Rev. Méd. RosaRio 91: 229-236, 2025
REVISTA MÉDICA DE ROSARIO 229
POSTOPERATIVE OUTCOMES OF TOTAL THYROIDECTOMY IN
CUSCO, PERU: INSIGHTS FROM A HIGH-ALTITUDE REGION
YuRi andRé RaMíRez Paliza
2,3,4,A
, YuRi PatRick RaMíRez chacón
1,B,C
*
1 Hospital Antonio Lorena, Cusco, Perú.
2 Universidad Peruana Cayetano Heredia, Lima, Perú.
a. Estudiante de Medicina Humana
b. Cirujano Oncólogo
* Correo electrónico: yurich12343@gmail.com
Abstract
Introduction: Total thyroidectomy is a common procedure in the treatment of thyroid diseases. However,
geographical factors such as high altitude may inuence postoperative outcomes.
Objective:To evaluate the incidence of postoperative complications following total thyroidectomy and identify
associated risk factors in a high-altitude setting in Cusco, Peru.
Methods:is was a retrospective and observational study based on the review of medical records from 85 patients
who underwent total thyroidectomy at Hospital Antonio Lorena between 2014 and 2024. Demographic, surgical,
and postoperative data were analyzed using descriptive statistics and logistic regression.
Results:e mean age was 45 ± 12 years, with a predominance of female patients (69.4%). yroid cancer (82.4%)
was the most common surgical indication. e overall complication rate was 47.1%, with transient hypocalcemia
being the most frequent (40%). Permanent hypocalcemia occurred in 2.4% of cases, and recurrent laryngeal nerve
injury in 9.4%. Postoperative hemorrhage (1.2%) and surgical site infections (2.4%) were rare. e average hospital
stay was 4.2 ± 1.1 days. Calcium supplementation was required in 80% of patients, and all received levothyroxine.
Conclusion: Total thyroidectomy can be safely performed in high-altitude regions, with mostly transient
complications. e ndings suggest that altitude may inuence the complication prole, highlighting the need for
further research on its impact on surgical outcomes.
Keywords:Total thyroidectomy; postoperative outcomes; thyroid neoplasm
Rev. Méd. RosaRio 91: 229-236, 2025
REVISTA MÉDICA DE ROSARIO230
IntroductIon
Total thyroidectomy is a common procedure
for benign and malignant thyroid diseases, such as
multinodular goiter, Graves’ disease, and dierentiated
thyroid carcinoma.
1,2
Despite its eectiveness,
postoperative complications are a major concern,
aecting both short- and long-term outcomes.
3
Hypocalcemia is a frequent complication, typically
caused by parathyroid injury or devascularization.
Transient hypocalcemia occurs in 20%-50% of cases,
while permanent hypoparathyroidism aects 1%-
3%.
4,5
Risk factors include the extent of thyroidectomy,
preoperative vitamin D deciency, and parathyroid
autotransplantation.
6
Calcium supplementation and
intraoperative parathyroid preservation can reduce these
risks.
7,8
Recurrent laryngeal nerve (RLN) injury can lead
to voice changes, aspiration, or respiratory distress.
Temporary RLN palsy occurs in 3%-10% of cases, and
permanent injury in 0.5%-2%.
9-12
Intraoperative nerve
monitoring (IONM) reduces RLN injury, especially
in complex surgeries.
9
Postoperative hemorrhage and
hematomas are rare but serious, occurring in 0.1%-
1% of cases.
13
Hematomas can obstruct the airway,
requiring urgent intervention.
14-16
Proper hemostasis
and careful surgical technique minimize this risk.
Surgical site infections are uncommon (0.3%-2%), but
they can cause abscesses and extended hospital stays.
17-19
Hypothyroidism is inevitable after total thyroidectomy,
requiring lifelong levothyroxine therapy to prevent
myxedema and metabolic disturbances.
20-23
High-altitude environments complicate postoperative
care. Cusco, at 3,600 meters above sea level, poses
challenges due to hypoxia, which impairs wound
healing and immune function, increasing infection
risk and delayed recovery.
