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Total thyroidectomy in geriatric patients: A retrospective study
International Journal of Surgery xxx (2014) 1e4
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Total thyroidectomy in geriatric patients: A retrospective study F. Tartaglia*, G. Russo, M. Sgueglia, S. Blasi, G. Tortorelli, L. Tromba, D. Krizzuk, R. Merola Department of Surgical Sciences e “Sapienza” University of Rome, Rome, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 May 2014 Accepted 15 June 2014 Available online xxx
In the English literature there is no single definition that identifies elderly patients. In our retrospective study, we divided total thyroidectomized patients operated on from 2000 to 2010 in the Department of Surgical Sciences of the “Sapienza” University of Rome, in two groups: group 1 consists of 448 patients over 65 years and group 2 consists of 1275 patients under 65 years. We compared both groups in terms of indications for surgery, histological diagnoses, postoperative complications (laryngeal nerv palsy, hypocalcemia, bleeding and seroma) and mortality. The results showed no statistically significant differences between the two groups with respect to the type of surgical indication, the type of comorbidities, the incidence of postoperative complications and perioperative mortality. The only data discordant with those in the international literature was the incidence of neoplastic disease that is found to be slightly greater in group 2. In conclusion, total thyroidectomy in patients over 65 years is a safe procedure and is not burdened with a higher percentage of postoperative complications, even if requires a careful preoperative assessment of risk factors related to comorbidity. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Total thyroidectomy Elderly patients Complications in thyroid surgery
1. Introduction An exact definition of the geriatric patient doesn't exist in the medical literature. There are a lot of different age definitions: 60 years, 65 years and 75 years [1,2]. The prevalence of nodular thyroid conditions increases with age: almost 50% of patients >65 years demonstrates nodules on US examination with a similar prevalence among autopsies performed in the general population [3,4]. The thyroid tumors in elderly patients are usually more aggressive: anaplastic carcinoma presents almost exclusively after the age of 60 years and differentiated carcinomas are usually more aggressive after the age of 45 years [5]. Although age is not a contraindication for major surgery [6e11], few elderly patients receive programmed thyroid surgery due to the major risk of morbidity [9e14]. The aims of this retrospective study are to analyze the indications for thyroid surgery in patients aged >65 years and the surgical results with
List of abbreviations: ASA score, American Society of Anesthesiologists score; Cal0, plasma calcium levels measured before surgery; CalS, plasma calcium levels measured 6 months after surgery; DCal, CalS Cal0. * Corresponding author. Largo Pannonia 48, 00183 Rome, Italy. E-mail addresses: [email protected] (F. Tartaglia), giuliarusso84@ gmail.com (G. Russo), [email protected] (M. Sgueglia), sarabl2001@gmail. com (S. Blasi), [email protected] (G. Tortorelli), luciana.tromba@ uniroma1.it (L. Tromba), [email protected] (D. Krizzuk), [email protected] (R. Merola).
regard to mortality, remission of symptoms and post surgical complications.
