Permanent Complication Rate Research Articles

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.

Optimal treatment strategy in patients with papillary thyroid cancer: A decision analysis

Background. The management of patients with papillary thyroid carcinoma (PTC) remains controversial. We used decision analysis to identify the optimal treatment strategy for patients with PTC, stratified by risk-group classification. Methods. We designed a Markov model to compare thyroid lobectomy and total thyroidectomy (with adjuvant radioiodine therapy) in low- and high-risk patients with PTC. Morbidity, recurrence, and mortality estimates were obtained from the literature. Outcomes were quality-adjusted by using health state preferences. Results. In low-risk patients, lobectomy and total thyroidectomy resulted in 31.7 and 32.9 quality-adjusted life years (QALYs). Total thyroidectomy was the optimal strategy as long as the relative risk of recurrence after lobectomy was greater than 1.3. Lobectomy became the preferred strategy if subjects were willing to give up 1.5 years of life to avoid thyroid hormone dependency and a remote risk of radioiodine-induced malignancy. In high-risk patients, lobectomy and total thyroidectomy resulted in 11.2 and 16.5 QALYs. Model results were robust to varying the permanent complication rates of initial or completion thyroidectomy, the efficacy of adjuvant radioiodine therapy, and the impact of complications and cancer recurrence on quality of life, irrespective of risk-group classification. Conclusions. Total thyroidectomy maximized quality-adjusted life expectancy in low- and high-risk patients with PTC. (Surgery 2001;130:921-30.)

Surgical management of GH-secreting pituitary adenomas: an outcome study using modern remission criteria.

The results of transsphenoidal surgery as initial therapy for GH-secreting pituitary adenomas in 57 acromegalic patients were analyzed retrospectively. Patients with prior surgery or radiation therapy were excluded from the study. Three different criteria were used to define remission: glucose-suppressed (nadir) GH less than 1.0 microg/liter, a normal sex- and age-adjusted IGF-I level, and postoperative random GH levels of 2.5 microg/liter or less. Additionally, we analyzed the neuropathological data, including immunohistochemistry and ultrastructural categorization, and the surgical complications. The short-term remission rate (6-wk postoperative follow-up visit), as determined by a random GH measurement of 2.5 microg/liter or less, was 48.8%; the remission rate, as determined by nadir GH, was 51.4%. For 57 patients followed for 12 months or more after surgery (mean, 37.7 months), surgical remission was achieved in 70.2%, 66.7%, and 61.1%, respectively, for patients assessed by normal IGF-I, random GH, and nadir GH. One patient (1.1%) developed recurrence of active acromegaly 81 months after initially successful surgical therapy. Extrasellar growth of the tumor (P = 0.04) and dural invasion by the adenoma (P = 0.008) were significant univariate predictors of a poor outcome. Tumor size was significantly greater in patients with persistent or recurrent acromegaly (P = 0.02). Patients with tumors of the ultrastructural categories of mixed GH/PRL cell and mammosomatotroph adenomas had the lowest remission rates (50% and 42.9%, respectively). There were no perioperative deaths, and there was no serious morbidity. The permanent complication rate was 3.3% (1 permanent DI and 2 nasal septal perforations). Surgical management of acromegaly currently provides prompt, effective, and satisfactory initial treatment for the majority of patients. Using stringent criteria for remission, primary transsphenoidal surgery for GH-secreting pituitary adenomas is effective and often definitive therapy for acromegaly. These results provide a benchmark for the contemporary results of surgical management as assessed by modern outcome criteria.

Deep brain stimulation of the corpus luysi (subthalamic nucleus) and other targets in Parkinson's disease. Extension to new indications such as dystonia and epilepsy.

