C lin ic a i a n d la b o ra to ria l c o rre la tio n o f p o sto p e ra tiv e
h y p o c a lc e m ia a fte r e x te n siv e th y ro id e c to m y
Departal1zent of Sllrgery of Santa Casa School of Medicine
- São Paulo, Brazil
T h e m e d ic a i re c o rd s o f 8 4 p a tie n ts s u b m itte d to e x te n s iv e th y ro id e c to m y fro m J a n u a ry 1 9 9 1 to A p ril1 9 9 5 w e re re v ie w e d a n d th e d a ta
w a s a n a ly z e d in o rd e r to v e rify a c o rre la tio n b e tw e e n p o s to p e ra tiv e la b o ra to rie s re s u lts a n d p h y s ic a l fin d in g s s u g g e s tiv e o f h y p o c a l-c e m ia . It w a s v e rifie d th a t th e re w a s h y p o l-c a ll-c e m ia in 5 1 .2 p e rl-c e n t o f th e p a tie n ts , o f w h il-c h o n ly 1 8 .6 p e rl-c e n t p re s e n te d s y m p to n is . It
w a s c o n c lu d e d th a t a s y m p to m a tic h y p o c a lc e m ia is fre q u e n t in e x te n s iv e th y ro id e c to m y a n d a ro u tin e s c re e n in g fo r s e ru m c a lc iu m in
th e p o s to p e ra tiv e p e rio d fo llo w in g th y ro id e c to m y a n d c a lc iu m re p o s itio n m u s t b e s y s te m a tic .
U N IT E R M S : T h y ro id , h y p o c a lc e m ia , th y ro id e c to m y .
IN T R O O U C T IO N
T
h e th y ro idc a n b e tre a te dc a n b e a ffe c te db y s u rg e ry .b y m a n y d is e a s e sT h e e x te n t o f s u rg ic a lw h ic h re s e c tio n o f th e th y ro id g la n d h a s b e e n d ic ta te d b y th e p a th o lo g y a n d th e s ite o f th e d is e a s e . T h y ro id e c to m y ln a y c a u s e v a rio u s c o m p lic a tio n s ,I-4 o n e o f w h ic h is h y p o c a lc e ln ia . lt is n o t u n u s u a l fo r p a tie n ts u n d e rg o in g o p e ra tiv e p ro c e d u re s o n th e th y ro id g la n d to e x p e rie n c e a tra n s ie n t 0 1 ' p e rn la n e n t d ro p in s e rU ln c a lc iu ln fo llo w in g o p e ra tio n .T h e c a u s a l ln e c h a n is ln o f th is h y p o c a lc e ln ia h a s s till n o t b e e n c O ln p le te ly e lu c id a te d ; h o w e v e r, th is ln e ta b o lic d is o rd e r is a ttrib u te d to s u rg ic a l d a ln a g e in flic te d o n th e p a ra th y ro id g la n d s d u rin g th y ro id e c to ln y ; fo r e x a m p le , d e v a s c u la riz a tio n , tra llln a 0 1 ' e x e re s i s , .0 1 ' to lo c a l p o s to p e ra tiv e c O ln p lic a tio n s s u c h a s c o m p ro m is e o f th e b lo o d s u p p ly o f th e p a ra th y ro id , I.2 ,ó -IO e d e m a , h e m a to m a s ,
a n d in fe c tio n Y O th e r c a u s e s s u c h a s p a ra th y ro id s u p p re s s io n d u e to re a b s o rp tio n o f b o n e c a lc iu m in h y p e lth y ro id is m
A d d r e s s f o r c o r r e s p o n d e n c e : A n t o n i o J o s é G o n ç a l v e s
R u a T a b a p u ã , 5 0 0 c j . 2 3 - I t a i m - B i b i S ã o P a u l o / S P - B r a s i l - C E P -0 4 5 3 3 -0 0 1
S ã o P a u lo M e d ic a i J o u rn a llR P M 1 1 5 (1 ): 1 3 6 8 -1 3 7 2 , 1 9 9 7
p a tie n ts , a n in c re a s e in re n a l e x c re tio n o f c a lc iu n l d u e to . p o s to p e ra tiv e h e ln o d ilu tio n , a n in c re a s e in th e re Ie a s e o f c a lc ito n in re s u ltin g fro m th y ro id g la n d ln a n ip u Ia tio n , th e Io s s o f b o n e c a lc iu m in th y ro to x ic o s te o d y s tro p h y p a tie n ts , a n d a u to iln n lu n e fib ro s is o f th e b lo o d s u p p ly o f th e p a ra th y ro id g la n d a re a ls o iIn p lic a te d in th e e tio lo g y o f h y p o c a lc e m ia , b u t n e e d fu rth e r c o n fin n a tio n .
