Complications Of Thyroidectomy Research Articles

A Clinical Study of Thyroidectomy Complications: Hoarseness, Hypocalcemia and Hematoma

A Clinical Study of Thyroidectomy Complications: Hoarseness, Hypocalcemia and Hematoma

Urgent complications of thyroidectomy

In the late 19th century the mortality rate of thyroidectomy was reported as being as high as 20% and it was suggested that thyroidectomies should only be performed to save life and never for discomfort or deformity (Bliss et al, 2000). Theodore Kocher pioneered surgical advances in thyroidectomies and since the early 20th century the mortality and morbidity have been dramatically reduced (Bergamaschi et al, 1998). Despite the low mortality complications can still occur that have the potential to be life threatening and this article will focus on these complications.

Randomized Controlled Trial of Harmonic Scalpel Use During Thyroidectomy

To compare operative factors, postoperative outcomes, and surgical complications of thyroidectomy when using the harmonic scalpel (HS) vs conventional hemostasis (CH). Single-blind, randomized controlled trial. Department of Surgery, S. Chiara Hospital, University of Pisa, Pisa, Italy. One hundred patients undergoing thyroidectomy. Postoperative pain, drainage volume, hypocalcemia, nerve injury, and operative time. Patients underwent total thyroidectomy in which either the HS or CH was used. We found no significant differences between the HS and CH groups at baseline. Postoperative pain was reduced in the HS group at 24 hours (mean visual analog scale score, 3.90 vs 5.30; P<.001) and 36 hours (2.27 vs 3.95; P<.001). Drainage volume was significantly lower in the HS group (40.1 mL vs 75.4 mL; P<.001). Transient hypocalcemia was significantly lower in the HS group (5 patients [10%] vs 16 [32%]; P=.01). No patients experienced nerve injury or permanent hypocalcemia. Mean operative times were shorter in the HS group (40.0 vs 46.7 minutes, P<.001). Use of the HS may reduce postoperative pain, drainage volume, and transient hypocalcemia in patients undergoing thyroidectomy. Shorter operative times and improved outcomes might justify the cost of the HS compared with that of CH.

Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy

Incidental parathyroidectomy is a complication of thyroid surgery. The aim of this report is to explore the incidence, risk factors, and clinical relevance of inadvertent parathyroidectomy during thyroidectomy. Patients who underwent thyroidectomy between January 1998 and June 2005 were evaluated. Pathology reports were reviewed for the presence of parathyroid tissue in the thyroidectomy specimens. Information regarding diagnosis, operative details, and postoperative hypocalcemia were collected. Three hundred and fifteen thyroid procedures were performed: 163 total thyroidectomies, 124 near-total thyroidectomies, and 28 lobectomies. The findings were benign in 240 and malignant in 75 cases. Incidental parathyroidectomy was found in 68 (21.6%) cases: 58 were benign and 10 were malignant. One and two parathyroids were accidentally removed in 46 and 22 patients, respectively. Parathyroid tissue was found in intrathyroidal (33%) and extracapsular (27%) sites. Total/near-total thyroidectomy was not associated with increased risk of incidental parathyroidectomy (P=0.646), and there was no association of inadvertent parathyroidectomy with postoperative hypocalcemia (P=0.859). Thyroid malignancy was associated with decreased incidence of incidental parathyroidectomy (P=0.047). Inadvertent parathyroidectomy, although not uncommon, is not associated with postoperative hypocalcemia. The type of surgical procedure does not increase the risk of incidental parathyroidectomy, while thyroid malignancy may reduce the incidence of inadvertent parathyroidectomy.

P014 Determination of the Function of the Internal Branch of the Superior Laryngeal Nerve After Thyroidectomy

Background. Several unique complications of thyroidectomy exist because of its regional anatomy; they are well studied and reported. A majority of thyroidectomy patients report vague upper aerodigestive tract complaints. Despite this, no formal assessment of the integrity of the internal branch of the superior laryngeal nerve after thyroidectomy exists in the literature. Methods. Thirty three patients undergoing thyroidectomy were prospectively evaluated with preoperative and postoperative laryngopharyngeal sensory testing. Results. Preoperatively, 16 patients (49%) reported dysphagia, and 19 (58%) complained of globus sensation. Postoperatively, 24 (73%) patients complained of dysphagia, and 25 (76%) reported globus sensation. Preoperative sensory testing showed a mean sensory threshold of 2.79 6 0.51 mm Hg. The mean change in thresholds postoperatively was trivial (0.07 6 0.29 mm Hg), and did not differ significantly from zero (p 1⁄4 .19). Conclusions. Althoughmost patients report significant difficulty swallowing after thyroidectomy, the sensory nerve to the laryngopharynx remains intact and is not at risk during thyroid surgery. VC 2007 Wiley Periodicals, Inc. Head Neck 30: 21–27, 2008

Complications of thyroidectomy.

