Thyroid Surgery at a Volunteer Program in Sub-Saharan Africa

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"apellidos" => "Nges" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "Mireille" "apellidos" => "Kemmoe" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "Mercedes" "apellidos" => "Vidal Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 7 => array:3 [ "nombre" => "Francisco Javier" "apellidos" => "Blázquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 8 => array:3 [ "nombre" => "Teresa" "apellidos" => "Vives Espejo-Saavedra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 9 => array:3 [ "nombre" => "Marina" "apellidos" => "Picón Maroñas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 10 => array:3 [ "nombre" => "Andrés" "apellidos" => "Varela de Ugarte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Servicio de CGD, Hospital Universitario Fuenlabrada, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de CGD, Hospital Universitario Puerta de Hierro, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de CGD, Hospital Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital de Notre Dame de Sante – Batseng’la, Dschang, Cameroon" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesia, Hospital Universitario Puerta de Hierro, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Anestesia, Hospital Quirón Pozuelo, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Medical student, Universidad Autónoma, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital Universitario Puerta de Hierro, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía tiroidea en programas de cooperación en África subsahariana" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 1400 "Tamanyo" => 110103 ] ] "descripcion" => array:1 [ "en" => "Patient with multinodular goiter, before and after surgery (bilateral subtotal thyroidectomy)." ] ] ] "textoCompleto" => "IntroductionThe World Health Organization (OMS) estimates that 43% of the African population has iodine deficiency,<a class="elsevierStyleCrossRef" href="#bib0055">1</a> which, together with other typical goitrogenic factors of African diets (cyanogenic glycosides in cassava, thiocyanate, selenium deficiency)<a class="elsevierStyleCrossRefs" href="#bib0060">2,3</a> make goiter an endemic problem.In Cameroon, which is 152nd out of the 187 countries classified in order of their Human Development Index according to the United Nations Program for Development report from 2014,<a class="elsevierStyleCrossRef" href="#bib0070">4</a> there is a series of circumstances that influence the practice of thyroid surgery.In these areas of limited resources, this type of surgery is quite a logistical challenge. It is impossible to conduct proper preoperative studies, which makes it difficult to comply with the recommendations of international treatment guidelines.<a class="elsevierStyleCrossRef" href="#bib0075">5</a> Hence, we surgeons must adapt our methods to the circumstances. Furthermore, the difficult access to medication in cases where thyroidectomy causes sequelae (hypothyroidism, hypocalcemia) can convert thyroid surgery into a potentially dangerous surgical intervention.A large part of the sub-Saharan African population has absolutely no possible access to this type of surgery in their countries due to the exorbitant cost compared to the income levels of this region.<a class="elsevierStyleCrossRef" href="#bib0080">6</a> Healthcare cooperation surgical programs provide one of the few possibilities for treatment.<a class="elsevierStyleCrossRefs" href="#bib0085">7,8</a> However, participating surgeons frequently express reticence to perform thyroidectomies due to the lack of adequate preoperative testing and the possible development of serious complications, which are easily treated in the Western world but are difficult to resolve in these countries given the lack of resources.The objective of this study is to describe the results of a series of thyroidectomies performed in Cameroon through a healthcare cooperation program. The article will explain the peculiar adaptations necessary in both the therapeutic approach and technique in order to conduct as many surgical interventions as possible and minimize postoperative complications.MethodsWe analyzed a cohort of 16 patients treated by thyroid surgery during a program carried out in Dschang, western Cameroon, in the month of June 2015, specifically at the Notre Dame de la Sante Hospital run by the Hermanas Siervas de María religious congregation.The expedition included 2 anesthetists, 2 experienced surgeons and 3 surgical residents, 2 pre-residency medical students and a pediatrician. The surgical activity took place over the period of 4 days. The patients with significant goiter had been previously selected by 2 Cameroonian physicians working at the hospital, who were also responsible for the patients’ long-term control. The first day was spent in the consultation reviewing the cases selected and screening them a second time to finally select 17 patients (our only exclusion criteria were suspicion of uncontrolled hyperthyroidism or the need for lymphadenectomy given the suspicion for cancer).Surgical intervention was not contraindicated in patients with giant goiter who, in fact, were half of the patients treated.Three patients had recent hormone studies and, in all except 2, hormone studies were done before surgery. For all patients, HIV serology was available. None of the patients had preoperative calcemia. Only 4 patients had previous ultrasound studies; in the remainder, we performed the examinations ourselves with portable ultrasound equipment, with the consequent limitations due to our moderate level of ultrasound experience. We did not have advanced imaging techniques available, such as computed tomography or isotope analysis. None of the patients had undergone fine-needle aspiration; it was not possible to perform this test as there was no pathologist available.We scheduled 17 thyroidectomies, although in the end only 16 patients were treated because orotracheal intubation was not possible in one case. All patients signed an informed consent form that was specifically designed for our campaign.All the patients were operated on with orotracheal intubation and under balanced anesthesia with intravenous propofol, anectine, fentanyl and rocuronium as well as inhaled oxygen, protoxide and isoflurane. Prophylactic dexamethasone was administered to all patients, and antibiotic therapy was given selectively (giant goiter, prolonged surgeries). As for the surgical technique, for cases with unilateral disease, hemithyroidectomy was planned of the side affected with isthmectomy. For cases of bilateral disease, subtotal thyroidectomy was planned for both sides in order to minimize the risk for parathyroid and recurrent nerve injury, and a thyroid remnant of 4–5g was left on each side in order to avoid life-long hormone replacement therapy. In patients with a clearly affected lobe and uncertain contralateral involvement (large goiters where one side greatly surpasses the midline), the decision was deferred until surgery and after having explored the less affected side; unilateral resection was preferred, providing the involvement of the remaining side was minimal. After surgery, the patients were transferred to a unit with continuous monitoring by nursing staff: Trousseau was done on each shift and calcemia was analyzed after 24h. Pathology studies of the surgical specimens were not possible.Data for the following variables were collected:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Preoperative: age, sex, laterality, goiter size, T4, TSH and HIV status.</li><li class="elsevierStyleListItem" id="lsti0010">-Intraoperative: surgical technique, visualization of parathyroid glands and recurrent laryngeal nerve, drain tubes and duration of the operation.</li><li class="elsevierStyleListItem" id="lsti0015">-Immediate post-op: hemorrhage, dysphonia and hypocalcemia.</li><li class="elsevierStyleListItem" id="lsti0020">-Late post-op: permanent dysphonia, permanent hypocalcemia, hypothyroidism.</li></ul>Results<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the demographic data of the series. The suspected diagnosis was bilateral goiter in 7 cases and unilateral goiter in 9 (all nodules >4cm), based on clinical examination (elastic consistency, absence of palpable cervical lymphadenopathies) and ultrasound (no calcifications, no nodules with irregular edges or intranodular vascular spots). Pathology studies of the specimens were not possible due to lack of resources; therefore, there was no histological confirmation and cancer could not be ruled out.