الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
 |  | from | 163 |  |  |
| | | from | 163 | | |
Abstract
T
hyroid gland surgery has passed from a condemned, bloody and frightening surgical procedure with a high mortality rate to a common and save one by the work of some competent and ambitious surgeons who have created this long amazing path. (Wojtczak B et al., 2018)
Thyroid gland has an embryology and anatomical position that make the intimately related anatomical structures vulnerable in an unusual way to the risk of the iatrogenic injury even with the hands of the experienced surgeons with the possibility of development of many of the post-thyroidectomy complications. (Bhargav PR. ,2014)
Hypocalcemia together with the recurrent laryngeal nerve injury remain the most common complications of the thyroid surgery with determinate effects on the patient’s quality of life that may last for a long time. (Zakaria HM et al., 2011)
The arterial supply of the parathyroid glands comes from a single dominant artery in about 80 % of cases branching from the inferior thyroid arteries, the remaining 20% of the superior parathyroid glands and the 10% of the inferior parathyroid glands derive their supply from the superior thyroid arteries. (Sadowski SM, 2017)
Post-thyroidectomy hypocalcemia believed to be a multifactorial complication reflecting the failure of the current literature to postulate an agreed definition for measuring its real incidence. (Yetkin G et al.,2016)
The chance to prevent the development of post-operative hypocalcemia is achieved by the preservation of at least one functioning parathyroid gland. (Yon Seon Kim,2012)
In our study we meant to evaluate the risk of hypocalcemia (transient or permanent) after total thyroidectomy for goiter, the frequency and impact of unintentional parathyroidectomy.
Our study is a prospective study on 50 cases presented with simple and toxic nodular goiters and malignant goiters with formal surgical indication for total thyroidectomy operation. They were evaluated, operated by the same surgical team. Patients were examined at our outpatient general surgery clinic in El-Dimerdash hospital with further surgical and medical evaluations were completed in our inpatient ward. Evaluation included history, physical examination, laboratory and radiological investigations. Inclusion criteria age ranged between 25 to 58years (19 male and 31 female) presented with benign or malignant simple multinodular goiter, toxic goiter relapsing after full medical treatment, selected cases of thyroiditis (Hashimoto’s thyroiditis) and thyroid cancer. Exclusion criteria were patients with previous thyroid (hemithyroidectomy, subtotal thyroidectomy) or parathyroid surgery or neck dissection, patients with recurrent goiter or for completion surgery, patients with hypoalbuminemia, unfit for surgery, receiving medications for (parathyroid gland, renal disease or receiving calcium medication).
All patients underwent total thyroidectomy. An incision is made in the skin two finger breadths above the sternal notch between the medial borders of the sternocleidomastoid muscles. Subcutaneous fat and Platysma are divided, and a subplatysmal dissection is made above the incision up to the level of the thyroid cartilage above but remaining superficial to the anterior jugular veins. The fascia between the sternohyoid, omohyoid and sternothyroid muscles (strap muscles) is divided along the midline and the muscles retracted laterally. This is an avascular plane, but care must be taken not to injure small veins crossing between the anterior jugular veins. The thyroid gland is rotated medially to identify is the middle thyroid vein (it will be tightly stretched by the medial rotation of the gland), which is then ligated. Identify the superior laryngeal artery as close to the superior pole of the thyroid parenchyma as possible. Great care should be taken while ligating the superior laryngeal artery to avoid injury to the external laryngeal nerve. The superior parathyroid gland is normally located in a posterior position, at the level of the upper two thirds of the thyroid and approximately 1 cm above the crossing point of the recurrent laryngeal nerve and the inferior thyroid artery. It is orange yellow in color but is difficult to identify. The gland must remain in situ with blood supply intact. The inferior parathyroid glands are normally located between the lower pole of the thyroid and the isthmus, most commonly on the anterior or the posterolateral surface of the lower pole of the thyroid. Care must be taken to preserve it in situ and to avoid damaging its inferior thyroid artery. The isthmus is divided, and the thyroid gland is removed.
All our participants have stayed in the hospital for at least two days, Postoperative follow up was made of clinical and laboratory components observation of the postoperative bleeding and nerve injury (voice changes, shocking or stridor) manifestations of hypocalcemia over the first 24 h (numbness, muscle cramps, Chvostek sign, Trousseau sign). (Rehman HU, Wunder S., 2011)
Serum calcium level was measured on morning of the first postoperative day for all the participants (24 h post-operative measure). Asymptomatic hypocalcemic patients managed by oral calcium (500 mg/8h) and oral vit. D (Calcitriol 0.25 ug/12h) until serum calcium level improved if still not improved treated with IV calcium supplementations (10 ml 10% calcium gluconate in 100 ml of normal saline IV over 10 min). Symptomatic hypocalcemic patients were treated with IV calcium supplementations (10 ml 10% calcium gluconate in 100 ml of normal saline IV over 10 min) till the patients become asymptomatic followed with maintenance therapy of 1-3 mg of calcium gluconate/kg/h usually over the first 24 to 48 h postoperatively and shift to oral calcium (1.5 gm / day) and Vit D (Calcitriol 1.5 ug/day) supplements.
All patients are discharged with Serum calcium level within the normal reference range with clear instructions to contact our hospital any time if symptoms of hypocalcemia develop and to visit our outpatient clinic one week after operation to assess patient’s wound, clinical manifestations of hypocalcemia and discuss pathology report. The patient will receive a replacement therapy (L-thyroxine) after the histopathological report. (Balentine CJ, Sippel RS., 2016)
Then visits our out-patient clinic every month to follow up manifestation of hypocalcemia and serum calcium level for the patients developed hypocalcemia post-operative and received medication. Also follow up of the thyroid hormone profile (T3, T4, TSH) for adjustment of L-thyroxine and finally follow up for serum calcium level after 6 months. (Balentine CJ, Sippel RS., 2016)
In our study 88% of patients were female, mean of age 44.14 with range from 25 to 58 years. The normal serum calcium level 8.5 – 10.5 mg/dl. The normal range of serum intact PTH level 10 – 55 pg/dl.
The time of operation ranged from 60 minutes to 140 minutes with mean of 100 minutes. The amount of intra-operative blood loss ranged from 100 ml to 220 ml with mean of 170 ml. There was no post-operative complication as (stridor, post-operative hemorrhage or change of voice).
Post-operative hypocalcemia developed in 10/50 patients (20%) after 24 hours (transient hypocalcemia) whereas there was no permanent hypocalcemia. There were no cases with transient hypoparathyroidism.
The incidence of unintentional parathyroidectomy in only 3 cases with 6% from the whole cases where 2 cases intracapsular and one case juxta-capsular. The 3 cases with unintentional parathyroidectomy were found among benign cases and no malignant case with unintentional parathyroidectomy.
As regard transient hypocalcemia and unintentional parathyroidectomy 9 cases of transient hypocalcemia were at the group of non-unintentional parathyroidectomy while only one case of transient hypocalcemia was at the group of patients with unintentional parathyroidectomy P value 0.552. So, there is no relation between transient hypocalcemia and unintentional parathyroidectomy.
There were 8 cases of hypocalcemia were benign (21%) while normocalcemic patients among benign were 30 cases (78.9%), whereas 2 cases of hypocalcemia were malignant (16.7%) while normocalcemic patients among malignant were 10 cases (83.3%). This shows that histopathological diagnosis and transient hypocalcemia is statistically insignificant.