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PubMed1999

Total thyroidectomy for bilateral benign multinodular goiter: effect of changing practice.

HYPOTHESIS: That changing practices in a single institution toward performing total thyroidectomy as the preferred option for the treatment of bilateral benign multinodular goiter (BMNG) can alter attitudes and practice within an entire region (Australia and New Zealand). DESIGN: (1) Single-institution study of patients with bilateral BMNG treated by thyroidectomy over a 40-year period, examining the changing pattern of use of bilateral subtotal thyroidectomy and total thyroidectomy in the initial surgical treatment of nodular goiter. (2) Mail survey of all endocrine surgeons (n = 75) in Australia and New Zealand, seeking information on their changing practice in the surgical treatment of BMNG. SETTING: Tertiary academic referral center. PATIENTS: A group of 3468 patients who underwent thyroidectomy for bilateral BMNG during the study period. Of these, 1838 had a subtotal thyroidectomy performed and 1251 had a total thyroidectomy as the primary surgical treatment. MAIN OUTCOME MEASURES: The changing incidence of each type of thyroid procedure each year over the study period. RESULTS: Within our unit, bilateral subtotal thyroidectomy was the principal procedure performed until 1984, when total thyroidectomy became the preferred procedure. Our unit now treats 94% of these patients with total thyroidectomy. Secondary thyroidectomy for recurrent goiter initially increased over the years (with a lag period of 13 years), reflecting the numbers of subtotal procedures previously performed, and is now declining. This pattern has been reflected throughout Australia and New Zealand; 60% of practicing endocrine surgeons now perform total thyroidectomy as the preferred treatment for bilateral BMNG. CONCLUSIONS: Total thyroidectomy is a safe and effective treatment for bilateral BMNG, and it is now the routine procedure throughout Australia and New Zealand. Its use has corresponded to a reduction in the need for secondary thyroidectomy for recurrent goiter.

Adult↗

PubMed2000

Total thyroidectomy or thyroid lobectomy in patients with low-risk differentiated thyroid cancer: surgical decision analysis of a controversy using a mathematical model.

There is a general consensus that total or near-total thyroidectomy is the optimal treatment for patients with high risk differentiated thyroid cancer (DTC), but the optimal extent of thyroidectomy in patients with low risk DTC continues to be controversial. To determine the optimal extent of thyroidectomy in patients with low risk DTC, we used decision analysis to compare the trade-offs of total thyroidectomy (TT) to thyroid lobectomy (TL). The decision analysis model included the probabilities of thyroidectomy complications, risk of DTC recurrence, and death from DTC. This information was obtained from the literature and from outcome data for patients with low risk DTC from our institution. In addition, the concept of utilities was used in the analysis. To determine the utility of each health outcome state (thyroidectomy complication, DTC recurrence, and DTC mortality for low risk patients) a survey was conducted. Overall, prospective patients viewed DTC recurrence as less desirable than thyroidectomy complication. The utilities assigned by the survey participants varied over a wide range, with 61.5% of the individuals viewing the occurrence of a thyroidectomy complication as better than DTC recurrence. At baseline utilities and probabilities, TT had a higher expected utility than TL. One-way sensitivity analysis varying the rates of (1) thyroidectomy complication, (2) DTC recurrence, and (3) DTC mortality over the possible range showed that complication from initial thyroidectomy was the most important factor that determined the preferred extent of thyroidectomy. TL was the preferred surgical approach only if a complication rate of > 33:1, TT/TL complication rate ratio, was assumed. When no differences in DTC recurrence between the two approaches was assumed in the model, TL had a higher expected utility using the baseline utilities of thyroidectomy complication and DTC mortality. The analysis indicates that TT in patients with low risk DTC is preferable to TL. However, TL is preferred if (1) no difference in the DTC recurrence rate between the two approaches is assumed, (2) a higher complication rate for TT is used (> 33 times higher), or (3) the utility ratio of thyroidectomy complication to DTC recurrence is < 0.8 TL. We believe this decision analysis model provides an objective approach that others can use to select the optimal extent of thyroidectomy based on patient preference of health outcome states, institution-specific outcome data for DTC recurrence or mortality, and the surgeon-specific complication rate.