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>All nodules were larger than 4cm, and all goiters were grade II according to the 1994 classification of the WHO (visible thyroid gland with the neck in normal position), although 8 would have been grade III according to the 1960 classification (goiter visible at a distance) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Only one case of the 14 in which hormone studies were available presented low T4 with elevated TSH (case 14). The remainder had strikingly elevated levels (between 34 and 114mU/L) of T4 (except case 9: 9.06) with normal TSH (except case 7 with minimal elevation; 4.3) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>As for surgical technique, we had planned for 7 bilateral subtotal thyroidectomies (BST), 7 hemithyroidectomies (HT) and 2 isthmectomies. However, given the intraoperative findings, the techniques that were finally done were as follows: 5 BST, 9 hemithyroidectomies and 2 isthmectomies (both cases with a 4cm central nodule and 2normal lobes). It should be mentioned that 3 of the cases with preoperative diagnosis of apparently bilateral giant goiter planned for BST (cases 2, 6 and 12) were found to be unilateral during surgical exploration and after having freed the massive growths from one side that greatly surpassed the midline over the trachea; these masses were also compressing and displacing the trachea laterally while hiding normal-appearing contralateral lobes. In all these cases, hemithyroidectomy was done of the affected side, minimizing risks. In contrast, one apparently unilateral giant case was in effect bilateral and required BST.It was only necessary to divide the pre-thyroid muscles in one of these cases of massive right goiter. The growth of the nodules was excentric in most cases, with cervical masses that were enormous in size in half of the patients treated (8 cases). In only 4 of these patients did we observe moderate retrosternal growth.Out of the 38 potentially locatable parathyroid glands (2 in hemithyroidectomies [2×9=18] and 4 in BST [4×5=20]), 33 were presumably visualized (86%): 17/19 (89%) superior parathyroid and 16/19 (84%) of the inferior parathyroid glands. The ipsilateral recurrent laryngeal nerve was visualized in all the hemithyroidectomies. In the bilateral surgeries, 7/10 of the potentially locatable recurrent laryngeal nerves were able to be visualized. In the 2 isthmectomies, nerve dissection was not attempted.Suction drains were selectively used (7/16) in cases of large-size goiters to help collapse the residual cavity. The median (IQR) duration of the interventions was 75 (68.7) min (range 40–180).<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the postoperative complications of the series. One patient who underwent BST the day before the end of the campaign was reoperated 12h later under sedation after having developed progressive occupation of the wound. Re-exploration was considered necessary because the surgical team was soon leaving the country, even though there was no suffocating hematoma (case 14). The patient did not have drain tubes. We evacuated a moderate hematoma and ligated a minimal blood vessel that was actively bleeding.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Mild dysphonia (hoarseness) was observed during the first 48h in one patient who completely recovered on the third day post-op, so it is not cataloged as a recurrent lesion (with the bias of not being able to evaluate more than the vocal alteration).Although the calcemia obtained after 24h was frequently low (<8mg/dL and 7/16 patients: 3/9 hemithyroidectomies and 4/5 BST), and even <7mg/dL in 3 cases, no patients presented signs of hypocalcemia. As we did not have preoperative calcemia results or levels of ionic calcium or albumin to correct calcium levels, we decided to dismiss treatment in these patients, who progressed without developing any symptoms. Therefore, there was no need for calcium replacement.Mean hospital stay was 2.3 days. Two patients were re-hospitalized due to purulent exudation after the accumulation of seroma.Postoperative hormone studies are available for 13 of our patients, done 4 weeks after surgery (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). T4 was slightly below normal levels in 2 patients, within normal range (5.0–13.0μg/dL) in one and slightly elevated (between 13.4 and 18.6) in the remainder, even in the patient who presented low T4 before surgery, but with levels that were far below preoperative levels. TSH was minimally low in one patient (0.37 in case 3=RHT), normal (0.4–4 mU/L) in 2 patients (the 2 isthmectomies, cases 13 and 15), slightly elevated (<10mU/L) in 5 patients (4 HT and one BST) and very elevated (>10mU/L) in another 5 (one HT and 4 BST). In 3 of these 5 latter patients (all BST), with TSH>40, including the 2 single cases with low T4, hormone treatment was initiated even though the patients were asymptomatic. The other 2 cases with TSH>10 maintain high levels of T4 and moderately elevated TSH.DiscussionCameroon is a country that is not much smaller than Spain (475000 vs 505000km2), but it has half the population (23 vs 46 million inhabitants). Life expectancy is estimated at 54 in women and 51 in men, while the mortality rate in children <5years of age is 13.6%.<a class="elsevierStyleCrossRef" href="#bib0095">9</a> The immense majority of the population cannot afford treatment for many diseases, as advanced technologies are only found in cities with large populations and are prohibitively expensive compared to the population's income levels.<a class="elsevierStyleCrossRef" href="#bib0080">6</a> Thyroid surgery is not an exception and, therefore, medical cooperation campaigns are for many patients the only hope for surgical treatment.Nonetheless, the possibility of developing permanent hypocalcemia or hypothyroidism, which can become fatal complications due to the difficulty in finding or financing replacement medication in this setting, make many surgeons reticent toward performing thyroid surgery in areas with such limited resources.If advanced radiology techniques (CT) or cytological analysis of the nodules had been available, the indication for surgical treatment in all these cases would not have changed. If cancer had been suspected, total thyroidectomy would have been recommended, although hormone replacement would have to be ensured for life, assuming the difficulty (or impossibility) for later radioactive iodine scan or therapeutic doses.Although we only performed 5 out of the 7 expected BST and these patients would have a real risk for developing hypocalcemia or hypothyroidism, the absence of hypocalcemia in the immediate postoperative period makes us believe that there would also be none in the future. The calcemias have very frequently been low (7/16), even in 3/9 (33%) cases of unilateral thyroidectomies, although no patients manifested clinical signs of hypocalcemia. We did not have preoperative calcium or albumin results (to verify whether they were also low) in order to correct their levels (presumably the population would have some degree of malnutrition that could explain the phenomenon). Other causes that could explain postoperative biochemical hypocalcemia could be, in addition to purely technical factors, hypomagnesemia, hypovitaminosis or functional hypoparathyroidism after stress or due to hyperthyroxinemia. For the former reasons, we decided to guide treatment according to symptoms, and calcium was not administered to any of the patients.Hormone studies are difficult to interpret. The preoperative functional pattern seems to correspond with thyroid hormone resistance (very elevated T4 with unsuppressed TSH),<a class="elsevierStyleCrossRef" href="#bib0100">10</a> although it does not seem reasonable to think that this rare genetic syndrome is present in such a high percentage of our patients. On the one hand, the incidence of this syndrome is not higher in Africa and, on the other, the reliability of the laboratory cannot be verified, and we also only have available total T4 levels measured by RIA, which present a level of interferences quite superior to those of free T4. As for thyroid function after 4 weeks, although T4 levels reduced to an important extent, they remained moderately elevated in 10 out of the 13 patients with hormone measurements after 4 weeks. Taking into account what has previously been reported about total T4 levels, we recommend guiding hormone replacement with TSH. We have found notable elevations (>10mU/L) in 4-week TSH in 4/5 BST, while this only happened in 1/9 hemithyroidectomies. Therefore, BST induced hypothyroidism in a very high percentage. Given the difficulties for obtaining hormone supplements, we have used very high TSH levels as a priority criterion for thyroid replacement and have given preference to women of child-bearing age (due to the severe consequences of hypothyroidism during pregnancy) or the existence of larger thyroid remains (to avoid the recurrence of goiter due to continuous stimulus). Thus, hormone therapy was initiated in the 3 patients with BST and TSH>40mU/L, including the only 2 cases with low T4 (the other case with moderate elevation), although none had evident symptoms of hypothyroidism. Therefore, we do not recommend performing any type of bilateral thyroidectomy if there is no possibility to monitor and substitute hormone function.In conclusion, if proper diagnostic and therapeutic approaches are followed, and modifications are planned to circumvent the lack of resources, we can obtain results that are comparable to international standards, at least in terms of complications and sequelae after thyroidectomy.Authorship/Collaboration<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">•Fernando Pereira: study design, data acquisition and collection, analysis and interpretation of the results, article composition, critical review and approval of the final version.</li><li class="elsevierStyleListItem" id="lsti0030">•Pablo Calvo: data acquisition and collection, analysis and interpretation of the results, critical review.</li><li class="elsevierStyleListItem" id="lsti0035">•Alejandro Arteaga: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0040">•Joaquín M. Muñoz: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0045">•Lionel W. Nges: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0050">•Mireille Kemmoe: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0055">•Mercedes Vidal: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0060">•Francisco J. Blázquez: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0065">•Teresa Vives: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0070">•Marina Picón: data acquisition and collection, analysis and interpretation of the results.</li><li class="elsevierStyleListItem" id="lsti0075">•Andrés Varela: data acquisition and collection, critical review.