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1 대한내분비외과학회지 : 제7권제4호 Vol. 7, No. 4, December 2007 원저 갑상선수술후합병증인애성, 저칼슘혈증및혈종에대한임상적연구 광주기독병원일반외과 범우성ㆍ문덕진ㆍ김준식ㆍ박범석 A Clinical Study of Thyroidectomy Complications: Hoarseness, Hypocalcemia and Hematoma Wooseong Beom, M.D., Dukjin Moon, M.D., Junsik Kim, M.D. and Bumsuk Park, M.D. Purpose: The use of thyroidectomy has increased as a diagnostic technique for thyroid disease. However, performance of a, thyroidectomy is accompanied with complications. Post-thyroidectomy complications include recurrent laryngeal nerve palsy, hypocalcemia, hematoma, infection, and thyroid storm. The aim of this study was to determine the clinical incidence and to evaluate complications after a thyroidectomy, including recurrent laryngeal nerve palsy, hypocalcemia, hematoma, and scaring, following a retrospective review of cases. Methods: From July 2004 to May 2006, 661 consecutive patients that had undergone a thyroidectomy were identified. Through a retrospective review, we evaluated the incidence and type of complications, including recurrent laryngeal nerve palsy, hypocalcemia, hematoma, and postoperative scaring. Results: 1) Recurrent laryngeal nerve palsy was a very serious complication, but had a very low incidence. Eight cases out of 661 cases developed and most of the cases developed after a total thyroidectomy. 2) Hypocalcemia was the most common complication. Each incidence of hypocalcemia of methods of thyroid surgery was significant (P= 0.019) but, thyroid disease did not have significant difference (P=0.071). 3) The incidence of postoperative hematoma was 2.74% (18/655). Graves disease was more predominant than other diseases. Conclusion: Post-thyroidectomy complications and cosmetic problems include recurrent laryngeal nerve palsy, hypocalcemia, hematoma, and postoperative scar. An understanding of the incidence and review of complications after a thyroidectomy may reduce their incidence. (Korean J Endocrine Surg 2007;7: ) Key Words: Thyroidectomy, Complications, Thyroid disease 중심단어 : 갑상선절제술, 합병증, 갑상선질환 Department of Surgery, Gwangju Christian Hospital, Gwangju, Korea 서 2003년에발표된한국암등록사업연례보고서에따르면갑상선암의발생건수가전체에서 6위, 여자에게서는 4위를차지하였다. 이러한이유로최근갑상선에대한일반인들의관심이늘어나고, 진단기술의발전과초음파나전산화단층촬영이이전보다쉽게접근할수있는여건으로, 갑상선질환의진단율이증가하고있다. 이러한갑상선질환의치료는내과적치료와외과적수술이있는데, 내과적치료에반응하지않거나, 재발하는갑상선양성종양과갑상선암인경우에는수술의적응증이된다. 그러나, 갑상선수술은되돌이후두신경손상, 일시적혹은영구적인부갑상선기능저하증, 수술중또는수술후출혈및그리고혈종등의합병증을동반한다. 이중되돌이후두신경손상은성대마비를일으켜서애성을가져오며, 양측손상의경우호흡곤란을일으킬수있다. 부갑상선기능저하는일시적혹은영구적저칼슘혈증을일으키는합병증으로갑상선수술시제일흔한합병증으로알려져있다.(1) 혈종의경우매우드물지만즉각적인처치가없을경우치명적일수있기때문에각별한주의가필요하며,(2,3) 수술후상흔은환자의미용적인측면에악영향을미칠수가있다. 이에본저자들은갑상선절제술후합병증의발생률과임상양상을고찰함으로써합병증의예방에기여하고자이연구를시작하였다. 론 책임저자 : 범우성, 광주시남구양림동 264 번지 , 광주기독병원외과 Tel: , Fax: tigerwoo2002@daum.net 게재승인일 :2007 년 11 월 15 일 방법 2004년 7월부터 2006년 5월까지본원에서갑상선질환으로경부접근술을이용하여갑상선일엽절제술및갑상선 252