Chronic high frequency (130 Hz) stimulation (HFS) of the thalamic target Vim, first used in our group in 1987 as a treatment of tremor of various origins, has been used over the last ten years in 137 patients. Since 1993, this method has been extended to two other targets (subthalamic nucleus (STN): 137 patients and the medial pallidum (GPi): 12 patients), based on recent experimental data in rats and monkeys. STN appears to be a target of major interest, able to control the three cardinal symptoms and to allow the decrease or suppression of levodopa treatment, which then also suppresses levodopa induced dyskinesias. The stereotactic technique is based on the determination of the target using ventriculography, MRI and electrophysiology, with both microrecording of single neuron activity and microstimulation inducing therapeutic symptom suppression and side effects. Chronic electrodes are then placed bilaterally at the best physiologically defined location and then connected to implantable stimulators (either 2 Itrel II or the new double channel Kinetra), operated at 130-185 Hz, 60 ms pulse width, 2.5 to 3.5 volts. There was no operative mortality and permanent morbidity was observed in 3 patients. The mechanisms of action of HFS are not fully understood, but are definitely related to high frequency and are probably different depending on the target. Inhibition of cellular activity or of neural network functions could be induced, by jamming of a retroactive loop for tremor, or by shutdown of neurotransmitter release in STN. Mechanisms within an individual target are also probably different for tremor or for other symptom alleviation. All cardinal symptoms are alleviated from tremor to akinesia and rigidity. This strong improvement allows the decrease of the drug dosage to approximately 30% of the preoperative level, which suppresses the levodopa-induced dyskinesias. The off period dystonias are also suppressed as well as freezings and falls. The effects remain stable over more than 5 years and in the same period, the off stimulation-off medication UPDRS remains stable and does not increase at the usual rate The low rate of permanent complications, the minor side effects and their immediate reversibility, the possibility of bilateral implantation in one session and the long-term persistence of symptom relief are strong arguments which support chronic HFS of STN as the method of choice when a surgical procedure is indicated for the treatment of Parkinson's disease and even more when a bilateral procedure is necessary. Recent data show that STN stimulation could be useful in the treatment of dystonia as well as some forms of epilepsy. It is therefore possible that DBS in STN as well as in other targets could become a potent therapeutic tool in the near future for neurological disorders.

Stereotactic radiosurgery XII. Large AVM and the failure of the radiation response modifier gamma linolenic acid to improve the therapeutic ratio

Large arteriovenous malformations (AVM) are less likely to be 'cured' by single fraction stereotactically delivered radiation therapy (radiosurgery) and such treatment is attended by higher complication risks. Out of 200 successive AVM patients accepted for curative radiosurgery at St. Bartholomew's Hospital (and all treated by the same 6MV x-ray technique to 17.5 Gy marginal dose) were 62 patients whose target volume exceeded 10 ml. Laboratory data demonstrating that gamma linolenic [omega-6-] acid (GLA) protected rat spinal cord from the damaging effect of single shot radiation prompted this study which employed GLA in conjunction with radiosurgery for large AVM. Without GLA, 41% of large AVM obliterated, but in the GLA treated cohort the obliteration rate was only 5.3% ( p < 0.02). The permanent complication rates in the same patient groups were 20% versus 0%, respectively. There was a small skew to smaller volume 'large AVM' in the GLA treated cohort. This fact strengthens the conclusion concerning a difference for AVM obliteration, but could lead to a false conclusion quae GLA modulation of complications. When four patients were censored to minimize this possible bias, the risk for complications in the GLA treated patients was still significantly ( p < 0.05), less than in the control group. We therefore conclude: (1) GLA spares AVM from radiation induced obliteration; (2) GLA modifies the response of normal human brain to radiation damage; (3) GLA does not improve the therapeutic ratio for AVM based radiosurgery; (4) GLA may have other uses (notably after radiation accidents and in radiation neuro-oncology, radiation cranial prophylaxis, chemoradiation protocols, whole brain radiation for metastases etc.).

