Abstract
Purpose
Hypocalcemia is the most common complication after total thyroidectomy. Some patients need to stay in the hospital for monitoring of hypocalcemic symptoms and serum calcium levels for several days. We investigated the efficacy and safety of using early postoperative parathyroid hormone (PTH) results for early discharge after thyroidectomy.
Materials and Methods
A retrospective cohort study of 2 sequential groups of patients undergoing total thyroidectomy between January 2010 and March 2013 was undertaken. Patients were divided into 2 groups. In Group 1 (before June 2011), patients had daily monitoring of serum calcium level and hypocalcemic symptoms. They were discharged when calcium level was static and asymptomatic. Postoperative PTH was not utilized for discharge plan. In Group 2 (after June 2011), postoperative PTH and calcium level on day 1 were utilized to dictate subsequent management and discharge plan.
Results
Of the 107 patients reviewed, 54 (50.5%) were in Group 1 and 53 (49.5%) were in Group 2. A total of 51 (47.7%) patients developed hypocalcemia. The two groups were comparable in demographic data, early postoperative PTH value, rate of hypocalcemia, the need for oral calcium and vitamin D supplements and rate of permanent hypoparathyroidism. Fewer patients in Group 2 experienced hypocalcemic symptoms, p = 0.005. None of the patients in Group 2 needed intravenous calcium supplement ( p = 0.003). The median postoperative hospital stay for Group 1 was 4 days and for Group 2 was 1 day ( p < 0.0001).
Conclusions
Postoperative PTH level after total thyroidectomy facilitates early supplementation therapy and abates symptomatic hypocalcemia. It also allows early and safe patient discharge.
1
Introduction
Thyroidectomy is the most commonly performed endocrine surgery. Contemporary thyroidectomy is a safe procedure with acceptable morbidity. The permanent vocal cord palsy and hypoparathyroidism following total thyroidectomy is nowadays below 3% in experienced hands . Nevertheless, transient postoperative hypoparathyroidism can be as high as 30%–50% if central compartment dissection is carried out in addition to total thyroidectomy for thyroid malignancy .
Total thyroidectomy has been proposed as the preferred operation over subtotal thyroidectomy even for benign goiter due to lower recurrent goiter and reoperation after total thyroidectomy despite more transient hypoparathyroidism .
Hypocalcemia will induce symptoms such as paresthesia or even tetany in severe cases. Demeester-Mirkine et al. actually disclosed that the nadir of calcium can be as late as day 7 postoperatively. Because of this, patients are often closely monitored for hypocalcemia in hospital after total thyroidectomy for a few consecutive days.
The genesis of post-thyroidectomy hypocalcemia is multifactorial but the most important cause is hypoparathyroidism . Various studies showed that postoperative parathyroid hormone (PTH) correlates with calcium level . These authors have alluded the potential use of postoperative PTH assay to predict hypocalcemia. Theoretically, it will enable early discharge of patients from the hospital and early supplement therapy when hypocalcemia has arisen. However, formal guidelines have rarely been proposed for the clinical application of postoperative PTH to expedite patient discharge.
Prompted by the Australian Endocrine Surgeons Guidelines AES 06/01 , we commenced to adopt postoperative PTH result to govern the informed discharge for patients after total thyroidectomy since June 2011. The additional benefit of the new discharge policy is more cost-effectiveness regarding the overall medical expense. We herein introduced the discharge guideline in our center and investigate whether it really fulfill our intention of safe early discharge by comparing with a cohort of patients who received discharge instructions according to the traditional model.
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