2 범우성외 : 갑상선수술후합병증인애성, 저칼슘혈증및혈종에대한임상적연구 253 아전절제술그리고갑상선전절제술을시행받은 661명의환자를대상으로입원및외래기록을재검토하여후향적연구를시행하였다. 재발이나림프전이로완결갑상선절제술을받은환자는재수술로인한편견이발생할수있어제외하였다. 우선되돌이후두신경손상은의무기록지상애성을호소하는환자의수술기록지소견을조사하여각수술법에따라발생률을비교하였고, 병리기록지결과를고찰하였다. 부갑상선기능저하의경우는수술후첫날검사한혈청칼슘치를조사하여혈청칼슘치가 8.5 mg/dl 이하인환자의수를각수술법및질환별로발생률을각각산출하였으며, 수술직후와수술후 1일째와퇴원후첫추적관찰시 ( 수술후약 2주후 ) 발생률을산출하였다. 혈종은각수술법과각질환별로구별하여비교하였다. 통계분석방법은 SPSS 13.0을프로그램을사용하여 Chi-square와 Fisher s extract test 을이용하였으며, P값은 0.05 미만을유의수준으로하였다. Table 1. Demography of thyroidectomy patients Characteristics 결 본원에서갑상선수술을받은환자중 661명의환자중여자는 593명, 남자는 68명으로남녀비는 1:8.72였고, 연령별로는 30 40대가가장많았으며, 평균연령은남자가 45±5.6, 여자가 43±13.2였다. 갑상선전절제술을시행받은 Feature of patients Sex Male 10.2% (68/661) Female 89.7% (593/661) Mean age (yrs) Male 45±5.6 Female 42±13.3 Method of thyroidectomy Total thyroidectomy 70.3% (465/661) Less than total thyroidectomy* 29.6% (196/661) *Less than total thyroidectomy involve in subtotal thyroidectomy and lobectomy. 과 환자는 465예, 일엽절제술및아전절제술을시행받은환자는 196명이었다. 평균재원일수는 5.2±1.1이었다 (Table 1). 1) 애성발생및되돌이후두신경손상 애성을호소하는환자는 59명에서발생하였으나, 수술후약 3개월후에는 51명이호전되었고, 수술기록지상의인성손상및암종의침윤으로되돌이후두신경손상을확인한경우는 8예였다. 갑상선전절제술을시행한경우에서 7 예였고, 부분절제술에서 1예였다 (Table 2). 애성은갑상선전절제술에서유의하게높았으나 (P=0.003), 신경손상은두군간의차이가없는걸로산출되었다 (P=0.447). 신경손상된 8예전부악성에서발생하였으며, T1인경우가 1예였고, 나머지 7예는 T4였다. 암종의되돌이후두신경침범여부가 확인된것은 5예였고, 그중 2예에서는신경절제후단단문합술을시행하였고, 다른 3예는신경을보존하면서조심스럽게분리하었다. 2) 부갑상선기능저하증 수술후부갑상선기능저하증을시사하는저칼슘혈증의발생은수술후첫날 75명에서발생하였으며, 75명중손발저림이나이학적검사상 Chvostek 사인이양성인경우는의무기록상 65명이었다. 수술후첫번째외래추적조사시인수술후 14일에칼슘제및비타민 D를경구투여한환자중증상이있어서시행한혈액검사상저칼슘혈증이지속된경우는 12예였다 (Table 3). 수술후첫째날혈청칼슘치가 8.5 mg/dl 미만인예는갑상선전절제술을시행한경우는 62명이었고, 일엽절제술및아전절술의경우는 13명으로두군간의차이가통계학적으로유의하였으나, 악성인경 Table 3. Incidence of hypocalcemia in thyroidectomy patients Interval Incidence Operation day 10.8% (72/661) POD #1* 11.3% (75/661) POD #14 1.8% (12/661) *POD is postoperative day. Table 2. Incidence of hoarseness and recurrent laryngeal nerve injury in thyroidectomy patients Method of surgery Hoarseness Nerve injury* Total thyroidectomy 11.1% 1.50% P=0.003 (52/465) (7/465) P=0.447 Less than total 3.57% 0.51% thyroidectomy (7/196) (1/196) *RLN injury identified during operation, P value was calculated by chi-square test and fisher extract test. Table 4. Incidence of hypocalcemia in thyroidectomy patients Group Incidence P value* Surgery Total thyroidectomy 13.3% (62/465) Less than total thyroidectomy 6.6% (13/196) Disease Malignancy 13.5% (58/446) Benign 7.90% (17/215) *P-value was calculated by chi-square test.

