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Toloneetal.BMCSurgery2013,13(Suppl2):S11http://www.biomedcentral.com/1471-2482/13/S2/S11
RESEARCHARTICLEOpenAccessTheimpactofageandoralcalciumandvitaminDsupplements
onpostoperativehypocalcemiaaftertotalthyroidectomy.Aprospectivestudy
SalvatoreTolone*,
RuggieroRoberto,GianmattiadelGenio,LuigiBrusciano,DomenicoParmeggiani,VincenzoAmoroso,GiuseppinaCasalino,
IgnazioVerde,AlfonsoBosco,AntonioDAlessandro,RaffaelePirozzi,GianlucaRossetti,
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PaoloLimongelli,LudovicoDocimo
From26thNationalCongressoftheItalianSocietyofGeriatricSurgeryNaples,Italy.19-22June2013
Abstract
Background:Hypocalcemiacausedbytransientordefinitivehypoparathyroidismis
themostfrequentcomplicationaftertotalthyroidectomy(TT).Weaimedtocomparethe
impactofageandtheclinicalusefulnessoforalcalcium
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andvitaminDsupplementsonpostoperativehypocalcemiaafterTT,andtodeterminewhichriskfactorsareimportantforhypocalcemiaincidence.
Methods:Two
hundredconsecutivepatientstreatedbyTTwereincludedprospectivelyinthepresentstudy.
AllpatientssupplementedoralcalciumandvitaminDinthepost-operativetime.The
dataconcerningsymptomaticandlaboratoristichypocalcemiawerecollected.Patientswereevaluated
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accordingtoage,sex,postoperativeserumcalciumlevels,andpreoperativeserumalkalinephosphatasislevels.
Results:Symptomatichypocalcemiadevelopedonlyin19patients
(9.5%),whereaslaboratoryhypocalcemiadevelopedin36patients(18%).Theriskforpostoperative
hypocalcemiawasincreate20-foldforpatientsolderthan50years.
Conclusions:
Ageissignificantlyassociatedwithpostoperativehypocalcemia.Implementingoralcalcium
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andvitaminDaftertotalthyroidectomycanreducetheincidenceofhypocalcemiarelatedtosurgery.
Background
Totalthyroidectomy(TT)
isnowthepreferredoptionforthemanagementofbenignmultinodulargoiter.Postoperative
hypocalcemiaisobservedinuptoonethirdoftotalorcompletionthyroidectomy
patientsandisthemostcommoncomplication,duetoparathyroid
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glandinsufficiency,anditcontinuestochallengeevenexperiencedsurgeonssinceitoftenextendsthedurationofhospitalstayandincreasestheneedfor
biochemicaltests[1-5].Surgicaltechniquehasevolvedtopreserveparathyroidfunctionwhereverpossible.
However,
*Correspondence:salvatore.tolone@unina2.itDivisionofGeneralandBariatricSurgery,Department
ofSurgery,SecondUniversityofNaples,ViaS.Pansini5,
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80131,Naples,Italytransienthypoparathyroidismstilloccursowingtoparathyroidmanipulation,devascularization,venousengorgementorinadvertentremovaloftheparathyroidglandswiththethyroid
specimen.
Hypocalcemiaaftertotalthyroidectomyisusuallytransient,andtheincidence
ofpermanenthypoparathyroidismis3%orlessaccordingtotheexperienceofmost
ofthesurgicalunitsstudied[6-8].Despitebeingself-limitingin
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mostpatients,symptomatichypocalcemiaisofparticularconcernbecauseofadelayinitsmanifestationandtheconsequentneedforprolongedpatienthospitalizationor
readmission.Followingtotalthyroidectomy,patientsarecloselyobservedforbleedinginthefirst
24h.Themaindischarge-limitingfactorthereafteristhedevelopmentof
©2013Toloneetal;licenseeBioMedCentralLtd.
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ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproduction
inanymedium,providedtheoriginalworkisproperlycited.
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Toloneetal.BMCSurgery2013,13(Suppl2):S11Page2of6http://www.biomedcentral.com/1471-2482/13/S2/S11
hypocalcaemiaaspatientsnotatriskofhypocalcaemia
maybedischargedonday1followingsurgery.
