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Parathyroid Surgery Myths

There are a lot of myths about parathyroid surgery floating around these days.  These stem from historic practices which are now antiquated, but still being practiced by many surgeons.  This post is designed to explain where these principles came from, why they were established, and how they are currently outdated.

1.     Hospitalization is needed after parathyroid surgery

False

Patients were routinely hospitalized after parathyroid surgery when parathyroid surgery involved large neck incisions and hours of neck exploration.  A drain was routinely left in the neck, the risk of bleeding was higher, and surgeons were not as aggressive with calcium supplementation after surgery.  Drains are no longer necessary (see #2 below), and low calcium (see #3 below) is not an issue so long as calcium supplementation is promptly instituted and the patient has a means of contacting their physician if they experience hypocalcemia.  An experienced surgeon can perform the operation through a 1 inch incision, without a drain, and without the need for an overnight stay in the hospital. 

  1.  A drain needs to be placed in the neck after surgery

False

Drains were historically placed in the neck after surgery to prevent blood collections (hematoma) and to drain excess fluid from the wound.  A hematoma can occur when a blood vessel starts bleeding after the operation.  This is a known complication of parathyroid surgery which is concerning because active bleeding in the operative bed causes significant swelling of the airway which can lead to asphyxiation if not controlled.  Fortunately, the risk of a significant bleed is rare (< 1%).  The reality is that with active bleeding, no drain can keep up as the plastic tubing clots off and the bleeding continues.  The treatment for a rapidly expanding hematoma is going back to the operating room to stop the bleeding, drain or no drain.  Drains were also beneficial for draining fluid which can collect in the days after surgery when routine parathyroid surgery required large incisions with more dissection and tissue injury.

Surgeons using minimally invasive techniques rarely lose more than a teaspoon (5 mL) of blood during a parathyroid operation and never need a large incision or a drain.

3.     Blood calcium needs to be checked immediately after surgery

False

Hypocalcemia (low blood calcium) is common after parathyroidectomy, as the remaining parathyroid glands are suppressed by high levels of calcium created by excess parathyroid hormone produced by the adenoma (benign parathyroid growth).  After successful surgery, the abnormal parathyroid gland or glands have been removed, and the parathyroid hormone levels fall to near zero.  Blood calcium subsequently falls, but this is a temporary phenomenon which resolves once the remaining parathyroid glands resume their normal function over a period of several weeks. 

When hyperparathyroidism has been present for a long time, a phenomenon known as “hungry bone syndrome”  occurs where the bones which have been starved of calcium take the calcium from the blood which can lead to prolonged or more severe hypocalcemia.  It is experienced by the patient as numbness or tingling around the fingers, lips, or toes.  If it progresses untreated, it can cause severe muscle cramping and even heart arrhythmias which can cause death.  Historically, patients had their calcium levels checked every 6 hours while in the hospital, and if their calcium levels had stabilized by the morning after surgery, they were cleared for discharge without calcium. 

A greater understanding of calcium metabolism has taught us that the lowest calcium levels do not typically occur until about 2 days after surgery, and that checking calcium levels every 6 hours generally only means more needles for blood draws and an artificial sense of security. 

Patients undergoing parathyroidectomy are always started on oral calcium supplements for a duration of 3 weeks after surgery to allow the remaining parathyroid glands to resume normal function and to provide additional calcium for the bones.  Occasionally a prescription strength vitamin D supplement is needed to control the hypocalcemia.  It is best to avoid hospitalization whenever possible because intravenously administered calcium causes phlebitis (irritation of the veins), and a higher degree of blood calcium fluctuation. 

4.     Nerve monitoring will reduce my risk of having a weak voice after surgery

False

Technology is available to monitor the function of the recurrent laryngeal nerve during surgery.  Its use is controversial, because it has not been proven to reduce the risk of vocal cord weakness after surgery but it has been proven to increase cost.  Nerve monitoring is of academic interest, and is frequently used in teaching institutions where surgeons write papers about its use.  However, the gold standard of preserving the nerve is visual identification using the surgeon’s eyes.  It is therefore not surprising that the only thing proven to reduce the risk of vocal fold weakness after surgery is surgeon volume and experience. 

Take Home Points

It’s not wrong to be hospitalized after parathyroid surgery with a drain, a large incision, and calcium checks every 6 hours.  You can still have an excellent outcome after surgery, but these measures are antiquated by modern standards.  These measures are unnecessary for an experienced, high volume parathyroid surgeon.  Those with high deductible insurance plans should investigate the potential cost savings of eliminating unnecessary equipment and practices. 

Thyroid Surgery Myths

There are a lot of myths about thyroid surgery floating around these days.  These stem from historic practices which are now antiquated, but still being practiced by many surgeons.  This post is designed to explain where these principles came from, why they were established, and how they are currently outdated. 

