|Year : 2021 | Volume
| Issue : 3 | Page : 112-116
Retrospective review of outcomes of thyroid surgeries performed over 4 years at a single center
Thamer Alghamdi1, Abdulaziz Alabidi2, Mohammed Gamal Aly2
1 Department of ENT, King Saud Medical City, Riyadh, Saudi Arabia
2 Department of ENT, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
|Date of Submission||24-Apr-2021|
|Date of Acceptance||22-Jun-2021|
|Date of Web Publication||05-Oct-2021|
Dr. Thamer Alghamdi
Department of ENT, King Saud Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
Context: Thyroid surgery may have severe postoperative complications; however, there is a lack of national data on its outcomes in Saudi Arabia. Aims: The aim of this study was to improve practice and develop efficient pre- and postoperative data. Settings and Design: A retrospective review of the medical files of 277 patients undergoing thyroidectomy, including total thyroidectomy, hemithyroidectomy, and completion thyroidectomy, for various indications at a single center from January 2016 to December 2019 was performed. Materials and Methods: The demographic and histopathological data and surgical outcomes were recorded. Statistical Analysis: Only descriptive statistics were used. Results: A total of 198 (71.4%) patients were female and 79 (28.5%) were male. Benign lesions were observed in 65.6% of the patients, while 34.4% of the patients had malignant lesions. Papillary thyroid carcinoma was the most common malignant pathology, followed by follicular thyroid carcinoma, medullary carcinoma, and mucosa-associated lymphoid tissue lymphoma. The total complication rate was 17.3%, and 81.2% of the complications occurred in females. Temporary hypocalcemia developed in 9% of the patients and permanent hypocalcemia in 2.9%. A postoperative hematoma occurred in 1.1%. Temporary and permanent recurrent laryngeal nerve injuries were recorded in 2.9% and 1.4% of the patients, respectively. Conclusions: Thyroidectomy is a safe and effective surgical procedure, and the results obtained in this study were similar to data in the literature. Auditing and reporting of the surgical outcomes of thyroidectomy at our institute and other national centers could help establish national guidelines that will improve these outcomes and ensure patient safety.
Keywords: Intraoperative complications, postoperative complications, recurrent laryngeal nerve injury, thyroid cancer, thyroidectomy
|How to cite this article:|
Alghamdi T, Alabidi A, Aly MG. Retrospective review of outcomes of thyroid surgeries performed over 4 years at a single center. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:112-6
|How to cite this URL:|
Alghamdi T, Alabidi A, Aly MG. Retrospective review of outcomes of thyroid surgeries performed over 4 years at a single center. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Jan 24];23:112-6. Available from: https://www.sjohns.org/text.asp?2021/23/3/112/327566
| Introduction|| |
Thyroidectomy is a common surgical procedure worldwide and is performed by surgeons of various training backgrounds, such as general surgery, thoracic surgery, endocrine surgery, otorhinolaryngology, oncological surgery, and head-and-neck surgery.
Thyroidectomy was considered a surgery associated with substantial risk and high mortality. However, with continuously improving operative techniques and a better understanding of the thyroid anatomy and physiology, thyroidectomy has emerged a safe surgery.
Thyroid surgery is associated with the possibility of severe postoperative complications, such as recurrent laryngeal nerve (RLN) palsy, superior laryngeal nerve injury, parathyroid insufficiency, and bleeding. RLN is one of the most grave complications of thyroid surgery, occurring in 0.5%–14.0% of interventions, depending on the type of disease, type of surgery, extent of the resection, and surgical technique.
This study aimed to establish the demographics, histopathology, and surgical outcomes of patients undergoing thyroidectomy at a single institution over recent years in order to improve routine clinical practice and develop an efficient and safe treatment protocol.
| Materials and Methods|| |
A retrospective file review of records of all the patients undergoing thyroidectomy, including total and hemithyroidectomy, for different indications, at a single center between January 2016 and December 2019 was performed. A total of 277 patients were eligible for this study. The age of the patients ranged from 14 to 86 years with a mean age of 48.9 years, and 79 (28.5%) were male and 198 (71.4%) female.
After applying the inclusion criteria, which included all the patients who underwent thyroid surgery in our institute, by the ear, nose, and throat (ENT) unit in the period from January 2016 to December 2019, 277 patients were included. Following the application of the exclusion criteria, which included missed postoperative visits and lack of filing documentation, 13 patients were excluded.
All the patients in this study underwent a conventional external cervical approach for thyroid surgeries; all surgeries were performed by three otorhinolaryngologists at our institute, with a similar surgical approach. Intraoperative nerve monitoring (IONM) was used in revision cases, large goiter, and total thyroidectomy according to the surgeon's preference. The total average of the procedure duration was 2.2 h. Magnification loops were not used.
We extracted the following parameters from the patients' records: age, gender, type of surgery, histopathology results, and postoperative complications.