Thecausesof
hypocalcemiaafterTTaremultifactorial,andsomeofthesefactorsincludeiatrogenicsurgical
traumatotheparathyroidglands,incidentalparathyroidectomy,thenumberof
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functioningglandsleftbehind,extentofsurgery,experienceofthesurgeon,hyperthyroidism,retrosternalgoiter,concomitantneckdissection,andthyroidcarcinoma[9,10].Severalauthorshave
attemptedtoidentifyriskfactorsinthedevelopmentofhypocalcemia.Declinesinserum
calcium[7]orintactparathyroidhormone(iPTH)levels[11,12]aftersurgeryhavebeen
suggestedasbeingreliablepredictorsofpostoperativehypocalcemia.Althoughmeasurements
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ofserumcalciumoriPTHallowtheidentificationofpatientswhohavenoriskofhypocalcemiaaftertotalthyroidectomy,itisnotalwayseasy
topredictwhichpatientscanbedischargedearlyfromthehospitalorto
identifythoserequiringclosemonitoringofserumcalciumlevelsorthosethatshould
receivecalciumandvitaminDsupplements.Implementationofprotocolsusing
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postoperativePTHmeasurementhasbeenshowntofacilitateday1dischargeafterthyroidectomy[13].However,rapidPTHmeasurementisnotreadilyavailableinmany
hospitals.
RoutineoralcalciumandvitaminDsupplementshavebeenproposed
topreventthedevelopmentofsymptomatichypocalcemiaandtoincreasethelikelihoodof
earlyhospitaldischargeafterbilateralsurgicaltreatmentofthethyroid
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glandorexplorationoftheparathyroidglands[14,15].VitaminDplaysacriticalroleincalciumhomeostasis[16].Insufficiencyincalciumabsorptiondueto
lowvitaminDconcentrationleadstoanincreaseinparathyroidhormone(PTH)secretion.
IncreasedPTHstimulatesthesynthesisofcalcitriolandtherebyimprovescalciumabsorptionefficiency.
However,eveninpatientswhopracticedapostoperativeimplementationwith
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oralcalciumandvitaminD,theriskofpostoperativehypocalcemiccrisisisnotavoided,suggestingaroleforotherriskfactors.Identifyingsomeof
thisriskfactorscanled,inturn,toareductionincostsassociated
withmultiplebloodsamplingsinmonitoringthedevelopmentofhypocalcemiaaswellas
costsassociatedwithprolongedhospitalization.
Theaimsof
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thisprospectiveclinicalstudyare:(1)tocomparetheimpactofageandtheclinicalusefulnessoforalcalciumandvitaminDsupplementson
postoperativehypocalcemiaafterTT,and(2)todeterminewhichriskfactorsareimportant
forhypocalcemiaincidence.
Methods
Inthesettingofaprospectivestudy,
200consecutivepatients[44men(22%,meanage45±
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14years),156women(78%,meanage43±18years)],undergoingtotal
thyroidectomyintheDivisionofGeneralandBariatricSurgeryatUniversity
ofNaplesS.U.N.betweenMarch2011andFebruary2013,wereenrolled.Allof
thepatientshadnohistoryofpriorthyroidornecksurgery.Patientsrequiring
unilaterallobectomyorsubtotalorcompletionthyroidectomywereexcluded,and
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onlypatientsundergoingtotalthyroidectomywereenrolledintothestudy.Allpatientshadnormalrenalfunctionatthetimeofsurgery.Noneofthepatientshadsignsorsymptomsindicating
metabolicbonedisease,andnoneofthepatientswereonmedications,suchas
oralcalcium/vitaminDsupplementation,anti-resorptiveagents,hormonereplacementtherapyforpostmenopausalwomen,
anabolicagents,thiazidetypediuretics,orantiepilepticagents,knownto
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affectserumcalciummetabolism.IndicationsforsurgeryarelistedinTable1;eachsubjectprovidedaspecificinformedconsent,beforebeingpartofthe
study.Thestudyplanwasreviewedandapprovedbylocalinstitutionalethicalcommittee.
TheTTprocedureconsistsofa3-to5-cmskinincision1
to1.5cmabovethesternalnotch.Afterdivisionof
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theplatysma,thecervicallineaalbaisopenedwithoutdivisionofthestrapmuscles.Thethyroidlobeisdissectedprogressivelyfromthestrapmuscles.After
identificationoftherecurrentlaringeanerveandparathyroidglands,thevascularpediclesof
thethyroidlobeareligatedwiththeHarmonicAce/Focusscalpel(EthiconEndo-SurgeryInc.,
Cincinnati,OH,USA),andthethyroidlobeisremoved[17-20].
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Afteracheckforhemostasis,adrainisplacedinthethyroidbed.Thecervicallineaalbaandplatysmaaresuturedwithabsorbablesutures,and
theskinisclosedbyanintracutaneousrunningsuture.
Patientswere
askedtotakeoralcalcium2g/dtakentwice(1gevery12hours)andvitaminD1g/dtakentwice
(0.5gevery12hours)fromthenightofoperation
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topost-operativeday14.Intravenouscalciumgluconatewasadministeredifsignificantsymptomatichypocalcemiapersistedaftersurgerydespiteoralsupplementation.