24,25
Studies show longer
hospital stays and higher complication rates in high-
altitude surgical patients.
26
Medication metabolism,
including pain relievers and anesthetics, can also be
altered.
27,28
Calcium metabolism may be aected at
high altitudes, altering parathyroid hormone secretion
and complicating hypocalcemia management.
29,30
Similarly, airway management after hematomas is more
challenging in hypoxic environments.
33
Given these factors, this study assesses postoperative
complications in thyroidectomy patients from high-
altitude regions like Cusco. We hypothesize that
complications occur more frequently and with altered
characteristics in these patients. e primary objective is
to evaluate the incidence and nature of complications at a
tertiary hospital in Cusco, while the secondary objective
is to identify specic risk factors for higher complication
rates in this unique environment. Findings will provide
insights into managing thyroid surgery at high altitudes
and contribute to better clinical strategies.
Methods
Study Design
is cross-sectional, retrospective, observational,
and descriptive study was based on secondary analysis
of medical records.
Population and Sample
A total of 85 patients who underwent total
thyroidectomy at Antonio Lorena Hospital in Cusco,
Peru, between 2014 and 2024 were included. Eligible
participants were patients aged 18 to 80 years with
complete medical records and a diagnosis of either
benign or malignant thyroid disease. Cases with
incomplete information were excluded.
Procedures
Medical records were reviewed from the hospital’s
central physical and electronic archives. A data
collection sheet was created, including the following
variables: age, sex, comorbidities, type and duration of
surgery, intraoperative complications, and postoperative
complications. e postoperative complications
evaluated were hypocalcemia, recurrent laryngeal nerve
(RLN) injury, hemorrhage, surgical site infections, and
hypothyroidism.
Data Analysis
Descriptive statistics were used for the analysis of the
variables. Categorical variables were reported as absolute
and relative frequencies (percentages), and continuous
variables were expressed as means. Data were processed
using Statistical Package for the Social Sciences (SPSS)
version 26.
Ethical Considerations
e study was approved by the Ethics Committee of
Antonio Lorena Hospital. Patient data were anonymized
to protect condentiality, and the study adhered to the
ethical guidelines outlined in the Declaration of Helsinki
(2013). Despite potential limitations such as incomplete
PostoPeRative outcoMes of total thYRoidectoMY in high-altitude cusco
REVISTA MÉDICA DE ROSARIO 231
data due to the retrospective design, this research aims
to provide valuable insights into the incidence and risk
factors of postoperative complications following total
thyroidectomy. e ndings aim to improve clinical
practice and patient care locally, with implications for
similar healthcare contexts.
results
A total of 85 patients underwent total thyroidectomy,
with a mean age of 45 ± 12 years. e age distribution
was as follows: 11.8% were under 30, 52.9% between
30 and 50, and 35.3% over 50 (Table I). Most patients
were female (69.4%), while 30.6% were male. e most
common comorbidities were hypertension (24.7%),
diabetes (17.6%), and cardiovascular diseases (7.1%)
(Table I).
Regarding surgical indications, 82.4% of patients
underwent surgery for thyroid cancer, 8.2% for
multinodular goiter, and 4.7% for uncontrolled
hyperthyroidism. Most surgeries were total
thyroidectomies (95.3%), with a mean duration of 120
± 30 minutes. Intraoperative complications were rare,
with accidental RLN injury occurring in 2.4% of cases
(Table II).