2. Materials and method Between 2000 and 2010 thyroid surgery was performed in 1723 patients (1312 women ad 411 men) at the Department of Surgical Sciences of “Sapienza” University of Rome. Patients were divided into groups: Group 1, 448 patients over 65 years (26%) and Group 2, 1275 patients under 65 years (74%). Patients in group 1 were defined as geriatric patients. All patients underwent total thyrodectomy. We compared both groups in terms of indications for surgery, histological diagnoses, postoperative complications (laryngeal nerv palsy, hypocalcemia, bleeding and seroma) and mortality. At the time of surgical consultation all patients underwent a complete physical examination, laboratory examinations and assessment of surgical risk. The only absolute contraindication to surgery was the high ASA Score for general anesthesia in non neoplastic patients. Advanced age was not considered a contraindication for surgery. Vocal fold mobility was assessed and documented before surgery with indirect laryngoscopy; only patients with temporary or permanent true vocal folds paralysis underwent postoperative control using flexible fiber optic laryngoscopy. The major indications for surgery were: benign goiter and thyrotoxicosis, suspected or verified malignancy, mechanical symptoms due to large and often retrosternal goiter. Total thyroidectomy was
http://dx.doi.org/10.1016/j.ijsu.2014.08.386 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386
2
F. Tartaglia et al. / International Journal of Surgery xxx (2014) 1e4
Table 1 Causes of postoperative death in the two groups. Causes of death
Group 1 (>65)
Group 2 (<65)
Lung cancer GI cancer Ictus Heart attack Trauma Other causes TOT
2 1 3 4 e 1 11
1 2 1 5 2 1 12
performed according to the dictates of modern thyroid surgery, with the preparation of the inferior laryngeal nerves throughout their cervical course and research and preservation of the parathyroid glands [15]. All patients after thyroidectomy were placed on a prophylactic calcium supplementation regimen, consisting of oral calcium carbonate combined with vitamin D [16]. Plasma calcium levels were measured before surgery (Cal 0) and 6 months after surgery (Cal S); we introduce the new variable DCal ¼ Cal S Cal 0 using it to compare group 1 and 2. Phosphorus concentrations may be evaluated only after ruling out any concomitant causes of hyper-or hypophosphatemia that might invalidate the assessment
Table 2 Student's T test shows no statistical differences between the two groups in DCal values. The average values, the standard deviation and the significativity of the F test on variance shows a greater variability in group 1.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386
F. Tartaglia et al. / International Journal of Surgery xxx (2014) 1e4
[17]. The follow up was performed for almost three years with blood examinations every three months in the first year after the thyroidectomy and every year after the first. A complication was defined permanent as having more than 6 months duration.
3. Results The indication for surgery in group 1 was suspected or verified malignancy in 61 over 448 patients (18.37%). In group 2 neoplastic disease was present in 271 patients (21.25%). In group 1, 15.3% of patients showed no comorbidities. All other patients in group 1 showed one or more comorbidities. The most common comorbidity was hypertension followed by diabetes, coronary disease, cardiac arrhythmias, pulmonary diseases and neurologic diseases. Group 1 was also characterized by a greater presence of compressive symptoms than in group 2. In group 2 66.4% showed no comorbidities. The distribution of comorbidities in the remnant 33.6% of patients is superimposable to that found in group 1. Perioperative mortality was 0% in both groups. The mortality in group 1 was 2.45% (11 patients) and in group 2 was 0.94% (12 patients). All patients died for comorbidities not related to thyroid surgery (Table 1). Postoperative complications were: postoperative bleeding that occurs in 15 patients (3.34%) of group 1 and 19 patients (1.49%) in group 2; seroma that occurs in 14 patients (3.12%) in group 1 and 33 patients (2.58%) in group 2; postoperative recurrent laryngeal nerve palsy was observed in 18 patients (4.01%) in group 1 and in 50 patients (3.92%) in group 2. In group 1, 4 patients (0.89%) had permanent palsy; the permanent nerve palsy in group 2 was observed in 12 patients (0.94%). Concerning postoperative transient hypocalcaemia the percentage in group 1 and 2 was respectively 31.7% and 29.8%. There was not significant statistical difference in DCal (CalS Cal0) values in the two groups (p ¼ 0.57). The results regarding the evolution of clinical features were excellent. Symptoms due to thyrotoxicosis and compressive symptoms (with tracheal and/or esophageal involvement) showed immediate post surgical remission.
