Hypocalcemia following thyroid surgery: incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients.

Postoperative hypocalcemia is the most frequent complication of total thyroidectomy. It may have a delayed onset, and therefore delays the discharge from the hospital, requiring calcium replacement therapy to alleviate clinical symptoms. During a 7-month period, 2,631 consecutive patients undergoing primary or completion thyroidectomy were prospectively followed up and underwent analysis regarding postoperative hypoparathyroidism. Data were prospectively collected by questionnaires from 39 Italian endocrine surgery units affiliated to the Italian Endocrine Surgery Units Association (Club delle Unità di EndocrinoChirurgia-UEC), where thyroid surgery is routinely performed. The incidence of hypoparathyroidism was 28.8 % (757 patients), including transient hypocalcemia (27.9 %-734 patients) and permanent hypocalcemia (0.9 %-23 patients). The rate of asymptomatic hypocalcemia was 70.80 %. The incidence of permanent hypocalcemia was higher in the symptomatic hypocalcemia group (7.5 %) than in asymptomatic one (1.5 %). Female patients experienced a transient postoperative hypocalcemia more frequently than male patients (29.7 and 21.2 %, respectively; p < 0.0001). The percentage developing hypocalcemia in patients in which parathyroid glands were intraoperatively identified and preserved was higher than in the patients in which the identification of parathyroid glands was not achieved (29.2 vs. 18.7 %, p < 0.01). This prospective study confirmed the main risk factors for postoperative hypocalcemia: thyroid cancer, nodal dissection, and female gender. It farther showed that identifying parathyroids has an important role to prevent permanent hypocalcemia though with a higher risk of transient hypocalcemia. A suitable informed consent should especially emphasize the importance of some primary factors in increasing the risk of hypocalcemia after thyroid surgery.

Limits and advantages of fundus-first laparoscopic cholecystectomy: lessons learned.

BACKGROUND: Fundus-first cholecystectomy is well recognized as a safe technique during open cholecystectomy (OC) because it minimizes the risk of injuries to the biliary structures at the Calot's triangle. Fundus-first laparoscopic cholecystectomy (FFLC), like the OC, has been proposed as a safe method to approach the cystic duct in cases of difficult anatomy in order to limit biliary injuries and to reduce the conversion rate. The aim of our study was to highlight the limits and advantages of the FFLC, in order to evaluate whether the potential complications are counterbalanced by the expected reduction of the conversion rate. METHODS: We retrospectively analyzed 1965 consecutive cases of laparoscopic cholecystectomies performed for gallbladder disease from 1994 to 2005. Reasons for adoption of the FFLC, conversion to OC, and complications were compiled. RESULTS: The FLC was performed in 29 cases (1.5%) and was successful in 23 patients (80%). The median operating time for the FFLC was 65 minutes (range, 40-170). In 6 patients (20%), FFLC was eventually converted to open operation. Intraoperative cholangiography (IOC) was performed successfully in 17 cases (74%). Common bile duct (CBD) stones were found in 6 cases (20%). Minor complications occurred in 6 patients (20%). No CBD injuries occurred. Two cases of residual CBD stones were treated postoperatively. Mortality rate was nil. CONCLUSIONS: The FLC remains a safe option when dealing with patients with difficult anatomy at the Calot's triangle, but its adoption needs a good surgical judgment. Considering the high incidence of CBD stones in this series, the high failure rates in performing an IOC represent the most important limiting factor.