H y p o c a lc e ln ia is m o re fre q u e n t in e x te n s iv e th y ro id e c to m y w h e n c o m p a re d to ln in o r re s e c tio n s o f th e th y ro id g la n d , in th e lig a tio n o fth e in fe rio r th y ro id a rte ry ,2 a n d h a s b e e n re la te d to th e s u rg e o n 's e x p e rie n c e . C a k n la k li e t a I.,IIin a p ro s p e c tiv e s tu d y , re p o rte d n o d iffe re n c e w ith
a n d w ith o u t b ila te ra llig a tio n o f th e in fe rio r th y ro id a rte ry in s u b to ta l th y ro id e c to m y .
T h e o b je c tiv e o f th is p a p e l' is to v e rify if p re s e n t p h y s ic a l fin d in g s a re p re s e n t in p o s to p e ra tiv e h y p o c a lc e ln ia a n d to a n a ly z e its in c id e n c e .
C A S E S A N O M E T H O O
T h e ln e d ic a l re c o rd s o f 8 4 p a tie n ts w h o u n d e rw e n t e x te n s iv e th y ro id e c to m y b e tw e e n J a n u a ry 1 9 9 1 a n d A p ril
1 9 9 5 w e re re v ie w e d a n d s ta tis tic a lly a n a ly z e d in th e H e a d
G ra p h ic 2 - C lin ic a i a n d la b o ra to ria l c o rre la tio n o f p o s to p e ra tiv e h y p o c a lc e m ia in e x te n s iv e th y ro id e c to m y
...6 8 .
Race
o rie n ta l w h ite
b la c k
o
5 0
2 0
4 0
80
1 0
70
30
60
a n d N e c k D i s c i p l i n e o f t h e D e p a r t l n e n t o f S u r g e r y o f
S a n t a C a s a S S h o o l o f M e d i c i n e , S ã o P a u l o , B r a z i I .
I t i n c l u d e d o n l y p a t i e n t s w h o u n d e r w e n t e x t e n s i v e
t h y r o i d e c t o l n i e s w h o h a d p o s t o p e r a t i v e t o t a l s e r u l n
c a l c i u l n I n e a s u r e . T o t a l t h y r o i d e c t o l n y a n d b i l a t e r a l a n d
u n i l a t e r a l s u b t o t a l t h y r o i d e c t o m i e s a s s o c i a t e d w i t h
c o n t r a l a t e r a l h e m i t h y r o i d e c t o m y w e r e c o n s i d e r e d
e x t e n s i v e t h y r o i d e c t o m i e s .
T o t a l s e r u m c a l c i u l n w a s m e a s u r e d i n t h e
i t n n l e d i a t e p o s t o p e r a t i v e p e r i o d o r o n t h e f i r s t d a y . T h e
t n e a s u r e o f s e r u l n c a l c i u l n w a s m a d e u s i n g t h e
o r t o c r e s o f t a l e i n - c o m p l e x o n e I n e t h o d w i t h o u t
d e p r o t e i n z a t i o n b y e s p e c t r o p h o t o m e t e r . H y p o c a l c e t n i a
w a s d e e m e d e x i s t e n t w h e n t o t a l s e r u m c a l c i u m w a s
l o w e r t h a n 8 .5 I n g / d I . 12
S e v e n t y - n i n e p a t i e n t s w e r e f e m a l e ( 9 4 .1 p e r c e n t )
a n d j u s t 5 w e r e I n a l e ( 5 .9 p e r c e n t ) , b e i n g 1 5 b l a c k , 6 8
w h i t e a n d 1 A s i a n . T h e I n e d i u m a g e w a s 4 4 w i t h a r a n g e
o f ] 5 t o 7 3 y e a r s ( G r a p h i c s 1 a n d 2 ) .
