Higher complication rates seen after thyroid surgery in elderly patients

Issue: October 2008

79th Annual Meeting of the ATA

CHICAGO — Patients aged 80 years or older underwent successful thyroid surgery but with significantly higher morbidity in a trial presented at the 79th Annual Meeting of the American Thyroid Association.

“Male gender, cardio comorbidity, respiratory comorbidity and number of comorbidities were significantly correlated with increased risk for complications in octogenarian patients,” Michal Mekel, MD, endocrine surgery research fellow at Massachusetts General Hospital in Boston, said during a presentation.

“Male gender and respiratory comorbidities were independent risk factors for the development of complications in patients over the age of 80,” she said.

The researchers reviewed the records of patients aged 80 years and older who underwent thyroid surgery between July 2001 and October 2007 (n=90) and compared them to randomly selected patients aged 18 years to 79 years who underwent thyroid surgery during the same time period (n=242).

Patients aged 80 years and older had a 28.9% rate of malignancy on final pathology vs. those aged younger than 80 years (35.1%). The overall complication rate was 23.3% in those aged 80 years and older compared with the group aged 18 to 79 years (9.1%; P<.0001).

Complications unique to patients aged 80 years and older included atrial fibrillation, sternotomy-related goiter, blood transfusion requirement, urosepsis, heart failure, arrhythmia, re-intubation, tracheostomy, pneumonia and ischemic colitis, according to the researchers.

“Age alone was not an independent risk factor for complications; therefore, thyroid surgery should not be avoided based on chronologic age alone,” Mekel said.

She offered the following potential recommendations based on this data:

Patients aged 80 years and older who clearly require surgery should receive better preoperative evaluation and risk certification, and improved postoperative care perhaps with the involvement of a geriatric team.
Endocrinologists and surgeons should carefully evaluate patients aged 80 years and older.
Earlier surgical intervention may be advised in patients at higher risk for disease progression; conversely, follow-up strategies without surgery may be advised for those at low risk for cancer or for disease progression, with the highest risk for complications. – by Christen Haigh

It is not surprising that elderly individuals, particularly those with more comorbidities, have a substantially higher surgical complication rate. These data suggest that it may be beneficial to opt for surgery sooner rather than later, particularly in cases of large benign goiter which might require sternotomy.

– Elizabeth N. Pearce, MD

Assistant Professor of Medicine, Boston University School of Medicine

In the study by Mekel et al from the Massachusetts General Hospital it was shown that individuals older than 80 years of age undergoing thyroidectomy had a very high complication rate (23.3%). Interestingly, the majority of patients were operated on for benign, rather than for malignant disease. It is likely that many of these patients had surgery for large goiters or substernal goiters, the indications for which might have been relative rather than absolute. Furthermore, emerging data show that radioactive iodine therapy of large goiters, particularly with adjuvant recombinant human thyroid-stimulating hormone stimulation of radioiodine uptake, may be an alternative approach in elderly patients or in those with significant comorbidities.

– David S. Cooper, MD

Professor of Medicine
Johns Hopkins University School of Medicine, Baltimore

For more information:

Mekel M, Stephen AE, Gaz RD, et al. #160. Presented at: 79th Annual Meeting of the American Thyroid Association; Oct. 1-5, 2008; Chicago.