What is thyroidectomy. Why might someone need thyroid surgery. How is the procedure performed. What are the potential risks and complications of thyroidectomy. How long does recovery typically take. What should patients expect after surgery.

Understanding Thyroidectomy: Definition and Purpose

Thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. This butterfly-shaped gland, located at the base of the neck, plays a crucial role in regulating the body’s metabolism through the production of thyroid hormones. But when does one need to consider this surgery?

There are several reasons why a healthcare provider might recommend a thyroidectomy:

• Thyroid cancer
• Noncancerous thyroid nodules
• Enlarged thyroid gland (goiter)
• Hyperthyroidism (overactive thyroid)
• Suspicious thyroid nodules

The extent of the surgery can vary depending on the underlying condition. A total thyroidectomy involves the removal of the entire gland, while a partial thyroidectomy (also known as a lobectomy) removes only a portion of the thyroid.

Types of Thyroidectomy Procedures

There are two main approaches to performing a thyroidectomy:

1. Traditional Thyroidectomy

This is the most common method used for thyroid removal. During a traditional thyroidectomy:

• The patient is placed in a semi-seated position with support under the neck and shoulders
• General anesthesia is administered
• A small incision is made in the front of the neck, typically along a natural skin crease to minimize visible scarring
• The surgeon carefully separates the muscles to access the thyroid gland
• One or both lobes of the thyroid are removed, along with any affected lymph nodes
• The muscles are repositioned, and the incision is closed with sutures or surgical glue

2. Scarless (Transoral) Thyroidectomy

This newer technique offers an alternative approach:

• The thyroid gland is accessed through the mouth
• No external incision is made, resulting in no visible neck scar
• This method may be suitable for certain patients, depending on their specific condition and anatomy

Preparing for Thyroidectomy Surgery

Prior to undergoing a thyroidectomy, patients can expect several preparatory steps:

1. Preoperative imaging studies, such as thyroid ultrasound, CT scan, or MRI
2. Blood tests to assess thyroid hormone levels and other relevant factors
3. Laryngoscopy to examine the vocal cords
4. Discussion of medications, including potential adjustments to current regimens
5. Fasting instructions for the hours leading up to surgery

For patients with hyperthyroidism, the medical team may administer medications to stabilize thyroid hormone levels before and after the procedure. This helps reduce the risk of thyroid storm, a potentially life-threatening complication.

Potential Risks and Complications of Thyroidectomy

As with any surgical procedure, thyroidectomy carries certain risks. While complications are relatively rare, especially when performed by experienced surgeons, it’s important for patients to be aware of potential issues:

• Voice changes or hoarseness due to damage to the laryngeal nerves
• Bleeding and blood clots
• Infection at the surgical site
• Hypoparathyroidism, leading to low calcium levels
• Hypothyroidism, requiring lifelong thyroid hormone replacement
• Injury to the trachea or esophagus
• Formation of keloid or hypertrophic scars
• Seroma (fluid accumulation) at the incision site

How common are these complications? While exact rates can vary, studies suggest that the overall complication rate for thyroidectomy is generally low, with most issues being temporary. Permanent complications occur in less than 5% of cases when performed by experienced surgeons.

The Thyroidectomy Procedure: What to Expect

On the day of surgery, patients can anticipate the following sequence of events:

1. Arrival at the hospital or surgical center
2. Change into a hospital gown and have vital signs checked
3. Placement of an intravenous (IV) line for medication and fluids
4. Administration of general anesthesia
5. Positioning on the operating table with neck support
6. Surgical procedure (lasting 2-4 hours, depending on complexity)
7. Transfer to recovery room for post-operative monitoring

During the procedure, the surgical team will closely monitor vital signs and ensure proper positioning to minimize the risk of complications. The surgeon may use specialized techniques, such as intraoperative nerve monitoring, to help preserve important structures in the neck.

Post-Operative Care and Recovery

After a thyroidectomy, the recovery process begins immediately. What can patients expect in the hours and days following surgery?

• Immediate post-op period: Patients are closely monitored in the recovery room for signs of bleeding or difficulty breathing
• Hospital stay: Some patients may be discharged the same day, while others may stay overnight for observation
• Pain management: Mild to moderate discomfort is common and can be managed with prescribed pain medications
• Incision care: Instructions for keeping the surgical site clean and dry will be provided
• Diet: Most patients can resume a normal diet within 24 hours
• Activity: Gradual return to normal activities over 1-2 weeks, with restrictions on heavy lifting

How long does it take to fully recover from thyroidectomy? While individual experiences may vary, most patients can return to work and normal activities within 1-2 weeks. Full recovery, including the fading of any surgical scars, may take several months.