Themedicaland
nursingnoteswerecarefullyexaminedfordocumentationofsymptomsofhypocalcaemia.Thetime
ofadministrationofcalcium,vitaminDanaloguesandintravenousfluidsinrelationto
serumcalciumandhypocalcaemicsymptomswasalsonoted.Serumcalcium,
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albumin,creatinine,andalkalinephosphatase
Table1Preoperativediagnosis
DiseaseTOTALN=200Multinodulargoiter168(84%)Carcinoma20
(10%)Basedow12(6%)
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Toloneetal.BMCSurgery2013,13(Suppl2):S11Page3of6http://www.biomedcentral.com/1471-2482/13/S2/S11
levelsweredeterminedthedaybeforesurgery,on
theeveningofsurgery(day0),onthemorningofday1and
thenevery24hoursuntilpatientdischarge.Serumcalciumconcentrationwascorrectedfor
changesinserumalbumin.Serumcalcium,creatinine,albumin,andalkaline
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phosphataseweremeasuredusingautomatedassays.Thereferencerangesforserumcalciuminourlaboratorywere8.5to10.5mg/dL.
Allpatients
wereseenintheoutpatientsdepartment2weeksaftersurgery.Thereportedsymptoms
ofhypocalcaemiaandthetreatmentrequiredtocontrolthesesymptomswerenoted.
Postoperativehypocalcemiawasdefinedaseithersymptomaticorlaboratory.
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Hypocalcemicsymptomsandsigns,fromperioraltinglingandnumbnesstocarpopedalspasmsandtetany,wereregisteredindetail.Laboratoryhypocalcemiawasdefined
asserumtotalcalciumconcentrationsof<8.0mg/dL,evenifrecordedonlyin
asinglemeasurement.
Statistics
DatawereanalyzedusingSPSS
15.0forWindows(SPSSInc,Chicago,IL).Resultswereexpressed
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asmean±SD.ComparisonsofdatausedtheWilcoxonsigned-ranktest,chi-squaretest,andlogisticregressionanalysis.Resultswereconsideredstatisticallysignificantwhen
the2-tailedPvaluewaslessthan0.05.
Results
All
patientsrespectedtheoralsupplementprotocol.Thethyroiddiseasesofthepatientsincluded
inthestudyareshowninTable1.Theoperative
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procedureswerealltotalthyroidectomy.Nomajorcomplicationoccurred
(e.g.persistentvocalcordparalysisandhypoparathyroidism,bleedingrequiringreintervention).Incidentalparathyroidectomywas
foundin3patients(1.5%).Themeans(±SD)forserumalbumin,creatinine,calcium
andalkalinephosphataselevelswere3.8±0.09g/dL,
0.8±
0.1mg/dL,8.9±0.2mg/dl,and162±74
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U/L,respectively.Thepostoperativeserumcalciumlevelwaslowerthanthepreoperativeserumcalciumlevel(8.9±0.2mg/dLvs8.2±0.9mg/dL,P<0.001).
Symptomatichypocalcemiadevelopedonlyin19patients(9.5%),whereaslaboratoryhypocalcemiadevelopedin
36patients(18%).Hypocalcemicsymptomswereminimalin12patients.Intravenouscalciumwas
administeredto7patientswithseverehypocalcemicsymptoms(Table2).
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Regardingtheselattercasesonly,inthesubsequenthystopathologicalanalysisonremovedthyroidtissue,incidentalparathyroidtissueswerefoundinthree.Permanenthypocalcemiadeveloped
innoneofpatients.Hypercalcemiaorothersideeffectsdidnotdevelopin
anyofthepatientsreceivingroutineoralsupplements.
Table2Patients
developinghypocalcemia
HypocalcemiaTotalN=200LaboratoryHypocalcemia
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36(18%)SymptomaticHypocalcemia19(9.5%)RequiringE.V.Calcium7(3.5%)
Ageandserumalkalinephosphataselevelsweresignificantlyhigherinpatientswho
developedhypocalcemiathaninothers(56.7±8yearsand242.21±72
U/Lvs
42.1±9yearsand123.21±41U/L,
P<0.001).Postoperativeserumcalciumlevelsweresignificantlylowerin
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hypocalcemicpatients(7.3±0.4mg/dLvs8.6±0.3mg/dL,P<0.001).Hospitalstaywassignificantlylongerinhypocalcemicpatients(4±1days,range
2-5days)thanothers(2±
0.5days,range1-3days)
(P<0.001).Infemalepatients,theratioofpostoperativehypocalcemiawasfoundto
besignificantlyhigherwhencomparedtomalepatients(24%vs
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8%,P<0.01).Therewasanegativecorrelationbetweenserumcalciumlevelandage(rs-0.501,P<0.001)andfemalegender(rs-0.203,P<0.01)andserumalkalinephosphatase
level(rs-0.498,P<0.001).
