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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 78-81

Incidence and risk factors of inadvertent parathyroidectomy during thyroid surgery: A single-center retrospective study


1 Department of Otorhinolaryngology - Head and Neck Surgery, King Abdulaziz Medical City, Jeddah, Saudi Arabia
2 Department of Otorhinolaryngology - Head and Neck Surgery, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
3 Department of Otorhinolaryngology - Head and Neck Surgery, King Abdulaziz University, Rabigh, Saudi Arabia

Date of Submission10-May-2020
Date of Decision10-Jun-2020
Date of Acceptance21-Jun-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Abdulaziz Rajeh Alanzi
Department of Otorhinolaryngology - - Head and Neck Surgery, King Abdulaziz Medical City, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJOH.SJOH_17_20

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  Abstract 


Context: Thyroidectomy is considered a relatively safe surgery with morbidity of <5% when undertaken by experienced surgeons. Inadvertent parathyroidectomy (IP) means pathology report has found parathyroid tissue in the thyroid specimen, and it was reported to range from 2.9% to 31%. Aims: The aim of this study is to measure the incidence rate and to evaluate the significant relationship between risk factors and IP during thyroid surgery. Settings and Design: A retrospective chart review study was carried out in King Fahad Armed Forces Hospital, Jeddah, between June 2015 and December 2019. Subjects and Methods: All consecutive patients undergoing unilateral or bilateral thyroidectomy were enrolled in this study. Histopathology reports were reviewed to identify the specimens that included parathyroid tissue and underlying thyroid disease, and these were compared to patients with no parathyroidectomy in terms of gender, pathological features, re-operation, Hashimoto thyroiditis, extrathyroidal extension, and central neck dissection. Statistical Analysis Used: Statistical analysis was carried out using the Statistical Package for the Social Sciences. Results: Retrospective analysis of 181 consecutive thyroidectomy cases reveals that 34 (18.7%) patients had IP. Significant risk factors for IP included extra-thyroid extension (P = 0.008), total thyroidectomy (P = 0.017), and Hashimoto thyroiditis (P = 0.021). Other risk factors, including gender, malignancy, central neck dissection, and re-operation, were not statistically significant in this study. Conclusions: IP during thyroid surgery is not uncommon (18.7%). Total thyroidectomy, hashimoto thyroiditis, and extrathyroidal extension of the tumor were found to be significant risk factors. We recommend more meticulous intra-operative identification of parathyroid glands, particularly for patients with these risk factors.

Keywords: Central neck dissection, completion thyroidectomy, during, extrathyroidal extension, Hashimoto thyroiditis, hemithyroidectomy, inadvertent, incidental, malignancy, parathyroidectomy, thyroidectomy, total thyroidectomy


How to cite this article:
Alanzi AR, Ghafouri A, Khalifa W, Hawsawi H, Alzaidi S. Incidence and risk factors of inadvertent parathyroidectomy during thyroid surgery: A single-center retrospective study. Saudi J Otorhinolaryngol Head Neck Surg 2020;22:78-81

How to cite this URL:
Alanzi AR, Ghafouri A, Khalifa W, Hawsawi H, Alzaidi S. Incidence and risk factors of inadvertent parathyroidectomy during thyroid surgery: A single-center retrospective study. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2021 Jan 20];22:78-81. Available from: https://www.sjohns.org/text.asp?2020/22/2/78/305460




  Introduction Top


Thyroidectomy is a widely performed surgery by otolaryngologists and general surgeons. It is considered a relatively safe surgery with morbidity of <5% when undertaken by experienced surgeons.[1] Major postoperative complications include permanent hypoparathyroidism (1.7%) and recurrent laryngeal nerve injury (1%).[2]

Inadvertent parathyroidectomy (IP) means pathology report has found parathyroid tissue in the thyroid specimen, and it was reported to range from 2.9% to 31%.[3] In the literature, studies aimed to determine the risk factors of IP, including type of surgery, central lymph node dissection, reoperation, malignancy, Hashimoto thyroiditis, and extrathyroidal extension. However, studies have shown variation in the significant relationship between these risk factors and IP. Therefore, identifying the parathyroid glands, preserving the blood supply, and autotransplantation are very important for avoiding postoperative permanent hypocalcemia.[3] The aim of our study is to measure the incidence rate and to evaluate the significant relationship between risk factors and IP during thyroid surgery.