3
4. Discussion Thyroid surgery in elderly patients is usually reserved for cases with a strong suspicion of malignancy, thyrotoxicosis resistant to medical treatment or for compression symptoms, because complications are considered to be more frequent in patients older then 65 years. Passler et al. [12] and Miccoli [18] indicated surgery in elderly patients only when absolutely necessary. However recent studies shows that the increase in mortality with old age depends more on biological age then chronological age [11] and on the number of associated comorbidities [9,18e22]. Terraciano et al. demonstrated in patients older than 70 years, age was an independent risk factor for increased morbidity and mortality. The most common comorbidities of our patients were cardiovascular diseases as in Steinau [6] and Passler's [12] studies. An individual risk and benefit analysis and careful selection are essential in elective surgery especially in geriatric patients [10,19]. Recent studies have shown that thyroid surgery can be performed with low morbidity and mortality rates [12,23] even in elderly patients. Mortality in other studies is low: Miccoli [18] and Passler [12] report 0%; Har-El [22] reports 1.9% in elderly patients with thyroid carcinoma. We report a 2.45% postoperative mortality in group 1 but all the 11 patients died for comorbidities unrelated to thyroid surgery. Moreover also the mortality in group 2 was due to extra surgical causes, although it was significantly lower. The difference between the rates of postoperative complications in the two groups is not statistically significant in our study. Hematomas, seromas and transient recurrent nerve palsy had a higher incidence in our elderly population (respectively: hematomas 3.34% in group 1 vs 1.49% in group 2; seromas 3.12% in group 1 vs 2.58% in group 2 and nerve palsy 4.01% in group 1 vs 3.92% in group 2) like in Passler's and Rios' studies. Also concerning postoperative hypocalcaemia we don't have a statistically significant difference between the two groups both for transient and permanent hypocalcaemia that occurred in 3.65% in group 1 and 3.85% in group 2. Student's T Test shows no statistical differences between the two groups in DCal values (Table 2). The F test on the variance and the standard deviation calculated on the two groups showed a higher
Table 3 Repeated measures analysis of variance. The factors AGE and TIME don't affect the amount of DCal in the two groups.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386
4
F. Tartaglia et al. / International Journal of Surgery xxx (2014) 1e4
variability in regard of the value of DCal in group 1. Age (over or under 65) and time (time 0, time S) don't influence DCal value and so doesn't exist a difference also in the relation between age and time (Table 3). The only difference between our study and the literature is the percentage of malignancy in the two groups. In fact, while many Authors [4,12,24e30] show a higher incidence of carcinomas in elderly patients, we found a small higher incidence of malignant pathology in group 2 (21.25% vs 18.37) even if this difference is not statistically significant. 5. Conclusions Thyroidectomy in elderly patients is a quite safe surgical procedure showed a better morbidity and mortality rate when compared with other elective general operative procedures. The age alone in our experience is not a contraindication to surgery. The rate of postoperative complications in elderly patients doesn't differ from those detected in younger patients. However further studies are necessary to evaluate the real impact of age on post thyroidectomy morbidity. Ethical approval Ethical approval was requested and obtained from the “Azienda Universitaria Policlinico Umberto I” ethical committee. Funding All authors have no source of funding. Author contribution Francesco Tartaglia: Participated substantially in conception, design, and execution of the study, and in the analysis and interpretation of data; performed surgery; also participated substantially in the drafting and editing of the manuscript. Giulia Russo: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Monica Sgueglia: Collected data and implemented the database. Sara Blasi: Performed statistical analysis. Giovanni Tortorelli: Draft the manuscript. Luciana Tromba: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Dimitri Krizzuk: Performed clinical controls at 6 months from surgery. Raffaele Merola: Performed clinical controls in the perioperative period. Conflicts of interest
