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Figure 1.  Preoperative, 12-Hour Postoperative, and 24-Hour Postoperative Serum Calcium Levels
Preoperative, 12-Hour Postoperative, and 24-Hour Postoperative Serum Calcium Levels

To convert calcium levels to millimoles per liter, multiply by 0.25. The bar within the quartile boxes represents the median value; error bars indicate 95% CIs; dots indicate outliers.

Figure 2.  Change in Serum Calcium Levels From Baseline
Change in Serum Calcium Levels From Baseline

To convert calcium levels to millimoles per liter, multiply by 0.25.

Table 1.  Patient Demographics
Patient Demographics
Table 2.  Results
Results
Table 3.  Hospital/Pharmacy Charge Analysis
Hospital/Pharmacy Charge Analysis
1.
Erbil  Y, Bozbora  A, Ozbey  N,  et al.  Predictive value of age and serum parathormone and vitamin D3 levels for postoperative hypocalcemia after total thyroidectomy for nontoxic multinodular goiter.  Arch Surg. 2007;142(12):1182-1187.PubMedGoogle ScholarCrossref
2.
Roh  JL, Park  CI.  Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy.  Am J Surg. 2006;192(5):675-678.PubMedGoogle ScholarCrossref
3.
Testa  A, Fant  V, De Rosa  A,  et al.  Calcitriol plus hydrochlorothiazide prevents transient post-thyroidectomy hypocalcemia.  Horm Metab Res. 2006;38(12):821-826.PubMedGoogle ScholarCrossref
4.
Mehanna  HM, Jain  A, Randeva  H, Watkinson  J, Shaha  A.  Postoperative hypocalcemia—the difference a definition makes.  Head Neck. 2010;32(3):279-283.PubMedGoogle Scholar
5.
Reeve  T, Thompson  NW.  Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient.  World J Surg. 2000;24(8):971-975.PubMedGoogle ScholarCrossref
6.
Jacobs  JK, Aland  JW  Jr, Ballinger  JF.  Total thyroidectomy: a review of 213 patients.  Ann Surg. 1983;197(5):542-549.PubMedGoogle ScholarCrossref
7.
Bringhurst  FR, Demay  MB, Krane  SM, Kronenberg  HM. Bone and mineral metabolism in health and disease. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
8.
Kirkby-Bott  J, Markogiannakis  H, Skandarajah  A, Cowan  M, Fleming  B, Palazzo  F.  Preoperative vitamin D deficiency predicts postoperative hypocalcemia after total thyroidectomy.  World J Surg. 2011;35(2):324-330.PubMedGoogle ScholarCrossref
9.
Erbil  Y, Ozbey  NC, Sari  S,  et al.  Determinants of postoperative hypocalcemia in vitamin D–deficient Graves’ patients after total thyroidectomy.  Am J Surg. 2011;201(5):685-691.PubMedGoogle ScholarCrossref
10.
Erbil  Y, Barbaros  U, Temel  B,  et al.  The impact of age, vitamin D3 level, and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy.  Am J Surg. 2009;197(4):439-446.PubMedGoogle ScholarCrossref
11.
Roh  JL, Park  JY, Park  CI.  Prevention of postoperative hypocalcemia with routine oral calcium and vitamin D supplements in patients with differentiated papillary thyroid carcinoma undergoing total thyroidectomy plus central neck dissection.  Cancer. 2009;115(2):251-258.PubMedGoogle ScholarCrossref
12.
Sanabria  A, Dominguez  LC, Vega  V, Osorio  C, Duarte  D.  Routine postoperative administration of vitamin D and calcium after total thyroidectomy: a meta-analysis.  Int J Surg. 2011;9(1):46-51.PubMedGoogle ScholarCrossref
13.
Tartaglia  F, Giuliani  A, Sgueglia  M, Biancari  F, Juvonen  T, Campana  FP.  Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy.  Am J Surg. 2005;190(3):424-429.PubMedGoogle ScholarCrossref
14.
Bellantone  R, Lombardi  CP, Raffaelli  M,  et al.  Is routine supplementation therapy (calcium and vitamin D) useful after total thyroidectomy?  Surgery. 2002;132(6):1109-1112.PubMedGoogle ScholarCrossref
15.
Bordelon  P, Ghetu  MV, Langan  RC.  Recognition and management of vitamin D deficiency.  Am Fam Physician. 2009;80(8):841-846.PubMedGoogle Scholar
16.
Docimo  G, Tolone  S, Pasquali  D,  et al.  Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy.  G Chir. 2012;33(11-12):374-378.PubMedGoogle Scholar
17.
Shindo  M, Stern  A.  Total thyroidectomy with and without selective central compartment dissection: a comparison of complication rates.  Arch Otolaryngol Head Neck Surg. 2010;136(6):584-587.PubMedGoogle ScholarCrossref
18.
Roh  JL, Park  JY, Park  CI.  Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone.  Ann Surg. 2007;245(4):604-610.PubMedGoogle ScholarCrossref
Original Investigation
July 2017

