Severe Symptomatic Hypocalcemia Following Total Thyroidectomy and Roux-en-Y Gastric Bypass
Case Report and Literature Review
Justin Gross, BA1; Steven M Olsen, MD2; Cody A Koch, MD2, Eric Moore, MD2
1University
of North Dakota School of Medicine & Health Sciences, Grand Forks, ND; 2Department of Otorhinolaryngology: Head and Neck Surgery, Mayo Clinic, Rochester, MN
ABSTRACT
CASE REPORT
Patients who undergo Roux-en-Y gastric bypass
(RYGB) procedures are at moderate risk for calcium
and vitamin D deficiency. Those who subsequently
undergo thyroid or parathyroid surgery are at high risk
for developing severe symptomatic hypocalcemia if
not monitored and prophylactically treated adequately.
We present a morbidly obese patient who
underwent Roux-en-Y gastric bypass six months prior
to the discovery of metastatic papillary thyroid
carcinoma.
He subsequently underwent total
thyroidectomy with central and bilateral neck
dissection. Following surgery, he developed severe
symptomatic hypocalcemia that reached a nadir of 6.0
mg/dL. He required aggressive oral and intravenous
repletion therapy with calcium, vitamin D, and
magnesium for ten days before hospital discharge.
Providers should institute careful preoperative
screening, patient counseling, and prophylactic
calcium and vitamin D therapy for all RYGB patients
who subsequently require thyroid surgery to prevent
the development of severe and life- threatening
hypocalcemia. To date, only four reports have
focused on the dangers of thyroid and parathyroid
surgery in post gastric bypass surgery. We report this
case to add to the growing body of literature for this
patient population.
40-year-old white male referred for evaluation of 5-cm neck mass, later
determined to be metastatic papillary thyroid carcinoma
6 months prior, he had undergone RYGB for treatment of morbid obesity
Preoperative calcium and TSH levels were within normal limits &
preoperative medications included calcium citrate plus vitamin D
He underwent total thyroidectomy with bilateral and central compartment
lymph node excision, with autotransplantation of one parathyroid gland
due to devascularization
Following surgery, he was started on CaCO3 liquid suspension, elemental
calcium, and cholecalciferol
Over the first 24h his calcium dropped from 8.8 to 6.9 mg/dl and he
remained asymptomatic. However, the following day he developed perioral
numbness and a positive Chvostek’s sign, with calcium ranging from 6.7
to 7.3 mg/dl
PICC access was obtained and he was treated symptomatically
On POD 4, cholecalciferol was discontinued and ergocalciferol was started.
CaCO3 was replaced with calcium citrate, HCTZ was initiated to decrease
urinary calcium loss, and calcitriol was also started
On POD 5-10, PTH increased from undetectable to 111 pg/mL, and calcium
gradually improved from 6.6 to 8.3 mg/dL
On POD ten, no signs or symptoms of hypocalcemia persisted, so the PICC
line was removed and calcium citrate and ergocalciferol were continued PO
Signs & symptoms of hypocalcemia were covered with the patient, and
instructions were provided to return to the ED if symptoms returned
At his three-week follow up appointment, calcium level was 8.2 mg/dL and
he was experiencing no symptoms of hypocalcemia
His current regimen includes ergocalciferol, calcium citrate, HCTZ, &
calcitriol
Figure 2 Average Daily Preoperative & Postoperative Calcium Values
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CONCLUSIONS
 Patients undergoing thyroid or parathyroid surgery should be screened for a history
of bariatric surgery. If positive, these patients should be counseled on the risk of
developing severe hypocalcemia and pre-surgical prophylactic treatment with calcium
and vitamin D should be instituted.
 In the five reviewed reports of post-thyroidectomy hypocalcemia, all nine patients
required intravenous calcium infusion to stabilize calcium levels. It follows, then, that
precautionary PICC line placement should be acquired at the time of surgery for such
patients.
 Maximal replacement with oral calcium citrate, ergocalciferol, and calcitriol should be
administered. We reserve intravenous calcium for symptomatic patients, in which case
calcium gluconate should be considered.
 Nursing staff should perform evaluations for symptomatic hypocalcemia q2h,
including testing for Chvostek’s and Trousseau’s signs, as well as questioning about
perioral and limb paresthesias.
 Although not studied in this population, intramuscular teriparatide (recombinant PTH)
injection may prove to be a useful drug in shortening hospital stay, and should be
studied in the future.
REFERENCES
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Figure 1 Schematic of preoperative ultrasound. Lymph nodes
color-coded black represent lymph nodes with ultrasound
features strongly suggestive of malignancy and those colored
blue represent lymph nodes with ultrasound features that
moderately suggest malignant metastases.
Figure 3 CT scan of neck through neck dissection level six, demonstrating adenopathy through
the central compartment.
