Turkiye Klinikleri Journal of Internal Medicine

.: REVIEW
Tiroid Cerrahisi Komplikasyonları ve Yönetimi
Complications of Thyroid Surgery and Their Management
Can KONCAa, Seher DEMİRERa
aGenel Cerrahi AD, Ankara Üniversitesi Tıp Fakültesi,
Ankara, TÜRKİYE
Turkiye Klinikleri J Intern Med. 2019;4(2):60-70
doi: 10.5336/intermed.2018-64269
Article Language: TR
Full Text
ÖZET
 Tiroid cerrahisi, günümüz cerrahi pratiğinde sık uygulanan cerrahi prosedürlerden biridir. Eskiden çok korkulan bir cerrahi alan iken, günümüzde cerrahi teknikteki ve teknolojik gelişmeler sayesinde çok daha az morbidite ve mortalite ile uygulanmaktadır. Tiroid cerrahisi komplikasyonları arasında; kanama ve üst solunum yolu obstrüksiyonu, geçici veya kalıcı hipoparatiroidi ve hipokalsemi, geçici veya kalıcı rekürrens laringeal sinir yaralanması, süperior laringeal sinirin eksternal dalının yaralanması ve hipertrofik skar ya da keloid oluşumu sayılabilmektedir. Tüm bu komplikasyonların önlenmesindeki ilk basamak preoperatif uygun hazırlık, intraoperatif sistematik ve dikkatli diseksiyondur. Postoperatif dönemde karşılaşılan komplikasyonların ise doğru yönetilmesi ve uygun tedavisi sayesinde mümkün olduğunca az morbidite ile komplikasyonların yönetimi sağlanabilmektedir.

Anahtar Kelimeler: Hipokalsemi; hipoparatiroidi; komplikasyonlar; rekürren laringeal sinir; tiroidektomi
ABSTRACT
 Thyroid surgery is one of the most common surgical procedures in today's surgical practice. While once it was a very fearful surgical procedure, nowadays it is carried out with much less morbidity and mortality, due to improvements in surgical technique, and technological advances. Complications of thyroid surgery include bleeding and upper airway obstruction, transient or permanent hypoparathyroidism and hypocalcemia, temporary or permanent recurrent laryngeal nerve injury, external branch injury of the superior laryngeal nerve, and hypertrophic scar or keloid formation. The first step in the prevention of all of these complications is appropriate preoperative preparation and intraoperative systematic and careful dissection. With the correct management and the appropriate treatment of the complications encountered in the postoperative period, the management of the complications could be achieved with as little morbidity as possible.

Keywords: Hypocalcemia; hypoparathyroidism; complications; recurrent laryngeal nerve; thyroidectomy
REFERENCES:
  1. Cernea CR, Brandão LG, Hojai FC, De Carlucci D, Montenegro FL, Plopper C, et al. How to minimize complications in thyroid surgery? Auris Nasus Larynx. 2010;37(1):1-5. [Crossref] [PubMed]
  2. Calo PG, Pisano G, Piga G, Medas F, Tatti A, Donati M, et al. Postoperative hematomas after thyroid surgery. Incidence and risk factors in our experience. Ann Ital Chir. 2010;81(5):343-7.
  3. Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg. 2013;150(4): 249-56. [Crossref ] [PubMed]
  4. Leyre PT, Desurmont L, Lacoste C, Odasso G, Bouche A, Beaulieu A, et al. Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery? Langenbecks Arch Surg. 2008;393(5):733-7. [Crossref] [PubMed]
  5. Promberger R, Ott J, Kober F, Koppitsch C, Seemann R, Freissmuth M, et al. Risk factors for postoperative bleeding after thyroid surgery. Br J Surg. 2012;99(3):373-9. [Crossref ] [PubMed]
  6. Godballe C, Madsen AR, Pedersen HB, Sørensen CH, Pedersen U, Frisch F, et al. Post-thyroidectomy hemorrhage: a national study of patients treated at the Danish departments of ENT Head and Neck Surgery. Eur Arch Otorhinolaryngol. 2009;266(12): 1945-52. [Crossref ] [PubMed]
  7. Oltmann SC, Alhefdhi AY, Rajaei MH, Schneider DF, Sippel RS, Chen H. Antiplatelet and anticoagulant medications significantly increase the risk of postoperative hematoma: review of over 4500 thyroid and parathyroid procedures. Ann Surg Oncol. 2016;23(9): 2874-82. [Crossref ] [PubMed] [PMC]
  8. Migueis A, Ucelay I, Migueis J, Urtasun A, Traissac L. [Galen's anastomosis, an anatomic study in man]. Rev Laryngol Otol Rhinol (Bord). 1989;110(4):423-5.