</li></ul>Conflict of InterestsThere are no conflicts of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres729559" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec733592" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres729558" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec733591" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Authorship/Collaboration" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-05" "fechaAceptado" => "2016-05-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec733592" "palabras" => array:7 [ 0 => "Thyroid gland" 1 => "Endemic goiter" 2 => "Thyroidectomy" 3 => "Thyroid nodule" 4 => "General surgery" 5 => "Surgical equipment" 6 => "Surgical aid program" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec733591" "palabras" => array:7 [ 0 => "Tiroides" 1 => "Bocio endémico" 2 => "Tiroidectomía" 3 => "Nódulo tiroideo" 4 => "Cirugía general" 5 => "Equipamiento quirúrgico" 6 => "Cooperación sanitaria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionThe aim of this study is to demonstrate our experience at a volunteer surgical program in Cameroon, which is of special interest given to the inability to adopt international treatment guidelines for thyroid surgery in areas of limited resources due to the lack of preoperative testing and to the difficulty to obtain sustitutive hormonal treatment. MethodsThis is a prospective observational study that includes 16 cases of thyroid surgery in Dschang (Cameroon) during June 2015. The patients were previously selected by a local medical team. All patients were black, 15 women and one man, with a mean age of 41 years. The surgical technique used for the removal of unilateral disease was hemithyroidectomy with isthmectomy and bilateral subtotal thyroidectomy for bilateral disease. ResultsFive subtotal thyroidectomies, 9 hemithyroidectomies and 2 isthmectomies were performed. Prethyroid muscles were divided only in one case. We visualized 86% of the parathyroid glands and 84% of the recurrent laryngeal nerves. The main complications observed were one symptomatic cervical hematoma that required reoperation and 2 surgical wound infections. There were no clinical episodes of hypocalemia or recurrent nerve lesion. The mean length of stay was 2.3 days. At follow-up, all bilateral thyroidectomies developed high TSH levels. ConclusionsThyroid surgery is safe in developing countries adopting protocols and techniques we use in our environment (avoiding total thyroidectomy). Bilateral thyroidectomies should not be performed unless functional studies are available in the follow-up and a thyroid hormone supplement stock guaranteed whenever necessary." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónNuestro objetivo es describir la experiencia adquirida en un programa de cooperación dedicado a la cirugía tiroidea en Camerún. Su interés radica en la imposibilidad para seguir las guías internacionales de tratamiento en áreas de recursos imitados debido a la falta de estudios preoperatorios y a la dificultad para conseguir medicación hormonal sustitutiva de por vida. MétodosEstudio observacional de una cohorte de 16 pacientes operados de enfermedad tiroidea en Dschang (Camerún) en junio de 2015. La técnica quirúrgica empleada fue la hemitiroidectomía con istmectomía en la enfermedad unilateral y la tiroidectomía subtotal bilateral en la enfermedad bilateral. ResultadosTodos los pacientes eran de raza negra, 15 mujeres y un hombre, con edad media de 41 años. Se realizaron 5tiroidectomías subtotales, 9hemitiroidectomías y 2istmectomías. Cuatro pacientes presentaban componente intratorácico. Fue necesaria la sección de músculos pretiroideos en un caso. Se visualizaron las glándulas paratiroides y los nervios laríngeos recurrentes en el 86 y el 84% de los casos, respectivamente. Se dejaron drenajes en 7 casos y la mediana de duración de la intervención fue de 75min. Como complicaciones cabe destacar un hematoma cervical que precisó reintervención y 2infecciones de herida quirúrgica. No hubo hipocalcemias clínicas ni lesiones recurrenciales apreciables. La estancia media fue de 2,3 días. A largo plazo, los pacientes con tiroidectomías bilaterales presentaban niveles elevados de TSH. ConclusionesLa cirugía tiroidea en países subdesarrollados, adaptando los protocolos y técnicas que utilizamos en nuestro medio (evitando la tiroidectomía total), tiene una tasa de complicaciones asumible. No deben realizarse tiroidectomías bilaterales salvo que se disponga de estudios funcionales y se asegure previamente la disponibilidad de la hormona tiroidea." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pereira Pérez F, Calvo Espino P, Sánchez Arteaga A, Muñoz Rodriguez JM, Nges LW, Kemmoe M, et al. Cirugía tiroidea en programas de cooperación en África subsahariana. Cir Esp. 2016;94:404–409." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 1400 "Tamanyo" => 110103 ] ] "descripcion" => array:1 [ "en" => "Patient with multinodular goiter, before and after surgery (bilateral subtotal thyroidectomy)." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "SD: standard deviation; MNG: multinodular goiter." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age: mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.3 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex: male/females \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Race: African/other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16/0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Presumed diagnosis</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Size MNG grade II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16/16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Grade III<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8/16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Hormone study<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4>13 (n=14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TSH>4 (n=14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HIV+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2/16 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1202560.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Grade III according to the WHO 1960 classification (goiter visible from a distance)." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Normal levels: T4: 5.0–13.0μg/dL, TSH: 0.4–4.0mIU/L." ] ] ] "descripcion" => array:1 [ "en" => "Demographic Data." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LHT, left hemithyroidectomy; RHT, right hemithyroidectomy; NA, not available; BST, bilateral subtotal thyroidectomy.Normal values: T4: 5.0–13.0μg/dL; TSH: 0.4–4.0mIU/L." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre T4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre TSH \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">24h Ca \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">One-month T4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">One-month TSH \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">114 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64.60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.95 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Isthmectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29.40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Isthmectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1202562.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pre- and Postoperative Hormone Study; 24h Calcemia." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HT, hemithyroidectomy; BST, bilateral subtotal thyroidectomy.*Normal calcemia values 8.5–10.5mg/dL." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cervical hematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dysphonia after 48h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcemia* after 24h: mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.2 (1.15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (4 BST, 3 HT) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><7.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2 BST, 2 HT) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (2 BST, 1 HT) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative clinical hypocalcemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean hospitalization, days: mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.3 (0.48) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wound infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypocalcemia after 4 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dysphonia after 4 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1202561.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Complications (n=16)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current global iodine status and progress over the last decade towards the elimination of iodine deficiency" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Andersson" 1 => "B. Takkouche" 2 => "I. Egli" 3 => "H.E. Allen" 4 => "B. de Benoist" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Bull World Health Org" "fecha" => "2005" "volumen" => "83" "paginaInicial" => "518" "paginaFinal" => "525" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16175826" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Youth of west-Cameroon are at high risk of developing IDD due to low dietary iodine and high dietary thiocyanate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I. Taga" 1 => "V.A. Oumbe" 2 => "R. Johns" 3 => "M.A. Zaidi" 4 => "J.N. Yonkeu" 5 => "I. Altosaar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Afr Health Sci" "fecha" => "2008" "volumen" => "8" "paginaInicial" => "180" "paginaFinal" => "185" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19357747" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Selenium deficiency a factor in endemic goiter persistence in Sub-Saharan Africa" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.A. Kishosha" 1 => "M. Galukande" 2 => "A.M. 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Original Article