Secondary thyroidectomy in patients with prior thyroid surgery for benign disease: A study of 203 cases

Background: The goal of this study was to evaluate the complication rate of secondary thyroidectomy in patients with prior thyroid surgery for benign disease. Methods: Over an 8-year period, 203 thyroid reoperations were performed on 202 patients. All information relating to operative procedures, pathology, and complications was recorded prospectively. Results: There were 24 men and 178 women with a mean age of 52 years. Prior surgery was unilateral in 136 cases (67%) and bilateral in 67 cases (33%), and 14 patients (6.9%) had more than 1 previous thyroid operation. For euthyroid or pretoxic recurrent nodular goiter, 190 reoperations were performed and 13 reoperations were performed for recurrent thyrotoxicosis. Twenty-three cancers were found in a specimen (11.4%). Completion thyroidectomy was done in 143 patients. Postoperative complications occurred in 21 patients (10.4%): recurrent laryngeal nerve palsy (7 patients), hypocalcemia (8 patients), hematoma requiring surgical evacuation (5 patients), and wound infection (1 patient). Complications remained permanent in 4 patients (2%). Conclusions: The permanent complication rate is higher in thyroid reoperations than in primary thyroid operations. However, we believe that this 2% rate is low enough to allow reoperation whenever it is necessary, provided precise operative rules are respected. (Surgery 1999;125:479-83.)

Secondary thyroidectomy in patients with prior thyroid surgery for benign disease: A study of 203 cases

<h2>Abstract</h2> <b>Background:</b> The goal of this study was to evaluate the complication rate of secondary thyroidectomy in patients with prior thyroid surgery for benign disease. <b>Methods:</b> Over an 8-year period, 203 thyroid reoperations were performed on 202 patients. All information relating to operative procedures, pathology, and complications was recorded prospectively. <b>Results:</b> There were 24 men and 178 women with a mean age of 52 years. Prior surgery was unilateral in 136 cases (67%) and bilateral in 67 cases (33%), and 14 patients (6.9%) had more than 1 previous thyroid operation. For euthyroid or pretoxic recurrent nodular goiter, 190 reoperations were performed and 13 reoperations were performed for recurrent thyrotoxicosis. Twenty-three cancers were found in a specimen (11.4%). Completion thyroidectomy was done in 143 patients. Postoperative complications occurred in 21 patients (10.4%): recurrent laryngeal nerve palsy (7 patients), hypocalcemia (8 patients), hematoma requiring surgical evacuation (5 patients), and wound infection (1 patient). Complications remained permanent in 4 patients (2%). <b>Conclusions:</b> The permanent complication rate is higher in thyroid reoperations than in primary thyroid operations. However, we believe that this 2% rate is low enough to allow reoperation whenever it is necessary, provided precise operative rules are respected. (Surgery 1999;125:479-83.)

Artificial disc replacement with the modular type SB Charité III: 2-year results in 50 prospectively studied patients

The Modular Type SB Charite disc prosthesis has been developed as a device for artificial disc replacement (ADR) in patients with symptomatic discopathies. Here, we report on our first series of 50 (out of 350) patients, who had a satisfactory clinical result in 70% of cases (2 years' follow-up). Subgroup analysis revealed that patients with an isolated discopathy without previous spinal operations or other pathology at the same or other spinal level benefitted more from the surgery. However, this technique was associated with some problems: a 13% rate of permanent side-effects and/or complications was observed caused by the anterior approach. Four percent were related to poor implantation technique. There were no problems related to the material of the prosthesis. Twelve patients needed re-operation, but this was beneficial in only three of them. In one patient we had to convert to an interbody fusion. We conclude that in patients with severe isolated symptomatic discopathies that are resistant to conservative treatment, a mobile disc prosthesis is worth considering as a real alternative to a spondylodesis. However, accurate patient selection is imperative. With these criteria we were encouraged by our results to continue the implantation of this artificial disc.

The role of the gamma knife in the treatment of malignant primary and metastatic brain tumors.

Gamma knife treatment is a clinically effective, safe, and cost-effective adjunctive therapy for primary malignant brain tumors. For most brain metastases, radiosurgery is the treatment of choice and will result in effective tumor control in more than 90% of treated tumors.

Ablative Therapy for Movement Disorders: Thalamotomy for Parkinson’s Disease

Thalamotomy for Parkinson's disease is a well-established procedure that has been in use for more than 40 years. Technologic advances, such as computerized and magnetic resonance imaging, and refinement of stereotactic techniques have increased the safety and efficacy of this procedure. Current studies reveal good results in 70% to 90% of patients. Reported transient neurologic deficits occur in up to 60% of patients undergoing this procedure, although the highest permanent complication rates have decreased to around 10% to 20%. These data suggest the safety and efficacy of thalamotomy as a primary therapeutic option for selected patients with parkinsonian tremor.