3 254 대한내분비외과학회지 : 제 7 권제 4 호 2007 Table 5. Incidence of hematoma in thyroidectomy patients Group Incidence P-value* Surgery 1.00 Total thyroidectomy 2.8% (13/465) Less than total thyroidectomy 2.6% (5/190) Disease Malignancy 2.5% (11/442) Benign 2.1% (4/188) Graves disease 11.1% (3/27) *P-value was calculated by fisher extract test. 우 58명, 양성인경우는 17명으로악성과양성의질환별로는통계학적으로유의할만한차이가없었다 (Table 4). 3) 혈종 연구에포함된 661명중, 아스피린과와파린 (Wafrin) 복용으로혈액응고장애가의심되는환자 5명을제외한 655 명중혈종의발생은 18예에서발생하였다. 이중남자는 2예였으며여자는 16예였다. 각각의질환별발생률은양성이 2.1% (4/188), 악성이 2.5% (11/442), 그레이브스병에서 11.1% (3/27) 으로그레이브스병에서유의할만하게높았으며 (P=0.024), 또한수술방법별발생률은갑상선전절제술에서 13예 (13/465) 이었고, 일엽절제술과아전절제술을포함한부분절제술에서는 5예 (5/190) 로통계적으로유의할만한차이가없었다 (P=1.00) (Table 5). 고 최근갑상선질환의유병률이높아짐에따라, 치료방법으로갑상선절제술이증가하는추세이다. Theodor Kocher 가근대적인갑상선수술을정립시킨이래현재까지술기의많은발전을이루어왔으며, 수술법에관한가이드라인이나치료지침의등장으로일부질환의수술범위에관한이견을제외하고는,(4,5) 표준화된수술법이적용되고있다. 그러나수술후필연적으로발생하는합병증은갑상선수술에도예외는아니다. 갑상선수술후발생할수있는합병증은되돌이후두신경손상, 부갑상선기능저하증, 혈종, 갑상선폭풍, 감염이있다. 이중되돌이후두신경손상은심각한합병증으로알려져있으며, 양측손상인경우는기관절개술이필요할수도있으며일단손상되면, 저자에따라이견이있을수있으나성대기능이회복되지않는다고알려져있다.(6-8) 그러나본연구의결과에서볼수있듯이되돌이후두신경손상의발생률이 1.2% (8/661) 로아주낮고, 본연구에서는악성과양성간에통계적으로유의할만한차이가없었으나, 갑상선전절제술에서부분절제술보다많이생기며, 갑상선양 찰 성질환보다악성질환에서많이발생한다는것을알수있었다. 이는수술범위가광범위해질수록의인성신경손상의가능성이높다는것을반영해줌으로갑상선암일때는초음파와혈액검사뿐만아니라, 전산화단층촬영등을이용하여암종의주위조직침범에대한적극적인검사가신경침윤을예상하는데도움이될것이라생각된다. 만약암종의침범으로필연적으로신경손상이되는경우, 신경의문합으로좋은결과를얻을수있다고알려져있다.(9-11) 저자의임상경험에서도되돌이후두신경단단문합을시행한 2 예에서수술후약 6개월에실시된후두경검사에서성대마비가호전된바있다. 저칼슘혈증의경우갑상선수술후가장흔한합병증으로일시적인경우 50% 에이르며영구적인경우 1 5% 로보고되고있다.(12,13) 원인으로는수술중혹은수술후의혈액희석에의한혈중단백농도저하, 갑상선조작에따른칼시토닌분비의증가, 수술중부갑상선의손상이알려져있으며, 열거한원인중에서수술중부갑상선손상이많게는 90% 로가장흔하며,(13) 수술중부갑상선의손상, 제거, 혈액공급의차단이발생한다면, 즉각적으로 1 mm 간격으로쪼개어자가이식을하는것이저칼슘혈증을예방하는데효과적이라고 Romanus 등 (14) 은주장한바있다. 저칼슘혈증의임상적양상으로는손발의저림, 입주위감각이상에서부터손발및안면근육의경련이있을수있다. 저칼슘혈증은본연구에서처럼일과성인경우수주에서수개월까지호전되며, 지속적인저칼슘혈증경우수술시부갑상선의손상을막는것이중요하다. 혈종의원인은주요혈관을결찰한혈관이재개방되는경우와경부압력이증가하는경우, 전신혈압이상승하는경우가있으며, 출혈부위로는동맥, 정맥, 갑상선절제면및정확한출혈부위가없이갑상선인접근육의파열에의한삼출성출혈이있다.(15-17) 본연구에서재수술한 18예중에서출혈부위및원인으로동맥이 6예, 정맥이 2예, 삼출성출혈이 10예였으며, 각각질환별로는본연구에서처럼그레이브스병에서발생빈도가높고각수술법에따른차이는없었다. 