Elsevier

Surgery

Volume 156, Issue 1, July 2014, Pages 130-136
Surgery

Original Communication
Predicting hypocalcemia after thyroidectomy in children

https://doi.org/10.1016/j.surg.2014.02.016Get rights and content

Background and aims

Hypocalcemia after thyroidectomy is caused by parathyroid trauma. There are no studies regarding the usefulness of intact parathyroid hormone (PTH) as a monitor of postoperative hypoparathyroidism tool in pediatrics. We evaluated the diagnostic accuracy of intra- and postoperative PTH to predict the risk of developing post thyroidectomy hypocalcemia in children.

Methods

A prospective longitudinal cohort study was conducted in 32 pediatric patients (3.2–17.6 years old) undergoing total thyroidectomy. Intact PTH measured by the assays (Immulite Immunoassay System [ICMA] or electrochemioluminescence assay [ECLIA]) at 5 (PTH-5) and 60 (PTH-60) minutes after thyroid removal were considered as predicting variables. The postoperative outcome was hypocalcemia (endpoint variable). Patients were clinically and biochemically monitored regularly for 48 hours after surgery.

Results

Of the patients, 47% developed hypocalcemia (15% symptomatic). An ICMA PTH-5 of ≤14 pg/mL or an ECLIA PTH-5 of ≤16 pg/mL predicted hypocalcemia with a sensitivity of 80%, specificity of 100%, positive predictive value (PPV) of 100%, and diagnostic efficiency (DE) of 91%. Using the same cutoff values, PTH-60 presented a sensitivity of 93%, specificity of 82%, PPV of 81%, and DE of 87%. Adjusting for variation in the assays and combining intra- and postoperative PTH determinations, we developed an algorithm that improved sensitivity, specificity, and DE.

Conclusion

PTH is useful for predicting hypocalcemia after total thyroidectomy in children. The use of our proposed strategy should be considered to (a) initiate preventive treatment in patients identified at high risk for hypocalcemia, (b) shorten the duration of hospitalization, and (c) reduce the clinical and biochemical controls in those who remained normocalcemic.

Section snippets

Patients and methods

We performed a prospective, longitudinal, cohort study. The study protocol was approved by the Institutional Review Board and Ethics Committee of the Hospital de Niños Dr Ricardo Gutierrez. Informed consent was obtained from parents and assent was obtained for children >7 years old; children of all ages were included in the study.

We included consecutively pediatric patients who underwent total thyroidectomy between October 2006 and March 2013 at our hospital. Exclusion criteria were patients

Results

Thirty-five patients underwent total thyroidectomy during the study period. Three patients were excluded: One was under octreotide treatment and the other 2 owing to pronounced deviations from protocol design. Of the remaining 32 patients, 22 were females and 10 males, aged 3.2–17.6 years (median, 11; Table I). Diagnoses that prompted thyroidectomy were prophylactic thyroidectomy in patients with proto-oncogene RET mutation associated with multiple endocrine neoplasia 2A (n = 9), thyroid

Discussion

To our knowledge, this is the first study that assessed the diagnostic performance of intra and postoperative measurements of PTH as a predictor post-thyroidectomy hypocalcemia in a pediatric population. In this pediatric cohort, hypocalcemia developed in 47% of thyroidectomized patients, which is greater than the reported frequency of 20–30% in adults.14 This finding could be owing to greater susceptibility within the pediatric population or to the difficulties inherent to pediatric neck

References (17)

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    LOS >1d secondary to hypocalcemia was determined by reviewing clinical note documentation by the primary surgical team, laboratory calcium values, and changes to supplementation regimen made during admission. Permanent hypoparathyroidism was defined as hypocalcemia that required calcium and/or calcitriol supplementation at least 6 months postoperatively, which is consistent with the literature [1,5–8]. The multidisciplinary thyroid team continued to monitor all cases on supplementation for recovery further.

  • Risk factors for the development of hypocalcemia in pediatric patients after total thyroidectomy – A systematic review

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    However, this study did not examine transient hypocalcemia and the majority (78%) of surgeries were performed for hyperthyroidism. Similarly, Freire and colleagues[3] reported no association between postoperative hypocalcemia and indications for surgery, patient age and sex, although multivariate analyses were not performed. While Jiang and colleagues also reported no association between the patients’ age, sex or indication for surgery (benign versus malignant) with the incidence of hypocalcemia, they found that patients who underwent total thyroidectomy were more likely to develop hypocalcemia than those who underwent a completion thyroidectomy (total 71.9% versus completion 16.7%, p = 0.01).

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