Prospective Analysis of Post-Operative Complications After Thyroid Surgery in a Tertiary Care Hospital

This study aimed to document thyroidectomy outcomes in the surgical endocrine unit, Mulago Hospital, Kampala, Uganda. The burden of global surgical disease is currently receiving much attention, especially in countries experiencing epidemiological transition. There is a paucity of publications on surgical outcomes from Sub-Saharan Africa. International thyroid guidelines from high-income countries do not factor in the logistical challenges or the advanced pathology faced by the surgeon in resource-limited settings. This was a prospective cohort study in 2013. Eight peri-operative variables of poor outcome were analysed statistically against six outcomes variables. Data was collected from 0 to 6 months post-operatively. Forty-two thyroidectomies were performed over a 3-month period (female = 38). Intraoperative events recorded included rebleeding = 10 %, infection = 0 %, transient voice symptoms = 30 %, transient hypocalcaemia = 12.5 %, recurrent laryngeal nerve (RLN) paralysis = 7.5 % and permanent hypocalcaemia = 15 %. There was a weak powered association between RLN paralysis and total thyroidectomy and smaller thyroid size. There were associations between large thyroid size and both permanent hypocalcaemia and rebleeding. Younger patients showed statistically more transient voice changes compared to older patients. Older patients were statistically more likely to develop rebleeding. Shorter operative duration was associated with transient voice change, permanent hypocalcaemia and rebleeding. Airway difficulties and transient hypocalcaemia were statistically significant in prolonged procedures. Whilst the thyroidectomy outcomes are not equal to international standards, an acceptable standard is achievable in this resource-limited setting. Poor outcomes are multifactorial but extremes of thyroid size, extremes of operation duration and total thyroidectomies all have statistically poorer outcomes in this setting.

Úvod: Poranění zvratného nervu je jedna znejzávažnějších komplikací chirurgie štítné žlázy, chirurgie příštítných tělísek achirurgie krčních obratlů. Vliteratuře se popisuje poranění zevní větve hrtanových nervů jako méně časté. Tato komplikace je natolik vážná, že může vést kinvalidizaci hlasových profesionálů (učitelů, herců, zpěváků, profesionálních řečníků amanažerů). Současná klinická praxe je spojena se zvýšeným úsilím operoperační ochranu funkce zvratných nervů využíváním elektrofyziologické monitorace funkce inervace hrtanu asoučasné vizualizace zvratných nervů. Metody: Design studie je prospektivní observační. Ze souboru 100 po sobě jdoucích operací byly chirurgy náhodně vytvořeny dvě skupiny: Skupina A- spoužitím neuromonitoringu (IONM) askupina B - identifikace avizualizace zvratného nervu (NLR) bez IONM. Jeden tým chirurgů byl složen zexperta (více než 1000 provedených operací) azačínajícího chirurga (méně než 100 operací) adruhý ze dvou zkušených chirurgů (jeden více než 150 operací adruhý více než 500 operací). Každý tým byl zapojen do operací několikrát vtýdnu. Porovnání bylo provedeno statistickými metodami apomocí indexu poranění zvratného nervu (recurrent nerve injury - IRI). Cílem studie je porovnat incidenci parézy zvratných nervů při využití neuromonitorace (IONM) avyužití peroperační vizualizace anatomicky neporaněného nervu dvěma týmy chirurgů. Výsledky: Bylo analyzováno 100 operací, respektive 50 operací ve skupině Aa50 ve skupině B. Skupina Azahrnovala 43 totálních thyreoidektomií a7 hemithyreoidektomií abyly zjištěny dvě dočasné jednostranné parézy. Skupina Aměla IRI=1,075. Skupina B zahrnovala 48 totálních thyreoidektomií a2 hemithyreoidektomie. Vtéto skupině byly zjištěna také dvě jednostranné dočasné parézy zvratného nervu. Skupina B měla IRI=1,02. Uvedené hodnoty IRI tak charakterizují asymetrické soubory, itato drobná asymetrie je ve výsledku hodnoty patrna. Celková incidence poranění zvratných nervů vcelém souboru operovaných sledovaného roku, ve kterém byl výběr pacientů dle metodiky této práce, byla 1,3%. Vsouboru bylo 16 dočasných a4 permanentní parézy zvratného nervu ve všech případech na jedné straně. Vesledovaném období nebyla zjištěna ani jediná oboustranná paréza trvalá ani dočasná. Index IRI pro operace štítné žlázy vuvedeném období byl 2,26. Tento soubor byl srovnáván se soubory skupiny Aaskupiny B avýsledky nevykazují statisticky významné rozdíly na hladině významnosti 1% (p=0,01). Závěr: Studie neprokázala statisticky významné rozdíly incidence poranění zvratného nervu (trvalá jednostranná paréza) vzávislosti na chirurgické technice bez využití IONM asvyužitím IONM prováděných chirurgem srozdílnou zkušeností vchirurgii štítné žlázy. Studie prokázala, že IONM může pomoci vyrovnat handicap uzačínajících améně zkušených chirurgů aomezit incidenci morbidity zvratného nervu vchirurgii štítné žlázy.

