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Background The optimal protocol for the detection and treatment of post-thyroidectomy hypoparathyroidism is unknown. We sought to identify and treat patients at risk for symptomatic hypocalcemia based on a single PTH obtained the morning after surgery (POD1). Methods We performed a prospective, randomized study of total thyroidectomy patients who had POD1 calcium and PTH (pg/mL) levels. Randomization was based on POD1 PTH: if ≥10, patients received no supplementation unless symptomatic; if <10, patients were randomized to calcium, calcium and calcitriol, or no supplementation. Results Of 143 patients, 112 (78%) had a POD1 PTH≥10. Hypocalcemic symptoms were transiently reported in 11 (10%) and managed with outpatient calcium. Of 31 patients with PTH<10, 15 (48%) developed symptoms, including 5 who required IV calcium. On multivariate logistic regression analysis, when adjusting for postoperative calcium level and performance of central neck dissection, predictors of hypocalcemic symptoms were younger age (OR 1.59, 95%CI 1.07 – 2.32) and a PTH <10 (OR 1.08, 95%CI 1.04 – 1.12). There were no patient or treatment-related factors that predicted a POD1 PTH<10. Conclusion A single POD1 PTH level<10 can accurately identify those patients at risk for clinically significant hypocalcemia. All total thyroidectomy patients with a postoperative PTH≥10 can be safely discharged without supplementation. Given the small number of patients with PTH<10, it is unclear if both calcium and calcitriol are needed for these higher-risk patients.

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Surgical volume influences the failure pattern after parathyroidectomy for hyperparathyroidism. Preventable operative failures are more common in low-volume centers.

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