Patientageandpreoperativeserumalkalinephosphatase
level,wereindependentsignificantvariablesinthedevelopmentofhypocalcemiaafterthyroidectomy.The
riskforpostoperativehypocalcemiawasincreased20foldforpatientsolder
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than50years(oddsratio[OR]20.2;95%confidenceinterval[CI]10.4-58.3).
Discussion
Thepresentstudyshowsthatpost-operativeoral
calciumandvitaminDsupplementscanreducetheincidenceofhypocalcemiaaftertotal
thyroidectomy.Also,weinvestigatedthepredictionvalueofage,preoperativeserumcalciumand
alkalinephosphataseonpostoperativehypocalcemiaaftertotalthyroidectomy.
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Wefoundthatagewassignificantlyassociatedwithpostoperativehypocalcemia.Negativecorrelationswereobservedbetweentheserumcalciumlevelandage,andserumalkaline
phosphataselevel.Accordingtoalogisticregressionanalysis,agewasasignificantindependent
variableassociatedwithpostoperativehypocalcemia.
Postoperativehypocalcemiaisoneofthe
mostfrequentcomplicationsafterTT[21].Inseveralstudies,the
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incidenceofhypoparathyroidismvariedfrom1.6%toabove50%[7,22].
ThecausesofhypocalcemiaafterTTaremultifactorial,andsomeofthese
causesincludeinjury,devascularization,andunintentionalexcisionofparathyroidglands,thenumberof
functioningglandsleftbehind,theextentofsurgery,theexperienceofthesurgeon,
hyperthyroidism,
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retrosternalgoiter,concomitantneckdissection,andthyroidcarcinoma
[22-27].
However,theroleofimplementationoforalcalciumandvitamin
Disnotnew,anditisconsideredaneffectiveapproachtothe
preventionofhypocalcemia.
Infact,thistreatmentpreventeda
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significantdecreaseofserumcalciumlevelsaswellasthesubsequentdevelopmentofmajorhypocalcemicsymptomsaftertotalthyroidectomy.Thesymptomsreportedbypatients
wereminimalandonlysevenrequiredintravenouscalciumadministrationafterhispersistentsignificant
hypocalcemiafailedtorespondtoimplementationoforalcalciumandvitaminD.However,
inthiscasehypocalcemicstatuswasprobablyduetothe
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accidentalremovalofparathyroidtissueduringsurgery,asshownbyhystologicalanalysis.
Twostudieshaveevaluatedtheefficacyofroutinecalciumsupplements
forthepreventionofhypocalcemiaafterthyroidectomy[28,29].Moore[28]reportedthatonly
4of124patientswhoreceiveddailytreatmentofcalcium(5g)after
bilateralthyroidresectiondevelopedhypocalcemia,and1requiredadministrationof
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intravenouscalcium.Basedonempiricalobservations,theprophylacticuseoforalcalciumtoreducetheriskofhypocalcemiccrisisandincreasethelikelihoodof
earlyhospitaldischargewasrecommended.Bellantoneetal
[29]reportedin
aprospectivecontrolstudythatonly3of26patients(11%)receivingoralcalciumsupplement(3g/d)hadsymptomsrelated
tohypocalcemiaaftertotalthyroidectomy,whereas11of27patients
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(40%)notreceivingcalciumsupplementhadsymptoms.Thesestudiessuggestthatpostthyroidectomyhypocalcemiacanbeconsiderablypreventedbytheroutineadministrationofcalciumsupplements.The
riskforpostoperativehypocalcemiaforpatientsundergoingTTwashigherthanthatfor
patientswithadvancedage.
Recently,therehasbeenagreatdeal
ofinterestinidentifyingperioperativefactorsthatcanpredictthe
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developmentofhypocalcemiaafterthyroidectomy[30,31].Thedrivetowardsashorterhospitalstayfollowingtotalthyroidectomyhasledtoanumberofstudiesevaluating
theuseofplasmabiochemicalmarkerstopredictthedevelopmentofhypocalcaemia.Thyroid
surgeryimpairsPTHsecretionbytheparathyroidglandsresultinginpostoperativeparathyroidinsufficiencyandsubsequent
developmentofhypocalcaemia[32].Themeasurementofserumcalciumconcentration
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followingthyroidectomyhasbeenusedinanattempttopredictthedevelopmentofhypocalcaemia.However,themeasurementoftotalserumcalciumisinaccurate,at
leastinpart,owingtopostoperativehaemodilution[33,34].
Thevalueof
PTHinpredictingpost-thyroidectomyhypocalcemiahasbeenextensivelyinvestigatedand
reported
intheliterature[35,36]AlthoughtheuseofPTHpost-thyroidectomy
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mayallowshorterhospitaladmission,rapidaccesstoresultsofpostop-erativePTHmeasurementisnotwidelyavailableinmosthospitals.Inaddition,thereis
noconsensusonthethresholdforPTHandtheoptimaltimingforits
measurementpost-thyroidectomy.ThePTHmeasurementonthefirstpostoperativedayhasbeenshown
tobeausefulmethodtopredictpost-thyroidectomyhypocalcemia[37].
