From the Guidelines
Parathyroid surgery is associated with a low complication rate, with no significant difference in total complications between total parathyroidectomy (TPTX) and total parathyroidectomy with autotransplantation (TPTX+AT) groups, as shown in a meta-analysis of 772 patients (OR = 1.44; 95%CI, 0.76e2.71; P = 0.27) 1.
Complications of Parathyroid Surgery
The complications of parathyroid surgery can be categorized into several types, including:
- Hypocalcemia: Transient hypocalcemia was reported to be higher in the TPTX group compared to the TPTX+AT group, but the overall rate of complications was not significantly different between the two groups 1.
- Recurrent laryngeal nerve injury: The study did not provide specific data on the incidence of recurrent laryngeal nerve injury, but it is a known potential complication of parathyroid surgery.
- Bleeding: Bleeding complications were reported in the study, but the incidence was not significantly different between the TPTX and TPTX+AT groups 1.
- Infection: Wound infections were rare, occurring in less than 1% of patients, but the study did not provide specific data on the incidence of infection in the TPTX and TPTX+AT groups.
- Persistent hyperparathyroidism: The study reported a lower incidence of recurrence or persistence in the TPTX group compared to the TPTX+AT group (OR = 0.18; 95%CI, 0.10e0.33; P < 0.01) 1.
Management of Complications
Patients who undergo parathyroid surgery should be monitored for hypocalcemia symptoms post-surgery, such as tingling and muscle cramps, and may require calcium supplementation (1-3g daily) with vitamin D (calcitriol 0.25-0.5mcg daily) 1. The study also reported that there was no significant difference in the requirement for calcium or vitamin D supplementation between the TPTX and TPTX+AT groups (OR = 1.12; 95%CI, 0.61e2.03; P = 0.72) 1.
Risk Factors for Complications
Risk factors for complications include surgeon inexperience, reoperation, extensive disease, and anatomical variations. The study reported that TPTX had a lower rate of reoperation than the TPTX+AT group (OR = 0.17; 95%CI, 0.06e0.54; P = 0.002) 1.
From the Research
Complication Rates of Parathyroid Surgery
- The overall incidence of recurrent nerve injury was 1.33 per cent overall (0.99% for each nerve encountered) in a study of 150 consecutive thyroid and parathyroid procedures performed by a single surgeon in a rural community hospital setting 2.
- The incidence of transient postoperative hypocalcemia was 13 per cent, with one patient suffering permanent hypoparathyroidism (0.8%) in the same study 2.
- The incidence of incidental parathyroidectomy (IP) is 3.7-24.9%, while the prevalence of permanent hypoparathyroidism is less frequent 6-12% 3.
- Parathyroidectomy in renal-related disease is associated with a significantly higher risk of morbidity and mortality compared with primary hyperparathyroidism, with a higher mortality (1.3% vs 0.1%, P = 0.011), overall complication rate (7.0% vs 2.3%, P = 0.001), surgery related complication rate (4.4% vs 1.7%, P = 0.03) and systemic complication rate (2.5% vs 0.4%, P = 0.005) 4.
- The most common complication of parathyroid surgery is operative failure, and other complications include recurrent laryngeal nerve paralysis, permanent hypoparathyroidism, hematoma, and error in diagnosis 5.
- There is a lack of high-quality evidence in the management of post-thyroidectomy temporary and long-term hypoparathyroidism, and further research focusing on clinically relevant outcomes is needed to examine the effects of current treatments in the management of temporary and long-term post-thyroidectomy hypocalcaemia 6.
Risk Factors for Complications
- Female patients, ectopic parathyroids, small thyroids, Graves', malignancy, redo surgeries and total thyroidectomy favour incidental parathyroidectomy (IP) 3.
- Reoperative surgery, male sex, and renal impairment were predictors of worse outcomes in patients with ASA score ≤ 2 4.
- Renal impairment, in addition to other variables, were not predictors of complications in patients with ASA score ≥3 4.
Prevention and Management of Complications
- Routine visualization of parathyroids, new hemostatic devices, magnifying instruments and fluorescence can prevent incidental removal of parathyroids 3.
- High volume, experienced and younger surgeons have lower complication rates (including hypoparathyroidism) 3.
- Routine use of calcium and vitamin D supplements in the postoperative period may reduce the risk of symptoms, temporary hypocalcaemia and hospital stay, but may lead to overtreatment and has no effect on long-term hypoparathyroidism 6.