F i f t y - e i g h t ( 6 9 p e r c e n t ) p a t i e n t s w e r e s u b m i t t e d
t o t o t a l t h y r o i d e c t o t n y , 1 7 ( 2 0 .3 p e r c e n t ) u n d e r w e n t
b i l a t e r a l s u b t o t a l t h y r o i d e c t o m y , a n d n i n e ( 1 0 .7
S e x
7 9
1 0 0
G ra p h ic 1 - C lin ic a i a n d la b o ra to ria l c o rre la tio n o f p o s to p e ra tiv e h y p o c a lc e m ia a fte r e x te n s iv e th y ro id e c to m y
T h e u n i l a t e r a l s u b t o t a l t h y r o i d e c t o m y a s s o c i a t e d w i t h
c o n t r a l a t e r a l h e m i t h y r o i d e c t o m y w a s t h e t n o s t p r e v a l e n t
s u r g i c a l r e s e c t i o n c a u s i n g h y p o c a l c e t n i a . I t o c c l l r r e d i n 6 6 .6
p e r c e n t ( 6 / 9 ) o f t h e c a s e s , f o l l o w e d b y t o t a l t h y r o i d e c t o l l l Y
i n 5 3 .4 p e r c e n t ( 3 1 / 5 8 ) a n d b y b i l a t e r a l s l I b t o t a l
t h y r o i d e c t o m y i n 3 5 .3 p e r c e n t ( 6 / 1 7 ) . T h e s t a t i s t i c a l a n a l y s i s
p e r f o r m e d s h o w e d n o s i g n i f i c a n t d i f f e r e n c e b e t w e e n t h e
o c c u r r e n c e o f h y p o c a l c e t n i a w h e n c O l n p a r e d t o d i f f e r e n t
s u r g i c a l p r o c e d u r e s ( p > 0 .0 5 ) ( T a b l e I ) .
F o r t y - t h r e e p a t i e n t s ( 5 1 .2 p e r c e n t ) h a d h y p o c a l c e t n i a ,
b u t o n l y 8 ( 1 8 .6 p e r c e n t ) h a d s i g n s a n d s y n l p t O t n s .
C h v o s t e k 's s i g n w a s t h e I n o s t f r e q u e n t , f o I l o w e d b y
p a r e s t h e s i a , T r o u s s e a u 's s i g n , I n y a l g i a , a n d f a c i a l a n e l
c a r p o p e d a l s p a s m s ( C h a r t 1 ) .
R E S U L T S
p e r c e n t ) u n i l a t e r a l s u b t o t a l a s s o c i a t e d w i t h c o n t r a l a t e r a l
h e l n i t h y r o i d e c t o m y ( l o b e c t o l n y +i s t t n e c t o t n y ) ( T a b l e I ) . H i s t o p a t h o l o g i c r e s u l t s w e r e s h o w n i n G r a p h i c 4 .