Life After Thyroidectomy: Long-Term Considerations

For many patients, thyroidectomy marks the beginning of a new chapter in their health journey. What long-term adjustments might be necessary?

Thyroid Hormone Replacement Therapy

Following a total thyroidectomy, patients will require lifelong thyroid hormone replacement. This involves taking synthetic thyroid hormone (typically levothyroxine) daily to maintain normal metabolic function. Regular blood tests will be necessary to ensure proper dosing.

Follow-Up Care

Ongoing monitoring is crucial after thyroidectomy, particularly for cancer patients. This may include:

• Regular check-ups with an endocrinologist
• Periodic imaging studies to check for recurrence (in cancer cases)
• Blood tests to monitor thyroid hormone levels and adjust medication as needed
• Calcium and vitamin D supplementation if parathyroid function is affected

Lifestyle Adjustments

While most patients can resume normal activities after recovery, some considerations include:

• Maintaining a consistent schedule for taking thyroid medication
• Being aware of symptoms that could indicate over- or under-replacement of thyroid hormone
• Discussing any new medications or supplements with healthcare providers, as they may interact with thyroid hormone replacement

Can patients live a normal life after thyroidectomy? With proper management and follow-up care, the vast majority of individuals who undergo thyroidectomy can lead healthy, active lives without significant limitations.

Advancements in Thyroidectomy Techniques

The field of thyroid surgery continues to evolve, with new techniques and technologies emerging to improve outcomes and patient experiences. What are some of the latest developments in thyroidectomy?

Minimally Invasive Approaches

In addition to the scarless transoral technique mentioned earlier, other minimally invasive approaches include:

• Endoscopic thyroidectomy: Using small incisions and a camera for visualization
• Robotic-assisted thyroidectomy: Employing robotic systems for enhanced precision

Energy-Based Devices

Advanced surgical tools that use ultrasonic or bipolar energy can help reduce bleeding and operating time, potentially leading to faster recovery.

Intraoperative Neuromonitoring

This technology helps surgeons identify and preserve important nerves during the procedure, reducing the risk of voice changes or swallowing difficulties.

How do these advancements benefit patients? These innovations aim to reduce surgical trauma, minimize scarring, and improve postoperative outcomes. However, it’s important to note that not all techniques are suitable for every patient, and the choice of approach depends on various factors including the specific condition, anatomy, and surgeon expertise.

As research continues and surgical techniques evolve, the future of thyroidectomy looks promising, with potential for even safer procedures and improved quality of life for patients requiring thyroid surgery.

Thyroidectomy | Johns Hopkins Medicine

Thyroidectomy is surgical removal of all or part of the thyroid gland, which is located in the front of the neck. The thyroid gland releases thyroid hormone, which controls many critical functions of the body.

What You Need to Know

• Thyroid cancer, thyroid nodules and other conditions may require thyroidectomy.
• Once the thyroid gland is removed, the person takes replacement thyroid hormone to keep the body’s functions in balance.
• Thyroidectomy can be performed through an incision at the front of the neck, or through the mouth (scarless thyroidectomy).

Why might I need a thyroidectomy?

A thyroidectomy may be appropriate for people who have a thyroid tumor, thyroid nodules or hyperthyroidism, which occurs when the thyroid gland produces too much thyroid hormone.

Hyperthyroidism can be the result of an autoimmune problem, too much iodine in the diet, a benign tumor in the pituitary gland, too much thyroid medication, a swelling (goiter) in the thyroid gland or an inflammatory process.

What are the risks of thyroidectomy?

• Voice changes, such as hoarseness
• Sore throat
• Bleeding and blood clots
• Adhesions or scar tissue that require another surgery
• Injury to the esophagus or trachea (windpipe)
• Hypoparathyroidism (too little parathyroid hormone, which can result in abnormally low blood calcium levels)

What happens during a thyroidectomy?

Before the Procedure

The doctor will order imaging and laboratory tests, including:

• Thyroid imaging with ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI)

• Blood test(s) for thyroid hormone levels and other factors

• Examination of the vocal cords using an instrument called a laryngoscope

Just before your procedure, the surgical team may give you an antibiotic if you have a weakened immune system or other condition that makes you prone to getting infections. You may receive medicines to reduce nausea and vomiting (antiemetics).

