TİROİDEKTOMİ SONRASI REKURREN SİNİR FELCİ VE HİPOPARATİROİDİ GELİŞİMİNİ ETKİLEYEN FAKTÖRLER

Başlık: TİROİDEKTOMİ SONRASI REKURREN SİNİR FELCİ VE HİPOPARATİROİDİ GELİŞİMİNİ ETKİLEYEN FAKTÖRLER
Yazar: İsmail Borucu
Yazar-email:
Kurum: İSTANBUL ÜNİVERSİTESİ İSTANBUL TIP FAKÜLTESİ
Yil: 2008
Anahtar: thyroidectomy, recurrent laryngeal nerve palsy, hypoparathyroidism
Ozet: İyod eksikliği olan bölgelerde tiroid ameliyatları en sık yapılan ameliyatlardır. Ameliyat sonrasında görülen komplikasyonlardan başlıcaları rekküren laringeal sinir yaralanması ve hipoparatiroidzmdir. Tiroidektomi sonrasında gelişebilen rekurren sinir felci ve hipoparatiroidinin sıklığı ve risk faktörlerini araştırdık. Haziran 1990 ile Haziran 2007 tarihleri arasında değişik tiroid hastalıkları nedeniyle 3250 hastaya tiroidektomi uygulanmıştır. Rekurren sinir felci ve hipoparatiroidi oranları tiroid patolojisi, seçilen cerrahi girişime, sinir identifikasyonu olup olmamasına ve cerrahın tecrübesine bağlı olarak değerlendirilmiştir.
Sinir felci oranı 1.8% ve hipoparatiroidi oranı 6.6% olarak saptanmıştır. Radikal tiroidektomi ve tekrardan tiroid cerrahisi uygulanan hastalarda primer tiroid operasyonu ve konservativ tiroid cerrahisi uygulanan hastalara göre komplikasyon oranları daha yüksektir. Asistanlar tarafından gerçekleştirilen ameliyatlardan sonra ortaya çıkan ameliyat sonrası koplikasyonlar ile tecrübeli cerrahlarca yapılan ameliyat sonrasında görülen koplikasyonlar arasında anlamlı bir istatiksel fark bulunamamıştır. Varyans analiz yöntemine göre komplikasyon oluşumunu etkileyen faktörler seçilen cerrahi yöntem, ikincil girişim, sinir diseksiyonu ve hasta yaşıdır. Uzamış tiroidektomi ameliyatından sonra sinir felcinin meydana gelme riski 12 kat artar. Tekrar yapılan cerrahi girişim sonrasında hipoparatiroidizim meydana gelme riski 3 kat artar.
Hasta yaşı, seçilen cerrahi yöntem, ikincil cerrahi girişim, sinir diseksiyonu komplikasyon oranları üzerine önemli etkisi mevcuttur. Bunun yanında deneyimli gözetmenlerin denetiminde asistanlar güvenli şekilde tiroidektomi yapmakta ve komplikasyon oranları kabul edilebilir düzeydedir.
Kaynak: 1. Bellantone R, Lombardi CP, Bossola M, et al. Total thyroidectomy for management of benign thyroid disease: review of 526 cases. World J Surg. 2002;26:1468-71.
2. Giles Y, Boztepe H, Terzioglu T, et al. The advantage of total thyroidectomy to avoid reoperation for incidental thyroid cancer in multinodular goiter. Arch Surg. 2004;139(2):179-82.
3. Mishra A, Agarwal A, Agarwal G,et al. Total thyroidectomy for benign thyroid disorders in an endemic region. World J Surg. 2001;25(3):307-10.
4. Bergamaschi R, Becouarn G, Ronceray J, et al. Morbidity of thyroid surgery. Am. J. Surg.1998;176: 71-5.
5. Sturniolo G., D’Alia C., Tonante A., et al. The recurrent laryngeal nerve related to thyroid surgery. Am. J. Surg.1999;177:485-8.
6. Bhattacharyya N & Fried MP, Assessment of the morbidity and complications of
total thyroidectomy. Arch. Otolaryngol. Head. Neck. Surg.2002;128:389-92.
7. Misiolek M, Waler J, Namyslowski G, et al. Recurrent laryngeal nerve palsy after thyroid cancer surgery: a laryngological and surgical problem. Eur. Arch. Otorhinolaryngol. 2001; 258:460-2.
8. Thomusch O, Machens A, Sekulla C, et al. Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World. J. Surg. 2000; 24:1335-41.
