Research

JAMA Otolaryngology–Head & Neck Surgery | Original Investigation

Association of Preoperative Calcium and Calcitriol Therapy

With Postoperative Hypocalcemia After Total Thyroidectomy
Anne K. Maxwell, MD; David C. Shonka Jr, MD; Derek J. Robinson, MD; Paul A. Levine, MD

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

OBJECTIVE To determine the effectiveness of preoperative calcium and calcitriol

supplementation in reducing hypocalcemia following total thyroidectomy.

DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted at a

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

INTERVENTIONS Calcium and calcitriol therapy.

MAIN OUTCOMES AND MEASURES Postoperative serum calcium levels and development of
postoperative hypocalcemia.

RESULTS Of the 65 patients who underwent total thyroidectomy 27 (42%) were men; mean
(SD) age was 49.7 (16.7) years. Thirty-three patients received preoperative calcium and
calcitriol supplementation, and 32 patients received only postoperative therapy. In the
preoperative supplementation group, 15 of 33 (45%) patients underwent complete central
compartment neck dissection and 11 of 33 (33%) had lateral neck dissection, compared with
16 of 32 (50%) and 12 of 32 (38%), respectively, patients without preoperative
supplementation. The mean measured serum calcium level in those without preoperative
supplementation vs those with supplementation are as follows: preoperative, 9.6 vs 9.4
mg/dL (absolute difference, 0.16; 95% CI, −0.12 to 0.49 mg/dL); 12 hours postoperative, 8.3
vs 8.6 mg/dL (absolute difference, −0.30; 95% CI, −0.63 to 0.02 mg/dL); and 24 hours
postoperative, 8.4 vs 8.5 mg/dL (absolute difference, −0.13; 95% CI, −0.43 to 0.16 mg/dL).
In patients not receiving preoperative supplementation, 5 of 32 (16%) individuals became
symptomatically hypocalcemic vs 2 of 33 (6%) in the preoperative supplementation group;
an absolute difference of 10% (95% CI, −6.6% to 26.3%). Compared with the group not
receiving preoperative supplementation, the mean [SD] length of stay was significantly
shorter in the preoperative supplementation group (3.8 [1.8] vs 2.9 [1.4] days; absolute Author Affiliations: University of
difference, −0.9; 95% CI, −1.70 to −0.105 days). Preoperative supplementation resulted in an Virginia School of Medicine,
estimated $2819 savings in charges per patient undergoing total thyroidectomy. University of Virginia Health System,
Charlottesville (Maxwell); Now with
Department of Otolaryngology,
CONCLUSIONS AND RELEVANCE Preoperative calcium and calcitriol supplementation, in University of Colorado, Denver
addition to routine postoperative supplementation, was associated with a reduced incidence (Maxwell); Department of
of symptomatic hypocalcemia, length of hospital stay, and overall charges following total Otolaryngology–Head and Neck
Surgery, University of Virginia Health
thyroidectomy. System, Charlottesville (Shonka,
Robinson, Levine).
Corresponding Author: David C.
Shonka Jr, MD, Department of
Otolaryngology–Head and Neck
Surgery, University of Virginia Health
JAMA Otolaryngol Head Neck Surg. 2017;143(7):679-684. doi:10.1001/jamaoto.2016.4796 System, Box 800713, Charlottesville,
Published online April 13, 2017. VA 22908 (dcs5z@virginia.edu).