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SerumPTHconcentration,whenchecked1-6hafterthyroidectomy,hasahigheraccuracyinpredictinghypocalcaemia[38].WhilsttheuseofserumPTHlevels
topredictpost-thyroidectomyhypocalcaemiaiswellestablished,itappearstolackthedesirable
100%accuracyrate.Wewerenotabletoanalysethepostoperativepercentagedecline
inPTHowingtothelackofpreoperativePTHdata.
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However,bothabsolutelevelsandpercentagedeclinehavebeenusedtopredicthypocalcaemiawithsimilaraccuracy,and,althoughsimilar,levelsvarybetweeninstitutions[36].
Also,wethinkthatpost-operativehypocalcemiacanbereducedwhena
preciseminimalsurgicaldissectionisperformed;infact,theuseofharmonicscalpel
canhelptoavoidenergyspread,bloodlossandedema,
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thuslimitingparathyroidfunctionimpairment[17-20].
VitaminDhasacriticalroleincalciumhomeostasis.VitaminDdeficiencyhasbeenfrequentlydocumented
inmedicallyillandfree-livingpopulations[39,40]Advancedageisreportedtobe
amajorriskfactorforvitaminDdeficiency.Agingisassociatedwithalterations
invitaminDmetabolism.Studieshaveobserved
(1)
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anage-relateddecreaseinrenal1-hydroxylaseactivityandintestinalcalciumabsorption,and(2)anage-relateddeclineinthecutaneousaccumulationof7-dehydrocholesterol,which
isconvertedintoprevitamin-D3bysolarultravioletradiation.Insufficientcalciumabsorptiondue
tolowvitaminDconcentrationsleadstoanincreaseinPTHsecretion.Increased
PTHstimulatesthesynthesisofcalcitriolandtherebyimprovescalcium
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absorptionefficiency[39,40].Inpreviousstudies,regimensoforalcalciumaloneandofacalciumandvitaminDcombinationwereeffective.Thestudyfrom
BellantoneetAl[29]alsorevealedthattheadditionofvitaminDto
oralcalciumsupplementswasassociatedwithsignificantlyhigherserumcalciumconcentrationsonpost-operative
days2and3andwithalowerincidenceof
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hypocalcemia.AlthoughithasbeenreportedthatvitaminDadministrationinhibitsiPTHsecretionbynormallyfunctioningparathyroidglands,priorstudiesandourownresults
showedthatiPTHsecretionwasnotaffectedbyvitaminDadministrationinpostthyroidectomy
patients.Therefore,theearlyuseofvitaminDinadditiontocalciumsupplements
canberecommendedforpatientsundergoing
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totalthyroidectomy.Thedosagesanddurationsofcalcium
andvitaminDadministrationarealsoofconcern.InastudyfromRoh
andPark[32],routineoralcalciumandvitaminDsupplementswereeffectivein
reducingtheincidence(6%)andseverityofhypocalcemiaaftertotal
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thyroidectomy.Onlyaminorityofpatientsreceivingthesupplementspresentedwithminimalsymptomsrelatedtohypocalcemia,andhigherlevelsofserumcalciumduringthe
firstfewdaysaftertotalthyroidectomyweremeasuredinpatientsreceivingthesupplement.
Inapreviousstudy,wealsodocumentedthatregimensoforalcalciumaloneandofacalciumand
vitaminDcombinationwereeffectiveinmostcasesofthyroidectomy
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performedforbenignthyrodealpathology[41-44].
Conclusions
Thepreventionofsignificantsymptomatichypocalcemiawillallowearlydischargeofpostthyroidectomypatients
fromthehospital.Inturn,earlydischargeeliminatesthenecessityofmultipleblood
samplingsforclosemonitoringofserumcalciumoriPTHlevels.However,therisk
ofpostoperativehypocalcemiaforpatientsundergoingTTwashigherthan
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thatforpatientswithadvancedage.Inthesepatients,anaccurateclinicalandlaboratoristicfollowupduringthepost-operativeperiodisnecessary.
Inconclusion,ourdatasuggestthatpostoperativeoralcalciumandvitaminDsupplements
cantakearolethepreventionofpostoperativehypocalcemiaandforincreasingthe
likelihoodofasafeandearlydischargefromthehospital.
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Listofabbreviations
TT:TotalThyroidectomy;PTH:ParathyroidHormone;iPTH:intactParathyroidHormone
Competinginterests
The
authorsdeclarethattheyhavenocompetinginterests.
