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Clinical problems in thyroid surgery

Hallgrimsson, Palli LU (2014) In Lund University, Faculty of Medicine Doctoral dissertation Series 2014:63.
Abstract (Swedish)
Popular Abstract in Swedish

POPULÄRVETENSKAPLIG SAMMANFATTNING

Dokumentation om Sjukdomar i sköldkörteln (thyroidea) finns dokumenterade i litteraturen sedan nästan 3000 år tillbaka. Många miljoner människor över hela världen lider av någon typ av sköldkörtelsjukdom, t.ex. förstorad sköldkörtel (struma/goiter), elakartade -, godartade förändringar eller överaktiv körtel (hyperthyreos, Graves’ sjukdom). Vissa sjukdomar kan behandlas med läkemedel medan andra behandlas mest effektivt med kirurgiska ingrepp. Sköldkörteln producerar viktiga hormoner som kallas tyroxin (T4) och trijodidtrionin (T3) som reglerar kroppens ämnesomsättning, det vill säga hur kroppen utvinner energi ur födan. Om din sköldkörtel inte fungerar... (More)
Popular Abstract in Swedish

POPULÄRVETENSKAPLIG SAMMANFATTNING

Dokumentation om Sjukdomar i sköldkörteln (thyroidea) finns dokumenterade i litteraturen sedan nästan 3000 år tillbaka. Många miljoner människor över hela världen lider av någon typ av sköldkörtelsjukdom, t.ex. förstorad sköldkörtel (struma/goiter), elakartade -, godartade förändringar eller överaktiv körtel (hyperthyreos, Graves’ sjukdom). Vissa sjukdomar kan behandlas med läkemedel medan andra behandlas mest effektivt med kirurgiska ingrepp. Sköldkörteln producerar viktiga hormoner som kallas tyroxin (T4) och trijodidtrionin (T3) som reglerar kroppens ämnesomsättning, det vill säga hur kroppen utvinner energi ur födan. Om din sköldkörtel inte fungerar normalt då använder kroppen energin långsammare eller snabbare än normalt. Total thyroidektomi (TT, borttagande av hela sköldkörteln) pga. hyperthyreos uppfattas av de flesta/många kirurger som den svåraste av sköldkörteloperationer. som genomförs vid sköldkörtels kirurgi, och många anser att risken för komplikationer som skada på stämbandsnerven, blödningar och sänkt kalcium (hypokalcemi) efter operation, är ökad. Hypertyreosis (Graves´ sjukdom) kan även behandlas med läkemedel (tyreostatika) och radiojod behandling, men risken är att sjukdomen kan komma tillbaka. Vid svårare fall av hypertyreosis, läggs även till betablockerare och kortison för att få bättre kontroll över sjukdomen. Principen för radiojodbehandling är att utnyttja sköldkörtelns förmåga att ta upp och lagra jod. Tyreostatika minskar produktionen av sköldkörtelhormonerna tyroxin, T4, och trijodtyronin, T3, i sköldkörteln. Höga doser av läkemedlet kan helt stoppa produktionen av sköldkörtelhormon. Radioaktiv form av jod (I-131) ges, som ansamlas i körtelvävnaden och i denna avger strålning med mycket kort räckvidd. Sköldkörteln är ett synnerligen kärlrikt vaskuliserad organ och därför viktigt att åstadkomma noggrann blodstillnings under operationen: Det kan uppnås med att ligera kärl med suturtråd. Med noggrann blodstillning blir det också lättare att identifiera bisköldkörtelar (producera parathyroidea hormon, PTH, som styr kalcium i kroppen) och stämbandsnerv. Komplikationer till sköldkörtelkirurgi är generellt relativt sällsynta men kan vara dyra för samhället. Hypokacalcemi är den vanligaste komplikationen till total thyroidektomi, som kan ge symtom bl.a. i form av stickningar i fingrar och runt munnen men i mer avancerade former kan det leda till kramp. Därför är det viktigt att försöka identifiera de riskfaktorer som ger ökad risk för komplikationer vid thyroidea kirurgi, både övergående och permanenta.

I den första studien i denna avhandling jämfördes skillnad mellan två olika operationstekniker vid TT hos patienter med Graves’ sjukdom. I den ena gruppen användes den konventionella tekniken som innebär ligaturer och diatermi för att uppnå hemostas, och i den andra gruppen användes ultraljudskniv (Harmonic Scalpel®, HS) som delar kärl med vibration vilket stänger tillkärlen samtidigt. Vi fann en signifikant kortare operation tid i HS-gruppen, vilket stämmer bra överens med övriga studier.

Många kirurger anser att risken för komplikationer vid TT hos patienter med Graves’ är högre jämfört med andra thyroidea diagnoser. I den andra studien i avhandlingen jämförde vi två olika patient grupper, en grupp med multinodös struma och en grupp med Graves´ sjukdom, som båda genomgick TT. Våra resultat kunde inte visa någon signifikant skillnad vad gäller risk för komplikationer mellan grupperna. Yngre patienter (Graves ´ patienter) upplevde mer symtom av hypokalcemi (stickningar och domningar) men det var ingen signifikant skillnad i blodprover. Detta är delvis överens med övriga studier, men flesta visar dock ökad risk för utveckling av postoperativa komplikationer som hypokalcemi efter TT hos Graves´ patienter.