Thyroid Surgery at a Volunteer Program in Sub-Saharan Africa

Cirugía tiroidea en programas de cooperación en África subsahariana

Fernando Pereira Péreza,

Corresponding author

fernando.pereira@salud.madrid.org

Corresponding author.

, Pablo Calvo Espinob, Alejandro Sánchez Arteagac, Joaquín Manuel Muñoz Rodriguezb, Lionel W. Ngesd, Mireille Kemmoed, Mercedes Vidal Fernándeze, Francisco Javier Blázquezf, Teresa Vives Espejo-Saavedrag, Marina Picón Maroñasg, Andrés Varela de Ugarteh

a Servicio de CGD, Hospital Universitario Fuenlabrada, Madrid, Spain

b Servicio de CGD, Hospital Universitario Puerta de Hierro, Madrid, Spain

c Servicio de CGD, Hospital Universitario Gregorio Marañón, Madrid, Spain

d Hospital de Notre Dame de Sante – Batseng’la, Dschang, Cameroon

e Servicio de Anestesia, Hospital Universitario Puerta de Hierro, Madrid, Spain

f Servicio de Anestesia, Hospital Quirón Pozuelo, Madrid, Spain

g Medical student, Universidad Autónoma, Madrid, Spain

h Servicio de Cirugía Torácica, Hospital Universitario Puerta de Hierro, Madrid, Spain

