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Near-Total Thyroidectomy Could Be the Best Treatment for Thyroid Disease in Endemic Regions

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Near-Total Thyroidectomy Could Be the Best Treatment for Thyroid Disease in Endemic Regions ORIGINAL ARTICLE Near-Total Thyroidectomy Could Be the Best Treatment for Thyroid Disease in Endemic Regions Zeki Acun, MD; Mustafa Comert, MD; Alper Cihan, MD; Suat Can Ulukent, MD; Bulent Ucan, MD; Guldeniz Karadeniz C¸ akmak, MD Hypothesis: Near-total thyroidectomy, on the basis of Results: In our clinic, near-total thyroidectomy was the its low morbidity rate, is an appropriate treatment op- principal surgical procedure performed for benign thy- tion in the surgical management of various thyroid dis- roid disease. The temporary recurrent laryngeal nerve eases in an endemic region in Turkey. palsy rate with respect to the nerves at risk was 3.3% (10 of 304 nerves), whereas temporary hypoparathyroidism Design: Single-institution study of patients with vari- was 7.2% (11 of 152 patients). Neither permanent re- ous thyroid diseases treated by means of near-total thy- current laryngeal nerve palsy nor permanent hypopar- roidectomy within 2 years in an endemic region, with athyroidism occurred. In 1 patient, wound hematoma de- comparison of the results vs the complication rates of bi- veloped and required re-exploration. Seroma in another lateral subtotal and total thyroidectomy reported in the patient needed no medical or surgical intervention. Nei- literature. ther wound infection nor mortality were noted. Setting: Tertiary academic referral center. Conclusions: Near-total thyroidectomy achieves a lower complication rate of hypoparathyroidism and a similar Patients: One hundred fifty-two patients who under- complication rate of recurrent laryngeal nerve palsy and went near-total thyroidectomy for various thyroid dis- recurrence when compared with the rates reported in the eases. literature for total thyroidectomy. It is an effective and safe surgical treatment option for various benign thy- Main Outcome Measures: Surgical treatments of vari- roid diseases. ous benign thyroid diseases were compared according to the complication rates and the achievable benefits of the procedures. Arch Surg. 2004;139:444-447 EALTH PROBLEMS RELATED An important disadvantage of total to the thyroid gland are thyroidectomy is the high incidence of hy- common. Goiter preva- pocalcemia due to parathyroid gland lence is reported to range devascularization.7 A low complication rate from 5% to 56% in Tur- is the advantage of subtotal thyroidec- Hkey.1 Many treatment modalities have been tomy, but secondary thyroidectomy may described for the surgical management of be necessary because of recurrence after various thyroid diseases, including exci- subtotal thyroidectomy and is associated sion, bilateral subtotal thyroidectomy, near- with increased morbidity and related to total thyroidectomy, and total thyroidec- tomy. However, the use of surgery should See Invited Critique always be based on the achievable benefits at end of article of the procedure and outweigh the poten- tial complications. All of the treatment al- recurrent laryngeal nerve injury and hy- ternatives achieve different kinds and inci- poparathyroidism resulting from par- dences of morbidities. As a result, most athyroid gland devascularization.8 The surgeons have been looking for a treat- goal of this study is to evaluate near-total From the General Surgery ment that results in the least recurrence and thyroidectomy as an appropriate treat- Department, School of lowest complication rate. Total thyroidec- ment for thyroid disorders in endemic Medicine, Zonguldak tomy for management of benign thyroid dis- regions in Turkey because its recurrence Karaelmas University, orders is increasingly accepted, although the rate is lower than that of subtotal thy- Zonguldak, Turkey. indications are not well defined.2-6 roidectomy and there is a lower possibil- (REPRINTED) ARCH SURG/ VOL 139, APR 2004 WWW.ARCHSURG.COM 444 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Table 1. Indications for Surgical Treatment Table 2. Clinical Signs in 152 Patients Indication No. (%) of Patients Clinical Sign No. (%) of Patients Suspicious or indefinite cytologic findings 0 Thyroid function test results Compressive symptoms 58 (38.2) Euthyroidism 86 (56.6) Recent enlargement 14 (9.2) Hyperthyroidism 66 (43.4) Cosmesis 14 (9.2) Hypothyroidism 0 Toxic multinodular goiter 66 (43.4) Ultrasonographic evaluation results Total 152 (100) Multinodular goiter 96 (63.2) Solitary nodules 53 (34.9) Diffuse goiter 3 (2.0) ity of parathyroid damage when it is compared with that of total thyroidectomy. Table 3. Postoperative Complications METHODS Complication No. (%) of Patients Between April 15, 2001, and May 15, 2003, 152 patients with