Safety of thyroidectomy and cervical neck dissection without drains

Risk factors of transient and permanent hypoparathyroidism after thyroidectomy: a systematic review and meta-analysis

BACKGROUND

Postoperative hypoparathyroidism (hypoPT) is a common complication following thyroid surgery. However, current research findings on the risk factors for post-thyroid surgery hypoPT are not entirely consistent, and the same risk factors may have different impacts on transient and permanent hypoPT. Therefore, there is a need for a comprehensive study to summarize and explore the risk factors for both transient and permanent hypoPT after thyroid surgery.

MATERIALS AND METHODS

Two databases (PubMed and Embase) were searched from inception to 2024. The Newcastle-Ottawa Scale was used to rate study quality. Pooled odds ratios were used to calculate the relationship of each risk factor with transient and permanent hypoPT. Subgroup analyses were conducted for hypoPT with different definition-time (6 or 12 months). Publication bias was assessed using Begg's test and Egger's test.

RESULTS

A total of 19 risk factors from the 93 studies were included in the analysis. Among them, sex and parathyroid autotransplantation were the most frequently reported risk factors. Meta-analysis demonstrated that sex (female vs. male), cN stage, central neck dissection, lateral neck dissection, extent of central neck dissection (bilateral vs. unilateral), surgery [total thyroidectomy (TT) vs. lobectomy], surgery type (TT vs. sub-TT), incidental parathyroidectomy, and pathology (cancer vs. benign) were significantly associated with transient and permanent hypoPT. Preoperative calcium and parathyroid autotransplantation were only identified as risk factors for transient hypoPT, while preoperative PTH was a protective factor. Additionally, node metastasis and parathyroid in specimen were associated with permanent hypoPT.

CONCLUSION

The highest risk of hypoPT occurs in female thyroid cancer patients with lymph node metastasis undergoing TT combined with neck dissection. The key to preventing postoperative hypoPT lies in the selection of surgical approach and intraoperative protection.

Evaluation of Hematoma Formation after Thyroidectomy Surgery and Its Related Factors

Background

In the last decade, the number of patients undergoing thyroidectomy has increased. Compared to other methods, thyroidectomy is a relatively safe method for treating various types of thyroid diseases. However, the blood flow rate in the thyroid gland is high, and hematoma after thyroidectomy is one of its complications. We aimed to evaluate hematoma after thyroidectomy and its related factors.

Methods

In this retrospective study, 2320 patients over 20 years of age who underwent thyroidectomy in Imam Khomeini, Arvand, and Mehr Ahvaz hospitals, Khuzestan Province, southern Iran between 2011 and 2022 were enrolled. Data were analyzed using SPSS software, version 22.

Results

70.7% of the patients were in the age range of 20-50 years. Twenty-five (1.1%) of patients developed a hematoma after thyroidectomy. Males are more likely to hematoma after surgery (P=0.01). Hematoma was significantly higher in patients with a history of hypertension (P=0.001). Moreover, a significant association was found between male gender, and age over 50 years with the risk of hematoma (P<0.05). The incidence of hematoma had a statistically remarkable correlation with follicular thyroid cancer pathology (P=0.001). Other pathology diagnoses were not significantly related to hematoma formation after thyroidectomy.

Conclusions

Hematoma after thyroidectomy surgery is a rare, but dangerous and life-threatening complication. It is important to identify risk factors for hematoma formation.

Clinical Usefulness of the Valsalva Manoeuvre to Improve Hemostasis during Thyroidectomy

Bleeding after total thyroidectomy remains a rare event that affects early postoperative morbidity, occurring in 0.3% to 4.2% of cases. Intraoperative bleeding is an unpleasant complication, and it is often easily manageable, although postoperative bleeding may represent a life-threatening condition for the patient. The purpose of our study was to clarify the role of the Valsalva manoeuvre to reduce postoperative bleeding. Between January 2019 to February 2022, 250 consecutive patients were listed for thyroid surgery at our surgical department. The study cohort consisted of 178 patients, divided into two groups based on the execution of the Valsalva manoeuvre. There was no difference in the duration of surgery between groups. Group B had fewer reinterventions for bleeding. Group A had a significantly greater volume of drainage output than Group B. Cervical haematoma can compromise a patient’s life, so bleeding control is crucial. Our results show that using a simple and safe Valsalva manoeuvre can improve the postoperative course with a significant reduction in drainage output, but does not prevent the risk of reoperation for hemorrhage.

Redo thyroid surgery without drains

PURPOSE

Redo thyroid surgery is associated with higher risk of hematoma than the initial thyroid surgery. We report a single surgeon's experience of performing redo thyroid surgery without drains.

