Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years

The factors related with postoperative complications in benign nodular thyroid surgery

Thyroid gland is an important endocrine organ because of its functions. Although the morbidity and mortality of thyroid surgery have decreased markedly, serious complications may still occur. The aim of this retrospective study was to identify the factors influencing the complications in benign nodular thyroid surgery. A total of 332 patients who underwent thyroid surgery between April 2004 and May 2008 were evaluated retrospectively to identify the factors influencing the complications. We found that in surgery lasting more than 90 minutes the risk of permanent recurrent laryngeal nerve (RLN) injury was high, daily drainage more than 50 cc increases the risk of seroma formation, retrosternal goiter surgery have higher risk for bleeding. The flap edema rates were high found in the operations made by resident surgeon and patients with size 3-4 thyroid glands. Low complication rates can be achieved after thyroidectomy with better knowledge of the surgical anatomy of the neck, thyroid pathology and required surgical treatment.

Flapless conventional thyroidectomy: a prospective, randomized study

PURPOSE

Conventional thyroid surgery is one of the most common operations performed worldwide. The conventional technique involves placement of small or large cutaneous flaps. However, the published data regarding flap use for thyroidectomy are contradictory. This study presents the results using a flapless conventional thyroidectomy and the efficacy of this approach in a thyroidectomy. In addition, the study determined whether there are any advantages associated with the use of this approach in comparison to conventional thyroid surgery.

METHODS

One hundred and forty-two patients underwent a thyroidectomy. The patients were randomly assigned to surgical procedures. Patients in Group 1 (n = 70) underwent a conventional thyroidectomy, and patients in Group 2 (n = 70) underwent a conventional thyroidectomy without a cutaneous flap.

RESULTS

There was no significant difference between the two groups in terms of age, sex, body mass index, length of incision, gland volume, and length of hospital stay. Postoperative pain was significantly less in Group 2 than in Group 1 (P = 0.006). Patients in Group 2 showed significantly lower requirement for postoperative intravenous analgesic (P = 0.001), and postoperative peroral analgesic (P = 0.023) in comparison to those in Group 1. Incidences of transient vocal cord paralysis and hypocalcemia were 1.4% and 1.4%, respectively. Of 140 patients, 5 (3.6%) developed postoperative wound complications.

CONCLUSIONS

These results indicate that a flapless thyroidectomy is safe and technically feasible, and therefore could be an alternative to a conventional thyroidectomy.

UltraCision harmonic scalpel versus clamp-and-tie total thyroidectomy: a clinical trial

BACKGROUND

Hemostasis is important in thyroid surgery to avoid complications. Our aim was to evaluate the effectiveness of the harmonic scalpel in patients undergoing total thyroidectomy.

METHODS

In this study, 90 patients were randomized into group A (classic technique of tying and knots) and group B (harmonic scalpel). We recorded the following: age, sex, pathology, thyroid weight, hemostatic technique, duration of operation, change in calcemia (DeltaCa), change in hematocrit (DeltaHt), change in hemoglobin (DeltaHgb), change in white blood cell count (DeltaWBC), vocal motility, operative difficulty, postoperative vocal alteration, postoperative pain, complications, blood in the drains, operating time, mass of gland excised per minute, and hospitalization.

RESULTS

Differences (p < .05) were observed concerning duration of surgery, operative difficulty, postoperative pain, hospitalization, DeltaWBC, and quantity of gland removed per minute. No recurrent laryngeal nerve (RLN) palsies were observed.

CONCLUSIONS

Use of the Harmonic Scalpel in total thyroidectomy is more effective than the clamp-and-tie technique: the duration of surgery, intraoperative difficulty, postoperative pain, and hospitalization are reduced. Both techniques are equivalent concerning RLN injuries, postoperative vocal alterations, and blood loss.

Recurrent laryngeal nerve and voice preservation: routine identification and appropriate assessment - two important steps in thyroid surgery

INTRODUCTION

The aims of this study were to assess and compare vocal cord functions before and after thyroid surgery after intra-operative identification of recurrent laryngeal nerve.