9. Chiang FY, Wang LF, Huang YF, et al. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery.2005; 137: 342-7.
10. Rosato L, Avenia N, Bernante P, et al. Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World. J. Surg.2004; 28: 271-6.
11. Prim MP, de Diego JI, Hardisson D, et al. Factors related to nerve injury and hypocalcemia in thyroid gland surgery. Otolaryngol. Head. Neck. Surg. 2001;124:111-4.
12. Goncalves Filho J & Kowalski LP. Surgical complications after thyroid surgery
performed in a cancer hospital. Otolaryngol. Head. Neck. Surg. 2005;132:490-4.
13. Abboud B, Sargi Z, Akkam M, et al. Risk factors for postthyroidectomy
hypocalcemia. J. Am. Coll. Surg.2002;195: 456-61.
14. Prim MP, de Diego JI, Hardisson D, et al. Factors related to nerve injury and hypocalcemia in thyroid gland surgery. Otolaryngol. Head. Neck. Surg.2001; 124: 111-4.
15. Giddings AEB. The history of thyroidectomy. J R Soc Med 1998;91:(Suppl. 33)3-6
16. Rolleston HD. The Endocrine Organs in Health and Disease. Oxford: OUP, 1936:150
17. Welbourn RB. The thyroid. In: The History of Endocrine Surgery. New York: Praeger, 1990:19-27.
18. Clark T, Savı N. History, ontogeny and anatomy. Wener I (ed). The Thyoid. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2000. 1-5.
19. Sadler GP, Clark OH. Thyroid and parathyroid. Schwartz SI, ShiresGT,SpencerFC (ed). Principles of Surgery. 7th ed. New York: McGraw-Hill; 1999. 1661-1687.
20. Reed AF. Relations of inferior laryngeal nerve to inferior thyroid artery. Anatomical Record. 1943;85:17.
21. Cummings CW. Thyroid Anatomy. In: Otolaryngology – Head and Neck Surgery, 3rd ed. St. Louis, M0. Mosby;1998:2445-49.
22. Naidoo D. Boon JM. Mieny CJ. et al. Relation of the external branch of the superior laryngeal nerve to the superior pole of the thyroid gland: an anatomical study. Clinical Anatomy. 2007;20:516-20.
23. Williams PL. Thyroid Gland. In: Gray’s anatomy. New York, NY:. Churchill Livingstone;1995:1891-96.
24. Gravante G, Delogu D, Rizzello A, et al. The Zuckerkandl tubercle. Am J Surg. 2007;193:484-5.
25. Lengelé B, Hamoir M. Anatomy and embryology of the parathyroid glands. Acta Otorhinolaryngol Belg. 2001;55(2):89-93.
26. Sussi PL, Brazzarola P, Angeli G, et al. Complications of thyroidectomy: hemorrhage] Chir Ital. 1995;47(4):41-3
27. Calò PG, Farris S, Tatti A, et al. Emergencies in thyroid surgery. Our experience. Chir Ital. 2006 May-Jun;58(3):323-9.
28. Hickey L, Gordon CM. Vitamin D deficiency: new perpectives on an old disease. Curr Opin Endocrinol Metab 2004;11:18-25.
29. Heaney RP, Weaver CM. Calcium and vitamin D. Endocrinol Metab Clin North Am. 2003;32:181-94,
30. Heaney RP. Vitamin D, nutritional deficiency, and the medical paradigm. J. Clin Endocrinol Metab. 2003;88:5107-8.
31. Mättig H, Bildat D, Metzger B. Reducing the rate of recurrent nerve paralysis by routine exposure of the nerves in thyroid gland operations. Zentralbl Chir. 1998; 123: 17-20.
32. Karlan MS, Catz B, Dunkelman D, et al. A safe technique for thyroidectomy with complete nerve dissection and parathyroid preservation. Head and Neck Surg 1984; 6:1014-9.
33. Reed AF. The relations of the inferior laryngeal nerve to the inferior thyroid artery. Anatom Record 1943; 85: 17-3.
34. Sasou S, Nakamura S, Kurihara H. Suspensory ligament of Berry: Its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies. Head Neck 1998; 20: 695-8.
35. Nakhjavani M, Gharib H. Diffuse nontoxic and multinodular goiter. Curr Ther Endocrinol Metab. 1997;6:109-12.
36. Hegedus L, Bonnema SJ, Bennedbaek FN. Management of simple nodular goiter: current status and future perspectives. Endocr Rev. 2003;24:102-32.
