Thyroid diseases are very common among elderly patients (1). The improvement of diagnostic techniques, an easier access to hospital facilities and the increase in average life expectancy have made thyroidectomies more feasible for the geriatric population (2). Therefore, worldwide, the indications for thyroid surgery have been continuously extended. The incidence of differentiated thyroid cancer in the elderly is increasing (3). Also, the prevalence of thyroid nodules during US performance is higher in old patients (4).
While the incidence of thyroid disease is increasing especially in elderly population, we must consider the risk of complex surgery in this type of patients. Geriatric patients are more often affected by a large burden of metabolic and cardiovascular comorbidities. Nonetheless the use of novel surgical and anesthesiological techniques could reduce the operative time and the incidence of some complications (1).
The aim of this study is to review the modern surgical literature in relation to the complications, the risks and the benefits of thyroid surgery in geriatric patients.
We evaluated the recent literature (from January 2005 up to April 2017) on PubMed Central. Our research was based on the following terms: thyroid, complication, elderly, aged, thyroidectomy, geriatric. All abstracts were read separately by four different residents. The scientific relevance of the papers was assessed considering the number of patients, the accuracy of the statistical method and the originality of the article. Each paper selected was read by at least two surgeons; the ones reported in the references have been considered scientifically relevant by the authors.
We analyzed the issue focusing on three main topics.
Indications for surgical treatment
If we consider the oncologic issue, the differentiated thyroid cancer has a worse prognosis in the old patients (5). These data seem to be quite concordant in the literature. It could be due to a higher incidence of more aggressive histotypes but also to a significant diagnostic delay (6). An article published by Grogan et al. demonstrated a higher risk of recurrence of PTC in older patients (7).
In elderly patients the clinical and pathological features, as far as T status, LN metastasis, extranodal and extracapsular extension seem to be more aggressive. This could be due to the high frequency of late diagnosis. The 5-year disease-free survival is significantly lower than in younger patients (81.3% vs. 94.7%) (8).
According to Longeu et al., surgeon’s experience is more important than patients’ age in terms of outcomes (9). Even though this study stressed the importance of surgical treatment in the elderly for oncological and histopathological reasons, the number of elderly patients in this paper was too low to make a definitive statement.
Assuming that thyroid cancer in the elderly is more invasive, increased mortality could depend also on less appropriate treatments for geriatric patients. Some surgeons tend to perform a less definitive surgery on these patients; a recent paper published by Shevchyk et al. showed that older patients with PTC are less likely to receive total thyroidectomy than younger patients (10).
Although the thyroid malignant disease has a lower incidence in the elderly, we must remember that it represents the 30% of all thyroid disorders compared to 6–8% in younger subjects (11). Tracheal compression and thyrotoxicosis are frequent surgical indications in the elderly (12).
In terms of medical complications, data on elderly patients are conflicting (13).
An interesting prospective cohort study, published by Grogan et al., described an increased incidence of medical complications after thyroid surgery in old patients, analyzing 7,915 procedures (14). This study divided the population in three groups according to age: young (age 16–64 years), elderly (age 65–79 years) and super elderly (80 years and above). A different rate of complications occurred among the subjects: 1% of the young patients, 2.2% of the elderly and 5% of the super elderly. In particular there was a significant increase in systemic infections and in pulmonary and cardiac complications. However, the differences in wound infections between the three groups were not statistically significant.
Considering the association between aging and many medical comorbidities, the impact of old age on length of hospital stay, rehospitalization and costs is easily predictable (15). Other studies confirmed that readmission is slightly more frequent among the elderly, but this difference was not statistically significant (16). Indeed, some other papers suggested that the higher incidence of complications is due to a greater amount of comorbidities than age itself (17).
As far as surgical complications are concerned, we considered hematoma, seroma, recurrent laryngeal nerve palsy and hypocalcemia. An interesting study conducted by Tartaglia et al., examined these complications in a large number of patients (4). In this paper, subjects were divided in two groups according to age (65-year-age cut-off). The difference between the two groups was not statistically significant; however, all the surgical complications occurred more frequently in elderly patients. According to Caulley et al., age could be considered as a risk factor for postoperative complications of total thyroidectomy; a BMI greater than 30 kg/m2 is a risk factor only in the aged over 70 (18).
In regards to hypocalcemia, Seybt et al. published an interesting study, involving 428 patients; elderly patients had a transient hypocalcemia rate comparable to that of the younger ones (12.5% vs. 11.1%, respectively) (16). Other articles did not find any statistical difference concerning hypocalcemia (4,19,20). The literature seems to be quite concordant not defining age as a risk factor for hypocalcemia. However, it should be noted that the treatment of hypocalcemia in the elderly is more difficult and risky, not mainly because of age itself, but because more frequently diuretics are used to treat hypertension and cardiac failure.
Laryngeal nerve palsy (LNP), due to the lesion of recurrent laryngeal nerve (RLN), is an important complication in thyroid surgery. Only few papers considered age as a risk factor for RLN injury. Most of them did not find any statistical difference between elderly and young patients. Bergenfelz et al. found instead a correlation between older age and permanent vocal cord palsy in a study conducted in 5,252 patients (21,22).
In terms of hematoma, we have to consider that older patients are more frequently on treatment with anticoagulants and antiplatelet agents. The increased incidence of postoperative hematoma in the elderly is confirmed by a study conducted by Dehal et al. (23). If we analyze the modern literature, it is rather clear that the use of energy-based devices can reduce the incidence of intraoperative bleeding and hematoma (24,25). Therefore, because of the higher incidence of this complication, hemostatic devices might have a greater impact on the geriatric surgical patients.
In addition, a higher incidence of diabetes could explain the occurrence of surgical site infection (9). On the other hand, a recent article published by Elfenbein et al. showed that in 49,326 patients that underwent thyroidectomy, age does not influence the onset of surgical site infections (26).
Certainly, the current literature analysis allows us to confirm that modern surgical devices could be helpful to minimize the risk of complications in old patients undergoing thyroid surgery. Tolone et al. compared surgical outcomes in old and young patients using energy-based devices; the authors found no difference in the two groups. Moreover, new technologies could be able to reduce the operation time, providing advantages especially to the elderly population (1).
Modern surgery must definitely consider the individual risk factors of each patient. Attempting to summarize the vast literature on this issue, we can consider age as a risk factor not in absolute terms but in relation to the comorbidities and the general clinical condition of the patient. Recent studies showed that the increase of complications in the elderly patients is more related to the biological than the chronological age and with the amount of associated comorbidities. The issue is not whether to operate an elderly patient, but whether to operate a patient with relevant comorbidities taking age into account as a further comorbidity. Considering the increase in average life expectancy, surgeons can’t avoid surgery just because of the patient age. It could be very useful to select special risk indices dedicated to geriatric patients in order to facilitate the decision-making process; however, relying on the current knowledge, we could state that there is value in providing surgery to geriatric patients in highly specialized and high-volume centers. The surgeon’s experience, associated to the availability of current technology such as laryngeal and vagal nerve neuromonitoring and energy-devices are nowadays the main factors that can reduce complications and improve the patient’s surgical outcomes.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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