Complications of thyroidectomy.

Long term follow-up of hyperthyroid patients treated by subtotal thyroidectomy.

The early and long term complications of subtotal thyroidectomy in 306 hyperthyroid patients (multinodular goitre and diffuse hyperplasia) followed for up to 30 yr are reviewed. There were no perioperative deaths. Sixteen patients (5.2 per cent) had transient symptomatic hypocalcaemia, while 9 (2.9 per cent) had permanent hypocalcaemia. Permanent unilateral vocal cord paralysis occurred in 11 (3.6 per cent) patients (1.8 per cent of nerves at risk). Cumulative per cent (+/- s.e.m.) relapse and hypothyroid rates at 30 yr (life-table analysis) were 15.6 +/- 2.4 per cent and 20.5 +/- 2.1 per cent, respectively. Lifelong follow-up of post-thyroidectomy patients is mandatory because of the risk of relapse of hypothyroidism.

Incidental Parathyroidectomy during Thyroid Surgery: An Underappreciated Complication of Thyroidectomy

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.

Serum intact parathyroid hormone as a predictor of hypocalcaemia after total thyroidectomy

Hypocalcaemia from hypoparathyroidism is a complication of total thyroidectomy. The aim of the present study was to determine whether an early postoperative level of serum parathyroid hormone (PTH) after total thyroidectomy predicts the development of significant hypocalcaemia and the need for treatment. Patients undergoing total thyroidectomy had their serum level of intact PTH checked 1 h after removal of the thyroid gland. Serum calcium level was checked on the following morning. Oral calcium and/or calcitriol was commenced if the patient developed hypocalcaemic symptoms, or if the corrected serum calcium level was <2.0 mmol/L. Seventy-nine patients were included in the present study. Thirteen patients had symptoms of hypocalcaemia on postoperative days 1 or 2 and 66 patients remained asymptomatic. The postoperative intact PTH, day 1 calcium and day 2 calcium was 0.32 +/- 0.60 pmol/L, 2.01 +/- 0.11 mmol/L, and 2.02 +/- 0.16 mmol/L, respectively, for the symptomatic group and 1.98 +/- 1.25, 2.21 +/- 0.13, and 2.19 +/- 0.14, respectively, for the asymptomatic group. Calcium support was given to 25 patients, of whom 14 also required calcitriol. Serum PTH 1-h after total thyroidectomy is a reliable predictor of hypocalcaemia and can allow safe early discharge of patients from hospital.

Pre-ablative Diagnostic Whole-body Scan Following Total Thyroidectomy for Well-differentiated Thyroid Cancer: Is It Necessary?

This study reviewed the incidence of positive pre-ablative diagnostic scan after total thyroidectomy and the efficacy of the current ablative dose. The predictive factors for outcome using a standard ablative dose and postoperative complications of total thyroidectomy were also examined. This was a retrospective review of patients referred for radioiodine ablation after total thyroidectomy between September 1997 and September 2001. Forty patients were included in this study, of whom 95% had a positive scan after total thyroidectomy. Of the 30 patients who underwent standard 80-mCi radioiodine ablation, 21 (70%) had successful single ablation while the remaining nine patients needed a higher ablative dose. There were no significant differences between patients who had successful ablation with the standard dose and those who did not in terms of tumour size, patient age, lymph node status and extra-thyroidal extension. Fifteen percent suffered from permanent hypoparathyroidism requiring calcium supplementation. Three patients had documented recurrent laryngeal nerve paralysis. Bypassing the pre-ablative diagnostic scan is feasible. The present ablation dose of 80 mCi of radioiodine is effective. The relatively high postoperative morbidity after difficult total thyroidectomy suggests less aggressive excision and postoperative radioiodine ablation of the remnant tissue.