References [1] T. Lehnert, Surgery for local recurrence or distant metastases in patient aged 75 years or older, Eur. J. Surg. Oncol. 24 (1998) 418e422. [2] Colorectal Cancer Collaborative Group, Surgery for colorectal cancer in elderly patients: a systematic review, Lancet 356 (2000) 968e974. [3] M. Mekel, Thyroid surgery in octogenarians is associated with higher complications rates, Surgery 146 (2009) 913e921. [4] M.W. Seybt, Thyroidectomy safety of thyroid surgery in an aging population, Arch. Otolaryngol. Head Neck Surg. 135 (2009) 1041e1044. [5] A.R. Rolla, Thyroid nodules in the elderly, Clin. Geriatr. Med. 11 (1995) 259e269. [6] G. Steinau, Risikofaktoren, preoperative Liegezeiten und mortatitat bei gerontochirurgischen Eingriffen, Langenbecks Arch. Surg. 381 (1996) 228e231. [7] P.M. Lauven, Perioperative Morbiditat und Mortalitat geriatrischer patienten. Eine retrospective studie an 3905 fallen, Anasthesiol. Intensivther. Nottfallmed. 25 (Suppl. 1) (1990) 13e19. [8] L. Hannoun, A report of forty-four instances of pancreaticoduodenal resection in patients more than seventy years of age, Surg. Gynecol. Obstet. 177 (6) (1993 Dec) 556e560. [9] M.F. Lubin, Is age a risk factor for surgery, Med. Clin. N. Am. 77 (1993) 327e333. [10] N.J. Nusbaum, How do geriatric patients recover from surgery? South Med. J. 89 (1996) 950e957. [11] T. Lehnert, Special issue on cancer surgery in the elderly (editorial), Eur. J. Surg. Oncol. 24 (1998) 361. [12] C. Passler, Thyroid surgery in the geriatric patient, Arch. Surg. 137, 1243e1248. [13] O.P. Ryynanen, Doctors' willingness to refer elderly patients for elective surgery, Fam. Pract. 14, 216e219. [14] W.J. Simpson, Thyroid malignancy in the elderly, Geriatrics 37, 119e125. [15] F.P. Campana, M. Marchesi, M. Biffoni, F. Tartaglia, G. Nuccio, F. Stocco, M.O. Jaus, R. Nobili Benedetti, C. Faloci, T. Mastropietr, M. Millarelli, Total thyroidectomy technique: suggestions and proposals of surgical practice, Ann. It. Chir. 67 (5) (1996) 627e635. [16] F. Tartaglia, A. Giuliani, M. Sgueglia, F. Biancari, T. Juvonen, F.P. Campana, Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy, Am. J. Surg. 190 (3) (2005 Sep) 424e429. [17] F. Tartaglia, S. Minisola, M. Sgueglia, S. Blasi, D. Brunelli, E. Degli Effetti, A. Maturo, A. Cola, F. Custureri, F.P. Campana, Tumor-induced hypophosphatemic osteomalacia associated with tertiary hyperparathyroidism: a case report, Giorn. Chir. 27 (1e2) (2006) 9e13. [18] P. Miccoli, Thyroid surgery in patients aged over 80 years, Acta Chir. Belg. 94 (1994) 222e223. [19] D.H. Berger, Cancer surgery in the elderly, Clin. Geriatr. Med. 13 (1997) 119e141. [20] M. Rorbaek Madsen, General surgery in patients aged 80 years and older, Br. J. Surg. 79 (1992) 1216e1218. [21] L. Tiret, Complications associated with anaesthesia: a prospective survey in France, Can. Anaesth. Soc. J. 33 (1986) 336e344. [22] G. Har-El, Thyroid cancer in patients 70 years of age or older: retrospective study of 50 patients, Ann. Otol. Rhinol. Laryngol. 96 (1987) 403e410. [23] R. Bliss, Age is no contraindication to thyroid surgery, Age Ageing 28 (1999) 363e366. [24] B. Amato, R. Compagna, L. Sivero, A. Rocca, M. Donisi, Lymphectomy for elderly in thyroid surgery, Chirurgia (Turin) 26 (4) (2013) 303e306. [25] W. Melanie, Geriatric thyroidectomy, Arch. Oto Head Neck Surg. 135 (2009) 1041e1044. [26] G.C. Biliotti, Specific features of differentiated thyroid carcinoma in patients over 70 years of age, J. Surg. Oncol. 93 (2006) 194e198. [27] C. Rispoli, N. Rocco, L. Iannone, B. Amato, Developing guidelines in geriatric surgery: role of the grade system, BMC Geriatr. 9 (Suppl. 1) (2009) A99. [28] B. Amato, L. Sivero, G. Vigliotti, et al., Surgery for cancer in the elderly: state of the art, Chirurgia (Turin) 26 (4) (2013) 313e315. [29] R. Gervasi, Thyroid surgery in geriatric patients: a literature review, BMC Surg. 12 (Suppl. l) (2012) s16. [30] A. Rios, Surgical treatment for multinodular goiters in geriatric patients, Langenbecks Arch. Surg. 390 (2005) 236e242.