The protocol of this study was approved by the institution's review board. The need for informed consent was waived because of the retrospective nature of the study.
Qualitative variables are presented as numbers and percentages, and quantitative variables are presented as mean and range. Descriptive statistics was used to report the study variables.
| Results|| |
A total of 277 patients underwent thyroid surgery at the ENT department during the study period. There were 79 (28.5%) male and 198 (71.4%) female patients. The gender distribution per year is shown in [Table 1].
|Table 1: Gender distribution among patients (n=277) undergoing thyroidectomy at a single center per year|
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A total of 163 (58.8%) patients underwent hemithyroidectomy for various reasons from January 2016 to December 2019. Among these, 22 patients required completion thyroidectomy (13.4%). A total of 114 patients (41.1%) initially underwent total thyroidectomy. The types of surgery per year are shown in [Table 2].
|Table 2: Type of surgery in patients (n=277) undergoing thyroidectomy at a single center per year|
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A total of 182 (65.7%) patients were found to have benign lesions, and 95 (34.3%) patients had malignant lesions. Benign lesions included multinodular goiter, Hashimoto's thyroiditis, adenomatous hyperplastic nodules, follicular adenomas, nodular hyperplasia, benign goiter, colloid nodules, chronic lymphocytic thyroiditis, colloidal goiter, amyloidosis, and benign Hürthle cell adenomas. The malignant lesions included papillary thyroid carcinoma (PTC; 82 patients, 86.3%), follicular thyroid carcinoma (10 patients, 10.5%), medullary thyroid carcinoma (1 patient, 1%), and mucosa-associated lymphoid tissue lymphoma (2 patients, 2.1%). The different lesion types per year are shown in [Table 3].
|Table 3: Histopathology of specimen in patients (n=277) undergoing thyroidectomy at a single center per year|
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In total, 48 (17.3%) patients experienced complications. Of these, 9 (18.7%) occurred in male patients and 39 (81.2%) in female patients. A total of 25 (9%), 8 (2.9%), and 3 (1.1%) patients had temporary hypocalcemia, permanent hypocalcemia, and hematoma, respectively. Eight patients (2.9%) had temporary RLN injuries, one of whom showed delayed RLN paralysis; four (1.4%) patients had a permanent RLN injury. Fortunately, a bilateral RLN injury was not encountered. The complications per year are shown in [Table 4].
|Table 4: Complications in patients (n=277) undergoing thyroidectomy at a single center per year|
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A total of 24 (8.6%) patients underwent neck dissection, with 18 (6.5%) underwent central neck dissection, 4 patients (1.4%) underwent lateral neck dissection on one side and 1 (0.4%) patient underwent bilateral lateral neck dissection, total average hospital stay was 3.2 days.
| Discussion|| |
In this study, majority of the patient population were female. Benign lesions were found in 65.7% of the total study population. Malignant thyroid lesions were found in 36.9% of the patients, with 73.5% of these in females and 26.4% in males, corresponding to the gender distribution in our study population. PTC was the most common malignancy and was found in 86.3% of the patients with malignant lesions; among them, 72% were female and 28% male. The second most common malignant thyroid lesion was follicular thyroid carcinoma, accounting for 10.5% of the malignant lesions. Eighty percent of these were found in female patients.
Thyroid cancer is more common in women than in men. Topstad and Dickinson reported the incidence of thyroid cancer in Canada in 2010 to be 23.4 per 100,000 for women and 7.2 per 100,000 for men. PTC was the most common thyroid malignancy in their study. In Saudi Arabia, a large 10-year study at King Faisal Specialist Hospital in Riyadh revealed a male-to-female ratio of 0.3:1 among patients with different histopathological thyroid cancers, which is similar to the ratio in this study.
The risk of complications is inherent in all surgical interventions. However, a significant decline in the mortality and complication rate has been achieved in patients undergoing thyroid procedures since the beginning of the last century resulting from the advances in the anesthesia techniques, sterilization, instrumentation, and new surgical techniques and approaches.
At the institution investigated in this study, every patient participated in a discussion in a multidisciplinary meeting before surgery, which included endocrinologists and oncologists; a comprehensive preoperative workup was ensured for each patient. During total thyroidectomy and in difficult cases, nerve monitoring was performed to reduce the surgical time and postoperative complications. The surgical method used in all patients was the conventional thyroid surgery through external cervical incision.
As described previously, thyroid surgery may result in significant complications, including postthyroidectomy hematoma, RLN injury, and hypocalcemia, which can be devastating. Structural damage can be avoided by meticulous dissection and maintaining a dry operative field.
Khanzada et al. conducted a similar study and reported an overall complication rate of 10.7% in thyroidectomy. The rate of postoperative hypocalcemia was 3.5%, with permanent hypocalcemia occurring in 0.7%. RLN injury was found in 2.8% of the patients, of whom 1.4% had permanent RLN dysfunction. The authors also reported an incidence of hematoma of 1.4%.
