Accidental parathyroidectomy during total thyroidectomy and hypoparathyroidism in a large series of 766 patients: incidence and consequences in a referral center.

PURPOSE: Transient hypoparathyroidism is the most common complication after total thyroidectomy, and accidental parathyroidectomy (AP) may be a cause. The aim of this study was to investigate the incidence of AP and its impact on postoperative calcemia. MATERIALS AND METHODS: From February 2016 to May 2018, 766 patients undergoing total thyroidectomy were prospectively included. Surgical indications, hormonal status, definitive histology, and postoperative calcium and PTH levels were analyzed. RESULTS: 578/(75.45%) were women and 188/(24.55%) men with mean age of 53.4 years. Parathyroid tissue on the thyroid specimen was observed in 40 (5.2%) patients: 30 APs and 10 parathyroid fragments. Among the 30 APs, 12 glands were intrathyroid and 18 (2.3%) in eutopic location. 97 (12.6%) patients were treated for postoperative hypocalcemia: 90 (11.7%) had transient and 5 (0.6%) definitive hypoparathyroidism; 2 were lost in follow-up. 13/30 (43.3%) with AP had transient hypoparathyroidism. A strong correlation was found (p < 0.0001) between AP and postoperative hypocalcemia. 1/30 (3.3%) patient with APs had definitive hypoparathyroidism. Transient and persistent nerve palsies were found in 10 (1.3%) and 3 (0.4%) patients, respectively. DISCUSSION: A careful examination of the thyroid gland after resection help to identify an AP that could be autotransplanted. Surgeon and hospital activity volume per years seem to reduce the risk of hypoparathyroidism. CONCLUSION: Total thyroidectomy and intrathyroid localization of parathyroid glands are risk factors for the AP. The incidence of AP was 2.3%, and this remains low due to our longstanding experience in thyroid and parathyroid surgery.

Effects of Multi-stage Procurement on the Viability and Function of Human Donor Parathyroid Glands.

INTRODUCTION: Parathyroid allotransplantation is an emerging treatment for severe hypoparathyroidism. Ensuring the viability and functional integrity of donor parathyroid glands following procurement is essential for optimal transplantation outcomes. METHODS: Cellular viability, calcium-responsive hormone secretion, and gland xenograft survival were assessed in a series of deceased donor parathyroid glands following a two-stage procurement procedure recently developed by our group (en bloc cadaveric dissection with subsequent gland isolation after transport to the laboratory). RESULTS: Parathyroid glands resected in this manner and stored up to 48 h in 4°C University of Wisconsin (UW) media retained in vitro viability with no induction of hypoxic stress (HIF-1α) or apoptotic (caspase-3) markers. Ex vivo storage did not significantly affect parathyroid gland calcium sensing capacity, with comparable calcium EC50 values and suppression of parathyroid hormone secretion at high ambient calcium concentrations. The isolated glands engrafted readily, vascularizing rapidly in vivo following transplantation into mice. CONCLUSIONS: Parathyroid tissue retains viability, calcium-sensing capacity, and in vivo engraftment capability after en bloc cadaveric resection, ex vivo dissection, and extended cold storage.

Comparison of different parathyroid autograft project after total parathyroidectomy in patients with secondary hyperparathyroidism.

OBJECTIVE: To evaluate the feasibility and efficacy of total parathyroidectomy followed by modified needle-quantified injection of parathyroid autograft compared with classic incision and transplantation. METHODS: We conducted a retrospective study of 171 patients with secondary hyperparathyroidism treated by hemodialysis or peritoneal dialysis. These patients were included in our study from April 2006 to December 2016, who had undergone total parathyroidectomies with autotransplantation. Patients were divided into classic incision for transplantation of parathyroid autograft group and modified needle-quantified injection group. Clinical and biochemical characteristics, including preoperative and postoperative intact parathyroid hormone levels were recorded and compared between two group patients. RESULTS: To compare the techniques of modified needle-quantified injection and classic incision and transplantation, pre- and postoperative biochemistry and length of operation was recorded and analyzed. Preoperative biochemistry was similarly in both groups. However, autograft function achieved was significantly faster in the group with modified needle-quantified injection compared with classic incision and transplantation (P = 0.03). Median time to parathyroid function regain was 3 months for injection compared with 7 months for classic incision. There was no remarkable difference in the recurrence rates between the two groups. CONCLUSION: The modified needle-quantified injection of parathyroid tissue is a feasible and simple alternative to the more commonly used method of classic incision and transplantation.