그러나일단발생하면재수술하는경우가많으므로, 수술전처치나수술후세밀한관찰이필요하다. 본원에서도그레이브스병은수술전에 Lugol 용액등으로혈관상태을조절하고있으며, 최근수술중 fibrin glue나 gelform 등의국소지혈제제를사용함으로써혈종의발생비율이낮아지는것을경험하였다. 한편, 이러한합병증외에도고식적인갑상선수술후필연적으로나타나는미용상의결점인, 경부수술상흔이최근미용수술의발달과더불어환자의불만이많아지면서중요한이슈가되므로무시할수없는부분이다. 본원에서의입원및외래기록지상상흔을 3차례이상호소하는환자는 10.1% (67/661) 이었고이중여자는 63명이었고, 남자는 4명이었으며, 연령별로는 20 50대까지상흔에대한호소

4 범우성외 : 갑상선수술후합병증인애성, 저칼슘혈증및혈종에대한임상적연구 255 Table 6. Incidence of the age distribution of scar complaints in thyroidectomy patients 것이다. Age Incidence P value* % (3/11) % (12/98) % (16/152) % (23/203) % (11/102) % (2/95) Total 10.1% (67/661) *P value is calculated by chi-square. 가유의할만한차이가없었다 (Table 6). 이와같이수술시필연적으로생기는상흔을호소하는경우는젊은여성이나중년여성에관계없으므로, 최근내시경을통한수술이대체할수있는수술법으로많이사용하고있다. 약간의이견이있을수있지만합병증의차이는두군과의차이가없는걸로보고되고있다.(18-20) 본원에서도 2003년부터내시경을통한갑상선절제술을시행하고있으며, 비용이나수술시간, 상흔을제외한합병증의발생은개경을통한수술법에비해유의할만한차이가없었으나, 상흔에대해서는환자들대부분에서만족하였다. 그럼으로내시경을통한갑상선절제술이앞으로더욱더발전해나갈것으로생각된다. 그러나상흔에대한연구는상흔과환자반응에대해좀더객관적인분석을해야할것이다. 결 갑상선수술후필연적으로생기는합병증으로되돌이후두신경손상, 일시적혹은영구적인저칼슘혈증, 혈종, 갑상선폭풍, 감염이있다. 이런합병증중본저자들은되돌이후두신경, 저칼슘혈증, 혈종을양성과악성종양및갑상선전절제술과부분절제술로구분하여조사한결과, 되돌이후두신경의경우수술범위가광범위해질수록의인성손상이많아지는것을알수있었고, 저칼슘혈증의경우원인으로는부갑상선손상이가장흔하며, 전절제술에서유의할만하게발생률이높아서수술시부갑상선손상을줄이는것이중요할것이다. 혈종의경우, 양성과악성종양에비해그레이브스병에서유의할만하게높았으며, 발생시재수술하는빈도가많아수술전후의세밀한전처치및주의가필요하리라생각된다. 이외에최근미용성형수술의발달로수술후경부상흔이환자들에게합병증과함께중요한이슈가되면서내시경수술이대안으로실시되고있다. 이렇게각합병증과수술후경부상흔에대한발생률을조사함으로써, 수술후문제발생에대해준비를할수있으며, 또한임상적고찰을함으로써합병증에대한이해와대안을생각하게하여결국합병증발생률을줄일수있을 론 REFERENCES 1) Shaha AR, Jaffe BM. Complications of thyroid surgery performed by residents. Surgery 1998;104: ) Farrar WB. Complications of thyroidectomy. Surg Clin North Am 1983;63: ) Foster RS. Morbidity and mortality after thyroidectomy. Surg Gynecol Obstet 1978;146: ) Katz AD, Bronson D. Total thyroidectomy the indication and results of 680 cases. Am J Surg 1978;136:450. 5) Mazzaferri EL, Young RL, Oertel JE, Kemmerer WT, Page C. Papillary thyroid carcinoma: the impact of therapy in 576 patients. Medicine 1977;56:171. 