THYROID AND PARATHYROID DISEASES: DIAGNOSIS, TREATMENT AND SURGERY WITH CURRENT APPROACHES

thyroid_and_parathyroid_diseasesnevinsakoglukapak1-0-25

POST-SURGICAL MANAGEMENT AND COMPLICATIONS

Bülent Özçetin

Bursa Yüksek İhtisas Training and Research Hospital, Department of General Surgery, Bursa, Türkiye

Özçetin B. Post-Surgical Management and Complications. Kesici U, ed. Thyroid and Parathyroid Diseases: Diagnosis, Treatment and Surgery with Current Approaches. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.119-133.

ABSTRACT

Since the mid-20th century, developments in medical practices have made thyroid surgeries common and extremely safe procedures. The most frequent complications after thyroid surgery include hypo- thyroidism, hypoparathyroidism, recurrent and superior laryngeal nerve injuries, and postoperative he- matoma. Rare but serious complications include tracheomalacia, laryngeal edema and spasm, thoracic duct injury, laryngeal and esophageal injuries, and skin scarring. Hypothyroidism is almost inevitable in near-total and total thyroidectomies. The diagnosis is made through biochemical tests of serum TSH and serum Ft4, along with the recognition of hypothyroid symptoms and signs. Treatment is based on the use of levothyroxine, the primary preparation. During thyroidectomy, parathyroid glands may be damaged due to stretching, traction, or thermal instrument usage. Intentional or accidental excision or devascularization of the glands may also lead to postoperative hypoparathyroidism. As a result, serum calcium levels drop, and serum phosphate levels rise. Hypocalcemia presents with symptoms ranging from muscle twitching to seizures and cardiac conduction issues due to increased neural sensitivity. Symptoms of hypocalcemia and serum calcium levels below the reference range after thyroidectomy are crucial for diagnosis. If the accidental removal of a parathyroid gland is noticed during surgery, the gland should be fragmented and reimplanted. Postoperative hypoparathyroidism treatment involves calcium and vitamin D supplements, aiming to maintain serum calcium levels at or just below the lower reference limit. Damage to the external branch of the superior laryngeal nerve can cause an inability to reach high-pitched notes and impaired voice quality. Without concurrent recurrent nerve in- jury, significant hoarseness or asphyxiation does not occur. Maintaining close proximity to the thyroid capsule during surgery is critical for nerve preservation. Voice therapy is the current treatment method for nerve injury. Recurrent laryngeal nerve (RLN) injury, another complication affecting quality of life after thyroidectomy, causes vocal cord paralysis on the affected side. Unilateral nerve damage leads to hoarseness and microaspiration, while bilateral paralysis can cause asphyxiation, posing a life-threat- ening risk. Identifying and fully exposing the nerve during surgery is the most crucial factor in prevent- ing injury. Intraoperative nerve monitoring (IONM) is highly beneficial as an adjunct. If nerve injury is detected during surgery, neurography and nerve implants may be used. Late interventions include laryngeal procedures to reduce medial compression and improve glottal widening. Tracheomalacia, which occurs in the presence of large and retrosternal goiters, refers to the narrowing of the tracheal lu- men by more than 50% due to a loss of tracheal tone. Treatment options include prolonged intubation, internal and external stenting, and tracheostomy. Postoperative hemorrhage, which develops within the first 24 hours, is a life-threatening complication requiring urgent intervention. If necessary, bedside intervention may be performed. The removal of the previously unremoved contralateral thyroid lobe is called complementary thyroidectomy, while the removal of residual or recurrent tissue is referred to as revision thyroidectomy. Revision procedures are more challenging than primary surgeries, with higher risks of parathyroid, recurrent nerve, and surrounding organ injuries.

Keywords: Intraoperative complications; Hipokalsemi; Trakeomalezi

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