Postoperative Calcium Management in Same-Day Discharge Thyroid

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Original Research Otolaryngology– Head and Neck Surgery 1–7 Postoperative Calcium Management in Ó American Academy of Otolaryngology—Head and Neck Same-Day Discharge Thyroid and Surgery Foundation 2016 Reprints and permission: sagepub.com/journalsPermissions.nav Parathyroid Surgery DOI: 10.1177/0194599816631732 http://otojournal.org

Kurt L. Nelson, MD1, Andrew M. Hinson, MD2, Bradley R. Lawson, MD1, Derek Middleton3, Donald L. Bodenner, MD, PhD2,4, and Brendan C. Stack Jr., MD1,4

No sponsorships or competing interests have been disclosed for this article. ypocalcemia is a potentially serious sequela of both total thyroid and parathyroid surgery. Operating within the thyroid bed of the neck may cause acci- Abstract H dental removal of, local trauma to, or devascularization of Objective. To describe a safe and effective postoperative pro- one or more of the parathyroid glands. Hypocalcemia can phylactic calcium regimen for same-day discharge thyroid occur in up to 30% of patients following total thyroidectomy, is and parathyroid surgery. usually not evident until 12 to 48 hours postoperatively, and Study Design. Case series with chart review. is defined as corrected serum calcium \8.5 mg/dL or ionized calcium \1.15 mmol/L.1,2 In parathyroid surgery, additional Setting. Tertiary referral academic institution. causes of hypocalcemia include slow response of the remain- Subjects and Methods. In total, 162 adult patients who under- ing parathyroid gland(s) due to long-term suppression from a went total thyroidectomy, completion thyroidectomy, unilat- hyperfunctioning gland(s) and, although rare, hungry bone 3 eral parathyroidectomy, parathyroidectomy with bilateral syndrome. Of note, hungry bone syndrome can also be seen neck exploration, or revision parathyroidectomy were identi- postoperatively in total thyroidectomy, especially in the set- fied preoperatively to be candidates for same-day discharge. ting of Grave’s disease. Hungry bone disease results from All patients in this study were successfully discharged the severe bone demineralization from chronic hyperparathyroid- same day on our standard prophylactic calcium regimen. ism (HPT) or Grave’s disease. Upon removal of the offending parathyroid gland(s) or the hyperfunctioning thyroid, the Results. Less than 1% (1/162) of patients re-presented to the bone demands return of lost calcium. hospital within 30 days of surgery, and that patient was suc- Risk factors for postoperative hypoparathyroidism include cessfully discharged from the emergency department after operating surgeon experience4 reflected in low annual surgical negative workup for hypocalcemia. There was no significant volumes, long total operative times, and excessive intraopera- difference between preoperative and postoperative calcium tive blood loss. Other risk factors include bilateral or revision levels in the total/completion thyroidectomy groups (9.3 vs central neck surgery, surgery for thyroid malignancy, female 9.2 mg/dL, respectively; P = .14). The average postoperative sex, surgery for parathyroid hyperplasia, lactation, pregnancy, calcium level in the parathyroid group was well within vitamin D deficiency, autoimmune thyroid disease (such as normal limits (9.5 mg/dL), and the difference in postopera- Grave’s disease or Hashimoto’s thyroiditis), and history of gas- tive calcium levels between revision and primary parathyroi- tric bypass.2 At our institution, postoperative calcium manage- dectomy cases was not significantly different (P = .34). ment is the same for both thyroid and parathyroid surgery and Conclusion. The reported calcium regimen demonstrates a safe, effective, and objective means of postoperative calcium management in outpatient thyroid and parathyroid surgery 1 in appropriately selected patients. Department of Otolaryngology–Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA 2Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA Keywords 3College of Medicine, University of Arkansas for Medical Sciences, Little same-day surgery, same-day discharge, intraoperative para- Rock, Arkansas, USA 4 thyroid hormone, hypocalcemia, parathyroidectomy, thyroi- UAMS Thyroid Center, Little Rock, Arkansas, USA dectomy, calcium management Corresponding Author: Brendan C. Stack Jr., MD, University of Arkansas for Medical Sciences Received October 22, 2015; revised January 12, 2016; accepted (UAMS), 4301 W. Markham St, #543, Little Rock, AR 72205, USA. January 20, 2016. Email: [email protected]

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Table 1. Absolute Criteria for and Relative Hindrances to Same-Day Surgery.a Relative Medical Relative Perioperative Relative Circumstantial Absolute Criteria Hindrances Hindrances Hindrances