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 Research Original Investigation
H
ypocalcemia is the most frequent complication of total
thyroidectomy. It can be defined either biochemi-
cally or clinically. There is no universal agreement on
the serum calcium level that constitutes biochemical hypo-
calcemia, but many studies define this as a measured serum
calcium level less than 8.0 mg/dL (to convert to millimoles per
liter, multiply by 0.25). Patients with clinical hypocalcemia ex-
hibit symptoms of perioral or fingertip numbness or tingling,
or presence of the Chvostek sign in the setting of biochemical
hypocalcemia. Hypocalcemia may also be categorized tempo-
rally as transient or permanent. In transient hypocalcemia, se-
rum calcium levels reach a nadir from 24 to 48 hours postop-
eratively, but subsequently return to the reference range within
6 months.1-3 Permanent hypocalcemia is defined as hypocal-
cemia persisting beyond 6 months postoperatively and is due
to permanent hypoparathyroidism. It is less frequent, occur-
ring in 2% to 8% of patients, compared with transient hypo-
calcemia, which occurs in up to half of patients.3-6 Persistent
symptomatic hypocalcemia, intravenous calcium require-
ments, and laboratory monitoring often prolong hospital stay
and delay recovery after total thyroidectomy.1 More severe risks
to the patient who experiences significant hypocalcemia in-
clude hypotension, tetany, seizure, and arrhythmia. The pa-
tients also bear additional financial burdens when they expe-
rience this complication, including hospital charges for
repletion, laboratory testing, and increased length of hospi-
tal stay.
Calcium absorption is regulated primarily via parathy-
roid hormone and vitamin D. Vitamin D3 (cholecalciferol) is
acquired via diet or photon-stimulated conversion of
precursors in the skin. In the liver, it is hydroxylated to 25-
hydroxyvitamin D3 (calcifediol), which, due to its half-life of
2 to 3 weeks, is the most useful measure of vitamin D levels.
When stimulated by parathyroid hormone, the enzyme 1α- hy-
droxylase in the kidney further hydroxylates 25-OHD3 to the
active form 1,25-dihydroxyvitamin D3 (calcitriol).1,7 Acti-
vated vitamin D increases calcium absorption from the intes-
tine. Vitamin D deficiency is a known independent risk factor
for postthyroidectomy hypocalcemia.1,8,9 Previous research has
identified 15 ng/mL as the threshold below which patients ex-
perience an increased risk of transient postoperative
hypocalcemia.8,10 Underlying secondary hyperparathyroid-
ism due to low calcium and vitamin D levels is thought to be
the mechanism behind the increased risk of hypocalcemia in
patients with vitamin D deficiency.8
Previous studies have demonstrated the efficacy of routine
postoperative calcium and vitamin D supplementation as a pro-
phylactic strategy for preventing hypocalcemia in patients un-
dergoing total thyroidectomy, but evaluations of preoperative
supplementation are limited.2,11-14 Preoperative supplementa-
tion with vitamin D in inactivated forms (ergocalciferol, chole-
calciferol) is unlikely to be beneficial because this can require up
to two 8-week courses of supplementation, which is unrealistic
in the preoperative setting.15 One single-arm study of preopera-
tive and postoperative supplementation with calcium and inac-
tivated vitamin D in patients undergoing total thyroidectomy
showed rates of symptomatic hypocalcemia and biochemical hy-
pocalcemia of 6% and 10%, respectively.16 Alternatively, activated
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Preoperative Calcium and Calcitriol and Hypocalcemia After Thyroidectomy
Key Points
Question Does preoperative calcium and calcitriol
supplementation decrease the incidence of hypocalcemia
following total thyroidectomy?
Findings In this cohort study of 65 patients, preoperative
supplementation with calcium and calcitriol was associated with a
reduced incidence of symptomatic hypocalcemia, length of
hospital stay, and overall costs following total thyroidectomy.
Meaning This study supports the use of preoperative calcium and
calcitriol supplementation for patients undergoing total
thyroidectomy.
vitamin D (ie, calcitriol) is immediately bioavailable and is theo-
retically beneficial within a few days of initiating therapy. The
hypothesis of this study is that preoperative supplementation
with calcium and calcitriol would result in decreased postthy-
roidectomy hypocalcemia and a shorter hospital stay. To our
knowledge, there are no published prospective studies to date
comparing preoperative and postoperative calcitriol and calcium
supplementation with postoperative supplementation alone.
Methods
A retrospective cohort study was conducted of patients un-
dergoing total thyroidectomy at the University of Virginia De-
partment of Otolaryngology–Head and Neck Surgery be-
tween January 1, 2008, and December 31, 2011. Data analyses
were conducted from March through June 2012, and from Oc-
tober through December 2016. This study was approved by the
University of Virginia Institutional Review Board with waiver
of informed consent. There was no financial compensation.
Patients were included in the study if they had a total thy-
roidectomy performed by the senior author (P.A.L.), if they
were treated with routine postoperative calcium and cal-
citriol supplementation, and if the presence or absence of pre-
operative calcium and calcitriol supplementation was clearly
documented in the medical record. Patients were analyzed in
2 groups: (1) those who received 5 days of preoperative oral cal-