Adenocarcinoma, Follicular↗

PubMed2006

The advantage of near-total thyroidectomy to avoid postoperative hypoparathyroidism in benign multinodular goiter.

BACKGROUND: In recent years, total or near-total thyroidectomy has emerged as a surgical option to treat patients with multinodular goiter, especially in endemic iodine-deficient regions. The aim of this study was to compare the complication rates of total and near-total thyroidectomy in multinodular goiter and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups. STUDY DESIGN: Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total thyroidectomy (group 1, n = 104) and near-total thyroidectomy leaving less than 2 g (group 2, n = 112). RESULTS: There were no persistent complications. The incidence of transient hypoparathyroidism in group 1 (26%) was significantly higher than in group 2 (9.8%) (p < 0.001). The rate of asymptomatic hypocalcemia in group 2 (7.4%) was lower than in group 1 (27%) (p < 0.001). The incidence of papillary cancer was 9.6% in group 1 and 12.5% in group 2 (p > 0.05). None of the patients underwent completion thyroidectomy before ablative therapy. Ten patients were found to have the histological criteria for radioactive iodine ablation. Of these 10 patients, four were in group 1 and six were in group 2 (p > 0.05). CONCLUSION: In conclusion, we recommend near-total thyroidectomy in multinodular goiter instead of total or subtotal thyroidectomy. While near-total thyroidectomy and total thyroidectomy obviate the need for completion thyroidectomy in incidentally found thyroid cancer, and while there is no difference in the rate of recurrent laryngeal nerve palsy between the two methods, near-total thyroidectomy causes a significantly lower rate of hypoparathyroidism compared to total thyroidectomy.

Adult↗

PubMed2004

Extent of thyroidectomy is not a major determinant of survival in low- or high-risk papillary thyroid cancer.

BACKGROUND: The optimal extent of thyroidectomy for papillary thyroid cancer (PTC) is controversial. Our objective was to evaluate the effect of total thyroidectomy or partial thyroidectomy on survival in low- and high-risk patients. METHODS: The Surveillance, Epidemiology, and End Results database was used to identify PTC patients who underwent thyroidectomy. The independent effects of age, distant metastases, extrathyroidal extension, tumor size, sex, lymph node metastases, radioactive iodine use, and extent of thyroidectomy on survival were analyzed for low- and high-risk PTC. RESULTS: There were 4402 (81%) low-risk and 1030 (19%) high-risk patients; 84.9% underwent total thyroidectomy. The 5- and 10-year survival were 95% and 89% in the low-risk patients and 84% and 73% in the high-risk patients, respectively (P = .001). In the low-risk patients, 10-year survival after total thyroidectomy was 89%, compared with 91% after partial thyroidectomy (adjusted hazard ratio for death, 1.73; 95% confidence interval, 1.28-2.33; P < .001); older age, male sex, larger tumor, lymph node metastases, and lack of radioactive iodine were associated with higher mortality. In the high-risk patients, 10-year survival after total thyroidectomy was 72%, compared with 78% after partial thyroidectomy (adjusted hazard ratio for death, 1.46; 95% confidence interval, .89-2.40; P = .14); older age, distant metastases, larger tumors, and lack of radioactive iodine were associated with higher mortality. CONCLUSIONS: Survival of patients with PTC was not significantly influenced by the extent of thyroidectomy. The survival after partial thyroidectomy was similar to total thyroidectomy within both the low- and high-risk prognostic groups.

Adult↗

PubMed2006

Local Anesthesia With Monitored Anesthesia Care vs General Anesthesia in Thyroidectomy: A Randomized Study.

