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Endocrine

P29: Hypocalcemia after cervical procedures in patients with history of short segment gastrojejunostomy: A multi-institutional study

Introduction: Hypocalcemia is common after parathyroidectomy and total thyroidectomy. Rates are increased in patients with histories of bariatric Roux-en-Y gastric bypass (RYGB), attributed to the loss of the predominant vitamin-D dependent calcium absorption in the proximal small intestine. We hypothesized that patients with prior short segment, non-bariatric gastrojejunostomy would also experience increased rates of hypocalcemia.

Methods: We performed a multi-institutional retrospective cohort study to evaluate patients who presented for parathyroidectomy and/or total thyroidectomy at three tertiary centers (2003-2023) and had undergone prior: 1. Short segment gastrojejunostomy following a Whipple, total pancreatectomy, or distal gastrectomy (GJ); 2. Bariatric RYGB (RYGB); or 3. Sleeve gastrectomy (SG). The primary outcomes were early (≤ 6 months) and late ( >6 months) postoperative hypocalcemia after the cervical operation, defined by individual institutional laboratory parameters and corrected for hypoalbuminemia. Chi-squared tests and logistic regression were performed.

Results: For 209 study patients (GJ: N=25, RYGB: N=103, and SG: N=81), the median age was 56 years (IQR:49-65), and 84% were female. A median of 50.2 (IQR:18.2-86.6) months elapsed between the intestinal and cervical operations. Most patients received postoperative calcium carbonate (67%) or calcium citrate (25%), with no difference in formulation between groups. Early hypocalcemia was present in 68% (GJ), 55% (RYGB), and 46% (SG) of patients, not statistically different between groups. Late hypocalcemia was significantly more common in patients with prior GJ (56%, p=0.04) or RYGB (47%, p=0.04) compared to SG (30%, Figure 1). By multivariable analysis, early hypocalcemia correlated with prior GJ (Coeff. 1.4, p=0.03), and late hypocalcemia correlated with prior GJ (Coeff. 1.5, p=0.02) or RYGB (Coeff. 1.2, p=0.004). Administration of calcium citrate and higher doses of elemental calcium were not protective against the presence of hypocalcemia or the nadir calcium level at each timepoint. Preoperative calcium levels did not correlate with early postoperative hypocalcemia.

Conclusions: Early and late postoperative hypocalcemia are exceedingly common after cervical procedures in patients with prior short segment GJ or bariatric RYGB. Traditional management does not eliminate the risk of hypocalcemia. This study highlights the need to further investigate strategies to mitigate hypocalcemia in these high-risk patients.

Learning Objectives:

  • Upon completion, participants will be able to understand anatomically why a patient with a history of gastrojejunostomy is at risk for postoperative hypocalcemia after cervical procedures.
  • Upon completion, participants will be able to quantify the risk of hypocalcemia after cervical procedures in patients with prior short-segment gastrojejunostomy or bariatric Roux-en-Y gastric bypass.
  • Upon completion, participants will be able to recognize independent predictors of hypocalcemia in patients with prior short-segment gastrojejunostomy or bariatric Roux-en-Y gastric bypass.