Dr Guy ANDRY, M. MOREAU, I.EL MOUSSAOUI,
E. WILLEMSE, M. QUIRINY, A. DIGONNET
Université 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 thyroïdectomy (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 hypocalcemia
No (n=520)
Malignant
Parathyroid I&P*
1.2
3
4
Lymph node
dissection
Weight of specimen
* Identified and Preserved
Hosp stay (d)
14.6%
Yes (n=17)
43.8%
Pvalue
0.001
0.004
1.9%
6.5%
91.6%
11.8%
17.6%
70.6%
11.2%
29.4%
47.5 (SD 
49.5)
55.4 (SD  55.1)
0.51
4.08 (SD 
4.2 (SD  0.84)
0.79
0.022
MANAGEMENT OF POSTOPERATIVE
HYPOCALCEMIA
Results (6)
Sensibility, specificity, ODDS ratio of hypocalcemia hypoPTH to predict
« definitive » hypocalcemia
Sensitivity
Specificity
ODD1
ratio
Pvalue
Ca 4 hrs < 8 mg/dl
Ca J1 < 8 mg/dl
Ca J5-20 < 8 mg/dl
Ca J30 < 8 mg/dl
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
<0.0001
PTH 4 hrs < 15 pg/ml
PTH J1 < 15 pg/ml
PTH J5-20 < 15 pg/ml
PTH J30 < 15 pg/ml
100%
100%
90%
63.6%
62.4%
56.4%
68.5%
92.2%
∞
∞
19.6
20.7
<.0001
<.0001
<.0001
<.0001
Ca: calcemia; PTH: level of « intact » on ice; 4 hrs: 4 hours postop; J1 to x: J postop 1 to x
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 prolonged, hypoparathyroidism
hypocalcemia.
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.