BACKGROUND: Early in the 20th century, thyroid surgery was performed using local anesthetic techniques. When general anesthesia became safer, surgeons started performing thyroidectomy exclusively under general anesthesia. However, recent descriptions of thyroidectomy under local anesthesia claim similar results to thyroidectomy under general anesthesia. Surgery conducted under local anesthesia can result in early discharge, ie, a hospital stay of less than 8 hours. HYPOTHESIS: Thyroidectomy can be performed under local anesthesia with monitored anesthesia care (MAC) with results similar to general anesthesia in an outpatient or inpatient surgery setting. DESIGN: A prospective randomized study comparing local anesthesia with MAC vs general anesthesia in adult patients undergoing thyroidectomy in a potential outpatient setting, defined as same-day discharge. Patients were excluded if they were not able to receive local or general anesthesia. In addition, we performed an outcome evaluation of the use of local anesthesia with MAC for thyroidectomy and the use of outpatient surgery for thyroidectomy. We compared 58 consecutive thyroidectomies performed prior to the study with 58 consecutive thyroidectomies performed after the study. SETTING: A 486-bed university-affiliated hospital. RESULTS: Fifty-eight patients undergoing thyroidectomy received random assignment: 29 to local anesthesia with MAC and 29 to general anesthesia under study protocol. Fifty-one surgical procedures (88%) were completed as outpatient surgery. No significant differences were found between the 2 study groups in demographics, postoperative adverse symptoms, complications, hospital admission, or patient satisfaction. Patients in the general anesthesia group spent, on average, more time postoperatively than patients in the group that received local anesthesia with MAC in the outpatient surgery center until same-day discharge (P = .02). When compared before the study, we found a significant increase after the randomized study in the use of local anesthesia with MAC (P<.001) and outpatient thyroidectomies (P<.001). CONCLUSIONS: Thyroidectomy can be performed in the studied patient population under either general anesthesia or local anesthesia with MAC, expecting similar operative results, clinical results, and patient satisfaction. In addition, local anesthesia with MAC can reduce the postoperative time spent in an outpatient surgery setting with potential health care cost savings.

Adult↗

PubMed1998

Total thyroidectomy does not enhance disease control or survival even in high-risk patients with differentiated thyroid cancer.

SUMMARY BACKGROUND DATA: The extent of primary thyroidectomy for differentiated thyroid cancer is controversial. There are strong proponents for total thyroidectomy based on its presumed and theoretical disease control benefits. In contrast, there are equally strong advocates of less aggressive thyroidectomy with its lower hazard of parathyroid and recurrent nerve injury. The authors have addressed whether total thyroidectomy has a survival benefit justifying its use in patients with high-risk primary cancer. The major risk factors include age and the following the pathologic determinants follicular histology, vascular invasion, and extracapsular extension. MATERIALS AND METHODS: The clinical pathologic, therapeutic, prognostic, and outcome data were reviewed in 347 patients with well-differentiated thyroid cancer. Seventy-five percent were women, 216 patients were in the younger age group (low-risk) (21-50 years), 103 were in the intermediate-risk group (51-70 years), and 28 were in the high-risk group (>70 years). Included in the high-risk pathologic category were 158 patients who had follicular histology (55), extracapsular extension (107), or vascular invasion (119). Total thyroidectomy was performed in 56 patients, near or subtotal thyroidectomy in 47 patients and lobectomy in 55 patients. The 10-year disease specific survival in the overall patient group was 82% in patients with total thyroidectomy, 78% in patients with subtotal thyroidectomy, and 89% in patients with lobectomy (p = 0.30). There was no significant survival difference according to extent of thyroidectomy in the intermediate or high-risk groups either by age or in patients who had high-risk pathologic feature. CONCLUSIONS: Total thyroidectomy in high-risk patients with differentiated thyroid cancer (containing follicular histology, vascular invasion, or extracapsular extension) showed no benefit over partial thyroidectomy. This suggests that the general use of total thyroidectomy is not indicated, except in highly selected patients.

Adult↗

PubMed2003

Total thyroidectomy for benign thyroid disease.

