Role of total thyroidectomy in the treatment of thyroid diseases.

Surgery on the thyroid gland has usually been reserved for patients with goiters accompanied by obstructive manifestations, malignancy and/or failed medical management. In their interesting paper, Misiakos et al (1) discuss some of the potential benefits of using a total thyroidectomy in the management of both benign and malignant thyroid disease in Greece. The authors make a case for total thyroidectomy on account of the ease of monitoring thyroid status postsurgery, the less likelihood of recurrence and the lack of need for completion thyroidectomy if malignancy is subsequently noted. The authors make the provocative assertion that total thyroidectomy is the preferred surgical approach to both benign and malignant thyroid disease.

The authors did not differentiate between total thyroidectomy and near-total thyroidectomy; in the latter, a small amount of thyroid tissue is left in situ to minimize trauma to the recurrent laryngeal nerve. Overall, malignancy in multi-nodular goiters is uncommon, on the order of 10%. The routine use of fine needle aspirate has revolutionized the approach to thyroid nodules. However, despite the accuracy of frozen sections, (2) they have failed to gain wide acceptance among surgeons. Increased costs for operative time, as well as processing pathologic specimens without proven clinical benefit in outcomes, may have contributed to this trend. (3)

In the United States, in recent times, a more aggressive approach involving a near total thyroidectomy for significant differentiated thyroid cancer lesions has been adopted. However, low risk patients with differentiated thyroid cancer have an excellent survival rate, and it is difficult to prove that a total thyroidectomy in this group offers significant advantages over limited surgery. The removal of the isthmus at the time of initial thyroid surgery may make completing a thyroidectomy easier; however, completion of thyroidectomies or adjunctive radioactive iodine ablation can often be done at specialized centers with acceptable morbidity.

[ILLUSTRATION OMITTED]

Data from other endemic areas, such Turkey and India, also indicate a variety of benign thyroid diseases possibly amenable to the surgical approach. Fine needle aspiration has reduced the number of patients requiring thyroid surgery; however, in some situations, surgery may be required. For a solitary benign nodule, a lobectomy and isthmusectomy appear sufficient, whereas with bilateral nodules, a near-total thyroidectomy appears reasonable. Many endocrinologists in the United States would consider a total thyroidectomy for benign solitary nodule as unwarranted and a high risk procedure.

A near-total thyroidectomy has, however, emerged as an excellent option for amiodarone-induced thyrotoxicosis refractory to medical management. In the United States, radioactive iodine treatment with or without initial treatment with thionamides is a popular option for hyperthyroidism. It is likely to remain the preferred option among many endocrinologists. Radioactive iodine has been used successfully to treat hyperthyroidism in developing countries. While surgery has traditionally been the approach to goiters with obstructive symptoms, radioactive iodine has also been used successfully in patients with obstructive goiters deemed high risk for surgery.

The main reticence to performing total thyroidectomy has been the higher likelihood of damage to the recurrent laryngeal nerve and induction of hypoparathyroidism. Unilateral recurrent nerve palsy can result in permanent hoarseness with social disability, while bilateral damage may result in a permanent tracheotomy. Identification of recurrent laryngeal nerve during surgery markedly reduces the risk of nerve injury during a thyroidectomy. Using newer surgical techniques, such as video assisted techniques and loupe magnification (4) for identification of the recurrent laryngeal nerve may result in better outcomes, but these newer techniques are expensive and require additional training, which may represent obstacles to widespread adoption.

There is no specific mention of the type of anesthesia used for the thyroid surgeries in the paper by Misiakos et al, (1) presumably most were done under general anesthesia. Local anesthesia is under reevaluation as an alternative method for thyroidectomy. (5) Its proponents claim similar outcomes may be achieved, but with the advantages of a quicker recovery time and a lower cost. However, most thyroid surgery in the United States will continue to be performed under general anesthesia.

An informed patient with thyroid disease and access to endocrinologists, pathologists, skilled anesthesiologists and surgeons has the potential for a good disease outcome. Other factors which need consideration include patient preferences, medico-legal aspects, costs, available local resources, and cultural idiosyncrasies, all which may impact both treatment and follow-up. The contribution by Misiakos et al (1) will stimulate a much needed discussion on the extent of thyroid surgery in the management of thyroid disease. However, while total or near-total thyroidectomy remains an important option in dealing with specific thyroid diseases, it is premature to proceed to widespread adoption of total thyroidectomy in lieu of partial thyroidectomy in thyroid disease.

References

1. Misiakos EP. Liakakos T, Macheras A, et al. Total thyroidectomy for the treatment of thyroid diseases in an endemic area. South Med J 2006;99:1224-1229.

2. Anton RC, Wheeler TM. Frozen section of thyroid and parathyroid specimens. Arch Pathol Lab Med 2005;129:1575-1584.

3. Wong Z, Muthu C, Craik J, et al. Role of intraoperative frozen section in the management of thyroid nodules. ANZ Surg 2004;74:1052-1055.

4. Testini M, Nacchiero M, Piccinni G, et al. Total thyroidectomy is improved by loupe magnification. Microsurgery 2004;24:39-42.

5. Snyder SK, Roberson CR, Cummings CC, et al. Local anesthesia with monitored anesthesia care vs general anesthesia in thyroidectomy: a randomized study. Arch Surg 2006;141:167-173.

Alan N. Peiris, MD, PhD, MRCP (UK), and Prith Peiris, MD

From the Department of Endocrinology, Mountain Home VAMC, and the Division of Endocrinology, East Tennessee State University, Johnson City, TN; and the Department of Anesthesiology, Mayo Clinic, Jacksonville, FL.

Reprint requests to Alan N. Peiris, MD, PhD, MRCP (UK), James H. Quillen Com/East Tennessee State Uiniversity, VAMC Building 2, PO Box 70622, Johnson City, TN. Email: [e-mail]