VARIABLE NUMBER OF CASES PERCENTAGE (%)
Mean Age 45 ± 12 years
Age Range
• <30 years
• 30-50 years
• >50 years
10
45
30
11.8%
52.9%
35.3%
Sex
• Female
• Male
59
26
69.4%
30.6%
Comorbidities
• Hypertension
• Diabetes
• Cardiovascular Diseases
• Other
21
15
6
18
24.7%
17.6%
7.1%
21.2%
Table I. Demographic Variables
VARIABLE NUMBER OF CASES PERCENTAGE (%)
Indications for Surgery
• yroid Cancer
• Multinodular Goiter
• Graves’ Disease
• Other
70
7
4
4
82.4%
8.2%
4.7%
4.7%
Type of Surgery
• Total yroidectomy
• Subtotal yroidectomy
81
4
95.3%
4.7%
Duration of Surgery (minutes) 120 ± 30
Intraoperative Complications
• Accidental Recurrent Laryngeal Nerve Injury
• Excessive Bleeding
• Other Complications
2
1
4
2.4%
1.2%
4.7%
Table II. Surgical Variables
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REVISTA MÉDICA DE ROSARIO232
Postoperative complications included transient
hypocalcemia in 40% of patients and permanent
hypocalcemia in 2.4%. Recurrent laryngeal nerve
injury occurred in 9.4% of patients, with 8.2%
having temporary injury and 1.2% permanent injury.
Hemorrhage requiring intervention occurred in 1.2%,
and minor hematomas in 2.4%. Surgical site infections
were rare, with 1.2% of patients experiencing supercial
infections and 1.2% developing deep infections
(abscesses). Hypothyroidism was observed in 100% of
patients (Table III).
e mean postoperative hospital stay was 4.2 ± 1.1
days. e majority of patients (64.7%) stayed between
3 to 5 days, with 14.1% discharged in less than 3 days,
and 21.2% requiring more than 5 days for recovery
(Table IV).
Postoperative treatment included calcium
supplementation in 80% of cases, and 91.8% of patients
were monitored for calcium levels. Levothyroxine was
administered to all patients, and 65.9% received vitamin
D supplementation as part of their postoperative
management (Table V).
Table III. Postoperative Complications
VARIABLE NUMBER OF CASES PERCENTAGE (%)
Hypocalcemia
• Transient Hypocalcemia
• Permanent Hypocalcemia
34
2
40%
2.4%
Recurrent Laryngeal Nerve Injury
• Temporary Injury
• Permanent Injury
7
1
8.2%
1.2%
Postoperative Hemorrhage / Hematoma
• Hemorrhage Requiring Intervention
• Minor Hematoma
1
2
1.2%
2.4%
Surgical Site Infections
• Supercial Infection
• Deep Infection (Abscess)
1
1
1.2%
1.2%
Hypothyroidism 85 100%
Table IV. Length of Hospital Stay
VARIABLE NUMBER OF CASES PERCENTAGE (%)
Mean Postoperative Stay 4.2 ± 1.1 days
Stay < 3 days 12 14.1%
Stay 3-5 days 55 64.7%
Stay > 5 days 18 21.2%
VARIABLE NUMBER OF CASES PERCENTAGE (%)
Calcium Supplementation 68 80%
Levothyroxine Treatment 85 100%
Calcium Monitoring 78 91.8%
Vitamin D Use 56 65.9%
Table V. Postoperative Treatment
PostoPeRative outcoMes of total thYRoidectoMY in high-altitude cusco
REVISTA MÉDICA DE ROSARIO 233
dIscussIon
In this study, we evaluated the incidence and factors
associated with postoperative complications following
total thyroidectomy in 85 patients at Antonio Lorena
Hospital in Cusco, Peru. Our ndings oer important
insights into thyroidectomy outcomes in a high-altitude
context, which may dier from those at lower altitudes
due to the unique physiological conditions. e mean
age of patients was 45 ± 12 years, with most being in
the 30-50 age range, consistent with other studies where
thyroidectomy is common in middle-aged adults.
34
e
majority were female (69.4%), reecting the higher
prevalence of thyroid disease in women, especially
conditions like multinodular goiter and thyroid cancer.
35
Interestingly, 82.4% of surgeries were for thyroid cancer,
a higher proportion compared to other studies where
benign conditions are more common.
36
is could
reect regional dierences in the prevalence of thyroid
cancer and access to healthcare. Most surgeries were
total thyroidectomies (95.3%), aligning with current
guidelines for dierentiated thyroid cancer.
37
Regarding postoperative complications, 40% of
patients had transient hypocalcemia, consistent with
literature where transient hypocalcemia occurs in 20%-
50% of cases.
38
Altitude-related changes in calcium
metabolism may have contributed to this higher
incidence.