OBJECTIVES/HYPOTHESIS: The use of total thyroidectomy in thyroid cancer treatment is not unanimous, and it is even more controversial when this procedure is advocated for benign diseases. On the other hand, the complication risk may have an increase up to 20 times in repeat operations for recurrence. The objective of the study was to evaluate the use of total thyroidectomy in benign diseases, multinodular goiter, and Graves disease to justify the authors' preference. STUDY DESIGN: Retrospective study of use of total thyroidectomy in benign diseases. METHODS: Retrospective study of 1789 patients who underwent thyroidectomies from June 1990 to December 2000. Indication, extension of thyroidectomy, cancer incidence, and complications were analyzed. RESULTS: Total thyroidectomy was performed in 81.19% of 456 patients with nontoxic multinodular goiter, 93.93% of 33 with toxic multinodular goiter, 93.93% of 66 with recurrent multinodular goiter, and 49.18% of 122 with Graves disease. Thyroid cancer was found in 16.62%, 9.09%, 3.03% and 5.73% of patients, respectively. Transitory and permanent hypoparathyroidism, hematoma requiring surgical intervention, and transitory and permanent recurrent laryngeal nerve injury occurred in 12.27%, 1.61%, 0.26%, 1.88%, and 0.35% of the patients undergoing total thyroidectomy, respectively. Permanent complications of total thyroidectomy for nontoxic multinodular goiter and Graves disease were similar to nontotal thyroidectomy. Use of total thyroidectomy for nontoxic multinodular goiter increased from 53.33% of the patient to 81.19%, on average, with a concomitant increase of cancer diagnosis from 11.11% to 16,62%. The authors performed total thyroidectomy for all patients with Graves disease. CONCLUSION: Total thyroidectomy is the treatment of choice for multinodular goiter and thyroiditis, when there is bilateral gland involvement posterior to middle thyroid veins, and for Graves disease because it decreases the likelihood of future repeat operations for recurrent disease and thus the associated risks, when performed safely.

Goiter, Nodular↗

PubMed2004

Total versus subtotal thyroidectomy for the management of benign multinodular goiter in an endemic region.

BACKGROUND: Because controversy still continuous to surround use of total thyroidectomy for the management of benign multinodular goiter, the present study aims to prospectively compare the safety and efficacy of total thyroidectomy with subtotal thyroidectomy. METHODS: A total of 200 consecutive patients with benign multinodular goiter were assigned to have either total thyroidectomy (n = 105) or subtotal thyroidectomy (n = 95) based on preoperative evaluation, intraoperative macroscopic findings and nodular dissemination. The patients with no healthy tissue or nodules localized in the dorsal part of the gland, which are usually left during normal subtotal resection, were assigned to the total thyroidectomy group. Demographic details, biochemical findings, indications for operation, operating time, specimen weight, complications and hospital stay were noted. RESULTS: There was no significant difference in the sex, hormonal status or duration of goiter between the two groups (P = 0.74, P = 0.59 and P = 0.59, respectively). The mean operating time was longer (148.52 min +/- 51.10 vs 135.10 min +/- 32.47, P = 0.03), and the mean weight of the specimens was greater (228.40 g +/- 229.91 vs 157.01 g +/- 151.23, P = 0.01) for total rather than subtotal thyroidectomy. Either temporary recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism occurred in 10 (9.3%) or 12 (11.4%) of the patients undergoing total compared with six (6.3%) or nine (9.5%) of the patients undergoing subtotal thyroidectomy (P = 0.40 and P = 0.65, respectively). Either permanent RLN palsy or hypoparathyroidism was observed in one patient undergoing total thyroidectomy (P = 0.34 for each comparison). The mean hospital stay was longer in the total thyroidectomy group (2.24 days +/- 1.18 vs 1.89 days +/- 0.72 for subtotal thyroidectomy, P = 0.01). CONCLUSIONS: The present study shows that total thyroidectomy can be performed without increasing risk of complication, and it is an acceptable alternative for benign multinodular goiter, especially in endemic regions, where patients present with a huge multinodular goiter.

Adult↗

PubMed2001

Minimally invasive open thyroidectomy.

