Surgery of the thyroid gland

Records of 92 patients operated on for thyroid diseases were reviewed. There were four histologic groups: adenoma-56 (61%), thyrotoxicosis-22 (24%), cancer-10 (11%) and Hashimoto's thyroiditis-4 (4%). Among the cold nodules, 9% were malignant. Routine frozen section examination revealed three cases of cancer and three other cases were missed but were discovered on permanent section examination. The type of operations were lobectomy with or without isthmusectomy, subtotal thyroidectomy and modified radical neck dissection. Postoperative complications included two thyroid crises, two recurrent laryngeal nerve injuries, one laryngeal obstruction and hypothyroidism, and one wound infection. There was no surgical mortality.

Outcome of sub-total thyroidectomy for thyrotoxicosis in Iceland and Northeast Scotland

A comparative study of the outcome of surgical treatment for thyrotoxicosis was carried out in two countries with dissimilar dietary iodine levels. In the area with a high iodine level (Iceland) the prevalence of post-operative hypothyroidism was five times lower, but recurrent hyperthyroidism was five times higher, than in the area with lower iodine levels (northeast Scotland). The total morbidity reached comparable levels in the two samples. The prevalence of positive thyroid antibody tests and serum thyrotrophin levels was lower and the functional capacity of the thyroid remnant higher in the area with the higher dietary iodine intake. The study provides further evidence that there are important regional differences in the prevalence of factors known to influence the response to surgical treatment of thyrotoxicosis which should be taken into account when planning treatment services.

Surgical treatment of hyperthyroidism in children

During the past ten years, subtotal thyroidectomy for hyperthyroidism was performed upon 43 children at Childrens Hospital of Los Angeles. There were no deaths, no recurrent laryngeal nerve injuries and no permanent hypoparathyroidism. During the one to ten year follow-up period, one patient had recurrent hyperthyroidism develop and was treated with 131I. Twenty-five patients are hypothyroid and require thyroid supplement; 14 are euthyroid and receiv no medication. Postoperative thyroid function did not correlate well with gland remnant size, degree of fibrosis or the extent of lymphoid follicle formation. Lymphocytic infiltration was more severe in patients who had hypothyroidism develop postoperatively. Transient hypocalcemia developed in 22 patients. The effectiveness and safety of the surgical treatment for hyperthyroidism in children is reaffirmed, and it is advocated for consideration over 131I or prolonged medical therapy.

Thyroid surgery in children and teenagers

From 1961 to 1976 62 patients under age 20 underwent thyroidectomy for various thyroid disorders. Twenty-four thyroid lobectomies and eight subtotal or near-total thyroidectomies were performed for benign nodular goiter. Eight near-total thyroidectomies and two thyroid lobectomies were performed for carcinoma. Two patients also had a radical neck dissection. Twenty patients with hyperthyroidism underwent near-total thyroidectomy. Postoperative complications occurred in six patients-all with hyperthyroidism. Operative mortality was zero. Two indications for thyroidectomy in our series were nodular goiter (to rule out carcinoma), and hyperthyroidism (that was not well-controlled medically or where surgery was chosen as primary therapy). In patients with nodular goiters that required surgery, a minimal complication rate occurred. By contrast, surgery for hyperthyroidism was associated with a high postoperative complication rate, six of 20 patients or 30%, which must be anticipated by the surgeon.

Hypocalcemia after thyroidectomy: mechanisms and management

Hypocalcemia persists as a problem after thyroidectomy. We reviewed our experience with 245 thyroidectomies to define the spectrum of hypocalcemia, elucidate the mechanisms of hypocalcemia, and formulate a rational basis for its management. Postoperative hypocalcemia occurred in 8.6% of all patients undergoing thyroid surgery with incidence the highest in patients with total thyroidectomy for cancer (28%) and those with subtotal thyroidectomy for thyrotoxicosis (23%). Incidence was low in patients having subtotal thyroidectomy for other diseases (1.5%) and lobectomy (0%). The high incidence of hypocalcemia following subtotal thyroidectomy for thyrotoxicosis but not for other diseases suggests that a mechanism other than removal or damage of the parathyroids is responsible for the hypocalcemia. This may well be thyrotoxic osteodystrophy. This hypocalcemia usually occurs early, is of moderate degree, and is transient. Management includes calcium gluconate for acute symptoms and calcium lactate with vitamin D2 for chronic symptoms.

[Preoperative treatment of hyperthyroidism (author's transl)]

The preoperative preparation of hyperthyroidism requires the selective use of various drugs. As in the past, Plummer's iodine therapy takes precedence. Thyrostatics or beta receptor blockers, on the other hand, are only used in selected cases. The aim of preoperative preparation is euthyroidism. It is most rapidly and safely attained with Endoiodin (prolonium iodide) or combination of Endoiodine plus beta receptor blokkers. Thyrostatics appear to be less suitable for preparation, because they have a slow onset of action. Moreover, thyrostatics lead to densifications and adhesions of the thyroid gland capsule to the surrounding tissue, so that the preparation becomes complicated. 254 patients with hyperthyroidism and decompensated toxic adenoma were surgically treated without complications as a result of preparation with Endoiodin.

[T3-thyrotoxicosis in a 12 year old girl (author's transl)]

Isolated Triiodothyronine (T3) hyperthyroidism in childhood is rate. The incidence among hyperthyroid children is about 10%. The authors present a case history of a 12 2/12 year old girl with T3-thyrotoxicosis. Cause, diagnosis and therapy are thoroughly discussed. The importance to estimating serum T3 concentration for establishing the diagnosis of T3 hyperthyroidism is emphasized.

