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Inadvertent Parathyroidectomy During Thyroid Surgery for Papillary Thyroid Carcinoma and Postoperative Hypocalcemia

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Inadvertent Parathyroidectomy During Thyroid Surgery for Papillary Thyroid Carcinoma and Postoperative Hypocalcemia ORIGINAL J Korean Thyroid Assoc ARTICLE Vol. 5, No. 1, May 2012 Inadvertent Parathyroidectomy during Thyroid Surgery for Papillary Thyroid Carcinoma and Postoperative Hypocalcemia Dongbin Ahn, MD1, Jin Ho Sohn, MD, PhD1, Jae Hyug Kim, MD1, Ji Young Park, MD2 and Junesik Park, MD, PhD3 Departments of Otolaryngology-Head and Neck Surgery1, Pathology2, School of Medicine, Kyungpook National University, Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Catholic University of Daegu3, Daegu, Korea Background and Objectives: The aim of this article is to report our experience of inadvertent parathyroidectomy during thyroid surgery and to analyze its associated factors and clinical implications. In addition, we attempted to determined causative factors that result in permanent hypocalcemia after thyroid surgery. Materials and Methods: We performed a retrospective review of 500 patients who underwent thyroid surgery for the treatment of papillary thyroid carcinoma from 2004 to 2008. Results: Inadvertent parathyroidectomy was identified in 7.4% of patients and only 1 parathyroid gland was inadvertently removed in most cases. The incidence of inadvertent parathyroidectomy was not associated with gender, age, type of surgical procedure, tumor size, coexisting Hashimoto’s thyroiditis (HT), extra-thyroidal extension (ETE), lymph node (LN) metastasis, and surgeon’s experience. Nor was inadvertent parathyroidectomy associated with permanent postoperative hypocalcemia. Although operating time >120 min, ETE, and total thyroidectomy (TT) with central neck dissection (CND) were found to be related to permanent hypocalcemia on univariate analysis, tumor size ≥1 cm and surgeon’s experience ≤5 years was statistically associated with permanent hypocalcemia on both univariate and multivariate analyses. Conclusion: Although inadvertent parathyroidectomy is not an uncommon complication of thyroid surgery, it appears to have only modest clinical implications. Permanent hypocalcemia was significantly associated with tumor size ≥1 cm and short surgical experience of surgeons, especially in the case of TT with CND. Therefore, we suggest that more accurate risk stratification should be made for routine CND, when it is performed by young surgeons. Key Words: Thyroidectomy, Parathyroidectomy, Hypocalcemia be due to a variety of factors, such as injury, Introduction devascularization of the parathyroid glands, and accidental resection of parathyroid parenchyma. Because thyroid cancer is the most common head Incidental parathyroidectomy during thyroid surgery is and neck malignancy worldwide, thyroidectomy is the a potential complication; its occurrence varies widely most frequent surgical procedure performed by head among centers and among surgeons and is depen- and neck surgeons.1,2) It is relatively safe and many dent on regional and individual experience. Anecdo- studies have reported a major complication rate tally, incidental removal of parathyroid gland is often around 1%.3,4) However, despite careful surgical identified in histological reports of thyroid specimens technique, postthyroidectomy hypoparathyroidism has from some patients, even after meticulous thyroide- been reported in up to 25% of patients.5,6) This may ctomy without signs or symptoms of clinical hypocal- Received November 29, 2011 / Revised 1st March 5, 2012, 2nd April 3, 2012 / Accepted April 12, 2012 Correspondence: Jin Ho Sohn, MD, PhD, Department of Otolaryngology-Head and Neck Surgery, Kyungpook National University Hospital, 50 Samduck 2-ga, Jung-gu, Daegu 700-712, Korea Tel: 82-53-200-5777, Fax: 82-53-423-4524, E-mail: Jinho [email protected] 65 Dongbin Ahn, et al cemia. However, the incidence of this complication men and 441 women, with a mean age of 48.1 years and its clinical impact on hypocalcemia remain at the time of surgery. Thyroid lobectomy including obscure. Although the removal of 1 or 2 parathyroid isthmusectomy was performed in 102 patients (20.4%), glands may not have any clinical relevance, it has and TT without neck dissection was performed in 318 been noted as a risk factor for postthyroidectomy patients (63.6%). TT with CND but without lateral neck hypocalcemia by some authors.2,7) Thus, in order to dissection was performed in 80 (16.0%). reduce the incidence of unintentional resection of Surgical technique parathyroid glands and of postthyroidectomy hypocal- cemia, it is important for thyroid surgeons to identify All surgeries were performed by 6 head and neck factors that could potentially increase the risk of surgeons including 2 senior surgeons (surgical inadvertent parathyroidectomy during