37. DeGroot LJ. Treatment of multinodular goiter by surgery. J Endocrinol Invest. 2001;24:820-2.
38. Diehl LA, Garcia V, Bonnema SJ, et al; Latin American Throid Society. Management of the nontoxic multinodular goiter in Latin America: comparison with North America and Europe, an electronic survey. J Clin Endocrinol Metab. 2005;90:117-23.
39. Bonnema SJ, Bennedbaek FN, Ladenson PW,et al. Management of the nontoxic multinodular goiter: a North American survey. J Clin Endocrinol Metab. 2002;87:112-7.
40. Erbil Y, Barbaros U, Salmaslioğlu A, et al. The advantage of near-total thyroidectomy to avoid postoperative hypoparathyroidism in benign multinodular goiter. Langenbecks Arch Surg. 2006;391:567-73
41. Sakorafas GH, Stafyla V, Bramis C, et al Incidental parathyroidectomy during thyroid surgery: an underappreciated complication of thyroidectomy. World J Surg. 2005;29:1539-43.
42. Gourgiotis S, Moustafellos P, Dimopoulos N, et al. Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy. Langenbecks Arch Surg. 2006;391:557-60.
43. Sasson AR, Pingpank JF Jr, Wetherington RW, et al. Incidental parathyroidectomy during thyroid surgery does not cause transient symptomatic hypocalcemia. Arch Otolaryngol Head Neck Surg. 2001;127:304-8.
44. Lin DT, Patel SG, Shaha AR, et al. Incidence of inadvertent parathyroid removal during thyroidectomy. Laryngoscope. 2002;112:608-11.
45. Erbil Y, Barbaros U, Deveci U,at al.Gamma probe-guided surgery for revision thyroidectomy: in comparison with conventional technique.
J Endocrinol Invest.2005;28:583-8.
46. Rubello D, Salvatori M, Casara D, et al. 99mTc-sestamibi radio-guided surgery of loco-regional 131Iodine-negative recurrent thyroid cancer. Eur J Surg Oncol. 2007;33:902-6.
47. Reeve TS, Delbridge L, Brady P, et al. Secondary thyroidectomy: a twenty-year experience. World J Surg 1988;12:449–53.
48. Chao TC, Jeng LB, Lin JD, et al. Reoperative thyroid surgery. World J Surg 1997;21:644–7.
49. Tan MP, Agarwal G, Reeve TS, et al. Impact of timing on completion thyroidectomy for thyroid cancer. Br J Surg 2002;89: 802–4.
50. Lombardi CP, Raffaelli M, Princi P, et al. Early prediction of postthyroidectomy hypocalcemia by one single iPTH measurement. Surgery. 2004;136:1236-41.
51. Quiros RM, Pesce CE, Wilhelm SM, et al. Intraoperative parathyroid hormone levels in thyroid surgery are predictive of postoperative hypoparathyroidism and need for vitamin D supplementation. Am J Surg. 2005;189:306-9.
52. Uruno T, Miyauchi A, Shimizu K, et al. A prophylactic infusion of calcium solution reduces the risk of symptomatic hypocalcemia in patients after total thyroidectomy. World J Surg. 2006;30:304-8.
53. Lindblom P, Westerdahl J, Bergenfelz A. Low parathyroid hormone levels after thyroid surgery: a feasible predictor of hypocalcemia. Surgery. 2002;131:515-20.
54. Pattou F, Combemale F, Fabre S, et al. Hypocalcemia following thyroid surgery: incidence and prediction of outcome. World J Surg. 1998;22:718-24.
55. Gulluoglu BM, Manukyan MN, Cingi A, et al. Early prediction of normocalcemia after thyroid surgery. World J Surg. 2005;29:1288-93.
56. Tartaglia F, Giuliani A, Sgueglia M, et al. Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy. Am J Surg. 2005;190:424-9.
57. Bellantone R, Lombardi CP, Raffaelli M, et al. Is routine supplementation therapy (calcium and vitamin D) useful after total thyroidectomy? Surgery. 2002;132:1109-12
58. Erbil Y, Bozbora A, Ozbey N, et al. Predictive value of age and serum parathormone and vitamin d3 levels for postoperative hypocalcemia after total thyroidectomy for nontoxic multinodular goiter. Arch Surg. 2007;142:1182-7.