Hypoparathyroidism: State of the Art on Cell and Tissue Therapies.

Hypoparathyroidism is an endocrine disorder characterized by low serum calcium levels, high serum phosphorus levels, and by inappropriate or absent secretion of the parathyroid hormone (PTH). The most common therapeutic strategy to treat this condition is hormone replacement therapy with calcium and vitamin D but, unfortunately, in the long term this treatment may not be sufficient to compensate for the loss of endocrine function. Glandular autotransplantation is considered the most effective technique in place of replacement therapy. Although it leads to excellent results in most cases, autotransplantation is not always possible. Allograft is a good way to treat patients who have not been able to undergo autograft, but this technique has limited success due to side effects related to tissue rejection. This therapy is supported by systemic immunosuppression, which leads to the onset of serious side effects in patients, with a risk of endocrine toxicity. Today, research on endocrine disorders is focused on discovering alternative graft therapies that can allow optimal results with the fewest possible side effects. In this review, we will make an update on the current state of the art about the cell and tissue therapy as treatment for hypoparathyroidism, to identify which type of therapeutic strategy could be valid for a future clinical use.

A Nomogram to Predict Hungry Bone Syndrome After Parathyroidectomy in Patients With Secondary Hyperparathyroidism.

BACKGROUND: Parathyroidectomy (PTX) has been demonstrated as an effective treatment for patients with secondary hyperparathyroidism (SHPT) of renal origin. However, severe hypocalcemia, called hungry bone syndrome (HBS), is a common complication following PTX in these patients and can lead to poor clinical outcomes, even death. Therefore, exploring risk factors for HBS and establishing a prediction nomogram allow intensive monitoring and prompt treating this postoperative complication, which is the main purpose of this study. METHODS: From October 2016 to October 2018, PTX with autotransplantation (PTX + AT) procedures were performed in 131 patients with SHPT of renal origin by a surgeon and his team in the Thyroid and Parathyroid Surgery Center, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 114 patients were enrolled for analyses in this study. Comprehensive data including preoperative, intraoperative, and postoperative variables were prospectively collected and retrospectively analyzed. The univariate and multivariate logistic regression analyses with internal validation by bootstrapping were used to confirm independent risk factors for postoperative HBS. The nomogram was developed based on the statistical analysis results. Receiver operator characteristic (ROC) curves were drawn to compare the prediction performance among different predictors. RESULTS: The occurrence of postoperative HBS was 76.3% (87 out of 114 patients) in this study. Univariate analysis showed that preoperative intact parathyroid hormone (iPTH), serum alkaline phosphatase, bone-specific alkaline phosphatase (bone-ALP) were significantly higher in HBS group than those in non-HBS group, while preoperative corrected serum calcium and albumin were significantly lower in HBS group than those in non-HBS group. Total weight of resected parathyroid glands was significantly heavier in HBS group versus non-HBS group. Multivariate logistic regression analysis with internal validation by bootstrapping demonstrated preoperative iPTH, bone-ALP, preoperative corrected serum calcium, and total weight of resected parathyroid glands were independently associated with postoperative HBS. The nomogram including the abovementioned four independent predictors was constructed and showed better prediction performance than the other four predictors in terms of postoperative HBS. CONCLUSIONS: On the basis of this study, we found higher preoperative iPTH level, higher bone-ALP level, heavier total weight of resected parathyroid glands, and lower preoperative corrected serum calcium level were independent predictors of postoperative HBS in patients with SHPT of renal origin. The nomogram can expediently, accurately, and objectively predict the risk of postoperative HBS in individual patient with SHPT of renal origin.

Total Versus Near-total Thyroidectomy in Graves Disease: Results of the Randomized Controlled Multicenter TONIG-trial.