Comparison of the Complications of Subtotal, Near Total and Total Thyroidectomy in the Surgical Management of Multinodular Goitre

Purpose of the study is to compare complication rates of bilateral subtotal (BST), near total (NTT) and total thyroidectomy (TT) in a cohort of patients undergoing surgery for benign multinodular goitre (MNG). Seven hundred and fifty patients undergoing surgery for MNG were studied with a median follow-up of 53 months (range 18-102). There was no operative mortality in this group and no patients required urgent re-exploration for haematoma. After BST 14 patients (14/170 - 8.2%) developed transient hypocalcaemia and 4 patients (4/170 - 2.4%) had transient and one permanent (1/170 - 0.6%) recurrent laryngeal nerve (RLN) palsy. In NTT group 39 patients (39/320 - 12.2%) developed transient hypocalcaemia and 2 patients (0.6%) transient voice disturbances. None of the patients in this group experienced permanent complications. However, in TT group 78 patients had (78/260 - 30%) transient hypocalcaemia whereas only one patient (1/260 - 0.4%) suffered permanent hypoparathyroidism and 5 patients (5/260 - 1.9%) had temporary RLN injury but none of them remained permanent. There are only 2 (2/170 - 1.2%) recurrences and those patients are in BST group. All of the patients in BST group required at least 100 microg of thyroxine supplementation following the operation. These results demonstrate low permanent complication rates following thyroid surgery. Although the incidence of transient hypoparathyroidism increases with the extent of the resection, permanent complication rates are similar for all three surgical procedures. Even with short follow-up, there is a risk of recurrence with BST and therefore NTT or TT may be the operation of choice for MNG.

Complication of Thyroidectomy in Patients With Radiation-Induced Thyroid Neoplasms

The complication rate for thyroidectomy is the same in patients with and without a history of radiation exposure. Retrospective medical record review of 171 consecutive patients who had a previous history of radiation treatment and had undergone a thyroid operation from 1961 to 1999. University of California, San Francisco, Medical Center and affiliated hospitals. We selected 107 patients with a history of radiation exposure who had undergone thyroid operations (81 total thyroidectomies) and 107 control patients who underwent comparable operations but had no history of radiation exposure. Among patients with a history of radiation exposure (mean age, 47.2 years), there was 1 recurrent nerve injury, 1 external nerve injury, 20 patients with transient hypocalcemia, and 1 patient with a hematoma. Among patients without a history of radiation exposure (mean age, 47.5 years), there were 2 recurrent nerve injuries, 18 patients with transient hypocalcemia, and 1 patient with a hematoma. All cases of hypocalcemia and recurrent nerve injury in both groups were transient. One patient had a permanent superior laryngeal nerve injury. In patients who underwent operations since January 1, 1990, duration of hospitalization was 1.2 days in patients with a history of radiation exposure (65 patients) and 1.1 days in patients without (101 patients). Our data document that the risk of transient and permanent complications after total thyroidectomy is similar in patients with and without a history of radiation exposure. The relatively low long-term complication rate supports prophylactic total thyroidectomy for patients with thyroid nodules and a history of radiation exposure.

Postoperative complications of thyroidectomy for differentiated thyroid carcinoma

Objective This study evaluates the incidence and risk factors of complications in patients submitted to thyroidectomy for differentiated thyroid carcinoma in a cancer hospital with residency training. Study design A retrospective chart and complications review of 316 consecutive patients who underwent thyroidectomy for differentiated thyroid carcinoma. Results Of the 316 patients, the main postoperative complications were transient hypocalcemia in 87 (27.5%), permanent hypocalcemia in 16 (5.1%), transient vocal cord palsy in 4 (1.2%), and permanent vocal cord palsy in 2 (0.6%). Neck dissection and paratracheal lymph node dissection when associated with total thyroidectomy were significantly related to transitory and permanent hypocalcemia. Conclusion Thyroid surgery can be performed safely in a hospital with medical residency training program under direct supervision of an experienced surgeon with acceptable morbidity. Hypocalcemia is the most significant complication. Neck and paratracheal lymph node dissections were the most significant predictors of hypocalcemia in patients submitted to total thyroidectomy.

Total thyroidectomy for benign thyroid disease.

