Elsevier

Endocrine Practice

Volume 21, Issue 6, June 2015, Pages 674-685
Endocrine Practice

AACE/ACE Disease State Clinical Review
American Association of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: Postoperative Hypoparathyroidism - Definitions and Management

https://doi.org/10.4158/EP14462.DSCGet rights and content

ABSTRACT

Abbreviations: BID = bis in die DSPTC = diffuse sclerosing papillary thyroid cancer FNA = fine-needle aspiration HT = Hashimoto thyroiditis iPTH = intact parathyroid hormone 25OHD = 25-hydroxy vitamin D PTH = parathyroid hormone TPO = thyroid peroxidase US = ultrasonography

Section snippets

INTRODUCTION

Postsurgical hypoparathyroidism is the most common and often the most troubling long-term consequence of aggressive thyroid surgery. Etiologies include injury to the parathyroid glands (or their blood supply) or inadvertent resection of parathyroid tissue. Risk factors for hypoparathyroidism are listed in Table 1. This potentially severe complication of endocrine surgery presents with a broad range of signs and symptoms that may be either transient or permanent. Postsurgical hypoparathyroidism

THYROID SURGERY

The manipulation of the parathyroid glands, even without their removal, can lead to transient disruption of PTH production and/or release. Given the short half-life of PTH (3–5 minutes) (5), even a temporary drop in output can result in at least transient hypoparathyroidism with associated hypocalcemia, hypomagnesemia, and hyperphosphatemia. Manipulation of the parathyroid glands in both thyroid beds is precisely the reason why most iatrogenic hypoparathyroidism occurs. Thus, bilateral central

DEFINITIONS OF HYPOPARATHYROIDISM

Hypoparathyroidism following surgery is commonly classified as temporary (transient) or permanent. The most common time marker used to delineate between these 2 conditions is 12 months following surgery (Table 2). Temporary hypoparathyroidism is treated with “parathyroid splinting,” which uses calcium supplementation and 1,25 dihydroxy cholecalciferol and occasionally magnesium supplementation to support or completely replace parathyroid function (10). This approach optimizes serum calcium

Preoperative Strategies

Patients can be tested for 25-hydroxy vitamin D (25OHD) blood levels preoperatively. If the patient is identified as being vitamin D deficient (25OHD<20 ng/mL), then aggressive treatment with high-dose vitamin D should be considered (12). If 25OHD is between 20 and 30 ng/mL, less aggressive replacement is sufficient. Typically, 50,000 IU vitamin D3 (cholecalciferol) is given by mouth weekly to correct the vitamin D deficiency and hopefully reduce the risk of postoperative hypocalcemia.

PARATHYROID SURGERY

There can be many parallels between thyroid and parathyroid surgery when it comes to hypoparathyroidism. Manipulation or removal of 1 or more unilateral parathyroid glands (i.e., in focused parathyroid exploration or thyroid lobectomy), whether normal or hyperfunctioning, generally does not result in transient hypoparathyroidism (like thyroid lobectomy) as long as there are other ipsi- or contralateral normal and undisturbed parathyroid glands. Hypocalcemia can occur in patients at risk for

Postoperative Prophylaxis

The best prophylaxis to avoid postoperative hypocalcemia after total thyroidectomy is intraoperative parathyroid gland preservation with a capsular dissection to maintain the blood supply to the parathyroid glands. It is not always necessary to visually identify all 4 parathyroid glands to accomplish this. One retrospective study demonstrated that operations identifying 1 or 2 parathyroid glands had less hypocalcemia than operations identifying 3 to 4 parathyroid glands (40). This suggests that

CONCLUSION

Evaluation and management of central neck surgical patients for postoperative hypoparathyroidism may present challenges. The degree of symptomatology, ranging from no manifestations to tetany, seizures, cardiac dysrhythmias, and even myocardial dysfunction, makes accurate identification of fnected patients difficult, yet important. An understanding of appropriate testing, prophylaxis, and treatment of hypocalcemia is paramount for the thyroid and parathyroid surgeon. Anticipating, monitoring,

REFERENCES (51)

  • MannstadtM. et al.

    Efficacy and safety of recombinant human parathyroid hormone (1-84) in hypoparathyroidism (REPLACE): a double-blind, placebo-controlled, randomized, phase 3 study

    Lancet Diabetes Endocrinol

    (2013)
  • DralleH.

    Postoperative hypoparathyroidism: central neck dissection is a significant risk factor [article in German]

    Chirurg

    (2012)
  • American Thyroid Association Surgery Working Group, American Association of Endocrine Surgeons, American Academy of Otolaryngology-Head and Neck Surgery

    Consensus statement on the terminology and classification of central neck dissection for thyroid cancer

    Thyroid

    (2009)
  • Walker HarrisV. et al.

    Postoperative hypoparathyroidism: Medical and surgical therapeutic options

    Thyroid

    (2009)
  • LeikerA.J. et al.

    Factors that influence parathyroid hormone half-life: determining if new intraoperative criteria are needed

    JAMA Surg

    (2013)
  • EbrahimiH. et al.

    Does autoimmune thyroid disease affect parathyroid auto transplantation and survival?

    ANZ J Surg

    (2009)
  • KrysiakR. et al.

    Hypoparathyroidism in pregnancy

    Gynecol Endocrinol

    (2011)
  • LassigA.A. et al.

    Recalcitrant hypocalcemia in a lactating woman after total thyroidectomy for papillary thyroid carcinoma

    Head Neck

    (2011)
  • Sitges-SerraA. et al.

    Outcome of protracted hypoparathyroidism after total thyroidectomy

    Br J Surg

    (2010)
  • Thyroid Cancer Alliance. International thyroid cancer patient survey 2010. Available at:...
  • RolighedL. et al.

    Vitamin D treatment in primary hyperparathyroidism: a randomized placebo controlled trial

    J Clin Endocrinol Metab

    (2014)
  • SchietromaM. et al.

    Dexamethasone for the prevention of recurrent laryngeal nerve palsy and other complications after thyroid surgery: a randomized double-blind placebo-controlled trial

    JAMA Otolaryngol Head Neck Surg

    (2013)
  • PrombergerR. et al.

    Intra- and postoperative parathyroid hormone-kinetics do not advocate for auto transplantation of discolored parathyroid glands during thyroidectomy

    Thyroid

    (2010)
  • KarakasE. et al.

    The impact of parathyroid auto transplantation during bilateral surgery for Graves' disease on postoperative hypocalcemia

    Endocr Regul

    (2008)
  • PalazzoF.F. et al.

    Parathyroid auto transplantation during total thyroidectomy--does the number of glands transplanted affect outcome?

    World J Surg

    (2005)
  • Cited by (198)

    • Secondary Hyperparathyroidism

      2024, Otolaryngologic Clinics of North America
    View all citing articles on Scopus

    DISCLOSURE

    The authors have no multiplicity of interest to disclose.

    The opinions represented in the AACE/ACE Disease State Clinical Review: Postoperative Hypoparathyroidism - Definitions and Management are the expressed opinions of the Endocrine Surgery Scientific Committee of the American Association of Clinical Endocrinologists. AACE/ACE Disease State Clinical Reviews are systematically developed documents written to assist health care professionals in medical decision making for specific clinical conditions, but are in no way a substitute for a medical professional's independent judgment and should not be considered medical advice. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment of the authors was applied.

    This review article is a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with, and not a replacement for, their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.

    View full text