For people with hyperthyroidism, the doctor will administer medications to keep thyroid hormones in balance during and after surgery.

Types of Thyroidectomy

Traditional Thyroidectomy

In the operating room, you will be in a semi-seated position, with or without your chin tilted back and with support under your neck and shoulders. Most thyroidectomies are performed under general anesthesia, meaning you are asleep and pain-free during the procedure.

The surgeon makes a small incision in the skin of the neck as close to a natural crease as possible to reduce the appearance of the scar. The surgeon parts a thin layer of muscle to gain access to the thyroid gland, then removes one or both lobes of the thyroid gland as well as any nearby lymph nodes that may be affected by disease.

The surgeon then returns the muscles of the front of the neck to their proper position and secures them in place. The skin is closed with sutures or glue.

Scarless (Transoral) Thyroidectomy

A newer technique involves accessing the thyroid gland through the mouth. This surgery leaves no visible scar since there is no incision on the outside of the neck.

Thyroidectomy: Recovery and Next Steps

In some cases, patients return home the same day as the surgery, but some
people spend the night in the hospital. There, the team can observe the
patient and monitor calcium levels in the blood.

When the thyroid gland is surgically removed, the body still requires
thyroid hormone to keep vital functions in balance.

Thyroid hormone replacement therapy

involves taking synthetic or naturally derived thyroid hormones in pill
form.

Thyroidectomy – Procedure & Risks

By Julie Lynn MarksMedically Reviewed by Robert Jasmer, MD

Reviewed: October 23, 2015

Medically Reviewed

Removal of the thyroid may be necessary due to cancer, enlargement, or noncancerous growths on the thyroid.

A thyroidectomy is surgery to remove part or all of a person’s thyroid.

The thyroid is a butterfly-shaped gland located at the base of your neck. It helps regulate your body’s metabolism.

A thyroidectomy might be needed if you have:

• Thyroid cancer
• Noncancerous growths on the thyroid
• An enlarged thyroid
• An overactive thyroid

A total thyroidectomy is a procedure to remove the entire thyroid.

A partial thyroidectomy means that just a portion of the gland is taken out.

The Thyroidectomy Procedure

A thyroidectomy can take up to four hours, depending on the type of surgery you’re having.

Most of the time, general anesthesia is given. This means you won’t be conscious during the procedure.

A surgeon will make an incision in the middle of your neck, or several small cuts in or near the neck.

If you’re having a conventional thyroidectomy, the surgeon will remove part or all of your thyroid through the incision in your neck.

If you’re having an endoscopic or robotic thyroidectomy, the surgeon will use small instruments and a video camera to perform the procedure through tiny incisions.

A catheter may be placed in the area to help drain blood and fluids.

Before a Thyroidectomy

Before your thyroidectomy, your doctor may perform tests to determine if a growth on your thyroid is cancerous.

You may also undergo imaging tests to find exactly where the thyroid growth is located.

Tell your doctor about all medicines you take before your surgery.

You might need to stop taking certain drugs, such as Plavix (clopidogrel bisulfate), aspirin, Advil (ibuprofen), Aleve (naproxen), or Coumadin (warfarin), prior to your procedure.

Let your doctor know if you smoke. Smoking may slow down your recovery.

Your doctor may prescribe a thyroid medicine or iodine treatment for you to take one to two weeks before your thyroidectomy.

You’ll probably be told not to eat or drink anything for several hours before your surgery. Follow your doctor’s instructions carefully.

After a Thyroidectomy

If you have a catheter in your neck to drain fluid, it’s usually removed the morning after your surgery.

You’ll probably be able to go home the day after your thyroidectomy, but you could spend up to three days in the hospital.

The length of your stay will depend on your medical condition and recovery. You must be able to swallow liquids and pills before you can return home.

It will take about three to four weeks for you to fully recover from your surgery.

If you’ve had your entire thyroid removed, you’ll probably need to take thyroid hormone pills for the rest of your life.

Risks of a Thyroidectomy

Potential risks of a thyroidectomy include:

• Bleeding or infection
• Difficulty breathing
• Permanent hoarseness or weak voice due to nerve damage
• Injury to parathyroid glands (glands near the thyroid) or their blood supply, which can cause low blood calcium levels and sometimes muscle spasms or other neuromuscular symptoms

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Editorial Sources and Fact-Checking

• Thyroid gland removal; MedlinePlus.
• Thyroidectomy; Mayo Clinic.
• Thyroidectomy; Cedars-Sinai.

