Total thyroidectomy for differentiated thyroid cancer: primary compared with completion thyroidectomy.

OBJECTIVE: To analyse morbidity after completion total thyroidectomy compared with primary total thyroidectomy in a specialist thyroid surgery centre. DESIGN: Retrospective study. SETTING: Tertiary referral hospital, India. PATIENTS: Medical records of 143 patients who had total thyroidectomy between January 1990 and December 1999. 95 had primary thyroidectomies and 48 were completion thyroidectomies. MAIN OUTCOME MEASURES: Complication rate in both groups. RESULTS: The groups were comparable in respect of clinicopathological variables. Residual tumour was found in 19/48 (40%). After completion thyroidectomy, transient hypoparathyroidism and transient recurrent laryngeal nerve palsy were recorded in 8/48 (17%) and 2/48 (4%), respectively. No permanent hypoparathyroidism or permanent recurrent laryngeal nerve palsy was recorded in the completion thyroidectomy group. CONCLUSIONS: Completion thyroidectomy can be done with acceptable morbidity in a specialist thyroid surgery centre. Fear of increased morbidity after the procedure should not deter surgeon from doing this operation or referring the patients to a specialist centre.     

Total thyroidectomy is now the preferred option for the surgical management of Graves' disease

Purpose: Subtotal thyroidectomy has been advocated as the standard treatment for Graves’ disease because of the possibility of avoiding thyroxine therapy as well as the assumed lower risk of complications compared to total thyroidectomy. However, the long‐term results of subtotal thyroidectomy are not as good as they were previously believed to be, as evidenced by the increasing incidence of hypothyroidism. If the risk of complications from total thyroidectomy is no higher, then that procedure offers significant advantages in the surgical management of Graves’ disease. The aim of this study therefore was to compare the complication rate of the two procedures in patients with Graves’ disease. Methods: This was a retrospective case control study in a tertiary referral hospital. Information was obtained from an endocrine surgery database over the study period from January 1957 to December 2000. During that period 1246 patients with Graves’ disease underwent subtotal thyroidectomy and 119 patients underwent total thyroidectomy. Results: Prior to 1987 total thyroidectomy was rarely if ever performed whereas in the last 12 months total thyroidectomy comprised 95% of all procedures. There was no significant difference in the rate of permanent complications between the two procedures although temporary hypocalcaemia was significantly more common following total thyroidectomy. Permanent hypoparathyroidism resulted in one patient each who underwent total thyroidectomy (0.8%) and subtotal thyroidectomy (0.1%). Permanent recurrent laryngeal nerve palsy occurred in one patient who underwent total thyroidectomy (0.8%) and 5 patients undergoing subtotal thyroidectomy (0.4%). Conclusion: Given that subtotal thyroidectomy provides an unpredictable outcome and that the risk of permanent complications is no greater than with total thyroidectomy, there appears little logical reason to continue to recommend subtotal thyroidectomy for the surgical management of Graves’ disease. We believe that Graves’ disease should join the increasing list of thyroid conditions for which total thyroidectomy is the preferred option.     

Safety of total thyroidectomy

BACKGROUND: Total thyroidectomy is the preferred operation for multinodular goitre, Graves' disease and thyroid cancer. This study reviewed prospectively collected data on a personal consecutive series of 336 total thyroidectomies to assess whether results reported in world centres of excellence could also be achieved elsewhere. METHODS: Between 1991 and 2004, 336 total thyroidectomies (85% over the last 6 years) of median age 53 years (13-86 years) and male : female ratio of 1:4.3 were undertaken for multinodular goitre 232 (69%), Graves' disease 26 (7.7%), thyroid cancer 60 (17.9%) and other benign conditions 17 (5.4%). Thirty-nine patients had 2-stage procedures. No patient required median sternotomy. Parathyroid autotransplantation was carried out in 43 (12.8%). RESULTS: Permanent unilateral recurrent laryngeal nerve palsy occurred in 0.3% and permanent hypoparathyroidism in 1.8%. Significant temporary hypocalcaemia occurred in 13.4%. Non-significant temporary hypocalcaemia occurred in 23.8%, resulting in an overall rate of hypocalcaemia of 38.9% for the total series. Hypocalcaemia was more common after 1-stage compared with 2-stage surgeries (P < 0.001). Temporary hypocalcaemia was commoner after surgery for Graves' disease than surgery for other conditions. The rate of postoperative haemorrhage was 0.9% and wound infection, 1.5%. There was no postoperative mortality. CONCLUSION: Total thyroidectomy removes the disease process completely, lowers local recurrence rates and avoids the substantial risks of reoperative surgery. Total thyroidectomy is safe and can be carried out with low complication rates that are equal to world centres of excellence.     

