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Background: Multiglandular parathyroid disease, which is particularly frequent in patients with mild primary hyperparathyroidism, is a surgical challenge requiring bilateral cervicotomy with 4-gland exploration. Near-infrared autofluorescence of the parathyroid is increasingly used to prevent hypocalcemia after total thyroidectomy. However, its utility in decreasing operating time and aiding parathyroid identification during bilateral 4-gland exploration remains debated., Methods: In our prospective trial, we enrolled consecutive patients with sporadic mild primary hyperparathyroidism (serum calcium <2.85 mmol/L with elevated or nonadapted serum parathyroid hormone levels). With randomization, we assigned patients to classic parathyroidectomy or parathyroidectomy with near-infrared autofluorescence using the Fluobeam 800 device (near-infrared autofluorescence group). All procedures involved planned bilateral neck exploration conducted by 2 experienced surgeons. The primary outcome was mean operating time. Secondary outcomes included the number of visualized and excised glands, complication rates, and cure rates., Results: In total, 132 patients were included (66 per group). Mean age was 64.0 ± 12.0 years, with 85.6% female. Mean preoperative serum calcium level was 2.63 ± 0.11 mmol/L, and median serum PTH level 86.1 [65.6-109.8] pg/mL. The mean operating time did not significantly differ between the classic parathyroidectomy and near-infrared autofluorescence groups (46.9 ± 15.3 minutes and 51.2 ± 22.9 minutes, respectively, P = .21). The use of near-infrared autofluorescence did not significantly modify the number of identified or resected glands nor the rate of complications. Cure rates were similar between groups (92.2% and 94.8%; P = .72)., Conclusion: In this study, near-infrared autofluorescence, in the hands of experienced surgeons, did not reduce operating time for parathyroidectomy during bilateral neck exploration in mild primary hyperparathyroidism. Although not increasing operating time, further evaluation is needed, particularly regarding its role in the surgeon's training., Competing Interests: Conflict of Interest/Disclosure The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Hypocalcemia is the most common postoperative complication of total thyroidectomy. Near-infrared autofluorescence (NIRAF) technology is a surgical adjunct that has been increasingly utilized with the aim of preventing postoperative hypocalcemia, but its clinical benefits have not yet been firmly established. The aim of this study was to assess the clinical benefit of utilizing NIRAF technology in patients undergoing total thyroidectomy., Methods: A systematic review and meta-analysis of randomized clinical trials was performed according to PRISMA guidelines., Results: Seven randomized clinical trials with 1437 patients (318 males, 22.13%) undergoing total thyroidectomy were included for analysis. Risk of postoperative hypocalcemia was reduced in the NIRAF arm (RR, 0.65; 95%CI, 0.50-0.84). Use of NIRAF was also associated with a reduction in the risk of permanent parathyroid dysfunction (RR, 0.46; 95%CI, 0.22-0.95) and inadvertent parathyroid gland resection (RR, 0.40; 95%CI, 0.26-0.60)., Conclusions: We present a systematic review and meta-analysis of randomized clinical trials examining the impact of NIRAF technology on preservation of parathyroid function. Our results suggest that use of camera-based NIRAF technology reduces the risk of postoperative hypocalcemia, permanent parathyroid dysfunction, and inadvertent parathyroid gland resection., (© 2024 Wiley Periodicals LLC.)

Background: One of the most common complications of total thyroidectomy is post-operative transient or persistent hypoparathyroidism that can cause symptomatic hypocalcaemia. To prevent this complication, shorten the period of hospitalization and reduce morbidity, routine supplementation of oral vitamin D and calcium has been suggested. This systematic review and meta-analysis aims to critically assess the association between pre-operative calcitriol supplementation and post-operative hypocalcaemia., Methods: Randomized controlled trial studies were identified by searching PubMed, Scopus, and Google Scholar databases up to 30 March 2023. Screening of titles, abstracts, and full texts of articles were performed, and data were extracted for a meta-analysis., Results: This meta-analysis includes data from nine randomized controlled trials with a total of 1259 patients but with significant heterogeneity. The results demonstrate that calcium levels were higher in patients who had pre-operative calcitriol supplementation, with a weighted mean difference (WMD) 0.18 (95% confidence interval (CI) = 0.00, 0.37). Pre-operative calcitriol supplementation did not lead to significant changes in parathyroid hormone (PTH) levels, with WMD -0.49 (95% CI: -1.91, 0.94)., Conclusion: Pre-operative calcitriol supplementation leads to higher calcium levels, but the high heterogeneity of the included studies (79% to 98.7%) could affect the results., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Thyroid surgeries are intricate operations that carry the risk of damaging the parathyroid glands, which can result in hypocalcemia and potential long-term hypoparathyroidism. Innovative surgical techniques including Intraoperative Nanocarbon Staining (INS), aim to enhance the preservation of parathyroid glands. This study assesses the effectiveness of INS combined with parathyroid autotransplantation in reducing postoperative complications and preserving parathyroid function., Methods: This retrospective cohort study assessed patients aged ≥ 18 who underwent thyroid surgery at a tertiary care hospital from January 2017 to December 2022. We compared the incidence of postoperative parathyroid injury, recovery rates of parathyroid function, and the incidence of permanent hypoparathyroidism between groups. Data on patient demographics, diagnosis, surgical details, parathyroid hormone levels, and calcium levels were collected and analyzed using chi-square tests, t-tests, and logistic regression., Results: The study included 198 patients, with 101 in the intervention group and 97 in the control group. Baseline characteristics such as sex ratio, age, BMI, and preoperative calcium levels showed no significant differences between groups. The intervention group demonstrated a significantly shorter duration of intravenous calcium supplementation (median 2 vs. 3 days, p < 0.001) and higher calcium nadir levels (median 8.36 vs. 7.85 mg/dL, p < 0.001) compared to controls. Furthermore, the incidence of postoperative parathyroid injury and permanent hypoparathyroidism was lower in the intervention group (15.84% vs. 20.62%, p = 0.045 and 4.95% vs. 15.46%, p = 0.003, respectively). Multivariate analysis revealed factors such as Blood iPTH monitoring level (OR 1.053, 95% CI 1.009-1.099, P = 0.018) and surgery type (Near Total Thyroidectomy) (OR 0.447, 95% CI 0.202-0.990, P = 0.047) were positively associated with surgical success. The intervention group also showed higher surgery success rates (OR 2.054, 95% CI 1.017-4.150, P = 0.045)., Conclusion: The application of INS and parathyroid autotransplantation during thyroidectomy significantly improves postoperative parathyroid gland function, reducing the incidence of permanent hypoparathyroidism. These findings support the incorporation of these techniques into standard surgical practice for thyroidectomy., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the Ethics Committee of the People’s Hospital of Suzhou New District (approval number 2024-092), with all procedures performed in accordance with ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. No other ethical statement is required. Due to the retrospective nature of this study, the requirement for informed consent was waived, contingent upon the anonymization of patient data. Clinical trial number not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Hypocalcemia after total thyroidectomy is a frequent complication that can be predicted and best managed by the postoperative measurement of parathyroid hormone levels., Methods: This study included consecutive patients who underwent total thyroidectomy between 2017 and 2022. Hypocalcemia was defined as serum calcium <8.0 mg/dL and hypoparathyroidism as parathyroid hormone <15 pg/mL. After comparing serum calcium levels on postoperative day 1 and intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy in the first period, an algorithm involving routine postoperative oral calcium and alfacalcidol administration in patients with intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy <20 pg/mL was developed and tested during the second period. The rates of symptomatic hypocalcemia, readmission for hypocalcemia, and permanent hypoparathyroidism were compared between the 2 periods., Results: In the first period, 1,965 total thyroidectomies (1,548 women; mean age, 51 years) were performed, including 617 patients (31%) with central neck dissection for thyroid carcinoma. Of 314 patients (16%) who experienced symptomatic hypocalcemia, only 183 (58%) could be predicted using serum calcium levels on postoperative day 1 <8.0 mg/dL. This rate increased to 96% (301 patients) when using intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy and serum calcium levels on postoperative day 1 (P < .001). Intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy alone could predict symptomatic hypocalcemia in 90% (282) of patients. Hypoparathyroidism was permanent in 20 patients (1%), with a greater predictive value of intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy over serum calcium levels on postoperative day 1 (18/20 [90%] vs 8/20 [40%], P < .01). Using the intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy-based algorithm and preventive calcium supplementation in the second period of the study, 1,420 total thyroidectomies (1,106 women; mean age, 50 years) were performed, including 392 (28%) cases with central neck dissection for thyroid carcinoma. Only 2.3% (32) patients developed a symptomatic hypocalcemia compared with 16% during the first period (P < .001). Thirty-eight patients (2.7%) experienced readmission after total thyroidectomy before implementation of the supplementation protocol in our study compared with 2 patients (0.01%) after we began using the protocol (P < .001). There was no significant difference in permanent hypoparathyroidism between the 2 periods (1.3% vs 1%) (P = .8)., Conclusions: The parathyroid hormone-based algorithm determined by intraoperative parathyroid hormone levels 20 minutes after total thyroidectomy and routine preventive administration of oral calcium/calcitriol reduced the risk of symptomatic hypocalcemia and readmission after total thyroidectomy., Competing Interests: Conflict of Interest/Disclosure The authors have no relevant financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The risk of hypoparathyroidism and hypocalcemia is a critical concern in thyroid surgery. Preserving parathyroid gland vascularization during surgery is essential for effective prevention. Preoperative and postoperative management, including calcium and Vitamin D supplementation, is paramount. Measurement of parathyroid hormone levels after surgery is the best predictor of hypoparathyroidism. This guideline offers recommendations for the prevention, diagnosis, and treatment of acute hypoparathyroidism and hypocalcemia after thyroid surgery., (© 2024 Wiley Periodicals LLC.)