PATIENTS AND METHODS

Recurrent laryngeal nerve (RLN) is seen intra-operatively in all cases undergoing thyroid surgeries. Vocal cord functions including any voice change were evaluated by indirect laryngoscopy (I/L) and direct laryngoscopy (D/L) before and after surgery.

RESULTS

Prospective study on 100 patients over 18 months with a total of 146 nerves at risk (NAR). Majority were women (n = 86) with mean age of 37.48 years (range, 13-60 years). RLN was seen in all patients and 19 patients complained of some change in quality of their voice after surgery. Evaluation by I/L and D/L at 6 weeks showed recurrent laryngeal nerve palsy (RLNP) in nine (47.36%) and five (26%) of these 19 patients respectively. Analysed according to total NAR, the incidence of voice change and temporary RLN palsy (I/L and D/L) at 6 weeks was still less at 13.01%, 6.16% and 3.42%, respectively. Voice change improved in all cases at 3 months with no RLNP palsy by I/L or D/L. All these 19 patients had undergone difficult or extensive surgery for malignancy, large gland, extratyhroidal spread or fibrosis.

CONCLUSIONS

Despite identification and preservation of RLN, patients can develop postoperative voice change and RLNP although all voice change cannot be attributed to damaged RLN. Proper assessment of vocal cord functions by I/L and D/L laryngoscopy is required to rule out injuries to these nerves. Risk of damage is higher in patients undergoing more difficult surgery.

Evaluation of a new ultrasonic device in thyroid surgery: comparative randomized study

BACKGROUND

Conventional techniques for hemostasis during thyroidectomy rely on knot tying, clips, and electrocoagulation. Recently, the Harmonic FOCUS Shear (Ethicon Endo-Surgery, Inc, Cincinnati, OH) was developed for thyroidectomy.

METHODS

Between December 2007 and March 2008, 62 consecutive patients (45 women, 17 men; mean age 50.9 years) undergoing thyroidectomy were randomized into 2 groups: group A, where the FOCUS was used, and group B, where electrocoagulation and clamp-and-tie technique were used.

RESULTS

The 2 groups were similar in terms of age, sex ratio, indication for surgery, and thyroid volume. Operative time was significantly shorter in group A. Significantly fewer clips and ties were used, and postoperative pain and suction balloon amount were also significantly lower in the FOCUS group. The only postoperative complication was a patient with transient hypocalcemia in group B.

CONCLUSIONS

FOCUS is a reliable and safe tool for thyroidectomy. Its utilization is associated with a shorter operative time, less blood loss, and less postoperative pain.

[Toxic intrathoracic goiter. Clinical profile and surgical morbidity in an endocrine surgery unit]

BACKGROUND

The development of postsurgical complications is exacerbated when several risk factors coincide in the same patient.

OBJECTIVE

To analyze the results of surgery for toxic intrathoracic goiter in terms of (a) the need for sternotomy; (b) morbidity and mortality; and (c) remission of compressive symptoms.

MATERIAL AND METHODS

A review (1980-2002) was carried out of 43 cases of toxic intrathoracic multinodular goiter according to Eschapase's definition (3 cm below the sternal manubrium) occurring in patients without previous thyroid surgery who underwent total thyroidectomy. There were 2 control groups: I (non-toxic intrathoracic goiter, without recurrence and not requiring total thyroidectomy) and II (non-intrathoracic, non-toxic goiter without recurrence, requiring total thyroidectomy). The following variables were analyzed: sociopersonal, clinical and surgical characteristics, morbidity, mortality, and outcome.

RESULTS

Compared with the control groups, the patient group had longer disease duration and was older. In 6 patients (14%) 1 was difficulty in intubation, and 2 patients required fiberoptic intubation. All goiters could be extirpated through the cervical route. The morbidity rate was 37% (n=16). Notably, 4 were recurrent lesions (9%), 1 of which was definitive, and 14 were hyperparathyroidism (33%), one of which was definitive. The only difference between the control groups and the patient group was a greater incidence of transitory hypoparathyroidism in the patient group than in control group II (33% versus 15%; p=0.0103). Surgical outcomes were excellent in terms of symptom remission.

