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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 1-9

Complications of thyroidectomy at a tertiary health institution in Nigeria


1 Department of Surgery, College of Health Sciences, University of Abuja; Department of Surgery, University of Abuja Teaching Hospital, Gwagwalada, Nigeria
2 Department of Pharmacy, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria

Date of Web Publication10-Oct-2019

Correspondence Address:
Dr. Sani Ali Samuel
Department of Surgery, College of Health Sciences, University of Abuja, Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssajm.ssajm_33_18

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  Abstract 


Introduction: Thyroid surgeries are the most common endocrine surgeries performed all over the world. The procedure has been through tremendous evolution to enhance patient safety. In spite improved techniques, every thyroid surgeon has come across complications with this operation. This is a retrospective study of complications of thyroidectomies at a tertiary health institution in Abuja, Nigeria. The study highlights some of the complications encountered at the University of Abuja Teaching Hospital, Gwagwalada, Abuja, following thyroid surgeries by General surgeons. Aim: This article aimed to determine the complication rates after thyroidectomies in our institution and proffer efficient methods of complication management, thus reducing postoperative morbidity and mortality. Material and Methods: A retrospective study of complications arising from consecutive thyroidectomies was carried out in the University of Abuja Teaching Hospital for over a 5-year period between January 1, 2012 and December 31, 2017. Clinical data on each case were extracted from patient folders using a structured questionnaire. Data was analyzed using SPSS, IBM version 21. Results: A total of 72 thyroidectomies were carried out during the period. There were seven males and 65 females with M:F ratio of 1:9. The median age of the patients was 38.5 years (range 18–75 years). Preoperative diagnoses included simple goiter (n = 6, 8.3%), nontoxic multinodular goiter (n = 51, 70.8%), toxic nodular goiter (n = 6, 8.3%), Grave’s disease (n = 2, 2.8%), toxic multinodular goiter (n = 5, 6.9%), simple multinodular goiter (n = 1, 1.4%), and others such as solitary thyroid cyst (n = 1, 1.4%) . The operations were total thyroidectomy (n = 15, 20.8%), subtotal thyroidectomy (n = 13, 18.1%), near-total thyroidectomy (n = 33, 45.8%), lobectomy (n = 10, 13.9%), and extended lobectomy (n = 1, 1.4%); 72.1% of the patients had no complications whereas 27.9% of the patients developed complications. The complications were temporary recurrent laryngeal nerve (RLN) palsy 9.7%, recurrent goiter 1.4%, hypothyroidism 1.4%, hypocalcemia 5.6%, hypertrophic scar formation 5.6%, and hematoma collection 4.2%. No patient developed wound infection, transient or permanent hypoparathyroidism, permanent RLN palsy, superior laryngeal nerve palsy, recessed scar, or mortality. All the patients were followed up for a period of 1 to 5 years. Conclusion: Thyroidectomy is safe in our institution. The complication rate of 27.9% is high, however, this is a summation of all complications recorded at the institution. Most of the complications were minor and resolved with conservative measures in 3 to 6 months. The dreaded complications of thyroidectomy such as permanent RLN injury, wound infection, and mortality is zero (0)% each. Careful patient selection and robust collaboration with cosmetic surgeons and endocrinologist in the management of goiters improved our outcome.

Keywords: Hematoma collection, L-thyroxine therapy, recurrent laryngeal palsy, thyroidectomy


How to cite this article:
Samuel SA, Rebecca SH. Complications of thyroidectomy at a tertiary health institution in Nigeria. Sub-Saharan Afr J Med 2019;6:1-9

How to cite this URL:
Samuel SA, Rebecca SH. Complications of thyroidectomy at a tertiary health institution in Nigeria. Sub-Saharan Afr J Med [serial online] 2019 [cited 2023 Jan 28];6:1-9. Available from: https://www.ssajm.org/text.asp?2019/6/1/1/268789




  Introduction Top


An understanding of the anatomy of thyroid gland is a sine qua none to a successful thyroidectomy. The main anlage of the thyroid gland develops as a median entodermal downgrowth from the first and second pharyngeal pouches. During its migration caudally, it contacts the ultimobranchial bodies developing from the fourth pharyngeal pouches. When it reaches the position it occupies in adults, just below the cricoid cartilage, the thyroid divides into two lobes. The site from which it originated persists as the foramen cecum at the base of the tongue. The path the gland follows may result in thyroglossal remnants (cysts) or ectopic thyroid tissue (lingual thyroid). A pyramidal lobe is frequently present.