Purpose: Hypocalcemia is associated with increased mortality in trauma patients with hemorrhagic shock who require massive transfusion protocols (MTPs). Despite known risks of potentiating hypocalcemia with blood product administration, there is little research discussing appropriate calcium replacement. The purpose of this study was to evaluate the ability of a standardized calcium replacement protocol to reduce the incidence of hypocalcemia in trauma patients undergoing MTP., Methods: This retrospective, single-center, pre-post study evaluated the use of a calcium replacement protocol during MTP. Adult trauma patients with MTP orders who received at least one "round" of product transfusion were included. Patients were excluded if their ionized calcium (iCa) levels were unavailable or they were transferred to a higher level of care within 4 hours of presentation. The primary outcome was incidence of hypocalcemia (iCa of <1.1 mg/dL) within 24 hours of MTP initiation. Secondary endpoints included the incidence of severe hypocalcemia (iCa of <0.9 mg/dL), time to first calcium dose, total calcium dose administered (mEq), resolution of hypocalcemia within 24 hours, hypercalcemia, adherence to the calcium replacement protocol, and mortality., Results: The incidence of hypocalcemia within 24 hours was significantly lower in the postprotocol group (63% vs 95.2%; P = 0.006). There was not a significant difference in the incidence of severe hypocalcemia between the groups (39.1% vs 69.1%; P = 0.083). Time to first calcium dose was significantly shorter in postprotocol patients compared to preprotocol patients (median [interquartile range], 5.5 [0-21] minutes vs 43 [22.8-73] minutes; P < 0.0001), and postprotocol patients were administered more calcium during MTP (40.8 [27.2-54.4] mEq vs 27.2 [14-32.2] mEq; P = 0.005). Adherence to the protocol was seen in only 37% of patients in the postprotocol group. There was no difference in the rate of adverse events or overall mortality., Conclusion: Trauma patients who received massive transfusion of blood products had a significantly lower incidence of hypocalcemia after a calcium replacement protocol was implemented., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: The preservation of parathyroid glands is crucial in endoscopic thyroid surgery to prevent hypocalcemia and related complications. However, current methods for identifying and protecting these glands have limitations. We propose a novel technique that has the potential to improve the safety and efficacy of endoscopic thyroid surgery., Purpose: Our study aims to develop a deep learning model called PTAIR 2.0 (Parathyroid gland Artificial Intelligence Recognition) to enhance parathyroid gland recognition during endoscopic thyroidectomy. We compare its performance against traditional surgeon-based identification methods., Materials and Methods: Parathyroid tissues were annotated in 32 428 images extracted from 838 endoscopic thyroidectomy videos, forming the internal training cohort. An external validation cohort comprised 54 full-length videos. Six candidate algorithms were evaluated to select the optimal one. We assessed the model's performance in terms of initial recognition time, identification duration, and recognition rate and compared it with the performance of surgeons., Results: Utilizing the YOLOX algorithm, we developed PTAIR 2.0, which demonstrated superior performance with an AP50 score of 92.1%. The YOLOX algorithm achieved a frame rate of 25.14 Hz, meeting real-time requirements. In the internal training cohort, PTAIR 2.0 achieved AP50 values of 94.1%, 98.9%, and 92.1% for parathyroid gland early prediction, identification, and ischemia alert, respectively. Additionally, in the external validation cohort, PTAIR outperformed both junior and senior surgeons in identifying and tracking parathyroid glands (p < 0.001)., Conclusion: The AI-driven PTAIR 2.0 model significantly outperforms both senior and junior surgeons in parathyroid gland identification and ischemia alert during endoscopic thyroid surgery, offering potential for enhanced surgical precision and patient outcomes., (© 2024 Wiley Periodicals LLC.)

Introduction: Postoperative hypocalcaemia is common after thyroidectomy. This study aimed to evaluate whether a standardised post-thyroidectomy protocol using prophylactic calcium and calcitriol reduces hypocalcaemia incidence after total thyroidectomy in children and adolescents., Methods: A cohort children and adolescents ≤18 years of age undergoing total thyroidectomy between January 2016 and October 2022 in one institution were retrospectively identified and divided into pre-protocol and post-protocol groups. The primary outcome measure was hypocalcaemia (total serum calcium of <2.0 mmol/L; ionised serum calcium of 0.9 mmol/L). Secondary outcome measures were the occurrence of hypercalcaemia (serum Calcium >2.7 mmol/L; ionised calcium >1.31 mmol/L), length of hospitalisation and number of postoperative blood tests., Results: There were 22 patients in each group (mean age 11.8; SD 4.3 years, female 36 %). The rate of hypocalcaemia was significantly higher in the pre-protocol group than the post-protocol group (54 % vs 13.6 %, p = 0.010). Patients in the pre-protocol group had more inpatient blood tests (mean 5.4; SD 3.2) than the post-protocol group (mean 3.3; SD 1.8, p = 0.011), although the total postoperative blood test count was similar between the groups. Six (13.6 %) patients developed hypercalcaemia. The rate of hypercalcaemia was similar between groups (pre-protocol 2, 9.1 %; post-protocol 4, 18.1 %; p = 0.664). Length of hospitalisation was similar between groups., Conclusion: Our standardized protocol decreased hypocalcemia and inpatient blood tests after total thyroidectomy in children. Future research should explore if incorporating preoperative calcium and calcitriol treatment, along with intraoperative PTH levels for risk management, can further reduce hypocalcemia rates in paediatric patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Severe and/or symptomatic hypocalcemia due to hypoparathyroidism is the main contraindication for discharge in patients who have undergone thyroid surgery. Hypomagnesemia may contribute to the onset of hypoparathyroidism and is frequently observed after thyroid surgery in hypocalcemic patients. The impact of prophylactic and postoperative Magnesium supplementation on postoperative hypocalcemia and hypomagnesemia was prospectively evaluated by comparing patients undergoing prophylactic supplementation to a control group of patients who had only received magnesium after evidence of postoperative hypomagnesemia., Methods: One hundred and twenty patients who underwent a total thyroidectomy participated in the study. Seventy-three patients were included in the study group, 47 in the control group. Prior to surgery, patients in the study group were given magnesium orally for 5 days; postoperatively, calcium and magnesium was administered to all patients who displayed hypocalcemia and hypomagnesemia., Results: Postoperative biochemical hypocalcemia (serum calcium <8.5 mg/dL, regardless of its clinical severity) was found in 60 patients (50%) on D1 and in 58 patients (48.4%) on D2. Among hypocalcemic patients, hypomagnesemia was recorded in 29 at D1 (48%), and in 46 at D2 (79%). A significant positive correlation was found between magnesium, calcium, and parathyroid hormone in the first two postoperative days, while a significant inverse correlation occurred for these same parameters and length of hospital stay (P<0.001). One hundred and five patients (87.5%) were discharged as expected on the second postoperative day (65 in the study group, 40 in the control group, P=0.724), whereas 15 patients (12.5%) required prolonged hospitalization (eight in the study group, seven in the control group, P=0.721). The Study group only showed significantly higher magnesium levels on the first postoperative day (P=0.03)., Conclusions: Although magnesium and calcium levels showed the same trend after thyroidectomy, neither Magnesium prophylaxis nor Magnesium treatment influenced the clinical course of postoperative hypocalcemia.