  9. Samraj K, Gurusamy KS. Wound drains following thyroid surgery. Cochrane Database Syst Rev. 2007;(4):CD006099. [Crossref ]
  10. Hurtado-López LM, López-Romero S, RizzoFuentes C, Zaldívar-Ramírez FR, CervantesSánchez C. Selective use of drains in thyroid surgery. Head Neck. 2001;23(3):189-93. [Crossref]
  11. Cannizzaro MA, Lo Bianco S, Picardo MC, Provenzano D, Buffone A. How to avoid and to manage post-operative complications in thyroid surgery. Updates Surg. 2017;69(2):211-5. [Crossref ] [PubMed]
  12. Dedivitis RA, Aires FT, Cernea CR. Hypoparathyroidism after thyroidectomy: prevention, assessment and management. Curr Opin Otolaryngol Head Neck Surg. 2017;25(2):142-6. [Crossref ] [ PubMed]
  13. Henry JF, Gramatica L, Denizot A, Kvachenyuk A, Puccini M, Defechereux T. Morbidity of prophylactic lymph node dissection in the central neck area in patients with papillary thyroid carcinoma. Langenbecks Arch Surg. 1998;383(2):167-9. [Crossref] [PubMed]
  14. Almquist M, Hallgrimsson P, Nordenstrom E, Bergenfelz A. Prediction of permanent hypoparathyroidism after total thyroidectomy. World J Surg. 2014;38(10):2613-20. [Crossref] [PubMed]
  15. Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ. 2008; 336(7656):1298-302. [Crossref] [PubMed] [PMC]
  16. Shoback D. Clinical practice. Hypoparathyroidism. N Engl J Med. 2008;359(4):391-403. [Crossref] [PubMed]
  17. Khan MI, Waguespack SG, Hu MI. Medical management of postsurgical hypoparathyroidism. Endocr Pract. 2011;17 Suppl 1:18-25. [Crossref] [PubMed]
  18. Higgins KM, Mandell DL, Govindaraj S, Genden EM, Mechanick JI, Bergman DA, et al. The role of intraoperative rapid parathyroid hormone monitoring for predicting thyroidectomy-related hypocalcemia. Arch Otolaryngol Head Neck Surg. 2004;130(1):63-7. [Crossref] [PubMed]
  19. Wang TS, Cayo AK, Wilson SD, Yen TW. The value of postoperative parathyroid hormone levels in predicting the need for long-term vitamin D supplementation after total thyroidectomy. Ann Surg Oncol. 2011;18(3):777-81. [Crossref] [PubMed]
  20. AES Guidelines 06/01 Group. Australian Endocrine Surgeons Guidelines AES06/01. Postoperative parathyroid hormone measurement and early discharge after total thyroidectomy: analysis of Australian data and management recommendations. ANZ J Surg. 2007;77(4): 199-202. [Crossref ] [ PubMed]
  21. Lecerf P, Orry D, Perrodeau E, Lhommet C, Charretier C, Mor C, et al. Parathyroid hormone decline 4 hours after total thyroidectomy accurately predicts hypocalcemia. Surgery. 2012;152(5):863-8. [Crossref ] [PubMed]
  22. Sakorafas GH, Stafyla V, Bramis C, Kotsifopoulos N, Kolettis T, Kassaras G. Incidental parathyroidectomy during thyroid surgery: an underappreciated complication of thyroidectomy. World J Surg. 2005;29(12):1539-43. [Crossref] [PubMed]