cium carbonate, 1000 to 1500 mg, 3 times daily and cal-
citriol, 0.25 to 0.5 μg twice daily supplementation and (2) those
who did not receive preoperative supplementation. Both
groups received routine postoperative calcium and calcitriol
supplementation at dosages the same as those described above.
The decision to treat patients with preoperative calcium and
calcitriol supplementation was made by the senior author at
the time of the preoperative workup in clinic. Although this
was not designed as a prospective trial, during the time of this
study there was a gradual transition from never using preop-
erative calcium and calcitriol supplementation to the routine
use of preoperative supplementation. During this transition in
clinical practice, the senior author randomly treated patients
with preoperative supplementation without regard to labora-
tory results or planned extent of surgery.
For patients who met the inclusion criteria, data collected
from the electronic medical record included age, sex, diagnosis,
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 Preoperative Calcium and Calcitriol and Hypocalcemia After Thyroidectomy
Table 1. Patient Demographics
No. (%)
Characteristic No Preoperative Supplement Preoperative Supplement
Patients, No. 32 33
Men 16 (50) 11 (33)
Women 16 (50) 22 (67)
Age, mean (SD), y 47 (16) 52 (17)
Diagnosis
Cancer 26 (81) 29 (88)
Benign 6 (19) 4 (12)
Central ND 16 (50) 15 (45)
Lateral ND 12 (38) 11 (33)
procedure performed (with or without a concomitant neck dis-
section), preoperative and postoperative calcium levels, symp-
tomatic hypocalcemia, intravenous calcium repletion, length
of hospital stay, and readmissions or emergency department vis-
its that were related to hypocalcemia. Patients who under-
went a subtotal thyroidectomy or completion thyroidectomy
were excluded. During the postoperative hospitalization, se-
rum calcium levels were checked every 12 hours. All patients
received the same postoperative regimen of oral calcium and
calcitriol supplementation. Intravenous calcium was given if se-
rum calcium levels dropped below 7.5 mg/dL or if the patient
developed symptoms of hypocalcemia (perioral numbness and
tingling, paresthesias, cramps or spasms of the hands and feet,
and/or the Chvostek sign) in the setting of serum calcium lev-
els lower than 8.0 mg/dL.
Primary outcome measures were postoperative calcium
levels and the development of postoperative hypocalcemia (cal-
cium levels <8.0 mg/dL). Secondary outcome measures were
development of symptomatic hypocalcemia (calcium level
<8 mg/dL with symptoms), length of hospital stay, and re-
quirements for intravenous calcium.
An analysis of hospital and pharmacy charges was per-
formed for patients in both groups using the mean number of
days each patient spent in the hospital postoperatively ($3042
per day) and mean number of intravenous calcium gluconate
doses required ($121 per 2-g dose). For patients receiving pre-
operative calcitriol and calcium supplementation, the charges
for 5 days of calcitriol ($1.20 per 0.25-μg tablet; dosage 0.5 μg
twice daily) and 5 days of oral calcium carbonate ($0.12 per
500-mg tablet; dosage 1500 mg 3 times daily) were calcu-
lated. These charges were then summed to determine the mean
total difference in charges per patient.
Statistical Analysis
The frequency of hypocalcemia is presented as the number and
percentage of patients in each group who experienced that
complication. The length of hospital stay is presented as the
mean (SD). Calcium levels in each group are presented as the
mean preoperatively and at approximately 12 and 24 hours
postoperatively. Group differences were analyzed using the χ2
test. Statistical analysis was performed with SPSS, version 20.0
(IBM Corp), using 2-tailed, paired and unpaired t tests and the
Fisher exact test, where indicated.
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Original Investigation Research
Effect Size (95% CI), %
17 (−7 to 38)
5.2 (−3.1 to 13.4)
7 (−11 to 25)
5 (−19 to 27)
4 (−18 to 26)
Abbreviation: ND, neck dissection.
Results
Demographics
Between January 1, 2008, and December 31, 2011, 65 patients
(mean [SD] age, 49.7 [16.7] years) underwent total thyroidec-
tomy performed by the senior author and met inclusion cri-
teria for analysis. Of those, 33 patients received preoperative
and postoperative calcium and calcitriol supplementation and
32 patients received only postoperative therapy. In the preop-
erative supplementation group, 22 of 33 patients (67%) were
women; in the group not receiving preoperative supplemen-
tation 16 of 32 (50%) were women for a difference in sex be-
tween the 2 treatment groups of 17% (95% CI, −7% to 38%). A
similar number of patients in each group underwent thyroid-
ectomy for cancer: 29 of 33 (88%) of the preoperative supple-
mentation group and 26 of 32 (81%) of those not receiving
supplementation.
In the group receiving preoperative supplementation, 15
of 33 patients (45%) underwent central compartment neck dis-
section and 11 of 33 (33%) underwent lateral neck dissection.
Of those without preoperative supplementation, 16 of 32 (50%)
and 12 of 32 (38%) patients had central compartment and lat-
eral neck dissections, respectively. There was no statistically
significant difference in the demographic data between the 2
groups (Table 1).
Biochemical Calcium Status
Serum calcium levels were measured and recorded preopera-
tively and again at 12 and 24 hours postoperatively. The mean
measured serum calcium level in patients without preopera-