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Thyroidectomy – removal of the thyroid gland

Prices Doctors Our centers

Indications Contraindications Preparation Surgery Rehabilitation Complications Thyroidectomy at SM-Clinic

Thyroidectomy is a surgical operation that involves complete or partial excision of the thyroid gland. Intervention is one of the main methods of treatment of malignant and benign neoplasms of this organ.

Indications

The most common indications for thyroidectomy are:

• thyroid cancer;
• large benign neoplasms: adenoma, nodes, cysts;
• multinodular goiter;
• diffuse toxic goiter;
• Thyroid nodes that produce hormones (toxic nodes).

Surgery is also indicated in cases where the patient develops cancer, but there are contraindications for radioiodine therapy.

Contraindications

Intervention is low-traumatic and therefore has a minimum number of contraindications. Thyroidectomy is not performed if the patient is found to have:

• acute infectious diseases;
• chronic pathologies in the acute stage;
• blood clotting disorders.

Preparation

As part of the preparation, you need to undergo a comprehensive examination, which includes:

• consultation with the attending physician;
• consultation with an anesthesiologist;
• blood tests, including coagulogram;
• urine tests;
• electrocardiogram.

If necessary, additional laboratory or instrumental studies, consultations with highly specialized specialists are prescribed.

Tell the doctor in advance about the medications the patient takes regularly. It is important to inform about the presence of allergies. As part of the preparation, a course of antibiotics may also be prescribed.

Promotion! Free consultation with a surgeon about surgery

Take advantage of this unique opportunity and get a free consultation about elective surgery.

Operation

Any type of thyroid surgery is performed under general anesthesia. The patient is put into a state of sleep and does not feel anything during the operation.

After the anesthesia has taken effect, the surgeon makes a transverse incision at the base of the neck. The incision is made in such a way that in the future the scar merges with the skin fold and is as inconspicuous as possible. After that, depending on the goals of the operation, the surgeon removes the pathology along with the thyroid gland or part of it. One of the main goals is to preserve the parathyroid glands and the recurrent nerve, if they are not affected by the disease.

After removing the tissues, the surgeon sews up the wound, puts a drain. Depending on the extent of the surgeon’s actions, the operation takes from 45 minutes to 3 hours.

Rehabilitation

After the intervention, you must stay in the hospital under the supervision of medical staff. Pain in the neck and throat persist for several days. Painkillers prescribed by a doctor help to get rid of pain.

The term of hospitalization is determined individually and depends on the volume of surgical intervention, the patient’s well-being. Often, after 2-3 days, discharge and continued recovery at home is possible.

If a total thyroidectomy, that is, the total removal of the thyroid gland, has taken place, a person will develop hypothyroidism after the operation. Therefore, there will be a need for a lifelong intake of hormonal drugs. However, even in the case of not total, but partial thyroidectomy, the thyroid gland may also lose its functions, which will have to be replenished with the help of drugs. Despite lifelong hormone replacement therapy, after recovery, a person will be able to lead a normal life without uncomfortable restrictions.

Complications

Complications after the intervention are quite rare. Among the most common: postoperative bleeding, hypoparathyroidism (lack of calcium in the body). If the laryngeal nerve is damaged during the operation, the timbre of the voice changes. Restoration of the usual timbre takes from 3 to 12 weeks. The risk of nerve damage is less than 1%.

Thyroidectomy at SM-Clinic

Surgical intervention on the thyroid gland refers to technically complex operations. The result of such treatment largely depends on the skills of the doctor. To minimize the risks and achieve the maximum positive effect, therapy should be trusted only by experienced surgeons who are proficient in advanced operating techniques. These are the doctors who work in the SM-Clinic.

We have been operating on patients since 2009. Our doctors perform more than 8500 operations annually in 20 surgical directions. Our team consists of over 140 experienced operating doctors and 18 anesthesiologists, including 20 doctors and candidates of medical sciences.

On the basis of our clinic in St. Petersburg, you can undergo a comprehensive preliminary examination. Our patients have at their disposal 7 operating theaters with modern equipment and 25 comfortable hospital wards.

Call us at the phone number listed on the website to find out the price of thyroidectomy, get acquainted with the price list for other services or sign up for a consultation.