  23. Gourgiotis S, Moustafellos P, Dimopoulos N, Papaxoinis G, Baratsis S, Hadjiyannakis E. Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy. Langenbecks Arch Surg. 2006;391(6):557-60. [Crossref ] [PubMed]
  24. Lin DT, Patel SG, Shaha AR, Singh B, Shah JP. Incidence of inadvertent parathyroid removal during thyroidectomy. Laryngoscope. 2002;112(4):608-11. [Crossref ] [PubMed]
  25. Harris AS, Prades E, Tkachuk O, Zeitoun H. Better consenting for thyroidectomy: who has an increased risk of postoperative hypocalcaemia? Eur Arch Otorhinolaryngol. 2016;273(12):4437-43. [Crossref ] [ PubMed]
  26. 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. [Crossref] [PubMed] [PMC]
  27. Al-Dhahri SF, Mubasher M, Mufarji K, Allam OS, Terkawi AS. Factors predicting post-thyroidectomy hypoparathyroidism recovery. World J Surg. 2014;38(9):2304-10. [Crossref ] [PubMed]
  28. McIntyre RC Jr, Eisenach JH, Pearlman NW, Ridgeway CE, Liechty RD. Intrathyroidal parathyroid glands can be a cause of failed cervical exploration for hyperparathyroidism. Am J Surg. 1997;174(6):750-3. [Crossref ]
  29. Libutti SK, Bartlett DL, Jaskowiak NT, Skarulis M, Marx SJ, Spiegel AM, et al. The role of thyroid resection during reoperation for persistent or recurrent hyperparathyroidism. Surgery. 1997;122(6):1183-7. [Crossref ]
  30. Cakmakli S, Aydintug S, Erdem E. Postthyroidectomy hypocalcemia: does arterial ligation play a significant role? Int Surg. 1992;77(4):284-6.
  31. Herranz González-Botas J, Lourido Piedrahita D. Hypocalcaemia after total thyroidectomy: incidence, control and treatment. Acta Otorrinolaringol Esp. 2013;64(2):102-7. [Crossref ]
  32. Lo CY, Lam KY. Routine parathyroid autotransplantation during thyroidectomy. Surgery. 2001;129(3):318-23. [Crossref ] [PubMed]
  33. Testini M, Rosato L, Avenia N, Basile F, Portincasa P, Piccinni G, et al. The impact of single parathyroid gland autotransplantation during thyroid surgery on postoperative hypoparathyroidism: a multicenter study. Transplant Proc. 2007;39(1):225-30. [Crossref] [PubMed]
  34. Song CM, Jung JH, Ji YB, Min HJ, Ahn YH, Tae K. Relationship between hypoparathyroidism and the number of parathyroid glands preserved during thyroidectomy. World J Surg Oncol. 2014;12:200. [Crossref] [PubMed] [PMC]
  35. Stack BC Jr, Bimston DN, Bodenner DL, Brett EM, Dralle H, Orloff LA, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: Postoperative Hypoparathyroidism--Definitions and Management. Endocr Pract. 2015;21(6):674-85. [Crossref] [PubMed]
  36. Brandi ML, Bilezikian JP, Shoback D, Bouillon R, Clarke BL, Thakker RV, et al. Management of hypoparathyroidism: summary statement and guidelines. J Clin Endocrinol Metab. 2016;101(6):2273-83. [Crossref ] [ PubMed]
  37. Kakava K, Tournis S, Papadakis G, Karelas I, Stampouloglou P, Kassi E, et al. Postsurgical hypoparathyroidism: a systematic review. In Vivo. 2016;30(3):171-9.