CONCLUSIONS

In any unit with ample experience of endocrine surgery, total thyroidectomy in toxic intrathoracic goiter can be carried out with a low risk of postsurgical complications, a low incidence of sternotomies and complete symptom remission. In intrathoracic goiter surgery, the presence of associated hyperthyroidism does not increase postoperative morbidity.

[Transoral endoscopic thyroidectomy. Part 1: rationale and anatomical studies]

BACKGROUND

Surgical access trauma in thyroidectomy has been minimized by the adoption of minimally invasive techniques. Extracervical approaches moved the incision lines outside of the visible neck region. However, because of the extensive dissection they no longer comply with the term minimally invasive. Therefore, our goal was to reduce the access trauma and establish a non-traumatic approach according to surgical planes for endoscopic minimally invasive thyroidectomy: the transoral approach.

MATERIAL AND METHODS

In a preclinical investigation anatomical dissection was performed on three human cadavers to visualize anatomical relationships and identify safe zones of access to the anterior neck and the submandibular regions. The investigation focused on relevant vascular and neural structures in the floor of mouth. Endoscopic minimally invasive thyroidectomy was additionally performed in five specimens with anatomical dissections for the evaluation of collateral damage.

RESULTS

For a safe approach the optic trocar can be placed sublingually in the midline as there are no relevant vascular or neural structures on the way to the thyroid region. The working trocars can be placed bilaterally in the oral vestibule behind the canine teeth. In this way access and dissection plane are placed directly in an avascular subplatysmal area and the pretracheal working space can be reached easily, safe and fast.

CONCLUSIONS

Minimum impact and a gentle dissection according to anatomical planes are the rational for the transoral route to the thyroid gland. Thus based on anatomical dissections the foundations of a novel procedure in the context of natural orifice surgery (NOS) could be established.

Monitoring performance in thyroidectomy: cumulative sum analysis of outcomes

BACKGROUND

Cumulative sum (CUSUM) analysis gives visual feedback on performance. It requires agreed benchmarks to compare binary outcomes. This process has not previously been applied to thyroidectomy. The objective of this study was to determine if CUSUM analysis can be employed to give feedback on performance of thyroidectomy.

METHODS

A literature review to define the CUSUM analysis key performance indicators for thyroidectomy was performed. The key performance indicators for thyroid surgery were hematoma (return to theater for evacuation), hypocalcemia (corrected calcium <2.0 mmol/L), and vocal cord palsy (postoperative hoarseness with nasal endoscopic confirmation). Pre- and postoperative laryngoscopy was not routinely performed by all surgeons. Permanent was defined as duration longer than 6 months. A prospective audit of 216 patients undergoing thyroidectomy between January 2003 and December 2006 at the Geelong Hospital was completed. CUSUM charting of outcomes was performed after agreeing by consensus the boundaries of acceptable and unacceptable performance.

RESULTS

Aggregate analysis of outcomes demonstrated acceptable performance across all clinical indicators. The incidence of temporary/permanent hypocalcemia and vocal cord palsy were 24%/2.6% and 3.2%/0.65%, respectively. About 1.39% of patients required evacuation of hematoma. CUSUM plotting of outcomes demonstrated acceptable performance.

CONCLUSIONS

There is some variation of how standard outcome indicators for thyroidectomy are measured in the literature. A prospective audit using aggregate outcomes and CUSUM analysis has demonstrated that the performance of thyroid surgery at the Geelong Hospital was acceptable. These indicators and our methods of analysis could be used to monitor the performance of thyroid surgery at other hospitals.

Postoperative complications of thyroid cancer in a single center experience

The aim of this study was to investigate the complications following surgical treatment of thyroid cancer and the association between the extent of surgery and complication rates. A total of 2,636 patients who underwent surgery due to thyroid cancer were retrospectively reviewed to identify surgical complications. Complication rates were assessed according to the extent of surgery, which was classified as follows; less-than-total thyroidectomy with central compartment node dissection (CCND) (Group I, n=636), total thyroidectomy with CCND (Group II, n=1,390), total thyroidectomy plus ipsilateral neck dissection (Group III, n=513), and total thyroidectomy plus bilateral neck dissection (Group IV, n=97). The most common surgical complication was symptomatic hypoparathyroidism, of which 28.4% of cases were transient and 0.3% permanent. The other surgical complications included vocal cord palsy (0.7% transient, and 0.2% permanent), hematoma (0.5%), seroma (4.7%), chyle fistula (1.8%), and Horner's syndrome (0.2%). The complication rates increased significantly with increasing the extent of surgery from Group I to Group IV. The more extensive surgery makes more complications, such as hypoparathyroidism, seroma, and others.