Absence of major medical Untreated respiratory or Size and extent of goiter comorbidities cardiac disease Proper preoperative education End-stage renal disease/need for Advanced malignancy Patient preference dialysis Approved vicinity to hospital Pregnancy Difficult hemostasis Lack of transportation and/or caretaker Safe discharge environment Visual or hearing deficiency Difficult operation Communication obstacles Willing and able caretaker Neurologic or psychiatric present after discharge disorder (ie, seizures, depression, anxiety) Obstructive sleep apnea Anticoagulation status aModified from ‘‘American Thyroid Association Statement on Outpatient Thyroidectomy’’ by Terris et al.7

is driven by postexcision intraoperative parathyroid hormone Methods (iPTH) measurements. A recent study comparing multistate ambulatory thyroi- Protocol dectomy readmission rates in California, Florida, Iowa, and All patients who undergo thyroid/parathyroidectomy receive New York found hypocalcemia to be the most common our standard iPTH protocol and must meet our criteria for reason for readmission within 30 days postoperatively, fol- same-day discharge, which mirror the criteria for discharge in lowed by hematoma/seroma/bleeding.5 A study from the the American Thyroid Association (ATA) statement for out- University of Wisconsin showed iPTH testing can reliably patient thyroidectomy (Ta b le 1 ).7 In addition, all patients are predict patients who are at the highest risk of developing reviewed on a case-by-case basis pre- and postoperatively for hypocalcemia. They concluded patients with an iPTH \10 other factors that would make them potentially unsafe to be pg/mL were at highest risk and should be treated with both discharged home, such as medical comorbidities, pain, post- calcium and calcitriol at discharge. Identifying these operative nausea and vomiting, and urinary retention. Patients patients prior to discharge and prophylactically managing who live outside of a 1-hour drive to our institution are asked their calcium decreased the rate of emergency department to stay at a local hotel or with family/acquaintance for the (ED) admissions for hypocalcemia from 8% to 1.8% (P = first night postoperatively. Our standard intraoperative proto- .008), leading to significant reduction in cost.1 col consists of intravenous (IV) acetaminophen unless contra- Echoing these findings, a study from our own institution indicated, IV steroids,8-10 placement of shoulder roll for reviewed patients who underwent total thyroidectomy or com- adequate exposure, placement of esophageal probe, absti- pletion thyroidectomy by a single surgeon and identified 268 nence from long-acting paralytic agents, and use of moni- cases intended for same-day discharge (SDD), defined as the tored endotracheal tubes. Also, the Harmonic Focus 1 patient being discharged from the hospital prior to midnight on Shears (Ethicon, Cincinnati, Ohio) device is used on all the day the operation was performed. One hundred patients cases. (37%) were not discharged home on the same day due to mul- The iPTH levels are then drawn both at 10 and 20 min- tiple factors.6 Concern for high risk of hypocalcemia was the utes after extirpation of the thyroid/parathyroid gland(s) leading barrier to SDD, accounting for 25.7% of cases that (Figure 1). The 20-minute value must be .10 pg/mL for were initially intended for SDD but instead were admitted. patients to be eligible for SDD,1,2,11 and if iPTH is \10 pg/ These patients all had iPTH values \10 pg/mL (mean, 6.0 pg/ mL, the patient is observed for 23 hours. mL) with a mean calcium level of 8.4 mg/dL. Social and Once discharged home, we adjust the dosing based on transportation issues were the next causes of admission. All serum calcium levels. Presence of surgical drain is not an patients successfully discharged home on the same day had absolute contraindication to SDD and is infrequently used. iPTH levels .10 pg/mL, and only one of those persons re- Levothyroxine prescription is given to all total/completion presented to the ED for transient hypocalcemia.6 thyroidectomy patients. With low rates of hypocalcemia related readmission at our We employ a modified ‘‘parathyroid splinting’’12 technique institution, we wish to publish our experience with outpatient that aids the parathyroid glands as they recover from surgery calcium management of total/completion thyroidectomy and by maximizing enteral absorption of calcium via aggressive parathyroidectomy cases guided by postexcision iPTH. supplementation of high doses of calcium in all patients.

