Sistemas de hemostasia en cirugía tiroidea y complicaciones

Bocio multinodular gigante. Revisión de la literatura a propósito de un caso

Introducción. La patología tiroidea abarca desde procesos benignos hasta cánceres. El manejo médico-quirúrgico del bocio gigante implica la realización de estudios citológicos y de imagen. El objetivo de este artículo fue hacer una revisión de la literatura y presentar un caso atendido de bocio multinodular gigante. Métodos. En el presente artículo se revisa la literatura sobre el tema en cuestión a propósito del caso de una paciente de 54 años de edad, intervenida quirúrgicamente por bocio multinodular, con evolución satisfactoria. Resultados. Se interviene la paciente de manera electiva, realizándo exéresis a un tiroides de 658 gramos, conservando los nervios laríngeos recurrentes y las glándulas paratiroides; se realizó una meticulosa hemostasia y se trasladó la paciente a la Unidad de Cuidados Intensivos. A los 3 días se retiraron ambos drenajes cervicales, y se dio alta hospitalaria definitiva a los 8 días. La biopsia por parafina corroboró el diagnóstico preoperatorio. Discusión. Las indicaciones de tratamiento quirúrgico del bocio incluyen: crecimiento rápido de la glándula, síntomas compresivos y sospecha de malignidad. Las complicaciones son mínimas cuando se realiza una técnica muy meticulosa. Conclusión. El bocio multinodular gigante es infrecuente, y en todos los casos, requiere de intervención quirúrgica.  

The patterns and treatment of postoperative hemorrhage and hematoma in total endoscopic thyroidectomy via breast approach: experience of 1932 cases

PURPOSE

Postoperative hemorrhage and hematoma formation is a potentially lethal complication in thyroid surgery, although the patterns and treatment of hemorrhage after total endoscopic thyroidectomy (TET) via breast approach has not been reported previously. We aim to share our experience about postoperative bleeding.

METHODS

A retrospective analysis of 1932 patients who underwent TET from April 2008 to May 2018 in our institution was carried out. The patterns of postoperative hemorrhage and hematoma formation that need surgical treatment were summarized and focused on the relation to the source of bleeding and the time interval between first surgery and hemorrhage. Related risk factors were analyzed by univariate or multivariate analysis processes.

RESULTS

The overall rate of hemorrhage and hematoma occurrence was only 0.724% (14 in 1932 patients). Of them, 12 occurred in the first 24 h after surgery, and the other two occurred after withdrawal of the drainage tube. The principle independent risk factors for postoperative hemorrhage and hematoma were age (older than 35 years old) and lateral compartment dissection (LCD) revealed by multivariate regression. During re-exploration, obvious bleeding points were detected in 13 patients. Among them, 12 bled from the vessels in the main trocar cavity and another 1 bled from a broken vein located between the two heads of the sternocleidomastoid (SCM) muscle with LCD.

CONCLUSIONS

Hemorrhage after TET usually occurs within 24 h, and the main video trocar cavity was the area most likely to bleed. Age and LCD may increase the bleeding risk. Appropriate dissection level is the main solution to prevent postoperative hemorrhage.

Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide inpatient sample database

CONTEXT

Postoperative neck hematoma is a well-known complication of thyroid and parathyroid surgery. Better understanding of risk factors for hematoma formation will help define high-risk populations.

OBJECTIVE

To examine possible risk factors for neck hematoma after thyroid or parathyroid surgery.

DESIGN

Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample database.

METHODS

Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedures codes, we identified adults who underwent thyroid or parathyroid surgery and in whom neck hematoma subsequently developed. Information about demographic, clinical, and hospital characteristics was collected. Multivariate regression analyses were used to predict independent risk factors for neck hematoma.

RESULTS

We identified 147,344 thyroid and parathyroid operations performed nationwide between 2000 and 2009. Overall incidence of postoperative neck hematoma was 1.5% (n = 2210). In multivariate analysis, age 65 years and older (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.4-2.1), male sex (OR = 1.3, 95% CI = 1.2-1.4), African-American race (OR = 1.5, 95% CI = 1.2-1.7), being from the South (OR = 1.3, 95% CI = 1-1.4), comorbidity score of 3 or more (OR = 2, 95% CI = 1.6-2.6), history of alcohol abuse (OR = 2.7, 95% CI = 1.6-2.5), Graves disease (OR = 3, 95% CI = 2.1-4.1), and substernal thyroidectomy (OR = 3.3, 95% CI = 2.8-3.9) were associated with a higher risk of neck hematoma.

CONCLUSION

We identified demographic and clinical factors associated with increased risk of neck hematoma after thyroid or parathyroid surgery.

[Contribution of neuromonitoring to the safety of tracheal extubation after total thyroidectomy. Prospective study with needle electrodes]

INTRODUCTION AND OBJECTIVES

Bilateral laryngeal paralysis cause serious respiratory complications. In thyroid surgery, neuromonitoring helps in identifying the recurrent laryngeal nerve, reports on its functioning at the end of surgery, supports decision making, and may reduce the risk of bilateral paralysis. Our objective was to estimate the influence of neuromonitoring in operative strategy and extubation safety in total thyroidectomy.

METHODS

A non-randomized prospective study was conducted on 210 patients undergoing total thyroidectomy (420 laryngeal nerves stimulated included). We collected qualitative neuromonitoring variables (presence or absence of final signal after stimulation of the vagus nerve), and postoperative indirect laryngoscopy (normal motility or paralysis), performed until 3rd day after the surgery.

RESULTS

The accuracy of the test was 99.5% (95% CI 98.3 to 99.9). The positive predictive value was 100% (95% CI 99.1 to 100), which showed the high ability of neuromonitoring to predict paralysis in case of loss of signal, and the negative predictive value was 99.5% (95% CI 98.3 to 99.9), which indicated its predictive capacity for normal motility when there is a normal signal.

CONCLUSIONS

In our group of patients, recurrent laryngeal nerve monitoring was useful in total thyroidectomy as it provided information on the prognosis of laryngeal motility, and helped in making decisions during surgery when there was signal loss. Due to the risk of serious respiratory complications due to bilateral recurrent laryngeal nerve paralysis, we opted for the performing of the 2-stage total thyroidectomy in case of signal loss in the first lobectomy. Thereby, neuromonitoring contributed to the safety of the airway in tracheal extubation, aiding in the prevention of a possible bilateral laryngeal paralysis.

Usefulness of neuromonitoring in thyroid surgery

INTRODUCTION

Identifying the recurrent laryngeal nerve is the gold standard for reducing injury in thyroidectomy.

OBJECTIVE

To evaluate the usefulness of neuromonitoring in identifying the recurrent laryngeal nerve.

METHODS

This was a study of 259 recurrent laryngeal nerves at risk during thyroidectomy performed with neuromonitoring (group A: 129 nerves) and without neuromonitoring (control group B: 130 nerves).

RESULTS

The percentage of visually unidentified nerves was 18% in group A and 20% in group B, with no statistical difference. From the moment of non-identification, identification with neuromonitoring was achieved in group A in 100% of cases. The difference was statistically significant. The positive and negative predictive value of neuromonitoring was 100%.

CONCLUSIONS

Neuromonitoring helps to identify the recurrent laryngeal nerve and increases the security of the surgeon in the technique. It is advisable to perform neuromonitoring routinely in thyroid surgery.