Septic bleeding of the common carotid artery following total thyroidectomy: an atypical complication

Septic rupture of the common carotid artery following total thyroidectomy may rapidly lead to exsanguination. We present a case report of a 16-year-old girl, diagnosed with a questionable thyroglossal duct cyst. Following the initial operative intervention with local excision of the cyst including resection of the medial part of the hyoid bone, pathology revealed papillary carcinoma. Thus secondary total thyroidectomy with locoregional lymphadenectomy was performed. One week later, a wound infection developed, necessitating lavage and drainage. On the 8th postoperative day, a dramatic bleeding of the right common carotid artery occurred. To our knowledge, this is the first reported case in the literature with a septic bleeding of the common carotid artery following total thyroidectomy after one week.

Thyroidectomy in Graves' disease: subtotal, near total or total?

Thyroidectomy is one of the possible therapeutic options in Graves' disease as are antithyroid drugs and (131)radioiodine. Emerging data reveal an advantage of total thyroidal ablation as the method of choice in patients with impending or overt Graves' orbitopathy. Pros and cons are discussed as presented at the 1st Swiss Symposium on Thyroid Eye Disease in Pontresina, Switzerland in December 2007.

Permanent hypocalcemia in patients operated for thyroid carcinoma

AIM AND OBJECTIVE

The incidence and risk factors for permanent hypocalcemia in thyroid carcinoma were investigated.

MATERIALS AND METHODS

The records of 417 patients were reviewed retrospectively at tertiary oncology referral center. Total or subtotal thyroidectomy patients constituted group I (n = 225), reoperative thyroid surgery patients constituted group II (n = 106), and therapeutic neck dissection cases constituted group III (n = 86). Age, gender, thyroid functions, pathologically verified tumor type, differentiation, localization and size, multicentricity, thyroid capsule invasion, extrathyroidal soft tissue invasion, coexistence of lymphocytic thyroiditis, metastatic lymph nodes dissected, incidental parathyroidectomy, and the type of surgery were investigated. RE SULTS: Permanent hypocalcemia was seen in 32 (7.7%) patients. The incidence of permanent hypocalcemia for each group was 1.7%, 10.3% and 19.7%, respectively. Related risk factors were hyperthyroidism for group I [adjusted relative risk (RR) = 21.1, 95% confidence interval (CI) = 2.6-165, p = 0.01] incidental parathyroidectomy for group II (RR = 7.8, 95% CI = 1.9-31.0, p = 0.004), and extrathyroidal soft tissue invasion (RR = 3.1, 95% CI = 1.1-9.5, p = 0.03) for group III.

CONCLUSION

Permanent hypocalcemia rate was increased with reoperative thyroid surgery and neck dissection added to total thyroidectomy. Hyperthyroidism, incidental parathyroidectomy and extrathyroidal extension were related risk factors.

Postoperative hypoparathyroidism: medical and surgical therapeutic options

BACKGROUND

Hypoparathyroidism occurs when the parathyroid glands, through lack of secretion of or resistance to parathyroid hormone (PTH), are unable to maintain calcium homeostasis. Transient and permanent hypoparathyroidism are most commonly seen as complications of neck surgery, resulting from devascularization of the parathyroids, unintentional resection, or accidental coagulation of the parathyroids.