The normal thyroid weighs 15 to 25 g and it is attached to the trachea by loose connective tissue. It is a highly vascular organ being supplied principally by the superior and inferior thyroid arteries and occasionally by thyroidea ima artery.[1]

The function of the thyroid gland is to synthesize, store, and secrete the hormones thyroxine (T4) and triiodothyronine (T3). Iodide is absorbed from the gastrointestinal tract and actively trapped by the acinar cells of the thyroid gland. It is then oxidized and combined with tyrosine in the thyroglobulin to form monoiodotyrosine and diiodotyrosine. These are coupled to form the active hormones T4 and T3, which initially are stored in the colloid of the gland. Following hydrolysis of thyroglobulin, T4 and T3 are secreted into plasma, becoming almost instantaneously bound to plasma proteins. Most T3 in euthyroid individuals are produced by peripheral conversion of T4 to T3.

The function of the thyroid gland is regulated by a feedback mechanism that involves the hypothalamus and pituitary. Thyrotropin-releasing factor, a tripeptide amide, is formed in the hypothalamus and stimulates the release of thyrotropin thyroid stimulating hormone (TSH), a glycoprotein from the pituitary.[1] Thyrotropin binds to TSH receptors on the thyroid plasma membrane, stimulating increased adenylyl cyclase activity; this increases cyclic-AMP production and thyroid cellular function. Thyrotropin also stimulates the phosphoinositide pathway and, along with cyclic - Adenosine MonoPhosphate (c-AMP), may stimulate thyroid growth.

A goiter is an enlargement of the thyroid gland. Goiters vary considerably in size, and enlargement may be diffused, involving the whole gland or irregular and affecting part or all of one lobe.

In endemic areas, 10% of the population have goiters. Goiters are common in certain regions of Nigeria and the Federal Capital Territory is within the goiter belt region.

The history of thyroid and parathyroid surgery dates back thousands of years ago, but the developments leading to the contemporary era began just over a century ago.[2] In 1909, the Nobel Prize was awarded to Emil Theodor Kocher for his work on thyroid gland.[3]

Thyroid operations are the most common endocrine surgeries performed all over the world, and the procedure has undergone tremendous evolution to enhance patient safety. Despite improved techniques, every thyroid surgeon has come across complications with this operation. The two most common early complications of thyroid surgery are hypocalcemia (20%–30%) and recurrent laryngeal nerve (RLN) injury (5%–11%).[4]

Some of the complications encountered in our institutions are presented and enumerated further.


  Material and methods Top


We conducted a retrospective review of complications arising from consecutive thyroidectomies carried out by general surgeons in the University of Abuja Teaching Hospital for over a 5-year period between January 1, 2012 and December 31, 2017. Clinical data on each case were extracted from patient folders. We retrieved data on age, sex, occupation, educational background, type of goiter, type of operation, anesthesia, drains, postoperative treatment, complications and their treatments, and follow-up period. All consecutive thyroidectomies within the study period were included. However, we excluded patients who were lost to follow-up during the period. Data was analyzed using SPSS, IBM version 21 (IBM Corporation, USA). The frequency of variables was identified using descriptive statistics. Chi-square test was equally employed in analyzing the data. Statistical significance was set at P < 0.05.


  Results Top


The results are presented in tabular form and analyzed using simple frequency distribution. The complications include hypocalcemia, transient hypoparathyroidism, permanent hypoparathyroidism, temporary RLN palsy, permanent recurrent laryngeal palsy, superior laryngeal nerve palsy, hypothyroidism, hematoma collection, wound infection, recessed scar, and hypertrophic scar formation.

