Vol 39 # 2 June 2007 - Kma.org.kw

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June 2007KUWAIT MEDICAL JOURNAL 151roidism were seen in the same patient who hadtough adhesions between the gland ands u r rounding tissue (histopathology: papillarycarcinoma). There was no mortality in this study.DISCUSSIONThe outcome of endocrine surgical diseases ism e a s u red by the success of the operation atrelieving the endocrinopathy and the ability of thesurgeon to minimize postoperative morbidity [13] .Currently, opinions differ on both the proper extentof primary resection and the need for re-operationfor nodular benign thyroid disease [ 14 ] . Subtotalthyroidectomy was advocated to be safer than totalthyroidectomy [15] as it was thought that leavingbehind some thyroid tissue would pre v e n tsubsequent thyroxine replacement. However,nodules can also arise from portions of the glandthat were previously normal, and small nodulescan become symptomatic. In addition, recurrencerates as high as 42 to 45 percent have been reportedfollowing subtotal thyro i d e c t o m y [ 16 , 17 ] . The incidenceof recurrence has been directly related to a longpostoperative follow up and to large amounts ofremnant tissue [18,19] Most recurrences develop 10 to20 years after the primary surgery [20] . It has beendocumented that total thyroidectomy can beperformed safely in benign nodular goiter, but reoperationscarry a five-fold risk of surg i c a lcomplications where both sides had been dissectedpreviously [11,20,21,22,23] . Patients with recurrent MNGoften present with severe symptoms, includingdyspnea, dysphagia, and pain which may be due toa small postero-lateral lobule of the thyroid leftbehind during subtotal thyroidectomy. This oftenextends into the retro- esophageal area, causingsignificant pre s s u re symptoms [ 9 ] . Scarring anddisruption of normal tissue planes make furtherthyroid surgery more hazardous.Bron et al [23] concluded in their study on 834patients that total thyroidectomy for benign thyroiddisease prevented disease re c u r rence and minimizedthe morbidity associated with secondary operation.Giles and associates [ 1 ] reported 8.2 perc e n tincidence of thyroid cancer in MNG withoutprevious suspicion of malignancy and that subtotalthyroidectomy resulted in a substantial number ofcompletion thyroidectomies. Our study revealed an8 percent incidence of incidentally diagnosedt h y roid malignancy without the need for re o p e r a t i o n .The only strong argument against totalthyroidectomy is the potentially higher associatedcomplication rate. However, with experience andappropriate surgical technique, the morbidity oftotal thyroidectomy can be minimized [24,25] . Presentstudy demonstrated 0.6 percent incidence ofpermanent RLN palsy and 3 percent incidence ofpermanent hypoparathyroidism while re c e n tstudies of total thyroidectomy for benign diseasehave reported an incidence of 0.3 to 1.7 percent and0.7 to 3 percent re s p e c t i v e l y [ 20 , 26 , 27 ] . This is littledifferent from the complication rates recorded aftersubtotal thyroidectomy; 0.2 percent for permanentRLN palsy and 0.3 percent for permanenth y p o p a r a t h y ro i d i s [ 2 m0 ] . Capsular dissection technique,which reduces damage to parathyroid glands andp rotects RLN, has reduced the morbidity incomparison to the complication rates describedearlier [28] . During re-operation the incidence of RLNpalsy ranges from 15 to 23 percent for temporary[8, 29]and 2.6 to 15.5 percent for permanent palsywhich makes total thyroidectomy the procedure offirst choice by many surgeons, whenever the wholegland shows nodular transformation [7,30] . Publisheddata described 47 to 53 percent incidence formalignancy in prophylactic completion thyro i d e c t o m yspecimens after initial lobectomy for solitaryt h y roid nodule [ 31 , 32 ] . This observation furthersubstantiates the role of total thyroidectomy in caseof unexpected thyroid malignancy, which willallow I 131 scanning to detect and treat metastaticdisease. The reported incidence of 0.9 to 1.6percent [7,30] for permanent hypoparathyroidism isslightly higher than 0.6 percent noted in our study.The current policy to reimplant diced parathyroidglands in muscle is widely accepted as an efficientway to avoid long term hypoparathyroidism [33] .CONCLUSIONWe recommend total thyroidectomy for bilateralmultinodular goiter to prevent disease recurrenceand to obviate the need for completiont h y roidectomy in case of a final diagnosis ofthyroid malignancy.REFERENCES1. Giles Y, Boztepe H, Terzoiglu T, Tezelman S. The advantageof total thyroidectomy to avoid reoperation for incidentalthyroid cancer in multinodular goiter. Arch Surg 2004;139:179-182.2. Gough IR, Wilkinson D. Total thyroidectomy formanagement of thyroid disease. World J Surg 2000; 24:962-963.3. Khadra M, Delbridge M, Reeve TS, Poole AG, Crummer P.Total thyroidectomy: its role in the management of thyroiddisease. Aust N Z J Surg 1992; 62:91-95.4. Rossi RL, Cady B, Silverman ML, Wool MS, Horner TA.Current results of conservative surgery for differentiatedthyroid carcinoma. World J Surg 1986; 10:612-622.5. Liu Q, Dijuricin G, Prinz R. Total thyroidectomy for benignthyroid disease. Surgery 1998; 123:2-7.6. Waldstrom C, Zedenius J, Guinea A, Reeve T, Delbridge L.Multinodular goiter presenting as a clinical single nodule:how effective is hemithyroidectomy? Aust NZ J Surg 1998;69:34-36.7. Mishra A, Agarwal A, Agarwal G, Mishra SK. To t a l
