Comparison of postoperative hypocalcemia rates between the patients
Comparison of postoperative hypocalcemia rates between the patients with benign and malignant tumors after total thyroidectomy 良性與惡性甲狀腺腫瘤病人施行全甲狀腺切除 術後低血鈣發生率之比較 林逸筑, 吳哲維, 王凌峰, 江豐裕 高雄醫學大學附設醫院 耳鼻喉部 20181104
Introduction • Postoperative hypocalcemia (PH) • Common complication of total thyroidectomy • Temporary: 15 -68% • Permanent: 3 -5% BMC Surgery (2018) 18: 55 European Archives of Oto-Rhino-Laryngology (2018) 275: 2373– 2378 • Prolonged hospitalization • Calcium and vitamin D supplementation 1
Introduction • Our study • The risk of postoperative hypocalcemia in the patients with benign and malignant tumors after total thyroidectomy. 2
Patients & Methods • January 2011 to June 2018 • 839 patients • Total thyroidectomy by single surgeon (Chiang, FY) • B (benign) group: 445 patients (53%) • M (malignant) group: 394 patients (47%) 3
Patients & Methods • Free calcium levels (FCL) • Pre-op and post-op 12, 24, 48, and 72 hours • Normal range (4. 2 -5. 2 mg/d. L): mean ± 2 SD of pre -op FCL • Postoperative hypocalcemia (PH) • Definition: FCL < 4. 2 mg/d. L on at least 2 measurements. • If PH occur measure FCL at post-op 2 weeks, 2, 4, 6 and 12 months. 4
Results – Baseline Characteristics Age (mean ± SD) Overall (N=839) Benign (N=445) Malignant (N=394) P 51. 89 ± 13. 04 53. 43 ± 12. 7 50. 16 ± 13. 22 0. 0003 Sex 0. 145 Female 688 (82%) 373 (83. 82%) 315 (79. 95%) Male 151 (18%) 72 (16. 18%) 79 (20. 05%) Pathology Benign 445 (100%) - Papillary thyroid carcinoma 382 (45. 53%) - 382 (96. 95%) Follicular thyroid carcinoma 3 (0. 36%) - 3 (0. 76%) Medullary thyroid carcinoma 1 (0. 12%) - 1 (0. 25%) Poorly differentiated carcinoma 1 (0. 12%) - 1 (0. 25%) Follicular lymphoma 1 (0. 12%) - 1 (0. 25%) Diffuse large B cell lymphoma 1 (0. 12%) - 1 (0. 25%) 5
Results – Benign vs Malignant Temporary PH Permanent PH Total PH Benign (N=445) 93 (20. 9%) 0 (0%) 93 (20. 9%) Malignant (N=394) 93 (23. 6%) 4 (1. 02%) 97 (24. 62%) Malignant + CND (N=169) Malignant + unilateral CND (N=131) 44 (26%) 4 (2. 37%) 48 (28. 4%) 33 (25. 2%) 1 (0. 7%) 34 (25. 9%) Malignant + bilateral CND (N=38) 11 (28. 9%) 3 (7. 89%) 14 (36. 8%) 6
Results • B group with PH • 97. 9% and 100% of patients had normal FCL at the time point of 2 weeks and 2 months, respectively. • M group with PH • 94. 9% and 95. 9% of patients had normal FCL at the time point of 2 weeks and 2 months. • Four patients with persistent PH at 2 months all developed permanent PH. 7
Discussion – Age & Gender • Meta-analysis of 5 studies, 2576 pts • No significant association between patient age and temporary PH. • Meta-analysis of 10 studies, 3443 pts • Temporary PH more common in women. Clin Endocrinol. (1997) 47: 71– 7. World J Surg. (2005) 29: 1282– 7 Br J Surg. (2010) 97: 1687– 95. Int J Surg. (2009) 7: 466– 71 Arch Surg. (2007) 142: 1182– 7 • Prospective multicenter study, 400 pts • Female gender (p= 0. 035) and older age (p = 0. 029) were statistically significant predictors. BMC Surgery (2018) 18: 55 8
Discussion – PTH vs Calcium level • Systematic review: PTH level • not reliable enough to predict PH • more technically demanding • expensive than calcium level JAMA Surg (2018) 153: 69– 76 • Systematic review and meta-analysis • decrease in post-operative PTH, 1 h to 1 day following surgery, had a 69 -100% chance of developing PH. Br J Surg. (2014) 101(4): 307– 20 9
Discussion – Benign vs Malignant • Retrospective cohort analysis • Disease pathology had no impact on occurrence of PH. • Multinodular goiter (N = 481, 68. 5%), autoimmune thyroiditis (N = 166, 23. 6%), malignant (N = 55, 7. 8%) • Temporary (p = 0. 17) or permanent (p = 0. 43) International Journal of Surgery 55 (2018) 46– 50 • Prospective study, 396 pts • No statistically significant relationship between the presence of malignant tumor and PH. (B = 307, M = 89) • Temporary (p = 0. 17) or permanent (p = 0. 15) European Archives of Oto-Rhino-Laryngology (2018) 275: 2373– 2378 10
Discussion – Central Neck Dissection • Significant relationship with an increased risk of PH, mainly if CND was performed. Am J Surg (2006) 192: 675– 678 • No significant relationship with temporary (p = 0. 51) or permanent (p = 0. 27) PH. • CND in 41 pts, 12% European Archives of Oto-Rhino-Laryngology (2018) 275: 2373– 2378 • No significant relationship with PH between TT without CND (p = 0. 124), with unilateral CND (p = 0. 175), with bilateral CND (p = 1. 000). BMC Surgery (2018) 18: 55 11
Conclusion • Temporary PH was common in patients after total thyroidectomy. • Parathyroid function recovered well within 2 weeks in most cases. • Total thyroidectomy combined with CND for malignant tumor has higher temporary and permanent PH rates. • For the permanent PH cases, total thyroidectomy combined with bilateral CND has higher risk than with unilateral CND. 12
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