The use of total thyroidectomy in thyroid cancer treatment is not unanimous, and it is even more controversial when this procedure is advocated for benign diseases. On the other hand, the complication risk may have an increase up to 20 times in repeat operations for recurrence. The objective of the study was to evaluate the use of total thyroidectomy in benign diseases, multinodular goiter, and Graves disease to justify the authors' preference. Retrospective study of use of total thyroidectomy in benign diseases. Retrospective study of 1789 patients who underwent thyroidectomies from June 1990 to December 2000. Indication, extension of thyroidectomy, cancer incidence, and complications were analyzed. Total thyroidectomy was performed in 81.19% of 456 patients with nontoxic multinodular goiter, 93.93% of 33 with toxic multinodular goiter, 93.93% of 66 with recurrent multinodular goiter, and 49.18% of 122 with Graves disease. Thyroid cancer was found in 16.62%, 9.09%, 3.03% and 5.73% of patients, respectively. Transitory and permanent hypoparathyroidism, hematoma requiring surgical intervention, and transitory and permanent recurrent laryngeal nerve injury occurred in 12.27%, 1.61%, 0.26%, 1.88%, and 0.35% of the patients undergoing total thyroidectomy, respectively. Permanent complications of total thyroidectomy for nontoxic multinodular goiter and Graves disease were similar to nontotal thyroidectomy. Use of total thyroidectomy for nontoxic multinodular goiter increased from 53.33% of the patient to 81.19%, on average, with a concomitant increase of cancer diagnosis from 11.11% to 16,62%. The authors performed total thyroidectomy for all patients with Graves disease. Total thyroidectomy is the treatment of choice for multinodular goiter and thyroiditis, when there is bilateral gland involvement posterior to middle thyroid veins, and for Graves disease because it decreases the likelihood of future repeat operations for recurrent disease and thus the associated risks, when performed safely.

Surgical complications of thyroidectomy

Complications from thyroid surgery continue to challenge even the most experienced surgeon. This article reviews the major and more common complications of thyroidectomy and their management. Damage to laryngeal nerves and hypoparathyroidism remain the major risks of this surgical procedure. However, post operative hemorrhage, airway obstruction and malignant spread of tumor to involve adjacent structures can also pose significant dilemma to the operating surgeon. The management of these and other complications are described along with advice on avoidance of the pitfalls of this procedure.

Influence of the Refinement of Surgical Technique and Surgeon’s Experience on the Rate of Complications after Total Thyroidectomy for Benign Thyroid Disease

Background: In recent years, many surgeons dealing with endocrine surgery have increasingly performed total thyroidectomy for benign thyroid disease. However, total excision of the thyroid in the treatment of benign lesions has been surrounded by even more controversy than its role in cancer treatment. The complication rate appears to be higher when the operation is done by inexperienced surgeons who have no special skills in endocrine surgery using proper techniques. The aim of this study is to determine whether surgeons experience and the refinement of surgical techniques are associated with postoperative recurrent laryngeal nerve (RLN) palsy or hypocalcemia after total thyroidectomy for benign thyroid disease.Methods: A total of 68 consecutive patients who underwent total thyroidectomy for benign thyroid disease were reviewed. Twenty-six of these were from between January 1998 and June 1999 (first period) and 42 from between June 1999 and September 2000 (second period). Patients were divided into two subgroups according to different periods and different surgical techniques to identify the RLNs and the parathyroid glands. RLNs function was evaluated pre-and post-operatively by an otolaryngologist, and serum calcium levels were measured at the postoperative follow-up. Results: During the first period of the study, transient hypocalcaemia was determined in 8 (31%) patients. Hypocalcaemia was clinically symptomatic in 5 (19%) patients. Transient RLN palsy developed in 4 (15%) patients. Unilateral permanent RLN palsy due to operative injury was observed in 1 (4%) patient. During the second period, we noted transient hypocalcemia in 11 (26%) patients and symptomatic hypocalcemia in 6 (4%) patients. Serum calcium levels returned to normal within 4 weeks after operation in all patients. Neither transient nor permanent RLN palsy was observed during this period.Conclusions: Complications of total thyroidectomy can be minimized with increasing experience and the refinement of surgical technique.

Risk factors for postthyroidectomy hypocalcemia.

