Complication Risk in Secondary Thyroid Surgery
Nurcihan Aygün1, Evren Besler2, Gürkan Yetkin2, Mehmet Mihmanlı2, Adnan Işgör3, Mehmet Uludağ21Siverek State Hospital, Sanliurfa, Turkey2Health Sciences University, Istanbul Sisli Hamidiye Etfal Health Practice and Research Center, Istanbul, Turkey
3Bahcesehir University Faculty of Medicine, Istanbul, Turkey
Objectives: Secondary thyroid surgery is rare, compared with primary thyroid surgery. However, secondary surgery has a greater risk of complications due to the formation of scar tissue as well as increased fragility of the tissues following the previous surgery. Several surgical techniques and strategies have been recommended to decrease the complication rate associated with secondary surgery. The aim of this study was to evaluate the complication rate in patients who underwent secondary thyroid surgery using a lateral approach and intraoperative nerve monitoring (IONM).
Methods: The data of 44 patients who underwent secondary surgical intervention after thyroid surgery performed for benign or malignant thyroid disease (Group 1), and of 44 patients who underwent primary surgery (Group 2) were compared. Lobectomy patients with a histopathological result of malignant disease, whom were applied completion thyroidectomy were excluded from the study. Secondary surgery was performed using a lateral approach. Access was achieved between the anterior edge of the sternocleidomastoid muscle and the strap muscles. In primary surgery, the thyroid lodge was entered through the midline. Standard IONM was applied in all cases. Hypocalcemia was defined as a serum calcium level of ≤8 mg/dL within the first postoperative 48 hours, regardless of clinical symptoms. Transient and permanent recurrent laryngeal nerve paralysis was evaluated based on the number of nerves at risk. The lobectomy was considered to be high-risk with the presence of recurrence, Graves’ disease, substernal goiter, and application of central dissection.
Results: The mean age of Group 1 and 2 was 49.9±14.1 years and 45±12.6 years, respectively (range: 22-90 years; p=0.69). Female patients constituted 90.9% (n=40) of the population in Group 1 and 75% (n=33) of the patient population in Group 2 (p=0.87). In Group 1, 11 (25%) patients, and 7 (15.9%) patients in Group 2 underwent surgical intervention due to the presence of a malignant disease (p=0.29). Bilateral intervention was applied in 26 (59.1%) patients in Group 1 and 28 (63.6%) patients in Group 2. The rate of transient and permanent hypocalcemia in Groups 1 and 2 was 34.1% (n=15) vs 22.5%, and 2.5% (n=1) vs 0%, respectively, without any significant intergroup difference (p=0.237, p=1). In Group 1, 71 lobes were operated on, and there were 72 in Group 2. All of the interventions in Group 1 (100%), and 31.9% (n=23) of those in Group 2 were high-risk, and there was a significant intergroup difference (p<0.0001). The rate of transient and permanent vocal cord paralysis were 4.2% (n=3) vs 2.8% (n=2) and 6.9 % (n=5) vs 0% in Groups 1 and 2, respectively (p=0.719; p=0.245).
Conclusion: When performed with a meticulous and attentive technique, secondary surgical intervention can be applied without increasing the incidence of permanent complications. Though there is substantial risk associated with all of these procedures, the rate of vocal cord paralysis was similar to that seen after primary intervention, and was thought to be related to surgical experience and technique, as well as the use of IONM.
İkincil Tiroid Cerrahisinde Komplikasyon Riski
Nurcihan Aygün1, Evren Besler2, Gürkan Yetkin2, Mehmet Mihmanlı2, Adnan Işgör3, Mehmet Uludağ21Siverek State Hospital, Sanliurfa, Turkey2Health Sciences University, Istanbul Sisli Hamidiye Etfal Health Practice and Research Center, Istanbul, Turkey
3Bahcesehir University Faculty of Medicine, Istanbul, Turkey
Amaç: Ikincil tiroid cerrahisi primer cerrahiye gore nadir uygulanmaktadir. Gecirilmis ameliyata bagli olusan skar dokusu ve dokularin artan frajilitesi nedeni ile ikincil cerrahilerde komplikasyon riskinin yuksek oldugu bilinmektedir. Ikincil cerrahilerde komplikasyon oranini azaltmak icin bircok cerrahi teknik ve strateji onerilmistir. Bu calismada; lateral yaklasimla intraoperative sinir monitorizasyonu (IONM) kullanilarak ikincil tiroid cerrahisi uygulanan olgularda komplikasyon oranlarini degerlendirmeyi amacladik.
Gereç ve Töntemler: Daha once benign ve malign tiroid hastaliklari nedeni bir tiroid cerrahisi geciren ve ikincil cerrahi girisim uygulanan 44 hastanin verileri (Grup 1), primer cerrahi uygulanan son 44 hastanin verileri (Grup 2) ile karsilastirildi. Lobektomi yapildiktan sonra patolojide malignite saptanan ve mudahale edilmemis diger loba tamamlayici tiroidektomi uygulanan hastalar calisma disi birakildi. Ikincil cerrahide sternokleidomastoid kas on kenari ve strep kaslari arasindan girilerek lateral yaklasim uygulandi. Primer cerrahide ise orta hattan tiroid lojuna girildi. Tum hastalara standart IONM uygulandi. Hipokalsemi klinik semptom olup olmadigina bakilmaksizin, serum kalsiyum duzeyinin ilk 48 saatte 8 mg/dl veya altinda bir deger saptanmasi olarak tanimlandi. Gecici ve kalici rekuren laringeal sinir paralizisi risk altindaki sinir sayisina gore degerlendirildi. Loba uygulanan girisim sekli; nuks, Graves hastaligi, substernal guatr, santral diseksiyon uygulanmasi yuksek riskli girisim olarak tanimlandi.
Bulgular: Yas ortalamasi grup 1 ve 2'de sirasi ile 49,9+14,1 ve 45+12,6 (22-90) idi (p=0,69). Cinsiyet dagilimi, grup 1 ve 2'de kadin orani %90,9 (n: 40), %75 (n: 33) idi (p=0,87). Grup 1 ve 2'de sirasi ile 11 (% 25) ve 7 hastaya (%15,9) malign hastalik nedeni ile girisim uygulandi (p=0,29). Iki tarafli girisim grup 1 ve 2'de sirasi ile 26 (%59,1) ve 28 (%63,6) hastaya uygulandi. Gecici ve kalici hipokalsemi oranlari grup 1 ve 2'de sirasi ile % 34,1 (n: 15), %22,5, % 2,5 (n: 1), %0 olup, fark anlamli degildi (p=0,237, p=1). Birinci grupta 71 ikinci grupta 72 loba mudahale edildi. Grup 1'deki girisimlerin hepsi (%100), grup 2'dekilerin 23'u (%31,9) yuksek riskli girisim olup, aralarindaki fark anlamli idi (p<0,0001). Grup 1 ve 2'de sirasi ile gecici vokal kord paralizisi oranlari %4,2 (n: 3), %6,9 (n: 5) (p=0,719), kalici vokal kord paralizisi oranlari ise %2,8 (n: 2) ve %0 (p=0,245) idi.
Sonuçlar: Ikincil cerrahi girisimler, dikkatli ve titiz cerrahi teknikle primer girisime gore kalici komplikasyon oranini arttirmadan uygulanabilir. Tum girisimler yuksek riskli girisim olmasina ragmen, vokal kord paralizisi oranlarinin primer girisime benzer olmasi cerrahi deneyim ve teknigin yaninda IONM kullanimi ile ilgili olabilir.
Manuscript Language: English