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creatinine, 25-hydroxyvitamin D, magnesium, chloride, and phosphate. The same battery of labs is used in all of our patients to standardize both our diagnostic and surveillance methods (Table 3). Conditions such as multiple-endocrine neoplasia type 1 (MEN1) can show inaccuracy in solely using the serum calcium level in the diagnosis as well monitoring of calcium postoperatively, which is why both serum and ionized calcium are used in all our patients.14 In addition, ionized calcium is not dependent on the patient’s nutritional status. Creatinine and phosphate are used to evaluate calcium homeostasis at the renal level. Vitamin D deficiency has 15 Figure 1. Intraoperative parathyroid hormone (PTH) (20 minutes) been reported to be up to 41.6% in the US population. and postoperative calcium levels. Elevated PTH and normocalcemia Hypovitaminosis D is a the most common cause of second- is reflective of vitamin D deficiency. ary hyperparathyroidism and can complicate postoperative hypoparathyroidism and hypocalcemia.16 Hypomagnesaemia causes impaired release and function of PTH and, if low, 2 Depending on the patient’s iPTH level, 1,25 dihydroxy chole- must be supplemented accordingly. Hyperchloremia in the calciferol (calcitriol) may also be added (Ta b l e 2 ). setting of borderline high PTH and calcium can aid in the Patients who are observed will have a recheck of their diagnosis of hyperparathyroidism, especially with a chloride 17 PTH and calcium levels on the morning of postoperative to phosphate ratio above 33. day 1. By evaluating both the patients’ PTH and calcium on If the patient’s 8-pack battery is within normal limits postoperative day 1 and correlating this with the iPTH (especially calcium and PTH measurements) at the 10- to levels, patients at risk for sustained hypocalcemia can be 14-day postoperative visit, we decrease the dose of calcium identified more accurately than relying on calcium alone.13 that the patient was discharged home on by half for 1 week, That being said, the majority of the time, we check PTH then discontinue altogether. If the patient is taking calcitriol, levels on postoperative day 1 only. We rely on calcium we will decrease the dose of calcitriol by half and recheck levels alone until stabilization is reached in the rare patients the calcium levels 1 week later. If normal, we discontinue who stay longer than 24 hours postoperatively. Depending calcitriol and taper calcium as previously discussed. We on the direction of the trend, we adjust the patient’s calcium also supplement vitamin D deficiency at the postoperative regimen accordingly until stabilization. visit as needed with 50 international units of vitamin D Patients are educated prior to discharge to be aware of once a week. signs and symptoms of hypocalcemia. We instruct patients to take an additional 1000 mg of calcium if they experience Patients any symptoms at 15-minute intervals. If symptoms do not After obtaining institutional review board (IRB) approval (IRB resolve in 60 minutes after supplementing 4000 mg of cal- protocol number 114616, ‘‘Peri-Operative Parathyroid Hormone cium, patients are instructed to call our service or go to a (PTH) Measurement for Outpatient Thyroid Surgery’’) from the local ED for evaluation. After discharge, all patients follow University of Arkansas for Medical Sciences, we reviewed our up in the clinic 10 to 14 days postoperatively for evaluation database of total/completion thyroidectomies (Figure 2)and of their wound and for laboratory testing. parathyroidectomies (Figure 3) and identified patients (n = We have instituted a standard ‘‘8-pack’’ battery of labs 162) who were discharged the same day from January 2013 to drawn preoperatively for total thyroid and parathyroid April 2015 after meeting our previously mentioned standards. patients and at the first postoperative visit for both parathyr- This data set represents 55% (162 patients included/296 total oid and total/completion thyroidectomy patients that gives a patients) of the senior author’s overall volume of total/comple- complete view of calcium homeostasis consisting of serum tion thyroidectomy (n = 134) or parathyroidectomy (n = 162) calcium, ionized calcium, parathyroid hormone (PTH), cases during the same time period.

Table 2. Outpatient Calcium Management Protocol. iPTH Level Calcium Carbonate Calcitriol Disposition

.15 pg/mL 1 g BID None Discharge 10-15 pg/mL 2 g BID None Discharge 5-10 pg/mL 2 g BID 0.25 mcg BID Overnight observation \5 pg/mL 2 g BID 0.5 mcg BID Overnight observation

Abbreviations: BID, twice a day; iPTH, intraoperative parathyroid hormone.