We recently developed a new surgical technique for carrying out thyroidectomy, to minimize tissue trauma by obviating unnecessary neck exploration. This report describes our technique of performing minimally invasive open thyroidectomy and compares the results with those of conventional thyroidectomy. Minimally invasive open thyroidectomy was performed by making a small skin incision, 3.0-4.5cm long, and approaching the thyroid directly via a transverse division of the strap muscles without raising skin flaps. The outcomes of 466 patients who underwent a minimally invasive open thyroidectomy were retrospectively compared with those of 437 patients who underwent conventional thyroidectomy for various types of thyroid nodules. There was no significant difference in the extent of surgery between the group of patients who underwent minimally invasive thyroidectomy and the group of patients who underwent conventional thyroidectomy. However, the length of the skin incision, at 3.7 +/- 0.7 vs 9.6 +/- 3.3 cm, respectively, operative time, at 57.6 +/- 11.7 vs 85.2 +/- 32.3 min, respectively, blood loss, at 18.4 +/- 15.3 vs 43.1 +/- 21.8 ml, respectively, and hospital stay, at 1.6 +/- 0.5 vs 4.3 +/- 1.6 days, respectively, were significantly reduced in the minimally invasive open thyroidectomy group (P < 0.05). Moreover, the number of patients who required postoperative analgesia was significantly less in the minimally invasive open thyroidectomy group. These results show that minimally invasive open thyroidectomy provides surgeons with a clear operative field, and that it has proven to be simple, safe, and practical for selected patients.

Adult↗

PubMed2004

Effect of thyroidectomy on the histology of rat sublingual gland.

This study was carried out to investigate the effect of thyroidectomy on the histology of rat sublingual gland. Twenty-eight male Wistar albino rats, aged 4 weeks and weighing between 45-55 g, were used. The rats were divided into two experimental groups (control and thyroidectomy), each containing 14 animals. Total thyroidectomy of rats was performed under ether anesthesia in thyroidectomy group. The rats in the control group were sham operated without having the thyroidectomy. Seven rats randomly selected from both groups were fixed using the perfusion fixation technique 2 and 6 weeks after thyroidectomy, and their sublingual glands were harvested for histological investigation. No histological difference was observed between the two groups 2 weeks after thyroidectomy. However, 6 weeks after thyroidectomy considerable cytoplasmic vacuolization of the epithelial cells of the mucous tubules was seen in the thyroidectomy group compared to the controls. Enlargement of mucous tubules was also observed, and the lumina in most of the tubules was quite dilated. In the stroma surrounding the parenchymal tissues, increased lipid tissue mass was observed. In addition, increased connective tissue mass and mononuclear cell infiltrations were evident. Furthermore, the number of mast cells was significantly higher in the thyroidectomy group than in the controls 6 weeks after thyroidectomy. It was concluded that the thyroid gland and hormones might have an influence on the histology of the sublingual gland.

Animals↗

PubMed1992

Completion thyroidectomy: a critical appraisal.

BACKGROUND: Completion thyroidectomy can most accurately be described as reexploration of the neck to remove the contralateral thyroid lobe. This procedure has commonly been performed when the histopathologic condition of the ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Because of a definitely increased risk of complications with completion thyroidectomy, avoiding its routine use is important. The purpose of this paper is to define the specific indications for completion thyroidectomy. METHODS: Over the past 9 years, we have performed 400 thyroidectomies; the patients ranged in age from 18 to 88 years. Although we have routinely used preoperative needle biopsy and intraoperative frozen section, decisions regarding the extent of thyroidectomy have been based on the gross findings at operation, taking into consideration such prognostic factors as patient age, tumor grade and size, the presence of extracapsular spread or distant metastasis, and associated risk factors. The minimal procedure for solitary thyroid nodule has been lobectomy with isthmusectomy. If the contralateral lobe is grossly normal, lobectomy with isthmusectomy has also been the maximal operation in most of patients. Very few specific indications exist for removal of the opposite lobe. RESULTS: Only three patients underwent completion thyroidectomy. All three patients had aggressive follicular carcinoma requiring radioactive iodine ablation, and all were referred after the initial surgery. We have not performed completion thyroidectomy on any of the patients on whom we initially operated. CONCLUSIONS: The most common indication considered for completion thyroidectomy is a frozen section diagnosis of a benign follicular adenoma that is subsequently changed on permanent pathologic condition to follicular carcinoma based on the presence of capsular and/or vascular invasion. However, if minimal invasion has occurred, no difference exists in survival related to the extent of the thyroidectomy. Local recurrence in the contralateral lobe occurs in less than 10% of the time. Because completion thyroidectomy carries more risks, it should be avoided in most patients when possible. The definitive decision should be made during the initial operation based on gross findings, prognostic factors, and frozen section, and this plan should only be changed to mandate completion thyroidectomy in select circumstances.