  Subjects and Methods Top


After Institutional Ethics Committee approval, a retrospective chart review study was carried out in King Fahad Armed Forces Hospital, Jeddah, between June 2015 and December 2019. All consecutive patients in this 4-year period with benign and malignant thyroid diseases undergoing unilateral or bilateral thyroidectomy performed by a single surgeon were enrolled in this study. The patient records were reviewed, and data on age, gender, history of previous surgery, and details of operative and postoperative reports were recorded on data sheets. Thyroid surgery was classified into hemithyroidectomy, total thyroidectomy, and completion thyroidectomy. Simultaneous central neck dissection was included in the analysis. Pathology reports were reviewed for histological diagnosis and specifically for the presence of inadvertent parathyroid tissue. Statistical analysis was carried out using the Statistical Package for the Social Sciences SPSS software (Chicago, IL, USA). The Chi-square test was used to analyze the association between the categorical study variables and IP in terms of gender, pathological features, re-operation, Hashimoto thyroiditis, extrathyroidal extension, and central neck dissection. P ≤ 0.05 was considered statistically significant.


  Results Top


Retrospective analysis of consecutive 181 patients reveals that 34 (18.7%) patients had inadvertently removed parathyroid glands. Patient is between the age group of 13 and 87 years. Mean and standard deviation were 46.3 and 14.4, retrospectively. The majority of patients were females 161 (89%). Indication of surgery was benign in 120 (66.3%) and malignant in 61 (33.7%) patients. However, gender (P = 0.4) and malignancy (P = 0.3) were not significant risk factors for IP.

The thyroid operations carried out were hemithyroidectomy in 37 (20.4%), total thyroidectomy in 136 (75.1%), and completion thyroidectomy in 8 (4.4%) patients. IP was common in total thyroidectomy compared with other operations (P = 0.017). Central neck dissection was done in 15 patients and was not found to be significant risk factor for IP (P = 0.15) [Table 1].
Table 1: Demographic and pathological data of the patients

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Papillary thyroid cancer was found to be the most common malignancy, whereas multinodular goiter was the most common benign thyroid disease [Table 2].
Table 2: Thyroid diseases

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Of the 34 patients with IP, 7 patients have extrathyroidal extension (20.5%), and 18 patients (52.9%) have Hashimoto thyroiditis background in histopathology. Using the Chi-square test for the analysis, extrathyroidal extension (P = 0.008) and Hashimoto thyroiditis (P = 0.021) were found to be significant risk factors for IP [Table 1].


  Discussion Top


In 2018, Bai et al. published the first systematic review and meta-analysis study about the risk factors and outcomes of incidental parathyroidectomy in thyroidectomy. This systematic review includes 35 reliable similar studies.[3] Only one of them was a local study done in Saudi Arabia.[4]

As far as we know; the current study is the second local study in Saudi Arabia to determine the incidence of IP during thyroid surgery. We found that the incidence rate was 18.7% and this compares favorably with the rates reported in the previous studies (2.9%–31.0%).[3] Understanding thyroid anatomy and parathyroid glands variation with strict adherence to surgical principles is vital for an operating surgeon in any thyroid surgery. There is also variability in the number of parathyroid glands, but in most patients, there are four glands located extracapsularly, posterior to the thyroid gland. Superior parathyroid glands are usually constant in their location behind the superior pole of thyroid gland, whereas inferior parathyroid glands are more variable in its location. However, intraoperative dissection for the identification of all parathyroid glands during thyroid surgery is not necessary and sometimes could be hazardous.[5],[6]

In our study, risk factors for IP included extra-thyroid extension (P = 0.008), total thyroidectomy (P = 0.017), and Hashimoto thyroiditis (P = 0.021) [Table 1]. Bilateral dissection in total thyroidectomy puts all parathyroid glands at risk. Hashimoto thyroiditis causes the formation of scar tissue secondary to inflammation, both of which can cause dissection difficulties, leading to increased risk of IP. Extra-thyroidal extension, which occurs in malignancy, and Hashimoto thyroiditis were not found to be a risk factor in some studies.[7],[8] However, in our study, we found them to be strong predictors for IP.

In previous studies, female gender,[5] male gender,[9] younger age,[10],[11] completion thyroidectomy,[1],[12],[13],[14] central neck dissection,[11],[12],[13],[15],[16],[17],[18] and malignancy[2],[11],[18],[19],[20] were found to be risk factors for IP. However, in our study, these factors were not found to be significant risks for IP.

Incidence of IP can be affected with different operating surgeons. In our study, all thyroid surgeries were performed primarily by a single surgeon or directly under his supervision.

