Objective: To compare the frequency of postoperative complications with thyroid surgical procedures and the expertise of the surgeon.

Design: Retrospective cross-sectional study from 1999 to 2018.

Setting: A public sector tertiary care teaching hospital.

Participants and methods: Patients undergoing thyroid surgery (lobectomy with isthmusectomy, subtotal thyroidectomy (STT), near total thyroidectomy (NTT), or total thyroidectomy (TT)) were included. Expertise level 1, 2 and 3 (L1, L2, L3) of the surgeon was based on years of experience or number of thyroid surgeries to their credit.

Primary and Secondary Outcome Measures: Postoperative complications (hypocalcemia, recurrent laryngeal nerve (RLN) damage, airway obstruction, hemorrhage and mortality) were measured against type of thyroid surgery and expertise of surgeon.

Results: 833 thyroid surgeries were performed on 695 (83.43%) females and 138 (16.57%) males. 502 (60.26%) STT, 228 (27.37%) TT, 61 (7.32%) NTT, 42 (5.04%) lobectomies with isthmusectomies were performed, with LI, 2, and 3 surgeons performing 21.25%, 45.74% and 33.01%, respectively. L1, 2 and 3 surgeons caused 49.47%, 33.45% and 17.08% of adverse events respectively. The permanent hypocalcemia, RLN damage and mortality were significantly (p<0.05) more common in surgeries performed by L1 compared with L2 and L3.  Transient and permanent hypocalcemia, transient and permanent RLN damage and mortality were significantly (p<0.01) more common for total thyroidectomy compared to subtotal thyroidectomy.

Conclusion: Minimizing the occurrence of complications like permanent hypocalcemia, RLN damage and mortality, expertise of the surgeon and anticipated difficulty of the procedure needs to be taken into account while selecting a thyroid procedure.

Keywords: Thyroid surgery, Total thyroidectomy, Subtotal thyroidectomy, near total thyroidectomy, Lobectomy with isthmusectomy, hypoparathyroidism, hypocalcemia, recurrent laryngeal nerve, postoperative complications

This data set describes the complications for benign thyroid surgery over twenty years in a tertiary care center in Pakistan. This is stratified according to the level of expertise of operating surgeon, type of surgery, type of complication and year. Moreover, surgical workload (outpatient and inpatient) is also added within the data file.

This is a retrospective study done over a period of 20 years, from 1999 to 2018. The study setting is of a public sector tertiary care teaching hospital affiliated with Rawalpindi Medical University. Inclusion criteria comprised of all patients with goiter irrespective of age and sex who underwent any thyroid surgery (lobectomy with isthmusectomy, subtotal thyroidectomy (STT), near total thyroidectomy (NTT), or total thyroidectomy (TT)). All preoperative, operative and post-operative findings were recorded in detail for every patient.

The detail of surgical option for each patient was retrieved from the operative notes.  The level of expertise of the operating surgeon was divided in to three categories on either the number of total thyroid surgeries performed or years of surgical experience in a tertiary care teaching hospital.

Level 1 was a surgeon with more than 5 years of experience and  50 thyroid surgeries to his credit, level 2, a surgeon with 10 years of experience and  100 thyroid surgeries, and level 3 a senior surgeon with 15 plus years of experience and  150 thyroid surgeries.

All patients were observed post operatively for variable period of time in ward. The patients were followed in the outpatient at weekly interval for 2 weeks, monthly for 6 months and then yearly or as necessary according to the nature of the disease.

Medical records were retrieved from the monthly audit data. They were reviewed for variables like age, sex, preoperative diagnosis, extent of surgery, postoperative calcium levels, transient and permanent hypocalcemia, hoarseness, reason and need for tracheostomy, hemorrhage/ hematoma, any need to re explore, wound infection, histopathological records and mortality. The post-thyroidectomy hypocalcemia on 1st, 2nd and 5^th postoperative day and at six months following surgery was measured. Transient hypocalcemia was defined as serum calcium less than 8.0 mg/dl (2mmol/L) on at least two consecutive measurements or signs and symptoms of hypocalcemia (perioral numbness, digital paresthesia, or positive Chvostek or Trousseau’s sign). Permanent hypocalcemia was defined as the need for calcium and or vitamin D supplements to maintain normal calcium levels at six months or more after the date of surgery

Type of Surgery

There were four basic modalities to surgically treat benign diseases of goitre. Subtotal thyroidectomy (STT), Total Thyroidectomy (TT), Lobectomy(Lob) and Near total thyroidectomy (NTT) are referenced in the excel file.

Complications

The type of surgery and level of expertise of the operating surgeon were related to the type of complication.

Permanent Hypocalcemia (Hypoc Perm) is defined as the need for calcium and or vitamin D supplements to maintain normal calcium levels at six months or more after the date of surgery

Transient Hypocalcemia (Hypoc Trans) is defied as serum calcium less than 8.0 mg/dl (2mmol/L) on at least two consecutive measurements or signs and symptoms of hypocalcemia (perioral numbness, digital paresthesia, or positive Chvostek or Trousseau’s sign).

Tracheostomy, Hypothyroidism, hyper thyroididsm and hemorrhage are also mentioned as complications in the excel file.

Level of expertise of the surgeon

Level of expertise of the surgeon are judged as follows;

Level 1 was a surgeon with more than 5 years of experience and  50 thyroid surgeries to his credit, level 2, a surgeon with 10 years of experience and  100 thyroid surgeries, and level 3 a senior surgeon with 15 plus years of experience and  150 thyroid surgeries.

Legend

Sheet 1, Sheet2 and Sheet 7 ( Complications during thyroid surgeries broken down on the basis of level of expertise and type of surgery)

Hypocalc Trans =  Transient Hypocalcemia

Hypocalc Perm = Permanent Hypocacemia

RLN Trans = Transient Recurrent Laryngeal Nerve paralysis

RLN Perm = Permanent Recurrent Laryngeal Nerve paralysis

Tracheostomy

Hemorrhage

W inf = Wound Infection

Hypothy = Hypothyroidism

Hyperthy = Hyperthyroidism

Complis = Complications

SST= Subtotal Thyroidectomy

NTT= Near total Thyroidectomy

TT= Total thyroidectomy

Lobec = Lobectomy

L1 = Level 1 specialist surgeon

L2 = Level 2 specialist surgeon

L3 = Level 3 specialist Surgeon

 

Sheet 3 ( Number of complications per year)

Complis = Complications

SST= Subtotal Thyroidectomy

NTT= Near total Thyroidectomy

TT= Total thyroidectomy

Lobec = Lobectomy

L1 = Level 1 specialist surgeon

L2 = Level 2 specialist surgeon

L3 = Level 3 specialist Surgeon

 

Sheet 4 ( Total outpatient, inpatient and surgical workload)

OPD= Out patient department visits

Admiss = Admissions

Elect = Elective surgeries

 

Sheet 5 (Presentation of patients with thyroid disease)

Euthy = Euthyroid 

Hyperthy = Hyperthyroid

Hypothy = Hypothyroid

MNG = Multinodular goitre

SolitNod = Solitary Nodule

Diffuse = Diffuse goitre

 

Sheet 6 ( thryoid surgeries for benign disease performed per year  )

SST= Subtotal Thyroidectomy

NTT= Near total Thyroidectomy

TT= Total thyroidectomy

Lobec = Lobectomy