BACKGROUND: Previous data suggest that the incidence of hypoparathyroidism after surgery for Graves disease (GD) is lower after subtotal thyroidectomy compared to total thyroidectomy (TT). The present study evaluated the incidence of postoperative hypoparathyroidism after near-total (NTT) versus TT in GD. METHODS/DESIGN: In a multicenter prospective randomized controlled clinical trial, patients with GD were randomized intraoperatively to NTT or TT. Primary endpoint was the incidence of transient postoperative hypoparathyroidism. Secondary endpoints were permanent hypoparathyroidism, transient recurrent laryngeal nerve palsy (RLNP), reoperations for bleeding, inadvertently removed parathyroid glands, and recurrent hyperthyroidism after 12 months. RESULTS: Eighteen centers randomized 205 patients to either TT (n = 102) or NTT (n = 103) within 16 months. According to intention-to-treat postoperative transient hypoparathyroidism occurred in 19% (20/103) patients after NTT and in 21% (21 of 102) patients after TT (P = 0.84), which persisted >6 months in 2% and 5% of the NTT and TT groups (P = 0.34). The rates of parathyroid autotransplantation (NTT 24% vs TT 28%, P = 0.50) and transient RLNP (NTT 3% vs TT 4%, P = 0.35) was similar in both groups. The rate of reoperations for bleeding tended to be higher in the NTT group (3% vs 0%, P = 0.07) and the rate of inadvertently removed parathyroid glands was significantly higher after NTT (13% vs 3%, P = 0.01). An existing endocrine orbitopathy improved in 35% and 24% after NTT and TT (P = 0.61). Recurrent disease occurred in only 1 patient after TT (P = 0.34). CONCLUSION: NTT for GD is not superior to TT regarding transient postoperative hypoparathyroidism.

Evaluation of Parathyroid Glands with Indocyanine Green Fluorescence Angiography After Thyroidectomy.

BACKGROUND: Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow. This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide autotransplantation and potentially decrease permanent hypoparathyroidism. METHODS: This was a retrospective study of patients who underwent total or near-total thyroidectomy (T-NT) between January 2015 and March 2018. Patients with preoperative hyperparathyroidism and those undergoing reoperation were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. Data were analyzed to assess the frequency of autotransplantation and incidence of hypoparathyroidism between groups. RESULTS: In total, 210 patients underwent T-NT: 86 with ICGA and 124 without. Autotransplantation was more common in the ICGA group at 36% compared to 12% in the control (p = 0.0001). There was no correlation with at least one normal parathyroid gland on ICGA and postoperative PTH levels (p = 0.75). There was a difference in having normal postoperative PTH when there were at least two normal parathyroid glands (n = 50) compared to patients with less than two normal ICGA glands (n = 36, p = 0.044). Visual assessment and ICGA assessment of vascularity were in agreement, 245/281 (87%). There were 19 glands (6.8%) that would have undergone autotransplant based on visual inspection that had adequate blood supply on ICGA. Transient hypoparathyroidism was present in 45 out of 124 controls (36%) and 32 out of 86 (37%) in the ICG group. CONCLUSIONS: ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection. ICGA can guide more appropriate autotransplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.

Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

BACKGROUND: Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation. PATIENTS AND METHODS: We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05. RESULTS: Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02). CONCLUSIONS: Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).

Microencapsulated parathyroid allotransplantation in the omental tissue.

Permanent hypoparathyroidism is a severe clinical condition accompanied by low parathyroid hormone level. Conventional treatment requires lifelong medication, and daily drug usage has some side effects. To avoid this circumstance, transplantation is an alternative and curative option. Microencapsulation may be used as a transplantation approach particularly to evade immune response. In order to define treatment of permanent hypoparathyroidism, a 37-year-old female recipient who has permanent hypoparathyroidism was evaluated for 3 years. Routine tests, viral markers, and T and B lymphocyte cross-match tests were analyzed. In addition intradermal skin test was performed for ultrapure alginate. Microencapsulation of cultured parathyroid cells was performed with ultrapure alginate. Cell suspension was prepared and spheroids were generated with calcium chloride. Afterward, transplantation was performed with a laparoscopic approach in the omental tissue. The recipient was discharged from the hospital without complications. Serum calcium, parathyroid hormone (PTH), and phosphorus levels were observed throughout 1 year. During the follow-up period, no complications were observed. Serum calcium levels were increased significantly on day 10 and PTH levels were increased on day 25 as well. According to our knowledge, this is the first study where ultrapure alginate-based microencapsulated parathyroid cells were transplanted in the omental tissue. A significant increment of PTH levels was detected. Microencapsulated parathyroid cells showed the functionality of this technique for more than 1 year. This study showed that using ultrapure alginate-based microencapsulation without immunosuppression appears to be a promising technique.

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: an updated systematic review and meta-analysis.

