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A B S T R A C T
Objective
Objective: To evaluate the incidence and predictors of post-thyroidectomy definitive hypocalcemia and hypoparathyroidism.
Methods
Methods: We assessed ionic calcium preoperatively and postoperatively (first, second and 30th day) in 333 patients undergoing
thyroidectomy. In those presenting hypocalcemia, measurements were also made 90 and 180 days after surgery, when parathormone
was also dosed. Patients were grouped according to the presence or absence of hypocalcemia and evaluated according to age,
gender, thyroid function, thyroid volume, number of parathyroid glands identified and need to parathyroid reimplantation, type of
operation, operative time, and histopathological diagnosis. Results
Results: The incidence of temporary hypocalcemia was 40.8% (136
patients), and of definitive hypoparathyroidism 4.2% (14 patients). Reoperation or total thyroidectomy, neck dissection, hyperthyroidism,
operative time and age above 50 years were factors related to higher incidence of hypocalcemia and definitive hypoparathyroidism
(p <0.05). Conclusion
Conclusion: predictors of postoperative hypocalcemia included age (> 50 years), total thyroidectomy, reoperation, neck
dissection and operative time. The predictors of post-thyroidectomy definitive hypoparathyroidism included type of operation,
histological diagnosis and hyperthyroidism.
Key words
words: Thyroidectomy. Incidence. Postoperative complications. Hypocalcemia. Hypoparathyroidism.
METHODS
INTRODUCTION
Work performed at the Faculty of Medicine of the Federal University of Minas Gerais - UFMG, and Alfa Institute of Gastroenterology, UFMG
Clinics Hospital, Minas Gerais MG, Brazil.
1. Associate Professor, Department of Surgery, Faculty of Medicine, Federal University of Minas Gerais UFMG; 2. Associate Professor, Faculty
of Medicine, Federal University of So Joo Del Rey; 3. Regular Member, Group of Head and Neck Surgery, Alfa Institute of Gastroenterology,
UFMG Clinics Hospital; 4. Professor, Department of Surgery, Federal University of Minas Gerais - UFMG.
Rev. Col. Bras. Cir. 2012; 39(6): 476-482
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477
RESULTS
We studied 333 patients of both genders and of
unspecified age who underwent thyroidectomy. Of the 333
patients, 29 (8.7%) were male and 304 (91.3%) female.
Ages ranged between eight and 88 years, mean 45 15
years and a median of 46 years; 303 patients (91%) were
euthyroid, nine (2.7%) had hypothyroidism and 21 (6.3%)
were hyperthyroid.
The mean preoperative calcium was 1.24 0.07
mmol / l. The thyroid volume averaged 47.23 82.52 cm3
and median of 25cm3.
Table 1 shows the types of operations performed,
their frequencies and the complication rate of each. Table
2 shows the frequency of histological types found, as well
as the complication rate in each.
The incidence of temporary hypocalcemia was
40.8% (136 patients), and of permanent
hypoparathyroidism, 4.2% (14 patients).
No significant difference was observed in
relation to gender or gland volume, considering the
incidence of postoperative hypocalcemia (p = 0.946 and
p = 0.475), the presence of symptoms (p = 0.948 and p
= 0.648) and definitive hypoparathyroidism (p = 0.724
and p = 0.723).
There were no significant differences in thyroid
function when compared with the incidence of postoperative
hypocalcemia (p = 0.653), nor with the presence of
symptoms (p = 0.212). However, patients with
hyperthyroidism had significantly higher incidence of
permanent hypoparathyroidism than the euthyroid ones (p
= 0.002).
Regarding age, by distributing patients into two
groups Group 1 over 50 years, and Group 2 50 years
or less we observed that in the first group the mean Ca
on the first (1.12 0.10 mmol / l) and the second (1.14
0.12 mmol / L) postoperative days (POD) were lower than
those of the second group (1.16 0.12 mmol / l in the first
POD and 1.17 0.09 mmol / l in the second POD), these
differences being statistically significant (p = 0.001 on 1st
POD and p = 0.007 in the 2nd POD) (Figure 1).
The parathyroid glands were identified in 293
(88%) operations and not identified in 40 (12%)
thyroidectomies. Considering only cases where both sides
were manipulated in the same operative time, ie TT + ND
or TT alone. no significant difference was observed in
relation to hypocalcemia (p = 0.441 and p = 0.222),
presence of symptoms (p = 0.481 and p = 0.445) and
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478
Table 1 -
Types of operation and incidence of clinical and laboratorial hypocalcemia and definitive hypoparathyroidism.
Type of Operation
Frequency (%)
TT
TP
TTL
TT+EC
ST
Reop
TOTAL
142
127
25
18
17
4
333
Table 2 -
Laboratorial
Hypocalcemia
(42.7%)
(38.1%)
(7.5%)
(5.4%)
(5.1%)
(1.2%)
85
(59.9%)
19
(15.0%)
8
(32.0%)
14
(77.8%)
6
(35.3%)
4 (100.0%)
136
Clinical
Hypocalcemia
32
1
3
9
1
1
47
(22.5%)
(0.8%)
(12.0%)
(50.0%)
(5.9%)
(25.0%)
Permanet
Hypoparathyroidism
11 (7.8%)
0
(0.0%)
1
(4.0%)
1
(5.6%)
0
(0.0%)
1 (25.0%)
14
Histologic Types and incidence of clinical and laboratorial hypocalcemia and definitive hypoparathyroidism.
