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Role of oral calcium supplementation alone or with vitamin D in preventing post-thyroidectomy hypocalcaemia: A meta-analysis.
Xing, T, Hu, Y, Wang, B, Zhu, J
Medicine. 2019;(8):e14455
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Abstract
BACKGROUND Thyroidectomy is the main intervention for thyroid malignancies and some benign thyroid diseases. Its most common complication is hypocalcaemia, which requires oral or intravenous calcium therapy. The aim of this meta-analysis was to assess the efficacy of routine calcium supplementation with or without vitamin D in preventing hypocalcaemia post-thyroidectomy. METHODS Systematic searches of the PubMed, EMBASE, and Cochrane Library databases were performed. The qualities of the included articles were assessed using the Cochrane risk of bias tool. The studies' qualities of outcomes and strengths of evidence were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Data analysis was performed using Review Manager 5.3, and odds ratio (ORs) with their 95% confidence intervals (CIs) were computed for dichotomous data. RESULTS Ten randomized controlled trials (RCTs) were included. The combined study recruited 1620 patients (343 men and 1277 women) who underwent total thyroidectomy alone or with neck dissection. Calcium supplementation decreased the risk of transient postoperative hypocalcaemia (OR 0.48 [95% CI, 0.31-0.74]; P < .001) but did not decrease the demand for intravenous supplementation or the rate of permanent hypocalcaemia compared to no treatment. Calcium and vitamin D supplementation significantly reduced the rate of transient hypocalcaemia and the demand for intravenous supplementation compared to either no treatment (OR 0.21 [95% CI, 0.11-0.40]; P < .001 and OR 0.26 [95% CI, 0.10-0.69]; P = .007, respectively) or calcium alone (OR 0.39 [95% CI, 0.18-0.84]; P = .02 and OR 0.18 [95% CI, 0.07-0.47]; P < .001, respectively), but did not decrease the rate of permanent hypocalcaemia. GRADE-based confidence was moderate. CONCLUSION Postoperative calcium supplementation is effective for preventing post-thyroidectomy hypocalcaemia. Calcium plus vitamin D was more effective than calcium alone in preventing postoperative hypocalcaemia and decreasing the demand for intravenous calcium supplementation. Further, well-designed RCTs with larger sample sizes are required to validate our findings.
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Systematic Review and Meta-Analysis of Unplanned Reoperations, Emergency Department Visits and Hospital Readmission After Thyroidectomy.
Margolick, J, Chen, W, Wiseman, SM
Thyroid : official journal of the American Thyroid Association. 2018;(5):624-638
Abstract
BACKGROUND Unplanned reoperation, emergency department (ED) visits, and hospital readmission following thyroid operations usually arise due to complications and are a source of frustration for both surgeons and patients. With the aim of providing insight important for the development of patient quality care improvement initiatives, the primary objective of this review was to evaluate the available literature systematically in order to determine the contemporary rates of reoperation, readmission, and ED visits following thyroid operations. A secondary study objective was to determine if there were any practices that showed promise in reducing the occurrence of these undesirable postoperative events. METHODS This systematic review was conducted in accordance with the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses protocols. Twenty-two studies were included in the systematic review. Meta-analysis was performed to obtain the weighted-pooled summary estimates of rates of reoperations, ED visits, and unplanned hospital readmission. Jackknife sensitivity analyses were performed for each data set. Finally, in order to detect the risk of publication bias and the small-study effect, funnel plot analysis was performed. RESULTS The pooled rate estimate for reoperation was very low (0.6% [confidence interval (CI) 0.3-1.1%]). This was subject to publication bias because smaller studies tended to report lower rates of reoperation. The pooled rate of ED visits was 8.1% [CI 6.5-9.8%], while the pooled rate of hospital readmission from 19 studies was 2.7% [CI 2.1-3.4%]. Neck hematoma was the most common reason for reoperation, while postoperative hypocalcemia was the most common reason for hospital readmission. CONCLUSIONS ED visits and hospital readmission after thyroidectomy are common, and there are several practices that can reduce their occurrence. Routine postoperative calcium and vitamin D supplementation may reduce rates of postoperative hypocalcemia, and avoiding postoperative hypertension may decrease the risk of neck hematoma development and the need for reoperation. Older age, thyroid cancer, dependent functional status, higher ASA score, diabetes, chronic obstructive pulmonary disease, steroid use, hemodialysis, and recent weight loss increase the risk of hospital readmission after thyroid surgery. By further identifying risk factors for reoperation, ED visits, and readmission, this review may assist practitioners in optimizing perioperative care and therefore reducing patient morbidity and mortality after thyroid operations.