Background: The added benefit of using near-infrared autofluorescence (NIRAF) during total thyroidectomy (TT) remains controversial. This study investigated whether or not NIRAF results in improved patient outcomes postoperatively., Materials and Methods: We analyzed 1711 TT patients, reported in nine randomized controlled trials, following a systematic search of five databases. NIRAF was compared to the standard of care (naked eye with/without white light). Outcomes included parathyroid gland (PG) and calcium parameters and other clinical outcomes. For dichotomous outcomes, the log odds ratio (logOR) was calculated, and for continuous outcomes, the crude mean difference (MD) was measured. Sensitivity analysis was performed when heterogeneity was significant. The revised Cochrane risk of bias tool was used to assess the methodological quality., Results: Compared to the standard of care, the use of NIRAF was associated with a significant reduction in postoperative hypoparathyroidism [logOR=-0.31; 95% CI: -0.57: -0.05], inadvertent PG removal [logOR=-0.93; 95% CI: -1.60: -0.26], and postoperative hypocalcemia [logOR=-0.43 mmol/l; 95% CI: -0.77: -0.09]. It was also associated with significantly higher postoperative PTH levels [MD=4.78 pg/ml; 95% CI: 2.13: 7.43], PG identification rate [logOR=1.02; 95% CI: 0.31: 1.72], postoperative serum calcium [MD=0.05; 95% CI: 0.00: 0.09], and operative time [MD=9.38 min; 95% CI: 6.68: 12.09]. No difference was seen regarding PG autotransplantation, length of hospital stay, and hospitalization due to hypocalcemia. Seven trials had low risk and the remainder had some concerns., Conclusion: NIRAF is superior to the naked eye in identifying all four PGs during TT. The reduced risk of postoperative hypoparathyroidism and hypocalcemia reflected this preservation value. However, it was not associated with a change in the length of hospital stay. Although rare, the readmission rate due to hypocalcemia was similar across both methods., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Although active vitamin D (VD) has been used both preoperatively and postoperatively to prevent hypocalcemia risk in patients undergoing total thyroidectomy, the role of 1,25-dihydroxyvitamin D (1,25(OH) 2 D) has not been examined. This study comprehensively investigated the effects of 1,25(OH) 2 D on calcium (Ca) concentrations after total thyroidectomy., Methods: Serum Ca, parathyroid hormone (PTH), and 1,25(OH) 2 D levels were measured in 82 patients with thyroid disease before and after surgery., Results: Serum Ca, PTH, and 1,25(OH) 2 D levels decreased significantly on the morning of the first postoperative day. Notably, the decrease in 1,25(OH) 2 D concentration was significantly lower than that of PTH concentration (10.5 ± 33.4% vs. 52.1 ± 30.1%, p<0.0001), with 28% of patients showing increases in 1,25(OH) 2 D. The only factor predicting a postoperative 1,25(OH) 2 D decrease was a high preoperative 1,25(OH) 2 D concentration. Postoperative 1,25(OH) 2 D concentrations, as well as the magnitude and rate of decrease from preoperative levels, showed strong positive correlations with preoperative 1,25(OH) 2 D concentrations (p<0.0001 for all three variables) but not with PTH concentrations. These findings suggest that 1,25(OH) 2 D concentrations after thyroidectomy were more strongly dependent on preoperative concentrations than on the effect of PTH decrease and were relatively preserved, possibly preventing sudden severe postoperative hypocalcemia. A high 1,25(OH) 2 D level was the most important preoperative factor for hypocalcemia (<2 mmol/L; p<0.05) on the first postoperative day; however, only PTH decrease was statistically significant (p<0.001) when intraoperative factors were added. In the PTH >10 pg/mL group, the decrease in 1,25(OH) 2 D levels was significantly associated with postoperative hypocalcemia (p<0.05). Similarly, in the PTH levels >15 pg/mL group, a decrease in 1,25(OH) 2 D concentration was a significant factor, and the amount of PTH decrease was no longer significant., Conclusion: 1,25(OH) 2 D plays an important role in preventing sudden, severe hypocalcemia due to decreased PTH levels after total thyroidectomy, whereas high preoperative 1,25(OH) 2 D levels are a significant risk factor for postoperative hypocalcemia. Optimizing preoperative protocols to adjust Ca, PTH, and 1,25(OH) 2 D levels to improve the management of patients undergoing total thyroidectomy and to prevent extreme intraoperative PTH decreases may reduce the risk of hypocalcemia., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Yamashita, Mori, Sato, Shindo, Yoshimoto, Tachibana, Fukuda and Takahashi.)

Minimally invasive thyroidectomy (MIT) is increasingly being used for the thyroid tumors. The comparison of bilateral axillo-breast approach robotic thyroidectomy (BABART) with other MIT has not yet led to a unified conclusion with regard to surgical outcomes. To conduct a systematic review and meta-analysis of the literature on the surgical outcomes of BABART compared with MIT. We performed a systematic search in PubMed, Web of Science, Embase and Cochrane Library database for randomized control trials (RCTs) and non-RCTs that compare BABART to MIT. The primary outcomes included perioperative, postoperative complications. The odds ratio (OR) and mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CIs). Nine studies, comprising 3645 patients, were included in the meta-analysis. Our findings indicated that there were no significant differences in hospital stay, number of retrieved lymph nodes, recurrent laryngeal nerve (RLN) injury, and vocal cord dysfunction between BABRT and MIT. However, BABART was associated with a shorter operation time (MD =  - 21.45 min, 95% CI [- 47.27, 4.38], p = 0.1) and lower rate of permanent hypoparathyroidism (OR = 0.42, 95% CI [0.20, 0.88], p = 0.02). Additionally, the MIT group had reduced postoperative pain score (MD = 0.45, 95% CI [0.02, 0.88], p = 0.04) and lower rate of hypocalcemia (OR = 2.31, 95% CI [1.04, 5.13], p = 0.04) than the BABART group. In comparison with MIT, BABART exhibits better results in terms of operative time and the rate of permanent hypoparathyroidism, with no significant difference in hospital stay, number of retrieved lymph nodes, RLN injury, and vocal cord dysfunction. However, the postoperative pain score and the rate of hypocalcemia of MIT are slightly better that of BABART., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: The purpose of this study was to investigate the impact of autofluorescence technology on postoperative parathyroid function and short-term outcomes in patients undergoing thyroid surgery., Methods: A total of 546 patients were included in the study, with 287 in the conventional treatment group and 259 in the autofluorescence group. Both groups underwent central lymph node dissection, which is known to affect parathyroid function. Short-term outcomes, including rates of postoperative hypocalcemia and parathyroid dysfunction, serum calcium and PTH levels on the first postoperative day, as well as the need for calcium supplementation, were analyzed. A multivariable analysis was also conducted to assess the impact of autofluorescence on postoperative parathyroid dysfunction, considering factors such as age, BMI, and preoperative calcium levels., Results: The autofluorescence group demonstrated significantly lower rates of postoperative hypocalcemia and parathyroid dysfunction compared to the conventional treatment group. The autofluorescence group also had better serum calcium and PTH levels on the first postoperative day, and a reduced need for calcium supplementation. Surprisingly, the use of autofluorescence technology did not prolong surgical time; instead, it led to a shorter hospitalization duration. The multivariable analysis showed that autofluorescence significantly reduced the risk of postoperative parathyroid dysfunction, while factors such as age, BMI, and preoperative calcium levels did not show a significant correlation., Conclusion: This study provides evidence that autofluorescence technology can improve the preservation of parathyroid function during thyroid surgery, leading to better short-term outcomes and reduced postoperative complications. The findings highlight the potential of autofluorescence as a valuable tool in the management of parathyroid hypofunction. Further research and validation are needed to establish the routine use of autofluorescence technology in the thyroid., (© 2024. The Author(s).)