A total of 72 thyroidectomies were carried out during the period. There were seven males (9.7%) and 65 females (90.3%), with a M:F ratio of 1:9. The median age of the patients was 38.5 years (range 18–75 years). [Table 1] shows the sociodemographic characteristics of the patients as depicted in [Figure 1],[Figure 2] to [Figure 3].
Table 1 Sociodemographic characteristics of the patients (n = 72)

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Figure 1 Gender distribution.

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Figure 2 Educational background.

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Figure 3 Occupation.

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Preoperative diagnoses included simple goiter (n = 6, 8.3%), nontoxic multinodular goiter (n = 51, 70.8%), toxic nodular goiter (n = 6, 8.3%), Grave’s disease (n = 2, 2.8%), toxic multinodular goiter (n = 5, 6.9%), simple multinodular goiter (n = 1, 1.4%), and others such as solitary thyroid cyst (n = 1, 1.4%). [Table 2] and [Figure 4] show the type of goiter(s).
Table 2 Type of goiter(s)

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Figure 4 Type of goiter(s).

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The operations were total thyroidectomy (n = 15, 20.8%), subtotal thyroidectomy (n = 13, 18.1%), near-total thyroidectomy (n = 33, 45.8%), lobectomy (n = 10, 13.9%), and extended lobectomy (n = 1, 1.4%). [Table 3] and [Figure 5] show the types of thyroidectomies; 72.1% of the patients had no complications whereas 27.9% of the patients developed complications. The complications were temporary RLN palsy 9.7%, recurrent goiter 1.4%, hypothyroidism 1.4%, hypocalcemia 5.6%, hypertrophic scar formation 5.6%, and hematoma collection 4.2%.
Table 3 Type of operation(s)

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Figure 5 Types of operation.

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No patient developed wound infection, transient or permanent hypoparathyroidism, permanent RLN palsy, superior laryngeal nerve palsy, recessed scar, or mortality.

All the patients were followed up for a period of 1 to 5 years.

­­


  Discussion Top


The total complication rate in our study is 27.9% [Figure 6]. The rate is slightly lower than 34.64% reported by Miguel et al.[5], but higher than the studies by Zambudio et al. (21%) and Rio et al. (24%) in patients with benign disease and symptomatic compression.[5] Extirpation of the thyroid gland as in total or near-total thyroidectomies were fraught with greater complication rates especially temporary RLN palsy, n = 7 (35%). Less radical procedures like subtotal thyroidectomy, lobectomy, and extended lobectomies were associated with fewer complication rates [Table 5].
Figure 6 Rate of complications after thyroidectomy.

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Table 4 Rate of complications after thyroidectomy

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Table 5 Distribution of type of thyroidectomy versus complications

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Majority of the patients had general anesthesia for thyroidectomy. Only three (3) of the patients who were administered local anesthesia for thyroidectomy developed complications, each having hematoma collection, hypertrophic scar formation, and temporary RLN palsy, respectively [Table 6]. Expectedly, local anesthesia is associated with lower complication rate, but this would largely depend on the size of the gland and extent of extirpation.
Table 6 Distribution of type of thyroidectomy and anesthesia versus complications

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There is no significant correlation between the expertise of the surgeon and complications, as all the thyroidectomies were carried out by consultant general surgeons at the Breast and Endocrine Surgery Unit, under the Division of General Surgery. No surgical trainee (e.g., Senior Registrar) undertook any of the operation as a primary surgeon [Table 7].
Table 7 Distribution of type of thyroidectomy and level of surgical expertise versus complications

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The rate of complications after thyroidectomy from the study as depicted in [Table 4] and [Figure 7] are further highlighted.
Figure 7 Rate of various complications.

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Laryngeal nerve injury is a potentially serious complication of thyroidectomy. Permanent unilateral RLN paralysis manifests clinically as hoarseness, weakness, and breathiness of the voice and occurs with an incidence between 0% and 3.6% after thyroidectomy.[6],[7],[8],[9]

In our study, 9.7% of patients developed temporary RLN injury and all fully recovered on conservative measures within 3 to 6 months. None of them developed unilateral or bilateral vocal cord paralysis due to transection of RLN.

