Thyroid disease and surgery

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Thyroid disease and surgery

• Mr A Ahmad
• Consultant General and Vascular Surgeon
• North Devon District Hospital

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Thyroid gland

• 20 grams
• Derived from embryonic endoderm
• Superior and inferior thyroid arteries
• 3 pairs of veins
• Maintain metabolic homeostasis by regulating
• Intermediary metabolism
• Body weight
• Oxygen requirements
• Body temperature
• control of growth, reproduction and
  differentiation

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THYROID HORMONES IN THE BLOOD

• Approximately 99.98 of T4 is bound to 3 serum
  proteins
• Thyroid binding globulin (TBG) 75
• Thyroid binding prealbumin (TBPA) 15-20
• Albumin 5-10
• Only 0.02 of the total T4 in blood is unbound
  or free.
• Only 0.4 of total T3 in blood is free.

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PITUITARY-THYROID AXIS



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History

• History very important
• Looking for symptoms that suggest tumour
• Duration
• Local symptoms
• Systemic symptoms

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Examination

• Signs that suggest tumour
• Local signs
• Systemic signs

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Investigations

• Haematological
• Ultrasound

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Investigations

• Haematological
• Ultrasound
• CT

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Investigations

• Haematological
• Ultrasound
• CT
• Radioisotope scans

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Investigations

• Haematological
• Ultrasound
• CT
• Radioisotope scans
• Histology
• FNA, Biopsy

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Pathology

• Benign
• Goitre, Cyst, Nodule, Graves, Hashimotos
• Malignant
• Papillary, Follicular, Medullary, Anaplastic,
  Lymphoma

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Indications for surgery

• Recurrent cyst
• Nodule
• Graves
• Goitre symptomatic
• Tumour

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Surgical Treatment of Graves' Disease
Evidence-Based approach. Stålberg P, at al. World
J Surg. 2008 Mar 8

• 1) There are no preference in the treatment
  options for adults.
• 2) Total thyroidectomy has same complication
  rates as subtotal, but higher cure rates and
  negligible recurrence rates (grade A
  recommendation).
• 3) If severe Graves Opthalmopathy(GO)is present,
  surgery or RAI combined with glucocorticoids
  (grade B recommendation).
• 4) The extent of thyroid resection does not
  influence the outcome of GO (grade B
  recommendation).
• 5) RAI or surgery advocated for children (grade C
  recommendation - lack of studies).
• 6) Increased cancer risk with RAI in children
  below the age of 5 years supports surgery in this
  setting (grade A recommendation).

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Total or subtotal thyroidectomy for Graves?

• Equal rate of complications RLN palsy (0.7 -
  0.9)?
• Equal rate of transient hypocalcemia (9.6 -
  7.4)?
• Equal rate of permanent hyporarathyroidism (0.9
  - 1.0)?
• Total thyroidectomy no recurrence
• Subtotal thyroidectomy 7.9 recurrence
  
  
• 
  Palit. Et al 2000 J.
  Surg Res
• 
  Witte
  et al 2000 WJ Surg
• Unpredictable rate of euthyroidism after subtotal
  (how mach to leave?) up to 70 develops long term
  hypothyroidism
• 
  Michie 1975 Br J Surg
• Micropapillary thyroid carcinoma found in 8 of
  patients with GD
• 
  Stalberg. 2008 WJ Surg
  

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Surgery

• Nodule excision
• Thyroid lobectomy
• Subtotal thyroidectomy
• Total thyroidectomy

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Theatre considerations

• Position
• Incision
• Diathermy options
• Flaps
• Poles
• Nerves
• Drains
• Skin closure

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Complications

• 1-2 risk or permanent RLN injury
• (In non-thyroid specialized surgeon up to
  10-15 reported)?
• 15-20 risk of temporary hoarseness
• Up to 15-20 chances of the EBSRN injury high
  pitched voice
• 1-2 risk of permanent hypoparathyroidism
• 0.5 - 1 risk of bleeding
• 0.5 - 1 risk of infection
• Scar

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Pearls from an Expert (Mazzaferri)?

• No imaging on asymptomatic pts with normal glands
  by palpation too many false positives
• Symptoms suggestive of invasion need tissue dx
• Two or more suspicious features (Hamming study)
  need surgery, regardless of FNA
• Multinodular goiter carries a substantial risk of
  cancer
• Greater suspicion of nodules in males
• Male over 60 consider surgery regardless of FNA,
  due to high likelihood of cancer