Objective: To investigate whether perioperative calcium and 1,25 OH vitamin D supplementation (PCDS) influences the rates of postoperative hypocalcemia and length of stay (LOS) following pediatric thyroidectomy., Study Design: Retrospective Cohort Review., Setting: Tertiary children's hospital., Methods: 94 patients who underwent completion or total thyroidectomy with or without concomitant neck dissection from 2010 to 2020 at a single institution were included. Patients with pre-existing hypocalcemia or preoperative vitamin D insufficiency were excluded. Rates of postoperative hypocalcemia and LOS were compared for patients receiving PCDS to those receiving no supplementation., Results: Thirty percent of patients with PCDS had documented postoperative hypocalcemia compared to 64% of patients without PCDS (p = 0.01). Patients with PCDS had a median LOS of 30 h compared to 36 h (p = 0.002). Multivariable analyses confirmed that patients with PCDS had lower odds of postoperative hypocalcemia (OR: 0.32, CI: 0.11, 0.89) and shorter LOS by 17 h (SE: 8, p = 0.04) after adjustment for confounders., Conclusion: PCDS is associated with significantly lower risk of hypocalcemia and shorter LOS. Standardizing preoperative care for pediatric patients undergoing thyroidectomy may decrease variability and improve outcomes following surgery., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Hypocalcemia following thyroidectomy is a common and potentially life-threatening complication. It is caused by intraoperative injury to the parathyroid glands or their blood supply. Although several studies have shown that patients with a prior history of bariatric surgery may be at an increased risk for hypocalcemia after thyroidectomy, no clear recommendations exist for preventing and managing this condition in this population. This paper highlights the significance of understanding this risk and of obtaining a history of prior bariatric surgery before thyroidectomy. We propose concise recommendations for preventing and managing hypocalcemia following thyroidectomy in patients with a history of bariatric surgery., (© 2023 The Authors. Otolaryngology-Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Background: This study aimed to assess the benefits and limitations of four intraoperative visualization of parathyroid gland (IVPG) strategies in the identification and functional protection of parathyroid glands (PGs)., Methods: We searched PubMed, the Cochrane Central Register of Controlled Trials, CNKI, EMBASE, Web of Science and Google Scholar databases until 30 June 2023. Four IVPG strategies were composed of the naked eyes (NE) and three imaging strategies: autofluorescence (AF), indocyanine green fluorescence (ICGF), and carbon nanoparticles (CN). We performed a pairwise meta-analysis (PMA) for direct comparisons and a Bayesian network meta-analysis (NMA) for indirect comparisons., Results: A total of 29 eligible studies were included. According to NMA and PMA, AF had significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, PG inadvertent resection, and PG auto-transplantation compared to NE, while had significantly higher rate of PG identification. CN showed significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, and PG inadvertent resection compared to NE in PMA and NMA. ICGF showed a significantly higher rate of PG auto-transplantation compared to NE in PMA and AF in NMA. According to SUCRA values, AF showed the best advantage in reducing the rate of postoperative hypocalcemia (0.85) and PG inadvertent resection (0.89), and increasing the rate of PG identification (0.80). CN had the greatest advantage in reducing the rate of postoperative hypoparathyroidism (0.95). ICGF ranked the highest in the rate of PG auto-transplantation (0.98)., Conclusions: Three imaging strategies demonstrate significant superiority over NE in the intraoperative PG identification and functional protection. AF is the best strategy in reducing the incidence of postoperative hypocalcemia, increasing the rate of PG identification, and reducing the rate of PG inadvertent resection and auto-transplantation. ICGF has great value in assessing PG viability, leading to the trend towards PG auto-transplantation. CN is the best strategy in reducing the incidence of postoperative hypoparathyroidism., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Bone metastases are frequently observed in advanced cancer, and bone modifying agents are used to prevent or treat skeletal-related events. Zoledronic acid is contraindicated in patients with severe renal impairment (Ccr < 30 mL/min), but it is not completely known whether denosumab can be used in them. We aimed to determine the association between renal function and hypocalcemia development during denosumab treatment., Methods: We included patients with solid cancer and bone metastases who started denosumab treatment between April 2017 and March 2019. They were classified into four groups based on creatinine clearance (Ccr; mL/min): normal (Ccr ≥ 80), mild (50 ≤ Ccr ˂80), moderate (30 ≤ Ccr ˂50), and severe (Ccr ˂30). Hypocalcemia was evaluated using the Common Terminology Criteria for Adverse Events (v5.0) based on the albumin-adjusted serum calcium levels; its incidence (stratified by renal function) and risk factors were investigated using a Chi-square test and logistic regression analysis., Results: Of 524 patients (age: 69 ± 11 years; 303 men), 153 had a normal renal function and 222, 117, and 32 had mild, moderate, and severe renal dysfunction. The albumin-adjusted serum calcium level was higher than the measured (total) calcium level in most patients. The incidence of grade ≥ 1 hypocalcemia was 32.0% in the normal group and 37.4%, 29.9%, and 62.5% in the mild, moderate, and severe renal dysfunction groups, respectively. It was, therefore, higher in the severe renal dysfunction groups than in the normal group (P = 0.002). The incidence of grade ≥ 3 hypocalcemia did not differ significantly among the groups. Pre-treatment low serum calcium levels and severe renal dysfunction were risk factors for hypocalcemia., Conclusions: Evaluating denosumab-induced hypocalcemia required albumin adjustment, and its incidence was high among patients with severe renal dysfunction. Reduced serum calcium levels and severely impaired renal function were associated with an elevated hypocalcemia risk., (© 2024. The Author(s).)

Patients undergoing thyroidectomy often develop hypocalcemia. While there is evidence suggesting that the prophylactic administration of dexamethasone in patients undergoing thyroidectomy can reduce the risk of postoperative complications including nausea, vomiting, and pain, it remains uncertain as to whether such treatment has a similar impact on hypocalcemia risk. Here, randomized controlled trials (RCTs) focused on comparing the risk of postoperative hypocalcemia in thyroidectomy patients that either were or were not administered a single preoperative dose of dexamethasone were systematically evaluated. These RCTs were identified by searching the Medline, PubMed, Embase, and Cochrane Library for all relevant publications as of April 2023. Primary study outcomes included biochemical hypocalcemia and symptomatic hypocalcemia incidence within 24 h after thyroidectomy, while the incidence of permanent hypocalcemia was a secondary outcome in this analysis. Random-effects models were used for all comparisons in this meta-analysis. In total, 8 RCTs enrolling 1666 patients were incorporated when conducting this meta-analysis. Relative to placebo control treatment, dexamethasone administration was associated with significant reductions in the rates of postoperative symptomatic hypocalcemia (OR = 0.40; 95%CI 0.16-1.00; p  = 0.050) and biochemical hypocalcemia (OR = 0.34;95%CI 0.14-0.83; p  = 0.020 ( p  < 0.05). No differences were detected between these groups with respect to the incidence of permanent hypocalcemia, and no trials revealed any evidence of glucocorticoid-associated complications. Significant heterogeneity was detected among studies, but the exclusion of any single study did not significantly alter study outcomes. The present pooled analyses suggested that one preoperative dexamethasone dose was sufficient to reduce the odds of thyroidectomy patients developing biochemical or symptomatic hypocalcemia within 24 h after the procedure. The prophylactic administration of steroids was both safe and effective, suggesting that it warrants consideration as a component of routine clinical care. However, additional prospective work will be vital to validate the efficacy of dexamethasone as a means of preventing objective hypocalcemia in this patient population.

Background: Prophylactic central neck dissection (pCND) remains controversial during the initial surgery for preoperative and intraoperative node-negative (cN0) papillary thyroid carcinoma (PTC)., Methods: Patients undergoing thyroidectomy with or without pCND (Nx) for PTC in nine French surgical departments, registered in the EUROCRINE® national data in France between January 2015 and June 2021, were included in a cohort study. Demographic and clinicopathological characteristics, complications, and recurrence rates were compared using multivariate regression analysis., Results: A total of 1905 patients with cN0 PTC were enrolled, including 1534 who had undergone pCND and 371 who hadn't (Nx). Of these, 1546 (81.2%) were female, and the median age was 49 years (range: 15-89 years). Patients who had undergone pCND were more likely to have multifocal tumors (n = 524 [34.2%] vs. n = 68 [18.3%], p < .001) and larger tumors (15.3 vs. 10.2 mm, p = .01) than patients with Nx. Of the patients with pCND, 553 (36%) had positive central LN (N1a), with a median of 1 N1 (IQR 0-5). pCND was associated with a higher temporary hypocalcemia rate (n = 25 [8%] vs. n = 15 [4%], p < .001). The rates of permanent hypocalcemia and temporary and permanent recurrent laryngeal nerve (RLN) palsy were not significantly different between the two groups (p > .2). After adjusting for covariates (age, sex, multifocality, and pathological T stage) in a multivariable Cox PH model, the performance of lymph node dissection (pCND vs. no-pCND) was not associated with PTC recurrence (p = .2)., Conclusion: pCND in PTC does not reduce recurrence and is associated with a two-fold increase in the incidence of transient hypoparathyroidism. These data should be considered while issuing further guidelines regarding the treatment of patients with cN0 PTC., (© 2024 The Authors. Cancer Reports published by Wiley Periodicals LLC.)

Symptoms of hypocalcemia are reported in up to 50% of patients undergoing leukapheresis procedures. There is no set standard of practice for administering calcium supplementation in the prevention or treatment of hypocalcemia symptoms. The goal of this descriptive, retrospective study was to determine the prevalence of baseline hypocalcemia and symptomatic hypocalcemia during leukapheresis with acid citrate dextrose solution A and to identify patient characteristics associated with symptomatic hypocalcemia. Three percent of patients were found to have hypocalcemia before leukapheresis with 35% experiencing hypocalcemia symptoms during leukapheresis. Older age, higher albumin levels, and longer procedure time were associated with increased risk of hypocalcemia symptoms., (© 2023 Wiley Periodicals LLC.)

Milk fever is one of the most historically relevant diseases of dairy cows. It is caused by tremendous calcium (Ca) expenditure at the initiation of lactation, so severe that cows can no longer stand and, if left untreated, die. Fortunately, through prepartum nutritional improvements, this version of clinical hypocalcemia is rare in the United States. Nonetheless, the opinion that all versions of postpartum hypocalcemia are detrimental remains pervasive, which is particularly significant given that 50% of cows are subclinically hypocalcemic after calving. This has led to a variety of available management and treatment strategies, ranging from prepartum dietary programs to postpartum Ca gels and boluses, targeted at preventing hypocalcemia in dairy cows. Recent research has determined that postpartum dairy cows can experience different types of subclinical hypocalcemia: transient, persistent, or delayed. We now know cows experiencing transient hypocalcemia as part of the homeorhetic adaptation to lactation are the highest milk producers in modern dairy herds, whereas cows with hypocalcemia several days after calving experience disease and losses in milk production. Therefore, it is wrong to assume all postpartum hypocalcemia is detrimental and that treatment of all cases is considered necessary and beneficial. Research indicates that milk synthesis at the onset of lactation contributes to immediate postpartum hypocalcemia, and that the mammary gland is a critical factor in management of Ca homeostasis. However, cows differ in their ability to manage this phenomenon, and it is possible that immediate postpartum influences such as dry matter intake, inflammation, and immune activation affect appropriate Ca regulation in the days following calving., (© 2023, The Authors. Published by Elsevier Inc. and Fass Inc. on behalf of the American Dairy Science Association®. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).)