PURPOSE: The optimal surgical approach of parathyroidectomy for patients with secondary hyperparathyroidism (SHPT) has been controversial. The updated meta-analysis aimed to compare the effectiveness of subtotal parathyroidectomy (SPTX) versus total parathyroidectomy with autotransplantation (TPTX + AT). METHODS: A thorough systematic search was performed on the databases of PubMed, EMBASE, and Cochrane library to identify eligible studies. Data were extracted and pooled into a meta-analysis. The primary outcomes were the symptomatic improvement, radiological changes, hypocalcemia rate, the requirement for vitamin D analogues, time to recurrence, recurrence, persistence, and reoperation rates of SPTX versus TPTX + AT. RESULTS: A total of 18 studies with 3656 patients (1864 patients in SPTX and 1792 patients in TPTX + AT group) were included, and 15 studies were included in quantitative synthesis. No significant difference was observed in symptomatic improvement (93.3%, 89.0%; P = 0.99), radiological changes (85.4%, 85.3%; P = 0.91), hypocalcemia rate (16.6%, 18.1%; P = 0.29), persistence rate (6.1%, 2.0%; P = 0.16), time to recurrence (mean difference 1.46; P = 0.87), recurrence rate (9.2%, 7.1%; P = 0.76), and reoperation rate (5.3%, 5.8%; P = 0.66) between SPTX and TPTX + AT groups. Longer operative time (150 vs. 120 min), prolonged in-hospital stay (5.0 vs. 4.1 days), lower 1-month serum calcium level, and higher requirement for vitamin D analogues at 12 months were significantly observed in patients who underwent TPTX + AT compared to SPTX. CONCLUSIONS: The two surgical approaches were both effective at controlling SHPT in clinical and laboratory terms. However, most of the data shown were not statistically significant. It was acceptable that surgeons chose either SPTX or TPTX + AT for SHPT.

Parathyroid carcinoma arising from auto-transplanted parathyroid tissue after Total Parathyroidectomy in chronic kidney disease patient: a case report.

BACKGROUND: Secondary hyperparathyroidism is a common complication in patients with chronic kidney disease that requires vigilant treatment due to its high mortality rate. Pharmacologic therapy is recommended as an initial treatment; if there is no response, a total parathyroidectomy is performed. In some cases, surgery is accompanied by auto-transplantation of parathyroid tissue. CASE PRESENTATION: The patient was diagnosed with chronic kidney disease and received a kidney transplant. However, due to rejection of the transplanted kidney, medical nephrectomy was carried out and routine hemodialysis was initiated and observed. At this time, secondary hyperparathyroidism with elevated parathyroid hormone and hyperphosphatemia developed and pharmacologic treatment was applied. However, there was no response to pharmacologic treatment; therefore, total parathyroidectomy with auto-transplantation was performed. Eight years after surgery, a growing mass was observed in the transplantation site, accompanied by an elevation of parathyroid hormone. A complete resection of the mass was performed, and the patient was diagnosed with parathyroid carcinoma. Additional adjuvant radiation therapy was ordered, and the patient is being monitored. CONCLUSIONS: This is a rare but remarkable case of parathyroid carcinoma arising from auto-transplanted parathyroid tissue after total parathyroidectomy in a patient with secondary hyperparathyroidism. We suggest caution should be taken when choosing to auto- transplant parathyroid tissue and that careful postoperative observation should be performed.

Clinical Aspects of Parathyroid Hyperplasia in Secondary Renal Hyperparathyroidism.

The secondary hyperparathyroidism (sHPT) affects all patients with chronic renal failure in different degrees. The chronic kidney disease is often associated with multiple severe comorbidities, therefore the figures for mortality are higher than in the general population. The failure of medical treatment is an indication for surgical treatment. The recurrence of the disease in secondary hyperpara-thyroidism after surgical treatment using total parathyroid with autotransplantation or subtotal parathyroidectomy may be a challenge due to hyperplasia of the remaining tissue. The purpose of this retrospective study was to highlight the risk factors for the occurrence of glandular hyperplasia in patients with secondary hyperparathyroidism and to determine optimal surgery approach for secondary hyperparathyroidism in order to minimize relapse rates. Parathyroid size evaluation may suggest the presence of nodular hyperplasia contributing to an early parathyroidectomy and at the same time selecting the best surgical treatment for sHPT patients. As resistance to medical therapy is due to the presence of nodular hyperplasia, some authors recomends subtotal parathyroidectomy with the excision of these glands, with the remaining parathyroids tissue and function controlled by medical therapy (20).

Parathyroid autotransplantation in thyroid surgery.