Association of Preoperative Calcium and Calcitriol Therapy With Postoperative Hypocalcemia After Total Thyroidectomy

Author Affiliations
  • 1University of Virginia School of Medicine, University of Virginia Health System, Charlottesville
  • 2Now with Department of Otolaryngology, University of Colorado, Denver
  • 3Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville
JAMA Otolaryngol Head Neck Surg. 2017;143(7):679-684. doi:10.1001/jamaoto.2016.4796
Key Points

Question  Does preoperative calcium and calcitriol supplementation decrease the incidence of hypocalcemia following total thyroidectomy?

Findings  In this cohort study of 65 patients, preoperative supplementation with calcium and calcitriol was associated with a reduced incidence of symptomatic hypocalcemia, length of hospital stay, and overall costs following total thyroidectomy.

Meaning  This study supports the use of preoperative calcium and calcitriol supplementation for patients undergoing total thyroidectomy.

Abstract

Importance  Hypocalcemia is the most common complication after total thyroidectomy and can result in prolonged hospital admissions and increased hospital charges.

Objective  To determine the effectiveness of preoperative calcium and calcitriol supplementation in reducing hypocalcemia following total thyroidectomy.

Design, Setting, and Participants  A retrospective cohort study was conducted at a tertiary care center in 65 patients undergoing total thyroidectomy by a single surgeon. Patients were divided into 2 groups: those receiving preoperative as well as postoperative supplementation with calcium carbonate, 1000 to 1500 mg, 3 times daily and calcitriol, 0.25 to 0.5 µg, twice daily, and those receiving only postoperative supplementation with those agents at the same dosages. Data on patients who underwent surgery between January 1, 2008, and December 31, 2011, were acquired, and data analyses were conducted from March through June 2012, and from October through December 2016.

Interventions  Calcium and calcitriol therapy.

Main Outcomes and Measures  Postoperative serum calcium levels and development of postoperative hypocalcemia.

Results  Of the 65 patients who underwent total thyroidectomy 27 (42%) were men; mean (SD) age was 49.7 (16.7) years. Thirty-three patients received preoperative calcium and calcitriol supplementation, and 32 patients received only postoperative therapy. In the preoperative supplementation group, 15 of 33 (45%) patients underwent complete central compartment neck dissection and 11 of 33 (33%) had lateral neck dissection, compared with 16 of 32 (50%) and 12 of 32 (38%), respectively, patients without preoperative supplementation. The mean measured serum calcium level in those without preoperative supplementation vs those with supplementation are as follows: preoperative, 9.6 vs 9.4 mg/dL (absolute difference, 0.16; 95% CI, −0.12 to 0.49 mg/dL); 12 hours postoperative, 8.3 vs 8.6 mg/dL (absolute difference, −0.30; 95% CI,  −0.63 to 0.02 mg/dL); and 24 hours postoperative, 8.4 vs 8.5 mg/dL (absolute difference, −0.13; 95% CI, −0.43 to 0.16 mg/dL). In patients not receiving preoperative supplementation, 5 of 32 (16%) individuals became symptomatically hypocalcemic vs 2 of 33 (6%) in the preoperative supplementation group; an absolute difference of 10% (95% CI, −6.6% to 26.3%). Compared with the group not receiving preoperative supplementation, the mean [SD] length of stay was significantly shorter in the preoperative supplementation group (3.8 [1.8] vs 2.9 [1.4] days; absolute difference, −0.9; 95% CI, −1.70 to −0.105 days). Preoperative supplementation resulted in an estimated $2819 savings in charges per patient undergoing total thyroidectomy.

