RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA BANGALORE.
SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. Name of the candidate and address( in block letters). / DR.CHANDRASHEKARA B G
S/o B G GURUVAIAH
SECOND CROSS BHOVI COLONY
NEHRU NAGAR
MANDYA-571401
Ph No-9964071612
2. Name of the Institution. / BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE.
3. Course of study and subject. / M.S. DEGREE IN GENERAL SURGERY.
4. Date of Admission to the course. / 3rd MAY 2010
5. Title of Dissertation. / “A CLINICAL STUDY OF POSTOPERATIVE COMPLICATIONS OF THYROIDECTOMY”
6 . BRIEF RESUME OF THE INTENDED WORK
6.1) NEED FOR THE STUDY:
Numerous complications may arise following surgical removal of the thyroid gland. These problems often result from either the surgical technique or from metabolic disturbances. Although the incidence of these complications is low, some problems are seen more frequently than others.
Primary complications associated with thyroid surgeries include recurrent laryngeal nerve injury, parathyroid deficiency, postoperative bleeding and respiratory distress. Problems less frequently seen are infection and sympathetic nerve injury. While prevention of these complications is a primary goal during thyroid surgery, early recognition and management by the surgeon is essential for the safe recovery of the patient.1-3
Since large number of thyroidectomy surgeries done in Victoria hospital and Bowring
Lady Curzon Hospitals, hence attempt has been made to analyze the various
postoperative complications, risk factors and management of postoperative complications
of thyroidectomy.
6.2) REVIEW OF LITERATURE:
One of the first anatomical descriptions of the thyroid was made by Professor Giulio Casserio of Padua in 1601, who thought that it consisted of one or two glands at the root of the larynx which he called the 'glands of the larynx'. Fabricius ab Aquapendente in 1620 recognized that a goitre was swelling of the glands.1
The leading thyroid surgeons at the second half of the nineteenth century were Theodor Kocher of Berne, a scholarly and meticulous surgeon and Theodor Billroth of Vienna, a great extrovert and fast operator. Both European Surgeons performed thousands of
thyroidectomies with progressively better results.1
Theodor Kocher who is regarded as the “Father of thyroid surgery”. He performed this operation in the late 1800s over 2000 times with only a 4.5% mortality. Kocher opened the neck through a vertical skin incision but later changed to the transverse collar incision, which is usually associated with his name. For his pioneering efforts in the field of thyroid surgery, he received the Nobel prize in 1909.2
Kocher was able to reduce his mortality rate to 12.8% in 101 thyroid operations during the first 10 years at Berne. By 1889, 250 additional cases were reported with a mortality rate of 2.4%.3
Complications will occur infrequently if the surgeon is fully knowledgeable about the anatomy of the thyroid gland and its adjacent organs. The nervous, vascular, and other structures met in performing a thyroidectomy must be identified and preserved to avoid complications both during operation and after the wound has been closed.4
Bleeding during operation when the thyroid gland is exposed does not constitute a serious problem to the experienced surgeon; but haemorrhage following operation can occur in almost any patient, especially in those with toxic goitre, and can be disastrous because the hematoma develops within the confines of the deep cervical fascia.5
The major advantage of thyroidectomy in thyrotoxicosis is the rapid reversal of the thyrotoxic state, which permits the patient to be quickly rehabilitated. It also appears that postoperative hypothyroidism is both initially and progressively lower than that of radioactive iodine therapy as it is usually given. The disadvantages include the stress of an operation, the risk of a general anaesthetic, a greater expense than the other forms of therapy, possible cosmetic difficulties, and finally, the risk of potential complications of operation, especially vocal cord paralysis and hypoparathyroidism.6
Total or near-total thyroidectomy is the treatment of choice for patients with multi nodular goitre and/or thyroid carcinoma. While in patients with solitary thyroid nodule hemithyroidectomy is performed.7
The most important complications are post-procedure hypocalcaemia secondary to devascularization of the parathyroid and significant hoarseness caused by recurrent laryngeal nerve injury induced by either traction or division.8
The RLN is most vulnerable to injury during the last 2 to 3 cm of its course. Approximately 20% of patients are at risk of injury to the external branches of the superior laryngeal nerve, especially if superior pole vessels are ligated en masse.9
Tension hematoma deep to the cervical fascia is usually due to slipping of a ligature on the superior thyroid artery; occasionally hemorrhage from a thyroid remnant or a thyroid vein may be responsible.10
6.3) AIMS AND OBJECTIVES OF STUDY:
1. To study and analyze various postoperative complications of different types of thyroidectomy.
2. To analyze the various causes for postoperative complications of thyroidectomy.
3. Management of postoperative complications of thyroidectomy.
7. MATERIALS AND METHODS:
7.1) SOURCE OF DATA-
Patients admitted in Victoria hospital and Bowring & Lady Curzon hospital attached to Bangalore Medical College and research institute from November 2010 to October 2012, a minimum of 100 cases.