BACKGROUND: Careful parathyroid gland dissection and in situ preservation was the time-honored approach to prevent parathyroid failure after total thyroidectomy. The relative success of parathyroid autotransplantation of hyperplastic parathyroid tissue in patients with renal or hereditary hyperparathyroidism did popularize the use of normal parathyroid tissue autografts during thyroidectomy to prevent permanent hypoparathyroidism. Proof of autograft function in this setting, however, is controversial. PURPOSE: This narrative review aims at reviewing critically the current status of parathyroid autotransplantation during total thyroidectomy. It is also meant to analyze from the historical, methodological, and clinical points of view the claimed benefit of normal parathyroid gland autotransplantation. A focus is placed on the prevention of permanent hypoparathyroidism by parathyroid autotransplantation. CONCLUSIONS: Liberal parathyroid autotransplantation was proposed in the mid 1970s but evidence of function is scarce. Proofs are accumulating that parathyroid autografts not only increase the rate of postoperative hypocalcemia, but may be also contribute to permanent hypoparathyroidism.

Patients' views about parathyroid transplantation for post-thyroidectomy hypoparathyroidism.

BACKGROUND: Permanent hypoparathyroidism (hypoPT) represents the most common postoperative complication associated with total thyroidectomy. Current treatment relies on high-dose calcium and/or vitamin D supplementation, but often this is insufficient and some patients remain symptomatic. Parathyroid allotransplantation is a new therapeutic option described recently in the literature. This study aims to investigate the patients' acceptability of parathyroid transplantation as a potential new treatment for hypoPT. METHOD: Online survey of members of HypoParaUK, a support group for individuals affected by hypoPT. RESULTS: Responses were received from 252 hypoPT patients. Majority declared to experience severe symptoms despite regular medical treatment. On a severity scale of 0-5, symptoms that were most troublesome were fatigue (3.8), low sense of well-being (3.5), and numbness/tingling (2.9). On a scale of 0-10, on average, their current quality of life (QoL) was 5 ± 3 and they expected this would improve to 7 ± 2 with correction of their hypoPT. Forty-four percent of patients were extremely interested in a potential technique involving intramuscular injection of parathyroid cell suspension compared to just 14% who were interested in the more invasive procedure of implantation of a parathyroid allograft into the forearm. The main concerns expressed were related to the possible need for immunosuppressive therapy. CONCLUSION: Patients with severe symptomatic hypoPT seem interested to consider participation in a clinical trial exploring the feasibility and success rate of parathyroid transplantation.

First Complex Allotransplantation of Neck Organs: Larynx, Trachea, Pharynx, Esophagus, Thyroid, Parathyroid Glands, and Anterior Cervical Wall: A Case Report.

OBJECTIVE: Evaluate the possibility of performing a complex vascular allotransplant of all neck organs including skin. SUMMARY BACKGROUND DATA: There are 2 previous attempts described in the literature, none of them being that complex. The first one is nonfunctional due to chronic rejection, the second one is viable yet considerably limited in complexity (no parathyroids, no skin). METHODS: The allotransplantation was performed simultaneously on 2 adjacent operating rooms, using microsurgical techniques. RESULTS: The patient's voice, breathing through mouth, swallowing, and endocrinal functions have been fully restored. CONCLUSIONS: Achieved results show clearly that such operations performed in selected patients can nearly fully restore functional and aesthetic effects in 1 single procedure.

Fresh tissue parathyroid allotransplantation with short-term immunosuppression: 1-year follow-up.

BACKGROUND: Permanent hypoparathyroidism is a serious problem and requires medications indefinitely. Parathyroid allotransplantation (PA) with short-term immunosuppression is definitive choice but long-term results are not clear. METHOD: We performed PA from two donors to two recipients. Both recipients were 39-year-old females. Donors were a 32-year-old female and a 36-year-old male, who both have chronic kidney disease. Routine tests, viral markers, and cross-matches were analyzed individually. The parathyroid glands were resected from the living donors, fragmented quickly in the operation room and injected into the left deltoid muscles of the two recipients. RESULTS: Methylprednisolone was administered on post-PA day one and two. Recipients were discharged from the hospital without complications. Calcium and PTH levels were observed throughout 1 year. We did not observe any complications during the follow-up period. Medications ceased in post-transplantation week 1 for Case 1 and after 1 month for Case 2. CONCLUSION: Fresh tissue PA with short-term immunosuppression appears to be a promising technique that is easy to perform, is cost-effective, has low risk of side effects and minimal complications with compatibility for HLA conditions. A longer follow-up period and more case studies are needed to determine the risks and benefits of this procedure for future cases.

Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution.

INTRODUCTION: Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision. METHODS: In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation. RESULTS: We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001). CONCLUSIONS: We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.