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I-131 for Remnant Ablation in Differentiated Thyroid Cancer After Thyroidectomy: A Meta-Analysis of Randomized Controlled Evidence.
Shengguang, Y, Ji-Eun, C, Lijuan, HL
Medical science monitor : international medical journal of experimental and clinical research. 2016;:2439-50
Abstract
BACKGROUND The aim of this study was to compare the success rate of various levels of I-131 activity for use in remnant ablation in low-risk differentiated thyroid cancer. MATERIAL AND METHODS We identified eligible studies in 5 electronic databases up to December 2014 and the reference lists of original studies and review articles were hand searched for additional articles on this topic. Summary relative risks with their 95% confidence intervals were calculated with a random-effects model. Heterogeneity was assessed using I2 statistics. RESULTS Fourteen randomized clinical trials met the eligibility criteria. The data suggest that the pooled successful ablation rate is 5% lower (95% CI, 1-9% lower) when using 30 mCi compared with 100 mCi (test for heterogeneity, p=0.468, I2=0.0%). In stratified analysis, ablation success rates using 30 mCi are similar to 100 mCi in Asia (SRRs=0.91; 95%CI=0.72-1.14). However, the results favor 100 mCi in Europe (SRRs=0.95; 95%CI=0.91-0.99). Ablation success rates using 30 mCi are similar to 100 mCi in patients who underwent TT/NTT (total thyroidectomy/near total thyroidectomy) (SRRs=0.96; 95%CI=0.92-1.00) and TT/STT (SRRs=0.98; 95%CI=0.73-1.31). However, the result favor 100 mCi in patients who underwent ST/HT (subtotal thyroidectomy/ hemithyroidectomy) (SRRs=0.80; 95%CI=0.65-0.99). There was no publication bias in the present meta-analysis. CONCLUSIONS High radioiodine activity is better than low activity in terms of successful ablation rate in low-risk differentiated thyroid cancer, but the advantage of high activity seems to only exist in patients who underwent hemithyroidectomy/subtotal thyroidectomy, but not lymph node involvement, preparation before ablation, and definition of successful ablation.
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The Effectiveness of Radioactive Iodine Remnant Ablation for Papillary Thyroid Microcarcinoma: A Systematic Review and Meta-analysis.
Hu, G, Zhu, W, Yang, W, Wang, H, Shen, L, Zhang, H
World journal of surgery. 2016;(1):100-9
Abstract
BACKGROUND This systematic review and meta-analysis aimed to evaluate the effectiveness of radioactive iodine (RAI) remnant ablation for thyroid cancer-related outcomes of patients with papillary thyroid microcarcinoma (PTMC). METHODS A systematic literature search of PubMed, EMBASE OvidSP, and EBSCO was conducted. Studies were selected that provided multivariable analysis of the effectiveness of RAI ablation or provided specific data of a 10 years history of thyroid cancer-related outcomes in patients that presented with PTMC. RESULTS Nineteen studies met the inclusion criteria. A multivariable analysis of the effectiveness of RAI ablation for any recurrence or thyroid cancer-related mortality in patients with PTMC was performed in several studies, among which only one study reported a positive result. Furthermore, for PTMC patients treated by total or near-total thyroidectomy (TT/NT), with or without RAI ablative therapy, the meta-analysis suggested that RAI ablation did not decrease the 10 years history of any tumor recurrence (relative risk [RR] 0.96; 95% confidence interval [CI] 0.63-1.48; P = 0.87), locoregional recurrence (RR 1.15; 95% CI 0.75-1.76; P = 0.51), distant metastases (RR 0.32; 95% CI 0.08-1.32; P = 0.11) or thyroid cancer-related mortality (RR 0.76; 95% CI 0.22-2.63; P = 0.66). CONCLUSIONS With regard to multivariable analyses, there was almost no positive treatment effect of RAI ablation noted for patients with PTMC. For PTMC patients already treated by TT/NT, incremental RAI ablation may not be beneficial at decreasing the 10 years recurrence of PTMC or incidence of thyroid cancer-related mortality.
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A systematic review and meta-analysis evaluating completeness and outcomes of robotic thyroidectomy.