Conclusions and Relevance  Preoperative calcium and calcitriol supplementation, in addition to routine postoperative supplementation, was associated with a reduced incidence of symptomatic hypocalcemia, length of hospital stay, and overall charges following total thyroidectomy.

Introduction

Hypocalcemia is the most frequent complication of total thyroidectomy. It can be defined either biochemically or clinically. There is no universal agreement on the serum calcium level that constitutes biochemical hypocalcemia, but many studies define this as a measured serum calcium level less than 8.0 mg/dL (to convert to millimoles per liter, multiply by 0.25). Patients with clinical hypocalcemia exhibit symptoms of perioral or fingertip numbness or tingling, or presence of the Chvostek sign in the setting of biochemical hypocalcemia. Hypocalcemia may also be categorized temporally as transient or permanent. In transient hypocalcemia, serum calcium levels reach a nadir from 24 to 48 hours postoperatively, but subsequently return to the reference range within 6 months.1-3 Permanent hypocalcemia is defined as hypocalcemia persisting beyond 6 months postoperatively and is due to permanent hypoparathyroidism. It is less frequent, occurring in 2% to 8% of patients, compared with transient hypocalcemia, which occurs in up to half of patients.3-6 Persistent symptomatic hypocalcemia, intravenous calcium requirements, and laboratory monitoring often prolong hospital stay and delay recovery after total thyroidectomy.1 More severe risks to the patient who experiences significant hypocalcemia include hypotension, tetany, seizure, and arrhythmia. The patients also bear additional financial burdens when they experience this complication, including hospital charges for repletion, laboratory testing, and increased length of hospital stay.

Calcium absorption is regulated primarily via parathyroid hormone and vitamin D. Vitamin D3 (cholecalciferol) is acquired via diet or photon-stimulated conversion of precursors in the skin. In the liver, it is hydroxylated to 25-hydroxyvitamin D3 (calcifediol), which, due to its half-life of 2 to 3 weeks, is the most useful measure of vitamin D levels. When stimulated by parathyroid hormone, the enzyme 1α- hydroxylase in the kidney further hydroxylates 25-OHD3 to the active form 1,25-dihydroxyvitamin D3 (calcitriol).1,7 Activated vitamin D increases calcium absorption from the intestine. Vitamin D deficiency is a known independent risk factor for postthyroidectomy hypocalcemia.1,8,9 Previous research has identified 15 ng/mL as the threshold below which patients experience an increased risk of transient postoperative hypocalcemia.8,10 Underlying secondary hyperparathyroidism due to low calcium and vitamin D levels is thought to be the mechanism behind the increased risk of hypocalcemia in patients with vitamin D deficiency.8

Previous studies have demonstrated the efficacy of routine postoperative calcium and vitamin D supplementation as a prophylactic strategy for preventing hypocalcemia in patients undergoing total thyroidectomy, but evaluations of preoperative supplementation are limited.2,11-14 Preoperative supplementation with vitamin D in inactivated forms (ergocalciferol, cholecalciferol) is unlikely to be beneficial because this can require up to two 8-week courses of supplementation, which is unrealistic in the preoperative setting.15 One single-arm study of preoperative and postoperative supplementation with calcium and inactivated vitamin D in patients undergoing total thyroidectomy showed rates of symptomatic hypocalcemia and biochemical hypocalcemia of 6% and 10%, respectively.16 Alternatively, activated vitamin D (ie, calcitriol) is immediately bioavailable and is theoretically beneficial within a few days of initiating therapy. The hypothesis of this study is that preoperative supplementation with calcium and calcitriol would result in decreased postthyroidectomy hypocalcemia and a shorter hospital stay. To our knowledge, there are no published prospective studies to date comparing preoperative and postoperative calcitriol and calcium supplementation with postoperative supplementation alone.

Methods

A retrospective cohort study was conducted of patients undergoing total thyroidectomy at the University of Virginia Department of Otolaryngology–Head and Neck Surgery between January 1, 2008, and December 31, 2011. Data analyses were conducted from March through June 2012, and from October through December 2016. This study was approved by the University of Virginia Institutional Review Board with waiver of informed consent. There was no financial compensation.