All authors have no conflict of interests.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Total thyroidectomy in geriatric patients: A retrospective study F. Tartaglia*, G. Russo, M. Sgueglia, S. Blasi, G. Tortorelli, L. Tromba, D. Krizzuk, R. Merola Department of Surgical Sciences e “Sapienza” University of Rome, Rome, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 May 2014 Accepted 15 June 2014 Available online xxx
In the English literature there is no single definition that identifies elderly patients. In our retrospective study, we divided total thyroidectomized patients operated on from 2000 to 2010 in the Department of Surgical Sciences of the “Sapienza” University of Rome, in two groups: group 1 consists of 448 patients over 65 years and group 2 consists of 1275 patients under 65 years. We compared both groups in terms of indications for surgery, histological diagnoses, postoperative complications (laryngeal nerv palsy, hypocalcemia, bleeding and seroma) and mortality. The results showed no statistically significant differences between the two groups with respect to the type of surgical indication, the type of comorbidities, the incidence of postoperative complications and perioperative mortality. The only data discordant with those in the international literature was the incidence of neoplastic disease that is found to be slightly greater in group 2. In conclusion, total thyroidectomy in patients over 65 years is a safe procedure and is not burdened with a higher percentage of postoperative complications, even if requires a careful preoperative assessment of risk factors related to comorbidity. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Total thyroidectomy Elderly patients Complications in thyroid surgery
1. Introduction An exact definition of the geriatric patient doesn't exist in the medical literature. There are a lot of different age definitions: 60 years, 65 years and 75 years [1,2]. The prevalence of nodular thyroid conditions increases with age: almost 50% of patients >65 years demonstrates nodules on US examination with a similar prevalence among autopsies performed in the general population [3,4]. The thyroid tumors in elderly patients are usually more aggressive: anaplastic carcinoma presents almost exclusively after the age of 60 years and differentiated carcinomas are usually more aggressive after the age of 45 years [5]. Although age is not a contraindication for major surgery [6e11], few elderly patients receive programmed thyroid surgery due to the major risk of morbidity [9e14]. The aims of this retrospective study are to analyze the indications for thyroid surgery in patients aged >65 years and the surgical results with
List of abbreviations: ASA score, American Society of Anesthesiologists score; Cal0, plasma calcium levels measured before surgery; CalS, plasma calcium levels measured 6 months after surgery; DCal, CalS Cal0. * Corresponding author. Largo Pannonia 48, 00183 Rome, Italy. E-mail addresses: [email protected] (F. Tartaglia), giuliarusso84@ gmail.com (G. Russo), [email protected] (M. Sgueglia), sarabl2001@gmail. com (S. Blasi), [email protected] (G. Tortorelli), luciana.tromba@ uniroma1.it (L. Tromba), [email protected] (D. Krizzuk), [email protected] (R. Merola).
regard to mortality, remission of symptoms and post surgical complications.