  38. 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(3):271-6. [Crossref] [PubMed]
  39. Duclos A, Voirin N, Touzet S, Soardo P, Schott AM, Colin C, et al. Crude versus casemix-adjusted control charts for safety monitoring in thyroid surgery. Qual Saf Health Care. 2010;19(6):e17. [Crossref ] [ PubMed]
  40. Acun Z, Cihan A, Ulukent SC, Comert M, Ucan B, Cakmak GK, et al. A randomized prospective study of complications between general surgery residents and attending surgeons in near-total thyroidectomies. Surg Today. 2004;34(12):997-1001. [Crossref] [PubMed]
  41. 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(11):1335-41. [Crossref ] [PubMed]
  42. Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Kruse E, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136(6):1310-22. [Crossref] [PubMed]
  43. Hartl DM, Travagli JP, Leboulleux S, Baudin E, Brasnu DF, Schlumberger M. Clinical review: current concepts in the management of unilateral recurrent laryngeal nerve paralysis after thyroid surgery. J Clin Endocrinol Metab. 2005;90(5):3084-8. [Crossref ] [PubMed]
  44. Sancho JJ, Pascual-Damieta M, Pereira JA, Carrera MJ, Fontané J, Sitges-Serra A. Risk factors for transient vocal cord palsy after thyroidectomy. Br J Surg. 2008;95(8): 961-7.[Crossref ] [PubMed]
  45. Serpell JW, Yeung MJ, Grodski S. The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann Surg. 2009;249(4):648-52. [Crossref] [PubMed]
  46. Efremidou EI, Papageorgiou MS, Liratzopoulos N, Manolas KJ. The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: a review of 932 cases. Can J Surg. 2009;52(1):39-44.
  47. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract. 2009;63(4):624-9. [Crossref] [PubMed]
  48. 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(5):667-73. [Crossref] [PubMed]
  49. Echternach M, Maurer CA, Mencke T, Schilling M, Verse T, Richter B. Laryngeal complications after thyroidectomy: is it always the surgeon? Arch Surg. 2009;144(2):149-53. [Crossref] [PubMed]
  50. Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010;34(2):223-9. [Crossref ] [ PubMed]
  51. Barczyński M, Konturek A, Cichoń S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg. 2009;96(3):240-6. [Crossref ] [PubMed]
  52. Higgins TS, Gupta R, Ketcham AS, Sataloff RT, Wadsworth JT, Sinacori JT. Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: a meta-analysis. Laryngoscope. 2011;121(5):1009-17. [Crossref ] [PubMed]
  53. Duclos A, Lifante JC, Ducarroz S, Soardo P, Colin C, Peix JL. Influence of intraoperative neuromonitoring on surgeons' technique during thyroidectomy. World J Surg. 2011;35(4):773-8. [Crossref ] [ PubMed]
  54. Dispenza F, Dispenza C, Marchese D, Kulamarva G, Saraniti C. Treatment of bilateral vocal cord paralysis following permanent recurrent laryngeal nerve injury. Am J Otolaryngol. 2012;33(3):285-8. [Crossref ] [PubMed]
  55. Miyauchi A, Inoue H, Tomoda C, Fukushima M, Kihara M, Higashiyama T, et al. Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve. Surgery. 2009;146(6):1056-62. [Crossref ] [PubMed]
  56. Laccourreye O, Malinvaud D, Menard M, Bonfils P. [Unilateral laryngeal immobility after surgery of the thyroid gland]. J Chir (Paris). 2009;146(6):553-8. [Crossref ] [PubMed]
  57. Crookes PF, Recabaren JA. Injury to the superior laryngeal branch of the vagus during thyroidectomy: lesson or myth? Ann Surg. 2001;233(4):588-93. [Crossref ] [PubMed]
  58. Cernea CR, Ferraz AR, Nishio S, Dutra A Jr, Hojaij FC, dos Santos LR. Surgical anatomy of the external branch of the superior laryngeal nerve. Head Neck. 1992;14(5):380-3. [Crossref] [PubMed]
  59. Cernea CR, Ferraz AR, Furlani J, Monteiro S, Nishio S, Hojaij FC, et al. Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Am J Surg. 1992; 164(6):634-9. [Crossref ]
  60. Cernea CR, Nishio S, Hojaij FC. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol. 1995;16(5):307-11. [Crossref ]

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30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com