Background Injury to the recurrent laryngeal nerve (RLN) is a frequently noted and serious complication in thyroid surgery. Several studies have established that identification of the RLN may reduce the incidence of RLN palsy. To date, no prospective study has evaluated whether the RLN palsy rate can be further reduced by intraoperative neuromonitoring of the RLN. Methods Between 1 January and 31 December 1998, surgery for benign and malignant goitre was performed on 7607 patients in 45 hospitals. Data were collected prospectively by questionnaire. RLN function was evaluated before and after operation in all patients. RLN palsy was defined as permanent when there was no evidence of recovery within 6 months after surgery. The RLN palsy rate was adjusted to nerves at risk in the three groups ‘no identification of the RLN’, ‘intraoperative identification of the RLN without neuromonitoring’ and ‘identification of the RLN with neuromonitoring’. Statistical analysis was by χ2 test. Results Mean patient age was 51·8 years; 72·7 per cent were women. Some 7256 patients were treated for benign goitre (multinodular goitre 74·0 per cent, uninodular goitre 16·6 per cent, recurrent goitre 6·1 per cent, Graves' disease 3·3 per cent, Hashimoto and De Quervain thyroiditis less than 0·1 per cent) and 351 patients for thyroid carcinoma, with a negative selection of recurrent goitre and thyroid carcinoma for the two groups with intraoperative RLN identification (P < 0·0001). With respect to the extent of resection, in cases of lobectomy the rate of permanent RLN palsy was 1·5 per cent with intraoperative neuromonitoring which was significantly lower than rate with intraoperative RLN identification without neuromonitoring (2·6 per cent) or no RLN identification (6·3 per cent) (P < 0·0001). Detailed analysis of the complete spectrum of extent of resection and indications for surgery showed a positive trend for intraoperative neuromonitoring in comparison to the group with RLN identification without the use of neuromonitoring, but this trend was not statistically significant because of the small number of permanent RLN palsies. Conclusion Intraoperative neuromonitoring of the RLN has a beneficial effect for high-risk patients with recurrent goitre and thyroid carcinoma in whom the RLN is at greatest risk in cases of lobectomy or total thyroidectomy.

Recurrent laryngeal nerve palsy during surgery for benign thyroid diseases: Risk factors and outcome analysis