1.     Hospitalization is needed after thyroid surgery

False

Patients were routinely hospitalized after thyroid surgery primarily because of the risk of bleeding, and the risk of hypocalcemia (low calcium from stunning of the parathyroid glands).  Drains are no longer necessary (see #2 below), and low calcium (see #3 below) is not an issue so long as calcium supplementation is promptly instituted and the patient has a means of contacting their physician if they experience hypocalcemia. 

Hospitalization of one night is only necessary for those patients with thyroid cancer who undergo a total thyroidectomy, central neck dissection, and lateral neck dissection, and then generally for only for one night. 

  1.  A drain needs to be placed in the neck after surgery

False

Drains were historically placed in the neck after surgery to prevent blood collections (hematoma) and to drain excess fluid from the wound.  A hematoma can occur when a blood vessel starts bleeding after the operation.  This is a known complication of thyroid surgery which is concerning because active bleeding in the operative bed causes significant swelling of the airway which can lead to asphyxiation if not controlled.  Fortunately, the risk of a significant bleed is rare (< 1%).  The reality is that with active bleeding, no drain can keep up as the plastic tubing clots off and the bleeding continues.  The treatment for a rapidly expanding hematoma is going back to the operating room to stop the bleeding, drain or no drain.  Drains were also beneficial for draining fluid which can collect in the days after surgery when routine thyroid surgery required large incisions with more dissection and tissue injury.

Surgeons using minimally invasive techniques rarely lose more than a teaspoon (5 mL) of blood during a thyroid operation and rarely need a large incision.  Drains are hence unnecessary, and large studies have shown that the only thing drains do is increase hospital length stay (rarely necessary, see #1) and consequently cost. 

Drain placement is generally only necessary for those patients with thyroid cancer who have a total thyroidectomy, central neck dissection, and lateral neck dissection, and then generally for one night. 

3.     Blood calcium needs to be checked after surgery

False

This myth applies only to patients undergoing total thyroidectomy, as patients undergoing a thyroid lobectomy are not at risk of hypocalcemia (low calcium levels).  Hypocalcemia is common after total thyroidectomy, and it occurs when the parathyroid glands or their blood supply are disrupted during the operation.  Fortunately, it is most often a temporary phenomenon which resolves once the parathyroid glands resume normal function.  It is experienced by the patient as numbness or tingling around the fingers, lips, or toes.  If it progresses untreated, it can cause severe muscle cramping and even heart arrhythmias which can cause death.  Historically, patients had their calcium levels checked every 6 hours while in the hospital, and if their calcium levels had stabilized by the morning after surgery, they were cleared for discharge without calcium. 

A greater understanding of calcium metabolism has taught us that the lowest calcium levels do not typically occur until about 2 days after surgery, and that checking calcium levels every 6 hours generally only means more needles for blood draws and an artificial sense of security. 

Patients undergoing total thyroidectomy are routinely started on oral calcium supplements for a duration of 3 weeks after surgery to allow the parathyroid glands to resume normal function.  Occasionally a prescription strength vitamin D supplement is needed to control the hypocalcemia.  It is best to avoid hospitalization whenever possible because intravenously administered calcium causes phlebitis (irritation of the veins), and a higher degree of blood calcium fluctuation. 

4.     Nerve monitoring will reduce my risk of having a weak voice after surgery

False

Technology is available to monitor the function of the recurrent laryngeal nerve during surgery.  Its use is controversial, because it has not been proven to reduce the risk of vocal cord weakness after surgery but it has been proven to increase cost.  Nerve monitoring is of academic interest, and is frequently used in teaching institutions where surgeons write papers about its use.  However, the gold standard of preserving the nerve is visual identification using the surgeon’s eyes.  It is therefore not surprising that the only thing proven to reduce the risk of vocal fold weakness after surgery is surgeon volume and experience. 

Take Home Points

It’s not wrong to be hospitalized after thyroid surgery with a drain, a large incision, and calcium checks every 6 hours.  You can still have an excellent outcome after surgery, but these measures are somewhat antiquated by modern standards.  These measures are unnecessary for an experienced, high volume thyroid surgeon.  Those with high deductible insurance plans should investigate the potential cost savings of eliminating unnecessary equipment and practices. 

Thyroid cancer variant no longer considered cancer

A thyroid cancer previously known as “encapsulated follicular variant of papillary thyroid carcinoma” is no longer classified as a cancer at all.  It is now known as “noninvasive follicular thyroid neoplasm with papillary-like nuclear features”, or NIFTP for short.

This type of lesion is diagnosed through a thyroid lobectomy.  Historically, the treatment would have been a completion thyroidectomy followed by radioactive iodine, but in studies of large volumes of patients, it turns out that additional treatment for these types of lesions is unnecessary.

Moving forward, patients previously diagnosed with these lesions no longer need routine cancer follow-up visits or scans, and patients who are diagnosed with these lesions do not get additional surgery or radioactive iodine indicated for cancerous lesions.

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