The use of nerve stimulators minimizes the risk of injury to RLN.

Hypothyroidism occurred in 1.4% of patients who had subtotal thyroidectomy implying that the amount of thyroid tissue remnant after thyroidectomy is not sufficient enough to subserve thyroid function. A definite relationship has been established between the estimated weight of the thyroid remnant and the development of thyroid failure after subtotal thyroidectomy for Graves’ disease. L-thyroxine supplementation is required for some selected patients following subtotal or near-total thyroidectomy to forestall development of postoperative hypothyroidism.

Recurrent goiter is a recognized complication of subtotal thyroidectomy; 1.4% of the patients in this study developed recurrent goiter. Subtotal thyroidectomy is associated with a recurrence rate of 10% and 30%.[10] Disease recurrence usually requires a repeat surgery, which greatly increases the risk (up to 20 times) of damage to parathyroid glands and laryngeal nerve.[11] The sequelae of incomplete surgical management of bilateral simple multinodular goiter includes a risk of recurrence[10] that progressively increases as the time from the first operation.[12] However, an increased risk of completion thyroidectomy must be weighed against the merits and demerits of partial thyroidectomy or a single definitive treatment paradigm of total thyroidectomy.[12]

Hypertrophic scar formation accounted for 5.6% of postthyroidectomy complications. Scar formation is a serious cosmetic concern for patients who undergo thyroidectomy. Thus, risk factors should be identified and prevention of these factors is considered to be critical in the management. In some studies, development of hypertrophic scar after thyroidectomy was found to be associated with specific preoperative factors such as incision site near the sternal notch, prominent sternocleidomastoid muscles, and high body mass index.[13] Racial variation may account for the significantly high risk of hypertrophic scar formation. Endocrine surgeons need to pay particular attention to this complication as proper patient selection and early engagement of cosmetic surgeons in the perioperative period will enhance better outcome. Our patients did well on corticosteroid therapy.

Temporary hypocalcemia sequel to parathyroid insufficiency was present in 5.6% of patients that resulted from inadvertent removal of parathyroid glands or infarction of parathyroid end-artery or direct trauma to the gland during dissection. Our finding is similar to the finding of Efremidou et al.[11] (7.3%) in Greece in 2009. Parathyroid glands that were removed or devascularized unintentionally were autotransplanted into the ipsilateral sternocleidomastoid muscle during operation. Reimplantation of the gland can ameliorate the complication. Postsurgical hypocalcemia is managed by administration of calcium along with vitamin D for at least 10 days.[4]

Chronic hypoparathyroidism is a serious and potentially debilitating disorder that results from a variety of causes. It most commonly occurs as a complication of thyroid surgery, with incidence rates of postthyroidectomy hypothyroidism ranging from 0% to 33% depending on the severity of the underlying disease and the extent of the operative procedure.[6] Persistent postoperative hypoparathyroidism usually results from intentional or inadvertent extirpation of the parathyroid glands during thyroidectomy or from interruption of the blood supply to the glands with subsequent infarction.[14] Signs and symptoms of the ensuing hypocalcemia include perioral or distal extremity paresthesia, muscle cramping, positive Trousseau and Chvostek signs, laryngeal stridor, and convulsions. The latter conditions may prove fatal. The long-term sequelae of untreated or inadequately treated hypoparathyroidism include premature cataract development, calcification of the basal ganglia, recurrent seizures, osteomalacia, and psychiatric symptomatology.[6] Clinical management of these patients is costly and can be challenging because the therapeutic window for vitamin D is narrow. Even short-term vitamin D intoxication, which may be asymptomatic, can cause nephrolithiasis and obstructive uropathy, resulting in permanent kidney damage.[14]

Permanent hypoparathyroidism was defined as symptoms of hypocalcemia along with a requirement for oral vitamin D or calcium 6 months after thyroidectomy.

No patient developed chronic or permanent hypoparathyroidism in this study.