thyroid surgery experience ＞5 years) and 4 junior surgeons (surgical and to understand its possible association with experience ≤5 years). Thyroidectomy was performed hypocalcemia. The aim of this article is to report our under general anesthesia via a transverse cervical experience of inadvertent parathyroidectomy during incision. The procedure was performed in a similar thyroid surgery, and to analyze its associated factors fashion by all surgeons by using careful subcapsular and clinical implications. In addition, we attempted to dissection technique and attempting to identify and determine causative factors related to the incidence of preserve the parathyroid glands and recurrent permanent hypocalcemia after thyroid surgery. laryngeal nerves. A particular effort was made to avoid injury to and devascularization of the parathyroid Materials and Methods glands. All resected thyroid specimens were carefully examined intraoperatively to identify the presence of Patients parathyroid tissue. Incidentally removed parathyroid A database of patients with thyroid cancer was glands were autotransplanted immediately and these established in 1997 at the authors’ institution. Analysis cases were not included in the present study. At the of data from these patients identified 1634 patients time this evaluation, novel hemostatic devices such as who underwent thyroid surgery at our institution during Harmonic Scalpels and LigaSure, which replaced the the 5-year period from January 2004 to December classical clamp-and-tie technique after 2009, were 2008. Of these patients, 500 who received initial not used. treatment including thyroid lobectomy with isthmu- Evaluation of clinical and biochemical hypocalcemia sectomy, total thyroidectomy (TT), and TT with central neck dissection (CND) for papillary thyroid carcinoma Data relating to postoperative biochemical and (PTC) at our institution and had medical records clinical hypocalcemia were thoroughly evaluated. accessible for review were included in the study. The Serum calcium levels were measured preoperatively, remaining patients were excluded due to inaccessible before surgery on the day of surgery, and on every or incomplete medical charts, inappropriate pathologic postoperative day until discharge. Biochemical slides for review of the previous diagnosis, revision hypocalcemia was defined as the lowest serum surgery for recurrence, or other types of thyroid calcium concentration of less than 8 mg/dl in serial cancer including follicular, medullary, and anaplastic postoperative calcium levels, regardless of signs or thyroid cancer. Patients who underwent comprehensive symptoms of hypocalemia. Transient hypocalcemia neck dissection, such as radical neck dissection, was defined as clinical hypocalcemia requiring modified radical neck dissection, and selective neck treatment and was associated with a serum calcium dissection level II to V, were also excluded for uniform level lower than 8.0 mg/dl after surgery that, resolved design of the present study. The cohort of 500 completely within 6 months. Permanent hypocalcemia patients enrolled in our present study consisted of 59 was defined as a case of oral calcium supplemen- Vol. 5, No. 1, 2012 66 Inadvertent Parathyroidectomy during Thyroid Surgery and Postoperative Hypocalcemia tation for more than 6 months following surgery regardless of calcium level. Results Review of histopathological parameters Characteristics of inadvertently removed parathyroid glands Histopathological parameters of each patient were blindly determined by 1 co-author specializing in Table 1 shows the characteristics of inadvertently thyroid and parathyroid pathology. All pathologic slides resected parathyroid glands. Inadvertent parathyr- were reviewed for the presence, number, and location oidectomy was identified in 37 patients (7.4%). One (extrathyroidal, intrathyroidal, or intracapsular) of and 2 parathyroids were accidentally removed in 35 inadvertently removed parathyroid glands within the (94.6%) and 2 (5.4%) patients, respectively. In most of submitted thyroid specimen. Histopathological features the patients (30 patients, 81.1%), the excised para- of the removed parathyroid glands were also thyroid was normal; however, in 5 patients (13.5%), evaluated. Moreover, in terms of thyroid direct PTC invasion was found in the excised gland, histopathology, primary tumor size, the status of the and in 2 other patients (5.4%), parathyroid adenoma extra-thyroidal extension (ETE) and subtype of each was found. In total, unnecessary excision of normal primary PTC and the presence of cervical lymph node parathyroid glands were identified in 30 patients (LN) metastasis and coexisting Hashimoto’s thyroiditis (6.0%). Examination of the location of the parathyroid (HT) were carefully reviewed. tissue within the thyroid specimen showed that of the inadvertently removed parathyroid glands, 21 (56.8%)
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