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Table 3. Patient Cost for ‘‘8-Pack’’ and Intraoperative Parathyroid Hormone (PTH) Laboratory Testing.a Test Costs (US Dollars)

Intraoperative PTH 4.10b Intact PTH 4.10c Ionized calcium 2.41 Serum calcium 0.51 Magnesium 4.10 Chloride 4.10 Phosphate 2.41 Creatinine 0.51 25-Hydroxyvitamin D 4.10 Figure 3. Percentage of unilateral (n = 58; 76.3%) vs bilateral neck exploration (n = 18; 23.7%) for parathyroid surgery (n = 76). One aCost reflects charge for patients at the University of Arkansas for Medical patient had parathyroid carcinoma and had a concurrent central Sciences. bRun in 15 minutes. neck dissection. cRun in 30 minutes.

a medical necessity for admission. However, many of our patients who undergo lateral neck dissection are admitted because of a Medicare requirement for inpatient admission for 2 midnights, a requirement that has also been adopted by other third-party payers. If this were not a requirement, many of the patients excluded from the 296 total patients would have been candidates for SDD. Results Serum calcium and parathyroid hormone levels, as well as the rate of readmission for hypocalcemia, were reviewed in 162 total patients (Tables 4 and 5). Statistical analyses were performed using SAS v9.3 software (SAS Institute, Figure 2. Diagnosis in patients undergoing total or completion Cary, North Carolina). Laboratory measurements are thyroidectomy (n = 86). Twelve of the 45 (26.7%) patients with expressed as the mean 6 standard deviation (SD) of the malignant thyroid disease underwent concurrent central neck mean. Quantitative unpaired values were compared using dissection. the Student t test. Variables that were not normally distribu- ted were expressed as the median value and assessed by use of the Mann-Whitney rank-sum test for nonparametric data. Furthermore, we divided the parathyroid group into uni- Pre- and postoperative calcium levels (drawn at the lateral, bilateral exploration, and revision surgery. Included patient’s 10- to 14-day postoperative visit) were compared in the parathyroidectomy group were patients with parathyr- in both groups, yielding a nonsignificant P value in the thyroid adenoma (n = 71), parathyroid carcinoma (n = 1), oid group (P = .14). Pre- and postoperative calcium levels double adenoma (n = 2), parathyroid hyperplasia (n = 1), were significantly different in the parathyroid group (P \ and MEN syndrome (n = 1). Excluded were any patients .0001), which is expected given this is a surgery for hyper- admitted as an inpatient or 23-hour observation, as the focus calcemia. However, the average postoperative calcium level of this study is to review the effectiveness of our SDD cri- was well within the normal range in both the bilateral teria. Also excluded were all hemithyroidectomies2 as well exploration and unilateral exploration groups. Six parathyr- as any patient who did not have both pre- and postoperative oidectomy patients had a history of neck surgery, including calcium measurements (n = 6). Each patient had a minimum thyroidectomy or parathyroidectomy; mean (SD) postopera- 30-day follow-up. None of the patients in our cohort under- tive calcium in these patients (9.25 [0.53] mg/dL; range, went parathyroid autotransplantation. 8.4-10.0 mg/dL) was not significantly (P = .34) lower than Of note, 3 patients in the completion thyroid/total thyroi- patients undergoing unilateral or bilateral exploration. dectomy cohort also underwent lateral neck dissection of In addition, \1% of our patients (1/162) presented to the levels 2 to 4 and were successfully discharged home the ED within 30 days of surgery. This patient presented to the same day. This is an important issue to point out because ED with complaints of perioral tingling. She was evaluated, lateral neck dissection does not objectively exclude a patient found to have normal calcium levels, and discharged from from SDD. Patients will obviously be admitted if they have the ED with instructions to follow up in the clinic without

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Table 4. PTH and Calcium Values before and after Total or Completion Thyroidectomy. PTH, pg/mL, Mean (SD) Calcium, mg/dL, Mean (SD)

Thyroidectomy Baseline 10 min 20 min Preoperative Postoperative (Days 10-14)

Total (n = 78) 66.7 (34.3) 55.8 (39.1) 55.9 (34.0) 9.3 (0.4) 9. 2 (0.5) Completion (n = 8) 61.2 (41.7) 53.2 (29.6) 50.5 (34.2) 9.3 (0.2) 9.0 (0.4) Grand total (n = 86) 66.2 (34.8) 56.0 (38.2) 55.5 (34.7) 9.3 (0.4) 9.2 (0.5)

Abbreviations: PTH, parathyroid hormone; SD, standard deviation.