Postthyroidectomy hematoma is a rare complication but associated with poor clinical outcomes. In this retrospective study, three patients (1.1%) developed a postthyroidectomy hematoma, two male patients and one female patient, and all three patients underwent surgical evacuation and hemostasis in OR. Dehal et al. reported a comparable incidence of postthyroidectomy neck hematoma of 1.5%. These rates are within the range reported in the literature (0.1%–4.7%).,,,
Male sex and old age were found to be independent risk factors for neck hematoma in the literature.,, Wojtczak et al. also reported that postthyroidectomy bleeding occurs more often in male than in female patients (2% vs. 1%, respectively; P = 0.006). Caló et al. reported an overall incidence of 1.36% and an incidence of 2.79% in male patients, compared to 0.90% in female patients.
In their meta-analysis, Kennedy et al. showed that the use of drains following thyroidectomy is not beneficial since no universal consensus exists on their use.
Adequate hemostasis should be ensured before wound closure. The Valsalva maneuver before wound closure is a beneficial, commonly applied method for evaluating hemostasis., In our institution, we routinely apply Avitene™ (Becton, Dickinson and Company, Franklin Lakes, NJ, USA), a microfibrillar collagen hemostat following thyroid tissue removal, and no drain is placed further unless lateral neck dissection was done.
Suzuki et al. demonstrated a relationship between greater age and the incidence of postthyroidectomy hematoma; they also showed that obese and overweight patients were predisposed to a higher risk than patients with normal weight or those who were underweight. They also showed that Graves' disease was an independent risk factor for postthyroidectomy hematoma. However, the increased risk of bleeding in patients with Graves' disease was not statistically significant, as shown by Caló et al. Intrathoracic goiters are also presumed to have a greater tendency for postthyroidectomy bleeding. Similarly, revision surgery has been considered to have a higher risk of postoperative bleeding.
RLN injury is a well-known complication of thyroid surgery. The incidence of temporary RLN injury in the literature ranges from 0% to 12%, while the incidence of permanent RLN injury ranges from 0% to 3.5%.,,, Malignancy, revision surgery, large goiters, and cases requiring central neck dissection all entail a higher risk of RLN injury.,
In our study, eight (2.9%) patients demonstrated temporary RLN paralysis, five female and three male patients, one of those male patients showed delayed RLN paralysis, while four (1.4%) patients had permanent RLN paralysis. Pantvaidya et al. found that the incidence of postoperative RLN injury was 9.5% in patients undergoing their first thyroid procedure and 16.2% in those undergoing revision surgery, while permanent RLN injury was 2.6% and 7.6%, respectively.
Taylor et al. reported an incidence of 8% for postoperative RLN palsy in patients with follicular thyroid carcinoma and 5.9% in patients with papillary thyroid cancer. Nishida et al. reported RLN injury in patients in whom the RLN was involved by their differentiated thyroid cancer. In one group of patients, the RLN was sacrificed, and in the other, it was preserved. In the preserved group, 17% showed total paralysis of vocal fold, 17% showed partial improvement, while 27% showed temporary RLN injury with complete recovery and 35% maintained normal ipsilateral vocal fold function following the surgery.
RLN injuries might be caused by direct trauma to the nerve, tension, heat, and albeit rarely, accidental severance. Intraoperative nerve integrity monitoring is becoming more widely available, but its role is still debated, and there is no consensus on the use of IONM in thyroid surgery. Currently, IONM is not considered a standard of care in the USA since a systematic review did not show a statistically significant difference between IONM and direct identification of the RLN., However, IONM is used in our institution, during revision surgeries, in large goiters, and total thyroidectomy, and it is determined by surgeon preference.
In our study population, 25 (9%) patients had temporary hypocalcemia, and 23 of them were female. Eight (2.9%) patients showed permanent hypocalcemia, six of them were female, no patient required readmission for hypocalcemia. Al Qubaisi and Haigh reported that the incidence of hypocalcemia following total thyroidectomy was 10.3%, with 5.7% of the patients experiencing symptoms of hypocalcemia. They showed that patients with Graves' disease were at a higher risk of developing hypocalcemia following total thyroidectomy than patients without Graves' disease (16.3% and 9.4%, respectively). An age range of >50 years, female sex, and patients who had parathyroid gland autotransplantation were considered independent risk factors for hypocalcemia in that study. The authors also showed that females have a higher risk of developing hypocalcemia and severe symptomatic hypocalcemia, and hypothesized that Vitamin D deficiency and genetic factors might contribute to this higher risk in females.
Our results should be interpreted within the limitations of this study being a retrospective study design.
| Conclusions|| |
Thyroidectomy is a safe surgical procedure. The demographic characteristics, histopathological results, and complication rates were consistent with those reported in the literature. Auditing and reporting of the surgical outcomes of thyroidectomy in all national centers in Saudi Arabia may help establish guidelines that will improve these outcomes and ensure patient safety.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]