* You can read more about the conditions here – Treatment on credit or installments

Preliminary cost. The exact cost of the operation can only be determined by the surgeon during a free consultation.

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Risk of hypocalcemia in patients after thyroid surgery

Risk of hypocalcemia in patients after thyroid surgery

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Shulutko A.M.

Department of Faculty Surgery No. 2 of the Medical Faculty of the First Moscow State Medical University. THEM. Sechenov

Semikov V.I.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov

Gryaznov S. E.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Gorbacheva A.V.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Patalova A.R.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Mansurova G.T.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Kazakova V.A.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Risk of hypocalcemia in patients after thyroid surgery

Authors:

Shulutko A.M., Semikov V.I., Gryaznov S.E., Gorbacheva A.V., Patalova A.R., Mansurova G. T., Kazakova V.A.

More about the authors

Journal:

Surgery. Journal them. N.I. Pirogov.

2015;(11): 35‑40

DOI:

10.17116/hirurgia20151135-40

How to quote:

Shulutko A.M., Semikov V.I., Gryaznov S.E., Gorbacheva A.V., Patalova A.R., Mansurova G.T., Kazakova V.A. Risk of hypocalcemia in patients after thyroid surgery. Surgery. Journal them. N.I. Pirogov.
2015;(11):35‑40.
Shulutko AM, Semikov VI, Gryaznov SE, Gorbacheva AV, Patalova AR, Mansurova GT, Kazakova VA. Risk of hypocalcemia after thyroid surgery. Pirogov Russian Journal of Surgery = Khirurgiya. Zurnal im. N.I. Pirogova. 2015;(11):35‑40. (In Russ.)
https://doi.org/10.17116/hirurgia20151135-40

Read metadata

The purpose of the study is to identify calcium metabolism disorders, which are often observed after thyroid surgery. Material and methods. To detect postoperative hypocalcemia, 202 patients operated on for various thyroid diseases with initially normal levels of calcium in the peripheral blood were examined. Results. According to laboratory tests, hypocalcemia was detected after surgery in 57 (28. 8%) patients. The decrease in calcium levels was not always clinically manifested and the severity of symptoms depended on the degree of decrease in the concentration of calcium in the blood. Clinical manifestations were more often observed when the calcium concentration in the blood was below 2.1 mmol/L. At 64.9% of observations with laboratory-detected hypocalcemia had no clinical manifestations. The frequency of hypocalcemia was higher after thyroidectomy (41.2%) compared with organ-sparing operations (11.8—25%). Clinical manifestations of a decrease in the level of calcium in the blood were observed only after thyroidectomy. The cause of hypocalcemia is not always the accidental removal of the parathyroid glands. In patients with hypocalcemia in surgical preparations, the removed parathyroid gland was found only in 14% of cases. On the other hand, in patients with postoperative normocalcemia, in 7.6% of cases, surgical preparations also had removed parathyroid glands. Clinical symptoms of hypocalcemia do not necessarily appear on the 1st day after surgery. They can develop much later, up to 5 days after surgery, and depend on a progressive decrease in calcium levels. Thyroidectomy is an operation accompanied by a high risk of postoperative hypocalcemia with clinical manifestations (19.6%), which is transient in 15.5% of observations and constant in 4.1% of observations.

Keywords:

hypocalcemia

epithelial body

thyroidectomy

Authors:

Shulutko A.M.

Department of Faculty Surgery No. 2 of the Medical Faculty of the First Moscow State Medical University. THEM. Sechenov

Semikov V.I.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov

Gryaznov S.E.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Gorbacheva A.V.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Patalova A. R.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Mansurova G.T.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Kazakova V.A.

Department of Faculty Surgery No. 2 of the First Moscow State Medical University. THEM. Sechenov, Moscow, Russia