Electrical identification and monitoring of the recurrent laryngeal nerve (RLN) has been proposed as an adjunct to standard visual identification of the nerve during thyroid and parathyroid surgery. This study was undertaken to assess laryngeal palpation as an intraoperative technique for identifying and assessing the RLN during surgery and to investigate the relation between laryngeal palpation and associated laryngeal electromyographic (EMG) activity. The postcricoid region of the larynx during surgery was palpated through the posterior hypopharyngeal wall to sense posterior cricoarytenoid muscle contraction in response to ipsilateral RLN stimulation (i.e., the "laryngeal twitch response.") Laryngeal palpation was performed in a series of 449 consecutive thyroid and parathyroid surgeries with 586 RLNs at risk. All patients underwent preoperative and postoperative laryngoscopy to assess vocal cord mobility. In a subset of patients, laryngeal palpation and simultaneous laryngeal EMG recordings were compared during intraoperative RLN stimulation. In this series, there was no permanent RLN paralysis. There was one case of temporary RLN paralysis secondary to neural stretch that resolved 6 weeks postoperatively (temporary paralysis rate: 0.2% of patients, 0.2% of nerves at risk). Intraoperative laryngeal palpation of the laryngeal twitch response reliably correlated with normal postoperative vocal cord function. Loss of the laryngeal twitch response occurred in the single case of temporary paralysis in the setting of an anatomically intact nerve. Laryngeal palpation correlated well with simultaneous laryngeal EMG activity. There were no palpation-induced laryngeal injuries or laryngeal edema. There were also no RLN injuries due to repetitive neural stimulation. Intraoperative laryngeal palpation during RLN stimulation is a safe, reliable method for neural monitoring that can assist in RLN identification and assessment during thyroid and parathyroid surgery. Most importantly, it provides important prognostic information regarding ipsilateral vocal cord function at the completion of the initial side of the thyroid or parathyroid surgery. Intraoperative laryngeal palpation allows the surgeon to stage contralateral surgery if RLN damage is diagnosed, thereby avoiding the potential for bilateral vocal cord paralysis. We believe that laryngeal palpation is useful as an adjunct to formal EMG monitoring during thyroid and parathyroid surgery.

Reprint of: The role of intra-operative nerve monitoring in reducing the risk of recurrent laryngeal nerve injury during thyroid surgery: A systematic review and meta-analysis

Intraoperative neuromonitoring of surgery for benign goiter.

The mechanism of recurrent laryngeal nerve injury during thyroid surgery—The application of intraoperative neuromonitoring

<p class="abstract"><strong>Background: </strong>Surgery of the thyroid gland is one of the most common surgical procedures performed. Recurrent laryngeal nerve injury is the most dreaded complication of thyroid surgery. Hence reducing intraoperative injury is of utmost importance. Routine dissection and identification of the recurrent nerve remain controversial.</p><p class="abstract"><strong>Methods:</strong> This study consists of 70 patients who underwent thyroid surgery. This study was conducted at our institute during the period of 2 years (2018-2020). Patients were evaluated and operated. Patients with thyroid diseases and normal vocal cords were allocated to two groups randomly; in group A the nerve was identified and in group B the nerve was not identified.</p><p class="abstract">Results: Most of the patients participating in the study were in the age group of 33-42 years. Male to female disease ratio was 0.13:1. In our study out of 70 patients who underwent thyroid surgery, 18 (25.71%) patients suffered from recurrent laryngeal nerve palsy. Amongst those 18 patients, 2 palsies (5.71%) were in Group A and 16 palsies (45.71%) were in Group B. Recurrent laryngeal nerve most commonly lied posterior to the inferior thyroid artery on both right (65.38%) as well as left side (45.45%). Most commonly injured recurrent laryngeal nerve was the right sided recurrent laryngeal nerve (77.77%).</p><p class="abstract"><strong>Conclusions:</strong> Careful dissection of nerve during thyroid surgery eliminates the risk of recurrent laryngeal nerve injury. A thorough knowledge of thyroid gland, recurrent laryngeal nerve and its anatomical relations and variations is of utmost importance in preserving the recurrent laryngeal nerve in thyroid surgery.</p>

Background: Recurrent laryngeal nerve (RLN) palsy (RLNP) is not uncommon after thyroid surgery and can be debilitating. This is a retrospective cohort analysis of outcomes in patients with RLNP post-thyroidectomy for differentiated thyroid malignancy. Method: Clinicopathological details as well as outcomes of thyroidectomies for differentiated thyroid cancer in 862 patients performed over a period of 22 years (2001–2023) for nerve palsy were collected. The patients were stratified into two groups based on whether the RLN was amputated or preserved. Results: Of the 1,520 nerves in 862 patients at risk during thyroidectomy, a total of 71 (8.2%) (20 M:51 F) patients, with a median age of 54 (range: 19–83), suffered RLNP, which was temporary in 14 (1.6%), unilateral in 51 (5.9%), and bilateral in 6 (0.7%) patients. The RLN was amputated in 31 of 62 patients (50%). In 29 of 71 (41%) patients, the nerve was intentionally sacrificed due to gross disease infiltration while the RLN was inadvertently severed during dissection in 2 (3%) patients. Among cases with RLN transection, only five underwent primary repair or ansa cervicalis to RLN anastomosis. The only factor associated with amputation of the RLN was a larger tumour size (40.4 vs. 24.7 mm, p = 0.007). Preservation of voice quality was higher in the shave group in comparison to the amputation group (93.5% vs. 71.0%, p = 0.0426). Conclusion: Preservation of nerve or reconstruction in transectional injuries should be considered where possible to improve voice outcomes except in cases when the laryngotracheal complex is involved.