Authors contributions
ST,RR,PLhavemadesubstantialcontributionstoconceptionanddesign;RP,
GRhavemadesubstantialcontributionstoacquisitionofdata;GC,
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AB,VA,ADAhavemadesubstantialcontributionstoanalysisandinterpretationofdata;ST,RR,IVhavebeeninvolvedindraftingthemanuscript;RR,
PL,GDG,LB,DPhavebeeninvolvedinrevisingitcriticallyforimportant
intellectualcontent;ST,RRandLDhavegivenfinalapprovaloftheversion
tobepublished.
Authors information
ST:
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ResearchGrantFellowatSecondUniversityofNaples;RR:AssistantProfessorofSurgeryatSecondUniversityofNaples;GDG:AssistantProfessorofSurgeryatSecondUniversity
ofNaples;LB:SeniorDoctoratSecondUniversityofNaples;DP:AssistantProfessorof
SurgeryatSecondUniversityofNaples;VA:SurgicalFellowResidentatSecondUniversityofNaples;GC:
SurgicalFellowResidentatSecondUniversityofNaples;IV:SeniorDoctoratSecond
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UniversityofNaples;AB:SurgicalFellowResidentatSecondUniversityofNaples;ADA:SurgicalFellowResidentatSecondUniversityofNaples;RP:SurgicalFellowResidentatSecondUniversity
ofNaples;GR:SeniorDoctoratSecondUniversityofNaples;PL:AssistantProfessorof
Surgeryat
SecondUniversityofNaples;LD:FullProfessorofSurgeryatSecond
UniversityofNaples.
Declarations
Fundingof
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thisarticlehascomefrompersonalfunds.ThisarticlehasbeenpublishedaspartofBMCSurgeryVolume13Supplement2,2013:Proceedingsfrom
the26thNationalCongressoftheItalianSocietyofGeriatricSurgery.Thefull
contentsofthesupplementareavailableonlineathttp://www.biomedcentral.com/bmcsurg/supplements/13/S2
Published:8
October2013
References
1.BergamaschiR,
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 60/83
BecouarnG,RoncerayJ,ArnaudJP:Morbidityofthyroidsurgery.AmJSurg1998,176:71-5.2.BhattacharyyaN,FriedMP:Assessmentofthemorbidity
andcomplicationsoftotalthyroidectomy.ArchOtolaryngolHeadNeckSurg2002,128:389-92.3.
ParmeggianiD,DeFalcoM,AveniaN,SanguinettiA,FioreA,DocimoG,
AmbrosinoP,MadonnaI,PeltriniR,ParmeggianiU:Nervesparingsuturelesstotalthyroidectomy.Preliminary
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 61/83
study.AnnItalChir2012,83(2):91-6,Mar-Apr,PMID:22462326.
4.SanguinettiA,DocimoG,RagusaM,CalzolariF,DAjelloF,RuggieroR,Parmeggiani
D,PezzollaA,ProcacciniE,Avenia:Ultrasoundscissorsversuselectrocauteryinaxillarydissection:ourexperience.
GChir2010,31(4):151-3,Apr.5.CirocchiR,BoselliC,GuarinoS,Sanguinetti
A,TrastulliS,DesiderioJ,SantoroA,RondelliF,Conzo
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 62/83
G,ParmeggianiD,NoyaG,DeTomaG,AveniaN:Totalthyroidectomywithultrasonicdissectorforcancer:multicentricexperience.WorldJSurgOncol2012,10:70,apr.6.
JacobsJK,AlandJWJr,BallingerJF:Totalthyroidectomy.Areviewof213
patients.AnnSurg1983,197:542-9.7.ReeveT,ThompsonNW:Complicationsofthyroid
surgery:howtoavoidthem,howtomanagethem,and
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 63/83
observationsontheirpossibleeffectonthewholepatient.WorldJSurg2000,24:971-5.8.DAjelloF,CirocchiR,DocimoG,CataniaA,Ardito
G,RosatoL,AveniaN:Thyroidectomywithultrasonicdissector:amulticentricexperience.GChir2010,
31(6-7):289-92,Jun-Jul.
9.AbboudB,SargiZ,AkkamM,etal:
Riskfactorsforpostthyroidectomyhypocalcemia.JAmCollSurg2002,195:456-61.10.Rosato
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 64/83
L,AveniaN,BernanteP,DePalmaM,GulinoG,NasiPG,PelizzoMR,PezzulloL:Complicationsofthyroidsurgery:analysisofamulticentric
studyon14,934patientsoperatedoninItalyover5years.WorldJ
Surg2004,28(271)-6.11.MarohnMR,LaCivitaKA:Evaluationoftotal/near-totalthyroidec-tomyin
ashort-stayhospitalization:safeandcost-effective.Surgery1995,118:943-7.12.