SUMMARY

Although strategies for treatment of transient and permanent hypoparathyroidism differ, the classical approach involves supplementation with calcium and vitamin D or its analogues with the major goal of achieving low normal serum calcium and normal serum phosphorus. There are a variety of calcium and vitamin D preparations available for use in the treatment of symptomatic hypoparathyroidism. In selecting the appropriate vitamin D sterol for treatment, it is important to consider the pharmocodynamics, the potency at the tissue level, the rapidity of action, and ease of reversal of toxicity. Drawbacks to conventional therapy, including narrow therapeutic window and propensity for hypercalciuria and hypercalcemia, have prompted investigation into alternatives, namely PTH replacement and parathyroid gland autotransplantation.

CONCLUSION

Long-term supplementation with vitamin D or its analogues and oral calcium is the mainstay of management of postoperative hypoparathyroidism; however, PTH replacement strategies with either PTH or parathyroid gland autotransplantation are emerging as alternative strategies to avoid the complications of conventional therapy.

Outpatient thyroid surgery and the advances making it possible

PURPOSE OF REVIEW

To review the literature regarding the safety and feasibility of outpatient thyroid surgery.

RECENT FINDINGS

Outpatient thyroidectomy is increasingly reported especially for hemithyroidectomy. Meta-analysis of 11 randomized trials comparing routine drain with no drains found no significant difference in respiratory distress or wound reexploration but found an increased length of stay with drain usage. In addition to risk from delayed hematoma formation, risk of hypocalcemia developing from hypoparathyroidism has traditionally challenged outpatient total or completion thyroidectomy. Routine calcium and vitamin D supplementation has been shown to reduce the risk of hypocalcemia. A meta-analysis of rapid postoperative parathyroid hormone (PTH) measurement confirmed a significantly increased risk of hypocalcemia for PTH less than 15 pg/ml.

SUMMARY

Outpatient thyroidectomy is increasingly performed and reported. The senior author currently offers outpatient thyroidectomy for patients not requiring drain placement (smaller goiters without significant blood loss) and with postanesthesia care unit PTH levels of at least 30 pg/ml or with postanesthesia care unit PTH levels of at least 20 pg/ml with oral calcium supplementation.

Antibiotic prophylaxis in thyroid surgery: a preliminary multicentric Italian experience

Post-operatory wound infections are a very uncommon finding after thyroidectomy. For these reasons international guidelines do not routinely recommend systemic antibiotic prophylaxis. The benefits of this antibiotic prophylaxis is not supported by clinical evidence in the literature. We have conducted a multicentric randomized double-blind trial on 500 patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The 500 patients enrolled in the study (mean age 47 years) were randomized in two subgroups of 250 patients. 250 patients were treated with standard antibiotic prophylaxis with sulbactam/ampicillin 1 fl (3 gr.) 30 min before surgery. No antibiotic prophylaxis was instituted in the remainder 250 patients. Our RCT showed that prophylactic antibiotic treatment is not beneficial in patients younger than eighty years old, with no concomitant metabolic, infective and hematologic disease, with no cardiac valvulopathies, not under steroidal or immunosuppressive treatment, and not severely obese. Our study should be regarded only as a preliminary RCT, and should be followed by a study in which a larger number of patients should be enrolled so that statistically significant data can be obtained.

Does near total thyroidectomy offer advantage over total thyroidectomy in terms of postoperative hypocalcemia?

Total thyroidectomy (TT) has emerged as a surgical option in the surgical treatment of patients with multinodular goiter. TT carries potential risk to all parathyroid glands and both recurrent laryngeal nerve. The aims of this study are to evaluate the difference between serum calcium levels before and after total and near total thyroidectomy and to compare the rate of postoperative hypocalcemia according to surgical procedures. This prospective study included 143 consecutive patients undergoing surgical therapy for non-toxic multinodular goiter. Patients were randomly assigned to surgical procedures. Patients in group 1 (n=75) performed TT, and patients in group 2 (n=68) performed near total thyroidectomy (NTT). The difference between serum calcium levels and percentage decrease in serum calcium levels before and after thyroidectomy were calculated. TT had a 33-fold (OR: 33.1; 95% CI: 7.5-145.02) increased risk for hypocalcemia. Moreover, TT had a 8-fold (OR: 8.09; 95% CI: 3-21.4) and a 27-fold (OR: 27.9; 95% CI: 3.5-219.6) higher risk than NTT for moderate and severe percentage decreases in serum calcium level, respectively. NTT can offer an advantage over TT in terms of postoperative hypocalcemia in the patients with benign multinodular goiter.