Late complications in elbow arthroplasty

The world literature (1986 to 92) reports an amazingly high complication rate of elbow arthroplasty, amounting to 43%. Accordingly, we also find a high revision rate (18% on average) and a considerable rate (15%) of permanent complications. These figures do not correspond to our own experience with the GSB III (Gschwend/Scheier/Bähler) elbow prosthesis, a sloppy hinge with flanges on the lower and anterior part of the distal humerus. Our respective figures of complications are two to four times lower for rheumatoid elbows. When complications are discussed, a clear distinction of the type of prosthesis is mandatory, because linked or nonlinked and nonconstrained or semiconstrained prostheses have specific complications. The following complications are discussed separately: loosening (radiologic and clinical), ulnar neuropathy, infection, dislocation and subluxation, uncoupling, intraoperative bone fractures, and failure of the implant. The possible causes are analyzed, and means to avoid or treat these complications are discussed. We conclude that even in the long term ( > 10 years), results obtained with elbow arthroplasty are approaching those of hip and knee arthroplasty.

Management of 100 consecutive direct carotid-cavernous fistulas: results of treatment with detachable balloons.

Direct carotid-cavernous fistulas are high-flow shunts with a direct connection between the internal carotid artery and the cavernous sinus. The goals of treatment are to eliminate the fistula and preserve carotid artery patency. The authors reviewed the outcome of 98 patients with 100 consecutive direct carotid-cavernous fistulas initially treated by transarterial embolization with detachable balloons (1979-1992) at the University of Cincinnati Medical Center to evaluate the merits of this technique and to provide a standard for comparison with future treatment alternatives. Among 100 fistulas, 76 were traumatic in origin, 22 resulted from a ruptured aneurysm, and 2 were iatrogenic. The most common presentations were orbital bruit (80%), proptosis (72%), chemosis (55%), abducens palsy (49%), and conjunctival injection (44%). Eighty-eight fistulas were successfully occluded in 86 patients with detachable balloon(s), and internal carotid blood flow was preserved in 66 patients (75%). Initial attempts at balloon occlusion failed in four patients in whom the fistula eventually closed spontaneously. Five patients required direct surgery to occlude the fistula, and two were treated with nondetachable balloons; one patient died from injuries sustained from trauma. The permanent neurological complication rate was 4%, including cerebral infarction in one patient, frontal intracerebral hemorrhage in one patient, and vision loss in another patient. One death occurred related to cerebral infarction from a balloon that shifted. Transient ischemia occurred in three patients. On the basis of these results, we conclude that transarterial embolization with detachable balloons provides a high rate of fistula obliteration with low morbidity and is the best initial procedure to treat direct carotid-cavernous fistulas.

Microsurgical neck dissection for occultly metastasizing medullary thyroid carcinoma. Three-year results

Medullary thyroid carcinoma (MTC) metastasizes early into the regional lymph nodes, but distant metastases occur late. Modified radical neck dissection might improve the treatment results for occultly metastasizing MTC. The authors report 23 patients after a minimal follow-up of 2 years (median, 36 months). There were 11 female and 12 male patients. The mean age was 43 years (+/- 13 years). The surgical technique included the meticulous dissection of all compartments of the neck, resulting in a unilateral or bilateral modified radical neck dissection with the complete removal of the lymphatic and fatty tissue between important anatomical structures. The surgical boundaries extended cranially to the mastoid, caudally to the brachiocephalic vein involving a transcervical mediastinal dissection, and laterally to the edge of the trapezoid muscle. Ten patients were treated bilaterally and 13 patients unilaterally. The basal calcitonin values of 18 of the 23 patients were postoperatively normalized with 4 patients having normal basal and pentagastrin-stimulated calcitonin levels. Five patients with persistently elevated basal serum calcitonin values had a marked reduction of the postoperative calcitonin levels compared with their preoperative concentrations. However, in these five patients histologic abnormalities precluded a surgical cure. The permanent complication rates were tolerable (4 of 33 neck dissections). The microsurgically extended neck dissection can reduce basal and pentagastrin-stimulated serum calcitonin values to normal levels even after long intervals following primary thyroidectomy.