S t a t i s t i c a l a n a l y s i s w a s p e r f o n n e d u s i n g t h e c h i
-s q u a r e t e c h n i q u e .
m a le fe m a le
o
80
6 0
4 0
20
G O N Ç A L V E S , A .J .; M A R T IN S , L .; S O U Z A ,T .R .B . e t. a l.- C lin ic a i a n d la b o ra to ria l c o rre la tio n o f p o s to p e ra tiv e h y p o c a lc e m ia a fte r e x te n s iv e th y ro id e c to m y
C h a rt 1
D is trib u tio n o f s y m p to m s a n d s ig n a ls o f
h y p o c a lc e m ia o f 8 s y m p to m a tic p a tie n ts
S ig n a ls a n d S y m p to m s P a tie n ts
C h v o s te k 7
p a re s th e s ia 6
T ro u s s e a u 3
m y a lg ia 2
fa c ia l s p a s m s 1
c a rp a l s p a s m s 1
p e d a l s p a s m s 1
P a tie n ts w ith h y p o c a lc e m ia N = 4 3
S y m p to m a tic p a tie n ts : N = 8 (1 8 .6%)
u p to 6 m o n th sY It sh o u ld b e n o ted th at th e classificatio n o f h y p o calcem ia as tran sien t o r p erm an en t is d ifficu lt. B o th h av e th e sam e p h y sical fin d in g s an d th e sam e treatm en t, th e o n ly d ifferen ce is th e tim e o f ev o lu tio n o f m o re o r less th an 6 0 d ay s. In th e p resen t p ap er, h y p o calceln ia w as n o t d iv id ed in to th ese tw o g ro u p s (p en n an en t o r tran sito ry ). W e fo u n d a h ig h er in cid en ce o f h y p o calcem ia th an th at d escrib ed in th e literatu re,2 .4 .5 .7 .9 .lo ,.1 2 -1 4alth o u g h th e rep o rted freq u en cy v aries fro m 0 .2 to 8 3 p ercen t.5
. ó
H y p o calcem ia creates a g reat d e aI o f ap p reh en sio n o n th e p art o f th e p h y sician b ecau se o f im m ed iate an d lo n g -term co m p licatio n s.'5
C h ro n ic co m p licatio n s .are in tracran ial calcificatio n s, p articu larly o f th e b asal g an g lia, v ario u s m en tal d istu rb an ces, su ch as irritab ility , d ep ressio n , an d ev en p sy ch o sis. P ap illed em a an d o th er sig n s o f in creased in tracran ial p ressu re h av e b een rep o rted . C h ro n ic h y p o calcem ia m ay lead to cataract fo rm atio n , ab n o rm alities o f th e sk in , n ails an d h air, can d id a in fectio n s an d d erm ato lo g y an o m alies. C ard iac effects o f h y p o calceln ia in clu d e p ro lo n g atio n o f th e Q T in terv al an d , rarely , co n g estiv e h eart failu re. D en tal an o m alies d ep en d o n th e ag e at o n set; in ch ild ren h y p o calcem ia can cau se en am el h y p o p lasia an d failu re o f th e ad u lt teeth to eru p t.1 ó
M u rak atn i 1 3 rep o rted th at in o rg an ic u rin e p h o sp h ate is a p red ictiv e facto r in th e d iag n o sis o f im m ed iate o r lo n g -term h y p o calcem ia. L o w lev eIs o f in o rg an ic u rin e p h o sp h ate are o b serv ed in th e p erm an en t h y p o calcem ia o f G rav es' D isease.
T h e in cid en ce o fh y p o calcem ia in to tal th y ro id ecto ln y w as n o t h ig h er th an in su b to tal th y ro id ecto m y . T h is d o es 5 6
28
8 4 5 8 1 709
8 44 6 .4
6 0 .7
5 1 .2 5 3 .4
3 5 .3
6 6 .6
5 2 .2
2 6
1 7
4 3
D IS C U S S IO N
T h e in cid en ce o f h y p o calcem ia in p atien ts w ith m alig n an t d isease w as h ig h er (6 0 .7 p ercen t) th an th o se w ith b en ig n d isease (4 6 .4 p ercen t). A n an aly sis o f h y p o calcem ia rev ealed n o statistically sig n ifican t d ifferen ce b etw een th ese g ro u p s, p > 0 .0 5 (T ab le 2 ).