Patients were included in the study if they had a total thyroidectomy performed by the senior author (P.A.L.), if they were treated with routine postoperative calcium and calcitriol supplementation, and if the presence or absence of preoperative calcium and calcitriol supplementation was clearly documented in the medical record. Patients were analyzed in 2 groups: (1) those who received 5 days of preoperative oral calcium carbonate, 1000 to 1500 mg, 3 times daily and calcitriol, 0.25 to 0.5 µg twice daily supplementation and (2) those who did not receive preoperative supplementation. Both groups received routine postoperative calcium and calcitriol supplementation at dosages the same as those described above. The decision to treat patients with preoperative calcium and calcitriol supplementation was made by the senior author at the time of the preoperative workup in clinic. Although this was not designed as a prospective trial, during the time of this study there was a gradual transition from never using preoperative calcium and calcitriol supplementation to the routine use of preoperative supplementation. During this transition in clinical practice, the senior author randomly treated patients with preoperative supplementation without regard to laboratory results or planned extent of surgery.

For patients who met the inclusion criteria, data collected from the electronic medical record included age, sex, diagnosis, procedure performed (with or without a concomitant neck dissection), preoperative and postoperative calcium levels, symptomatic hypocalcemia, intravenous calcium repletion, length of hospital stay, and readmissions or emergency department visits that were related to hypocalcemia. Patients who underwent a subtotal thyroidectomy or completion thyroidectomy were excluded. During the postoperative hospitalization, serum calcium levels were checked every 12 hours. All patients received the same postoperative regimen of oral calcium and calcitriol supplementation. Intravenous calcium was given if serum calcium levels dropped below 7.5 mg/dL or if the patient developed symptoms of hypocalcemia (perioral numbness and tingling, paresthesias, cramps or spasms of the hands and feet, and/or the Chvostek sign) in the setting of serum calcium levels lower than 8.0 mg/dL.

Primary outcome measures were postoperative calcium levels and the development of postoperative hypocalcemia (calcium levels <8.0 mg/dL). Secondary outcome measures were development of symptomatic hypocalcemia (calcium level <8 mg/dL with symptoms), length of hospital stay, and requirements for intravenous calcium.

An analysis of hospital and pharmacy charges was performed for patients in both groups using the mean number of days each patient spent in the hospital postoperatively ($3042 per day) and mean number of intravenous calcium gluconate doses required ($121 per 2-g dose). For patients receiving preoperative calcitriol and calcium supplementation, the charges for 5 days of calcitriol ($1.20 per 0.25-µg tablet; dosage 0.5 µg twice daily) and 5 days of oral calcium carbonate ($0.12 per 500-mg tablet; dosage 1500 mg 3 times daily) were calculated. These charges were then summed to determine the mean total difference in charges per patient.

Statistical Analysis

The frequency of hypocalcemia is presented as the number and percentage of patients in each group who experienced that complication. The length of hospital stay is presented as the mean (SD). Calcium levels in each group are presented as the mean preoperatively and at approximately 12 and 24 hours postoperatively. Group differences were analyzed using the χ2 test. Statistical analysis was performed with SPSS, version 20.0 (IBM Corp), using 2-tailed, paired and unpaired t tests and the Fisher exact test, where indicated.

Results
Demographics

Between January 1, 2008, and December 31, 2011, 65 patients (mean [SD] age, 49.7 [16.7] years) underwent total thyroidectomy performed by the senior author and met inclusion criteria for analysis. Of those, 33 patients received preoperative and postoperative calcium and calcitriol supplementation and 32 patients received only postoperative therapy. In the preoperative supplementation group, 22 of 33 patients (67%) were women; in the group not receiving preoperative supplementation 16 of 32 (50%) were women for a difference in sex between the 2 treatment groups of 17% (95% CI, −7% to 38%). A similar number of patients in each group underwent thyroidectomy for cancer: 29 of 33 (88%) of the preoperative supplementation group and 26 of 32 (81%) of those not receiving supplementation.

In the group receiving preoperative supplementation, 15 of 33 patients (45%) underwent central compartment neck dissection and 11 of 33 (33%) underwent lateral neck dissection. Of those without preoperative supplementation, 16 of 32 (50%) and 12 of 32 (38%) patients had central compartment and lateral neck dissections, respectively. There was no statistically significant difference in the demographic data between the 2 groups (Table 1).

