid function, is a common complication, leading to low calcium levels and symptoms like muscle cramps. Incidence rates vary. Surgeons must prioritize parathyroid gland identification and protection during surgery to prevent complications and ensure patient well-being.
Aim of the study: The aim of this study has been to evaluate the incidence of hypoparathyroidism and clinical manifestations of hypocalcemia after total thyroidectomy.
Methods: This retrospective study, spanning 2020-2022 across four different hospital and teaching institutes in various parts of the world, analyzed 350 patients who underwent thyroid gland surgeries, including 350 total thyroidectomies. Focused on postoperative hypoparathyroidism as an early complication. Inclusion criteria involved age (18-85), complete thyroidectomy, and no prior hypoparathyroidism. Exclusion criteria included coexisting medical conditions and pregnancy. Postoperative hypoparathyroidism diagnosis relied on low serum calcium and parathyroid hormone levels within 24 hours.
Result: The study examines the characteristics of a population undergoing thyroid surgeries. Among 144 patients, most are aged 60-65 (41.14%), with 86% females. Total thyroidectomy is standard (87.14%), while 12.86% involve lymphadenectomy. PTH levels below 15.0 pg/ml indicate potential hypoparathyroidism, more prevalent in surgeries with lymphadenectomy.
Conclusion: This multicenter study highlights a significant incidence of postoperative hypoparathyroidism after total thyroidectomy and decreased parathyroid hormone (PTH) levels. Early detection and management strategies for postoperative hypoparathyroidism are crucial, with routine monitoring of serum PTH levels within 24 hours post-surgery recommended.
Thyroid diseases are prevalent globally, and treatment approaches vary depending on the specific disorder [1-3]. Over a decade, the incidence rate of thyroid cancer in India in women increased from 2.4 (95% CI 2.2-2.7) to 3.9 (95% CI 3.6-4.2) [4]. Thyroidectomy, the most common surgical procedure for endocrine glands, is employed in treating various conditions such as multinodular goiter, large goiter compressing adjacent structures, Graves’ disease, nodular variant of Hashimoto thyroiditis, and amiodarone-induced thyrotoxicosis [5,6]. Total thyroidectomy and broader indications for more radical operations are emerging trends in the surgical treatment of thyroid diseases. The primary complications of thyroidectomy include permanent recurrent laryngeal nerve palsy, permanent hypoparathyroidism, transient hypocalcemia, postoperative hemorrhage, and wound infection. Hypoparathyroidism, characterized by decreased parathyroid gland function and underproduction of parathyroid hormone (PTH), is the most common complication. It can result in low blood calcium levels, leading to muscle cramping, twitching, and various symptoms. Incidence rates of temporary and permanent postoperative hypoparathyroidism vary, with rates ranging from 7-60% and 0-9%, respectively [7-9]. Postoperative hypoparathyroidism is attributed to accidental parathyroidectomy, impaired blood supply, mechanical damage, or fibrotic processes occurring in the neck post-surgery. Symptoms typically manifest 24-48 hours after surgery, with transient cases resolving within weeks to months. However, some patients experience permanent hypoparathyroidism, requiring lifelong calcium and vitamin D supplementation, significantly impacting their quality of life. Hypocalcemia resulting from hypoparathyroidism increases neuromuscular excitability, leading to symptoms like perioral numbness, peripheral paresthesia, and muscle cramps. Severe hypocalcemia can cause laryngeal spasms, tetany, seizures, and potentially life-threatening cardiac complications [9,11]. Despite the surgical challenges, identifying and protecting parathyroid glands during surgery is crucial for safe treatment. Surgeons should aim to prevent postoperative hypoparathyroidism, recognize early parathyroid insufficiency, and plan appropriate pharmacotherapy to avoid symptomatic hypocalcemia, ensuring better patient well-being and comfort during recovery. The aim of this study has been to evaluate the incidence of hypoparathyroidism and clinical manifestations of hypocalcemia after total thyroidectomy.
This is a retrospective study, a total of 350 patients were enrolled and analyzed in this study. The study was conducted at the Department of General Surgery in four different Hospital, (Prime Hospital, American Hospital, NMC Hospital and Gladstone hospital; though it is a multi-center study), in different parts of the world. The study spanned two years, from 2020 to 2022, during which a total of 820 thyroid gland surgical operations were conducted, including 350 total thyroidectomies. The focus of the study was on postoperative hypoparathyroidism, specifically as an early complication of surgery. However, the investigation did not extend to determining this complication's temporary or permanent nature in the longer perspective. Before data collection, explicit informed consent was obtained from each participant, and stringent measures were in place to ensure the data's confidentiality.
Postoperative hypoparathyroidism was diagnosed by assessing low levels of serum calcium and parathyroid hormone (PTH). Given the short half-life of PTH in circulation, ranging from 2 to 4 minutes, measuring PTH levels serves as an effective early diagnostic approach for postoperative hypoparathyroidism (Singh et al. 2013). The information was organized systematically into tables or graphs based on their relevance. Detailed descriptions accompanied each table and graph to ensure a clear understanding. Statistical analysis was conducted using the Statistical Package for Social Science (SPSS) program on the Windows platform. Continuous parameters were transformed into categorical parameters and presented as frequency and percentage for clarity.
Table 1 shows the age distribution of the study population; most of the 144(41.14%) patients were from the age range 65-60 years, second most 101(28.86%) patients were aged more than 60 years, and 30.00% of the study population were from the age group 18-45 years. Females dominate the cohort with 86.00%, while males account for 14.00% (Figure 1).
| Age range (in years) | Frequency (n) | Percentage (%) |
| 18-45 years | 105 | 30.00 |
| 45-60 years | 144 | 41.14 |
| >60 years | 101 | 28.86 |
| Total | 350 | 100.00 |
Table 1: Age distribution of the study population (N=350).