39
Permanent hypocalcemia occurred in 2.4%,
similar to the reported 1%-3% in other studies.
9
e
lower rate of permanent hypocalcemia suggests eective
intraoperative techniques and calcium supplementation.
Recurrent laryngeal nerve (RLN) injury was noted
in 9.4% of patients, with 8.2% having temporary and
1.2% permanent injury. is rate is slightly higher than
the typical 3%-10% for temporary injury and 0.5%-2%
for permanent injury (40). e increased RLN injury
rate may be attributed to the complexity of surgeries,
particularly in patients with large or advanced thyroid
tumors. e absence of intraoperative nerve monitoring
(IONM) at our institution might also have contributed,
as IONM reduces RLN injury, especially in complex
surgeries.
41
Postoperative hemorrhage or hematoma occurred in
3.6%, consistent with the rare but serious complications
seen in 0.1%-1% of cases.
13
Minor hematomas (2.4%)
were within expected ranges and generally required no
signicant intervention. Surgical site infections (SSIs)
were rare (2.4%), similar to other studies where SSIs are
infrequent, ranging from 0.3%-2%.
19
is suggests that
infection control and sterility practices were eective.
e average postoperative hospital stay was 4.2 ±
1.1 days, with 64.7% staying between 3 and 5 days,
which aligns with typical recovery times. Shorter
(14.1%) and longer stays (21.2%) were observed,
likely due to complications or comorbidities.
Postoperative care followed best practices, with 80%
of patients receiving calcium supplementation and
91.8% monitored for calcium levels, in line with
current standards.
4
Levothyroxine therapy was given
to all patients, as required after total thyroidectomy to
maintain euthyroidism.
21
Vitamin D supplementation
was provided to 65.9% of patients, consistent with
guidelines recommending it to enhance calcium
absorption and prevent hypocalcemia post-surgery.
42
While this study provides valuable data, there are
limitations. e retrospective design may introduce
biases, such as incomplete data. e ndings may also
not be generalizable to populations outside high-altitude
regions like Cusco, as altitude could aect recovery and
complication rates. Altitude’s impact on thyroid surgery
outcomes warrants further study, as it may alter calcium
metabolism and recovery times.
39
Additionally, the lack
of intraoperative nerve monitoring at our institution
may explain the higher rate of RLN injury compared to
studies using this technique.
41
Future prospective studies
comparing outcomes across dierent altitudes and with
nerve monitoring could provide a clearer understanding
of factors inuencing postoperative complications in
thyroid surgery.
Acknowledgments
We would like to thank the administrative sta,
doctors, and nurses at Antonio Lorena Hospital in
Cusco, especially those who facilitated access to medical
records.
conclusIons
is study is the rst to explore postoperative
complications following total thyroidectomy in Cusco,
Peru, a high-altitude region at 3,600 meters above
sea level. It highlights key ndings, including a 40%
incidence of transient hypocalcemia, with lower-than-
expected rates of permanent hypocalcemia (2.4%)
and recurrent laryngeal nerve injury (1.2%). ese
results suggest that eective surgical techniques and
postoperative care can minimize complications even in
challenging high-altitude environments.
Rev. Méd. RosaRio 91: 229-236, 2025
REVISTA MÉDICA DE ROSARIO234
e study is novel in examining how high-altitude
conditions might impact postoperative recovery,
particularly concerning calcium metabolism and healing.
Altered physiological changes at high altitudes could
inuence complication rates and recovery times, an area
that remains underexplored in thyroid surgery literature.
is research opens the door for further studies on the
eects of altitude on thyroidectomy outcomes.
Overall, this study provides valuable insights into
thyroid surgery in high-altitude regions and encourages
further investigation into how altitude aects surgical
outcomes. Understanding these factors can improve
perioperative management and enhance patient care in
similar regions worldwide.
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Abbreviation Full Term
RLN Recurrent Laryngeal Nerve
IONM Intraoperative Nerve Monitoring
STROBE Strengthening the Reporting of Observational Studies in Epidemiology
SSIs Surgical Site Infection
AppendIx