Post-thyroidectomy hypocalcemia: clinical and laboratory findings

Hypocalcaemia is a possible sequela of thyroidectomy, the causes of which are not fully understood. Today, correct surgical technique is the most important factor in decreasing the incidence of hypocalcaemia. We analysed 1223 patients (930 total thyroidectomies, 293 hemi-thyroidectomies) treated in our institute from January 1995 to July 2003. Serum calcium, ionized calcium, parathyroid hormone and phosphoraemia were screened pre- and postoperatively. Hypocalcaemia, as defined by a serum calcium concentration below 8.5 mg/dL, occurred in 241 patients (25.1%). In 90.9% of these patients, serum calcium was normal 7 days after thyroidectomy. In three patients we registered permanent hypoparathyroidism 180 days after thyroidectomy. We found a statistically significant difference in the incidence of hypocalcaemia between patients treated for benign disease and those treated for malignant disease with a greater incidence in the latter group (P < 0.05). Several factors are important in determining the incidence of post-thyroidectomy hypocalcaemia but the inadvertent excision of the parathyroid gland, ischaemia and injury are the main causes of the lowering of serum calcium concentrations.     

Hypoparathyroid risk after total thyroidectomy

From January 1970 to December 1999, 881 patients with thyroid pathology underwent surgery consisting in 551 subtotal thyroidectomies and 330 total thyroidectomies. Permanent hypocalcaemia was present in 32 patients (3.6%). The importance of accurate isolation and ultraligature of the branches of the inferior thyroid artery in the prevention of parathyroid damage is stressed.     

Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up.

SUMMARY BACKGROUND DATA: Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy. METHODS: An analysis of 194 patients having thyroidectomy and simultaneous parathyroid autotransplantation at Barnes Hospital from 1990 to 1994 was performed. Data were collected regarding patient demographics, indication for thyroidectomy, operative procedure, pathologic diagnoses, and postoperative course, including biochemical assessment of parathyroid autograft function. RESULTS: Of 194 patients having either total, subtotal, or completion thyroidectomy, 104 (54%) experienced a [Ca(+2)]nadir less than or equal to 8.0 mg/dL and had symptoms and signs of hypocalcemia. Parathyroid autotransplantation was successful in 103 (99%) of these 104 cases and resulted in a 1.0% incidence of hypoparathyroidism in this series. CONCLUSIONS: Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.     

Early results after minimal lobectomy for benign nodular goiter

Following traditional operations (enucleation and subtotal resection) for benign nodular goiters recurrences may develop. Reoperations for this condition can cause complications, such as hypoparathyroidism and damage of the recurrent laryngeal nerve. That is why total thyroidectomy is recommended by many specialists in benign thyroid disease. We performed lobectomy on one side, and, if necessary, partial resection on the other side. Lobectomy was performed on one side in 31 cases, with partial resections on the other side in 73 patients. We tried to identify the parathyroid glands and both recurrent laryngeal nerves. Postoperative complications were evaluated. Temporary dysfunction of the recurrent laryngeal nerve was detected in 2.3%, permanent damage in 1.1%. Temporary hypocalcaemia developed in 16.4%, permanent hypocalcemia in 1.9%. Two reoperations were necessary for bleeding. Because of the low postoperative complication rate we recommend this method as an alternative to thyroidectomy for benign nodular goiters. We know that our favourable results can be compared with traditional subtotal resection and thyroidectomy when long term results of thyroid function and data about nodular recurrences will be collected.     

The Change in Surgical Practice from Subtotal to Near-Total or Total Thyroidectomy in the Treatment of Patients with Benign Multinodular Goiter