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 65/83
AdamsJ,AndersenP,EvertsE,CohenJ:Earlypostoperativecalciumlevelsaspredictorsofhypocalcemia.Laryngoscope1998,108:1829-31.13.LindblomP,WesterdahlJ,
BergenfelzA:Lowparathyroidhormonelevelsafterthyroidsurgery:afeasiblepredictorof
hypocalcemia.Surgery2002,131:515-20.14.LoCY,LukJM,TamSC:Applicabilityof
intraoperativeparathyroidhormoneassayduringthyroidectomy.AnnSurg2002,236:564-9.
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 66/83
15.GrodskiS,LundgrenCI,SidhuS,etal:PostoperativePTHmeasurementfacilitatesday1dischargeaftertotalthyroidectomy.InClinicalEndocrinology.Volume70.Oxford;
2009:322-325.16.HickeyL,GordonCM:VitaminDdeficiency:newperpectivesonan
olddisease.CurrOpinEndocrinolMetab2004,11:18-25.17.DocimoG,RuggieroR,GubitosiA,Casalino
G,BoscoA,GiliS,ConzoG,DocimoL:Ultrasoundscalpel
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 67/83
inThyroidectomy.Prospectiverandomizedstudy.AnnItalChir2012,83:491-6.18.DocimoG,ToloneS,GiliS,DAlessandroA,CasalinoG,BruscianoL,RuggieroR,Docimo
L:MinimallyInvasiveThyroidectomy(MIT)Indicationsandresults.AnnItalChir2012,Oct,doi:pii:
S0003469X12020386.19.BellevicineC,MalapelleU,DocimoG,CianciaG,MossettiG,Pettinato
G,TronconeG:Multicentricencapsulatedpapillaryoncocyticneoplasmofthe
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 68/83
thyroid:Acasediagnosedbyacombinedcytological,histological,immunohistochemical,andmolecularapproach.DiagnCytopathol2012,40(5):450-4,May,doi:10.1002/dc.21828.Epub2011Sep30.PMID:21965084.
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 69/83
Toloneetal.BMCSurgery2013,13(Suppl2):S11Page6of6http://www.biomedcentral.com/1471-2482/13/S2/S11
20.PezzollaA,DocimoG,RuggieroR,Ruggiero
R,MonacelliM,CirocchiR,ParmeggianiD,ConzoG,GubitosiA,LattaruloS,
CiampolilloA,AveniaN,DocimoL,PalascianoN:Incidentalthyroidcarcinoma:amulticentricexperience.Recenti
ProgMed2010,101(5):194-8,May.21.Demeester-MirkineN,HoogheL,Van
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 70/83
GeertruydenJ,DeMaertelaerV:Hypocalcemiaafterthyroidectomy.ArchSurg1992,127:854-8.22.ThomuschO,MachensA,SekullaC,UkkatJ,LippertH,Gastinger
I,DralleH:Multivariateanalysisofriskfactorsforpostoperativecomplicationsinbenign
goitersurgery:prospectivemulticenterstudyinGermany.WorldJSurg2000,24:1335-41.
23.TronconeG,VolanteM,IaccarinoA,ZeppaP,
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 71/83
CozzolinoI,MalapelleU,CalmieriEA,ConzoG,CapottiM,PalombiniL:CyclinD1andD3overexpressionpredictsmalignantbehaviorinthyroidfine-needleaspirates
suspiciousforHurtlecellneoplasms.CancerCytopathol2009,117(6):522-9.24.DeBellisA,
ConzoG,CennamoG,PaneE,BellastellaG,ColellaC,IacovoAD,Paglionico
VA,SinisiAA,WallJR,BizzarroA,BellastellaA:Time
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 72/83
courseofGraves ophthalmopathyaftertotalthyroidectomyaloneorfollowedbyradioiodinetherapy:a2-yearlongitudinalstudy.Endocrine2012,41(2):320-6,Apr.25.ConzoG,
PasqualiD,BellastellaG,EspositoK,CarellaC,DeBellisA,DocimoG,
KlainM,IorioS,NapolitanoS,PalazzoA,PizzaA,SinisiAA,Zampella
E,BellastellaA,SantiniL:Totalthyroidectomy,withoutprophylacticcentral
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 73/83
lymphnodedissection,inthetreatmentofdifferentiatedthyroidcancer.Clinicalretrospectivestudyon221cases.Endocrine2013,Jan19.
26.Conzo
G,DocimoG,RuggieroR,NapolitanoS,PalazzoA,GambardellaC,MaurielloC,
TartagliaE,CavalloF,SantiniL:Surgicaltreatmentofpapillarythyroidcarcinomawithout
lymphnodalinvolvement.GChir2012,33(10):339-42,Oct,PMID:23095564.
