Goiter Surgery

• Extent of Surgery
  • Decisions regarding the extent of surgery:
    • Relate to the balance between operative complications and the risk of recurrence
  • Some suggest total thyroidectomy for goiter:
    • Others recommend a more conservative initial surgical plan
    • Some, such as Kraimps, support a selectively aggressive surgical treatment plan based on extent of disease
• Complication rates must be kept extremely low in the setting of treatment of benign thyroid disease:
  • Therefore, I suggest a conservative philosophy:
    • Tailoring the extent of surgery to the initial disease with the minimum procedure being:
      • A total unilateral lobar resection:
        • Reserving bilateral surgery for significant bilateral goiter
• Studies looking at the extent of surgery and benign multinodular goiter recurrence are confounded by several factors:
  • Variability in the initial extent of thyroid gland nodularity
  • Variability in the extent of recognition of contralateral nodularity at first surgery
  • Insufficient follow-up periods in many studies
  • Variable definitions of recurrence:
    • Some studies, for example, diagnose recurrence based on an asymptomatic, ultrasonographic identification of thyroid nodularity
    • A more reasonable definition of recurrence is the development of:
      • Clinical, palpable thyroid enlargement:
        • Which again meets surgical criteria for goiter treatment
• The question is, can less than total thyroidectomy and even hemithyroidectomy:
  • Be performed if anodular normal tissue is left?
• Complication rates of bilateral surgery are expected to be higher than unilateral
• Conservative initial surgery also allows a patient to avoid a lifetime of replacement therapy
• However, long-term studies show the overall recurrence rate after surgery for goiter:
  • Is in the range of 15% to 42%
• When recurrence occurs and requires revision goiter surgery:
  • The complication rates are significantly higher than for first-time surgery:
    • With RLN rates of paralysis ranging from:
      • 3% to 18%
    • Permanent hyperparathyroidism ranging from:
      • 0% to 25%
• The literature offers conflicting conclusions on factors associated with recurrence of goiter:
  • The duration of postoperative follow-up is important to consider when examining recurrence of goiter
  • The data offered by Delbridge, Guinea, and Reeve suggest recurrences:
    • May require 10 to 13 years to manifest
  • Rojdmark and Jarhult found that the overall recurrence rate rose to:
    • 42% with 30-year postoperative follow-up
  • Bistrup et al., in a randomized, prospective, non-placebo, controlled study, showed rates of recurrence for nontoxic goiter between:
    • 14% and 22%
    • They found the extent of surgery did not relate to the likelihood of recurrence
  • Hegedus, Nygaard, and Hansen found that the weight of thyroid tissue resected was actually greater in those patients who developed subsequent recurrence
  • However, Berghout et al., with a 7-year follow-up:
    • Found that unilateral surgery was associated with higher recurrence rates than bilateral surgery
  • Australian workers have shown that in patients with unilateral disease:
    • Hemithyroidectomy results in a 12% recurrence rate in the contralateral lobe
• Other workers have supported a philosophy of total thyroidectomy or bilateral subtotal thyroidectomy in most patients with goiter
  • Subtotal thyroidectomy is defined as:
    • Total lobectomy with a contralateral remnant approximately equivalent to a small normal lobe
  • Near total thyroidectomy is defined as:
    • A remnant of several grams is maintained in the contralateral bed typically adjacent to the RLN entry point
• In patients who require bilateral surgery:
  • The technique of subtotal lobectomy has been both recommended and condemned:
    • Cohen-Kerem, in a study of 124 patients with a follow-up of 7.6 years, noted that with bilateral subtotal technique:
      • Only 4% of patients required additional surgery
    • Pappalardo found similar rates of recurrence in 69 patients treated for benign goiter randomized to total versus subtotal procedures
    • Reeve et al., however, found subtotal thyroidectomy was associated with a 23% recurrence rate
• Clearly, less than lobectomy as a minimum procedure is unwise:
  • Cohen-Kerem et al. found a recurrence rate after unilateral subtotal resection was 60%
  • Kocher noted an 18% recurrence rate with nodule enucleation
• Kraimps, using a selectively aggressive surgical treatment plan based on the extent of disease, noted very low recurrence rates of 1% with lobectomy and 3% with bilateral surgery:
  • Others have supported such a selectively aggressive approach to surgery based on extent of disease
• Modern series show that in skilled hands:
  • Total thyroidectomy for goiter can be performed without significant complications, given the work of Reeve et al., Netterville et al., and others
  • Delbridge, Guinea, and Reeve noted that for patients with bilateral multinodular goiter, total thyroidectomy:
    • Can be associated with permanent paralysis of the RLN in 0.5% and permanent hypoparathyroidism in 0.4%
    • They believe the policy of autotransplantation of at least one parathyroid during each total thyroidectomy is in part responsible for the low rate of hypoparathyroidism
  • Grant, in his commentary of this article, wrote, “to consider total thyroidectomy as the only acceptable alternative would probably risk causing more cases of troublesome hypoparathyroidism than it would prevent cases of goiter recurrence:
    • Moreover, it seems difficult to assert total thyroidectomy as the only option for benign disease when many surgical authorities strongly disagree with its use, even in thyroid cancer
  • Some workers have suggested that the likelihood of identifying cancer in goiter specimens justifies total thyroidectomy:
    • Most studies document an incidence of malignancy in such specimens of between 3% and 17%:
      • Most are small, occult, incidentally noted malignancies within otherwise benign multinodular goiters and would not normally justify an aggressive surgical approach
• Berghout et al., has suggested a greater likelihood of recurrence in females and in patients with a positive family history of thyroid disease:
  • Overall, females were found to be three times more likely to require revision surgery
  • Those with a positive family history of thyroid disease were six times more likely to require revision surgery:
    • Others have found no such increased risk in these populations
      • I tend to be more aggressive in females and in those with a positive family history:
      • Especially if they are young
• Summary of the extent of Surgery for Goiter:
  • Complication rates must be low in the setting of surgery for benign thyroid disease
  • Less than unilateral lobectomy leads to extremely high recurrence rates and difficult reoperations and is to be condemned
  • The extent of surgery should be rationally tailored to the extent of initial disease
  • Dominant goitrous enlargement should be treated with total lobectomy on that side
  • Preoperative assessment with imaging will help to document the extent of surgery necessary on the contralateral side:
    • With clear-cut unilateral disease, total lobectomy is appropriate
    • With clear-cut evidence of bilateral goiter, bilateral surgery is appropriate
  • Consideration should be given for more aggressive surgery in young females and in patients with a positive family history of thyroid disease who may have a higher recurrence rate
  • In patients who have required multiple thyroid surgeries for benign recurrence and still have some remnant tissue remaining after the last revision surgery, radioactive iodine ablation can be considered
• Hashimoto’s Thyroiditis:
  • Other variables important during surgery are:
    • The degree of capsular blood vessel engorgement and friability, and goiter consistency
  • Goiters that are soft and compressible are more easily manipulated during surgery, whereas those that are firm can be challenging even when of small size
  • Generally, glands affected by Hashimoto’s thyroiditis are more difficult to work on than the more typical benign adenomatous goiter
  • Hashimoto’s glands, especially those resulting from the fibrotic variant of Hashimoto’s thyroiditis:
    • Can be firm and less compressible and have a friable, “sticky” surface, which bleeds easily
    • Such goiters can be associated with multiple perithyroidal lymph nodes that can sometimes make a surgeon consider papillary carcinoma
    • Such nodes also make parathyroid identification more challenging
    • The rare fibrous variant of Hashimoto’s thyroiditis is an especially firm variant:
      • Which makes the performance of less than total lobectomy challenging

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