H y p o calcem ia w as treated in 1 4 p atien ts (3 2 .5 p ercen t) w ith in trav en o u s in fu sio n o f 1 0 p ercen t calciu m g lu co n ate so lu tio n , o ral calciu m ch lo rid e, o r b o th . In so m e p atien ts, th e lab o rato ry resu lts w ere o b tain ed in th e first am b u lato ry retu rn w h erein h y p o calcem ia w as treated .
B e n ig n
M a lig n
T o ta l
T a b le 2
P o s to p e ra to ry h y p o c a lc e m ia a n d h is to p a th o lo g ic re s u lts in
8 4 p a tie n ts s u b m itte d to e x te n s iv e th y ro id e c to m y .
S u rg e ry H y p o c a lc e m ia T o ta l
N ° %
T .T . 3
S .B .T . 0 6
H .T .+ S .C .T . 0 6
T o ta l 4 3
T .T .= T o ta l T h y ro id e c to m y
S .B .T .= S u b to ta l B ila te ra l T h y ro id e c to m y
H .T .+ S .C .T . = H e m ith y ro id e c to m y + S u b to ta l C o n tra la te ra l
T h y ro id e c to m y
T a b le 1
S u rg e ry re s e c tio n a n d h y p o c a lc e m ia c o rre la tio n in 8 4
p a tie n ts s u b m itte d to e x te n s iv e th y ro id e c to m y .
S u rg e ry H y p o c a lc e m ia T o ta l
N ° %
A s th e ex ten t o f th e resectio n o f th e th y ro id in creases, th e risk o f co m p licatio n s su ch as h y p o calcem ia an d v o cal co rd p araly sis also in crease. T h is is d u e to b ru isin g , ex eresis, an d co m p ro m ise o f th e b lo o d su p p ly o f th e . p arath y ro id g lan d .1
P o sto p erativ e h y p o calcem ia can b e classified as tran sien t o r p erm an en t, th e latter lastin g m o re th an 6 0 d ay s5
...58 . S u rg e ry
70
60
50
4 0
3 0
20
10
o
TT
S B T U S C H Tnot agree w ith the literature.1.7 H em ithyroidectolny plus subtotal contralateral thyroidectom y w as the m ost frequent procedure associated w ith hypocalcem ia in the present series. T he occurrence ofhypocalcem ia w as not influenced by the m alignant potential of the disease.
L a G am m a found 49 percent of asym ptom atic hypocalcem ia in his study, w hile M cH enry found 6 7 .9
percent. In this study, asym ptom atic hypocalcem ia w as found in
81.4
percent. W hen the balance betw een ionized and protein-bound calcium is acutely altered, the sym ptoll1s m ay be precipitated.13H ypocalcem ia folIow ing extensi ve thyroidectoll1Y m ust alw ays be investigated because of the infrequent sym ptom s and grave com plications if there is not adequate repositioning.
C O N C L U S IO N
T T = to ta l th y ro id e c to m y ; S B T = s u b to ta l b ila te ra l th y ro id e c to m y ;
U S C H T
=
u n ila te ra l s u b to ta l + c o n tra la te ra l h e m ith y ro id e c to m yG ra p h ic 3 - C lin ic a i a n d la b o ra to ria l c o rre la tio n o f p o s to p e ra tiv e h y p o c a lc e m ia a fte r e x te n s iv e th y ro id e c to m y
W e concluded that hypocalcem ia is frequent in the postoperative of extensive thyroidectoll1Y but physical findings are uncom m on, and thus foIlow ing extensive thyroidectom y, serum calcium investigation is m andatory.
H is to p a to lo g ic R e s u lts
4 0
... 3 3 ' , .
35
3 0
25
2 0
1 5
1 0
5
o
G o ite r G ra v e s H a s h im o to P a p p ila ry
c a rc in o m a
F o llic u la r c a rc in o m a
G ra p h ic 4 - C lin ic a i a n d la b o ra to ria l c o rre la tio n o f p o s to p e ra tiv e h y p o c a lc e m ia a fte r e x te n s iv e th y ro id e c to m y
G O N Ç A L V E S , A .J .; M A R T IN S , L .; S O U Z A ,T .R .B . e t. a l.- C lin ic a i a n d la b o ra to ria l c o rre la tio n o f p o s to p e ra tiv e h y p o c a ic e m ia a fte r e x te n s iv e th y ro id e c to m y
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9 9 3 ;7 3 (2 ):3 0 7 -2 1 .
