Thyroid Surgery Complications 101: What can go Wrong?
Everyone needs to know all that could happen to them if they think thyroid surgery is a minor procedure. A harmless micro-cancer needs the same hospitalization and recovery as any major operation. Complications from thyroid surgery:
1.Calcium problems: permanent parathyroid 1-3% or temporary 10-15%
2. Hypothyroid even with just single lobe alone.Also from a hemorrhage or hematoma 15-50%
3.Seroma: fluid buildup 1-6% with infection <2% May cause post op problems with needed intubation 5-8%
4.Softening of the trachea: Large goiters <6% 5.Keloid 6. Air in the chest Pneumothorax 7.Unequal pupils: Horner’s syndrome 8.Cut or knick the thorax duct :Fistula with milky lymph fluid 9.Thyroid storm: Poor pre-op preparation No SSKI or beta blockers 10.Injury to esophagus 11.One sided Nerve to your voice box injury: temporary or permanent 1-10% 12. Both nerves damaged = need a tracheostomy rare 13. Injury to superior nerve to voice box. 3-28% This is not counting hospital based cardiac problems, infections,anesthesia, and wrong medication errors, death on the table, morbidity with pain, suffering and post surgery fatigue and loss of work. An DDr.Guttler’s keys to diagnosis of C Cell Hyperplasia CCH 1. Not all elevation in calcitonin is due to C cell disease or MCT. 2. Smokers and women have higher basal calcitonin. 3. Drugs,other cancers and other diseases can increase calcitonin and some antibodies can cause a false elevation in calcitonin. 4.CCH is not a pre-malignant condition in the sporadic MCT case but is in familial MCT. Removal of the thyroid before the onset of MCT is the goal. 5. CCH may be difficult to tell from MCT requiring surgery. DR.Guttler’s keys to diagnosis treatment of rare medullary thyroid cancer MCT. 1. Nodules in the upper 1/3 of the thyroid where the C cells are located are at risk. During the FNA add a needle washout for calcitonin and a serum calcitonin. Cytology alone is only 50% effective in diagnosing MCT without calcitonin studies pre-op. 2. Beware that because it is rare pathologists can mistake them for Hurthle cell neoplasms because of oncocytic look and eccentric nuclei. Experience can tell the difference as the nuclei of MCT are extremely located in the cell and the nuclei are salt and pepper. This has been the down fall of at least two of my second opinions that missed the diagnosis and were sued after the patient died. 3. The use of doubling time for calcitonin and CEA has allowed the prognosis for long life or rather early death. 4. Short doubling time( 6-12 months) is associated with a bad prognosis and the need for frequent imaging studies. A longer doubling time ( 12-24 months)suggests a slower progression. 5. RET oncogene + cases have a more aggressive disease. 6. Many of my patients with slow doubling time have lived a relatively normal life on just thyroid replacement therapy alone. 7. Systemic therapy should be reserved for those with multiple sites with disease, unresectable local disease and clear progression. 8. 7% of sporadic MCT on RET testing have familial MCT. 9.Case finding of all relatives of the NCT patient with RET mutation. Dr.Guttler’s keys to clinical management of large invasive PTC with residual disease T4 stage. 1. This is not a case for the patient’s local physicians. 2. A team of specialists from multiple cancer areas found in places as MD Anderson,Mayo Clinic or Sloan Kettering is needed to plan the attack on this aggressive cancer. 3.Elderly patients may benefit from EBT or intensity modulated radiation IMRT may help local control. 4. I refer out these serious cases to the experts Dr.Guttler’s clinical keys when confronted with a Hurthle cell lesion 1.Most nodules with some Hurtle cells in large groups are found in nontoxic nodules, and Hashimoto’s thyroiditis.This is metaplasia not neoplasia, and is not in need of surgery to R/O Hurthle Cell carcinoma HCC. 2. Hurthle cell neoplasia has a single cell pattern and most still are benign, but need surgery to make sure. 3. Large HC neoplasms > 4 cm and in elderly patients is a red flag for HCC.
4. HCC are different than the usual follicular carcinoma FC as it can go to neck lymph nodes and soft tissue metastatic sites in addition to angioinvasion in FC.
5. 4 or more sites of invasion through the capsule is a strong indication this is an aggressive HCC.
6.Usual routine is remnant ablation followed by radiation therapy EBT or targeted chemotherapy.
DR Guttler’s clinical keys to the use of thyroid hormone TSH suppression therapy for thyroid cancer
1. T4 suppression therapy does not improve survival, in low risk Thyroid cancers.
2. It is beneficial in high risk patients for several years after surgery and RAI/131.
3.TSH targets for long term follow up depends on the severity of the disease.
4.Elderly are at risk of complications of suppression therapy. (Osteoporosis and atrial fibrillation.)
5. Calcium and bisphosphonates may help those needing TSH suppression.
6.Targeting sub-normal TSH 0.1 rather than complete suppression 45.
5. Thyroidectomy surgery during pregnancy is safe but usually best done in the middle trimester.
DR.Guttler’s clinical keys to diagnosis and treatment of a patient with recurrent lymph node involvement.
1. Endocrine Neck Ultrasound by an ECNU certified sonologist/endocrinologist is the best diagnostic test to find cancer lymph nodes.
2. Suspicious nodes should by biopsied, and in addition to cytology needle washout sample should be sent for thyroglobulin.
3. Additional thyroid specific gene mRNA can be collected and if positive is 100% diagnostic of cancer in
4. The first neck dissection is successful in 50-70 % but carries a increased risk of permanent complications.
5. After the recurrence in the 30-50% failures of the first neck dissection additional surgery may replaced by low cost out-patient ethanol ablation PEI which I do in my office unless the nodes have extranodal extension or there are an extensive number cancer nodes (> 3-4).
6. Further neck surgery such be limited to expert neck surgeons with vast experience in doing surgery in “dirty necks”. Dr.Gary Clayman has done my re-op necks with remarkable results. In one of my cases he did a re-op neck dissection on the recurrence in the lateral neck and thyroid bed on the side with the only functioning recurrent nerve! Another case had extensive biopsy proven disease in the whole lateral neck with many nodes with extra-nodal extension. After the surgery and EBT therapy she returned to me with nondetectable TG and her voice and parathyroid glands intact. He has move to Tampa from MD Anderson in Texas to found his own Thyroid Cancer Center. These cases are the job for the “Big Boys” not your local general surgeons.