tive supplementation vs those with preoperative supplemen-
tation were as follows: preoperative, 9.6 vs 9.4 mg/dL (abso-
lute difference, 0.16; 95% CI, −0.12 to 0.49); 12 hours
postoperative, 8.3 vs 8.6 mg/dL (absolute difference, −0.30;
95% CI, −0.63 to 0.02); and 24 hours postoperative, 8.4 vs 8.5
mg/dL (absolute difference, −0.13; 95% CI, −0.43 to 0.16)
(Figure 1). The decrease in serum calcium levels from base-
line to 12 hours postoperative was significantly greater in the
group that received postoperative supplementation only (ab-
solute difference, −0.36 mg/dL; 95% CI, −0.6 to −0.05)
(Figure 2). At 24 hours postoperatively, 5 of 33 (15%) patients
in the preoperative supplementation group had serum cal-
681
 Research Original Investigation
Figure 1. Preoperative, 12-Hour Postoperative, and 24-Hour
Postoperative Serum Calcium Levels
12 Without preoperative
supplementation
With preoperative
11 supplementation
10
Calcium, mg/dL
9
8 8.0
7
6
Preoperative 12 24
Time, h
To convert calcium levels to millimoles per liter, multiply by 0.25. The bar within
the quartile boxes represents the median value; error bars indicate 95% CIs;
dots indicate outliers.
cium levels below 8.0 mg/dL vs 10 of 32 (31%) patients who
did not receive preoperative supplementation for an absolute
difference between the 2 groups of 16% (95% CI, −4% to 35%)
(Table 2).
Clinical Calcium Status
During their postoperative course, 2 of 33 (6%) of the preop-
erative supplementation group became symptomatically hy-
pocalcemic, compared with 5 of 32 (16%) in the group with-
out preoperative supplementation for an absolute difference
of 9.6% (95% CI, −6.6% to 26.3%). No patients receiving pre-
operative supplementation were readmitted to the hospital or
visited the emergency department. In the group without pre-
operative supplementation, 3 of 32 (9%) patients required re-
admission or were seen in the emergency department for symp-
toms of hypocalcemia (absolute difference, 9%; 95% CI, −3%
to 24%). Those who received preoperative supplementation
had a mean postoperative hospital stay of 2.9 (1.4) days, which
was significantly shorter by 0.9 days compared with those with-
out preoperative supplementation who stayed a mean of 3.8
(1.8) days (95% CI, 0.11 to 1.70) (Table 2).
Hospital/Pharmacy Charge Analysis
Preoperative supplementation with calcium and calcitriol
resulted in charges of $29 per patient, based on the dosage of
1500 mg of oral calcium carbonate 3 times daily and 0.5 μg
of calcitriol twice daily starting 5 days before surgery. The
group receiving preoperative supplementation required a
total of 10 doses of intravenous calcium gluconate, which
resulted in a mean charge of $37 (83) per patient. The group
without supplementation required a total of 37 doses of
intravenous calcium, with a mean charge of $140 (246) per
patient. Assuming a hospital charge of $3042 per day, the
mean charge for the hospital stay per patient receiving pre-
operative supplementation (mean hospital stay, 2.9 [1.4]
days) was $8757. The mean charge of the hospital stay per
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Preoperative Calcium and Calcitriol and Hypocalcemia After Thyroidectomy
Figure 2. Change in Serum Calcium Levels From Baseline
10.0
9.5
Calcium Level, mg/dL
9.0
8.5
Without preoperative
supplementation
With preoperative
supplementation
7.5
Preoperative 12-h Postoperative
To convert calcium levels to millimoles per liter, multiply by 0.25.
patient not receiving preoperative supplementation (mean
hospital stay, 3.8 [1.8] days) was $11 503. Both groups
received similar routine postoperative oral calcium and cal-
citriol supplementation, so these charges were not calcu-
lated in the analysis. Thus, preoperative supplementation
resulted in an estimated $2819 savings in charges per patient
undergoing total thyroidectomy (Table 3).
Complications of Treatment
No patient in either group experienced symptoms of hyper-
calcemia. No patients experienced adverse effects of cal-
citriol and/or calcium supplementation. All patients reported
adherence to prescribed dosing and none reported adverse
symptoms.
Discussion
Transient hypocalcemia is a common complication follow-
ing total thyroidectomy, occurring in up to one-half of
patients, 3,5 and serum calcium levels reach their nadir
approximately 24 hours postoperatively. Calcitriol increases
calcium absorption by promoting expression of calcium-
binding protein in intestinal cells, thus increasing intestinal
calcium transport across the mucosa into the blood.7 This
effect on calcium absorption requires several days. There-
fore, preoperative supplementation in patients undergoing
thyroidectomy with calcitriol would be expected to increase
the efficacy of routine calcium supplementation in the
immediate postoperative period, thereby mitigating the
extent of transient hypocalcemia.
The aim of this study was to examine the effect of 5 days
of preoperative supplementation with calcium and calcitriol
on the incidence of postthyroidectomy hypocalcemia. In this
study, patients in the preoperative supplementation group re-
ceived a straightforward regimen of calcium and calcitriol for
5 days immediately prior to surgery. The short time-frame al-
lows preoperative supplementation to be accomplished with-
out unduly delaying definitive surgical treatment of the un-
derlying thyroid disorder. The low pharmacy charge of
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 Preoperative Calcium and Calcitriol and Hypocalcemia After Thyroidectomy Original Investigation Research

