Guidelines for complications after thyroid surgery: pitfalls in diagnosis and advices for continuous quality improvement
Background: There are four major complications after thyroidectomy, including palsy of the recurrent laryngeal nerve (RLN), hypoparathyroidism, postoperative bleeding, and surgical site infection (SSI). Another clinical problem is the injury and palsy of the external branch of the superior laryngeal nerve (EBSLN). We present a 1-year analysis of our prospective data on complications and outline our guidelines for follow-up and management, including quality assessment.
Methods: We prospectively analyzed 1,384 thyroid operations. Vocal fold/RLN function was determined routinely before surgery and on postoperative day 1 or 2 by laryngoscopy and/or stroboscopy. Postoperative hypoparathyroidism was defined as hypocalcemia in conjunction with low or low-normal parathormone levels or symptoms. Postoperative bleeding was specified as bleeding after wound closure that required reoperation. SSI was classified according to the Centers for Disease Control and Prevention. Palsy of the EBSLN was not determinable. Permanent impairment was defined if the complication persisted for more than 6 months.
Results: Postoperative palsy of the RLN occurred in 96 of 2,458 nerves-at-risk (3.9 %), of which 78 % fully recovered. The overall incidence of permanent palsy was 0.7 % per nerve-at-risk and highly dependent on the surgeon (range: 0–3.2 %, p < 0.001). Postoperative hypoparathyroidism was diagnosed in 487 patients (35.2 %), of whom full recovery was noted in 93.0 %. There were 26 postoperative bleedings (1.9 %) requiring reoperation. Three patients (0.2 %) developed superficial SSI with Staphylococcus aureus after a postoperative interval of 2, 6, and 7 days, respectively.
Conclusions: Our definitions and diagnostic and therapeutic approaches are presented and should be a proposal for standardization. Standardization will facilitate benchmarking and comparison of complication rates and surgical techniques among surgeons and institutions. An interdisciplinary team is necessary for quality control. Only continuous quality improvement of the individual surgeon will ultimately improve quality of a surgical department.