Histologic Types
Colloid goiters (BC)
Papillary carcinoma (PC)
Follicular adenoma (FA)
Basedow-Graves disease (GD)
Thyroiditis (Tir)
Follicular carcinoma (FC)
Medullary carcinoma (MC)
TOTAL
Frequency (%)
180
68
41
19
15
5
5
333
(54.1%)
(20.4%)
(12.3%)
(5.7%)
(4.5%)
(1.5%)
(1.5%)
Laboratorial
Hypocalcemia
64
40
11
10
6
1
4
136
(35.6%)
(58.8%)
(26.8%)
(52.6%)
(40.0%)
(20.0%)
(80.0%)
Clinical
Hypocalcemia
11
20
2
7
4
0
3
47
(6.1%)
(29.4%)
(4.9%)
(36.8%)
(26.7%)
(0.0%)
(60.0%)
Permanet
Hypoparathyroidism
2
6
0
4
1
0
1
14
(1.1%)
(8.8%)
(0.0%)
(21.1%)
(6.7%)
(0.0%)
(20.0%)
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DISCUSSION
According to DeMeester-Mirkine et al. 1 ,
hypocalcemia is a complex, multifactorial phenomenon,
where decreased function of the parathyroid glands seems
to be the main contributing factor4, and it may occur even
when preserving the glands and their vascularization. Lam
and Kerr7 showed decrease in PTH levels in 83% of total
thyroidectomies one hour after the procedure, indicating
greater susceptibility of the parathyroid glands to surgical
trauma.
When all glands are compromised by injury of
the vascular pedicle, resection or inadvertent surgical
manipulation occurs and sudden significant drop in levels
of PTH, leading to more intense and faster hypocalcemia
and hence triggering the symptoms. With partial
maintenance of the function of the parathyroid glands, the
PTH decrease is less expressive, remaining so until there is
recovery or repair of the remaining glands of the ischemic
parathyroid cell. In such cases, the calcium concentration
falls more slowly and with less intensity, consequently less
likely to cause clinical symptoms.
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481
hypocalcemia,
symptoms
and
definitive
hypoparathyroidism were lower.
Basedow-Graves disease was associated with
higher incidence of symptomatic hypocalcemia when
compared to colloid goiter and follicular adenoma and to
the presence of symptoms, the same happening with
permanent hypoparathyroidism when compared to colloid
goiter. Factors that may have contributed to it are the more
difficult technique in the surgical treatment of BasedowGraves disease and the presence of hyperthyroidism.
The operative time was also associated with
higher incidence of hypocalcemia. This data is directly linked
to the size of the operation and should always be considered
in conjunction with the type of surgical procedure.
In conclusion, the predictors of postoperative
hypocalcemia include age (> 50 years), extensive surgical
procedures and neck dissection. Thyroid diseases indirectly
lead to postoperative hypocalcemia in cases of more
extensive operation, the same occurring with operative time.
The predictors of post-thyroidectomy permanent
hypoparathyroidism included type of operation, histological
diagnosis and hyperthyroidism.
R E S U M O
Objetivo: Avaliar a incidncia e os fatores preditores da hipocalcemia e hipoparatireodismo definitivo ps-tireoidectomia. MtoObjetivo
dos: Foi dosado clcio inico no pr e no ps-operatrio (primeiro, segundo e 30dia) em 333 pacientes submetidos tireoidectomia.
Naqueles que apresentaram hipocalcemia, as dosagens foram feitas tambm aos 90 e 180 dias de ps-operatrio, quando se dosou
tambm o paratormnio. Os pacientes foram agrupados segundo a presena ou ausncia de hipocalcemia e avaliados segundo
idade, sexo, funo tireoidiana, volume tireoidiano, nmero de paratireoides identificadas e necessidade de reimplante de paratireoides,
Resultados: A incidncia de hipocalcemia temporria foi de
tipo de operao, tempo operatrio e diagnstico histopatolgico. Resultados
40,8% (136 pacientes), e hipoparatireoidismo definitivo de 4,2% (14 pacientes). Tireoidectomia total ou reoperao, esvaziamento
cervical, hipertireoidismo, tempo operatrio e idade acima de 50 anos foram fatores determinantes de incidncia significativamente
Concluso: os fatores preditores da hipocalcemia ps-operatria
maior de hipocalcemia e hipoparatireodismo definitivo (p<0,05). Concluso
incluem idade (>50 anos), tireoidectomia total, reoperao, esvaziamento cervical e tempo operatrio. Os fatores preditores do
hipoparatireoidismo definitivo ps-tireoidectomia incluram tipo de operao, diagnstico histolgico e hipertireoidismo.
Descritores: Tireoidectomia. Incidncia. Complicaes ps-operatrias. Hipocalcemia. Hipoparatireoidismo.
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