goiter who underwent surgical treatment in our clinic (Gen- Recurrent laryngeal nerve palsy eral Surgery Department, Zonguldak Karaelmas University, Temporary 10 (6.6)* School of Medicine, Zonguldak, Turkey) were included in this Permanent 0 study. All patients provided informed consent. All patients were Hypoparathyroidism evaluated by means of physical examination, thyroid function Temporary 11 (7.2) tests, thyroid ultrasonography, and thyroid scintigraphy. Fine- Permanent 0 Wound hematoma 1 (0.7) needle aspiration biopsy was performed for hypoactive and domi- Bleeding 0 nant thyroid nodules. In our surgical department, we per- Wound infection 0 formed total thyroidectomy in single nodules that were suspected Seroma 1 (0.7) of malignancy at fine-needle aspiration biopsy; therefore, these Total 23 (15.2) patients were specifically excluded. Antithyroid medications were used for hyperthyroidism before surgery to attain euthy- *The rate of temporary recurrent laryngeal nerve palsy was 3.3% with roidism. respect to the nerves at risk. Videolaryngostroboscopic examinations were performed to evaluate vocal cord motility 24 hours before surgery and 48 hours after surgery in all patients and included confirmation topathologically. Intraoperative frozen section evalua- of normal vocal cord movement in patients who had tempo- tions were used for nodules suspected of being malig- rary neuropraxia. Near-total thyroidectomy was performed in nant that had not been suspected of being malignant all cases and consisted of total lobectomy in the lobe having the dominant nodule, with isthmectomy and near-total lobec- preoperatively; there was no malignancy at frozen sec- tomy in the contralateral side, leaving a small quantity of about tion evaluation. Parathyroid autotransplantation was per- 2 g of thyroid tissue adjacent to the parathyroid glands and their formed in 7 patients, and none developed temporary or blood supply. Recurrent laryngeal nerves in all cases were iden- permenant hypoparathyroidism. tified and traced to the cricoid cartilage in either side. Every Postoperative complications are summarized in attempt was made to demonstrate and preserve all of the par- Table 3. The temporary recurrent laryngeal nerve palsy athyroid glands with their blood supply. When a parathyroid rate with respect to the nerves at risk was 3.3% (10 of gland was damaged, it was transplanted into the sternocleido- 304 nerves), whereas temporary hypoparathyroidism was mastoid muscle. 7.2% (11 of 152 patients). Neither permanent recurrent In each patient, serum calcium and phosphorus levels were laryngeal nerve palsy nor permanent hypoparathyroid- checked on the first and second postoperative days. Hypocal- cemia is defined as low ionized serum calcium levels and the ism occurred. Wound hematoma developed in 1 patient presence of symptoms of hypocalcemia. We considered hypoc- and required re-exploration. Seroma in another patient alcemia temporary when it lasted about 3 to 6 weeks after sur- needed no medical or surgical intervention. Five papil- gery. Calcium levels were followed up in patients who were tem- lary carcinomas in 4 female patients and 1 male patient porarily hypocalcemic and who needed calcium supplements. were diagnosed by using paraffin blocks. We performed iodine I 131 ablation in these patients. Neither wound RESULTS infection nor mortality was noted. There were 113 female and 39 male patients, with a mean COMMENT age of 43 years (range, 24-77 years). We performed near- total thyroidectomy in all patients; the various indica- The surgical treatment of benign thyroid disease is still tions are summarized in Table 1. The clinical signs in controversial. Many treatments have been described for these patients are summarized in Table 2. Sixty-six pa- the surgical management of multinodular goiter, includ- tients were treated medically because of hyperthyroid- ing unilateral or bilateral subtotal thyroidectomy, hemithy- ism to achieve euthyroidism preoperatively. Thyroid scin- roidectomy, near-total thyroidectomy, and total thy- tigraphy depicted hypoactive nodules in 73 patients. Fine- roidectomy. Despite numerous studies of operative needle aspiration biopsy was performed in 87 patients, strategies, we still do not have clear evidence about which and the results were neither suspected nor malignant his- option is the best. When the disorder affects both lobes, (REPRINTED) ARCH SURG/ VOL 139, APR 2004 WWW.ARCHSURG.COM 445 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 total or near-total thyroidectomy is mandatory, espe- ablation. An advantage of near-total thyroidectomy over sub- cially in younger persons, to obviate suppressive therapy total thyroidectomy is that the thyroid remnant of about and possible relapse. Subtotal thyroidectomy may be 2 g renders it accessible to 131I
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