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        "titulo" => "Cirug&#237;a tiroidea en programas de cooperaci&#243;n en &#193;frica subsahariana"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient with multinodular goiter&#44; before and after surgery &#40;bilateral subtotal thyroidectomy&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;OMS&#41; estimates that 43&#37; of the African population has iodine deficiency&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> which&#44; together with other typical goitrogenic factors of African diets &#40;cyanogenic glycosides in cassava&#44; thiocyanate&#44; selenium deficiency&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> make goiter an endemic problem&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In Cameroon&#44; which is 152nd out of the 187 countries classified in order of their Human Development Index according to the United Nations Program for Development report from 2014&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> there is a series of circumstances that influence the practice of thyroid surgery&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In these areas of limited resources&#44; this type of surgery is quite a logistical challenge&#46; It is impossible to conduct proper preoperative studies&#44; which makes it difficult to comply with the recommendations of international treatment guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Hence&#44; we surgeons must adapt our methods to the circumstances&#46; Furthermore&#44; the difficult access to medication in cases where thyroidectomy causes sequelae &#40;hypothyroidism&#44; hypocalcemia&#41; can convert thyroid surgery into a potentially dangerous surgical intervention&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A large part of the sub-Saharan African population has absolutely no possible access to this type of surgery in their countries due to the exorbitant cost compared to the income levels of this region&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Healthcare cooperation surgical programs provide one of the few possibilities for treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> However&#44; participating surgeons frequently express reticence to perform thyroidectomies due to the lack of adequate preoperative testing and the possible development of serious complications&#44; which are easily treated in the Western world but are difficult to resolve in these countries given the lack of resources&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study is to describe the results of a series of thyroidectomies performed in Cameroon through a healthcare cooperation program&#46; The article will explain the peculiar adaptations necessary in both the therapeutic approach and technique in order to conduct as many surgical interventions as possible and minimize postoperative complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We analyzed a cohort of 16 patients treated by thyroid surgery during a program carried out in Dschang&#44; western Cameroon&#44; in the month of June 2015&#44; specifically at the Notre Dame de la Sante Hospital run by the Hermanas Siervas de Mar&#237;a religious congregation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The expedition included 2 anesthetists&#44; 2 experienced surgeons and 3 surgical residents&#44; 2 pre-residency medical students and a pediatrician&#46; The surgical activity took place over the period of 4 days&#46; The patients with significant goiter had been previously selected by 2 Cameroonian physicians working at the hospital&#44; who were also responsible for the patients&#8217; long-term control&#46; The first day was spent in the consultation reviewing the cases selected and screening them a second time to finally select 17 patients &#40;our only exclusion criteria were suspicion of uncontrolled hyperthyroidism or the need for lymphadenectomy given the suspicion for cancer&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Surgical intervention was not contraindicated in patients with giant goiter who&#44; in fact&#44; were half of the patients treated&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Three patients had recent hormone studies and&#44; in all except 2&#44; hormone studies were done before surgery&#46; For all patients&#44; HIV serology was available&#46; None of the patients had preoperative calcemia&#46; Only 4 patients had previous ultrasound studies&#59; in the remainder&#44; we performed the examinations ourselves with portable ultrasound equipment&#44; with the consequent limitations due to our moderate level of ultrasound experience&#46; We did not have advanced imaging techniques available&#44; such as computed tomography or isotope analysis&#46; None of the patients had undergone fine-needle aspiration&#59; it was not possible to perform this test as there was no pathologist available&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We scheduled 17 thyroidectomies&#44; although in the end only 16 patients were treated because orotracheal intubation was not possible in one case&#46; All patients signed an informed consent form that was specifically designed for our campaign&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All the patients were operated on with orotracheal intubation and under balanced anesthesia with intravenous propofol&#44; anectine&#44; fentanyl and rocuronium as well as inhaled oxygen&#44; protoxide and isoflurane&#46; Prophylactic dexamethasone was administered to all patients&#44; and antibiotic therapy was given selectively &#40;giant goiter&#44; prolonged surgeries&#41;&#46; As for the surgical technique&#44; for cases with unilateral disease&#44; hemithyroidectomy was planned of the side affected with isthmectomy&#46; For cases of bilateral disease&#44; subtotal thyroidectomy was planned for both sides in order to minimize the risk for parathyroid and recurrent nerve injury&#44; and a thyroid remnant of 4&#8211;5<span class="elsevierStyleHsp" style=""></span>g was left on each side in order to avoid life-long hormone replacement therapy&#46; In patients with a clearly affected lobe and uncertain contralateral involvement &#40;large goiters where one side greatly surpasses the midline&#41;&#44; the decision was deferred until surgery and after having explored the less affected side&#59; unilateral resection was preferred&#44; providing the involvement of the remaining side was minimal&#46; After surgery&#44; the patients were transferred to a unit with continuous monitoring by nursing staff&#58; Trousseau was done on each shift and calcemia was analyzed after 24<span class="elsevierStyleHsp" style=""></span>h&#46; Pathology studies of the surgical specimens were not possible&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Data for the following variables were collected&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Preoperative</span>&#58; age&#44; sex&#44; laterality&#44; goiter size&#44; T4&#44; TSH and HIV status&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intraoperative</span>&#58; surgical technique&#44; visualization of parathyroid glands and recurrent laryngeal nerve&#44; drain tubes and duration of the operation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Immediate post-op</span>&#58; hemorrhage&#44; dysphonia and hypocalcemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Late post-op</span>&#58; permanent dysphonia&#44; permanent hypocalcemia&#44; hypothyroidism&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the demographic data of the series&#46; The suspected diagnosis was bilateral goiter in 7 cases and unilateral goiter in 9 &#40;all nodules &#62;4<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; based on clinical examination &#40;elastic consistency&#44; absence of palpable cervical lymphadenopathies&#41; and ultrasound &#40;no calcifications&#44; no nodules with irregular edges or