Background  Although total thyroidectomy is the procedure of choice in patients with thyroid carcinoma, this surgical approach has emerged as a surgical option to treat patients with benign multinodular goiter (BMNG), especially in endemically iodine-deficient regions. The aim of this study was to review our experience with patients with BMNG in an endemically iodine-deficient region treated by either subtotal or total/near-total thyroidectomy, and to document whether total or near-total thyroidectomy decreased the rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma in comparison to the patients with BMNG treated initially by subtotal thyroidectomy. Methods  Two thousand five hundred ninety-two patients with BMNG were included. There were 1695 bilateral subtotal thyroidectomies (group 1) and 1211 total or near-total thyroidectomies (group 2) for BMNG during this period. All patients were euthyroid and had no history of hyperthyroidism, radiation exposure, or familial thyroid carcinoma. Any patient with preoperative or perioperative suspicion of malignancy or hyperthyroidism was excluded. Results  Bilateral subtotal thyroidectomy was performed in 1695 patients (58.3%) in group 1 and total or near-total thyroidectomy in 1211 patients (41.7%), in group 2, respectively. The incidence of incidental thyroid carcinoma was found to be 7.2% (n = 210/2906). Although the rate of permanent hypoparathyroidim and transient or permanent unilateral recurrent laryngeal nerve (RLN) palsy were not significantly different between the two groups, transient hypoparathyroidism was significantly higher in group 2 than in group 1 (8.4% vs. 1.42%; p < 0.001, odds ratio [OR] = 52.98). The incidence of thyroid carcinoma was significantly higher in group 2 (10.7%, n = 129/1211) than in group 1 (4.68%, n = 81/1695) (p < 0.001; OR = 39.1).Thirty-eight patients in group 1 (2.24%) underwent completion thyroidectomy, whereas completion thyroidectomy has been not indicated in group 2 (p = 0.007). Two of 38 patients (5.26%) had thyroid papillary microcarcinoma on their remnant thyroid tissue. The rate of recurrent goiter was 7.1% in group 1. The average time to recurrence in group 1 was 14.9 ± 8.7 years. Six of 121 patients with recurrent disease (4.95%) has been operated on. Conclusions  Subtotal thyroidectomy resulted in a significantly higher rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma compared with total or near-total thyroidectomy in patients with BMNG. The extent of surgical resection had no significant effect on the rate of permanent complications. We recommend total or near-total thyroidectomy in BMNG to prevent recurrence and to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid carcinoma.     

Parathyroid autotransplantation during thyroidectomy

Permanent hypoparathyroidism is a debilitating morbidity following thyroidectomy, with a reported incidence of up to 43%. Apart from meticulous dissection to preserve parathyroid glands and their blood supply, parathyroid autotransplantation (PA) has been increasingly employed to preserve parathyroid function. The adoption of PA during thyroidectomy has been reported to be associated with a low incidence of permanent hypoparathyroidism. Biochemical function of parathyroid autografts can be demonstrated objectively by forearm reimplantation or during long-term follow up. The clearest indication for PA is for inadvertently removed or devascularized parathyroid glands during thyroid surgery. Other strategies, including routine autotransplantation of at least one parathyroid gland, can be considered, but is associated with a high incidence of transient hypocalcaemia. Apart from refinement in technique to facilitate graft success, a reliable way to assess overall parathyroid function or viability of individual parathyroid gland may assist in monitoring parathyroid function and selecting patients requiring this procedure to prevent permanent hypoparathyroidism.     

原位保留甲状旁腺血供及甲状旁腺自体移植术

目的 介绍甲状腺肿瘤手术中保护甲状旁腺血供及甲状旁腺自体移植的方法及疗效.方法 46例全甲状腺切除或近全切除手术中,血管化甲状旁腺保留24例,单纯自体甲状旁腺移植5例,1～2枚甲状旁腺血管化保留同时其余甲状旁腺Ⅰ期自体移植17例.结果 应用此法行全甲状腺切除或近全切除患者中,有2例原位血管化保留甲状旁腺及3例血管化保留+自体甲状旁腺移植患者术后48～72 h内出现一过性低血钙,予以补钙后3 d左右恢复正常.2例单纯甲状旁腺自体移植患者术后出现低血钙,服用钙尔奇D/罗盖全4周～8周后复查血钙维持在正常水平.术后出现永久性甲状旁腺功能低下的仅1例(2.2%).结论 血管化甲状旁腺保留及自体甲状旁腺移植可大大降低全甲状腺切除或近全切除手术导致甲状旁腺功能低下的发生率.     