Table 2. Results

No. (%)
Characteristic No Preoperative Supplement Preoperative Supplement Effect Size % (95% CI)
Biochemical
Calcium level <8.0 at 24 h 10 of 32 (31) 5 of 33 (15) 16 (−4.5 to 35.4)
Clinically symptomatic 5 of 32 (16) 2 of 33 (6) 9.6 (−6.6 to 26.3)
IV calcium repletion Abbreviations: ED, emergency
Required 11 of 32 (34) 7 of 33 (21) 13.2 (−8.5 to 33.4) department; IV, intravenous.
No. of dosesa 37 10 SI conversion factor: To convert
calcium to millimoles per liter,
Readmissions/ED visits 3 of 32 (9) 0 of 33 9.4 (−2.7 to 24.2)
multiply by 0.25.
Length of stay, mean (SD), d 3.8 (1.8) 2.9 -0.90 (-1.70,-0.11) a
Effect size, 27 doses.

Table 3. Hospital/Pharmacy Charge Analysis

Charges per Patient, Mean (SD), $

Characteristic No Preoperative Supplement Preoperative Supplement Difference (95% CI)
IV calcium repletion 139.91 (246.08) 36.67 (82.76) 103.24 (12.80 to 193.68)
Length of stay 11 502.56 (5394.00) 8757.27 (4352.66) 2745.29 (319.49 to 5171.09)
Preoperative supplementation 0 29.40 (0) −29.40 (−29.40)
Total 11 642.47 (5512.97) 8823.34 (4388.22) 2819.13 (353.31 to 5284.95)

Abbreviation: IV, intravenous.