2. Materials and method Between 2000 and 2010 thyroid surgery was performed in 1723 patients (1312 women ad 411 men) at the Department of Surgical Sciences of “Sapienza” University of Rome. Patients were divided into groups: Group 1, 448 patients over 65 years (26%) and Group 2, 1275 patients under 65 years (74%). Patients in group 1 were defined as geriatric patients. All patients underwent total thyrodectomy. We compared both groups in terms of indications for surgery, histological diagnoses, postoperative complications (laryngeal nerv palsy, hypocalcemia, bleeding and seroma) and mortality. At the time of surgical consultation all patients underwent a complete physical examination, laboratory examinations and assessment of surgical risk. The only absolute contraindication to surgery was the high ASA Score for general anesthesia in non neoplastic patients. Advanced age was not considered a contraindication for surgery. Vocal fold mobility was assessed and documented before surgery with indirect laryngoscopy; only patients with temporary or permanent true vocal folds paralysis underwent postoperative control using flexible fiber optic laryngoscopy. The major indications for surgery were: benign goiter and thyrotoxicosis, suspected or verified malignancy, mechanical symptoms due to large and often retrosternal goiter. Total thyroidectomy was
http://dx.doi.org/10.1016/j.ijsu.2014.08.386 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386
2
F. Tartaglia et al. / International Journal of Surgery xxx (2014) 1e4
Table 1 Causes of postoperative death in the two groups. Causes of death
Group 1 (>65)
Group 2 (<65)
Lung cancer GI cancer Ictus Heart attack Trauma Other causes TOT
2 1 3 4 e 1 11
1 2 1 5 2 1 12
performed according to the dictates of modern thyroid surgery, with the preparation of the inferior laryngeal nerves throughout their cervical course and research and preservation of the parathyroid glands [15]. All patients after thyroidectomy were placed on a prophylactic calcium supplementation regimen, consisting of oral calcium carbonate combined with vitamin D [16]. Plasma calcium levels were measured before surgery (Cal 0) and 6 months after surgery (Cal S); we introduce the new variable DCal ¼ Cal S Cal 0 using it to compare group 1 and 2. Phosphorus concentrations may be evaluated only after ruling out any concomitant causes of hyper-or hypophosphatemia that might invalidate the assessment
Table 2 Student's T test shows no statistical differences between the two groups in DCal values. The average values, the standard deviation and the significativity of the F test on variance shows a greater variability in group 1.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386
F. Tartaglia et al. / International Journal of Surgery xxx (2014) 1e4
[17]. The follow up was performed for almost three years with blood examinations every three months in the first year after the thyroidectomy and every year after the first. A complication was defined permanent as having more than 6 months duration.
3. Results The indication for surgery in group 1 was suspected or verified malignancy in 61 over 448 patients (18.37%). In group 2 neoplastic disease was present in 271 patients (21.25%). In group 1, 15.3% of patients showed no comorbidities. All other patients in group 1 showed one or more comorbidities. The most common comorbidity was hypertension followed by diabetes, coronary disease, cardiac arrhythmias, pulmonary diseases and neurologic diseases. Group 1 was also characterized by a greater presence of compressive symptoms than in group 2. In group 2 66.4% showed no comorbidities. The distribution of comorbidities in the remnant 33.6% of patients is superimposable to that found in group 1. Perioperative mortality was 0% in both groups. The mortality in group 1 was 2.45% (11 patients) and in group 2 was 0.94% (12 patients). All patients died for comorbidities not related to thyroid surgery (Table 1). Postoperative complications were: postoperative bleeding that occurs in 15 patients (3.34%) of group 1 and 19 patients (1.49%) in group 2; seroma that occurs in 14 patients (3.12%) in group 1 and 33 patients (2.58%) in group 2; postoperative recurrent laryngeal nerve palsy was observed in 18 patients (4.01%) in group 1 and in 50 patients (3.92%) in group 2. In group 1, 4 patients (0.89%) had permanent palsy; the permanent nerve palsy in group 2 was observed in 12 patients (0.94%). Concerning postoperative transient hypocalcaemia the percentage in group 1 and 2 was respectively 31.7% and 29.8%. There was not significant statistical difference in DCal (CalS Cal0) values in the two groups (p ¼ 0.57). The results regarding the evolution of clinical features were excellent. Symptoms due to thyrotoxicosis and compressive symptoms (with tracheal and/or esophageal involvement) showed immediate post surgical remission.