  Conclusion Top


Thyroidectomy is safe in our institution. The complication rate of 27.9% is high, however, this is a summation of all complications recorded at the institution. Most of the complications were minor and resolved with conservative measures in 3 to 6 months. The dreaded complications of thyroidectomy such as permanent RLN injury, wound infection, and mortality is zero (0)% each. Careful patient selection and robust collaboration with cosmetic surgeons and endocrinologist in the management of goiters improved our outcome. The result obtained would increase the body of knowledge in this specialty and foster a prospective study that could mitigate compounding factors. Improved surgical techniques during thyroid surgery and efficient methods of complication management can reduce the postoperative morbidity and mortality. In spite of all measures, keen observation in the postoperative period is important to look for complications so that early intervention can be instituted.

Our findings are germane, especially working in an area that is endemic for goiter and where the fear of complications of thyroidectomy is palpable among patients.

Ethics

Approval was obtained from Health Research Ethics Committee of the hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Orlo HC. Thyroid and parathyroid. In Gerard MD, Lawrence WW, editors. Current Surgical Diagnosis and Treatment. 12th ed. New York: McGrawHill; 2006.p.274.  Back to cited text no. 1
    
2.
Rogers-Stevane J, Kauffman GL Jr. A historical perspective on surgery of the thyroid and parathyroid glands. Otolaryngol Clin North Am 2008;41:1059-67.  Back to cited text no. 2
    
3.
Niazi AK, Kalra S, Irfan A, Islam A. Thyroidology over the ages. Indian J Endocrinol Metab 2011;15(Suppl 2):S121-6.  Back to cited text no. 3
    
4.
Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg 2013;150:249-56.  Back to cited text no. 4
    
5.
Miguel EN, Tagliarini JV, López BE, Padovani CR, Marques Mde A, Castilho EC et al. Factors influencing thyroidectomy complications. Braz J Otorhinolarygol 2012;78:63-9.  Back to cited text no. 5
    
6.
Burge RM, Zeise TM, Johnsen MW, Conway MJ, Qualls CR. Risks of complication following thyroidectomy. J Gen Intern Med 1998;13:24-31.  Back to cited text no. 6
    
7.
Tovi F, Noyek A, Chaonik J, Freeman J. Safety of total thyroidectomy: a review of 100 consecutive cases. Laryngoscope 1989;99:1233-7.  Back to cited text no. 7
    
8.
Heraanz-Gonzalez J, Gavilan J, Martinez-Vidal J, Gavilán C. Complications following thyroid surgery. Arch Otolaryngol Head Neck Surg 1991;117:516-8.  Back to cited text no. 8
    
9.
Martensson H, Terins J. Recurrent laryngeal nerve palsy in thyroid gland surgery related to operations and nerves at risk. Arch Surg 1985;11:475-7.  Back to cited text no. 9
    
10.
Reeve TS, Delbridge L, Cohen A, Crummer P. Total thyroidectomy: the preferred option for multinodular goiter. Ann Surg 1987;206:782-6.  Back to cited text no. 10
    
11.
Efremidou EI, Papageorgiou MS, Manolas K. The efficacy and safety of a total thyroidectomy in the management of benign thyroid disease; a review of 932 cases. Can J Surg 2009;52:39-44.  Back to cited text no. 11
    
12.
Afolabi AO, Oyandipo OO, Afuwape OO, Agundoyin AO. A fifteen year experience of total thyroidectomy for the management of simple multinodular goiters in a low medium income country. S Afr J Surg 2016;54:40-5.  Back to cited text no. 12
    
13.
Kim JH, Sung JY, Kim YH, Lee YS, Chang HS, Park CS et al. Risk factors for hypertrophic surgical scar development after thyroidectomy. Wound repair and regeneration, the international journal of tissue repair and regeneration. Wiley online library. 2012. Available at https://doi.org/10.1111/j.1524-475X.2012.00784.x, Accessed on [Aug 2018]  Back to cited text no. 13
    
14.
Foster R. Thyroid gland. In Davis J, Sheldon G, eds. Surgery: A Problem Solving Approach. St. Louis, MO: Mosby-Yearbook; 1995.pp.2185-247.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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