Prospectives and surgical usefulness of perioperative parathyroid hormone assay in thyroid surgery

Hypocalcemia is the most frequent complication after thyroid surgery. The incidence varies and has been reported as ranging from 1.2 to 40%. Permanent hypoparathyroidism occurs in less than 3% of patients, whereas transient postoperative hypocalcemia is much more common. Postoperative hypoparathyroidism is traditionally detected by serial measurement of serum calcium concentrations and requires multiple venepunctures and, potentially, several days of hospitalization following the procedure. The parathyroid hormone (PTH) molecule is a polypeptide composed of an 84-amino acid sequence with an active amino terminal on one end and an inactive carboxyl unit on the other. Measurement of the intact PTH (iPTH) is an accurate representation of the true parathyroid state. In recent years, iPTH assay has been under investigation for thyroid surgery in many centers as an early iPTH measurement may be of value for prediction of postoperative symptomatic hypocalcemia, guiding the surgeon for parathyroid autotransplatation, and selection of patients requiring onset of calcium substitution or safe discharge home. This paper reviews the relevant medical literature published regarding the influence of PTH assay technology on the quality of thyroid surgery, as well as on the prevention of postoperative symptomatic hypocalcemia. Searches were last updated in April 2008.

Horner's syndrome as a complication of thyroidectomy: report of a case

We report a case of Horner's syndrome (HS) occurring as a complication after total thyroidectomy. Horner's syndrome is characterized by myosis, eyelid ptosis, enophthalmos, and lack of sweating, with vascular dilatation of the lateral part of the face, caused by damage of the cervical sympathetic chain. We found only 28 other reports of HS developing after thyroidectomy, and only seven of these patients recovered completely. Of the 495 thyroidectomies performed at our hospital between 1997 and 2007, only one (0.2%) was complicated by the development of HS. The patient was a 35-year-old woman who underwent total thyroidectomy for Basedow-Graves' disease. Horner's syndrome manifested on postoperative day 2, but without anhydrosis or vascular dilatation of the face, and the symptoms resolved spontaneously 3 days later. The possible causes of HS after thyroidectomy include postoperative hematoma, ischemia-induced neural damage, and stretching of the cervical sympathetic chain by the retractor. The prompt and complete recovery of this patient suggests that the cervical sympathetic chain was damaged by retractor stretching.

Evidence-based surgical management of substernal goiter

BACKGROUND

A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology.

METHODS

This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution.

RESULTS

Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nerve injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation).

CONCLUSION

Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.

Kinetics of serum parathyroid hormone during and after thyroid surgery

Background

Hypocalcaemia after thyroidectomy is thought to result from surgical damage to the parathyroid glands. This study analysed postoperative outcomes related to perioperative parathyroid hormone (PTH) levels.

Methods

Some 402 consecutive patients undergoing thyroid surgery were studied prospectively to monitor perioperative changes in serum PTH and Ca2+ levels, and clinical symptoms of hypocalcaemia.

Results

Transient symptomatic hypocalcaemia and persistent hypoparathyroidism occurred in 61 (15 per cent) and six (1·5 per cent) of 402 patients respectively. The intraoperative decline in PTH was 20·2 per cent; the trough (63·8 per cent of preoperative value) was reached 3 h after surgery. Before surgery, PTH levels were correlated inversely with serum Ca2+ concentration. The correlation remained positive from 3 h after surgery until postoperative day 14. Thus, PTH secretion was reduced, but remained sufficient to prevent symptomatic hypocalcaemia in most patients. A low serum PTH level was predictive of persistent hypoparathyroidism (sensitivity and negative predictive value 100 per cent, but poor specificity of 54·1 per cent).

Conclusion

Thyroid surgery impairs hormone secretion by the parathyroid glands resulting in postoperative latent parathyroid insufficiency. Normal PTH levels 3 h after surgery and a normal serum calcium level on the first postoperative day rule out persistent hypoparathyroidism.

