Dr Guy ANDRY, M. MOREAU, I.EL MOUSSAOUI, E. WILLEMSE, M. QUIRINY, A. DIGONNET Université Libre de Bruxelles, Brussels.

Dr Guy ANDRY, M. MOREAU, I.EL MOUSSAOUI, E. WILLEMSE, M. QUIRINY, A. DIGONNET

Université Libre de Bruxelles, Brussels

Despite all the methods to evaluate and to

predict postoperative hypocalcemia, no

consensus exists on the role of routine

calcium and/or Vit. D following thyroid surgery

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Hypocalcemia is the most frequent complication after total thyroidectomy

Transient: 9 to 50 %Permanent: 0.5 to 13% (→ 33 %)

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Patients and methods

Patients were prospectively registered from January 2006 till December 2009.

Calcemia (phosphoremia) pre and postopPth levels

After the first blood sample (2 to 3 hours postop.): calcium gluconate 2 g/l of perfusion if calcemia ≤ 8.2 mg/dl

Symptoms and signs of hypocalcemia registered

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Patients and methods

From postop day 1 to day 2 (discharged): pth, calcemia, phosphoremia

Treatment for Ca < 8.0 mg/dl for 8.0 < Ca < 8.3 mg/dl

- 1 g calcium carbonate TID - 1g calcium BID

- Alfacalcidiol 1 mcg/day - Alfacalcidiol 1 mcg/day

0.5 mcg/day

Day 6 to 10 (outpatient clinic): pth, calcemia, phosphoremia and OH-vitD, TSH; T4L, …

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Materials & methods

Pth level and calcemia : between 5th and 10th

day postop, after 1 month, 3 months, 6 to 9 months,

1 year; 1/yr thereafter if prolonged hypocalcemia

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Results (1)

(near) total thyroïdectomy (or totalisation): 537 pts from Jan 2006 till

Dec 2009 (421:W; 116:M)Mean age: 51 yrs (12-82)Selective neck dissection (mainly central compartment: 63 pts)Cancer: 81 pts (72 PTC, 5 MTC, 4 follicular)Multinodular goiter: 415 (50 with throiditis)Basedow : 2912 pts (benigh adenomas, follicular nodule, …)

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Results (2)

43.4% (n=233) developped a transient hypocalcema3.91% (n=21) developped a 1 year hypocalcemia3.17% (n=17) prolonged hypocalcemia 4 PTS had a PTH normal level 15, 23, 32, 39 pg/ml but maintained calcemic supplements to avoid symptoms

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Results (4)PTS characteristics for prolonged hypocalcemia

No (n=520)

Yes (n=17) Pvalue

Malignant 14.6% 43.8%

Parathyroid I&P* 1.2 3 4

1.9%6.5%

91.6%

11.8%17.6%70.6%

Lymph node dissection

11.2% 29.4%

Weight of specimen

47.5 (SD 49.5)

55.4 (SD 55.1)

0.51

Hosp stay (d) 4.08 (SD 0.79)

4.2 (SD 0.84)

0.79

* Identified and Preserved

0.001

0.022

0.004

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Results (6)Sensibility, specificity, ODDS ratio of hypocalcemia hypoPTH to predict « definitive » hypocalcemia

Ca: calcemia; PTH: level of « intact » on ice; 4 hrs: 4 hours postop; J1 to x: J postop 1 to x

Sensitivity

Specificity ODD1 ratio

Pvalue

Ca 4 hrs < 8 mg/dlCa J1 < 8 mg/dlCa J5-20 < 8 mg/dlCa J30 < 8 mg/dl

17.65%70.60%92.30%31.30%

90.3%64.7%94.3%98.3%

24.4

196.125.6

0.280.0029

< 0.0001<0.000

1

PTH 4 hrs < 15 pg/mlPTH J1 < 15 pg/mlPTH J5-20 < 15 pg/mlPTH J30 < 15 pg/ml

100%100%90%

63.6%

62.4%56.4%68.5%92.2%

∞∞

19.620.7

<.0001<.0001<.0001<.0001

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Discussion (1)

Hypocalcemia postop J5-20: < 8 mg/dl (sens: 92.3%; specif : 94.3%)

Hypo PTH level postop < 15 pg/ml

are predictive of definitive hypocalcemia

ROC curve was constructed PTH early < 9 pg/ml is predictive of definitive hypocalcemia:

100% sensitivity76% specificity ODDS ratio ∞ p < 0.0001

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Discussion (2)

Late recovery of normal parathormone activity

Among 21 PTS with prolonged hypocalcemia

4 showed normal calcemia and PTH levels after 4, 5, 6 and 7 yrs (4 parathyroids respected during the operation; 2 M, 2W; 3 MN Goiters, 1 Basedow)

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA

Role of postoperative vitamin D and/or

calcium routine supplementation in preventing hypocalcemia after thyroidectomy:

a systematic review and meta-analysis

A. Alhefdhi et al, The Oncologist 2013;18:539-542

Role of postoperative vitamin D and/or calcium routine supplementation in preventing hypocalcemia after

thyroidectomy: a systematic review and meta-analysis (1)

Out of 1180 studies on hypocalcemia post T thyroidectomy9 studies responding to the strength of recommendation taxonomy grading system (SORT)*

* Ebell M.H. 2004, J. Am. Board Fam. Pract.

N = 2285 PTSSymptomatic

hypocalcemia (%)

22 PTS : vit D only580 PTS : Ca++ only

792 PTS : vit D + Ca++

891 PTS : no

4.6 %14 %14 %

20.5 %

After A. ALHEFHI & al 2013

Conclusion

Systematic assays of iPTH at 4 hrs Ca++ between D5-20

are a good indicators of prolonged, hypoparathyroidism

hypocalcemia.

Immediate postop administration of IV Ca++ gluconate (2 g/l) followed at D1-2 by calcidial 1 mg and calcium carbonate (1 to 6 g tailorized by Ca++ levels) prevent the stress of symptomatic hypocalcemic.

MANAGEMENT OF POSTOPERATIVE HYPOCALCEMIA