What is thyroidectomy and why might it be necessary. How is thyroidectomy performed and what are the potential risks. What should patients expect during recovery after thyroid gland removal.

Understanding Thyroidectomy: Definition and Purpose

Thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland, which is located in the front of the neck. This butterfly-shaped gland plays a crucial role in regulating the body’s metabolism by producing thyroid hormones. But when does a person need to undergo this procedure?

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

• Thyroid cancer
• Thyroid nodules (non-cancerous growths)
• Enlarged thyroid (goiter)
• Hyperthyroidism (overactive thyroid)

In cases of thyroid cancer, removing the gland is often necessary to prevent the spread of malignant cells. For benign conditions like nodules or goiter, surgery may be recommended if they cause discomfort or interfere with breathing or swallowing.

Types of Thyroidectomy Procedures

Depending on the underlying condition and its severity, surgeons may perform different types of thyroidectomy:

Total Thyroidectomy

This procedure involves the complete removal of the thyroid gland. It’s typically recommended for thyroid cancer or when both lobes of the thyroid are affected by a condition.

Partial Thyroidectomy

Also known as a hemithyroidectomy, this surgery removes only a portion of the thyroid gland. It may be suitable for patients with localized nodules or when preserving some thyroid function is possible.

Traditional vs. Scarless Thyroidectomy

Advancements in surgical techniques have led to the development of scarless thyroidectomy options. How do these differ from traditional methods?

• Traditional thyroidectomy: Involves an incision in the neck, typically placed in a natural crease to minimize visible scarring.
• Scarless (transoral) thyroidectomy: Accesses the thyroid gland through the mouth, leaving no visible external scar.

The choice between these methods depends on factors such as the patient’s condition, anatomy, and surgeon’s expertise.

Preparing for Thyroidectomy: Pre-Operative Steps

Before undergoing thyroidectomy, patients typically go through a series of preparatory steps. What can one expect in the lead-up to the surgery?

1. Imaging tests: Ultrasound, CT, or MRI scans to visualize the thyroid gland and surrounding structures.
2. Blood tests: To check thyroid hormone levels and other relevant factors.
3. Laryngoscopy: Examination of the vocal cords using a specialized instrument.
4. Medication adjustments: Patients with hyperthyroidism may receive medications to balance thyroid hormone levels before surgery.

In some cases, particularly for patients with weakened immune systems, antibiotics may be administered just before the procedure to reduce the risk of infection.

The Thyroidectomy Procedure: What Happens in the Operating Room?

Understanding the steps involved in a thyroidectomy can help alleviate anxiety for patients preparing for the surgery. So, what exactly happens during the procedure?

Traditional Thyroidectomy

1. Anesthesia: The patient is placed under general anesthesia.

2. Positioning: The patient is placed in a semi-seated position, sometimes with the chin tilted back and support under the neck and shoulders.

3. Incision: A small incision is made in the neck, typically in a natural crease to minimize scarring.

4. Access: The surgeon parts a thin layer of muscle to reach the thyroid gland.

5. Removal: One or both lobes of the thyroid gland are removed, along with any affected lymph nodes.

6. Closure: Muscles are returned to their proper position, and the incision is closed with sutures or glue.

Scarless (Transoral) Thyroidectomy

This newer technique involves accessing the thyroid gland through the mouth, eliminating the need for an external neck incision. The basic steps of gland removal are similar, but the approach differs significantly.

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, patients should be aware of potential issues:

• Voice changes or hoarseness
• Sore throat
• Bleeding and blood clots
• Formation of adhesions or scar tissue
• Injury to the esophagus or trachea
• Hypoparathyroidism (low parathyroid hormone levels)

Hypoparathyroidism can lead to abnormally low blood calcium levels, which may require ongoing management. Are these risks the same for all patients? The likelihood of complications can vary based on factors such as the extent of the surgery, the patient’s overall health, and the surgeon’s experience.

Recovery After Thyroidectomy: What to Expect

The recovery process following thyroidectomy is crucial for optimal healing and return to normal activities. What should patients anticipate in the days and weeks following surgery?