METHODS

This retrospective single-institutional study evaluates the safety and efficiency of redo thyroid surgery without drains by comparing three groups of patients: those who underwent primary bilateral thyroidectomy (Group 1), those who underwent completion thyroidectomy (Group 2); and those who underwent thyroidectomy for recurrent thyroid diseases (Group 3).

RESULTS

The demographic characteristics did not differ among the groups. Substernal extension and hyperthyroidism were more frequent in group 1, whereas the weight of the resected thyroid gland was lower in groups 2 and 3. Hematoma occurred in 5%, 4%, and 4% of patients in Groups 1, 2, and 3, respectively. Postoperative transient hypocalcemia occurred in 19%, 16%, and 21% of patients in Groups 1, 2, and 3 respectively. The postoperative incidence of transient recurrent laryngeal nerve (RLN) paralysis in Groups 1, 2, and 3, was 6%, 7%, and 8%, respectively. The incidence of permanent unilateral RLN paralysis in Groups 2 and 3 was 1%. The postoperative length of stay was 1 day in 92% of the patients from all groups.

CONCLUSIONS

Avoiding the routine use of drains in redo thyroid surgery is safe and effective, it does not increase overall surgical morbidity, and it reduces the overall length of stay in hospital.

Evaluating risk factors for re-exploration due to postoperative neck hematoma after thyroid surgery: a nested case-control study

Purpose

Postoperative bleeding after thyroid surgery remains a potentially lethal complication. Outpatient thyroidectomy is an increasing trend in the high volume centers. There is a need to identify risk factors for postoperative bleeding in order to select proper patients for outpatient thyroidectomy. This study aimed to investigate this issue using a national population-based register.

Material and method

A nested case-control study on patients registered in the Swedish national register for endocrine surgery (SQRTPA) was performed. Patients with postoperative bleeding were matched 1:1 by age and gender to controls. Additional information on cases and controls was obtained from attending surgeons using a questionnaire. Risk factors for postoperative bleeding were evaluated with logistic regression and are presented as odds ratios (ORs) with 95% confidence intervals (CIs). The time of bleeding in relation to surgery was also investigated.

Results

There were 9494 operations, and 174 (1.8%) of them involved postoperative bleeding. In the whole cohort, patients with postoperative bleeding were older, 58 (46–69) vs. 49 (37–62) years, than patients without, p < 0.01. Male patients had a higher risk of bleeding, OR 2.18 (95% CI 1.58–2.99). In the case-control cohort, drain was an independent risk factor for bleeding, OR 1.64 (1.05–2.57). Two-thirds of patients bled within 6 h after surgery. The incidence of bleeding after 24 h was 10%.

Conclusion

High age, male gender, and drain are independent risk factors for bleeding after thyroid surgery. Even with careful patient selection, prolonged observation might be necessary in thyroid surgery.

Systematic review of international guidelines for perioperative antibiotic prophylaxis in Head & Neck Surgery. A YO-IFOS Head & Neck Study Group Position Paper

BACKGROUND

Surgical site infection (SSI) is defined as an infection that occurs after a surgical incision or organ manipulation during surgery. The frequency reported for clean head and neck surgical procedures without antimicrobial prophylaxis is <1%. In contrast, infection rates in patients undergoing complicated cancer surgery are high, ranging from 24% to 87% of patients without antimicrobial prophylaxis.

METHODS

Guidelines and recommendations about the use of antibiotics in head and neck surgery from 2004 to 2019 were reviewed.

RESULTS

Four guidelines from Oceania, 5 from South America, 5 from North America, 2 from the United Kingdom, 11 from Europe, 1 from Africa, 1 from the Middle East, and 3 from Asia were included. A total of 118 papers were included for analysis and recommendation.

CONCLUSION

Antibiotic prophylaxis can decrease the incidence of SSI. However, the risks associated with antibiotic exposure and the risk of antibiotic resistance need to be taken into consideration.

Impact of drains on nausea and vomiting after thyroid and parathyroid surgery: a randomized controlled trial

OBJECTIVE

Nausea and vomiting are common side effects following thyroid and parathyroid surgery. In a prospective controlled randomized trial, postoperative nausea and vomiting (PONV) and the number of episodes of vomiting were defined as two primary endpoints. We analysed whether the placement of drains after thyroid or parathyroid surgery enhances PONV and/or influences vomiting.

PATIENTS AND METHODS

From November 2007 to January 2012, 136 consecutive patients were included for thyroid or parathyroid surgery and were randomly assigned to group A (drain, n = 69) or group B (no drain, n = 67). PONV was assessed with visual analogue scale (VAS; range 0 to 10) measurements. Furthermore, episodes of vomiting as well as analgetic and antiemetic therapies were recorded. Difference in neck circumference was compared pre- and postoperatively.