The release of LH and FSH during the thyroid surgery for hyperthyroidism

Serial blood samples, collected from 21 females and 9 males through the thyroid surgery procedures were assayed for LH and FSH by a radioimmunoassay (RIA) technique. During thyroid surgery the serum LH increased significantly in the male patients from the preoperative levels 20.66 +/- 11.67 to 45.49 +/- 18.50 mIU/ml (p less than 0.01), being unchanged or slightly lower in the female group. The serum LH progressively fell towards the end of the surgery, remaining over the preoperative levels i4 hrs after surgery; occasionally very high levels were observed. The release of LH seemed to be more precocious during the surgery in both sexes in patients belonging to the age group under 40 years by comparison to the older group. The serum FSH showed nonsignificant changes during and after surgery in both female and male patients excepting two menopaused female hyperthyroid patients and a woman of 60 years under laborious surgery for a cervicothoracic polynodular goiter. The data are suggesting the dissociated secretion of LH and FSH in both sexes excepting some cases of menopaused women.

Hypothyroidism following partial thyroidectomy for thyrotoxicosis and its relationship to thyroid remnant size

One hundred and twenty-two patients were reviewed 1-7 years after partial thyroidectomy for thyrotoxicosis by two surgeons who had left thyroid remnants of different size. There was no significant difference in the prevalence of hypothyroidism or in the serum levels of thyroxine, tri-iodothyronine or thyroid-stimulating hormone between the two groups of patients. The overall prevalence of hypothyroidism was 16 per cent.

Management of carcinoma of the thyroid

Greater precision has developed in recent decades in the selection of patients for operation for thyroid nodules suspicious for malignancy and in adapting operative procedures to the extent and pathologic variety of the individual thyroid carcinoma, when present. A thyroid lobectomy is considered to be the minimal operative procedure usually indicated for a suspicious thyroid nodule or carcinoma involving one lobe of the thyroid gland. Factors determining the extent of operation for thyroid carcinoma include the pathologic variety, gross distribution of the malignancy, and health status of the individual patient. Total or near total thyroidectomy should be considered for all patients with thyroid carcinoma except for single occult carcinomas and unilateral low grade angio-invasive carcinomas. Removal of lymph nodes in regions adjacent to the thyroid carcinoma is advisable, lateral neck dissections being reserved for patients with palpable lymphadenopathy, demonstrated metastases to lateral cervical lymph nodes, or a poorly differentiated carcinoma likely to metastasize to these lymph nodes. A modified radical lymph node dissection is satisfactory except for those carcinomas invading muscles in the neck. Anatomic neck dissections provide a better prognosis than incomplete lymph node procedures for patients with regional lymph node metastases. Following operation, patients should receive thyroid hormone therapy, be evaluated for possible treatment with radioactive iodine or other therapeutic measures, and be followed for evidence of recurrent disease as well as thyroid and parathyroid function. Adequate early operation is preferred to late ultraradical procedures, from standpoints of morbidity and prognosis. Unfavorable prognostic factors include extensive gross disease, poorly differentiated carcinoma present as the entire lesion or as foci in a differentiated carcinoma, and age over 40. With adequate surgical treatment, the prognosis for operable thyroid carcinoma is good.

[131I therapy in hyperthyroidism. Results of treatment from 1960-1974]

488 PATIENTS WITH Graves' disease were treated by 131Iodine between 1960 and 1974. 427 (87,5%) of these patients were reexamined several times (clinically, 131I-uptake, PB127I, T4 (CPB-A), T3-uptake, and since 1973 TRH-test). The 131I was given as an individually calculated single dose treatment, using 7 000 -- 10 000 rd before 1965 and 6 000 rd thereafter. Two thirds of the patients became euthyroid after a single 131I-dose. In 20% the treatment had to be repeated. These patients show evidently a different biological behaviour of their disease, since multiple treatments revealed a higher rate of failure (33--35%). There is no principal difference between the out-come after 131I-therapy and surgery concerning the rate of failure, respectively relapse (3--4%) and hypothyroidism. Early incidence of hypothyrodism is dose--dependent, as could be shown in patients treated with higher doses before 1965. The reduction of the irradiation dose to 6 000 rd was followed by a drop of hypothyroidism from 18% to 7%. The reasons of late incidence of hypothyroidism are discussed. The incidence of hypothroidism was calculated by three different methods (over-all incidence, incidence within the observed interval after therapy, life-table method). All three methods revealed different results. This has to be taken into account comparing results after radioiodine as well as after surgery. Radioiodine therapy for hyperthyroidism offers a true alternative to surgery.

Does preoperative iodide treatment for thyrotoxicosis bring about involution?

It is generally believed that preoperative iodide decreases the hyperplasia of the toxic thyroid gland. Histometric studies of glands from thyrotoxic patients pretreated with propranolol alone compared with those from patients pretreated with propranolol and iodide failed to confirm this. Although histological appearances and volume percentage measurement of component tissues suggested that the glandular epithelium had involuted after iodine treatment, measurement of their absolute mass indicated that the mean mass of epithelium was the same in both groups and that involution had not occurred. We conclude that considerable confusion in the thyroid literature has arisen through incorrect use of the term involution.