Adenocarcinoma↗

PubMed1990

Total versus subtotal thyroidectomy. Arguments, approaches, and recommendations.

Arguments for routine total thyroidectomy or routine, less than total resection have been espoused for treatment of well-differentiated intrathyroidal carcinoma. Numerous reports in the literature support either approach. No prospective randomized studies have been performed, partly because of the indolent nature of the disease. Many reports are also complicated by the failure of the authors to divide patients into high-risk and low-risk groups and to categorize and evaluate fully the histologic types of the resected tumors. Good evidence exists to show that in the majority of cases of intrathyroidal, well-differentiated lesions, bilateral subtotal resection yields results that compare favorably with total thyroidectomy. Logically, at least, a total thyroidectomy would seem to be preferable, because subtotal resection can be imprecise. Therefore, subtotal thyroidectomy can be recommended over total thyroidectomy, if only on the basis of comparison of complications. The type and rate of complications vary among surgeons. Each thyroid surgeon, therefore, must establish an individual complication rate. Total thyroidectomy in inexperienced hands is not recommended. We recommend, therefore, that total thyroidectomy be used selectively by surgeons who have the skill and experience necessary to make the decision intraoperatively. If, for example, during resection of the lobe that contains the primary tumor, the laryngeal nerves and parathyroid glands can be clearly identified and if there is minimal bleeding and trauma, the surgeon may proceed to side two to perform a total thyroidectomy. If the lesion is large, however, with distortion of anatomy, dissection may be difficult even for an experienced surgeon. Intracapsular parathyroids or undiscovered parathyroids on the side of initial resection should prompt the surgeon to perform a subtotal resection on side two. Under these circumstances, the surgeon should not feel that a total thyroidectomy justifies the increased risk. A unilateral resection, such as lobectomy plus isthmusectomy, can be performed with satisfactory long-term results in low-risk patients, that is, in those with small (less than 1.5 cm) unilateral intrathyroidal exposure and in those with no evidence of metastatic disease. Alternately, the AGES criteria of Hay et al can be used to identify patients in low- or high-risk groups. If the decision to perform a bilateral resection is based on the previous criteria, we recommend that a total thyroidectomy be performed only by an experienced surgeon. During surgery, if there is any suggestion that the laryngeal nerves or parathyroid glands would be at increased risk if a total resection were performed, it may be necessary to revert to a subtotal procedure.(ABSTRACT TRUNCATED AT 400 WORDS)

Adenocarcinoma↗

PubMed1998

Completion total thyroidectomy in children with thyroid cancer secondary to the Chernobyl accident.

OBJECTIVE: To evaluate the usefulness of submitting children with thyroid cancer secondary to nuclear accidents to a completion total thyroidectomy. DESIGN: A case series consisting of patients living and operated on in Belarus whose parents had asked for a clinical evaluation in a western European center. SETTING: A tertiary care referral center. PATIENTS: The conditions of 47 children from Gomel, Belarus, with differentiated thyroid carcinoma following the nuclear accident at Chernobyl, Ukraine, were evaluated at the University of Pisa, Pisa, Italy. In approximately half of the cases, the treatment in Belarus consisted of a hemithyroidectomy. After a complete evaluation, the decision was made to reoperate on 19 of them by performing a completion total thyroidectomy. The preoperative evaluation revealed that 5 (26%) of the 19 patients who had undergone a hemithyroidectomy had unilateral recurrent nerve palsy and that 2 (10.5%) had hypoparathyroidism. INTERVENTIONS: Neck ultrasonography was used for the preoperative localization of thyroid residuals, thyroid nodules, suspicious lymph nodes, and a guided fine-needle aspiration biopsy specimen. The circulating thyroglobulin measurement was obtained before reoperation. An iodine 131 whole-body scan (WBS) was performed and circulating thyroglobulin levels were obtained after completion of the thyroidectomy during withdrawal of levothyroxine sodium therapy. MAIN OUTCOME MEASURE: The number of patients with a recurrence of thyroid cancer and lung or lymph node metastases after the completion total thyroidectomy. RESULTS: The results of the histologic examination were positive for papillary thyroid cancer in 6 (28.6%) of 21 patients, 3 with residual cancer in the remaining thyroid lobe and 3 with metastatic lymph node disease. A posttherapy WBS demonstrated lung metastases in 5 (28%) of 18 patients and lymph node metastases in 6 (33%) of 18 patients; the results of a posttherapy WBS were negative for metastases in 7 (39%) of 18 patients. Hypoparathyroidism developed in 4 (21%) of 19 patients who underwent a completion total thyroidectomy; unilateral laryngeal nerve palsy developed in 1 (5.2%) of these 19 patients. Among 22 children who previously underwent total thyroidectomy in Belarus, a diagnostic WBS showed lung metastases in 10 (45%) of the children and lymph node metastases alone in 3 (14%) of the children; the results of a diagnostic WBS were negative for metastases in 9 (41%) of the children. Statistical analysis showed a nonsignificant (P>.05) difference in the prevalence of lung and lymph node metastases in patients who previously underwent total thyroidectomy compared with patients who underwent completion total thyroidectomy. CONCLUSION: Completion total thyroidectomy allowed for the diagnosis and treatment of recurrent thyroid cancer and lung or lymph node metastases in 61% (11/18) of the patients in whom residual differentiated thyroid carcinoma was not previously recognized.