RESULTS

Patients' characteristics did not differ between group A and B. Postoperative VAS values for pain were 2.4 ± 0.3 (group A) and 2.6 ± 0.2 (group B) (p = 0.62), and for nausea 1.4 ± 0.2 (group A) and 1.1 ± 0.2 (group B) (p = 0.57). The relative occurrences of episodes for postoperative vomiting were equal in both groups 0.3 ± 0.1 (p = 1.0). Antiemetic drugs were administered 37 times (group A) and 18 times (group B) (p = 0.099). The total number of treatments of patients with antiemetic drugs was 23 (33.3%) in group A vs. 13 (19.4%) in group B (p = 0.081). The neck circumference postoperatively was significantly larger in group B (p = 0.0025).

CONCLUSIONS

Drains after surgery do not enhance postoperative pain, nausea and vomiting. The placement of drains in thyroid surgery is recommended to avoid relevant fluid collection. Drains however may influence the amount of antiemetic drug requirements.

TRIAL REGISTRATION

CLINICALTRIALS.

GOV IDENTIFIER

NCT01679418.

Antibiotic Prophylaxis in Clean Head and Neck Surgery: An Observational Retrospective Single-Centre Study

INTRODUCTION

Surgical site infection (SSI) is a common complication in surgery. In head and neck surgeries, different rates are reported in the indexed literature. Nowadays, this indiscriminate use of antibiotics is associated with increased cost and risks for patients. Antimicrobial misuse has also contributed to the development of antibiotic-resistant bacteria.

PATIENTS AND METHODS

A total of 204 patients were included in this observational retrospective cohort study. The primary outcome of this study was to describe the rate of SSI. Wound infection was considered as SSI and was defined as any cellulitis or pus drainage requiring treatment with antibiotics.

RESULTS

Of all, 127 were included in group A (not antibiotic) and 77 in group B (antibiotic prophylaxis); 109 (53.5%) patients were male, and 97 (47.5%) were female. Four (3.14%) patients developed SSI in group A and 3 (3,89%) developed SSI in group B, being not statistically significant (P = .592). In group A, 2 patients suffered SSI after a submandibular gland resection (SGR), 1 patient after a parotid gland resection (PGR), and another one after a branchial cleft cyst resection. In group B, 1 patient suffered SSI after an SGR and 2 after a PGR. On univariate and multivariate analyses, we did not find any variable associated with the development of SSI.

CONCLUSION

According to our results, the prophylactic antibiotic in clean, benign head and neck surgery is not necessary. Nevertheless, physicians and surgeons should be aware that severe or even fatal SSIs might be developed, and it needs to be explained to our patient before any surgery.

Independent predisposing factors for subcutaneous and deep wound collection after total thyroidectomy, a prospective cohort study

BACKGROUND

The literature contains diverse and sometimes contradicting results about wound seroma following thyroidectomy. This is probably due to the subjective clinical estimation of seroma, or due to failure to differentiate between the occurrence of subcutaneous (SC) and deep wound collections. This work aimed at objectively investigating the factors affecting subcutaneous and deep wound seroma after thyroidectomy.

METHODS

The relation between various operative and clinico-pathological factors and the collection formation was prospectively analyzed in a cohort of 100 patients after conventional thyroidectomy. Wound seroma was assessed clinically and via high-resolution ultrasonography at 24 h, 48 h and two weeks postoperatively. Sonographically detected collections were expressed as SC and/or deep wound collections according to the relation to strap muscles.

RESULTS

Operative duration was the only independent factor significantly affecting the incidence of clinical seroma. Older patients (>40ys) showed significantly larger volumes of early SC collections. Early postoperative pain was significantly related to drain insertion, to the occurrence of clinical seroma and to the volume of SC collections.Sonographically, suction drains and shorter operative durations resulted in significantly less amount of deep collections. Suction drains did not result in less amount of SC collections or in a lower incidence of clinical seroma.

CONCLUSIONS

Operative duration is the only independent factor significantly related to clinically-detected postoperative seroma with its subsequent postoperative pain. Especially in elderly patients, a flapless technique would be recommended as these patients developed larger volumes of SC collections with subsequent higher pain scores, even if seroma was not clinically detected.