7.2) METHOD OF COLLECTION OF DATA-
After admission data to be collected regarding clinical history, examination, diagnostic investigations, operative procedure and postoperative complications of thyroidectomy.
Prospective study of postoperative follow up will be done to note the complications both
in hospital and after discharge for one year of follow up.
INCLUSION CRITERIA:
1. Patients more than 18 years of age and of both
sex.
2. No previous thyroid surgery.
3. No associated parathyroid pathology.
4. Minimum follow-up of one year.
EXCLUSION CRITERIA:
1. Patients with age less than 18 years.
2. Patients who are not willing to participate in the
study.
3. Patients with previous thyroid surgery.
4. Patients with parathyroid pathology.
7.3) Duration of study: Two years.
7.4) Statistical method in analysis of data: All the data will be tabulated, graphical analysis will be made and statistical analysis in the form of ratios and
percentages will be done.
7.5) Does the study require any investigation or intervention to be conducted on patient or other humans or animals? If so please describe briefly.
A. It does not require any intervention on animals.
B. Investigations of patients with their consent:
1. Routine investigations:
a. Hematological : Hemoglobin, TLC, Differential count, ESR.
b. Renal Parameters: Blood urea , Serum creatinine.
c. Thyroid function test.
d. Serum calcium levels.
e. Serum electrolytes.
f. Blood sugars.
g. FNAC.
i. Laryngoscopy.
2. Special investigations (when required):
a. Ultrasonography of neck, Chest X-Ray and cervical X-Ray.
b. Radio iodine uptake and bone scan.
c. Cervical CT scan.
7.6) Has ethical clearance been obtained from your institution in case of
7.5?
YES
8. LIST OF REFERANCES:
1. Beaugie John M, Principles of Thyroid Surgery,Kent; Pitman, 9th Medical publishing company Ltd, 2005: Page no 221.
2. Geeta Lal, Orlo H Clark, "Thyroid and parathyroid". Seymour I, Schwartz Principles of Surgery 8th edition, McGraw-Hill, 2005: Page no 1395-1470.
3. Donald P, Vrabec. “Historical perspectives in thyroid surgeries”. Pellitte PK, Mc Cafferey TV. Delmar Endocrine surgery of the head and neck 9th edition ,Thomson learning Inc, 2003: page no 1-13.
4. Hardy JD. “Complications of thyroid and parathyroid surgery”. In CP Artz and J D Hardy’s Management of Surgical Complications, W B Saunders Company, Philadelphia, London, Toronto 2006: page no 291-308.
5. Aidonopoulos A, Dokmetzioglou I, Gamvros O, Papavramidis S, Doulgerakis M, Deligiannidis N, Vogiatzis I. Complications of thyroidectomy , Surgical Chronicles 1996, volume 1,page no 216-23.
6. Aidonopoulos A. Thyroidology – What is new? Surgical Chronicles 2000,volume 5,page no 145-148.
7. Aidonopoulos A, Gamvros O, Dokmetzioglou I, et al. Observations and comments on 3434 thyroidectomy surgeries. Surgical Chronicles 2005,volume 2,page no 13-19.
8. John B. Hanks, MD, and Leslie J. Salomone, MD.,” Thyroid”. Townsend, Beauchamp, Evers, Matlox Sabiston Textbook of Surgery 18th edition, Elsevier , 2008:volume 1, Page no951-952.
9. Geeta Lal, Orlo H Clark., "Thyroid, parathyroid and adrenal". Seymour I, Schwartz Principles of Surgery 9th edition, McGraw-Hill, 2010: Page no 1372-1374.
10. Zugmunt H, Krukowski.,” The Thyroid gland and the Thyroglossal tract”, Bailey and Love’s Short practice of Surgery 25th edition, Arnold international, 2008: Page no790-792.
9. Signature of the candidate:
DR CHANDRASHEKARA B G
Postgraduate student in MS General Surgery
Bangalore medical college and research institute.
10. Remarks of the guide:
Even though complications following thyroid surgery are less common still when they do occur can cause significant morbidity. Hence a study of the same is helpful to avoid the complications.
11. Name and Designation of Guide (in Block letters):
11.1) GUIDE:
DR K ZIAULLA SHARIFF
PROFESSOR OF SURGERY
BOWRING AND LADY CURZON HOSPITAL
BANGALORE MEDICAL COLLEGE AND
RESEARCH INSTITUTE
BANGALORE.
