Dr Guy ANDRY, M. MOREAU, I.

EL MOUSSAOUI,
E. WILLEMSE, M. QUIRINY, A. DIGONNET
Universit Libre de Bruxelles, Brussels

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Despite all the methods to evaluate
and to predict postoperative
hypocalcemia, no consensus exists
on the role of routine calcium and/or
Vit. D following thyroid surgery

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA

Hypocalcemia is the most frequent

complication after total thyroidectomy
Transient: 9 to 50 %
Permanent: 0.5 to 13% ( 33 %)

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Patients and methods

Patients were prospectively registered from January 2006

till December 2009.
Calcemia (phosphoremia)
Pth

pre and postop

levels

After the first blood sample (2 to 3 hours postop.):

calcium gluconate 2 g/l of perfusion if calcemia 8.2

mg/dl
Symptoms and signs of hypocalcemia registered

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Patients and methods

From postop day 1 to day 2 (discharged): pth, calcemia,

phosphoremia
Treatment for Ca < 8.0 mg/dl

for 8.0 < Ca < 8.3 mg/dl

- 1 g calcium carbonate TID

- 1g calcium BID

- Alfacalcidiol 1 mcg/day

- Alfacalcidiol 1 mcg/day 0.5

mcg/day

Day 6 to 10 (outpatient clinic): pth, calcemia, phosphoremia

and OH-vitD, TSH; T4L,

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Materials & methods
Pth level and calcemia : between 5th and 10th

day postop, after 1 month, 3 months, 6 to 9 months,

1 year; 1/yr thereafter if prolonged hypocalcemia

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results (1)
(near) total thyrodectomy (or totalisation): 537 pts from Jan 2006 till Dec

2009 (421:W; 116:M)

Mean age: 51 yrs (12-82)
Selective neck dissection (mainly central compartment: 63 pts)
Cancer: 81 pts (72 PTC, 5 MTC, 4 follicular)
Multinodular goiter: 415 (50 with throiditis)
Basedow : 29
12 pts (benigh adenomas, follicular nodule, )

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results (2)
43.4% (n=233) developped a transient hypocalcema
3.91% (n=21) developped a 1 year hypocalcemia
3.17% (n=17) prolonged hypocalcemia

4 PTS had a PTH normal level 15, 23, 32, 39

pg/ml
but maintained calcemic supplements to avoid
symptoms

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results (4)
PTS characteristics for prolonged
Yes (n=17)
Pvalue
hypocalcemiaNo
(n=520)

Malignant

14.6%

43.8%

Parathyroid I&P*
1.2
3
4

1.9%
6.5%
91.6%

11.8%
17.6%
70.6%

11.2%

29.4%

Lymph node
dissection

Weight of
47.5 (SD
* Identified and Preserved
specimen
49.5)

55.4 (SD
55.1)

0.00
1
0.00
4
0.02
2

0.51

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results (6)
Sensibility, specificity, ODDS ratio of hypocalcemia
hypoPTH to predict definitive hypocalcemia

Ca 4 hrs < 8
mg/dl
Ca J1 < 8 mg/dl
Ca J5-20 < 8
mg/dl
Ca J30 < 8 mg/dl

Sensitivit
y

Specificity

ODD1
ratio

Pvalue

17.65%
70.60%
92.30%
31.30%

90.3%
64.7%
94.3%
98.3%

2
4.4
196.1
25.6

0.28
0.0029
<
0.0001
<0.000
1

PTH 4 hrs < 15

100%
62.4%

<.0001
pg/ml
100%
56.4%

<.0001
PTH J1 < 15 pg/ml
90%
68.5%
19.6
<.0001
PTH J5-20 < 15
63.6%
92.2%
20.7
<.0001
Ca: calcemia;
PTH:
level
of
intact
on
ice;
4
hrs:
4
hours
postop;
J1 to x: J
pg/ml
postop 1 to x
PTH J30 < 15
pg/ml

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Discussion (1)
Hypocalcemia postop J5-20: < 8 mg/dl (sens: 92.3%;

specif : 94.3%)
Hypo PTH level postop < 15 pg/ml
are predictive of definitive hypocalcemia
ROC curve was constructed PTH early < 9 pg/ml is predictive of definitive
hypocalcemia:
100% sensitivity
76% specificity ODDS ratio

p < 0.0001

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Discussion (2)
Late recovery of normal parathormone activity
Among 21 PTS with prolonged hypocalcemia
4 showed normal calcemia and PTH levels after 4,

5, 6 and 7 yrs (4 parathyroids respected during the

operation; 2 M, 2W; 3 MN Goiters, 1 Basedow)

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Role of postoperative vitamin D and/or
calcium routine supplementation in
preventing hypocalcemia after thyroidectomy:
a systematic review and meta-analysis

A. Alhefdhi et al, The Oncologist 2013;18:539-542

Role of postoperative vitamin D and/or calcium routine

supplementation in preventing hypocalcemia after
thyroidectomy: a systematic review and meta-analysis
(1)
Out of 1180 studies on hypocalcemia post T thyroidectomy
9 studies responding to the strength of recommendation

taxonomy grading system (SORT)*

N = 2285 PTS

Symptomatic
hypocalcemia (%)

22 PTS : vit D only

580 PTS : Ca++ only
792 PTS : vit D + Ca++
891 PTS : no

4.6 %
14 %
14 %
20.5 %

* Ebell M.H. 2004, J. Am. Board Fam. Pract.

After A. ALHEFHI & al 2013

MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Conclusion
Systematic assays of iPTH at 4 hrs
Ca++ between D5-20
are
a
good
indicators
of
hypoparathyroidism
hypocalcemia.

prolonged,

Immediate postop administration of IV Ca ++

gluconate (2 g/l) followed at D1-2 by calcidial 1 mg
and calcium carbonate (1 to 6 g tailorized by Ca ++
levels) prevent the stress of symptomatic
hypocalcemic.