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 74/83
27.DocimoG,RagusaM,RuggieroR,ProcacciniE,BoselliC,DAjelloF,BarberiniF,ParmeggianiD,RosatoL,SciannameoF,DeTomaG,
NoyaG,etal:Antibioticprophylaxisinthyroidsurgery:Apreliminarymulticentricitalianexperience.AnnSurgInnovRes2009,5(3):10,
Aug5.28.MooreFDJr:Oralcalciumsupplementstoenhanceearlyhospitaldischarge
afterbilateralsurgicaltreatmentofthethyroidglandorexploration
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 75/83
oftheparathyroidglands.JAmCollSurg1994,178:11-16.29.BellantoneR,LombardiCP,RaffaelliM,BoscheriniM,AlesinaPF,DeCreaC,TrainiE,
PrinciP:Isroutinesupplementationtherapy(calciumandvitaminD)usefulaftertotalthyroidectomy?Surgery2002,132:1109-12.
30.McLeodIK,ArcieroC,NoordzijJP,StojadinovicA,PeoplesG,MelderPC,
LangleyR,BernetV,ShriverCD:Theuseofrapid
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 76/83
parathyroidhormoneassayinpredictingpostoperativehypocalcemiaaftertotalorcompletionthyroidectomy.Thyroid2006,16:259-65.31.ChiaSH,WeismanRA,TieuD,KellyC,
DillmannWH,OrloffLA:Prospectivestudyofperioperativeactorspredictinghypocalcemiaafterthyroid
andparathyroidsurgery.ArchOtolaryngolHeadNeckSurg2006,132:41-5.32.RohJL,
ParkCI:RoutineoralcalciumandvitaminDsupplementsfor
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 77/83
preventionofhypocalcemiaaftertotalthyroidectomy.AmJSurg2006,192:675-678.33.FalkSA,BirkenEA,BaranDT:Temporarypostthyroidectomyhypocalcemia.ArchOtolHeadNeckSurg
1998,114:168-174.34.P.DespreauxG,FrachetB,ModiglianiE,PerretGY:Transient
hypocalcemiaafterthyroidectomy.AnnOtRhinLaryn1993,102:496-501.35.RichardsML,Bingener-CaseyJ,Pierce
DD,StrodelWE,SirinekKR:Intraoperativeparathyroidhormoneassay:an
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 78/83
accuratepredictorofsymptomatichypocalcemiafollowingthyroidectomy.ArchSurg2003,138:632-635.
36.LamA,KerrPD:Parathyroidhormone:anearlypredictorof
postthyroidectomyhypocalcemia.Laryngoscope2003,113:2196-2200.37.PayneRJ,HierMP,TamiliaM:Same-daydischarge
aftertotalthyroidectomy:thevalueof6-hourserumparathyroidhormoneandcalciumlevels.
HeadandNeck2005,27:1-7.38.GrodskiS,SerpellJ:
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 79/83
EvidencefortheroleofperioperativePTHmeasurementaftertotalthyroidectomyasapredictorofhypocalcemia.WJSurg2008,32:1367-1373.39.HeaneyRP,
WeaverCM:CalciumandvitaminD.EndocrinolMetabClinNorthAm2003,32:181-94.40.Heaney
RP:VitaminD,nutritionaldeficiency,andthemedicalparadigm.JClinEndocrinolMetab2003,88:5107-8.
41.ToloneC,CirilloG,PapparellaA,ToloneS,Santoro
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 80/83
N,GrandoneA,PerroneL,delGiudiceEM:AcommonCTLA4polymorphismconferssusceptibilitytoautoimmunethyroiddiseaseinceliacchildren.DigLiverDis
2009,41(6):385-9,Jun.42.GervasiR,OrlandoG,LeroseMA,AmatoB,Docimo
G,ZeppaP,PuzzielloA:Thyroidsurgeryingeriatricpatients:aliteraturereview.BMCSurg2012,
12(Suppl1):S16.43.RispoliC,RoccoN,IannoneL,Amato
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 81/83
B:Developingguidelinesingeriatricsurgery:roleofthegradesystem.BMCGeriatrics2009,9(SUPPL.1):A99.44.DocimoG,ToloneS,PasqualiD,ConzoG,DAlessandro
A,CasalinoG,GiliS,BruscianoL,GubitosiA,delGenioG,Ruggiero
R,DocimoL:Roleofpreandpost-operativeoralcalciumandvitaminD
supplementsinpreventionofhypocalcemiaaftertotalthyroidectomy.GChir
7/27/2019 Jurnal Dr Sobari
http://slidepdf.com/reader/full/jurnal-dr-sobari 82/83
2012,33:374-8.doi:10.1186/1471-2482-13-S2-S11Citethisarticleas:Toloneetal.:TheimpactofageandoralcalciumandvitaminDsupplementsonpostoperativehypocalcemia
aftertotalthyroidectomy.Aprospectivestudy.BMCSurgery201313(Suppl2):S11.
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