Objective: More than 30,000 thyroid surgeries are performed annually in the Russian Federation. The surgeries are relatively safe because of the prevention methods for postoperative complications. Currently, there is no single effective method of postoperative hypoparathyroidism prevention. This complication is frequently reported and may be health and life-threatening., Aim: We aimed to estimate the effectiveness of the intraoperative ICG-angiography and intrathyroid injection of Brilliant Green for the prevention of postoperative hypoparathyroidism., Material and Methods: One hundred and forty-three thyroidectomies were performed. Patients were divided into three groups: intraoperative angiography was used in 24 cases; Brilliant Green was injected in 58 cases to identify parathyroid glands; the visual estimation of the parathyroid preservation was used in 61 cases. Calcium level was measured in all patients before and after surgery., Results: Calcium level in the serum before and after surgery was 2.37±0.14 and 2.27±0.17 in Group 1, 2.38±0.16 and 2.21±0.16 in Group 2, and 2.39±0.17 and 2.18±0.19 in Group 3. Postoperative hypocalcemia was more prominent in the group with the visually estimated PTG than in the two other groups. The differences in postoperative calcium levels in Groups 1 and 3 were statistically different. Pre- and postoperative Parathormone levels were 6.2±0.4 in Group 1, 5.6±0.57 in Group 2, and 3.5±0.32 in Group 3. Postoperative levels significantly differed in Groups 1 and 3 (p<0.01) and in Groups 2 and 3 (p<0.05)., Conclusions: ICG-angiography and intrathyroid injection of the Brilliant Green are safe methods of identification and sparing of the parathyroid glands. The severity of hypocalcemia and hypoparathormonemia in Group 3 shows the necessity of finding new methods in endocrine surgery to improve patient outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Vabalayte, Romanchishen and Somova.)

Introduction: Blood component resuscitation is associated with hypocalcemia (HC) (iCal <0.9 mmol/L) that contributes to coagulopathy and death in trauma patients. It is unknown whether or not whole blood (WB) resuscitation helps mitigate the risk of HC in trauma patients. We hypothesized that calcium homeostasis is maintained and mortality improved in patients who only receive WB., Materials and Methods: This is a retrospective review of all adult trauma patients who received WB from July 2018 to December 2020. Variables included transfusions, ionized calcium levels, and calcium replacement. Patients were characterized as follows based on blood products received: WB or WB with other blood components. Groups were compared with respect to HC, correction of HC, 24 h, and inpatient mortality., Results: Two hundred twenty-three patients received WB and met the inclusion criteria. 107 (48%) received WB only. HC occurred in 13% of patients who received more than one WB unit compared to 29% of WB and other blood component patients (P = 0.02). WB patients received less calcium replacement (median 250 mg versus 2000 mg, P < 0.01). HC and total units transfused within 4 h were associated with mortality in the adjusted model. HC significantly increased after 5 units of blood products were transfused, regardless of product type. WB was not protective against HC., Conclusions: HC and failure to correct HC are significant risk factors for mortality in trauma. Resuscitations with WB only and WB in combination with other blood components are associated with HC especially when more than 5 units of any blood product are transfused. Calcium supplementation should be prioritized in any large volume transfusion, regardless of blood product type., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: In severe renal hyperparathyroidism (RHPT), whether administrating Cinacalcet before total parathyroidectomy can reduce post-operative hypocalcemia remains unclear. We compared post-operative calcium kinetics between those who took Cinacalcet before surgery (Group I) and those who did not (Group II)., Methods: Patients with severe RHPT (defined by PTH ≥ 100 pmol/L) who underwent total parathyroidectomy between 2012 and 2022 were analyzed. Standardized peri-operative protocol of calcium and vitamin D supplementation was followed. Blood tests were performed twice daily in the immediate post-operative period. Severe hypocalcemia was defined as serum albumin-adjusted calcium < 2.00 mmol/L., Results: Among 159 patients who underwent parathyroidectomy, 82 patients were eligible for analysis (Group I, n = 27; Group II, n = 55). Demographics and PTH levels before Cinacalcet administration were comparable (Group I: 169 ± 49 pmol/L vs Group II: 154 ± 45, p = 0.209). Group I had significantly lower pre-operative PTH (77 ± 60 pmol/L vs 154 ± 45, p < 0.001), higher post-operative calcium (p < 0.05), and lower rate of severe hypocalcemia (33.3% vs 60.0%, p = 0.023). Longer duration of Cinacalcet use correlated with higher post-operative calcium levels (p < 0.05). Cinacalcet use for > 1 year resulted in fewer severe post-operative hypocalcemia than non-users (p = 0.022, OR 0.242, 95% CI 0.068-0.859). Higher pre-operative ALP independently correlated with severe post-operative hypocalcemia (OR 3.01, 95% CI 1.17-7.77, p = 0.022)., Conclusion: In severe RHPT, Cinacalcet led to significant drop in pre-operative PTH, higher post-operative calcium levels, and less frequent severe hypocalcemia. Longer duration of Cinacalcet use correlated with higher post-operative calcium levels, and the use of Cinacalcet for > 1 year reduced severe post-operative hypocalcemia., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

This article reviews the history of clinical hypocalcemia and the evolving definition of subclinical hypocalcemia, targeting a concept for consideration that not all hypocalcemia is negative. With a goal of presenting bovine practitioners information to assist with individual animal hypocalcemia diagnosis and treatment as well as herd-level monitoring and prevention, we present current methods of direct calcium measurement, therapeutic interventions for clinical hypocalcemia, and postpartum calcium supplementation options and their efficacy. We encourage veterinarians to understand calcium dynamics in the immediate postpartum period and evaluate how individual cow therapy and herd prevention protocols can assist with supporting calcium regulation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The main postoperative complications of thyroidectomy are hypoparathyroidism and recurrent laryngeal nerve (RLN) palsy. Methylene blue, which is a drug and dye, is safe and easy to get, and we can use it to avoid complications during thyroidectomy. Objectives: We aim to assess that we can spray Methylene blue to allow the identification of important structures intraoperative which are the parathyroid gland and recurrent laryngeal nerve. Also, to evaluate that this technique is safe, effective, technically feasible, and less dangerous than other techniques. Methods: Our study is a prospective cohort study of patients, patients who presented with simple nodular goiter, solitary thyroid nodule, controlled toxic goiter, and failed medical treatment with the indication for thyroidectomy, suspected malignancy, and retrosternal goiters at El-Demerdash Hospital from the period of August 2021 to August 2022. In the specified study period of 1 year from 1/8/2021 to 31/7/2022. Results: Sixty patients underwent thyroidectomy 54 underwent total while 6 only underwent hemithyroidectomy. The time taken to wash out the dye over the thyroid gland was 15 to 25 minutes, the parathyroid gland was 4 to 7 minutes and the recurrent laryngeal nerve (RLN) was almost 0 to 1 minute and this indicated that the RLN almost did not take the dye. In the controlled group, two patients had symptoms and signs of hypocalcemia only one of them had signs of tetany, 8 patients had laboratory hypocalcemia, two patients suffered from a change of voice and another two patients suffered difficulty breathing one of which needed temporary tracheostomy while in the interventional group, only one patient had symptoms and signs of hypocalcemia no one had signs of tetany, two patients had laboratory hypocalcemia, one patient suffered from the change of voice and another two patients suffered the difficulty of breathing but no one needed a tracheostomy tube. Conclusions: It is safe, useful, and suitable to use Methylene blue spraying to keep the parathyroid gland and RLN during thyroidectomy, which led us to reduce the percentage of incidence of postoperative complications. Also, it helped us to find the parathyroid gland and RLN during the surgery, despite some surgeons seeing that searching for the parathyroid and RLN can lead to harmful effects and increase the incidence of injury., (Celsius.)

Postoperative hypoparathyroidism, resulting from removal and/or devascularization of one or more parathyroid glands, is a feared complication of total thyroidectomy. Two forms, which are distinguished by their frequency, their time to onset and their duration as well as by their presentation, must be individualized: early postoperative hypocalcemia, often secondary to early hypoparathyroidism is a frequent and often transient situation occurring within the first days after surgery; permanent hypoparathyroidism, which is rarer, manifests when parathyroid function remains impaired for more than six months after surgery. Because of their severity, these conditions must be known and ideally prevented during total thyroidectomy. The objective of this article is to provide surgeons with practical recommendations for the prevention, diagnosis, and treatment of hypoparathyroidism after total thyroidectomy. These recommendations, which are the fruit of a medico-surgical consensus, were developed by the Francophone Association of Endocrine Surgery (AFCE), the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine and Molecular Imaging. (SFMN). The content, grade and level of evidence for each recommendation was decided after consultation within a panel of experts, based on an analysis of recent literature., (Copyright © 2023. Published by Elsevier Masson SAS.)