supplementation ($29 per patient), twice-daily dosing, and ab-
sence of reported adverse effects in this study can encourage
adherence to the treatment.
This study demonstrated a significant decrease in post-
operative hospital stay for patients receiving preoperative
supplementation (2.9 days) compared with those who did not
(3.8 days)—a mean decrease of nearly 1 full day. Although se-
rum calcium levels in both groups decreased from baseline lev-
els postoperatively, the decrease was 0.36 mg/dL greater in pa-
tients who did not receive preoperative supplementation,
which was statistically and clinically significant. These data
also demonstrate a decreased incidence of both biochemical
and clinical hypocalcemia, need for intravenous calcium reple-
tion, and hospital readmissions with the upper bound of the
95% CI consistent with as much as a 35%, 26%, 33%, and 24%
reduction, respectively, in each of these factors associated with
preoperative supplementation. These differences translated
into significant savings in charges for the preoperative supple-
mentation group. Based on these results, preoperative supple-
mentation, in addition to routine postoperative supplemen-
tation, should be considered for patients undergoing total
thyroidectomy.
Limitations
This study contains limitations. First, the patient population
may not be representative of a typical thyroidectomy prac-
tice. This is demonstrated by the high percentage of study pa-
tients undergoing thyroidectomy for cancer (85%) and under-
going a complete central compartment neck dissection (46%)
and/or lateral neck dissection (35%) in addition to total thy-
roidectomy. The incidence of temporary hypocalcemia has
been shown to be much higher in patients with a diagnosis of
cancer undergoing central compartment neck dissections or
lateral neck dissections at the time of total thyroidectomy.17,18
As a result, the patient population in this study may be at
greater risk of postoperative hypocalcemia and receive greater
benefit from preoperative supplementation compared with a
more typical patient population. Second, patients were not ran-
domized to their respective treatment groups and preopera-
tive supplementation was provided at the discretion of the sur-
geon. Although the surgeon did not use preoperative laboratory
results or the planned extent of surgery to decide to prescribe
preoperative supplementation, because the study was not de-
signed as a randomized trial, there may have been a selection
bias with patients presumed to be at greater risk of postopera-
tive hypocalcemia receiving preoperative supplementation.
This bias would result in a diminished observed effect of pre-
operative supplementation. Presumably the selection bias was
minimal since the patient characteristics (cancer incidence and
extent of surgery) of the 2 groups were similar. Nonetheless,
future studies would benefit from randomized analysis. Third,
vitamin D levels were not routinely measured preopera-
tively. Because patients with low vitamin D levels are more
likely to develop postoperative hypocalcemia, a preponder-
ance of these patients in either group would be expected to
affect the results. Finally, to more precisely quantify the im-
pact of preoperative supplementation, future studies may ben-
efit from an increased sample size.
Conclusions
Preoperative calcium and calcitriol supplementation
resulted in increased postoperative serum calcium levels,
lower postoperative intravenous calcium repletion require-
ment, and less symptomatic hypocalcemia in this cohort of
patients undergoing total thyroidectomy. Direct patient ben-
efits include fewer symptoms, significantly decreased length