Ligasure versus Ultracision in thyroid surgery: a prospective randomized study

PURPOSE

New hemostatic technologies (NT) are often employed in thyroid surgery in the effort to reduce operating time and complications. The aim of this study is to compare three different hemostatic techniques.

METHODS

This is a prospective randomized study. There were 150 patients, aged 56 +/- 14 years, randomized for total thyroidectomy with conventional technique (CT), Ligasure vessel sealing system (LI) or Harmonic Scalpel (HS) at the university surgical department. One hundred thirty-five patients had benign diseases; 15 had malignancies.

RESULTS

Mean postoperative hospital stay was 2.6 days. Mean operation time was 113 +/- 31 min; in HS patients, it was significantly shorter (p < 0.001). Morbidity was 43.3%; mortality was nil. Morbidity was significantly different between CT and NT groups (p = 0.0002); HS and LI groups had a higher morbidity (p = 0.0001 and p = 0.02, respectively). Mean postoperative calcemia was 1.12 +/- 0.1 mmol/l with a significant difference between groups; NT patients had a significantly lower calcemia (p < 0.05). There was no difference in recurrent laryngeal nerve palsies and in intraoperative blood losses (p = ns).

CONCLUSIONS

According to our experience, the only real advantage of new hemostatic technologies was a shorter operation time with HS.

Total thyroidectomy is safer with identification of recurrent laryngeal nerve

OBJECTIVE

To investigate the effect of recurrent laryngeal nerve (RLN) identification on the complications after total thyroidectomy and lobectomy.

METHODS

Total 134 consecutive patients undergoing total thyroidectomy or thyroid lobectomy from January 2003 to November 2004 were investigated retrospectively. Patients were divided into two groups: RLN identified (Group A) or not (Group B). The two groups were compared for RLN injury and hypocalcaemia.

RESULTS

The numbers of patients and nerves at risk were 71 and 129 in Group A, and 63 and 121 in Group B, respectively. RLN injury in Group A (0) was significantly lower than that in Group B (5 [7.9%]) patients, 7 [5.8%] nerves) for the numbers of patients (P=0.016) and nerves at risk (P=0.006). Temporary hypocalcaemia was significantly higher in Group A than in Group B (14 [24.1%] vs 6 [10.3%], P=0.049). Permanent complications in Group B were significantly higher than those in Group A (13 [20.6%] vs 4 [5.6%], P=0.009).

CONCLUSION

RLN injury was prevented and permanent complications were decreased by identifying the whole course and branches of the recurrent laryngeal nerve during total thyroidectomy.

Electrocautery for cutaneous flap creation during thyroidectomy: a randomised, controlled study

Background:

Although electrocautery has been used widely in surgery, the fear of delayed wound healing and infection persists. We aimed to evaluate the risk factors for wound complications and the rate of wound complications, comparing the use of electrocautery or scissors in cutaneous flap creation during thyroidectomy.

Design:

The study group comprised 239 consecutive patients scheduled for thyroidectomy.

Subjects:

Patients were randomly assigned to cutaneous flap dissection by either electrocautery (group one, n = 126) or scissors (group two, n = 113). Age, gender, body mass index, American Society of Anesthesiology score, tissue weight, operating time, incision length, cutaneous tissue depth, thyroid function and surgeon experience were recorded and compared with the rate of post-operative wound complications in both groups.

Results:

There were no significant differences between the overall rate of post-operative wound complications, comparing groups one and two (7.9 vs 10.6 per cent, respectively; p = 0.74). Significant positive correlations were found between wound complication and age (Spearman's rank coefficient (rs) = 0.135, p = 0.036), body mass index (rs = 0.379, p = 0.0001), cutaneous tissue depth (rs = 0.677, p = 0.0001) and tissue weight (rs = 0.643, p = 0.0001). According to logistic regression analysis, a body mass index of more than 27.5 kg/m2 was associated with a 13.7-fold increased rate of post-operative wound complications.

Conclusion:

When creating cutaneous flaps during thyroidectomy, the use of electrocautery is as safe as the use of scissors. Such electrocautery does not increase the risk of wound complications in thyroid surgery.