intranodular vascular spots&#41;&#46; Pathology studies of the specimens were not possible due to lack of resources&#59; therefore&#44; there was no histological confirmation and cancer could not be ruled out&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">All nodules were larger than 4<span class="elsevierStyleHsp" style=""></span>cm&#44; and all goiters were grade II according to the 1994 classification of the WHO &#40;visible thyroid gland with the neck in normal position&#41;&#44; although 8 would have been grade III according to the 1960 classification &#40;goiter visible at a distance&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Only one case of the 14 in which hormone studies were available presented low T4 with elevated TSH &#40;case 14&#41;&#46; The remainder had strikingly elevated levels &#40;between 34 and 114<span class="elsevierStyleHsp" style=""></span>mU&#47;L&#41; of T4 &#40;except case 9&#58; 9&#46;06&#41; with normal TSH &#40;except case 7 with minimal elevation&#59; 4&#46;3&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">As for surgical technique&#44; we had planned for 7 bilateral subtotal thyroidectomies &#40;BST&#41;&#44; 7 hemithyroidectomies &#40;HT&#41; and 2 isthmectomies&#46; However&#44; given the intraoperative findings&#44; the techniques that were finally done were as follows&#58; 5 BST&#44; 9 hemithyroidectomies and 2 isthmectomies &#40;both cases with a 4<span class="elsevierStyleHsp" style=""></span>cm central nodule and 2<span class="elsevierStyleHsp" style=""></span>normal lobes&#41;&#46; It should be mentioned that 3 of the cases with preoperative diagnosis of apparently bilateral giant goiter planned for BST &#40;cases 2&#44; 6 and 12&#41; were found to be unilateral during surgical exploration and after having freed the massive growths from one side that greatly surpassed the midline over the trachea&#59; these masses were also compressing and displacing the trachea laterally while hiding normal-appearing contralateral lobes&#46; In all these cases&#44; hemithyroidectomy was done of the affected side&#44; minimizing risks&#46; In contrast&#44; one apparently unilateral giant case was in effect bilateral and required BST&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">It was only necessary to divide the pre-thyroid muscles in one of these cases of massive right goiter&#46; The growth of the nodules was excentric in most cases&#44; with cervical masses that were enormous in size in half of the patients treated &#40;8 cases&#41;&#46; In only 4 of these patients did we observe moderate retrosternal growth&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Out of the 38 potentially locatable parathyroid glands &#40;2 in hemithyroidectomies &#91;2&#215;9&#61;18&#93; and 4 in BST &#91;4&#215;5&#61;20&#93;&#41;&#44; 33 were presumably visualized &#40;86&#37;&#41;&#58; 17&#47;19 &#40;89&#37;&#41; superior parathyroid and 16&#47;19 &#40;84&#37;&#41; of the inferior parathyroid glands&#46; The ipsilateral recurrent laryngeal nerve was visualized in all the hemithyroidectomies&#46; In the bilateral surgeries&#44; 7&#47;10 of the potentially locatable recurrent laryngeal nerves were able to be visualized&#46; In the 2 isthmectomies&#44; nerve dissection was not attempted&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Suction drains were selectively used &#40;7&#47;16&#41; in cases of large-size goiters to help collapse the residual cavity&#46; The median &#40;IQR&#41; duration of the interventions was 75 &#40;68&#46;7&#41; min &#40;range 40&#8211;180&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the postoperative complications of the series&#46; One patient who underwent BST the day before the end of the campaign was reoperated 12<span class="elsevierStyleHsp" style=""></span>h later under sedation after having developed progressive occupation of the wound&#46; Re-exploration was considered necessary because the surgical team was soon leaving the country&#44; even though there was no suffocating hematoma &#40;case 14&#41;&#46; The patient did not have drain tubes&#46; We evacuated a moderate hematoma and ligated a minimal blood vessel that was actively bleeding&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Mild dysphonia &#40;hoarseness&#41; was observed during the first 48<span class="elsevierStyleHsp" style=""></span>h in one patient who completely recovered on the third day post-op&#44; so it is not cataloged as a recurrent lesion &#40;with the bias of not being able to evaluate more than the vocal alteration&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Although the calcemia obtained after 24<span class="elsevierStyleHsp" style=""></span>h was frequently low &#40;&#60;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 7&#47;16 patients&#58; 3&#47;9 hemithyroidectomies and 4&#47;5 BST&#41;&#44; and even &#60;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 3 cases&#44; no patients presented signs of hypocalcemia&#46; As we did not have preoperative calcemia results or levels of ionic calcium or albumin to correct calcium levels&#44; we decided to dismiss treatment in these patients&#44; who progressed without developing any symptoms&#46; Therefore&#44; there was no need for calcium replacement&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Mean hospital stay was 2&#46;3 days&#46; Two patients were re-hospitalized due to purulent exudation after the accumulation of seroma&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Postoperative hormone studies are available for 13 of our patients&#44; done 4 weeks after surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; T4 was slightly below normal levels in 2 patients&#44; within normal range &#40;5&#46;0&#8211;13&#46;0<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dL&#41; in one and slightly elevated &#40;between 13&#46;4 and 18&#46;6&#41; in the remainder&#44; even in the patient who presented low T4 before surgery&#44; but with levels that were far below preoperative levels&#46; TSH was minimally low in one patient &#40;0&#46;37 in case 3&#61;RHT&#41;&#44; normal &#40;0&#46;4&#8211;4 mU&#47;L&#41; in 2 patients &#40;the 2 isthmectomies&#44; cases 13 and 15&#41;&#44; slightly elevated &#40;&#60;10<span class="elsevierStyleHsp" style=""></span>mU&#47;L&#41; in 5 patients &#40;4 HT and one BST&#41; and very elevated &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>mU&#47;L&#41; in another 5 &#40;one HT and 4 BST&#41;&#46; In 3 of these 5 latter patients &#40;all BST&#41;&#44; with TSH&#62;40&#44; including the 2 single cases with low T4&#44; hormone treatment was initiated even though the patients were asymptomatic&#46; The other 2 cases with TSH&#62;10 maintain high levels of T4 and moderately elevated TSH&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">Cameroon is a country that is not much smaller than Spain &#40;475<span class="elsevierStyleHsp" style=""></span>000 vs 505<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>km<span class="elsevierStyleSup">2</span>&#41;&#44; but it has half the population &#40;23 vs 46 million inhabitants&#41;&#46; Life expectancy is estimated at 54 in women and 51 in men&#44; while the mortality rate in children &#60;5<span class="elsevierStyleHsp" style=""></span>years of age is 13&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The immense majority of the population cannot afford treatment for many diseases&#44; as advanced technologies are only found in cities with large populations and are prohibitively expensive compared to the population&#39;s income levels&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Thyroid surgery is not an exception and&#44; therefore&#44; medical cooperation campaigns are for many patients the only hope for surgical treatment&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Nonetheless&#44; the possibility of developing permanent hypocalcemia or hypothyroidism&#44; which can become fatal