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Postoperative D
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1. Straub DA. Calcium supplementation in clinical practice: a review of forms, doses, and indications. Nutr Clin Pract. 2007; 22(3):286-96.
2. Slater GH, CF Ren, N Siegel, T Williams, D Barr, B Wolfe, K Dolan, and GA Fielding. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after
malabsorptive bariatric surgery. J Gastrointest Surg. 2004; 8(1):48-55.
3. Asari R, C Passler, K Kaczirek, C Scheuba, and B Niederle. Hypoparathyroidism after total thyroidectomy. Arch Surg. 2008; 143(2):132-7.
4. Glinoer D, G Andry, G Chantrain, and N Samil. Clinical aspects of early and late hypocalcemia after thyroid surgery. Eur J Surg Onc. 2000; 26:571-7.
5. Cooper MS and NJL Gittoes. Diagnosis and management of hypocalcemia. BMJ. 2008; 336:1298-302.
6. Pietras SM and MF Holick. Refractory hypocalcemia following near-total thyroidectomy in a patient with a prior Roux-en-Y gastric bypass. Obes Surg. 2009; 19(4):524-6.
7. Durr ML, JR Saunders, JA Califano, RP Tufano, WM Koch, and PK Ha. Severe hypocalcemia complicating thyroid surgery after Roux-en-Y gastric bypass procedure. Arch
Otolaryngol Head Neck Surg. 2009; 135(5):507-10.
8. Manco M, G Nanni, V Tondolo, A Iaconelli, AV Greco, M Castagneto, and G Mingrone. Hypocalcemia complicating near-total thyroidectomy in patients with coexisting lipid
malabsorption due to biliopancreatic diversion. Obes Surg. 2004; 14(10):1429-34.
9. Rojas-Marcos PM, MA Rubio, WI Kreshki, L Cabrerizo, and A S疣chez-Pernaute. Severe hypocalcemia following total thyroidectomy after biliopancreatic diversion. Obes Surg.
2005; 15(3):431-4.
10. Cavicchi O, O Piccin, U Caliceti, A De Cataldis, R Pasquali, and AR Ceroni. Transient hypoparathyroidism following thyroidectomy: a prospective study and multivariate
analysis of 604 consecutive patients. Otolaryngol Head Neck Surg. 2007; 137(4):654-8.
11. Toniato A, IM Boschin, A Piotto, M Pelizzo, and P Sartori. Thyroidectomy and parathyroid hormone: tracing hypocalcemia-prone patients. Am J Surg. 2008; 196(2):285-8.
12. Roh JL and CI Park. Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy. Am J Surg. 2006; 192(5):675-8.
13. Roh JL, JY Park, and CI Park. Prevention of postoperative hypocalcemia with routine oral calcium and vitamin D supplements in patients with differentiated papillary thyroid
carcinoma undergoing total thyroidectomy plus central neck dissection. Cancer. 2009; 115(2):251-8.
14. Goldner WS, JA Stoner, E Lyden, J Thompson, K Taylor, L Larson, J Erickson, and C McBride. Finding the optimal dose of vitamin D following Roux-en-Y gastric bypass: a
prospective, randomized pilot clinical trial. Obes Surg. 2009; 19(2):173-9.
15. Testa A, V Fant, A De Rosa, GF Fiore, V Grieco, P Castaldi, R Persiani, S Rausei, D D’ugo, and G De Rosa. Calcitriol plus hydrochlorothiazide prevents transient postthyroidectomy hypocalcemia. Horm Metab Res. 2006; 38(12):821-6.
16. Tondapu P, D Provost, B Adams-Huet, T Sims, C Chang, and K Sakhaee. Comparison of the absorption of calcium carbonate and calcium citrate after Roux-en-Y gastric
bypass. Obes Surg. 2009; 19(9):1256-61.
17. Heaney RP, MS Dowell, J Bierman, CA Hale, and A Bendich. Absorbability and cost-effectiveness in calcium supplementation. J Am Coll Nutr. 2001; 20(3):239-46.
18. Kurukahvecioglu A, A Karamercan, M Akin, E Tezel, B Ege, F Taneri, and E Onuk. Potential benefit of oral calcium/vitamin D administration for prevention of symptomatic
hypocalcemia after total thyroidectomy. Endocr Regul. 2007; 41(1):35-9.
19. Houghton LA and R Vieth. The case against ergocalciferol (vitamin D2) as a vitamin supplement. Am J Clin Nutr. 2006; 84(4):694-7.
20.Bringhurst FR, MB Demay, SM Krane, and HM Kronenberg. “Chapter 346: Bone and Mineral Metabolism in Health and Disease.” In Fauci AS, E Braunwald, DL Kasper, SL
Hauser, DL Longo, JL Jameson, and J Loscalzo, Eds: Harrison’s Principles of Internal Medicine, 17th Edition. McGraw-Hill; 2008.