Background: Anatomic and functional preservation of the recurrent laryngeal nerve (RLN) is the gold standard in thyroid and various neck surgery. Aim of the work: To assess incidence and risk factors for (RLN) injury which may be just palsy or permanent injury postoperative after thyroid surgery in patient with recurrent multiple nodular goiter (MNG) and observe the timing of recovery. Methods: This prospective cross-sectional study was done on fifty patients with recurrent MNG. The study was done from December 2018 to October 2019. Patients with voice changes, RLN injury from previous operation and other type of cancer thyroid were excluded from the study. Results: Identification of the RLN was succeeded in 45 patients and failed in 5, due to sever fibrosis from pervious surgery. Intra-operative identification of both RLN done in 34 patients, we identify Right RLN in 8 while left RLN identified in 3. During dissection, intra-operative injury of RLN happen in 4 patients on one side only. seven patients developed hoarseness of voice which was transient and voice returned after Speech therapy from three weeks to two months. Postoperative indirect laryngoscopy done, only four patients suffered from immobile vocal cord on one side. Conclusion: Previous history of thyroid surgery is not significant and intraoperative RLN injury is significant so incidence of re-operation related transient vocal cord paresis was rare in our study four patients only. The median recovery time for transient RLN injuries was 8 weeks after operation.

In this study, we aimed to investigate the effects of Ultrasonic Coagulation (UC), Bipolar Energy Sealing System (BESS), Intra Operative Nerve Monitoring (IONM) and surgical experience on the complications of thyroid surgery. The data of 1627 patients who underwent thyroid surgery for various indications in our department between 2009 and 2018 were analyzed retrospectively and the effects of different technological devices on complications were investigated. Transient recurrent laryngeal nerve (RLN) palsy was higher between 2009 and 2013, when IONM was not in routine use (p=0.029). There were no significant differences between two energy devices (UC and BESS) in terms of transient or permanent RLN palsy, bleeding, and transient or permanent hypocalcemia. Multivariate analysis showed that young age (0.006), female gender (0.016), surgery type (p<0.001), and lateral neck dissection (p=0.026) are independent risk factors for transient hypocalcemia. The results indicate that there is no superior hemostatic device. IONM and specific branching decrease transient RLN palsy. Female gender, young age, completion thyroidectomy, and lateral neck dissection were independent risk factors for the development of transient hypocalcemia.

IntroductionEven though incidence of recurrent laryngeal nerve palsy (RLNP) is low, it affects importantly the quality of life of patients and remains one of main medicolegal litigation problems in surgery. Intraoperative neuromonitoring (IONM) has become widely accepted tool helping in recurrent laryngeal nerve identification, however no clear association of IONM with RLNP rate has been demonstrated. The aim of our study was to assess whether training in IONM influences rates of RNLP after thyroid surgery as an independent factor.Material and methodsWe analysed retrospectively 1235 patients who underwent thyroidectomy at the 1st Department of General and Endocrine Surgery, Medical University of Bialystok. Possible risk factors for RLNP were evaluated: application or not of IONM, the extent of surgery or thyroid pathology in correlation with surgeons’ experience in IONM (trained or untrained).ResultsThere were 2351 nerves at risk (NAR) and 39 RNLP were diagnosed after thyroid surgery (1.66%). Surgeons trained in IONM performed 52.2% of all operations (1200 NAR) with 7 RLNP (0.58%), whereas not-trained had 32 RLNP for 1151 NAR (2.8%; p < 0.001). After 182 thyroidectomies (357 NAR) guided by IONM (14.7%) 3 RLNP were observed (0.84%) vs. 36 palsies per 1994 NAR without IONM (1.81%; p = 0.189). The highest danger of RLNP was reported after reoperations and the lowest after subtotal thyroidectomies. We found no association between thyroid pathology and RLNP rate.ConclusionsAccording to our study training in IONM decreases chances of RLNP especially during total or near total thyroidectomy.

