Total Thyroidectomy for Non-Malignant goiter Javed Iqbal, FCPS,FRCS Professor of surgery Quaid-e-Azam Medical College, Bahawalpur
Total thyroidectomy is the procedure of choice for thyroid malignancy
Commonly performed procedures for non-malignant thyroid: Lobectomy Lobectomy with isthamectomy Sub-total thyroidectomy Total Thyroiectomy
Sub-total thyroidectomy is commonly performed because: It is thought that it is associated with low incidence of RNL damage It is thought that the chances of parathyroid damage is less Of the fear that total thyroidectomy will need permanent replacement therapy It is easier to perform then total thyroidectomy
Problems with lesser resection Significant chances of recurrence (up to 23% in MNG) Small but Significant number of MNG have been found to have tiny foci of Malignancy Thyrotoxicosis can also reoccur and specially the ophthalmopathy may stay or even progress after lesser resection
The mid-term freedom rate from thyroid nodulerecurrence or parenchymalirregularity after lobectomy for solitary nodule of the thyroid is unsatisfactory.
Theodore Kocher performed thefirst total thyroidectomy for MNG with very good results andthought it to be the procedure of choice in 1909 mortality less than 0.18% minimal risk to RNL and Parathyroids
He, however abandonedthis procedure due to post- operative hypothyroidism As the thyroid extract was made much later Thyroxine was available in 1913
Capsular dissection technique 1992….Professor Reeve and Professor Delbridge
Total thyroidectomy is now the preferred option for the surgical management of Graves disease," ANZ Journal of Surgery, Volume 72 Issue 5 Page 321 - 2002 Total thyroidectomy will remove the target organ for the immune response in patients with hyperthyroidism and the risk of toxic ophthalmopathy is minimised. Lastly, the risk of recurrent disease is eliminated. Six per cent had minor and probably transient local complaints at control three months after the operation .00000[Benign diseases of the thyroid: indications for surgical treatment and the current role of total thyroidectomy ]Chir Ital 2003 Mar-Apr;55(2):179-87
Total thyroidectomy for management of thyroid disease.World J Surg 2000 Aug;24(8):962-5 (ISSN: 0364-2313) A comparison of total thyroidectomy and lobectomy in the treatment of dominant thyroid nodules. Am Surg 2002 Aug;68(8):678-82; discussion 682-3 Farkas EA; King TA; Bolton JS; Fuhrman GM
Assessment of the morbidity and complications of total thyroidectomy .Arch Otolaryngol Head Neck Surg 2002 Apr;128(4):389- 92 (ISSN: 0886-4470 [Total thyroidectomy in the surgical treatment of thyroid disease a retrospective clinical study] [La tiroidectomia totale nel trattamento della patologia tiroidea.]Minerva Endocrinol 2001 Jun;26(2):41-51 (ISSN: 0391-1977)
Total thyroidectomy for the treatment of hyperthyroidism in patients with ophthalmopathy. Thyroid 2002 Mar;12(3):265-7 (ISSN: 1050- 7256) Kurihara H Kurihara Thyroid Clinic, Morioka, Japan. [Basedow disease. From subtotal to total thyroidectomy ] [Morbus Basedow. Von subtotaler zu totaler Thyreoidektomie.] Schweiz Rundsch Med Prax 2002 Feb 6;91(6):206-15 (ISSN: 1013- 2058) Gemsenjager E; Valko P; Schweizer I Chirurgische Klinik, Spital Zollikerberg, Zollikerberg.
Indications, risks, and acceptance oftotal thyroidectomy for multinodular benign goiter.Surg Today 2001;31(11):958- 62 Surgery for Graves disease: total versus subtotal thyroidectomy -results of a prospective randomized trial.World J Surg 2000 Nov;24(11):1303-11
[Benign thyroid disease: 20-year experience in surgical therapy][Malattia tiroidea benigna: esperienza ventennale di terapia chirurgica.]Chir Ital 2000 Jan- Feb;52(1):41-7 (ISSN: 0009-4773) Complications of total thyroidectomy : incidence, prevention and treatment] [Complicanze della tiroidectomia totale: incidenza, prevenzione e trattamento.]Chir Ital 2002 Sep-Oct;54(5):635-42 (ISSN: 0009- 4773)
Complication rates after operations for benign thyroid disease. Acta Otolaryngol 2002 Sep;122(6):679- 83 (ISSN: 0001-6489) Dener C Department ol Surgery, Fatih University School of Medicine, Ankara, Turkey. High rate of recurrence after lobectomy for solitary thyroid nodule. Eur J Surg 2002;168(7):397-400 (ISSN: 1102- 4151) Marchesi M; Biffoni M; Faloci C; Biancari F; Campana FP 3rd Department of Surgery, University La Sapienza, Rome, Italy.
Total thyroidectomy : the procedure of choice for multinodular goitre.Eur J Surg 2002;168(3):196; Kaushal M; Agarwal G; Mishra SK Total Thyroidectomy: A study of 58 cases: Javed Iqbal, Babar Ali and Haroon K. Pasha: 1997 JCPSP Vol. 7 (1) 20-21
Acceptable results RLN peresis 2.4% RNL damage 0.8% Transient hypocalcaemia 4.2% Long standing Hypocalcaemia 1.4% These results are not different from patients who underwent lesser resection studies
TOUCH WOOD NO RLN damage 3.7% transient Hypocalcaemia 2 patient with long standing Hypocalcaemia
Conclusions No chances of recurrence Lesser resection has no influence on post- operative thyroxine therapy Chances of missing a focus of malignancy is eliminated. The total resection has better effect of progression of Ophthalmopathy in Toxic goiter
Conclusions With capsular dissection technique the incidence of damage to RLN and Parathyroids is comparable with that of sub-total resection