Ultrasound Identifies Broken Drainage Tube Postthyroidectomy

Drains are routinely used after thyroidectomy and lateral neck dissection. In rare cases, the drainage tube is broken and retained in the neck. It is difficult to identify the sonographic features of the remnant tube due to variable reasons. However, through comparative and phantom observations, we noticed the double-tract sign of the tube wall and drainage holes as the key points to solving this problem. We report such a case of the ultrasound-guided localization of a broken drainage tube that was retained in the patient.

Predisposing factors for seroma formation in patients undergoing thyroidectomy: Cross-sectional study

Introduction

Seroma is defined as collection of fluid within the surgical site during postoperative period that causes several complications. Recognition of predisposing risk factors can lead to avoid seroma formation after thyroidectomy.

Materials and methods

A cross-sectional study was carried out during a 3-year period and 678 patients were enrolled the study. We recorded demographic data, past medical history and the type of thyroidectomy were for all patients. We measured total and ionized serum calcium and albumin level in all patients before surgery and a day after it. All patients underwent total or subtotal thyroidectomy and if needed central neck dissection was performed subsequently. Patients underwent serial aspiration If they had seroma formation.

Results

The overall post-thyroidectomy seroma incidence was 2.2%. There was no statistically significant correlation while evaluating gender, age and body mass index with post-operative seroma formation. However, seroma formation was significantly higher in patients underwent total thyroidectomy (P = 0.041). The results of postoperative laboratory tests showed a significant lower level of ionized calcium in patients with seroma formation (P < 0.0001). Logistic regression showed statistically significant value for variables including age, BMI and decreased ionized calcium level, in developing of seroma.

Conclusion

We showed that Seroma formation was lower during thyroidectomy via electrical vessel sealing system in comparison with previous studies. In our study, older age, greater body mass index and decreased ionized calcium level were predictors of seroma formation.

Effect of Intraoperative Valsalva Maneuver Application on Bleeding Point Detection and Postoperative Drainage After Thyroidectomy Surgeries

The purpose of this paper was to analyze the effect of Valsalva maneuver application before finalizing thyroidectomy operations on the identification of bleeding points and postoperational drainage. One hundred patients (age range, 24-76 years) with multinodular goiter, recurrent multinodular goiter, toxic diffuse multinodular goiter, or papillary thyroid cancer were included in the study and were divided into 2 groups of 50 randomly. Both groups underwent thyroidectomy operation, only 1 group received intraoperative Valsalva maneuver application (twice, 30 seconds of 30-cm PEEP). The size of the thyroid gland, the duration of operation, hospital stay, and drain usage were reported. Postoperational occurrences of drainage, hematoma, reoperation, and additional complications were compared between the groups. Valsalva maneuver application helped to identify minor bleeding points in 32% of the cases. There was no significant difference between the study groups regarding the thyroid gland size, operation duration, hospital stay, and the duration of drain usage (P > 0.05 for all). The amount of drainage as well as the frequencies of hematoma, reoperation, and further complications was not significantly different between the study groups (P > 0.05 for all). Intraoperative application of Valsalva maneuver is only useful to detect minor bleeding points in some patients during thyroidectomy operations, but it had no effect on the duration of postoperative drain usage, the amount of drainage, and risk of hematoma. Therefore, intraoperative application of Valsalva maneuver has no beneficial effect on postoperative hemorrhagic complication after thyroidectomy operations.

Risk factors for hematoma after thyroidectomy: results from the nationwide inpatient sample

BACKGROUND

Hematoma after thyroidectomy is a potentially lethal complication. We sought to evaluate risk factors for hematoma formation using the Nationwide Inpatient Sample. We hypothesized that certain risk factors could be identified and that this information would be useful to surgeons.

METHODS

The Nationwide Inpatient Sample database was queried for patients who underwent thyroidectomy from 1998 to 2010. Bivariate analysis was used to compare patients with and without hematoma. Logistic regression was performed to identify important predictors of hematoma.

RESULTS

There were 150,012 patients. The rate of hematoma was 1.25%. Female sex and high-volume hospitals were important for decreased hematoma risk (odds ratio 0.61[0.54-0.69] and 0.71 [0.56-0.83], respectively). Black race, age >45 years, inflammatory thyroid disease, partial thyroidectomy, chronic kidney disease, and bleeding disorders increased the risk of hematoma (odds ratio 1.37, 1.44, 1.59, 1.69, 1.8, 3.38; respectively). Overall mortality was 0.32% for the entire group and 1.34% in patients with postoperative hematoma (P < .001). Patients with hematoma after thyroidectomy were 2.94 [1.76-4.9] times more likely to die than those without hematoma.

CONCLUSION

We identified risk factors associated with postoperative hematoma after thyroidectomy. Such information should be useful for surgeons for predicting patients at risk for this potentially lethal complication.

[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.