Purpose: To evaluate whether the application of carbon nanoparticles (CNs) in total or near-total thyroidectomy combined with central lymph node dissection (CLND) for thyroid cancer (TC) is beneficial to lymph node dissection, parathyroid, and recurrent laryngeal nerve (RLN) protection., Methods: Relevant literatures were systematically searched on PubMed, EMBASE, and Cochrane Library Databases until March 31, 2021. All analyses were performed using Revman Manager 5.3 software. The main results were the number of central lymph nodes, the number of central metastatic lymph nodes, accidental parathyroidectomy, postoperative hypoparathyroidism, postoperative hypocalcemia, and postoperative transient RLN paralysis., Results: This meta-analysis identified 4 randomized controlled trials and 8 non-randomized controlled trials comprising 1870 patients. Compared with the control, the use of CNs was helpful to dissect more central lymph nodes (weighted mean difference [WMD]: 3.55, 95% confidence interval [CI]: 2.12-4.98, P < .00001) and central metastatic lymph nodes (WMD: 1.69, 95% CI:1.31-2.08, P < .00001), lower rate of accidental parathyroidectomy (odds ratio [OR]: .33, 95% CI: .23-.47, P < .00001), lower rate of both postoperative transient hypoparathyroidism (OR: .40, 95% CI: .31-.51, P < .00001), and transient hypocalcemia (OR: .37, 95% CI: .27-.51, P < .00001). However, there were no statistical difference between the groups for postoperative permanent hypoparathyroidism (OR: .29, 95% CI: .06-1.28, P = .10), postoperative permanent hypocalcemia (OR: .94, 95% CI: .10-9.16, P = .96), and postoperative transient RLN paralysis (OR: .66, 95% CI: .40-1.12, P = .12)., Conclusions: The application of CNs in total or near-total thyroidectomy combined with CLND for TC can better dissect the central lymph nodes and protect parathyroid glands (PGs) and their function.

Background: Hypocalcemia is the most common complication after parathyroidectomy, contributing to extended hospital stays and higher hospitalization costs. The present study aimed to evaluate whether preoperative Calcitriol could help reduce hypocalcemia rates., Method: In this randomized controlled trial, we included 80 patients with primary hyperparathyroidism candidates for parathyroidectomy. The intervention group received Calcitriol 0.25 µg/day 1 week before parathyroidectomy. Baseline laboratory data, parathyroid hormone level (before, during, after 5, and 10 min of operation), calcium level (6, 24, and 48 h after operation), and clinical signs and symptoms were recorded., Results: Of the 80 participants, 40 (mean age: 53.36 ± 12.97) were randomized to the intervention, and 40 (mean age: 52.84 ± 12.32) to the control group. There were no statistically significant differences in age, tumor size, gender, baseline laboratory data, intra-operative PTH, and calcium level 6 and 24 h after the operation. We observed a significantly higher calcium level in the intervention group 48 h post-operation (8.57 ± 0.30 vs. 8.33 ± 0.38). Also, days of hospital stay and symptomatic hypocalcemia rate were significantly lower in the intervention group., Conclusion: In patients with primary hyperparathyroidism, preoperative Calcitriol may be of value in preventing post-parathyroidectomy hypocalcemia and subsequent complications., (© 2022. The Author(s), under exclusive licence to Italian Society of Endocrinology (SIE).)

Hypocalcaemia following thyroid surgery can occur in up to 38% of patients. With over 7100 thyroid surgeries performed in 2018 in the UK, this is a common postoperative complication. Undertreated hypocalcaemia can result in cardiac arrhythmias and death. Preventing adverse events from hypocalcaemia requires preoperative identification and treatment of at-risk patients with vitamin D deficiency, timely recognition of postoperative hypocalcaemia and prompt appropriate treatment with calcium supplementation. This project aimed to design and implement a perioperative protocol for prevention, detection and management of post-thyroidectomy hypocalcaemia. A retrospective audit of thyroid surgeries (n=67; October 2017 to June 2018) was undertaken to establish baseline practice of (1) preoperative vitamin D levels assessment, (2) postoperative calcium checks and incidence of postoperative hypocalcaemia and (3) management of postoperative hypocalcaemia. A multidisciplinary team approach following quality improvement principles was then used to design a perioperative management protocol with all relevant stakeholders involved. After dissemination and implementation, the above measures were reassessed prospectively (n=23; April-July 2019). The percentage of patients having their preoperative vitamin D measured increased from 40.3% to 65.2%. Postoperative day-of-surgery calcium checks increased from 76.1% to 87.0%. Hypocalcaemia was detected in 26.8% of patients before and 30.43% of patients after protocol implementation. The postoperative component of the protocol was followed in 78.3% of patients. Limitations include low number of patients which precluded from analysis of the impact of the protocol on length of stay. Our protocol provides a foundation for preoperative risk stratification and prevention, early detection and subsequent management of hypocalcaemia in thyroidectomy patients. This aligns with enhanced recovery protocols. Moreover, we offer suggestions for others to build on this quality improvement project with the aim to further advance the perioperative care of thyroidectomy patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine the effect of a 4-hour postoperative serum parathyroid hormone (PTH)-guided calcium (Ca) and calcitriol supplementation protocol on the incidence of hypocalcemia and hospital readmissions in patients undergoing total thyroidectomy., Methods: This was a single-institution, retrospective chart review of patients who underwent total thyroidectomy; 148 and 389 of the patients underwent surgery prior to and after the protocol implementation, respectively. The risk of hypocalcemia was stratified as low (PTH level of >30 pg/mL), medium (15-30 pg/mL), and high (<15 pg/mL), using serum PTH values obtained 4 hours postoperatively. Hypocalcemia was defined as a total serum Ca level of <8 mg/dL. Baseline demographic and operative characteristics and postoperative outcome were recorded for both groups. The Fisher exact test and Wilcoxon rank sum test were used to compare the characteristics of the 2 groups. A multivariate logistic regression model was applied to account for potentially confounding variables., Results: Postoperative hypocalcemia occurred significantly less frequently in the protocol group compared with that in the preprotocol group (10.3% vs 20.9%, P = .002). The reduction in hypocalcemia in the protocol group was observed in both patients with (16.3% vs 25.6%) and without (8.4% vs 19.3%) cervical lymph node dissection. The protocol group had a significantly lower incidence of hospital readmission events than the preprotocol group (1.0% vs 4.7%, P = .013)., Conclusion: Compared with a historical cohort, a PTH-guided protocol for Ca and calcitriol supplementation significantly reduces the postoperative hypocalcemia and hospital readmission rates in patients undergoing total thyroidectomy., Competing Interests: Disclosure The authors have no multiplicity of interest to disclose., (Copyright © 2023 AACE. Published by Elsevier Inc. All rights reserved.)