DOES PRE-OPERATIVE VITAMIN D DEFICIENCY PREDICT POSTOPERATIVE HYPOCALCEMIA AFTER THYROIDECTOMY?

OBJECTIVE: Postoperative hypocalcemia is frequent after total thyroidectomy. The role of pre-operative vitamin D levels in the pathogenesis of this condition has not been studied under the most current guidelines for evaluation of the role of vitamin D in calcium homeostasis. We hypothesized that patients who are vitamin D deficient (VDD) pre-operatively are more likely to suffer from postoperative hypocalcemia, thereby requiring prolonged hospitalization. METHODS: A retrospective chart review of patients undergoing total thyroidectomy at the University of New Mexico Hospital between 2005 and 2014 was performed. Patients who underwent intentional parathyroidectomy were excluded. The study included 30 patients who had a 25-hydroxyvitamin D levels obtained within 12 months before surgery. RESULTS: Twelve patients who were VDD (25-hydroxyvitamin D ≤20 ng/mL) were compared to 18 patients who did not have VDD (non-VDD; 25-hydroxyvitamin D >20 ng/mL). The mean nadir postoperative ionized calcium concentration was lower in the VDD group (0.99 ± 0.10 vs. 1.06 ± 0.06 mmol/L, P = .04) (reference range = 1.15-1.27 mmol/L), as was the postoperative concentration of phosphorus (3.48 ± 0.60 vs. 4.17 ± 0.84 mg/dL, P = .03). VDD patients had a longer length of stay (4.3 ± 4.4 vs. 1.7 ± 1.5 days, P = .03). Three patients in the VDD group required intravenous calcium for treatment of symptomatic hypocalcemia, but none of the non-VDD patients required this intervention (P = .054). CONCLUSION: Pre-operative vitamin D deficiency is associated with an increased risk of postoperative hypocalcemia and a prolonged length of stay in patients undergoing total thyroidectomy. Vitamin D replacement before thyroidectomy may improve postsurgical outcomes in VDD patients. ABBREVIATIONS: BMI = body mass index non-VDD = non-vitamin D deficient PTH = parathyroid hormone VDD = vitamin D deficient.

Failure of fragmented parathyroid gland autotransplantation to prevent permanent hypoparathyroidism after total thyroidectomy.

PURPOSE: Parathyroid autotransplantation during total thyroidectomy leads to higher rates of postoperative hypocalcaemia. It has been argued, however, that it prevents permanent hypoparathyroidism. The impact of autografted normal parathyroid gland fragments on long-term parathyroid status has not been assessed properly. To clarify this, the short- and long-term parathyroid function was assessed in patients with three glands remaining in situ after total thyroidectomy, in whom the fourth gland was either autotransplanted (Tx) or accidentally resected (AR). METHODS: Consecutive patients (n = 669) undergoing first-time total thyroidectomy were prospectively studied recording the number of parathyroid glands remaining in situ: PGRIS =4-(glands autografted + glands in the specimen). The study was focused on the subgroup of 186 patients with three parathyroid glands remaining in situ as a result of either accidental resection (AR, n = 76) or autotransplantation into the sternocleidomastoid muscle (Tx, n = 110). Prevalence of postoperative hypocalcaemia, protracted, and permanent hypoparathyroidism were compared between the two groups. Demographic, disease-related, laboratory, and surgical variables were recorded. All patients were followed for at least 1 year. RESULTS: Both groups were comparable in terms of disease and extent of surgery. Mean postoperative serum calcium was the same (AR: 1.97 ± 0.2 vs Tx: 1.97 ± 0.22 mmol/L). Rates of protracted (AR: 24% vs Tx: 25.5%) and permanent hypoparathyroidism (AR: 5.3% vs Tx: 7.3%) were similar in both groups. CONCLUSIONS: The prevalence of parathyroid failure syndromes after total thyroidectomy was similar whether a parathyroid gland was inadvertently excised or autotransplanted. Autotransplantation did not influence the permanent hypoparathyroidism rate.

[Current status and consideration of parathyroid autotransplantation].

Hypoparathyroidism is one of the most common complications of thyroid surgery. Permanent hypoparathyroidism would bring great pain to patients, seriously affect the postoperative quality of life, is becoming the source of medical disputes. Parathyroid autotransplantation can effectively reduce the incidence of postoperative permanent hypoparathyroidism. However, there are still some dispute about the choice, including the time, the number, the method and the location of parathyroid autotransplantation, which need to be further researched. As a result, the program and survival rate of parathyroid autotransplantation will be optimized and improved, respectively.