Adolescent↗

PubMed1994

Can total thyroidectomy be performed as safely by general surgeons in provincial centers as by surgeons in specialized endocrine surgical units? Making the case for surgical training.

OBJECTIVE: To determine whether surgeons who had received appropriate training in the technique of total thyroidectomy could continue to perform the procedure with minimal morbidity after moving to a provincial surgical practice. DESIGN: Comparison of the complication rates from total thyroidectomy between a specialized endocrine surgical unit and provincial centers. SETTING AND PATIENTS: Six hundred fifty patients undergoing total thyroidectomy by two surgeons over a 5-year period in the endocrine surgical unit at Royal North Shore Hospital, St Leonards, Australia, were compared with 120 patients undergoing total thyroidectomy by seven provincial surgeons who were former trainees in the unit. MAIN OUTCOME MEASURES: Indications for surgery and specific complications of thyroidectomy including recurrent laryngeal nerve palsy, permanent hypoparathyroidism, and postoperative bleeding. RESULTS: Each of the seven surgeons in provincial practice performed only between two and 16 thyroidectomies annually. The percentage of total thyroidectomies for benign and malignant disease was identical for both the endocrine surgical unit and provincial center groups (44%). There was no difference in the incidence of recurrent laryngeal nerve palsy, permanent hypoparathyroidism, or postoperative bleeding between the two groups. CONCLUSION: Total thyroidectomy is an operation that always engenders controversy relating to the morbidity of recurrent laryngeal nerve and parathyroid injury. Surgeons who have completed a well-designed training program and who have become proficient at total thyroidectomy as trainees will remain proficient at the procedure despite practicing in a provincial center. Achieving a low morbidity rate demands meticulous attention to operative technique and anatomical detail.

Clinical Competence↗

PubMed1995

Completion thyroidectomy for differentiated thyroid carcinoma.

Completion thyroidectomy is defined as the surgical removal of the remnant thyroid tissue following procedures less than total or near-total thyroidectomy. The extent of surgical management for differentiated thyroid carcinoma (DTC) is controversial. Although some authors advocate subtotal thyroidectomy with lower complication rates, total or near-total thyroidectomy and completion thyroidectomy have been defended by others because of the improved survival and lower morbidity that is comparable with subtotal thyroidectomy. In this study, the incidence of residual tumor and surgical complication rates in patients who underwent completion thyroidectomy were investigated. The medical records of 165 patients undergoing completion thyroidectomy for DTC were reviewed. Seventy-seven (46.6%) of these patients were found to have residual tumor in the remaining thyroid tissue. Anaplastic transformation developed in two of these patients. Permanent bilateral recurrent laryngeal nerve palsy occurred in three patients, and permanent hypoparathyroidism was seen in one patient. We recommend completion thyroidectomy as an efficient and safe method of surgical treatment with a low complication rate for DTC.

Adolescent↗

PubMed2005

[Evolution of the thyroid surgical treatment to the total thyroidectomy. Study of about 735 patients].