Close metadata

Introduction

In recent years, thyroidectomy has firmly taken the leading place among surgical interventions of a different scope for diseases of the thyroid gland. Currently, this operation is considered by most surgeons as the only pathogenetically substantiated surgical intervention for diffuse toxic goiter, which provides optimal long-term results. It is increasingly performed for multinodular proliferating colloid goiter instead of the previously common subtotal resection of the thyroid gland [5—7, 9, 23, 26]. Thyroidectomy with central lymphadenodissection (removal of level VI neck tissue) is considered by many surgeons and oncologists as the operation of choice for differentiated thyroid cancer [1, 10, 11]. However, such an operation is still associated with a high risk of complications – not so much with impaired voice and respiratory function (now almost all surgeons extract the recurrent laryngeal nerve during the operation), but with postoperative hypocalcemia as a result of trauma to the parathyroid glands. According to the literature, the proportion of transient hypocalcemia after thyroidectomy reaches (sometimes exceeds) 30% [16, 19, 20], and a permanent form of hypoparathyroidism, according to the results of multicenter studies, is observed with a frequency of up to 10.5% [24]. Calcium metabolism disorders and clinical manifestations of hypocalcemia lead to serious changes in the body and significantly reduce the quality of life of operated patients.

Material and methods

We conducted our own study aimed at determining the frequency of postoperative hypocalcemia in patients operated on for various thyroid diseases. The only criterion for inclusion of patients in the study was the normal preoperative level of total calcium in the peripheral blood (2.2–2.65 mmol/l). We examined 202 patients who underwent surgery on the thyroid gland. Among them were 173 (85.6%) women and 29(14.4%) men. The patients’ age ranged from 16 years to 81 years (mean age 50.2±13.4 years). In all patients, on the eve of the operation, the level of total calcium in the peripheral blood was determined, the content of which varied from 2.2 to 2.65 mmol/l (average concentration 2.40±0.11 mmol/l). Given the need to recalculate the level of total serum calcium in hypoalbuminemia [14], we determined the protein content in the blood serum in all patients before surgery, the values ​​of which were within the normal range in 100% of cases. Nodular forms of goiter were observed in 155 (76.7%) patients. 47 (23.3%) patients were operated on for diffuse toxic goiter. In 132 (65.3%) patients, the thyroid gland was enlarged to the size of a grade III goiter (according to the classification of O. V. Nikolaev). 65 (32.2%) patients were operated on for grade IV goiter with compression syndrome, 2 (1%) patients had giant goiter (grade V). In 3 (1.5%) patients, II degree of thyroid enlargement was diagnosed. More often the disease proceeded without dysfunction of the thyroid gland — in 133 (65.8%) patients. Hypothyroidism was detected only in 3 (1.5%) cases. In 66 (32.7%) observations, thyrotoxicosis of varying severity occurred, which was confirmed by the results of the study of hormones. Mild, moderate and severe thyrotoxicosis was observed in 10 (4.95%), 20 (9.9%) and 36 (17.85%) patients, respectively. All 47 patients with diffuse toxic goiter had moderate or severe thyrotoxicosis, however, by the time of surgery, it was compensated with thyreostatic drugs. In 19 patients with increased thyroid function, nodular forms of goiter were observed (functional autonomy).

Thyroidectomy was performed in 97 (48%) patients with thyroid cancer (tumor stage T2 and higher), in the presence of regional metastases or in the presence of a tumor in both lobes of the thyroid gland. Thyroidectomy was also performed for diffuse toxic goiter with high risk factors for disease recurrence and for localization of benign nodules in both thyroid lobes. Hemithyroidectomy was performed in 68 (33.7%) patients. The lobe of the thyroid gland was removed for T1 cancer without regional metastases and with unilateral localization of benign nodules. Operative interventions of a different volume were undertaken much less frequently. So, subtotal resection of the thyroid gland (7.9%) or hemithyroidectomy with subtotal resection of the contralateral lobe (9.9%) was performed for diffuse toxic goiter with low risk factors for disease recurrence or with bilateral localization of benign nodular formations. A small amount of thyroid tissue was left in the paratracheal region and in the area where the recurrent laryngeal nerve enters the larynx, as well as in the region of the parathyroid glands. In all cases, the morphological diagnosis was confirmed during a planned histological examination of the removed preparations (Table 1).

Table 1. Distribution of operated patients depending on the disease and the volume of surgical intervention

Results and discussion

In all patients, the next day after the operation, the clinical manifestations of hypocalcemia were assessed and the level of total calcium in the peripheral blood was examined. The concentration of total calcium in the peripheral blood decreased on the 1st day after surgery in 57 (28.2%) patients to 1.77–2.19 mmol/l (average 2.08±0.1 mmol/l). However, a decrease in calcium levels was not always clinically manifested, in 37 (64.9%) out of 57 patients with reduced calcium levels, there were no clinical manifestations of hypocalcemia. Some studies have also shown that in most cases, postoperative hypoparathyroidism is asymptomatic and is detected only during routine determination of calcium concentration in all operated patients [15, 25]. In 20 (35.1%) patients, we observed clinical manifestations of hypocalcemia of varying severity: the presence of only Chvostek’s symptom in 2 (3. 5%), paresthesia in 14 (24.6%) and convulsions in 4 (7% ). It should be added that Chvostek’s symptom was present in all patients with paresthesias and convulsions, and paresthesias were present in all patients with convulsions (Table 2).

