The morbidity of subtotal thyroidectomy

Abstract

THE introduction of the antithyroid drugs and of radio-active iodine in the treatment of thyrotoxicosis has in recent years focused the attention of both surgeons and physicians on to the risks of operations on the thyroid gland. The vast majority of goitre operations performed are subtotal thyroidectomies either for simple goitre or for toxic goitre, and whilst the immediate mortality of these operations is now within acceptable limits, the post-operative complications are out of proportion to most other surgical operations of similar magnitude. It seemed to me that it would be of value to study the morbidity of subtotal thyroidectomy for simple and toxic goitre in a series of operations carried out in a general surgical practice.From June, 1954, to June, 1957, 139 patients with simple or toxic goitres were operated on in my beds at Llandough Hospital (the United Cardiff Hospitals) and at East Glamorgan Hospital, Church Village. Cases for this study were taken from these two large hospitals because the in-patient records are maintained by resident house surgeons and surgical registrars, and because the out-patient and laboratory services facilitated the follow-up. In this series of 139 thyroidectomies the great majority of patients were operated on by me personally, and the remainder by surgical registrars using a similar operative technique. There was I immediate postoperative death: this was a woman aged 77 years with a very large multinodular goitre associated with thyrotoxicosis and tracheal compression. Of the remaining patients I I 9 were satisfactorily followed up, the maximum duration of the follow-up period being 34 years and the minimum period I year.The investigation was directed at an analysis of the morbidity of subtotal thyroidectomy under the following headings :-(I) Injury to the recurrent laryngeal nerve;(2) Post-operative hypoparathyroidism;(3) Post-operative hypothyroidism;(4) Recurrence of the goitre;( 5 ) Hzcmatoma formation; (6) Wound infection. Rarer complications such as malignant exophthalmos or tracheal collapse were not encountered in this survey. METHOD OF INVESTIGATIONRecurrent Laryngeal Nerve Injuries.-The routine investigation for recurrent nerve injuries was as follows : In every case in this series indirect laryngoscopy was carried out pre-operatively, immediately post-operatively (usually one week after operation), and again at a final interview at a time varying from I year to 3+ years after operation. In cases where the immediate post-operative examination showed evidence of nerve injury further laryngoscopies were carried out at more frequent follow-up examinations. The majority of the pre-operative laryngoscopies and all the post-operative examinations were carried out by consultant surgeons to the Ear, Nose, and Throat Department of the United Cardiff Hospitals, or by senior registrars to the department. In this way an expert and unbiased opinion on cord function was obtained.Other Post-operative Complications.-The data for the other aspects of this investigation were obtai...

Results of Partial Thyroidectomy for Thyrotoxicosis

“…Persistent vocal cord paralysis is reported to be rare with such an operative technique 0-0.3% (4,12). This observation is also well confirmed in the comparison between our series with and without routine nerve identification, 0 and 2 %, respectively.…”

“…However, the modes of Table V A routine identification of parathyroid glands is, however, no guarantee for the avoidance of postoperative hypoparathyroidism. It is not always possible to find the parathyroids (12) and in attempting to identify the glands there is always the risk of damaging their vascular supply (1).…”

Incidence of Complications of Thyroid Surgery

“…iv) Total thyroidectomy. v) Total thyroidectomy with neck dissection 9 .The complications which is most feared is trauma to the recurrent laryngeal nerve, estimated to occur between 1 and 10% of operations 10,11 . Hypocalcaemia is uncommon after subtotal thyroidectomy but is common in the total thyroidectomy.…”

The importance of the ligation of the inferior thyroid artery in parathyroid function after subtotal thyroidectomy

“…This curious finding can be easily explained by the nonspecific nature of these symptoms and the possibility that they were suggested to the patients by insistent interrogation, as has also been postulated by other authors 75,76,77,78 . The only definitively hypocalcemic patient was asymptomatic, as they usually are 16,74 .…”

“…Another very significant observation is the low reliability of clinical observations when evaluating postoperative hypocalcemia in thyroidectomies. It has been reported that most hypocalcemic patients are asymptomatic 11,16,44,74,75,76,77 . This was also true in our study, since 77.8% of our hypocalcemic patients had no symptoms.…”