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12. Surgery

  • Page ID
    18305
  • Surgical Considerations for Thyroid Tumours

    • Thyroid lobectomy
      • 25% may require long-term thyroid hormone replacement
      • Thyroid replacement may not be available
      • TSH/T3/T4 monitoring may be unavailable
    • Total thyroidectomy
      • Transient hypocalcaemia in 5-60%
      • Permanent hypocalcaemia in 1.5-5%
      • Calcium monitoring and replacement may not be available
      • Hypocalcaemia may be fatal
    • Bilateral RLN injury may be fatal
    • Central neck dissection increases complication rates (RLN and hypocalcaemia)
    • Occasional thyroid surgeons have higher hypocalcaemia and RLN complication rates
    • If RAI unavailable
      • Must rely on curative surgical treatment
      • May not require total thyroidectomy
    • Follow-up may be unreliable

     

    Surgical Options for Thyroid Tumours

    • Standard of care for suspected cancer
      • Thyroid lobectomy
      • Total thyroidectomy
    • Lesser surgery a consideration when
      • Diagnostic tests such as FNAC and U/S are not available
      • Patients cannot access thyroid or calcium monitoring and replacement
      • Surgical options
        • Open biopsy and await histology before planning definitive surgery
        • Nodulectomy (no referral possible, isthmic and anterior placed nodules rather than posterior which makes repeat surgery difficult and dangerous)
        • Subtotal thyroidectomy
    • Neck dissections
      • Central neck dissection
      • Lateral neck dissection

     

    Diagnostic Nodulectomy vs. Thyroid Lobectomy

    In the absence of a cytologic diagnosis of a thyroid nodule, and when clinically indicated to obtain a histopathologic diagnosis, the question arises whether one should perform a nodulectomy or thyroid lobectomy. Even though thyroid lobectomy is the standard of care, at least 25%* of lobectomy patients will require long-term thyroid replacement therapy.

    • Thyroid lobectomy
      • Therapeutic for some differentiated cancers
      • Ipsilateral revision surgery not required
    • Nodulectomy
      • Consider only if patients do not have access to thyroid replacement
      • Nodulectomy ideal for isthmus nodules, or nodules located along the anterior/inferior aspect of the thyroid lobe
      • If nodule situated deeply/posterior in gland, then one should identify the RLN prior to the nodulectomy to avoid injuring the RLN
      • May need to do completion lobectomy depending on histology of nodule, with increased risk to RLN associated with revision surgery

    * Ahn D, Sohn JH, Jeon JH. Hypothyroidism Following Hemithyroidectomy: Incidence, Risk Factors, and Clinical Characteristics J Clin Endocrinol Metab. 2016 Apr;101(4):1429-36https://doi.org/10.1210/jc.2015-3997

    * Said M, Chiu V, Haigh PI. Hypothyroidism after hemithyroidectomy. World J Surg. 2013 Dec;37(12):2839-44 https://www.ncbi.nlm.nih.gov/pubmed/23982782

     

    Subtotal Thyroidectomy

    Subtotal thyroidectomy may be applicable in selected patients with benign thyroid goitres and differentiated cancers who cannot undergo total thyroidectomy due to lack of access to thyroid or calcium monitoring and replacement.

    The Dunhill procedure involves complete removal of one thyroid lobe with preservation of the superior and posterior thyroid on contralateral side.  The posterior thyroid tissue near the cricothyroid joint is preserved, with the intent of not disturbing the recurrent laryngeal nerve, although failure to identify the nerve does potentially increase risk of injury.  Similarly, the intent of preservation of the superior and posterior thyroid tissue is to increase the likelihood of preservation of the superior parathyroid glands, which are generally located along the posterosuperior aspect of the gland.

    Risks (Compared to thyroid lobectomy/total thyroidectomy)

    • Haemorrhage
    • Potential increased risk of recurrent laryngeal nerve injury (if RLN not identified)
    • Parathyroid glands are generally not specifically identified
    • Uncertainty whether sufficient functioning thyroid tissue preserved to render  patient euthyroid
    • Risk of recurrence of a goitre
    • Revision surgery more difficult
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