To investigate whether the recurrent laryngeal nerve (RLN) identification technique used in thyroidectomy affects RLN paralysis and hypoparathyroidism. Patients were allocated into 2 groups according to the thyroidectomy technique used to identify the RLN: (1) superior-inferior direction, exploring the nerve where it enters the larynx, followed by superior pedicle ligation; and (2) inferior-superior direction, following the inferior pedicle ligation and identifying the nerve in the tracheoesophageal groove. The first and second groups included 67 and 128 patients, respectively. In the first group, 19 patients underwent lobo-isthmectomy, and 48 underwent total thyroidectomy. In the second group, 42 patients underwent lobo-isthmectomy, and 86 underwent total thyroidectomy. We performed 115 and 214 RLN dissections in the first and second groups, respectively. Academic tertiary hospital. The study included 195 consecutive patients, 161 female (82.5%), and 34 male (17.5%), who underwent thyroidectomy for goiter between January 2006 and August 2009. Their mean age was 44.7 years (range, 14-79 years). The mean follow-up was 26 months (range, 12-42 months). Unilateral or bilateral total thyroidectomies performed using extracapsular dissection with 2 different RLN identification techniques. Incidence of hypocalcemia, vocal cord paralysis, hemorrhage, and wound infection. No RLN paralysis was observed in the first group. In the second group, unilateral RLN paralysis was seen in 2 of 128 patients (1.5%). Groups 1 and 2 included 48 and 86 total thyroidectomies, respectively. Temporary hypoparathyroidism was observed in 4 patients in the first group (8.3%). In the second group, permanent hypoparathyroidism was observed only in 4 patients (4.6%), and temporary hypoparathyroidism was observed in 14 patients (16.2%). Comparing the 2 groups based on the frequencies of RLN paralysis and hypoparathyroidism, we found that complications were significantly lower in the first group (P < .05) in terms of hypoparathyroidism. The rate of hypoparathyroidism was significantly lower in the thyroidectomies that located the RLN using the superior-inferior approach. In our hands, the superior-inferior approach was a safer technique, in terms of avoiding complications.

Background Recurrent laryngeal nerve paralysis in esophagectomy is one of the most concerned complications. In recent years, intraoperative neurostimulation monitoring system (IONM) in thyroid surgery have been widespread for identification of recurrent laryngeal nerve and assessment of soundness. Therefore, IONM is often used during esophagectomy in Japan. In this study, we examined the efficacy of IONM in the patients undergoing esophagectomy. Methods Of 66 patients underwent esophagectomy since April 2015 until December 2017, IONM used in 27 patients in the surgery for the examination of recurrent nerve paralysis. We retrospectively reviewed these cases for intraoperative findings, neurostimulation monitoring findings and their outcomes. Results Of 27 patients, 25 were male and two were female, and the median age at operation was 66 years old. Although IONM was used in cervical lymph node dissection, there were no vocal cord responses in 5 patients (left side in 4 and right side in 1) with stimulation of the vagus nerve. Because all patients had no vocal cord paralysis due to stimulation of the cervical recurrent laryngeal nerve, it was diagnosed that there was the recurrent laryngeal nerve injury due to thoracic para recurrent nerve lymph node dissection. IONM was able to facilitate the identification and preservation of cervical recurrent nerve in all patients. Three out of 5 patients with no vocal cord response by IONM were confirmed recurrent laryngeal nerve paralysis in postoperative endoscope. In patients with vocal cord paralysis by IONM, it was possible to carefully performed postoperative management. On the other hand, in patients without paralysis, extubation on the operation day seemed possible without the concern for aspiration. Conclusion By using IONM in esophagectomy, we were able to evaluate the damage of the recurrent laryngeal nerve in real-time. Confirming the intraoperative recurrent nerve injuries is important for postoperative management or prediction of postoperative aspiration pneumonia. IONM in esophagectomy was useful not only in terms of surgical procedures but also in the evaluation of postoperative management. Disclosure All authors have declared no conflicts of interest.