complications due to the difficulty in finding or financing replacement medication in this setting&#44; make many surgeons reticent toward performing thyroid surgery in areas with such limited resources&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">If advanced radiology techniques &#40;CT&#41; or cytological analysis of the nodules had been available&#44; the indication for surgical treatment in all these cases would not have changed&#46; If cancer had been suspected&#44; total thyroidectomy would have been recommended&#44; although hormone replacement would have to be ensured for life&#44; assuming the difficulty &#40;or impossibility&#41; for later radioactive iodine scan or therapeutic doses&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Although we only performed 5 out of the 7 expected BST and these patients would have a real risk for developing hypocalcemia or hypothyroidism&#44; the absence of hypocalcemia in the immediate postoperative period makes us believe that there would also be none in the future&#46; The calcemias have very frequently been low &#40;7&#47;16&#41;&#44; even in 3&#47;9 &#40;33&#37;&#41; cases of unilateral thyroidectomies&#44; although no patients manifested clinical signs of hypocalcemia&#46; We did not have preoperative calcium or albumin results &#40;to verify whether they were also low&#41; in order to correct their levels &#40;presumably the population would have some degree of malnutrition that could explain the phenomenon&#41;&#46; Other causes that could explain postoperative biochemical hypocalcemia could be&#44; in addition to purely technical factors&#44; hypomagnesemia&#44; hypovitaminosis or functional hypoparathyroidism after stress or due to hyperthyroxinemia&#46; For the former reasons&#44; we decided to guide treatment according to symptoms&#44; and calcium was not administered to any of the patients&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Hormone studies are difficult to interpret&#46; The preoperative functional pattern seems to correspond with thyroid hormone resistance &#40;very elevated T4 with unsuppressed TSH&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> although it does not seem reasonable to think that this rare genetic syndrome is present in such a high percentage of our patients&#46; On the one hand&#44; the incidence of this syndrome is not higher in Africa and&#44; on the other&#44; the reliability of the laboratory cannot be verified&#44; and we also only have available total T4 levels measured by RIA&#44; which present a level of interferences quite superior to those of free T4&#46; As for thyroid function after 4 weeks&#44; although T4 levels reduced to an important extent&#44; they remained moderately elevated in 10 out of the 13 patients with hormone measurements after 4 weeks&#46; Taking into account what has previously been reported about total T4 levels&#44; we recommend guiding hormone replacement with TSH&#46; We have found notable elevations &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>mU&#47;L&#41; in 4-week TSH in 4&#47;5 BST&#44; while this only happened in 1&#47;9 hemithyroidectomies&#46; Therefore&#44; BST induced hypothyroidism in a very high percentage&#46; Given the difficulties for obtaining hormone supplements&#44; we have used very high TSH levels as a priority criterion for thyroid replacement and have given preference to women of child-bearing age &#40;due to the severe consequences of hypothyroidism during pregnancy&#41; or the existence of larger thyroid remains &#40;to avoid the recurrence of goiter due to continuous stimulus&#41;&#46; Thus&#44; hormone therapy was initiated in the 3 patients with BST and TSH&#62;40<span class="elsevierStyleHsp" style=""></span>mU&#47;L&#44; including the only 2 cases with low T4 &#40;the other case with moderate elevation&#41;&#44; although none had evident symptoms of hypothyroidism&#46; Therefore&#44; we do not recommend performing any type of bilateral thyroidectomy if there is no possibility to monitor and substitute hormone function&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In conclusion&#44; if proper diagnostic and therapeutic approaches are followed&#44; and modifications are planned to circumvent the lack of resources&#44; we can obtain results that are comparable to international standards&#44; at least in terms of complications and sequelae after thyroidectomy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Authorship&#47;Collaboration</span><p id="par0175" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Fernando Pereira&#58; study design&#44; data acquisition and collection&#44; analysis and interpretation of the results&#44; article composition&#44; critical review and approval of the final version&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Pablo Calvo&#58; data acquisition and collection&#44; analysis and interpretation of the results&#44; critical review&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Alejandro Arteaga&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Joaqu&#237;n M&#46; Mu&#241;oz&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Lionel W&#46; Nges&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Mireille Kemmoe&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Mercedes Vidal&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Francisco J&#46; Bl&#225;zquez&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Teresa Vives&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Marina Pic&#243;n&#58; data acquisition and collection&#44; analysis and interpretation of the results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Andr&#233;s Varela&#58; data acquisition and collection&#44; critical review&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of Interests</span><p id="par0235" class="elsevierStylePara elsevierViewall">There are no conflicts of interests to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres729559"
          "titulo" => "Abstract"
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              "titulo" => "Conclusiones"
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          "identificador" => "xpalclavsec733591"
          "titulo" => "Palabras clave"
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    "fechaRecibido" => "2015-11-05"
    "fechaAceptado" => "2016-05-26"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec733592"
          "palabras" => array:7 [
            0 => "Thyroid gland"
            1 => "Endemic goiter"
            2 => "Thyroidectomy"
            3 => "Thyroid nodule"
            4 => "General surgery"
            5 => "Surgical equipment"
            6 => "Surgical aid program"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:7 [
            0 => "Tiroides"
            1 => "Bocio end&#233;mico"
            2 => "Tiroidectom&#237;a"
            3 => "N&#243;dulo tiroideo"
            4 => "Cirug&#237;a general"
            5 => "Equipamiento quir&#250;rgico"