Table 2. The level of total calcium in the peripheral blood on the 1st day after surgery and clinical manifestations of hypocalcemia

The severity of clinical manifestations of hypocalcemia depended on the content of calcium in the blood (see Table 2). In patients with calcium levels from 1.77 to 2.10 mmol/l, paresthesias (37%) and convulsions (11.1%) were more often observed than with calcium concentrations from 2.11 to 2.19 mmol/l, 13.4 and 3.3% respectively. Clinical manifestations of hypocalcemia were absent in 80% of patients with high levels of calcium in the blood and in 48.2% of patients with lower levels of calcium. The average calcium content in the peripheral blood was lower in patients with seizures (1.98±0.17 mmol/l) in comparison with the group of patients in whom only paresthesias were observed (2. 04±0.1 mmol/l) or in patients without clinical manifestations of hypocalcemia (2.10±0.08 mmol/l ). Our results are consistent with the opinion of other authors, according to which, at a calcium concentration in the blood of 2–2.2 mmol/l, there are no clinical manifestations of hypocalcemia, and at a lower calcium content, clinical symptoms appear in the form of an increase in neuromuscular excitability [2]. Thus, the clinical manifestations of hypocalcemia and their severity depend on the level of calcium in the peripheral blood.

Of greatest interest is the question of the incidence of hypocalcemia depending on the volume of surgery. Today, thyroidectomy is considered as an operation with a complication rate comparable to that after organ-sparing operations, primarily after subtotal resection of the thyroid gland. However, many researchers associate the frequency of postoperative hypocalcemia with the volume of surgery [4, 12]. We have detected hypocalcemia by laboratory method not only after thyroidectomy, but also after surgeries with preservation of thyroid tissue. However, after thyroidectomy, hypocalcemia developed more frequently (41.2%, in 40 of 97 cases) than after subtotal resection of the thyroid gland and hemithyroidectomy with subtotal resection of the contralateral lobe (25%, in 9 of 36 cases) and hemithyroidectomy (11.8%, in 8 of 68 cases). Moreover, clinical manifestations of a decrease in calcium in the blood were observed, as a rule, after thyroidectomy. Only one patient developed paresthesia on the 2nd day after hemithyroidectomy, which was stopped by administration of calcium preparations. It should be noted that this patient had a recurrent goiter and one of the lobes of the thyroid gland was removed many years ago; it is possible that the parathyroid glands were accidentally removed during the first operation. In the other 7 patients after hemithyroidectomy and in 9In patients after surgery with preservation of thyroid tissue against the background of hypocalcemia detected in laboratory tests, there were no clinical signs of a decrease in calcium (Table 3).

Table 3. Clinical manifestations of hypocalcemia in patients with a reduced level of calcium in the peripheral blood on the 1st day after surgery of various sizes

Thus, thyroidectomy is an operation accompanied by a high risk of developing hypocalcemia with clinical manifestations. Out of 9In 7 patients who had completely removed the thyroid gland, 40 (41.2%) patients had hypocalcemia (mean calcium level 2.07 ± 0.11 mmol/l) by the laboratory method, and clinical manifestations of a decrease in the level of calcium in the blood (2.04 ±0.12 mmol/l) was observed in 19 (19.6%) patients: in 2 (2.1%) only Chvostek’s symptom, in 13 (13.3%) – paresthesia and in 4 (4.2%) ) – convulsions.

There were no clinical manifestations in 21% of cases. Normocalcemia was registered in 58.8% of cases.

We have established the timing of the onset of clinical symptoms of hypocalcemia in patients with postoperatively reduced levels of calcium in the peripheral blood. In the absence of clinical symptoms of hypocalcemia, we did not prescribe calcium preparations immediately after the operation (Table 4).