I den tredje studien försökte vi att identifiera riskfaktorer hos Graves´ patienter för symtomatisk hypokalcemi som kräver medicinsk behandling med kalcium och/eller D-vitamin. Patienter som opererats på grund av Graves' sjukdom är registrerade i det skandinaviska kvalitetsregistret för tyroidea - och parathyroideakirurgi, därifrån data hämtades för att försöka identifiera risk faktorer för hypokalcemi. Vi fann att Graves´ patienter som förbehandlas med beta blockare inför kirurgi, hade en ökad risk för behandlingskrävande hypokalcemi vid första uppföljningen, efter ca 6 veckor. Reoperation och högre preparatvikt var risk faktorer för behov av behandling med vitamin D vid 6 månaders uppföljning. I vårt sista det fjärde arbetet undersökte vi riskfaktorer för permanent hypokalcemi bland patienter som opererats vid Lunds Universitet Sjukhus. I denna studie fann vi att lågt eller omätbart PTH

tidigt efter operation är en risk faktor för långdragen eller permanent hypokalcemi, och att inplantera bisköldkörtels vävnad under operation kan eventuellt undvika permanenta hypokalcemi. (Less)
Abstract
Background: Thyroid surgery is the most common endocrine surgical operation and is considered by many to be at the zenith of endocrine surgery. A good hemostasis is mandatory during a thyroid operation and many new devices have been available during the last two decades. Total thyroidectomy, (TT) is now by many surgeons considered the method of choice when treating Graves´ disease (GD) and multinodular goitres (MNG) surgically. Hypocalcaemia is the most common adverse event after thyroid surgery and the reported frequency ranges from 4-55 %. It is difficult to identify and predict patients at risk for developing postoperative hypocalcaemia. Previously described risk factors for transient hypocalcaemia are extent of surgery, lymph node... (More)
Background: Thyroid surgery is the most common endocrine surgical operation and is considered by many to be at the zenith of endocrine surgery. A good hemostasis is mandatory during a thyroid operation and many new devices have been available during the last two decades. Total thyroidectomy, (TT) is now by many surgeons considered the method of choice when treating Graves´ disease (GD) and multinodular goitres (MNG) surgically. Hypocalcaemia is the most common adverse event after thyroid surgery and the reported frequency ranges from 4-55 %. It is difficult to identify and predict patients at risk for developing postoperative hypocalcaemia. Previously described risk factors for transient hypocalcaemia are extent of surgery, lymph node dissection, GD, bone hunger and the number of parathyroid glands identified peroperatively and parathyroid autotransplantation.

Aims: To compare two different operation techniques for patients with GD undergoing TT and the risk of hypocalcaemia after TT for patients with MNG and GD, respectively. To identify risk factors for postoperative hypocalcaemia after TT in patients with GD and to predict risk factors for permanent hypocalcaemia after TT. Methods: In Paper I we compared in a prospective randomised controlled trial, a conventional operation technique vs. ultracision (Harmonic Scalpel(HS)) when performing TT. In Paper II, we compared the risk for hypocalcaemia between patients with GD and MNG undergoing TT. In Paper III, data were extracted from the Scandinavian Quality Register for Thyroid and Parathyroid Surgery (SQRTP) and patients with GD undergoing TT during year 2004 – 2008 in 23 surgical departments in Sweden were studied. In Paper IV, risk factors of permanent hypoparathyroidism after TT from a prospective database at the same surgical department was analysed.

Results: 27 patients were randomised to the HS group and 24 patients to the conventional group (knot tying). Operation time was significantly shorter in the HS group (I). Patients with GD (n=129) were younger than patients with MNG (n=81). Symptoms of hypocalcaemia were more common in patients with GD but there were no other differences between the two groups (II). Risk factors for i.v. calcium after TT in patients with Graves´ disease were low hospital volume, operative time, university hospital and reoperation due to postoperative hematoma. Risk factors for treatment with vitamin D at discharge increased with operative time, weight of the specimen, parathyroid autotransplantation and reoperation. Risk factors for treatment with vitamin D at first follow up at 6 weeks were weight of the specimen, preoperative treatment with beta blockers. At 6 months follow up, risk factors for treatment with vitamin D were weight of the specimen and reoperation (III). There were 519 patients, median follow up (range) was 2.7 years (1.2 – 10.3). The rate of permanent hypoparathyroidism was 1.9 %. Parathyroid autotransplantation was performed in 90/519, 17.3 % and none of these developed permanent hypoparathyroidism, as did no patient with normal PTH level on day one postoperatively.