ROUTINE AUTOTRANSPLANTATION OF AT LEAST ONE PARATHYROID GLAND DURING TOTAL THYROIDECTOMY MAY REDUCE PERMANENT HYPOPARATHYROIDISM TO ZERO

Background : Permanent hypoparathyroidism, although a recognized complication of total thyroidectomy, is an outcome that all endocrine surgeons try to avoid. Methods : To minimize the risk of postoperative hypoparathyroidism a strategy was developed of routine autotransplantation of at least one parathyroid gland into the ipsilateral sternomastoid muscle during every total thyroidectomy. One hundred consecutive patients undergoing total thyroidectomy were included in the study. Serum calcium and albumin levels were measured pre-operatively, on the first 2 postoperative days, and after 2 weeks, or until return to normal serum calcium levels without calcium supplementation. If patients developed biochemical evidence or symptoms of hypocalcaemia postoperatively, a calcium replacement was administered according to defined protocol. Results : In 74 cases one parathyroid gland was autotransplanted: 44 for inadvertent removal or anatomical reasons, 19 because of devascularization (assessed by a cut through the gland’s capsule and evaluation of the capillary bleeding pattern), and 11 by protocol. In 25 cases, two or more glands were autotransplanted. Fourteen patients developed symptoms of hypocalcaemia and received calcium supplementation, as did another 13 asymptomatic patients with only biochemical evidence of hypocalcaemia. At follow-up 3 months postoperatively the incidence of permanent hypoparathyroidism was zero, with all patients being normocalcaemic without calcium supplementation. Conclusions : This strategy, easily adopted by any experienced surgeon, has the potential to eliminate permanent hypoparathyroidism following total thyroidectomy.     

Autotransplantation of at least one parathyroid gland during thyroidectomy in benign thyroid disease minimizes the risk of permanent hypoparathyroidism

OBJECTIVE:Permanent hypoparathyroidism is a distressing complication of thyroid surgery. The reported incidence varies between 0.4 and 13.8 % and is directly correlated to the extent of thyroidectomy. The aim of this retrospective study was to analyze whether simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease could reduce the risk of permanent hypoparathyroidism. METHODS: Since 01/1999 all thyroid operations are prospectively recorded. Beside daily postoperative measurement of serum calcium level, iPTH is routinely determined on the third post op day. Patients with complications are followed closely. Postoperative hypoparathyroidism persisting for more than 6 months is defined permanent. RESULTS: Between 01/1999 and 02/2001 146 total thyroidectomies for benign thyroid disease have been performed (81 pat. with Graves disease, 62 with nodular goiter, 3 with thyroiditis de Quervain/Hashimoto). In 37 pat. (25 %) at least one parathyroid gland was simultaneously autotransplanted into the ipsilateral sternocleidomastoid muscle. Group I (no parathyroid autotransplantation, n = 109) and group II (parathyroid autotransplantation, n = 37) were comparable concerning patient age, thyroid disease and lowest post op calcium level (2.07 versus 2.05 mmol/l). The incidence of postoperative symptomatic hypocalcemia (14.7 % versus 21.6 %) and temporary hypoparathyroidism (15.6 % versus 18.9 %) was higher in group II patients (n. s.). Conversely, permanent hypoparathyroidism occurred exclusively in group I patients (2.75 %), patients with parathyroid autotransplantation (group II) did not develop this complication. CONCLUSIONS: Simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease seems to minimize the risk of permanent hypoparathyroidism. The potential of routine autotransplantation in this setting has to be evaluated. The incidence of postoperative temporary hypocalcemia may be elevated with this policy.     

Routine autotransplantation of at least one parathyroid gland during total thyroidectomy may reduce permanent hypoparathyroidism to zero.

BACKGROUND: Permanent hypoparathyroidism, although a recognized complication of total thyroidectomy, is an outcome that all endocrine surgeons try to avoid. METHODS: To minimize the risk of postoperative hypoparathyroidism a strategy was developed of routine autotransplantation of at least one parathyroid gland into the ipsilateral sternomastoid muscle during every total thyroidectomy. One hundred consecutive patients undergoing total thyroidectomy were included in the study. Serum calcium and albumin levels were measured pre-operatively, on the first 2 postoperative days, and after 2 weeks, or until return to normal serum calcium levels without calcium supplementation. If patients developed biochemical evidence or symptoms of hypocalcaemia postoperatively, a calcium replacement was administered according to defined protocol. RESULTS: In 74 cases one parathyroid gland was autotransplanted: 44 for inadvertent removal or anatomical reasons, 19 because of devascularization (assessed by a cut through the gland's capsule and evaluation of the capillary bleeding pattern), and 11 by protocol. In 25 cases, two or more glands were autotransplanted. Fourteen patients developed symptoms of hypocalcaemia and received calcium supplementation, as did another 13 asymptomatic patients with only biochemical evidence of hypocalcaemia. At follow-up 3 months postoperatively the incidence of permanent hypoparathyroidism was zero, with all patients being normocalcaemic without calcium supplementation. CONCLUSIONS: This strategy, easily adopted by any experienced surgeon, has the potential to eliminate permanent hypoparathyroidism following total thyroidectomy.     