6) Gorden JH, McCabe BF. The effect of accurate neurorrhaphy on reinnervation and return of laryngeal function. Laryngoscope 1968;78:236. 7) Tashiro T. Experimental studies on the reinnervation of larynx after accurate neurorrhaphy. Laryngoscope 1972;82:225. 8) Siribodhi C, Sundmaker W, Atkins JP, Bonner FJ. Electromyographic studies of laryngeal paralysis and regeneration of laryngeal motor nerves in dogs. Laryngoscope 1963;73:148. 9) Miyauchi A, Ishikawa H, Matsusaka K, Maeda H, Matsuzuka F, Hirai K, et al. Treatment of recurrent laryngeal nerve paralysis by several types of nerve suture. Japan J Surg 1993;94: ) Green DC, Ward PH. The management of the divided recurrent laryngeal nerve. Laryngoscope 1990;100: ) Ezaki H, Ushio H, Harada Y, Takeichi N. Recurrent laryngeal nerve anastomosis following thyroid surgery. World J Surg 1982;6: ) Falk SA, Birken EA, Baran DT. Temporary postthyroidectomy hypocalcemia. Arch Otolaryngol Head Neck Surg 1988; 114: ) Demeester-Mirkine N, Hooghe L, Geertruyden JV, Maertelaer VD. Hypocalcemia after thyroidectomy. Arch Surg 1992; 127: ) Romanus ME, Farndon JR, Wells Jr. SA. Transplantation of the parathyroid glands. In: Johnston IDA, Thompson NW, editors. Endocrine Surgery. 15th. London: Butterworth; p ) Shaha AR, Jaffe BM. Practical management of postthyroidectomy hematoma. J Surg Oncol 1994;57: ) Burkey SH, Jon A van Heerden, Thompson GB, Grant CS, Schleck CD, Farley DR. Reexploration for symptomatic hematomas after cervical exploration. Surgery 2001;130: ) Cichon S, Anielski R, Orlicki P, Krzesiwo-Stempak K. Postthyroidectomy hemorrhage. Przegl Lek 2002;59: ) Yeung GH. Endoscopic surgery of neck: a few frontier. Surg

5 256 대한내분비외과학회지 : 제 7 권제 4 호 2007 Laparosc Endosc 1998;8: ) Ikeda Y, Takemi H, Sasaki Y, Tagayama J, Niimi M, Kan S. Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg 2003;196: ) Nam SY, Park YL, Bae WG. Clinical analysis of one hundred cases of endoscopic thyroidectomy. J Korean Surg Soc 2002; 62:303-7.

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar