Assessment of the Early and Late Complication after Thyroidectomy
Esmaeil Chahardahmasumi1, Rezvan Salehidoost2, Massoud Amini2, Ashraf Aminorroaya2, Hassan Rezvanian2, Ali Kachooei2, Bijan Iraj2, Masoud Nazem3, Mohsen Kolahdoozan3
1 Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 General Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||27-Feb-2019|
Dr. Rezvan Salehidoost
Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: The complications in thyroid surgery have been reported variable in literature. The aim of this study was to evaluate the early and late (3 months after surgery) complication rates of thyroidectomy in a cohort of patients undergoing thyroid surgery at two hospitals of Isfahan University of Medical Science, Iran. Materials and Methods: This study included 204 patients who candidates for thyroidectomy presenting at Medical Educational Centers of Al-Zahra and Kashani hospitals in Isfahan between March 2016 and March 2017. Clinical data are collected for all patients by continuous enrollment. The patients examined before and after thyroid surgery and the findings were recorded. Results: The highest prevalence of thyroidectomy was in women (81.9%). The most frequent thyroid surgery was total thyroidectomy and the most common indication for thyroid surgery was suspicious fine-needle aspiration for thyroid malignancy. Hypocalcemia was the most common complication with a frequency of 54.4%. The odds ratios for early complications were 2.375 and 2.542 for intermediate- and low-volume surgeons, respectively, compared to high-volume surgeons. Conclusions: According to the results of this study, the high level of surgeon's skill is effective to reduce the likelihood of late and early complications; furthermore, the chance of late complications increases with age.
Keywords: Complications, hypocalcemia, morbidity, surgery, thyroidectomy
|How to cite this article:|
Chahardahmasumi E, Salehidoost R, Amini M, Aminorroaya A, Rezvanian H, Kachooei A, Iraj B, Nazem M, Kolahdoozan M. Assessment of the Early and Late Complication after Thyroidectomy. Adv Biomed Res 2019;8:14
|How to cite this URL:|
Chahardahmasumi E, Salehidoost R, Amini M, Aminorroaya A, Rezvanian H, Kachooei A, Iraj B, Nazem M, Kolahdoozan M. Assessment of the Early and Late Complication after Thyroidectomy. Adv Biomed Res [serial online] 2019 [cited 2019 Mar 24];8:14. Available from: http://www.advbiores.net/text.asp?2019/8/1/14/253115
| Introduction|| |
Thyroid disorders are one of the most common endocrine diseases. Surgical resection of the thyroid gland maybe necessary for the treatment of these disorders. Thyroidectomy is recommended for benign condition such as symptomatic large goiters and for the treatment of malignant disease of the thyroid gland.
Thyroidectomy has potential complications. The major postoperative complications are hypocalcemia, wound infection, hematoma, recurrent laryngeal nerve (RLN) injury, and Horner's syndrome.,, Hypocalcemia is the important postoperative complication of thyroid surgery causing potentially severe symptoms and increasing hospitalization time., Hypoparathyroidism is the usual cause of hypocalcemia, it results from accidental gland injury, removal, or devascularization., Hoarseness is mostly caused by RLN injury, which often results in vocal and laryngeal dysfunction. The patient's quality of life can be negatively influenced by the incidence of potential complications leading to increase in individual's health-care costs and requiring a lifelong alternative therapy. Complications associated with thyroidectomy are related to the type of disease, extent of disease, removal approaches, surgeon's training, and experience.,,, Several studies have shown that increased surgeon experience is significantly associated with decreases in complications after thyroid surgery.,
To the best of our knowledge, no published data have been found about the early and late complications of thyroid surgery in Isfahan. The aim of this study was to evaluate the early and late complication rates of thyroidectomy in a cohort of patients undergoing thyroid surgery at two hospitals of Isfahan University of Medical Science, Iran.
| Materials and Methods|| |
This cross-sectional, descriptive analytic study was conducted in Isfahan, a large urban area located in the center of Iran. This study included 204 candidates for thyroidectomy presenting at Medical Educational Centers of Al-Zahra and Kashani hospitals in Isfahan between March 2016 and March 2017. Clinical data are collected for all patients by continuous enrollment. The study was approved by the Isfahan University of Medical Sciences, Medical Ethics Committee, and all patients gave informed consent for participation in the examination and registration.
The patients with hypocalcemia, vocal cord paralysis, Horner's syndrome, tracheal injury, and esophagus injury were excluded from the study. The patients were examined initially and the demographic characteristics, past medical history, and the indication of thyroid surgery were recorded. The height, weight, and blood pressure were measured, and a general examination was done.
Following thyroid surgery, the patients were examined for early and late (3 months after thyroid surgery) complications of thyroid surgery, including hypocalcemia, hoarseness, dysphagia, hematoma, infection, and Horner's syndrome. The findings were recorded.
Concentrations of total calcium in normal serum generally range between 8.5 mg/dl and 10.5 mg/dl. The corrected levels of total calcium for albumin concentration below 8.5 mg/dl were considered as hypocalcemia. Dysphagia was defined as a subjective sensation of difficulty or abnormality of swallowing. The term hoarseness was used to describe any change in voice quality. Surgeon volume was classified on the basis of the number of thyroid surgery performed per year as low volume (lesser than 10 thyroid surgery/year), intermediate volume (10–99 thyroid surgery/year), and high volume (>99 thyroid surgery/year).
The collected data were analyzed with SPSS software (version 20; SPSS Inc., Chicago, Ill., USA) Quantitative data were expressed as mean ± standard deviation (SD) and qualitative data were reported by frequency (%). For interfered analysis, we used Fisher's exact test and Chi-square to compare qualitative data in frequency distribution. Based on the result of Kolmogorov–Smirnov test indicating the normality of data distribution, we used independent samples t-test to compare quantitative data in each gender. The logistic regression was applied to evaluate the association of factors such as sex, age, body mass index (BMI), past medical history, type of surgery, indication of surgery, and experience of surgeon, with the incidence of postoperative early and late complications. Thus, values for 95% confidence interval and odd ratio were reported. For all analyses, the significance level was considered <0.05.
| Results|| |
This study included 204 patients undergoing thyroidectomy (37 [18.9%] men and 167 [81.9%] women). The mean (SD) of age, BMI, systolic blood pressure, diastolic blood pressure, and pulse rate at baseline were 41.2 (13.4) (years), 25.30 (3.6) (kg/m2), 119.7 (10.9) (mmHg), 73.7 (7.4) (mmHg), and 74.0 (6.1) (bpm), respectively. [Table 1] presents baseline characteristics by gender. Hypertension was significantly more common among women than men and smoking was significantly more frequent among men than women (P < 0.05) [Table 1]. Other variables were not different between men and women (P > 0.05).
Type of surgery and indication for thyroid surgery in patients undergoing thyroidectomy were shown in [Table 2]. Total thyroidectomy and suspicious fine-needle aspiration (FNA) for malignancy were the most frequent type of surgery and indication for thyroid surgery, respectively. Subtotal thyroidectomy and Graves' disease were the least frequent types of surgery and indication for thyroid surgery, respectively. There was no significant difference in frequency distributions of the type of surgery and indication for surgery by genders (P > 0.05).
Early and late postoperative complications in patients undergoing thyroidectomy were shown in [Table 3]. 152 patients (74.5%) experienced early complications. 111 patients (54.4%) were with hypocalcaemia (41.4% [n = 46] on the first day, 54.9% [n = 61] on the second day, and 3.6% [n = 4] on the third day), 68 patients (33.3%) with hoarseness, 7 patients (3.4%) with wound infection, 9 patients (5.9%) with hematoma, 67 patients (32.8%) with dysphagia to solids, and 1 patient with other complications.
|Table 3: Early and late postoperative complications in patients undergoing thyroidectomy|
Click here to view
Furthermore, in 3-month follow-up after surgery from 194 evaluated patients (10 patients were not responding), 164 (84.5%) had no complication and 30 (15.5%) were associated with late complications; as 12 patients (6.2%) had hypocalcemia, 16 (8.2%) had hoarseness, and 7 (3.6%) had dysphagia. Furthermore, 6 (3.1%) patients died after 3 months [Table 3].
Of the 6 patients died after 3-month follow-up, 4 were female and 2 were male, with the mean age of 66 ± 14.45 years. Early complications of hypocalcemia, hoarseness, and dysphagia were seen in 4, 4, and 3 cases, respectively. The cause of surgery in the majority of them (4 cases) was FNA, and the type of surgery in 5 cases was total thyroidectomy and in one case was near-total thyroidectomy. The volume surgeon was also low in 1 case, intermediate in 3 cases, and high in 2 cases [Table 4].
|Table 4: Died patients during the follow-up after surgery (3-month follow-up)|
Click here to view
Ultimately, evaluation of the effect of factors including sex, age, BMI, past medical history, type of surgery, indications for surgery, and experience of surgeon, on the surgical complications using logistic regression showed than surgeon's skill is associated with the incidence of complication; the likelihoods of the incidence of complication for low-volume surgeon and intermediate-volume surgeon were, respectively, 2.54 and 2.375 times more than that for high-volume surgeon (P < 0.05). Increasing age was also associated with an increased risk of late complications so that the incidence of late complications in patients with the age range of greater than 60 years was 4.80 times higher than the patients under the age of 40 years [Table 5].
|Table 5: Association of factors with the incidence of early and late complications of thyroidectomy|
Click here to view
| Discussion|| |
In our study, the highest prevalence of thyroidectomy was in women (81.9%). The most frequent thyroid surgery was total thyroidectomy and the most common indication for thyroid surgery was suspicious FNA for thyroid malignancy. Hypocalcemia was the most common complication with a frequency of 54.4% and surgeon experience is associated with the incidence of complication.
In line with this study, Yan et al. showed that of 7385 patients undergoing thyroidectomy, 71% were female and Huang et al. reported that among 3428 patients undergoing thyroidectomy, the ratio of female to male was 5.24:1, while the mean age of patients was more than 40 years. In fact, overall, the findings of many epidemiologic studies indicated a higher prevalence of thyroid disorders among women than men.,
Overall, 152 cases (74.5%) were with postoperative complications of thyroidectomy, in which the most common complication was hypocalcemia with a frequency of 54.4%. In many previous studies, hypocalcemia is identified as the most common postoperative complication. In a previous study, the incidences of temporary hypocalcemia and permanent hypocalcemia were reported about 2%–53% and 0.4%–13.8%, respectively.,,, Suwannasarn et al. reported immediate hypocalcemia was observed in 38.5% patients. Early postoperative hypocalcemia was 42% in Seo et al. study. The higher rate in our study maybe due to higher percentage of total thyroidectomy. Hypoparathyroidism is the usual cause of hypocalcemia; it results from accidental gland injury, removal, or devascularization., Signs and symptoms of hypocalcemia are paresthesia, numbness around the mouth and fingertips, tetany, carpopedal spasm, positive Chvostek's sign, positive Trousseau's sign, convulsion, laryngospasm, prolonged QT interval on the electrocardiogram, coma, and death. Hypocalcemia was mostly occurred on first and second days after surgery and most physicians obtain serial serum calcium measurements after surgery to recognize and manage appropriately the low levels of calcium. Transient hypocalcemia, generally, responds well to calcium replacement therapy within a few days or weeks. Hypocalcemia is considered permanent when it does not return to normal within 6 months.,
In our study, this complication was reported as 6.2% in 3 months' follow-up after surgery. In fact, the timely diagnosis of this complication (in the first 24 h after surgery) and early onset of complementary therapies prevented the symptom and long-term complications. According to some studies, the delayed hypocalcemia can occur in the first postoperative week and has been reported to occur months and even years following thyroidectomy., Of significant concern and consequence is the development of hypocalcemia after thyroidectomy for Graves' disease. Despite excellent surgical technique and anatomical preservation of the parathyroid glands and their blood supply, these patients can demonstrate a delayed and rapid drop in serum calcium 2–3 days after total thyroidectomy.
Other complications in our study were hoarseness, dysphagia to solids, hematoma, and wound infection. Hypocalcemia, hoarseness, and dysphagia were more common in our study. Hematoma and wound infection were less common. Furthermore, previous studies have reported RLN injury, transient hypocalcemia, and hypoparathyroidism as the common complications of thyroidectomy, while other complications such as cellulitis, infection, and damages to the carotid artery, jugular vein, and esophagus are uncommon., It is considered that the incidence of postoperative complications can be influenced by the extent of surgery and the experience of the surgeon.,,
In the current study, the experience of the surgeon was influenced significantly in the incidence of early and late complications. The higher volume surgeons had lower complication rates. The relationship between surgeon volume and patient outcomes has been studied extensively over the last 20 years. Other studies have made similar results.,, Sosa et al. found a strong association between higher surgeon volume and favorable patient outcomes. In a recent study of patients undergoing thyroidectomy in the Health Care Utilization Project Nationwide Inpatient Sample, high-volume surgeons had the lowest complication rates. It can be concluded that referral of patients to high-volume thyroid surgeons is associated with better outcomes.
Some studies reported that the incidences of RLN injuries, hypocalcemia, and other postoperative complications in patients undergoing total thyroidectomy were significantly higher than patients undergoing unilateral thyroidectomy., In our study, the complication rates did not influence by the extent of surgery.
The likelihood of late complications also increases in older patients (over 60 years of age). It has been also confirmed in previous studies as reported that the patients over 65 years of age, and especially those over 80, have significantly more complications and a longer hospital stay than younger patients. Older patients have a greater risk for transient vocal fold paralysis and hematoma than other adult patients, with odds ratios of 1.04 and 1.92, respectively, in the study by Bergenfelz et al. Vitamin D deficiency is also more prevalent in elderly patients and has been shown to be a risk factor for transient postoperative hypoparathyroidism., This issue should be addressed preoperatively when treating elderly patients.
Our study was prospective study to evaluate the patients who candidate for thyroid surgery before and after operation. The prospective design of the study can show more accurate data about the early postoperative complication rate. It is known that retrospective studies often fail to detect all cases and some complications are missed using the database.
| Conclusions|| |
This study showed that higher surgeon volume is associated with improved patient outcomes after thyroid surgery. Furthermore, it has been revealed that the chance of complications increases with the patient's age during the 3-month postoperative follow-up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sun GH, DeMonner S, Davis MM. Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006. Thyroid 2013;23:727-33.
Hegner CF. A history of thyroid surgery. Ann Surg 1932;95:481-92.
Reeve T, Thompson NW. Complications of thyroid surgery: How to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg 2000;24:971-5.
Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, et al.
Complications of thyroid surgery: Analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg 2004;28:271-6.
Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg 2013;150:249-56.
Bourrel C, Uzzan B, Tison P, Despreaux G, Frachet B, Modigliani E, et al.
Transient hypocalcemia after thyroidectomy. Ann Otol Rhinol Laryngol 1993;102:496-501.
Pattou F, Combemale F, Fabre S, Carnaille B, Decoulx M, Wemeau JL, et al.
Hypocalcemia following thyroid surgery: Incidence and prediction of outcome. World J Surg 1998;22:718-24.
Wagner HE, Seiler C. Recurrent laryngeal nerve palsy after thyroid gland surgery. Br J Surg 1994;81:226-8.
Rao JS. Clinical study of post operative complications of thyroidectomy. J Dent Med Sci 2016;15:20-6.
Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998;228:320-30.
Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H, Gastinger I, et al.
Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: Prospective multicenter study in Germany. World J Surg 2000;24:1335-41.
Cherenfant J, Gage M, Mangold K, Du H, Moo-Young T, Winchester DJ, et al.
Trends in thyroid surgery in illinois. Surgery 2013;154:1016-23.
Godballe C, Madsen AR, Sørensen CH, Schytte S, Trolle W, Helweg-Larsen J, et al.
Risk factors for recurrent nerve palsy after thyroid surgery: A national study of patients treated at Danish departments of ENT head and neck surgery. Eur Arch Otorhinolaryngol 2014;271:2267-76.
Duclos A, Peix JL, Colin C, Kraimps JL, Menegaux F, Pattou F, et al.
Influence of experience on performance of individual surgeons in thyroid surgery: Prospective cross sectional multicentre study. BMJ 2012;344:d8041.
Yan HX, Pang P, Wang FL, Tian W, Luo YK, Huang W, et al.
Dynamic profile of differentiated thyroid cancer in male and female patients with thyroidectomy during 2000-2013 in China: A retrospective study. Sci Rep 2017;7:15832.
Huang CF, Jeng Y, Chen KD, Yu JK, Shih CM, Huang SM, et al.
The preoperative evaluation prevent the postoperative complications of thyroidectomy. Ann Med Surg (Lond) 2015;4:5-10.
Vanderpump MP. The epidemiology of thyroid disease. Br Med Bull 2011;99:39-51.
Abboud B, Sargi Z, Akkam M, Sleilaty F. Risk factors for postthyroidectomy hypocalcemia. J Am Coll Surg 2002;195:456-61.
Seo ST, Chang JW, Jin J, Lim YC, Rha KS, Koo BS. Transient and permanent hypocalcemia after total thyroidectomy: Early predictive factors and long-term follow-up results. Surgery 2015;158:1492-9.
Suwannasarn M, Jongjaroenprasert W, Chayangsu P, Suvikapakornkul R, Sriphrapradang C. Single measurement of intact parathyroid hormone after thyroidectomy can predict transient and permanent hypoparathyroidism: A prospective study. Asian J Surg 2017;40:350-6.
Tovi F, Noyek AM, Chapnik JS, Freeman JL. Safety of total thyroidectomy: Review of 100 consecutive cases. Laryngoscope 1989;99:1233-7.
Gann DS, Paone JF. Delayed hypocalcemia after thyroidectomy for Graves' disease is prevented by parathyroid autotransplantation. Ann Surg 1979;190:508-13.
Shiryazdi SM, Kargar S, Afkhami-Ardekani M, Neamatzadeh H. Risk of postoperative hypocalcemia in patients underwent total thyroidectomy, subtotal thyroidectomy and lobectomy surgeries. Acta Med Iran 2014;52:206-9.
Berri T, Houari R. Complications of thyroidectomy for large goiter. Pan Afr Med J 2013;16:138.
Loyo M, Tufano RP, Gourin CG. National trends in thyroid surgery and the effect of volume on short-term outcomes. Laryngoscope 2013;123:2056-63.
Kandil E, Noureldine SI, Abbas A, Tufano RP. The impact of surgical volume on patient outcomes following thyroid surgery. Surgery 2013;154:1346-52.
Baldassarre RL, Chang DC, Brumund KT, Bouvet M. Predictors of hypocalcemia after thyroidectomy: Results from the nationwide inpatient sample. ISRN Surg 2012;2012:838614.
Sosa JA, Mehta PJ, Wang TS, Boudourakis L, Roman SA. A population-based study of outcomes from thyroidectomy in aging Americans: At what cost? J Am Coll Surg 2008;206:1097-105.
Bergenfelz A, Jansson S, Kristoffersson A, Mårtensson H, Reihnér E, Wallin G, et al.
Complications to thyroid surgery: Results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg 2008;393:667-73.
Kirkby-Bott J, Markogiannakis H, Skandarajah A, Cowan M, Fleming B, Palazzo F. Preoperative Vitamin D deficiency predicts postoperative hypocalcemia after total thyroidectomy. World J Surg 2011;35:324-30.
Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: Consequences for bone loss and fractures and therapeutic implications. Endocr Rev 2001;22:477-501.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]