甲状腺癌患者甲状腺全切手术安全性探讨

目的 探讨甲状腺癌患者行甲状腺全切除手术的安全性.方法 回顾性分析1986年1月至2006年12月因甲状腺癌行甲状腺全切除(全切组)以及次全或近全切除术(双叶手术组)的患者资料,比较两组间喉返神经损伤和继发性甲状旁腺功能低下的发生率.结果 双叶切除手术组433例:13例发生暂时性单侧喉返神经损伤,5例发生永久性单侧喉返神经损伤;11例发生暂时性甲状旁腺功能低下,无永久性甲状旁腺功能下病例.甲状腺全切手术组共70例:4例发生暂时性单侧喉返神经损伤(P>0.05),1例发生永久性单侧喉返神经损伤(P>0.05);7例发生暂时性甲状旁腺功能低下(P<0.01),2例永久性甲状旁腺功能低下(P<0.05).结论 甲状腺全切除术并不增加喉返神经损伤的概率,但手术后甲状旁腺功能低下发生率增加,因此应该有选择的施行甲状腺全切除手术.     

Early (1 hour) post-operative parathyroid hormone (PTH) measurement predicts hypocalcaemia after thyroidectomy: a prospective case-control single-institution study

The aim of the study was to evaluate the efficacy of parathyroid hormone 1-hour assay for the early prediction of hypoparathyroidism after thyroidectomy. Candidates for total, subtotal, completion thyroidectomy or lobectomy were entered into the study. Pre- and postoperative calcium and parathyroid hormone (1 hour and postoperative day 1 after thyroidectomy) levels and clinical hypocalcaemia were recorded. Patients were divided into 3 groups and 2 subgroups: 1. patients who underwent lobectomy (control group); 2. patients who underwent total thyroidectomy with postoperative hypocalcaemia (2A: asymptomatic patients, 2B: symptomatic patients); 3. asymptomatic patients with normal calcium levels after total thyroidectomy. Of 119 patients, 109 underwent total thyroidectomy and 10 lobectomy. Of the 109 patients submitted to total thyroidectomy, 35 (32.11%) developed postoperative transient hypocalcaemia. Twenty-one patients (19.27%) were asymptomatic and 14 (12.84%) were symptomatic. Parathyroid hormone levels decreased after 1 hour in group 3 (32.98 pg/dl), 2A (9.84 pg/dl) and 2B (7.46 pg/dl). There was no significant difference in parathyroid hormone levels at 1 hour between group 2A and 2B (p = 0.06), but were significantly lower compared to groups 3 and 1 (p < 0.05). Parathyroid hormone levels at 1 hour after total thyroidectomy is a good predictor of early hypocalcaemia. It might be more useful than serum calcium monitoring for the early identification of patients requiring postoperative calcium supplementation.     

The cricothyroid space: a guide for successful thyroidectomy

OBJECTIVE: The frequent complications of thyroid surgery are mostly related to the anatomy of the region. This stimulated us to look for a starting point that makes exploration of the region easier and consequently reduces complications. We aimed to explore and define the anatomy of the cricothyroid [CT] region from cadaveric dissection and to present the outcome of 73 consecutive thyroidectomies starting from a space in the CT region. METHODS: Dissection in the thyroid gland region and creating a space in the CT region was performed on five cadavers [10 spaces], followed by 73 consecutive thyroidectomies through a standard approach beginning from the CT space. RESULTS: In all cadavers, a space was easily created in the CT region. Vessels, nerves and the parathyroid glands were identified. Standard thyroidectomy starting from the CT space was performed on 73 patients. The external laryngeal nerve was seen in 40% of the cases. The recurrent laryngeal nerve was identified and preserved in all patients. Six patients had temporary hypocalcaemia and eight had a temporary voice change. None of the patients had permanent hypoparathyroidism or recurrent laryngeal nerve palsy. CONCLUSION: The CT space is an avascular space medial to the thyroid lobe and is a good starting point for thyroidectomy that allows easy and safe exploration of the region.     