OBJECTIVES: To study the place of the total thyroïdectomy compared to the sub-total thyroidectomy and the lobectomy in benign nodular thyroid pathology, about complications and prevention of the recurrence. PATIENTS AND METHODS: The evolution of the number and the type of thyroïdectomy among the total thyroidectomy, subtotal thyroidectomy and the lobectomy was analyzed in a retrospective study including 735 patients in the service of Head and Neck Surgery in the University Hospital in Amiens, France over a 12 years period, for a multinodular goiter, a toxic and a nontoxic solitary nodule. The post-operative transient and permanent recurrent nerve paralysis and hypocalcemia of the total thyroidectomies were studied and compared with the other surgical procedures of the study and in a review of the literature in order to study benefit and risks. RESULTS: Multinodular goiters were the most thyroid pathologies (80%). The total thyroidectomy became gradually the most frequent surgical procedure, from 17% to nearly 70% of the surgical procedures over 12 years, with depend on the currently abandoned subtotal thyroidectomy and the lobectomy. No significant difference appeared concerning the recurrent and parathyroid complications between the 3 procedures. CONCLUSION: The post-operative morbidity is not statistically different between the total thyroidectomy and the other procedures. The total thyroidectomy prevents moreover nodular recurrences whose surgical treatment is difficult without benefit of the L-thyroxine treatment prevention. It implies a substitute opotherapy that the other surgical techniques cannot nevertheless always avoid. Nowadays, the total thyroidectomy is the gold treatment for surgical treatment of multinodular benign goiters. Many factors must be considered concerning the solitary nodules: the size, the evolutivity, the fine needle aspiration the aspect of the contralateral lobe. In all the cases, the decision will have to be consensual between the patient, the endocrinologist and the surgeon.

France↗

PubMed2002

[Is the timing of completion thyroidectomy for differentiated thyroid carcinoma prognostic significant?].

The purpose of this study was to evaluate whether the timing of completion thyroidectomy for differentiated thyroid carcinoma had an influence on the risk of the operation and patient's survival. From January 1, 1985 to March 31, 2001, 230 consecutive patients underwent surgery for differentiated thyroid carcinoma (178 papillary and 52 follicular carcinomas). In this article completion thyroidectomy was defined as the removal of the remaining thyroid tissue after any initial surgical procedure less than total thyroidectomy within an interval ranging from 3 days to 4 months after the initial surgical procedure. Of 99.1 % (n = 228) of the 230 patients the postoperative course is known for 1 month to 36 years with a median follow-up of 5 years. Among 81 patients undergoing thyroidectomy as the initial operation, recurrent laryngeal nerve palsy occurred in 13.5 % (n = 11). In 2 of these patients (2.5 %) recurrent laryngeal nerve palsy was permanent. Transient recurrent laryngeal nerve palsy occurred more frequent in patients who underwent completion thyroidectomy within 8 days to 3 months of the initial surgical procedure (20.5 %) than in patients, in whom completion thyroidectomy was performed either within 7 days of the primary operation or after a minimum of 3 months (5.2 % in each group). Disease-free survival as well as long-term survival was not different after thyroidectomy or completion thyroidectomy for all differentiated thyroid carcinomas and in patients with papillary carcinomas. In order to reduce surgical morbidity we suggest that completion thyroidectomy should be performed either within 7 days of the primary operation or after a minimum of 3 months.

Adenocarcinoma, Follicular↗

PubMed1996

Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up.

SUMMARY BACKGROUND DATA: Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy. METHODS: An analysis of 194 patients having thyroidectomy and simultaneous parathyroid autotransplantation at Barnes Hospital from 1990 to 1994 was performed. Data were collected regarding patient demographics, indication for thyroidectomy, operative procedure, pathologic diagnoses, and postoperative course, including biochemical assessment of parathyroid autograft function. RESULTS: Of 194 patients having either total, subtotal, or completion thyroidectomy, 104 (54%) experienced a [Ca(+2)]nadir less than or equal to 8.0 mg/dL and had symptoms and signs of hypocalcemia. Parathyroid autotransplantation was successful in 103 (99%) of these 104 cases and resulted in a 1.0% incidence of hypoparathyroidism in this series. CONCLUSIONS: Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.

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