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 Research Original Investigation
of hospital stay, decreased hospital readmissions, and
decreased charges. Benefits to society include reduction in
health care costs. Weighing the safety of a short course of
calcium and calcitriol supplementation against the risks
ARTICLE INFORMATION
Accepted for Publication: December 24, 2016.
Published Online: April 13, 2017.
doi:10.1001/jamaoto.2016.4796
Author Contributions: Drs Maxwell and Shonka
contributed equally to the study, had full access to
all the data in the study, and take responsibility for
the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Shonka, Levine.
Acquisition, analysis, or interpretation of data:
Maxwell, Shonka, Robinson.
Drafting of the manuscript: Maxwell, Shonka.
Critical revision of the manuscript for important
intellectual content: Shonka, Robinson, Levine.
Statistical analysis: Maxwell, Shonka, Robinson.
Supervision: Shonka, Levine.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Meeting Presentation: This study was presented
as a poster at the Combined Sections Meeting,
Triological Society; January 25, 2013; Scottsdale,
Arizona.
REFERENCES
1. Erbil Y, Bozbora A, Ozbey N, et al. Predictive
value of age and serum parathormone and vitamin
D3 levels for postoperative hypocalcemia after total
thyroidectomy for nontoxic multinodular goiter.
Arch Surg. 2007;142(12):1182-1187.
2. Roh JL, Park CI. Routine oral calcium and vitamin
D supplements for prevention of hypocalcemia
after total thyroidectomy. Am J Surg. 2006;192(5):
675-678.
684 JAMA Otolaryngology–Head & Neck Surgery July 2017 Volume 143, Number 7 (Reprinted)
© 2017 American Medical Association. All rights reserved.
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Preoperative Calcium and Calcitriol and Hypocalcemia After Thyroidectomy
associated with postthyroidectomy hypocalcemia, this study
supports the use of preoperative supplementation in addi-
tion to postoperative supplementation for patients undergo-
ing total thyroidectomy.
3. Testa A, Fant V, De Rosa A, et al. Calcitriol plus
hydrochlorothiazide prevents transient
post-thyroidectomy hypocalcemia. Horm Metab Res.
2006;38(12):821-826.
4. Mehanna HM, Jain A, Randeva H, Watkinson J,
Shaha A. Postoperative hypocalcemia—the
difference a definition makes. Head Neck. 2010;32
(3):279-283.
5. Reeve T, Thompson NW. Complications of
thyroid surgery: how to avoid them, how to manage
them, and observations on their possible effect on
the whole patient. World J Surg. 2000;24(8):971-975.
6. Jacobs JK, Aland JW Jr, Ballinger JF. Total
thyroidectomy: a review of 213 patients. Ann Surg.
1983;197(5):542-549.
7. Bringhurst FR, Demay MB, Krane SM,
Kronenberg HM. Bone and mineral metabolism in
health and disease. In: Longo DL, Fauci AS, Kasper
DL, Hauser SL, Jameson JL, Loscalzo J, eds.
Harrison's Principles of Internal Medicine. 18th ed.
New York: McGraw-Hill; 2012.
8. Kirkby-Bott J, Markogiannakis H, Skandarajah A,
Cowan M, Fleming B, Palazzo F. Preoperative
vitamin D deficiency predicts postoperative
hypocalcemia after total thyroidectomy. World J Surg.
2011;35(2):324-330.
9. Erbil Y, Ozbey NC, Sari S, et al. Determinants of
postoperative hypocalcemia in vitamin D–deficient
Graves’ patients after total thyroidectomy. Am J Surg.
2011;201(5):685-691.
10. Erbil Y, Barbaros U, Temel B, et al. The impact of
age, vitamin D3 level, and incidental
parathyroidectomy on postoperative hypocalcemia
after total or near total thyroidectomy. Am J Surg.
2009;197(4):439-446.
11. Roh JL, Park JY, Park CI. Prevention of
postoperative hypocalcemia with routine oral
calcium and vitamin D supplements in patients with
differentiated papillary thyroid carcinoma
undergoing total thyroidectomy plus central neck
dissection. Cancer. 2009;115(2):251-258.
12. Sanabria A, Dominguez LC, Vega V, Osorio C,
Duarte D. Routine postoperative administration of
vitamin D and calcium after total thyroidectomy:
a meta-analysis. Int J Surg. 2011;9(1):46-51.
13. Tartaglia F, Giuliani A, Sgueglia M, Biancari F,
Juvonen T, Campana FP. Randomized study on oral
administration of calcitriol to prevent symptomatic
hypocalcemia after total thyroidectomy. Am J Surg.
2005;190(3):424-429.
14. Bellantone R, Lombardi CP, Raffaelli M, et al.
Is routine supplementation therapy (calcium and
vitamin D) useful after total thyroidectomy? Surgery.
2002;132(6):1109-1112.
15. Bordelon P, Ghetu MV, Langan RC. Recognition
and management of vitamin D deficiency. Am Fam
Physician. 2009;80(8):841-846.
16. Docimo G, Tolone S, Pasquali D, et al. Role of
pre and post-operative oral calcium and vitamin D
supplements in prevention of hypocalcemia after
total thyroidectomy. G Chir. 2012;33(11-12):374-378.
17. Shindo M, Stern A. Total thyroidectomy with
and without selective central compartment
dissection: a comparison of complication rates.
Arch Otolaryngol Head Neck Surg. 2010;136(6):
584-587.
18. Roh JL, Park JY, Park CI. Total thyroidectomy
plus neck dissection in differentiated papillary
thyroid carcinoma patients: pattern of nodal
metastasis, morbidity, recurrence, and
postoperative levels of serum parathyroid
hormone. Ann Surg. 2007;245(4):604-610.
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