Lang, BH, Wong, CK, Tsang, JS, Wong, KP, Wan, KY
The Laryngoscope. 2015;(2):509-18
Abstract
OBJECTIVES/HYPOTHESIS Despite immense interest, robotic-assisted thyroidectomy (RT) remains controversial in differentiated thyroid carcinoma (DTC). This systematic review and meta-analysis compared surgical completeness and/or oncological outcomes between RT and open thyroidectomy (OT) in low-risk DTC. STUDY DESIGN Systematic review. METHODS A systematic review was performed to identify studies that compared surgical completeness and/or oncological outcomes between RT and OT in DTC. Any study that compared at least one parameter relating to surgical completeness and/or oncological outcome for DTC was considered. Number of central lymph nodes (CLNs) retrieved during central neck dissection (CND), preablation stimulated thyroglobulin (sTg) level, radioiodine uptake on post-therapy scan, and locoregional recurrence (LRR) were examined. Meta-analysis was performed using a fixed or random-effects model depending on heterogeneity between studies. RESULTS Ten studies were eligible. Of the 2,205 DTCs, 752 (34.1%) had RT, whereas 1,453 (65.9%) had OT. Relative to OT, RT had significantly fewer CLNs retrieved during CND (4.7 ± 3.2 vs. 5.5 ± 3.8, standardized mean difference [SMD] = -0.240, 95% confidence interval [CI]: -0.364 to -0.116, P < .001) and higher preablation sTg level (3.6 ± 6.7 ng/mL vs. 2.0 ± 5.0 ng/mL, SMD = 0.272, 95% CI: 0.022 to 0.522, P = .033). Interestingly, these differences were more evident in the robotic transaxillary approach (RTAA) than the robotic bilateral axillo-breast approach. After a mean follow-up of 17.7 months, no LRR was found in RT, whereas after 18.6 months, one LRR was found in OT. CONCLUSIONS Relative to OT, total thyroidectomy by RTAA was associated with fewer CLNs retrieved and less-complete thyroid resection. However, using RTAA is unlikely to compromise the outcomes of low-risk DTC because of its inherently good prognosis.
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Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia.
Edafe, O, Antakia, R, Laskar, N, Uttley, L, Balasubramanian, SP
The British journal of surgery. 2014;(4):307-20
Abstract
BACKGROUND Hypocalcaemia is common after thyroidectomy. Accurate prediction and appropriate management may help reduce morbidity and hospital stay. The aim of this study was to perform a systematic literature review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. METHODS A systematic search of PubMed, EMBASE and the Cochrane Library databases was undertaken, and the quality of manuscripts assessed using a modified Newcastle-Ottawa Scale. RESULTS Some 115 observational studies were included. The median (i.q.r.) incidence of transient and permanent hypocalcaemia was 27 (19-38) and 1 (0-3) per cent respectively. Independent predictors of transient hypocalcaemia included levels of preoperative calcium, perioperative parathyroid hormone (PTH), preoperative 25-hydroxyvitamin D and postoperative magnesium. Clinical predictors included surgery for recurrent goitre and reoperation for bleeding. A calcium level lower than 1·88 mmol/l at 24 h after surgery, identification of fewer than two parathyroid glands (PTGs) at surgery, reoperation for bleeding, Graves' disease and heavier thyroid specimens were identified as independent predictors of permanent hypocalcaemia in multivariable analysis. Factors associated with transient hypocalcaemia in meta-analyses were inadvertent PTG excision (odds ratio (OR) 1·90, 95 per cent confidence interval 1·31 to 2·74), PTG autotransplantation (OR 2·03, 1·44 to 2·86), Graves' disease (OR 1·75, 1·34 to 2·28) and female sex (OR 2·28, 1·53 to 3·40). CONCLUSION Perioperative PTH, preoperative vitamin D and postoperative changes in calcium are biochemical predictors of post-thyroidectomy hypocalcaemia. Clinical predictors include female sex, Graves' disease, need for parathyroid autotransplantation and inadvertent excision of PTGs.
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Routine postoperative administration of vitamin D and calcium after total thyroidectomy: a meta-analysis.
Sanabria, A, Dominguez, LC, Vega, V, Osorio, C, Duarte, D
International journal of surgery (London, England). 2011;(1):46-51
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BACKGROUND Temporary hypocalcemia is a frequent complication after total thyroidectomy. Routine postoperative administration of vitamin D and calcium can reduce the incidence of symptomatic postoperative hypocalcemia. We undertook a systematic review to assess the effectiveness of this intervention. METHODS We identified randomized controlled trials comparing the administration of vitamin D or metabolites to oral calcium or no treatment in patients after total thyroidectomy in MEDLINE, EMBASE and LILACS databases. RESULTS Four studies with 706 patients were included: 346 in the calcitriol group, 288 in the oral calcium group and 72 in the control group. The rates of hypocalcemia symptoms were 4%, 19% and 31%, respectively. The OR value for the comparison between calcitriol + calcium as compared to no treatment and to exclusive calcium treatment groups was 0.32 (95% CI, 0.13-0.79) and 0.31 (95% CI, 0.14-0.70), respectively. CONCLUSION The prophylactic treatment with vitamin D or metabolites + calcium is effective to decrease the incidence of symptoms of temporary hypocalcemia.