Conclusion: Patients with GD undergoing TT performed with Harmonic Scalpel® had a significantly shorter operation time, without an increased risk for complications. Patients with GD were younger and experienced more often symptoms of hypocalcaemia after TT compared to patients with goitres, but there were no biochemical differences. Risk factors for medically treated hypocalcaemia after TT in patients with Graves´ disease are multifactorial and vary over follow-up time. A low PTH level early after TT is associated with a high risk of permanent hypoparathyroidism. Normal levels of PTH postoperatively exclude long term hypoparathyroidism. Parathyroid autotransplantation seems to be warranted as a way of minimizing the risk of permanent hypoparathyroidism (Less)
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author
supervisor
opponent
  • Professor Gimm, Oliver, Nolne
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Total thyroidectomy, Graves´ disease, multinodular goitre, transient hypocalcaemia, permanent hypocalcaemia
in
Lund University, Faculty of Medicine Doctoral dissertation Series
volume
2014:63
pages
125 pages
publisher
Department of Surgery, Clinical Sciences Lund, Lund University
defense location
Föreläsningssal 3, Blocket, Skånes Universitetssjukhus, Lund
defense date
2014-06-14 10:00
ISSN
1652-8220
ISBN
978-91-87651-89-2
language
English
LU publication?
yes
id
8646ced0-c58f-4b8d-a69d-a552010fc18c (old id 4448266)
date added to LUP
2014-05-27 09:47:17
date last changed
2016-09-19 08:44:46
@phdthesis{8646ced0-c58f-4b8d-a69d-a552010fc18c,
  abstract     = {Background: Thyroid surgery is the most common endocrine surgical operation and is considered by many to be at the zenith of endocrine surgery. A good hemostasis is mandatory during a thyroid operation and many new devices have been available during the last two decades. Total thyroidectomy, (TT) is now by many surgeons considered the method of choice when treating Graves´ disease (GD) and multinodular goitres (MNG) surgically. Hypocalcaemia is the most common adverse event after thyroid surgery and the reported frequency ranges from 4-55 %. It is difficult to identify and predict patients at risk for developing postoperative hypocalcaemia. Previously described risk factors for transient hypocalcaemia are extent of surgery, lymph node dissection, GD, bone hunger and the number of parathyroid glands identified peroperatively and parathyroid autotransplantation. <br/><br>
Aims: To compare two different operation techniques for patients with GD undergoing TT and the risk of hypocalcaemia after TT for patients with MNG and GD, respectively. To identify risk factors for postoperative hypocalcaemia after TT in patients with GD and to predict risk factors for permanent hypocalcaemia after TT. Methods: In Paper I we compared in a prospective randomised controlled trial, a conventional operation technique vs. ultracision (Harmonic Scalpel(HS)) when performing TT. In Paper II, we compared the risk for hypocalcaemia between patients with GD and MNG undergoing TT. In Paper III, data were extracted from the Scandinavian Quality Register for Thyroid and Parathyroid Surgery (SQRTP) and patients with GD undergoing TT during year 2004 – 2008 in 23 surgical departments in Sweden were studied. In Paper IV, risk factors of permanent hypoparathyroidism after TT from a prospective database at the same surgical department was analysed. <br/><br>
Results: 27 patients were randomised to the HS group and 24 patients to the conventional group (knot tying). Operation time was significantly shorter in the HS group (I). Patients with GD (n=129) were younger than patients with MNG (n=81). Symptoms of hypocalcaemia were more common in patients with GD but there were no other differences between the two groups (II). Risk factors for i.v. calcium after TT in patients with Graves´ disease were low hospital volume, operative time, university hospital and reoperation due to postoperative hematoma. Risk factors for treatment with vitamin D at discharge increased with operative time, weight of the specimen, parathyroid autotransplantation and reoperation. Risk factors for treatment with vitamin D at first follow up at 6 weeks were weight of the specimen, preoperative treatment with beta blockers. At 6 months follow up, risk factors for treatment with vitamin D were weight of the specimen and reoperation (III). There were 519 patients, median follow up (range) was 2.7 years (1.2 – 10.3). The rate of permanent hypoparathyroidism was 1.9 %. Parathyroid autotransplantation was performed in 90/519, 17.3 % and none of these developed permanent hypoparathyroidism, as did no patient with normal PTH level on day one postoperatively. <br/><br>
Conclusion: Patients with GD undergoing TT performed with Harmonic Scalpel® had a significantly shorter operation time, without an increased risk for complications. Patients with GD were younger and experienced more often symptoms of hypocalcaemia after TT compared to patients with goitres, but there were no biochemical differences. Risk factors for medically treated hypocalcaemia after TT in patients with Graves´ disease are multifactorial and vary over follow-up time. A low PTH level early after TT is associated with a high risk of permanent hypoparathyroidism. Normal levels of PTH postoperatively exclude long term hypoparathyroidism. Parathyroid autotransplantation seems to be warranted as a way of minimizing the risk of permanent hypoparathyroidism},
  author       = {Hallgrimsson, Palli},
  isbn         = {978-91-87651-89-2},
  issn         = {1652-8220},
  keyword      = {Total thyroidectomy,Graves´ disease,multinodular goitre,transient hypocalcaemia,permanent hypocalcaemia},
  language     = {eng},
  pages        = {125},
  publisher    = {Department of Surgery, Clinical Sciences Lund, Lund University},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral dissertation Series},
  title        = {Clinical problems in thyroid surgery},
  volume       = {2014:63},
  year         = {2014},
}