Immediate Post-Operative Period

Some patients may be able to return home on the same day as the surgery, while others might spend a night in the hospital for observation. During this time, medical staff will monitor vital signs and blood calcium levels.

Pain Management

Patients typically experience some discomfort in the neck area, which can be managed with prescribed pain medications. The level of pain usually decreases significantly within a few days.

Incision Care

Proper care of the surgical site is essential for preventing infection and promoting healing. Patients will receive specific instructions on how to clean and protect the incision.

Voice Rest

To protect the vocal cords and allow for healing, patients may be advised to rest their voice for a certain period after surgery.

Gradual Return to Activities

Most patients can resume light activities within a week or two, with a full return to normal activities typically possible within a few weeks, depending on individual recovery progress.

Life After Thyroidectomy: Managing Without a Thyroid

Following the removal of the thyroid gland, patients need to adjust to life without this important endocrine organ. How does this impact daily life and health management?

Thyroid Hormone Replacement Therapy

After a total thyroidectomy, patients require lifelong thyroid hormone replacement to maintain proper metabolic function. This typically involves taking synthetic thyroid hormone in pill form daily.

The dosage of thyroid hormone replacement is carefully calibrated based on regular blood tests to ensure optimal levels. It may take some time to find the right balance, and adjustments are often necessary.

Regular Monitoring

Patients who have undergone thyroidectomy will need ongoing medical follow-up, including:

• Regular blood tests to check thyroid hormone levels
• Periodic imaging scans, especially for thyroid cancer patients
• Check-ups with an endocrinologist or primary care physician

Lifestyle Adjustments

While most people can return to their normal activities after recovery, some lifestyle adjustments may be necessary:

• Consistent timing of thyroid medication intake
• Awareness of symptoms that could indicate thyroid hormone imbalance
• Possible dietary modifications, particularly regarding iodine intake

With proper management and care, most individuals who have undergone thyroidectomy can lead healthy, normal lives. The key lies in maintaining regular medical follow-ups and adhering to prescribed thyroid hormone replacement therapy.

Advances in Thyroidectomy Techniques and Future Prospects

The field of thyroid surgery continues to evolve, with ongoing research and technological advancements aimed at improving outcomes and patient experience. What are some of the recent developments and future directions in thyroidectomy?

Minimally Invasive Techniques

Surgeons are increasingly adopting minimally invasive approaches, such as:

• Endoscopic thyroidectomy: Using small incisions and specialized instruments for reduced scarring and faster recovery
• Robotic-assisted thyroidectomy: Employing robotic systems for enhanced precision and visualization

Improved Imaging and Monitoring

Advanced imaging techniques and intraoperative monitoring systems are enhancing surgical precision and reducing the risk of complications. These include:

• High-resolution ultrasound for better preoperative planning
• Intraoperative nerve monitoring to protect vocal cord function
• Near-infrared fluorescence imaging to aid in identifying parathyroid glands

Personalized Medicine Approaches

The future of thyroidectomy may involve more personalized treatment strategies based on genetic profiling and molecular markers. This could lead to more tailored surgical approaches and post-operative management plans.

Alternative Treatments

For certain thyroid conditions, researchers are exploring alternatives to surgical removal, such as:

• Radiofrequency ablation for benign thyroid nodules
• Targeted drug therapies for specific types of thyroid cancer

These advancements aim to improve surgical outcomes, reduce complications, and enhance the overall patient experience. As research progresses, we can expect further refinements in thyroidectomy techniques and management strategies.

In conclusion, thyroidectomy remains a crucial treatment option for various thyroid conditions. While it carries certain risks, ongoing advancements in surgical techniques and perioperative care continue to improve outcomes. For patients facing thyroid surgery, understanding the procedure, its potential risks, and the recovery process can help in making informed decisions and preparing for the journey ahead. As always, consulting with experienced healthcare providers is essential for personalized advice and optimal care.

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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Surgeon, mammologist and oncologist. Doctor of the highest category.

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Khokhlov Sergey Viktorovich

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Work experience: 28 y.o.

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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.