Table 4. Timing of the development of clinical manifestations of hypocalcemia in patients after thyroidectomy

As can be seen from the table. 4, in 9 out of 19 patients with hypocalcemia, clinical manifestations of a decrease in calcium levels were noted on days 2–5 after thyroidectomy. The average calcium level on the 1st day in these patients was slightly higher compared to patients who had paresthesias and convulsions on the 1st day after surgery. However, on the day of the onset of clinical symptoms, the calcium concentration in the blood of these patients decreased to 1.8-1.9mmol/l. This once again confirms the dependence of the clinical manifestations of hypocalcemia on the concentration of calcium in the blood serum.

Our results are consistent with the data of other authors on the timing of the onset of postoperative hypoparathyroidism, according to which hypoparathyroidism most often, sometimes up to 50% of cases, develops within 1–2 days after surgery [13, 25]. The progression of postoperative hypocalcemia is probably extended in time, the decrease in calcium levels increases. It is possible that this is due to a deterioration in the blood supply to the parathyroid glands due to increasing tissue edema or other reasons. Indeed, by the end of the operation, the volume of blood flow in the parathyroid gland is 30% of the initial one [3, 17], so late clinical manifestations of hypocalcemia are possible, up to 5 days after the operation. In this regard, the question arises of the advisability of prophylactic administration of calcium preparations on the 1st day after thyroidectomy in patients with hypocalcemia, but in the absence of its clinical manifestations.

Some researchers believe that routine prophylactic administration of calcium and vitamin D preparations to all patients after thyroidectomy will prevent the development of symptoms of hypocalcemia, reduce the frequency and severity of clinical manifestations [8, 21, 22]. It should be borne in mind that not all patients after thyroidectomy have a decrease in the level of calcium, and in the presence of hypocalcemia, clinical symptoms develop, therefore, it may be advisable to identify risk groups for the development of clinical symptoms. At the same time, as one of the options, it is possible to determine the threshold calcium concentration on the 1st day after the operation, at which the administration of calcium supplements will prevent the further development of clinical manifestations. However, this should be the subject of a more extensive study.

One cause of postoperative hypocalcemia may be accidental removal of the parathyroid glands during thyroid surgery. In this regard, we conducted a histological examination of surgical preparations in order to identify accidentally removed parathyroid glands. It turned out that in 8 (14%) of 57 patients with postoperative hypocalcemia, one parathyroid gland was removed. However, we observed clinical manifestations of hypocalcemia only in 3 of these 8 patients. 49(86%) of 57 patients, the removed parathyroid glands were not found in the preparation. Nevertheless, in 17 (34.7%) of these 49 patients, we observed clinical manifestations of hypocalcemia, and very severe — 3 patients had convulsions, 12 had paresthesia. Moreover, in 11 (7.6%) of 145 patients with normocalcemia after surgery, one parathyroid gland was removed, including in 1 case of its intrathyroid localization. This confirms that the cause of hypocalcemia after surgery is not always mechanical removal of the parathyroid glands. Apparently, there are other reasons associated with surgical trauma, postoperative edema, and impaired blood supply.

All patients with convulsions and paresthesia were prescribed calcium preparations, as a result of which the clinical manifestations of hypocalcemia were quickly stopped. As an emergency, we usually prescribed calcium chloride or calcium gluconate intravenously, and then switched to oral medications (AT-10, calcid, calcium D3, calcium gluconate). In most cases, hypocalcemia was transient. In 15 (15.5%) of 97 patients who underwent thyroidectomy, while taking oral medications, clinical symptoms were stopped and the level of calcium in the peripheral blood returned to normal. Calcium preparations were canceled within the next few months, and normocalcemia was recorded in the patients’ peripheral blood up to 1 year after the operation. 4 (4.1%) out of 9In 7 patients after thyroidectomy, we observed a permanent form of hypocalcemia. One year after the operation, they are forced to continue taking AT-10 (2 patients) or calcium D3 (2 patients). Not all authors distinguish between persistent and temporary hypoparathyroidism. But doing this is very important, since long-term treatment of hypoparathyroidism does not completely restore physiological calcium metabolism and can lead to serious side effects, such as calcification and urolithiasis. The diagnosis of persistent hypoparathyroidism is established if there are signs of reduced parathyroid function for at least 6 months after surgery [18]. In our study, to distinguish between transient and permanent forms of hypoparathyroidism, we adopted a time limit of 1 year. It should be added that in all patients with postoperative hypocalcemia, but without its clinical manifestations, the level of calcium in the blood returned to normal within a few months after the operation on its own or after outpatient treatment.