102例甲状腺癌中央区淋巴清除术中甲状旁腺保护体会

目的:总结甲状腺切除+中央区淋巴清除中甲状旁腺保护的体会。方法:回顾性分析102例于我院行甲状腺切除+中央区淋巴清除的患者,统计术后患者出现低甲状旁腺激素血症、低钙血症、症状性低钙血症的发生率。结果:术后暂时性低甲状旁腺激素血症发生率35.29%(36/102);低钙血症发生率69.61%(71/102);症状性低钙血症发生率36.27%(37/102);无一例出现永久性低钙血症。结论:各种甲状腺术式对甲状旁腺功能均有不同程度的影响,手术范围越大,术后并发甲状旁腺功能减退的可能性越大。术后甲状旁腺功能减退的预防,就在于术者必须秉承高度负责的态度,术中仔细识别甲状旁腺,精细化操作,注意对甲状旁腺动脉及回流静脉的保护,采取以原位保留为主,自体移植为辅的原则。     

Total thyroidectomy. The preferred option for multinodular goiter.

Total thyroidectomy is an operation that has generally been reserved for the management of differentiated thyroid carcinoma. Over the last decade total thyroidectomy has become used increasingly and is now the preferred option in the authors' unit for the management of multinodular goiter affecting the entire gland. Over the period from 1975 to 1985, 853 thyroidectomies have been performed for multinodular goiter; of these, 115 have been total thyroidectomies. During that time, the incidence of total thyroidectomy for multinodular goiter has increased in percentage terms from 9% in 1975 to 50% in 1985. There have been two cases of permanent hypoparathyroidism and one case of permanent recurrent laryngeal nerve injury, and these occurred in patients who had less than total thyroidectomy. Total thyroidectomy is an appropriate operation for the management of diffuse multinodular goiter where the entire gland is involved because it precludes patients from requiring further surgery for recurrent disease, with its high associated risks. It must be emphasized, however, that protection of the recurrent laryngeal nerve and parathyroid glands must still be paramount in dealing with benign thyroid disease.     

Extent of thyroidectomy in nodular thyroid disease.

OBJECTIVE: To find out which procedure was the safest for each indication for operation in diseases of the thyroid gland. DESIGN: Retrospective study. SETTING: Two teaching hospitals, The Netherlands. SUBJECTS: 599 consecutive patients who had 601 thyroid operations between 1 October 1985 and 1 June 1993. MAIN OUTCOME MEASURES: Incidence of complications, particularly postoperative hypocalcaemia and injuries to the recurrent laryngeal nerve. RESULTS: Accidental injuries to the recurrent laryngeal nerve occurred in 0.7% of the nerves at risk (7/948) and the incidence of permanent hypocalcaemia was 5.2% (31/599). In subtotal procedures (bilateral subtotal thyroidectomy with the remnant left dorsally or total hemithyroidectomy combined with subtotal hemithyroidectomy on the other side with a remnant left at the upper pole) the rate was 11/390 (2.8%) compared with 18/525 (3.4%) after total resections. The corresponding numbers of accidental injuries to the recurrent laryngeal nerve were 2 and 4. CONCLUSIONS: Total thyroidectomies are more likely to be done for malignant disease, so the slightly higher complication rates probably reflect the nature of the disease, which requires more radical resection. Both subtotal procedures can be done with comparable low morbidity.     

Complications of thyroid surgery performed by residents

The purpose of this report is to study the incidence of complications in thyroid surgery performed by the residents in a surgical training program. This is a report of complications in 200 consecutive thyroidectomies performed by residents with attending surgeons' assistance. There were 128 female and 72 male patients, ranging in age from 16 to 89 years. Ten patients had undergone previous thyroid surgery. There were 40 total thyroidectomies, 38 subtotal thyroidectomies, and 122 lobectomies with isthmusectomy. Preoperative and postoperative evaluation of the vocal cords was a standard routine. Identification of the recurrent laryngeal nerve was routine except in patients with large goiters, who underwent intracapsular subtotal thyroidectomy. An attempt was made to identify and preserve all four parathyroid glands. Even in lobectomy procedures, the ipsilateral parathyroids were identified and preserved. Parathyroid autotransplantation into the sternomastoid muscle was performed in thirteen instances, whenever any of the parathyroids was devascularized. Complications included superior laryngeal nerve palsy (one case) and temporary recurrent laryngeal nerve palsy (one case). There was only one patient in whom temporary hypoparathyroidism developed. In three patients hematomas developed in the recovery room and reexploration was required. Two diabetic patients had wound infections develop that required drainage. Seromas and minor wound collections were noted in 6% of the patients. The incidence of major postoperative complications of thyroidectomy is low, even when residents are the primary surgeons. Thyroidectomy appears to be a safe operation in the hands of residents with close supervision and assistance by the attending surgeons.