Table 5. PTH and Calcium Values before and after Parathyroidectomy. PTH, pg/mL, Mean (SD) Calcium, mg/dL, Mean (SD)

Parathyroidectomy Baseline 10 min 20 min Preoperative Postoperative (Days 10-14)

Unilateral (n = 58) 123.6 (54.1) 56.2 (44.8) 44.8 (34.8) 10.5 (0.7) 9.5 (0.6) Bilateral (n = 18) 116.5 (38.8) 71.6 (60.2) 47.1 (44.7) 10.5 (0.8) 9.5 (0.8) Grand total (n = 76) 121.9 (50.7) 59.9 (48.9) 37.7 (29.2) 10.5 (0.7) 9.5 (0.6)

Abbreviations: PTH, parathyroid hormone; SD, standard deviation. receiving IV calcium supplementation. We asked our proportion of SDD vs overnight admission in the outpatient patients at follow-up if they presented to an outside ED, and surgery group. This study did not report a cost comparison none reported this. In addition, nurses’ notes were reviewed between SDD and overnight admission. as part of this study, and we did not find any patient who Parathyroid surgery attempts to correct hypercalcemia called our clinic to report that he or she presented to another caused by an abnormal parathyroid gland via removal of the ED. offending gland(s). As a result, patients are at risk for developing hypoparathyroidism with hypocalcemia postoperatively. Discussion However, patients who undergo single-sided parathyroid sur- Thyroid and parathyroid surgeries have historically been per- gery are at a lower risk (albeit not zero) for developing post- formed as inpatient procedures, but over the past decade, out- operative hypoparathyroidism with hypocalcemia compared patient procedures have increased and can be done safely in with patients who undergo either bilateral/revision parathyroi- appropriately selected patients.7,18 A 2013 article reviewed dectomy or total/completion thyroidectomy. However, we University Health Consortium (UHC) data and found that manage all of these patients the same in terms of prophylactic from 2005 to 2010, the proportion of outpatient thyroid sur- calcium. gery compared with inpatient thyroid surgery rose steadily As previously stated, concern for postoperative hypopar- over that time period. In 2010, 55% of all thyroid surgery in athyroidism and subsequent hypocalcemia is the leading that cohort was performed as an outpatient surgery.19 barrier to SDD at our institution.6 Due to the unique nature In addition to increasing in frequency, outpatient thyroi- of our institution, we serve a multitude of patients who live dectomy has been shown to be reducing costs as well. A more than 2 to 3 hours away and may not live in close prox- study by Terris and associates20 found a mean cost of $7814 imity to another highly skilled health care facility. We for outpatient thyroidectomy compared to $10,288 for inpa- believe it is much safer to discharge these patients home on tient. A similar study of UHC data showed the total cost of a prophylactic calcium regimen to minimize the risk of outpatient thyroidectomy and compared the cost of SDD developing symptomatic hypocalcemia contrasted to dis- with 23-hour observation. The average cost of outpatient charging these patients home without calcium supplementa- thyroidectomy was $5617, with the average cost of SDD tion. With regards to oversupplementing and creating a state being $4642 compared with $6101 for overnight observation of hypercalcemia, we have not observed this to be an issue. (P \ .0001).21 A 10- to 14-day postoperative follow-up is a protection for Another study using UHC data reported a cost reduction this. Conversely, in our experience, the risk of developing in outpatient parathyroidectomy compared with inpatient hypercalcemia from supplementation has shown to be essen- parathyroidectomy. In total, 21,057 patients underwent outpa- tially zero, evidenced by an average postoperative calcium tient parathyroid surgery between 2005 and 2010 with a level of 9.5 mg/dL in patients undergoing unilateral para- reported average cost of $12,738 for outpatient parathyroi- thyroidectomy (Table 4). dectomy compared to $14,657 for inpatient parathyroidect- We employ a modified ‘‘parathyroid splinting’’12 technique omy (P =.004).22 Moreover, the study also reported a higher to avoid postoperative hypoparathyroidism and hypocalcemia.