152Total Thyroidectomy for Bilateral Benign Thyroid Disease: Safety Profile and Therapeutic Efficacy June 2007thyroidectomy for benign thyroid disorders in an endemicregion. World J Surg 2001; 25:307-310.8. Reeve TS, Delbridge L, Brady P, Crummer P, Smyth C.Secondary thyroidectomy: a twenty-year experience. WorldJ Surg 1988; 12:449-453.9. Colak T, Akca T, Kanik A, Yapici D, Aydin S. Total versussubtotal thyroidectomy for the management of benignmultinodular goiter in an endemic region. Aust NZ J Surg2004; 74:974-978.10. Koru N, Asci C, Yilmazlar T, et al. Total thyroidectomy orlobectomy in benign nodular disease of the thyro i d :changing trends in surgery. Int Surg 1997; 82:417-419.11. Pappalardo G, Guadalaxara A, Frattaroli FM, Illomei G,Falaschi P. Total compared with subtotal thyroidectomy inbenign nodular disease: personal series and review ofpublished reports. Eur J Surg 1998; 164:501-506.12. Menegaux F, Turpin G, Dahman M, et al. Secondarythyroidectomy in patients with previous surgery for benigndisease: a study of 203 cases. Surgery 1999; 126:479-483.13. Reeve TS, Delbridge L, Cohen A, Crummer P. To t a lt h y roidectomy: the pre f e r red option for multinodulargoiter. Ann Surg 1987; 206:782-786.14. Wilson DB, Staren ED, Prinz RA. Thyroid Reoperations:Indications and risk. Am Surg 1998; 64:674-678.15. Hay ID, Grant CS, Taylor WF, McConahey WM. Ipsilaterallobectomy versus bilateral lobar resection in papillarythyroid cancer: a retrospective analysis of surgical outcomeusing a novel prognostic scoring system. Surgery 1987;102:1088-1095.16. Rojdmark J, Jarhult J. High long term recurrence rate aftersubtotal thryoidectomy for nodular goiter. Eur J Surg 1995;161:725-727.17. Geerdsen JP, Frolund L. Recurrence of non toxic goiter withand without prospective thyroxine medication. ClinEndocrinol 1984; 21:529- 533.18. Piraneo S, Vitri P, Galimberti A, Salvaggio A, Bastalgi A.Ultrasonographic surveillance after surgery for euthyroidgoiter in patients treated or not treated with thyroxine. EurJ Surg 1997; 163:21-26.19. Zelmanovitz T, Zelmanovitz F, Genro S, Gus P, de AzevedoMJ, Gross JL. Analysis of the factors associated with therecurrence of post thyroidectomy goiter. Rev Assoc MedBras 1995; 41:86-90.20. Delbridge L, Guinea AI, Reeve TS. Total thryoidectomy forbilateral benign multinodular goiter: effect of changingpractice. Arch Surg 1999; 134:1389-1393.21. Siragusa G, Lanzara P, Di Pace G. Subtotal thyroidectomyor total thyroidectomy in the treatment of benign thyroiddisease: our experience [in Italian]. Minerva Chir 1998;53:233-238.22. Gough IR, Wilkinson D. Total thyroidectomy for managementof thyroid disease. World J Surg 2000; 24:962-965.23. Bron LP, O’Brien CJ. Total thyroidectomy for clinicallybenign disease of the thyroid gland. Br J Surg 2004; 91:569-574.24. Gough IR. Total thyroidectomy: indications, technique andtraining. Aust NZ J Surg 1992; 62:87-89.25. Bhattacharyya N, Fried MP. Assessment of the morbidityand complications of total thyroidectomy. Arch OtolaryngolHead Neck Surg 2002; 128:389-392.26. Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H,Gastinger I. Multivariate analysis of risk factors forpostoperative complications in benign goiter surg e r y :prospective multicenter study in Germany. World J Surg2000; 24:1335-1341.27. Liu Q, Dijuricin G, Prinz RA. Total thyroidectomy inmanagement of 909 patients with thyroid disease. Surgery1998; 123:2-7.28. Martensson H, Ternis J. Recurrent laryngeal palsy rate inthyroid gland surgery related to operations and nerves atrisk. Arch Surg 1985; 120:475-477.29. Wheeler MI. Thyroid surgery and the recurrent laryngealnerve. Br J Surg 1999; 86:291-292.30. Muller PE, Kabus S, Robens E, Spelsberg F. Indication, risks,and acceptance of total thyroidectomy for multinodulargoiter. Surg Today 2001; 31:958-962.31. Eroglu A, Berberglu U, Buruk F, Yildirim E. Completionthyroidectomy for differentiated thyroid cancer. J SurgOncol 1995; 59:261-267.32. Pasieka JL, Thompson NW, Mcleod MK, Burney RE. Theincidence of bilateral well differentiated thyroid cancerfound at completion thyroiectomy. World J Surg 1992;16:711-717.33. de Roy van Zuidewijin DBW, Songun I, Kievit J, van deVelde CJH. Complications of thyroid surgery. Ann SurgOncol 1995; 2:56-60.
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206WHO-Facts Sheet June 2007TB and
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