11.2) Signature & Seal:
11.3) Remarks of the Head of the Department:
11.4) Head of Department:
DR B S SHIVASWAMY
PROFESSOR & HOD OF SURGERY
BANGALORE MEDICAL COLLEGE AND
RESEARCH INSTITUTE
BANGALORE.
11.5) Signature & Seal:
12) Remarks of the Dean cum Director:
12.1) Dean cum Director:
DR G T SUBHAS
DEAN CUM DIRECTOR
BANGALORE MEDICAL COLLEGE AND
RESEARCH INSTITUTE
BANGALORE.
12.2) Signature & Seal:
PROFORMA
Case No : IP No. :
Name : Ward No. :
Age : Hospital :
Sex : Unit :
Occupation : D.O.A. :
Address : D.O.S. :
D.O.D. :
CLINICAL DIAGNOSIS :
I. PRESENTING COMPLAINTS
a) Swelling in front of neck
b) Pressure symptoms
c) Symptoms of thyrotoxicosis or hypothyroidism
d) Other symptoms
II. HISTORY OF PRESENT ILLNESS:
a) Swelling in front of neck :
- Duration
- Site
- Size
- Onset
- Progression
- Associated pain or discomfort
b) Pressure Symptoms:
- Dyspnoea
- Dysphagia
- Hoarsness of voice
- Voice fatigue
c) Symptom s of thyrotoxi cosi s or hy pothy roi di sm
- Anxiety
- Fear
- Palpitation
- Precordial pain
- Tremors - Fingers/Tongue
- Sweating - Increased/Decreased
- Weight - Increased/Decreased
- Appetite - Increased/Decreased
- Preference to heat/cold
97
- Diarrhoea/constipation
- Exhaustion or strain
- Lethargy
- Loss of hair
- Skin changes
- Behavioral changes
d) Other symptoms
- Haemoptysis
- Bony pain
- Persistent headache
III. PAST HISTORY
Irradiation to head and neck in childhood
IV. FAMILY HISTORY
V. PERSONAL HISTORY
· Diet
· Appetite
· Sleep
· Bowel and bladder habits
VI. MENSTRUAL HISTORY
Flow ______days
Menoorhagia / amenorrhoea, oligomenorrhea
VII. TREATMENT HISTORY
VIII. GENERAL PHYSICAL EXAMINATION :
Pallor Icterus Cyanosis
Clubbing Lymphadenopathy Oedema
Vital signs :
Pulse ______Rate Rhythm, Tensio n, Volume, Character
BP ______mm of Hg
Respiratory rate ______cycles / min
Temperature
98
IX. LOCAL EXAMINATION :
1) Inspection
a) Situation
b) Size
c) Shape
d) Extent
e) Surface
f) Borders
g) Movement with deglutition
h) Skin over the swelling – Colour, scar, sinuses
Fungation
Ulceration
i) Visible pulsation
j) Visible veins
k) Surrounding area
l) Any secondary changes
2. PALPATION:
a) Local rise of temperature
b) Tenderness
c) Site
d) Shape
e) Extent
f) Surface
g) Borders
h) Consistency
i) Mobility
j) Plane of the swelling
k) Thrill
l) Carotid pulsation
m) Position of the trachea
3. PERCUSSION : Sternum - Dull / Resonant
4. AUSCULTATION :
5. MEASUREMENT :
6. TOXIC SIGNS : Toxic eye signs-
- Fine tremors in fingers/tongue
--
Moist skin
99
X SYSTEMIC EXAMINATION:
1) RESPIRATORY SYSTEM
2) CARDIO-VASCULAR SYSTEM
3) PER ABDOMINAL EXAMINATION
4) CENTRAL NERVOUS SYSTEM AND REFLEXES
XI. CLINICAL DIAGNOSIS :
XII. INVESTIGATIONS :
1) ROUTINE - Hb% TCDC:
ESR
Urine : Sugar : Albumin:
Microscopy :
- Blood urea
- Serum creatinine
- Fasting blood sugar
- Blood grouping & typing
- Serum cholesterol
2) SPEICAL - Sleeping pulse rate
- ECG
- X-ray chest
- X- ray neck AP & Lat. views
- FNAC
- Indirect laryngoscopy
- Serum T3,T4 & TSH estimation
- Others
XIII. TREATMENT
1) Medical line of treatment
2) Surgical line of treatment
XIV. HISTOPATHOLOGICAL DIAGNOSIS :
XV. POST-OPERATIVE FOLLOW-UP