            6 => "Cooperaci&#243;n sanitaria"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to demonstrate our experience at a volunteer surgical program in Cameroon&#44; which is of special interest given to the inability to adopt international treatment guidelines for thyroid surgery in areas of limited resources due to the lack of preoperative testing and to the difficulty to obtain sustitutive hormonal treatment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a prospective observational study that includes 16 cases of thyroid surgery in Dschang &#40;Cameroon&#41; during June 2015&#46; The patients were previously selected by a local medical team&#46; All patients were black&#44; 15 women and one man&#44; with a mean age of 41 years&#46; The surgical technique used for the removal of unilateral disease was hemithyroidectomy with isthmectomy and bilateral subtotal thyroidectomy for bilateral disease&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Five subtotal thyroidectomies&#44; 9 hemithyroidectomies and 2 isthmectomies were performed&#46; Prethyroid muscles were divided only in one case&#46; We visualized 86&#37; of the parathyroid glands and 84&#37; of the recurrent laryngeal nerves&#46; The main complications observed were one symptomatic cervical hematoma that required reoperation and 2 surgical wound infections&#46; There were no clinical episodes of hypocalemia or recurrent nerve lesion&#46; The mean length of stay was 2&#46;3 days&#46; At follow-up&#44; all bilateral thyroidectomies developed high TSH levels&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Thyroid surgery is safe in developing countries adopting protocols and techniques we use in our environment &#40;avoiding total thyroidectomy&#41;&#46; Bilateral thyroidectomies should not be performed unless functional studies are available in the follow-up and a thyroid hormone supplement stock guaranteed whenever necessary&#46;</p></span>"
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            "titulo" => "Introduction"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Nuestro objetivo es describir la experiencia adquirida en un programa de cooperaci&#243;n dedicado a la cirug&#237;a tiroidea en Camer&#250;n&#46; Su inter&#233;s radica en la imposibilidad para seguir las gu&#237;as internacionales de tratamiento en &#225;reas de recursos imitados debido a la falta de estudios preoperatorios y a la dificultad para conseguir medicaci&#243;n hormonal sustitutiva de por vida&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional de una cohorte de 16 pacientes operados de enfermedad tiroidea en Dschang &#40;Camer&#250;n&#41; en junio de 2015&#46; La t&#233;cnica quir&#250;rgica empleada fue la hemitiroidectom&#237;a con istmectom&#237;a en la enfermedad unilateral y la tiroidectom&#237;a subtotal bilateral en la enfermedad bilateral&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes eran de raza negra&#44; 15 mujeres y un hombre&#44; con edad media de 41 a&#241;os&#46; Se realizaron 5<span class="elsevierStyleHsp" style=""></span>tiroidectom&#237;as subtotales&#44; 9<span class="elsevierStyleHsp" style=""></span>hemitiroidectom&#237;as y 2<span class="elsevierStyleHsp" style=""></span>istmectom&#237;as&#46; Cuatro pacientes presentaban componente intrator&#225;cico&#46; Fue necesaria la secci&#243;n de m&#250;sculos pretiroideos en un caso&#46; Se visualizaron las gl&#225;ndulas paratiroides y los nervios lar&#237;ngeos recurrentes en el 86 y el 84&#37; de los casos&#44; respectivamente&#46; Se dejaron drenajes en 7 casos y la mediana de duraci&#243;n de la intervenci&#243;n fue de 75<span class="elsevierStyleHsp" style=""></span>min&#46; Como complicaciones cabe destacar un hematoma cervical que precis&#243; reintervenci&#243;n y 2<span class="elsevierStyleHsp" style=""></span>infecciones de herida quir&#250;rgica&#46; No hubo hipocalcemias cl&#237;nicas ni lesiones recurrenciales apreciables&#46; La estancia media fue de 2&#44;3 d&#237;as&#46; A largo plazo&#44; los pacientes con tiroidectom&#237;as bilaterales presentaban niveles elevados de TSH&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a tiroidea en pa&#237;ses subdesarrollados&#44; adaptando los protocolos y t&#233;cnicas que utilizamos en nuestro medio &#40;evitando la tiroidectom&#237;a total&#41;&#44; tiene una tasa de complicaciones asumible&#46; No deben realizarse tiroidectom&#237;as bilaterales salvo que se disponga de estudios funcionales y se asegure previamente la disponibilidad de la hormona tiroidea&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Pereira P&#233;rez F&#44; Calvo Espino P&#44; S&#225;nchez Arteaga A&#44; Mu&#241;oz Rodriguez JM&#44; Nges LW&#44; Kemmoe M&#44; et al&#46; Cirug&#237;a tiroidea en programas de cooperaci&#243;n en &#193;frica subsahariana&#46; Cir Esp&#46; 2016&#59;94&#58;404&#8211;409&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient with multinodular goiter&#44; before and after surgery &#40;bilateral subtotal thyroidectomy&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#58; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;3 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex&#58; male&#47;females</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Race&#58; African&#47;other</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#47;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Presumed diagnosis</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Size MNG grade II</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#47;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Grade III<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Hormone study</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>T4&#62;13 &#40;n&#61;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>TSH&#62;4 &#40;n&#61;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">HIV&#43;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;16&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Normal levels&#58; T4&#58; 5&#46;0&#8211;13&#46;0<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dL&#44; TSH&#58; 0&#46;4&#8211;4&#46;0<span class="elsevierStyleHsp" style=""></span>mIU&#47;L&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demographic Data&#46;</p>"
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      ]
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">LHT&#44; left hemithyroidectomy&#59; RHT&#44; right hemithyroidectomy&#59; NA&#44; not available&#59; BST&#44; bilateral subtotal thyroidectomy&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Normal values&#58; T4&#58; 5&#46;0&#8211;13&#46;0<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;dL&#59; TSH&#58; 0&#46;4&#8211;4&#46;0<span class="elsevierStyleHsp" style=""></span>mIU&#47;L&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre TSH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">24<span class="elsevierStyleHsp" style=""></span>h Ca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">One-month T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">One-month TSH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">114&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BST&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BST&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BST&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LHT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Isthmectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BST&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Isthmectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BST&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pre- and Postoperative Hormone Study&#59; 24<span class="elsevierStyleHsp" style=""></span>h Calcemia&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Cervical hematoma</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Calcemia&#42; after 24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#58; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;2 &#40;1&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;4 BST&#44; 3 HT&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;7&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;2 BST&#44; 2 HT&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;2 BST&#44; 1 HT&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postoperative clinical hypocalcemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean hospitalization&#44; days&#58; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;3 &#40;0&#46;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Wound infection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hypocalcemia after 4 weeks</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Dysphonia after 4 weeks</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 21735077
Original language: English

DOI:10.1016/j.cireng.2016.08.009

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