Figure 1: Gender distribution of the study population (N=350).
The majority (87.14%) underwent total thyroidectomy without lymphadenectomy, while a smaller proportion (12.86%) had the procedure with lymphadenectomy (Figure 2).
Figure 2: Types of surgical procedures performed in the studied group (total thyroidectomies).
| Histopathological diagnoses | Frequency (n) | Percentage (%) |
| Thyroid cancers | ||
| Papillary thyroid carcinoma | 36 | 10.29 |
| Follicular thyroid carcinoma | 4 | 1.14 |
| Medullary thyroid carcinoma | 2 | 0.57 |
| Anaplastic thyroid carcinoma | 1 | 0.29 |
| Metastasis of claro-cellular carcinoma to the thyroid gland | 2 | 0.57 |
| Nodular goiter | ||
| Non-toxic nodular goiter | 199 | 56.86 |
| The nodular variant of Hashimoto's disease | 2 | 0.57 |
| Nodular goiter with morphological features of hyperactivity | 92 | 26.29 |
| The nodular variant of Graves’ disease | 12 | 3.43 |
Table 2: Histopathological diagnoses of the study population (N=350).
Table 2 outlines the histopathological diagnoses in the study population where Thyroid cancers, predominantly papillary thyroid carcinoma (10.29%), form a notable subset. However, Non-toxic nodular goiter dominates at 56.86%, indicating a prevalent benign thyroid condition, and hyperactivity features (26.29%) emphasize the complexity of thyroid pathology. In total thyroidectomy without lymphadenectomy, 46.86% exhibit PTH levels below 15.0 pg/ml, indicating potential hypoparathyroidism. Conversely, in total thyroidectomy with lymphadenectomy, a majority (58.00%) has PTH levels below 15.0 pg/ml, suggesting a potential impact on parathyroid function due to more extensive surgery (Table 3).
| Serum PTH level | Total thyroidectomy without lymphadenectomy | Total thyroidectomy with lymphadenectomy | ||
| n | % | n | % | |
| 0-14.99 pg/ml | 164 | 46.86 | 203 | 58.00 |
| ≥15.0 pg/ml | 186 | 53.14 | 147 | 42.00 |
Table 3: Serum PTH concentrations depending on the extent of surgery.
| Variables | Decreased PTH level | Normal PTH level | ||
| n | % | n | % | |
| Lymphadenectomy | 201 | 57.43 | 149 | 42.57 |
| Graves’ disease | 224 | 64.00 | 126 | 36.00 |
| Recurrent goiter | 200 | 57.14 | 150 | 42.86 |
| Intraoperative hemorrhage/reoperation because of hemorrhage | 210 | 60.00 | 140 | 40.00 |
| Huge retrosternal goiter | 197 | 56.29 | 153 | 43.71 |
| Thyroidectomies without additional risk factors | 157 | 44.86 | 193 | 55.14 |
Table 4: Variation in serum PTH levels, either reduced or within the normal range, is influenced by factors that elevate the likelihood of postoperative hypoparathyroidism.
According to Table 4, instances of lymphadenectomy, Graves' disease, recurrent goiter, intraoperative hemorrhage, and huge retrosternal goiter show a higher incidence of decreased PTH levels, ranging from 57.43% to 64.00%. In contrast, thyroidectomies without additional risk factors demonstrate a lower prevalence of decreased PTH levels at 44.86%. The contrast in normal PTH levels is evident, with thyroidectomies without added risk factors exhibiting a higher percentage (55.14%), while cases with risk factors show lower percentages ranging from 36.00% to 43.71%. In Table 5,
| Number of parathyroid glands | Serum PTH level | |||
| 0-14.99 pg/ml (n=212) | ≥15 pg/ml (n=138) | |||
| n | % | n | % | |
| No gland | 77 | 45.56 | 97 | 70.29 |
| 1 | 130 | 76.92 | 41 | 29.71 |
| 2 | 5 | 2.96 | 0 | 0.00 |
Table 5: The levels of parathyroid hormone (PTH) in serum vary based on the quantity of parathyroid glands identified in histopathological specimens.
when no glands are identified, most exhibit PTH levels in the lower range (0-14.99 pg/ml) at 45.56%, while 70.29% of cases with PTH levels ≥15 pg/ml have no identified glands. Conversely, when one gland is identified, a higher percentage (76.92%) demonstrates PTH levels in the lower range, and when two glands are identified, all 5 cases (2.96%) have PTH levels in the lower range. This suggests a potential association between the quantity of identified parathyroid glands and serum PTH levels.
Hypoparathyroidism resulting from thyroidectomy worsens quality of patients’ life because of the necessity of chronic pharmacological treatment and medical care. Most frequently, postoperative hypoparathyroidism is not a result of permanent destruction of parathyroid glands and usually it persists during 6 months (sometimes 1-2 years) after surgery. When patients treated because of persistent postoperative hypoparathyroidism were reevaluated after therapy withdrawal, it turned out that 2-5 years after surgery 50% of them did not need substitutive therapy (they had normal PTH and calcium levels) [12]. In this study, majority of 144(41.14%) patients were aged between 45-60 years and our male-female ratio is 1:6.34, which is similar to a study done by Marcinkowska in 2017 [13]. Another study done by Zobel et., al. 2020 found 16.18% male and 83.82
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