3
4. Discussion Thyroid surgery in elderly patients is usually reserved for cases with a strong suspicion of malignancy, thyrotoxicosis resistant to medical treatment or for compression symptoms, because complications are considered to be more frequent in patients older then 65 years. Passler et al. [12] and Miccoli [18] indicated surgery in elderly patients only when absolutely necessary. However recent studies shows that the increase in mortality with old age depends more on biological age then chronological age [11] and on the number of associated comorbidities [9,18e22]. Terraciano et al. demonstrated in patients older than 70 years, age was an independent risk factor for increased morbidity and mortality. The most common comorbidities of our patients were cardiovascular diseases as in Steinau [6] and Passler's [12] studies. An individual risk and benefit analysis and careful selection are essential in elective surgery especially in geriatric patients [10,19]. Recent studies have shown that thyroid surgery can be performed with low morbidity and mortality rates [12,23] even in elderly patients. Mortality in other studies is low: Miccoli [18] and Passler [12] report 0%; Har-El [22] reports 1.9% in elderly patients with thyroid carcinoma. We report a 2.45% postoperative mortality in group 1 but all the 11 patients died for comorbidities unrelated to thyroid surgery. Moreover also the mortality in group 2 was due to extra surgical causes, although it was significantly lower. The difference between the rates of postoperative complications in the two groups is not statistically significant in our study. Hematomas, seromas and transient recurrent nerve palsy had a higher incidence in our elderly population (respectively: hematomas 3.34% in group 1 vs 1.49% in group 2; seromas 3.12% in group 1 vs 2.58% in group 2 and nerve palsy 4.01% in group 1 vs 3.92% in group 2) like in Passler's and Rios' studies. Also concerning postoperative hypocalcaemia we don't have a statistically significant difference between the two groups both for transient and permanent hypocalcaemia that occurred in 3.65% in group 1 and 3.85% in group 2. Student's T Test shows no statistical differences between the two groups in DCal values (Table 2). The F test on the variance and the standard deviation calculated on the two groups showed a higher
Table 3 Repeated measures analysis of variance. The factors AGE and TIME don't affect the amount of DCal in the two groups.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386
4
F. Tartaglia et al. / International Journal of Surgery xxx (2014) 1e4
variability in regard of the value of DCal in group 1. Age (over or under 65) and time (time 0, time S) don't influence DCal value and so doesn't exist a difference also in the relation between age and time (Table 3). The only difference between our study and the literature is the percentage of malignancy in the two groups. In fact, while many Authors [4,12,24e30] show a higher incidence of carcinomas in elderly patients, we found a small higher incidence of malignant pathology in group 2 (21.25% vs 18.37) even if this difference is not statistically significant. 5. Conclusions Thyroidectomy in elderly patients is a quite safe surgical procedure showed a better morbidity and mortality rate when compared with other elective general operative procedures. The age alone in our experience is not a contraindication to surgery. The rate of postoperative complications in elderly patients doesn't differ from those detected in younger patients. However further studies are necessary to evaluate the real impact of age on post thyroidectomy morbidity. Ethical approval Ethical approval was requested and obtained from the “Azienda Universitaria Policlinico Umberto I” ethical committee. Funding All authors have no source of funding. Author contribution Francesco Tartaglia: Participated substantially in conception, design, and execution of the study, and in the analysis and interpretation of data; performed surgery; also participated substantially in the drafting and editing of the manuscript. Giulia Russo: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Monica Sgueglia: Collected data and implemented the database. Sara Blasi: Performed statistical analysis. Giovanni Tortorelli: Draft the manuscript. Luciana Tromba: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Dimitri Krizzuk: Performed clinical controls at 6 months from surgery. Raffaele Merola: Performed clinical controls in the perioperative period. Conflicts of interest
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All authors have no conflict of interests.
Please cite this article in press as: F. Tartaglia, et al., Total thyroidectomy in geriatric patients: A retrospective study, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.386