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The rationale behind this technique is based on a study by At our institution, the cost of iPTH and early postoperative Sitges-Serra and associates,12 who found that patients with PTH is the same (Ta bl e 3 ); however, the results of iPTH higher calcium levels 1 month after surgery had improved have a turnaround time of 15 minutes compared to 30 min- return of native parathyroid function. The hypothesis was that utes with early postoperative PTH. In addition, we use iPTH by decreasing the physiologic burden on the parathyroid as part of our approach for minimally invasive radio-guided glands as they recover from transient postsurgical changes parathyroidectomy (MIRP), and to make the operating room such as injury and ischemia, they are better able to recover as efficient as possible, we use iPTH for both MIRP and total and return to normal function. thyroidectomy since cost and efficacy are the same. Harmonic Focus 1 Shears are used on all cases in an However, either iPTH or early postoperative PTH can be attempt to further decrease the rate of postoperative hypo- used to assess a patient’s appropriate calcium regimen as calcemia. Thermal energy devices have been shown in a described earlier if a significant cost difference exists meta-analysis to decrease the rate of postoperative transient between the 2 tests at a given institution; however, iPTH hypocalcemia as well as total operative time.23 Anecdotally, offers cost savings in eliminating extended observation. we feel hemostasis using thermal energy devices is superior In addition to the requirements listed in Ta bl e 1 and the compared with traditional techniques. iPTH requirement of .10 pg/mL, each patient’s discharge It is worth discussing why we obtain both 10- and 20- from the hospital should be considered on a case-by-case minute iPTH levels. First, by comparing the rate of change basis as to whether he or she is safe for same-day discharge. between the 10- and 20-minute values in both parathyroid As mentioned previously, factors such as medical comorbid- and thyroid surgery, we may find it necessary—if there is a ities, pain, postoperative nausea and vomiting, urinary reten- drastic change between the two levels—to obtain a third tion, and so on would all be obstacles to same-day discharge. value to ensure the iPTH level does not drop below 10 pg/ Therefore, it is extremely vital to examine the patient prior to mL. On the other hand, sometimes the 10-minute level is discharge to assess for any of these particular issues. actually \10 pg/mL, but the 20-minute level is within the range for SDD. In these cases, we will use the 20-minute Conclusion level as this shows the patient has parathyroid function. Also, Outpatient thyroid and parathyroid surgery is a safe and in parathyroid surgery, we use must ensure biochemical cure effective procedure.7 Thirty-day representation was \1%, that is based on the Miami Criterion,24 and at times this level consistent with literature.18,25 Our algorithm demonstrates a is not yet reached 10 minutes after extirpation of the gland. safe and effective protocol for outpatient thyroid/parathyroid Using 2 iPTH levels allows for analysis of a trend. surgery. Also, both iPTH and early postoperative PTH are Houlton and associates25 reported similar outcomes to adequate means to manage the patient’s calcium regimen our cohort in a 2011 study with no readmissions in patients accordingly.26 By identifying patients at high risk for devel- who underwent outpatient thyroidectomy using a standar- oping hypocalcemia and placing all patients on an appropri- dized protocol that used rapid PTH obtained in the posta- ate calcium prophylaxis, both ED readmission rates and nesthesia care unit (PACU) as a major determining factor hospital costs can be reduced.1,6,18-22 for discharge. In their series, in the absence of other factors, patients were eligible for discharge if their PACU PTH was Author Contributions 18 .20 pg/mL. In addition, Norman and Aronson reported a Kurt L. Nelson, writing, editing, data gathering, approval, accounta- readmission rate of \1% following outpatient parathyroi- ble; Andrew M. Hinson, writing, data gathering, editing, approval, dectomy in a cohort of patients who were discharged home accountable; Bradley R. Lawson, content idea, data gathering, edit- with prophylactic calcium supplementation. ing, writing, approval, accountable; Derek Middleton,datagathering, Given the debate regarding the superiority of iPTH editing, approval, accountable; Donald L. Bodenner, content idea, (defined as PTH obtained in the operating room) vs early editing, approval, accountable; Brendan C. Stack Jr., content idea, postoperative PTH (PTH obtained 1-4 hours after surgery), editing, writing, approval, accountable. a meta-analysis was recently done that compared the effi- Disclosures cacy of iPTH with early postoperative PTH in patients Competing interests: None. undergoing total thyroidectomy. Fourteen studies were Sponsorships: None. found that met inclusion criteria. Excluded were studies that only had a hemithyroidectomy as well as studies that did Funding source: None. not report a PTH value or had a PTH value that did not References meet criteria as iPTH or early postoperative PTH. The authors found that iPTH and early postoperative PTH values 1. Youngwirth L, Benavidez J, Sippel R, Chen H. Postoperative were both significantly lower in hypocalcemic individuals parathyroid hormone testing decreases symptomatic hypocal- and that there was no statistically significant difference cemia and associated emergency room visits after total thyroi- between iPTH and early postoperative PTH.26 This implies dectomy. Surgery. 2010;148:841-844. that both methods are an acceptable means to measure a 2. Stack BC Jr, Bimston DN, Bodenner DL, et al. American patient’s PTH level and place them on the appropriate cal- Association of Clinical Endocrinologists and American cium regimen. College of Endocrinology Disease State Clinical Review:

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