Background: The thyroid gland plays an important endocrine function regulating metabolism, growth and development. A variety of benign and malignant conditions necessitate surgical removal of the thyroid gland, either in its entirety, or partially. Thyroidectomy is the most commonly undertaken endocrine surgery. Hypocalcaemia, occurring at a rate of approximately 25%, is the most common complication following total thyroidectomy. Hypocalcaemia can increase healthcare costs requiring further investigations, treatment and delaying discharge. Severe hypocalcaemia can be potentially life threatening. It has been demonstrated that routine post-operative supplementation with Vitamin D and calcium, can reduce post-operative hypocalcaemia, at present it is unclear whether preoperative supplementation has a similar effect., Methods: This systematic review includes randomised controlled trials on human adult subjects, who received preoperative Vitamin D and/or calcium, and which studied the effect on post-operative hypocalcaemia following total or near total thyroidectomy. There were no restrictions in respect of post-operative supplementation regimen. Studies were limited to those published in English., Result: Seven of the eleven trials demonstrated a reduction in either laboratory or clinical hypocalcaemia with preoperative supplementation. This benefit was most likely to be seen when postoperative supplementation was performed on an as needed basis. IV calcium was required to treat resistant or severe hypocalcaemia, in five of the eleven trials, in each of these five trials, rates of IV replacement were lower in the preoperative supplementation group., Conclusion: The use of preoperative Vitamin D, with or without calcium, may provide a modest reduction in the incidence of laboratory and clinic hypocalcaemia following total or near total thyroidectomy. There is a trend toward a reduced requirement for IV calcium with preoperative supplementation. Larger robust randomised trials are needed to provide a definitive answer. Preoperative supplementation can be considered in patients undergoing total or near total thyroidectomy., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Routine prophylaxis for at-risk patients may reduce the occurrence of postoperative hypocalcemia but is not widely adopted due to a lack of evidence on the efficacy of available prophylactic strategies. In this study, we compared the relative efficacy of prophylactic strategies for postthyroidectomy hypocalcemia with a systematic review and network meta-analysis., Methods: PubMed, Embase, and Cochrane Library were searched, covering the period from 1980 to May 2022, for randomized controlled trials (RCTs) comparing calcium, vitamin D 3 , activated vitamin D 3 , teriparatide, steroids, and magnesium with placebo or each other in patients receiving total or completion thyroidectomy. Involved RCTs reporting symptomatic or biochemical hypocalcemia. The primary outcome was symptomatic hypocalcemia, defined as circumoral tingling, and Chvostek and Trousseau signs. The secondary outcome was biochemical hypocalcemia. Risk of bias was assessed using the Cochrane risk of bias assessment tool for randomized trials. Pooled estimates were calculated using a random-effects inverse-variance weighting model. The network meta-analysis was performed under the frequentist framework. This meta-analysis was registered on the PROSPERO (International prospective register of systematic reviews) (CRD42022299982)., Results: Twenty-seven RCTs comprising 3382 patients are included. Prophylactic strategies of teriparatide, oral calcium plus vitamin D 3 , and oral calcium plus activated vitamin D 3 are superior to placebo in reducing symptomatic hypocalcemia. Teriparatide emerged as the most effective strategy for symptomatic hypocalcemia [relative risk (RR): 0.18; 95% CI: 0.03-0.98], followed by oral calcium plus activated vitamin D 3 (RR: 0.42; 95% CI: 0.25-0.73) and oral calcium plus vitamin D 3 (RR: 0.43; 95% CI: 0.26-0.71). Evidence on monotherapy with either oral calcium or vitamin D 3 in reducing symptomatic hypocalcemia is insufficient. Intravenous calcium and oral calcium are effective in reducing biochemical hypocalcemia., Conclusions: This network meta-analysis provides information on the relative efficacy of current prophylactic strategies for postthyroidectomy hypocalcemia. Teriparatide performed better than other interventions and would seem appropriate for deployment among high-risk populations., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Hypoparathyroidism is the most frequent complication after total thyroidectomy and, when permanent, it becomes a severe chronic disease. We assessed the usefulness of indocyanine green (ICG) angiography-guided thyroidectomy to reduce the postoperative hypocalcemia., Methods: Prospective study with two consecutive cohorts of patients who underwent total thyroidectomy: historical control group (CG) and angiography-guided thyroidectomy group (AG). In all patients, ICG-angiography was performed at the end of the surgery to predict immediate parathyroid gland (PG) function. In the AG, ICG-angiography was also done after PG identification to show their vascular supply. We compared the rate of postoperative hypocalcemia (calcium supplementation needed due to hypocalcemia symptoms or calcium levels < 1.8 mmol/L on the first postoperative day) and permanent hypocalcemia (need of calcium ± vitamin D supplementation 12 months after thyroidectomy)., Results: We included 120 consecutive patients (84 CG; 36 AG). Thyroid cancer was the most common diagnostic (63.1% CG-69.4% AG; p = 0.646) and central neck dissection was also frequent (54.8% CG-64.3% AG; p = 0.468). The AG developed a lower rate of postoperative (26.2-5.6%; p = 0.011) and permanent hypocalcemia (11.9-0%; p = 0.032). The OR for permanent hypocalcemia was 0.673 (95% CI 0.591-0.766). A significant higher rate of well vascularized PG at the end of the surgery (score 2) in the AG (39.2-52.9%; p = 0.018) was also seen., Conclusion: ICG angiography-guided thyroidectomy is a useful tool to identify PG vascularization, allowing a better PG preservation and a significant decrease in hypocalcemia rates., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: Near-infrared autofluorescence and indocyanine green fluorescence are 2 recent tools introduced to improve postoperative parathyroid function during thyroid surgery., Methods: We conducted a randomized prospective study. Patients undergoing total thyroidectomy were randomly assigned either to the fluorescence group, in which near-infrared autofluorescence and indocyanine green fluorescence were used, or to the control group. The primary outcomes of the study were the rate of postoperative transient and symptomatic hypocalcemia., Results: A significantly higher number of parathyroid glands were identified in the fluorescence group (3.83 vs 3.64, P = .028). The rate of postoperative symptomatic hypocalcemia was significantly lower in the fluorescence group (6% vs 17%, P = .015), as was the dosage (1.53 vs 1.91 g, P = .007) and the duration of calcium therapy (32.30 vs 45.66 days, P = .003). Having at least 2 well-vascularized parathyroid glands correlates to lower rates of transient hypocalcemia (7.4% vs 21.9%, P = .037) as well as to higher serum calcium (8.70 vs 8.42 mg/dL, P = .027) and parathyroid hormone levels (19.15 vs 11.4 pg/mL, P = .0002) on postoperative day 1., Conclusion: Near-infrared autofluorescence and indocyanine green fluorescence are novel tools that may support the endocrine surgeon in preserving and predicting post-thyroidectomy parathyroid gland function., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Hypoparathyroidism is a recognised complication following laryngectomy; it is associated with significant short-and long-term morbidity. This study aimed to further characterise this condition, identify risk factors and describe preventative and management strategies in a large cohort., Materials and Methods: This was a retrospective study at a tertiary referral centre for head and neck cancers. All consecutive patients who had total laryngectomy over an eight-year period were included., Results: A total of 140 patients were included. Rates of transient and long-term hypoparathyroidism were 14.3% and 10.1%, respectively. The following factors were significantly associated with transient post-surgical hypocalcaemia or hypoparathyroidism: total thyroidectomy (relative risk, RR, 4.33; 95% confidence interval, CI, 1.86-10.10), oesophagectomy (RR 6.05; 95% CI 2.92-12.53) and female sex (RR 3.23; 95% CI 1.45-7.19). In addition, total thyroidectomy (RR 5.89; 95% CI 1.94-17.86), central neck dissection (RR 3.97; 95% CI 1.42-11.10), oesophagectomy (RR 9.38; 95% CI 4.13-21.3), pharyngectomy (RR 7.14; 95% CI 2.08-24.39) and female sex (RR 5.52; 95% CI 1.95-15.63) were risk factors for long-term hypoparathyroidism. There was variability in the use of preventative measures, monitoring and management of hypocalcaemia and hypoparathyroidism following total laryngectomy., Conclusions: Transient hypocalcaemia and long-term hypoparathyroidism occur in a significant proportion of patients after laryngectomy. A standard protocol is required to improve care.

Background: Hypocalcemia is the most common complication following total thyroidectomy. This study aimed to evaluate the efficacy of perioperative combined calcium and vitamin D supplementation compared to postoperative combined calcium and vitamin D supplementation in reducing symptomatic hypocalcemia., Materials and Methods: A prospective randomized placebo-controlled trial was carried out in patients undergoing total or completion thyroidectomy from June 2017 to May 2022. Eligible patients were assigned to receive either calcium carbonate and alfacalcidol or placebo 3 days before surgery, and both groups were given calcium carbonate and alfacalcidol for 14 days after surgery. Clinical outcomes (signs and symptoms of hypocalcemia, requirement of intravenous calcium, and medication-induced hypercalcemia) and laboratory results (calcium and parathyroid hormone levels) were compared between the two groups., Results: One hundred and thirty-four patients were included in the analysis, 68 were in perioperative oral calcium and vitamin D supplementation group, and 66 were in postoperative oral calcium and vitamin D supplementation group. Symptomatic hypocalcemia rates were significantly lower in the perioperative group than in the postoperative group (8.8 and 22.7%, respectively, P=0.033). All symptomatic hypocalcemia cases in the perioperative group occurred in the first 24 hours after surgery. Mean calcium levels were significantly higher in the perioperative group at 24 and 48 hours after surgery. Intravenous calcium requirement rate was lower in the perioperative group but the difference was insignificant (2.9 and 12.1%, P=0.053). Mean parathyroid hormone levels were within the normal range and did not differ between groups. No medication-induced hypercalcemia was detected in either group., Conclusion: Perioperative oral calcium and vitamin D supplementation significantly decreased the risks of symptomatic and biochemical hypocalcemia compared to postoperative oral calcium and vitamin D supplementation. The perioperative supplementation also shortened the recovery period of symptomatic hypocalcemia to within 24 hours., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Hypocalcaemia prevention programmes have been widely studied in experimental settings, but their feasibility has not been assessed under field conditions. The main objective of this study was to evaluate, in the context of small dairy farms in western France, whether and how dairy farmers implement prevention programmes and manage the feeding of dry cows to prevent hypocalcaemia. Seventy-nine commercial Holstein dairy farms in Brittany (France) were enrolled in a qualitative study in 2019. We conducted in-person interviews with the farmers to 1) understand the rationale behind the type and seasonality of prevention programmes they implemented and 2) assess how closely they followed common recommendations when implementing them. Most farmers (80 %) used at least one prevention programme, especially supplying a mineral mix formulated to meet the needs of dry cows in late gestation (53 %), acidifying the diet in late gestation (37 %), and supplying calcium at calving (oral or injectable form, 37 %). The use of programmes depended on whether the diet composition varied throughout the year. Among farmers who provided an acidified diet, 25 % did not supply a specific mineral mix to dry cows to ensure an adequate amount of P, Ca, and Mg, which could decrease the effectiveness of the acidification programme. A lack of reliability in feeding practices, such as not weighing feed or not delivering feed frequently enough, was identified for 61 % of contributing farms. Management practices could result in supplying an unsuitable amount of P, Ca, or Mg immediately before calving; for example, inappropriate batching practices around calving were identified for 22 % (cows) to 32 % (heifers) of farms. In addition, nearly all contributing farmers had no processes in place to monitor the effectiveness of the programmes implemented. Reasons for this overall lack of compliance should be explored., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Hypocalcemia remains a common metabolic disorder of dairy cattle; therefore, an efficient prevention is still challenging. Among the various prevention strategies for hypocalcemia is the use of anionic compounds to induce a mild metabolic acidosis during the prepartum period. Acid-base status can be readily assessed through urine pH. Accordingly, a target urine pH during the prepartum period between 6.0 and 6.8 has been recommended for Holstein cows; however, in several countries, including the US, certain nutritional strategies are still focused on benchmarking the urine pH to below 6.0. Unfortunately, over-acidification can have no advantages and/or detrimental effects on both the dam and her offspring. In this review, updated information regarding the use of anionic diets on prepartum dairy cows and the potential negative impact of such diets on both cow and calf performance are discussed. There is an urgent need for studies that will elucidate the pathophysiological mechanisms by which very acidotic diets may impact the well-being and productive efficiency of dairy cows, and the transgenerational effects of such diets on offspring performance and survival., (Copyright © 2022 Texas Tech University. Published by Elsevier B.V. All rights reserved.)

