Aspectos quirúrgicos de los bocios multinodulares. A propósito de una serie de 680 casos

[Morbidity and costs in complete thyroidectomies. Improvement in Value of the Process by a change in the management]

OBJECTIVES

1) To present the postoperative morbidity of complete thyroidectomies and the results of their clinical management and costs obtained after surgery. 2) To compare the results obtained for the morbidity and costs in the complete thyroidectomy Process, after the management changes introduced by the Endocrine Surgical Unit (ESU). 3) To define whether these changes improve the Value (benefit/cost ratio) of the Process.

MATERIAL AND METHODS

Prospective study of cohorts conducted on 529 complete thyroidectomies performed between 1998 and 2011. We present their clinical-pathological characteristics and we compare the clinical and management results obtained after surgery in 2 time periods: 1998-2006 without ESU (group 1, 205 patients) and 2007-2011 with ESU (group 2, 324 patients). The clinical results and the possible benefits are assessed by studying the morbimortality (recurrent lesions, hypocalcaemia [<8 mg/dl], suffocative haematomas and bleeding), and those of management, for the evaluation of the use of operating room time, the average stay and the total cost of the Process. The statistical comparison study was made using Student t test, for the comparison of means and the Chi(2) to compare percentages, accepting P<.05 as significant.

RESULTS

The global percentage of transient recurrent dysfunctions (TRD) was 6%, and for definitive recurrent paralysis (DRP) it was 1.5%. Hypocalcaemia, at 24 hours was 54.6%, at one month 7%, at six months 6.2% and that of definitive hypoparathyroidism 1.3%. There were 2.8% of suffocative haematomas and 2% adverse effects. The mean surgical time was 98 minutes, and the average stay was 3.66 days. In the comparison of results of the groups, the ESU improved the TRD index by nearly 7 points (10.2 vs. 3.4%, P=.002), that of DRP by 1.5 (2.4 vs. 0.4%; P=.3) until reaching under 1%. The figures on bleeding at 24 hours (53 vs. 44 cc; P=.002) and 48 hours (23 to 17 cc; P<.001), the rate of haematomas by another 6 points (6.3 vs. 0.6%; P<.001), and that of hypocalcaemia at 24 hours (P=.01). The average stay also improved (4.79 vs. 2.94 days; P<.001), the use of operating room time (reduced by 20 minutes/operation; P<.001), the total cost of the Process, decreasing by more than € 2,000/Process (P<.001), and produced a total savings for the hospital in the period of study of € 665,820.

CONCLUSIONS

1) The global results (post-operative morbidity) of our total thyroidectomies are within the quality standards. 2) The surgical specialisation and the changes introduced by the ESU improved the clinical results (greater benefit) and those of management, cutting down the average stay and the operating room usage time and decreasing costs. 3) The change in management increased the Value of the Process.

Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery

OBJECTIVES

(1) To show that total thyroidectomy (TT) can be performed in multinodular goiter (MG) by surgeons with experience in endocrine surgery with a definitive complication rate of 1% or less; and (2) to analyze the risk factors for complications in these patients.

SUMMARY BACKGROUND DATA

There is current controversy over the role of TT in the treatment of MG; although there are potential benefits, high rates of complications are not acceptable in surgery for a benign pathology.

PATIENTS AND METHOD

A prospective study was conducted on 301 MGs meeting the following criteria: (1) bilateral MG; (2) no prior cervical surgery; (3) operation by surgeons with experience in endocrine surgery; (4) no associated parathyroid pathology; (5) no initial thoracic approach; and (6) minimum follow-up of 1 year. Age, sex, time of evolution, symptoms, cervical goiter grade, intrathoracic component, thyroid weight, and presence of associated carcinoma were analyzed as risk factors for complications. The chi test and a logistic regression analysis were applied.

RESULTS

Complications were presented by 62 patients (21%), corresponding to 29 hypoparathyroidisms, 26 recurrent laryngeal nerve injuries, 4 lesions of the superior laryngeal nerve, 3 cervical hematomas, and 1 infection of the cervicotomy. The variables associated with the presence of these complications were hyperthyroidism (P = 0.0033), compressive symptoms (P = 0.0455), intrathoracic component (P = 0.0366), goiter grade (P = 0.0195), and weight of excised specimen (P = 0.0302); hyperthyroidism (relative risk [RR] 2.5) and intrathoracic component (RR 1.5) persisted as independent risk factors. Definitive complications appeared in 3 patients (1%), corresponding to 2 hypoparathyroidisms and 1 recurrent laryngeal nerve injury. Two cases corresponded to a toxic goiter, and the third to an intrathoracic goiter with compressive symptoms.

CONCLUSION

In endocrine surgery units, TT can be performed for MG with a definitive complication rate of around 1%; the main independent risk factors for the development of complications are hyperthyroidism and goiter size.

[Hypoparathyroidism and hypocalcemia following thyroid surgery of multinodular goiter. Multivariant study of the risk factors]

BACKGROUND AND OBJECTIVE

The hypoparathyroidism is one of the most important complications in the patients submitted to thyroid surgery. The aim is to analyze across a multivariate statistical analysis the risks factors for the development of transient and permanent hypoparathyroidism following the multinodular goiter (MG) surgery.

PATIENTS AND METHOD

Between 1970 and 1999, 672 thyroidectomies by MG were reviewed. It was considered transient hypoparathyroidism when the calcemia was minor of 7.5 mg/dl or when being minors of 8.5 mg/dl the patient was presenting symptomatology for the hipocalcemia. The hypoparathyroidsm was considered permanent when the calcemia was minor of 8.5 mg/dl to the year of the surgery.

RESULTS

The hypoparathyroidism appeared in 75 patients (11.2%), 20 with symptomatology (3%), persisting like permanent 6 cases (0.9%). The risk factors for the development of this were the hyperthyroidism (p = 0.0370), and the surgical technique (p < 0.00001) (unilateral versus bilateral surgery), persisting in the multivariate analysis both variables. With respect to the permanent hypoparathyroidism, the risk factor was the toxic MG (p = 0.0109), persisting as independent risk factor in the multivariate analysis (RR = 2.3).

CONCLUSIONS

The principal risk factor of permanent hypoparathyroidism in the MG surgery is the presence of hyperthyroidism.