Complications of intraarterial digital subtraction angiography in patients investigated for cerebral vascular disease.

395 patients (236 males, mean age 55.6 years: 159 females, mean age 52.2 years) with suspected transient ischaemic attacks or previous strokes underwent intraarterial digital subtraction angiography (IADSA) over a 3-year period ending in March 1991. All procedures were performed via the femoral approach and the majority consisted of arch studies followed by selective catheterization. 253 (64.1%) of the patients had extracranial vascular disease confirmed at angiography. A retrospective analysis of the patients' records was made to extract all possible complications. Complications were defined as any untoward symptoms or signs occurring within 48 h and which could have been related to the angiogram. Neurological complications occurred in 15 (3.89%) patients. 10 (2.5%) patients had transient complications which resolved completely within 24 h. In three (0.8%) patients the neurological deficit was reversible, recovering fully within 6 days. Two (0.52%) patients were left with residual disability from stroke at 10 days. The permanent neurological complication rate is in the lower range of the rates recorded in previous conventional angiographic studies. We conclude that IADSA is a relatively safe and reliable form of investigation in patients with suspected cerebral vascular disease.

Complications of cerebral angiography in patients with symptomatic carotid territory ischaemia screened by carotid ultrasound.

After nearly 40 years, carotid endarterectomy has been shown to be of benefit to patients with symptomatic carotid territory ischaemia and greater than 70% stenosis of the relevant internal carotid artery. Cerebral angiography is performed before surgery and is not without risk. These risks must be added to those of surgery before recommending the procedure to patients. The study evaluated the local, systemic and neurological complications following digital subtraction angiography with selective catheterisation of the carotid arteries in 200 patients presenting to a cerebrovascular clinic for assessment of cerebral ischaemia. All patients had carotid ultrasound screening before angiography to screen out those with normal arteries or mild disease (less than 30% stenosis of symptomatic internal carotid artery). Complications occurred in 28 patients. There were six (3%) local, two (1%) systemic and 20 (10%) neurological complications. Seventeen neurological complications occurred within 24 hours and there were three late complications (24-72 hours). Neurological complications occurred more frequently when angiography was performed by a trainee rather than a consultant neuroradiologist (p < 0.01). The neurological complications were transient (resolved within 24 hours) in 10/200 (5%), reversible (resolved within seven days) in two (1%) and permanent in 8/200 (4%). Two patients died after a stroke and two other patients suffered a disabling stroke. At 24 hours post angiography the permanent (persisting beyond seven days) neurological complication rate was 2.5%. The incidence of total neurological complications and post angiographic strokes was higher in patients with greater than 90% stenosis of the symptomatic internal carotid artery (p < 0.001). The increased use of non-invasive Doppler duplex screening will reduced the absolute number of patients put at risk of angiography, yet the rate of post angiographic complications is likely to increase as patients with severe stenosis of the symptomatic internal carotid artery are probably most at risk of complications and have most to gain from carotid endarterectomy.

Complications of cerebral angiography.

SUMMARYThe total neurological complication rate in 783 consecutive carotid angiograms was 2.3% (2.7 % per patient). The permanent complication rate, including death, was 1.5% (1–8% per patient).With one exception, the patients in the permanent neurological complication group were over the age of 50.Of the patients experiencing neurological complications, 55.5% had received an intramural injection of contrast medium into the common carotid artery.The use of polaroid film to check the position of the needle is advocated to minimize intramural injection of contrast medium.Toxic side effects of the contrast medium was a less common cause for complications, but was considered potentially harmful in those patients with occlusive cerebro‐vascular disease.General anaesthesia should be kept to a minimum, particularly in patients with subarachnoid haemorrhage, as the complication rate is two to three times higher than when angiography is carried out under local anaesthetic.