Hypocalcemia is a common complication of thyroidectomy. The aim of this study was to evaluate the incidence of hypocalcemia after thyroid operation and its relation to clinical, biologic, and surgical factors. A retrospective study of 265 patients who underwent unilateral (n = 50) or bilateral (n = 215) thyroidectomy between 1996 and 2000 was done to determine incidence and risk factors for hypocalcemia. Free thyroxine and thyrotropin levels were obtained before operation in 254 patients, together with preoperative and postoperative calcium and phosphorus levels. All patients were examined for age, gender, extent of thyroidectomy, initial versus reoperative neck operation, pathologic characteristics of resected thyroid tissue, substernal thyroid extension, and parathyroid resection and autotransplantation. Hypocalcemia, defined as a calcium level less than 2 mmol/L, occurred in 42 of 265 patients (16%), including 11 (4%) symptomatic patients who required vitamin D, calcium, or both for 2 to 6 weeks. Factors significantly predictive of postoperative hypocalcemia in univariate analysis included elevated free thyroxine level (p = 0.0064), bilateral thyroidectomy (p = 0.00064), parathyroid autotransplantation (p = 0.0128), and female gender (p = 0.0028). Independent risk factors on multivariate analysis were elevated free thyroxine level (p = 0.0476), bilateral thyroidectomy (p = 0.0338), and parathyroid autotransplantation (p = 0.0003). Bilateral thyroidectomy, elevated free thyroxine level, and parathyroid autotransplantation are independent risk factors for postthyroidectomy hypocalcemia. Oral calcium supplements may be of value in this group of patients to enhance early hospital discharge.

Tracheal Necrosis and Surgical Emphysema: A Rare Complication of Thyroidectomy

We describe the first reported case of tracheal necrosis following a thyroidectomy. This complication resulted in massive subcutaneous emphysema and pneumomediastinum, which required emergency exploration of the neck to decompress the trapped air. We also discuss the suggested etiology and management of this rare condition.

Assessment of the Morbidity and Complications of Total Thyroidectomy

To determine the incidence and predictive factors for complications after total thyroidectomy. Cross-sectional analysis of a national database on total thyroidectomy cases. The National Hospital Data Survey database was examined and all cases of total thyroidectomy performed during 1995 to 1999 were extracted. In addition to demographic information, postoperative complications including hypocalcemia, recurrent laryngeal nerve paralysis, wound complications, and medical morbidities were identified. Statistical analysis was conducted to determine potential predictive factors for postoperative complications. A total of 517 patients were identified (mean age, 48.3 years). The most common indications for total thyroidectomy were thyroid malignancy and goiter (73.9% of cases). Eighty-one patients (15.7%) underwent an associated nodal dissection along with total thyroidectomy, and 16 patients (3.1%) underwent parathyroid reimplantation. The mean length of stay was 2.5 days (95% confidence interval, 2.3-2.8 days). The incidence of postoperative wound hematoma was 1.0%, wound infection was 0.2%, and mortality rate was 0.2%. The incidence of postoperative hypocalcemia was 6.2%. Younger age was statistically associated with an increased incidence of hypocalcemia (P =.002, t test), whereas sex (P =.48), indication for surgery (P =.32), parathyroid reimplantation (P>.99), and associated neck dissection (P =.21) were not. The mean length of stay was 2.5 days and was unaffected by occurrence of postoperative hypocalcemia. The incidences of unilateral and bilateral vocal cord paralyses were 0.77% and 0.39%, respectively. Postoperative hypocalcemia is the most common immediate surgical complication of total thyroidectomy. Other complications, including recurrent laryngeal nerve paralysis, can be expected at rates approximating 1%.

Routine autotransplantation of at least one parathyroid gland during total thyroidectomy may reduce permanent hypoparathyroidism to zero.

Permanent hypoparathyroidism, although a recognized complication of total thyroidectomy, is an outcome that all endocrine surgeons try to avoid. To minimize the risk of postoperative hypoparathyroidism a strategy was developed of routine autotransplantation of at least one parathyroid gland into the ipsilateral sternomastoid muscle during every total thyroidectomy. One hundred consecutive patients undergoing total thyroidectomy were included in the study. Serum calcium and albumin levels were measured pre-operatively, on the first 2 postoperative days, and after 2 weeks, or until return to normal serum calcium levels without calcium supplementation. If patients developed biochemical evidence or symptoms of hypocalcaemia postoperatively, a calcium replacement was administered according to defined protocol. In 74 cases one parathyroid gland was autotransplanted: 44 for inadvertent removal or anatomical reasons, 19 because of devascularization (assessed by a cut through the gland's capsule and evaluation of the capillary bleeding pattern), and 11 by protocol. In 25 cases, two or more glands were autotransplanted. Fourteen patients developed symptoms of hypocalcaemia and received calcium supplementation, as did another 13 asymptomatic patients with only biochemical evidence of hypocalcaemia. At follow-up 3 months postoperatively the incidence of permanent hypoparathyroidism was zero, with all patients being normocalcaemic without calcium supplementation. This strategy, easily adopted by any experienced surgeon, has the potential to eliminate permanent hypoparathyroidism following total thyroidectomy.