Statement of ethics

The study has been approved by the regional Institutional Review Board. All participants have given their consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Bergamaschi R, Becouarn G, Ronceray J, Arnaud JP. Morbidity of thyroid surgery. Am J Surg 1998;176:71-5.  Back to cited text no. 1
    
2.
Spiliotis J, Vaxevanidou A, Sergouniotis F, Tsiveriotis K, Datsis A, Rogdakis A, et al. Risk factors and consequences of incidental parathyroidectomy during thyroidectomy. Am Surg 2010;76:436-41.  Back to cited text no. 2
    
3.
Bai B, Chen Z, Chen W. Risk factors and outcomes of incidental parathyroidectomy in thyroidectomy: A systematic review and meta-analysis. PLoS One 2018;13:e0207088.  Back to cited text no. 3
    
4.
Khairy GA, Al-Saif A. Incidental parathyroidectomy during thyroid resection: Incidence, risk factors, and outcome. Ann Saudi Med 2011;31:274-8.  Back to cited text no. 4
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5.
Sakorafas GH, Stafyla V, Bramis C, Kotsifopoulos N, Kolettis T, Kassaras G. Incidental parathyroidectomy during thyroid surgery: An underappreciated complication of thyroidectomy. World J Surg 2005;29:1539-43.  Back to cited text no. 5
    
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Sheahan P, Mehanna R, Basheeth N, Murphy MS. Is systematic identification of all four parathyroid glands necessary during total thyroidectomy? A prospective study. Laryngoscope 2013;123:2324-8.  Back to cited text no. 6
    
7.
Rajinikanth J, Paul MJ, Abraham DT, Ben Selvan CK, Nair A. Surgical audit of inadvertent parathyroidectomy during total thyroidectomy: Incidence, risk factors, and outcome. Medscape J Med 2009;11:29.  Back to cited text no. 7
    
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Manatakis DK, Balalis D, Soulou VN, Korkolis DP, Plataniotis G, Gontikakis E. Incidental parathyroidectomy during total thyroidectomy: Risk factors and consequences. Int J Endocrinol 2016;2016:7825305.  Back to cited text no. 8
    
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Manouras A, Markogiannakis H, Lagoudianakis E, Antonakis P, Genetzakis M, Papadima A, et al. Unintentional parathyroidectomy during total thyroidectomy. Head Neck 2008;30:497-502.  Back to cited text no. 9
    
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Sippel RS, Ozgül O, Hartig GK, Mack EA, Chen H. Risks and consequences of incidental parathyroidectomy during thyroid resection. ANZ J Surg 2007;77:33-6.  Back to cited text no. 10
    
11.
Sorgato N, Pennelli G, Boschin IM, Ide EC, Pagetta C, Piotto A, et al. Can we avoid inadvertent parathyroidectomy during thyroid surgery? In Vivo 2009;23:433-9.  Back to cited text no. 11
    
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Lin DT, Patel SG, Shaha AR, Singh B, Shah JP. Incidence of inadvertent parathyroid removal during thyroidectomy. Laryngoscope 2002;112:608-11.  Back to cited text no. 12
    
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Youssef T, Gaballah G, Abd-Elaal E, El-Dosoky E. Assessment of risk factors of incidental parathyroidectomy during thyroid surgery: A prospective study. Int J Surg 2010;8:207-11.  Back to cited text no. 13
    
14.
Turanli S, Karaman N, Ozgen K. Permanent hypocalcemia in patients operated for thyroid carcinoma. Indian J Otolaryngol Head Neck Surg 2009;61:280-5.  Back to cited text no. 14
    
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Sasson AR, Pinpank JF Jr., Wetherington RW, Hanlon AL, Ridge JA. Incidental parathyroidectomy during thyroid surgery does not cause transient symptomatic hypocalcemia. Arch Otolaryngol Head Neck Surg. 2001;127:304–8.  Back to cited text no. 15
    
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Sitges-Serra A, Gallego-Otaegui L, Suárez S, Lorente-Poch L, Munné A, Sancho JJ. Inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid carcinoma. Surgery 2017;161:712-9.  Back to cited text no. 16
    
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Paek SH, Lee YM, Min SY, Kim SW, Chung KW, Youn YK. Risk factors of hypoparathyroidism following total thyroidectomy for thyroid cancer. World J Surg 2013;37:94-101.  Back to cited text no. 17
    
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Chew C, Li R, Ng MK, Chan ST, Fleming B. Incidental parathyroidectomy during total thyroidectomy is not a direct cause of post-operative hypocalcaemia. ANZ J Surg 2018;88:158-61.  Back to cited text no. 18
    
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Campos NS, Cardoso LP, Tanios RT, Oliveira BC, Guimarães AV, Dedivitis RA, et al. Risk factors for incidental parathyroidectomy during thyroidectomy. Braz J Otorhinolaryngol 2012;78:57-61.  Back to cited text no. 19
    
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McGoldrick DM, Majeed M, Achakzai AA, Redmond HP. Inadvertent parathyroidectomy during thyroid surgery. Ir J Med Sci 2017;186:1019-22.  Back to cited text no. 20
    



 
 
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