Objective: This meta-analysis aimed to assess the position of near-infrared autofluorescence (NIRAF) imaging in the recognition and protection of the parathyroid gland (PG) during thyroidectomy., Methods: The PubMed, MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were searched up to June 2021. The primary outcome was to evaluate the rates of postoperative hypocalcemia, inadvertent PG resection, and autotransplantation of PG when adopting NIRAF imaging compared with standard naked-eye (N-E) surgery., Results: Eight studies with 2,889 patients were enrolled in the analysis. Our analysis showed that the incidence of transient hypocalcemia was 7.11% (60/844) in the NIRAF group and 22.40% (458/2045) in the N-E group ( p  < 0.0001) and the rate of transient hypoparathyroidism was 28.31% (126/445) and 33.36% (496/1487) in the NIRAF and N-E groups ( p  = 0.0008). The rate of inadvertent resection of PGs was 7.65% (55/719) in the NIRAF group and 14.39% (132/917) in the N-E group ( p  < 0.0001). No significant difference was observed in other indexes including the pooled proportion of permanent hypocalcemia and rate of PG autotransplantation., Conclusions: The application of NIRAF imaging in thyroidectomy can help lower the incidence of inadvertent PG resection and reduce the risk of postoperative hypocalcemia and hypoparathyroidism compared with N-E recognition.

Denosumab-induced hypocalcemia is sometimes severe, and although a natural vitamin D/calcium combination is used to prevent hypocalcemia, some patients rapidly develop severe hypocalcemia even under supplementation. It is clinically important to predict this risk. This study aimed to develop a risk prediction model for grade ≥2 hypocalcemia within 28 days after the first denosumab dose under natural vitamin D/calcium supplementation. Using a large database containing multicenter practice data, 2399 patients with bone metastasis who were treated with denosumab between June 2013 and May 2020 were retrospectively analyzed. Background factors in patients who developed grade ≥2 hypocalcemia within 28 days after the first denosumab dose and those who did not were compared by univariate analysis. Multivariate analysis was conducted to develop a risk prediction model. The model was evaluated for discriminant performance (receiver operating characteristic-area under the curve, sensitivity, specificity) and predictive performance (calibration slope). A total of 124 patients in the hypocalcemia group and 1191 patients in the nonhypocalcemia group were extracted. A risk prediction model consisting of sex, calcium, albumin, alkaline phosphatase, osteoporosis, breast cancer, gastric cancer, proton pump inhibitor combination, and pretreatment with zoledronic acid was developed. The receiver operating characteristic-area under the curve was 0.87. Sensitivity and specificity were 83% and 81%, respectively, and the calibration slope indicated acceptable agreement between observed and predicted risk. This model appears to be useful to predict the risk of denosumab-induced hypocalcemia and thus should be helpful for risk management of denosumab treatment in patients with bone metastases., (© 2022, The American College of Clinical Pharmacology.)

Background: Prediction of postoperative hypocalcemia is a fundamental issue in thyroidectomy. Indocyanine green (ICG) angiography of parathyroid glands is a feasible method to detect the perfusion of parathyroid glands and predict postoperative hypocalcemia., Materials and Methods: A prospective observational study was conducted at Ain Shams University Hospitals between April 2018 and April 2021. The included cases of total thyroidectomy underwent intraoperative ICG fluorescence angiography to identify the four parathyroid glands and score each gland according to the viability. Patients in which less than four glands were identified were excluded. Intraoperative intact parathyroid hormone (ioPTH) level assay was also measured to compare with ICG in predicting postoperative transient hypocalcemia., Results: A total of 134 cases underwent total thyroidectomy during the study period. We could identify the four parathyroid glands in 90 patients, including them in the study. We had postoperative hypocalcemia in 28 cases (31.1%). The diagnostic accuracy of ICG angiography and ioPTH level assay was high and almost similar (82.22% versus 87.78%). Both were higher than the surgeons' diagnostic accuracy of visual inspection (62.22%)., Conclusions: ICG angiography of the parathyroid gland is a safe, reliable predictor for postoperative transient hypocalcemia with a high and almost similar accuracy compared to intraoperative parathyroid hormone level.

Background: Comparative studies among protocols for the management of post-total thyroidectomy (TT) hypocalcemia are lacking. We compared the effectiveness of PTH-driven selective supplementation (PD-SS) and routine calcium and calcitriol supplementation with preoperative calcitriol administration in preventing symptomatic hypocalcemia (SH) and readmission., Methods: Three-hundred consecutive patients undergoing TT were assigned to 3 groups: the PD-SS group, the high-dose routine supplementation (HD-RS) group and the low-dose routine supplementation (LD-RS) group., Results: Mean post-operative stay was shorter in HD-RS patients when compared to PD-SS and LD-RS (p < 0.001). Significantly more patients in the PD-SS group experienced SH (p = 0.042). The rate of post-operative hypocalcemia was not significantly different among the groups (p = 0.063). No readmission for SH or hypercalcemia occurred., Conclusions: HD-RS emerged as the most effective treatment to prevent SH, without increasing the risk of readmission for calcitriol-related hypercalcemia. Basing on the present results, HD-RS should be recommended as the preferable protocol., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Periparturient hypocalcemia is a frequently observed metabolic disorder in fresh cows. While the clinical form affects approximately 7 % of German dairy cows, nearly half of the multiparous cows exhibit subclinical hypocalcemia. Although both diagnosis and therapy have not changed over the last three decades, some farmers and practitioners are still unaware about the prevalence of and risk period for subclinical hypocalcemia. Moreover, various recommendations exist concerning the amount of calcium that is to be administered intravenously to a cow experiencing clinical signs of hypocalcemia. This article reviews the causes and prevalence of periparturient hypocalcemia. The aim is further to summarize the results of studies investigating therapy of clinical hypocalcemia in order to provide an evidence-based recommendation on the treatment of recumbent cows. Despite the high prevalence of hypocalcemia, it has been shown that the majority of German farmers do not implement preventive strategies against hypocalcemia. Therefore, we furthermore describe preventive strategies that may be useful in reducing the risk of hypocalcemia, based on what is known from the current literature., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Hypocalcaemia is a common complication after total thyroidectomy (TT). Treatment consists of calcium and active vitamin D supplementation. Low levels of vitamin D before surgery have been shown to be a risk factor for postoperative hypocalcaemia, yet studies examining routine preoperative vitamin D supplementation have shown conflicting results. This retrospective cohort study aims to investigate the potential benefit of preoperative active vitamin D supplementation on hypocalcaemia and its symptoms after TT., Methods: This study included patients undergoing TT at Uppsala University Hospital from January 2013 to December 2020, resulting in a total of 401 patients after exclusion. Routine preoperative alfacalcidol treatment was initiated for all TT patients in January 2017 resulting in two groups for comparison: one group (pre-January 2017) that was prescribed preoperative alfacalcidol and one that was not. Propensity score matching was used to reduce bias. The primary outcome was early postoperative hypocalcaemia (serum calcium, S-Ca less than 2.10 mmol/l); secondary outcomes were symptoms of hypocalcaemia and length of stay., Results: After propensity score matching, there were 108 patients in each group. There were 2 cases with postoperative day one S-Ca less than 2.10 in the treated group and 10 cases in the non-treated group (P < 0.001). No patients in the treated group had a S-Ca below 2.00 mmol/l. Preoperative alfacalcidol was associated with higher mean serum calcium level day one (2.33 versus 2.27, P = 0.022), and reduced duration of hospital stay (P < 0.001). There was also a trend toward fewer symptoms of hypocalcaemia (18.9 per cent versus 30.5 per cent, P = 0.099)., Conclusions: Prophylactic preoperative alfacalcidol was associated with reduced biochemical hypocalcaemia and duration of hospital stay following TT. Also, with this protocol, it is suggested that routine day 1 postoperative S-Ca measurement is not required., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.)