Biochemical Calcium Status

Serum calcium levels were measured and recorded preoperatively and again at 12 and 24 hours postoperatively. The mean measured serum calcium level in patients without preoperative supplementation vs those with preoperative supplementation were as follows: preoperative, 9.6 vs 9.4 mg/dL (absolute difference, 0.16; 95% CI, −0.12 to 0.49); 12 hours postoperative, 8.3 vs 8.6 mg/dL (absolute difference, −0.30; 95% CI, −0.63 to 0.02); and 24 hours postoperative, 8.4 vs 8.5 mg/dL (absolute difference, −0.13; 95% CI, −0.43 to 0.16) (Figure 1). The decrease in serum calcium levels from baseline to 12 hours postoperative was significantly greater in the group that received postoperative supplementation only (absolute difference, −0.36 mg/dL; 95% CI, −0.6 to −0.05) (Figure 2). At 24 hours postoperatively, 5 of 33 (15%) patients in the preoperative supplementation group had serum calcium levels below 8.0 mg/dL vs 10 of 32 (31%) patients who did not receive preoperative supplementation for an absolute difference between the 2 groups of 16% (95% CI, −4% to 35%) (Table 2).

Clinical Calcium Status

During their postoperative course, 2 of 33 (6%) of the preoperative supplementation group became symptomatically hypocalcemic, compared with 5 of 32 (16%) in the group without preoperative supplementation for an absolute difference of 9.6% (95% CI, −6.6% to 26.3%). No patients receiving preoperative supplementation were readmitted to the hospital or visited the emergency department. In the group without preoperative supplementation, 3 of 32 (9%) patients required readmission or were seen in the emergency department for symptoms of hypocalcemia (absolute difference, 9%; 95% CI, −3% to 24%). Those who received preoperative supplementation had a mean postoperative hospital stay of 2.9 (1.4) days, which was significantly shorter by 0.9 days compared with those without preoperative supplementation who stayed a mean of 3.8 (1.8) days (95% CI, 0.11 to 1.70) (Table 2).

Hospital/Pharmacy Charge Analysis

Preoperative supplementation with calcium and calcitriol resulted in charges of $29 per patient, based on the dosage of 1500 mg of oral calcium carbonate 3 times daily and 0.5 µg of calcitriol twice daily starting 5 days before surgery. The group receiving preoperative supplementation required a total of 10 doses of intravenous calcium gluconate, which resulted in a mean charge of $37 (83) per patient. The group without supplementation required a total of 37 doses of intravenous calcium, with a mean charge of $140 (246) per patient. Assuming a hospital charge of $3042 per day, the mean charge for the hospital stay per patient receiving preoperative supplementation (mean hospital stay, 2.9 [1.4] days) was $8757. The mean charge of the hospital stay per patient not receiving preoperative supplementation (mean hospital stay, 3.8 [1.8] days) was $11 503. Both groups received similar routine postoperative oral calcium and calcitriol supplementation, so these charges were not calculated in the analysis. Thus, preoperative supplementation resulted in an estimated $2819 savings in charges per patient undergoing total thyroidectomy (Table 3).

Complications of Treatment

No patient in either group experienced symptoms of hypercalcemia. No patients experienced adverse effects of calcitriol and/or calcium supplementation. All patients reported adherence to prescribed dosing and none reported adverse symptoms.

Discussion

Transient hypocalcemia is a common complication following total thyroidectomy, occurring in up to one-half of patients,3,5 and serum calcium levels reach their nadir approximately 24 hours postoperatively. Calcitriol increases calcium absorption by promoting expression of calcium-binding protein in intestinal cells, thus increasing intestinal calcium transport across the mucosa into the blood.7 This effect on calcium absorption requires several days. Therefore, preoperative supplementation in patients undergoing thyroidectomy with calcitriol would be expected to increase the efficacy of routine calcium supplementation in the immediate postoperative period, thereby mitigating the extent of transient hypocalcemia.