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-5 3 .
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1 9 9 2 ; 1 2 7 (7 ):8 5 4 -8 .
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im p o 1 1 â n c ia c lin ic a . In : W in g a a rd e n lB , S m ith L M , e d s : C e c il
T ra ta d o d e M e d ic in a In te rn a , V o I. 2 , R io d e la n e iro : E d ito ra
G u a n a b a ra K o o g a n , 1 9 9 0 :2 1 0 3 -1 4 .
S ã o P a u lo M e d ic a i J o u rn a l/R P M 1 1 5 (1 ): 1 3 6 8 -1 3 7 2 , 1 9 9 7
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T e x tb o o k o f S u rg e ry : T h e b io lo g ic a l b a s is o f m o d e rn s u rg ic a l p ra c tic e . P h ila d e lp h ia : W .B . S a u n d e rs C o m p a n y , 1 9 9 1 :5 5 6
-9 0 .
9 . M c H e n ry C R , S p e ro ff T , W e n tw o rth D , M u rp h y T . R is k
fa c to rs fo r p o s t-th y ro id e c to m y h y p o c a lc e m ia . S u rg 1 9 9 4 ;
1 16 (4 ): 6 4 1 -7 .
1 0 . O s im e U , O fili O P . In c id e n c e o f h y p o p a ra th y ro ic lis l1 1
fo llo w in g th y ro id e c to m y in a p ro s p e c tiv e s tu c ly o f 1 0 8 c o n s e c u tiv e A fric a n p a tie n ts . C e n tra l A fric a n 1 M e c l
1 9 9 2 ;3 8 (8 ):3 4 3 -5 .
1 1 . C a k m a k 1 i S , A y d in tu g S , E rd e m E . P o s t-th y ro ic le c to tn y
h y p o c a lc e m ia : D o e s a rte ria llig a tio n p la y a s ig n ific a n t ro le ? In tl S u rg 1 9 9 2 ;7 7 (0 4 ):2 8 4 -6 .
1 2 . H e rra n z -G o n z a le z 1 ,G a v ila n 1 ,M a tin e z -V id a l 1 ,G a v ila n C .
C o m p lic a tio n s fo llo w in g th y ro id s u rg e ry . A rc h O to la ry n g o l H e a d N e c k S u rg 1 9 9 1 ; 1 1 7 (5 ):5 1 6 -8 .
1 3 . M u ra k a m i T , T a jiri 1 ,N o g u c h i S . P re d ic tio n o f th e o u tc 0 l1 1 e
o f p o s to p e ra tiv e h y p o c a lc e m ia in G ra v e s ' D is e a s e . E n d o c rin o lo g ia la p o n ic a 1 9 9 2 ; 3 9 ( 1 ): 1 0 3 -7 .
1 4 . S m ith M A , la ro s z H , H e s s e l P . P a ra th y ro ic l
a u to tra n s p la n ta tio n in to ta l th y ro id e c to m y . A m e ric a n S u rg e o n
1 9 9 0 ; 5 6 (7 ):4 0 4 -6 .
1 5 . K a lis n ik M , Z o rc -P le s k o v ic R , P a je r Z . T h e e ffe c t o f c h ro n ic h y p e rc a lc e m ia o r h y p o c a lc e m ia o n th e fo llic u la r a n d
p a ra fo llic u la r c e lls in ra t th y ro ic l g la n c l. A 1 A n a t
1 9 9 0 ; 1 8 9 (3 ):2 0 1 -6 .
1 6 . A ttie M . H y p o c a lc e m ic s y m p to n lS fo llo w i n g p a ra th y
-ro id e c to m y . lA M A 1 9 9 1 ;2 6 5 (2 1 ):2 8 8 8 .