The aim of this study was to examine the effect of 5 days of preoperative supplementation with calcium and calcitriol on the incidence of postthyroidectomy hypocalcemia. In this study, patients in the preoperative supplementation group received a straightforward regimen of calcium and calcitriol for 5 days immediately prior to surgery. The short time-frame allows preoperative supplementation to be accomplished without unduly delaying definitive surgical treatment of the underlying thyroid disorder. The low pharmacy charge of supplementation ($29 per patient), twice-daily dosing, and absence of reported adverse effects in this study can encourage adherence to the treatment.

This study demonstrated a significant decrease in postoperative hospital stay for patients receiving preoperative supplementation (2.9 days) compared with those who did not (3.8 days)—a mean decrease of nearly 1 full day. Although serum calcium levels in both groups decreased from baseline levels postoperatively, the decrease was 0.36 mg/dL greater in patients who did not receive preoperative supplementation, which was statistically and clinically significant. These data also demonstrate a decreased incidence of both biochemical and clinical hypocalcemia, need for intravenous calcium repletion, and hospital readmissions with the upper bound of the 95% CI consistent with as much as a 35%, 26%, 33%, and 24% reduction, respectively, in each of these factors associated with preoperative supplementation. These differences translated into significant savings in charges for the preoperative supplementation group. Based on these results, preoperative supplementation, in addition to routine postoperative supplementation, should be considered for patients undergoing total thyroidectomy.

Limitations

This study contains limitations. First, the patient population may not be representative of a typical thyroidectomy practice. This is demonstrated by the high percentage of study patients undergoing thyroidectomy for cancer (85%) and undergoing a complete central compartment neck dissection (46%) and/or lateral neck dissection (35%) in addition to total thyroidectomy. The incidence of temporary hypocalcemia has been shown to be much higher in patients with a diagnosis of cancer undergoing central compartment neck dissections or lateral neck dissections at the time of total thyroidectomy.17,18 As a result, the patient population in this study may be at greater risk of postoperative hypocalcemia and receive greater benefit from preoperative supplementation compared with a more typical patient population. Second, patients were not randomized to their respective treatment groups and preoperative supplementation was provided at the discretion of the surgeon. Although the surgeon did not use preoperative laboratory results or the planned extent of surgery to decide to prescribe preoperative supplementation, because the study was not designed as a randomized trial, there may have been a selection bias with patients presumed to be at greater risk of postoperative hypocalcemia receiving preoperative supplementation. This bias would result in a diminished observed effect of preoperative supplementation. Presumably the selection bias was minimal since the patient characteristics (cancer incidence and extent of surgery) of the 2 groups were similar. Nonetheless, future studies would benefit from randomized analysis. Third, vitamin D levels were not routinely measured preoperatively. Because patients with low vitamin D levels are more likely to develop postoperative hypocalcemia, a preponderance of these patients in either group would be expected to affect the results. Finally, to more precisely quantify the impact of preoperative supplementation, future studies may benefit from an increased sample size.

Conclusions

Preoperative calcium and calcitriol supplementation resulted in increased postoperative serum calcium levels, lower postoperative intravenous calcium repletion requirement, and less symptomatic hypocalcemia in this cohort of patients undergoing total thyroidectomy. Direct patient benefits include fewer symptoms, significantly decreased length of hospital stay, decreased hospital readmissions, and decreased charges. Benefits to society include reduction in health care costs. Weighing the safety of a short course of calcium and calcitriol supplementation against the risks associated with postthyroidectomy hypocalcemia, this study supports the use of preoperative supplementation in addition to postoperative supplementation for patients undergoing total thyroidectomy.

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Article Information

Accepted for Publication: December 24, 2016.

Corresponding Author: David C. Shonka Jr, MD, Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Box 800713, Charlottesville, VA 22908 (dcs5z@virginia.edu).

Published Online: April 13, 2017. doi:10.1001/jamaoto.2016.4796

Author Contributions: Drs Maxwell and Shonka contributed equally to the study, had full access to all the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Shonka, Levine.

Acquisition, analysis, or interpretation of data: Maxwell, Shonka, Robinson.

Drafting of the manuscript: Maxwell, Shonka.

Critical revision of the manuscript for important intellectual content: Shonka, Robinson, Levine.

Statistical analysis: Maxwell, Shonka, Robinson.

Supervision: Shonka, Levine.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Meeting Presentation: This study was presented as a poster at the Combined Sections Meeting, Triological Society; January 25, 2013; Scottsdale, Arizona.

References
1.
Erbil  Y, Bozbora  A, Ozbey  N,  et al.  Predictive value of age and serum parathormone and vitamin D3 levels for postoperative hypocalcemia after total thyroidectomy for nontoxic multinodular goiter.  Arch Surg. 2007;142(12):1182-1187.PubMedGoogle ScholarCrossref
2.
Roh  JL, Park  CI.  Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy.  Am J Surg. 2006;192(5):675-678.PubMedGoogle ScholarCrossref
3.
Testa  A, Fant  V, De Rosa  A,  et al.  Calcitriol plus hydrochlorothiazide prevents transient post-thyroidectomy hypocalcemia.  Horm Metab Res. 2006;38(12):821-826.PubMedGoogle ScholarCrossref
4.
Mehanna  HM, Jain  A, Randeva  H, Watkinson  J, Shaha  A.  Postoperative hypocalcemia—the difference a definition makes.  Head Neck. 2010;32(3):279-283.PubMedGoogle Scholar
5.
Reeve  T, Thompson  NW.  Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient.  World J Surg. 2000;24(8):971-975.PubMedGoogle ScholarCrossref
6.
Jacobs  JK, Aland  JW  Jr, Ballinger  JF.  Total thyroidectomy: a review of 213 patients.  Ann Surg. 1983;197(5):542-549.PubMedGoogle ScholarCrossref
7.
Bringhurst  FR, Demay  MB, Krane  SM, Kronenberg  HM. Bone and mineral metabolism in health and disease. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
8.
Kirkby-Bott  J, Markogiannakis  H, Skandarajah  A, Cowan  M, Fleming  B, Palazzo  F.  Preoperative vitamin D deficiency predicts postoperative hypocalcemia after total thyroidectomy.  World J Surg. 2011;35(2):324-330.PubMedGoogle ScholarCrossref
9.
Erbil  Y, Ozbey  NC, Sari  S,  et al.  Determinants of postoperative hypocalcemia in vitamin D–deficient Graves’ patients after total thyroidectomy.  Am J Surg. 2011;201(5):685-691.PubMedGoogle ScholarCrossref
10.
Erbil  Y, Barbaros  U, Temel  B,  et al.  The impact of age, vitamin D3 level, and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy.  Am J Surg. 2009;197(4):439-446.PubMedGoogle ScholarCrossref
11.
Roh  JL, Park  JY, Park  CI.  Prevention of postoperative hypocalcemia with routine oral calcium and vitamin D supplements in patients with differentiated papillary thyroid carcinoma undergoing total thyroidectomy plus central neck dissection.  Cancer. 2009;115(2):251-258.PubMedGoogle ScholarCrossref
12.
Sanabria  A, Dominguez  LC, Vega  V, Osorio  C, Duarte  D.  Routine postoperative administration of vitamin D and calcium after total thyroidectomy: a meta-analysis.  Int J Surg. 2011;9(1):46-51.PubMedGoogle ScholarCrossref
13.
Tartaglia  F, Giuliani  A, Sgueglia  M, Biancari  F, Juvonen  T, Campana  FP.  Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy.  Am J Surg. 2005;190(3):424-429.PubMedGoogle ScholarCrossref
14.
Bellantone  R, Lombardi  CP, Raffaelli  M,  et al.  Is routine supplementation therapy (calcium and vitamin D) useful after total thyroidectomy?  Surgery. 2002;132(6):1109-1112.PubMedGoogle ScholarCrossref
15.
Bordelon  P, Ghetu  MV, Langan  RC.  Recognition and management of vitamin D deficiency.  Am Fam Physician. 2009;80(8):841-846.PubMedGoogle Scholar
16.
Docimo  G, Tolone  S, Pasquali  D,  et al.  Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy.  G Chir. 2012;33(11-12):374-378.PubMedGoogle Scholar
17.
Shindo  M, Stern  A.  Total thyroidectomy with and without selective central compartment dissection: a comparison of complication rates.  Arch Otolaryngol Head Neck Surg. 2010;136(6):584-587.PubMedGoogle ScholarCrossref
18.
Roh  JL, Park  JY, Park  CI.  Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone.  Ann Surg. 2007;245(4):604-610.PubMedGoogle ScholarCrossref
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