Less than total thyroidectomy for goiter: when and how?

A case report of coexisting multinodular goiter with carotid body tumor

INTRODUCTION

Carotid body tumor (CBT), a neuroendocrine neoplasm, and benign multinodular goiter (BMNG) are distinct pathologies affecting the neck region. Although rare, they can occur concurrently. This case contributes to the limited evidence regarding the association between these distinct pathologies and their operative management.

CASE PRESENTATION

The patient was a 45-year-old female with a palpable mass on the right side of her neck. She was diagnosed with Shamblin type III non-secretory CBT alongside BMNG. The surgical intervention included resection of the CBT, carotid artery bypass, and Dunhill thyroidectomy.

DISCUSSION

This case is the third reported instance of coexisting CBT and BMNG. Their causative relationship is evident in the literature without a clear explanation of the underlying mechanism. Both conditions are treated surgically. Dunhill thyroidectomy for BMNG is a safer option, offering more flexibility and advantages over other thyroidectomies.

CONCLUSION

This case highlights the complexity of managing such dual pathologies and may provide further evidence of their association.

Tracheomalacia following a total thyroidectomy in a patient with a large non-toxic goiter: A case report

INTRODUCTION

Nontoxic nodular goiter is one of the most prevalent thyroid conditions worldwide. Thyroidectomy for large goiters has a relatively high risk of postoperative airway obstruction, with tracheomalacia being one of the potential complications.

CASE REPORT

A 61-year-old woman complained of a lump in her neck for 45 years. The node is progressively enlarged, but she did not experience any breathing difficulty, hoarseness, or pain while swallowing. A total thyroidectomy was then performed. The histopathologic examination revealed colloid goiter. During the procedure, evaluation of the trachea revealed a tracheomalacia, so a tracheotomy was then performed on the patient. After a follow-up period of three months, the patient was no longer experiencing tracheomalacia, and the tracheostomy was successfully closed.

DISCUSSION

Surgery has been considered an acceptable approach for managing non-toxic goiter. The most common indications are compressive symptoms, substernal extension, inability to control hyperthyroidism through medication, and a suspicion of malignancy. However, thyroidectomy for large goiter carries a relatively high risk of postoperative respiratory obstruction. Diagnosing tracheomalacia can be challenging and often relies on bronchoscopy to assess the airway and observe the collapse of cartilage and membranes. Acquired tracheomalacia can be managed through internal or external stenting or tracheostomy.

CONCLUSION

Total thyroidectomy has been recommended as a suitable procedure for non-toxic and toxic multinodular goiter. Tracheomalacia may occur following thyroidectomy in patients with thyroid enlargement. Tracheostomy effectively manages tracheomalacia by creating a channel across the malacia's focal segment, restoring the airway's patency.

Total vs less than total thyroidectomy for benign multinodular non-toxic goiter: an updated systematic review and meta-analysis

BACKGROUND

We have performed an updated meta-analysis of randomized controlled trials (RCT) comparing total thyroidectomy (TT) with less than total thyroidectomy (LTT) for benign multinodular non-toxic goiter (BMNG).

OBJECTIVES

The objective was to evaluate the effects and outcomes of TT as compared to LTT.

METHODS

Eligibility criteria: RCTs comparing TT vs LTT.

INFORMATION SOURCES

PubMed, Embase, Cochrane Library and online registers were searched for articles comparing TT with LTT. Risk of bias: Articles were assessed for risk of bias using the Cochrane's revised tool to assess risk of bias in randomized trials (RoB 2 tool).

SYNTHESIS OF RESULTS

The main summary measures were risk difference using a random effects model.

RESULTS

Five randomized controlled trials were included in the meta-analysis. Recurrence rate was lower for TT compared to LTT. Adverse events like temporary or permanent recurrent laryngeal nerve (RLN) palsy and permanent hypoparathyroidism were similar in both groups except for the rate of temporary hypoparathyroidism which was lower in the LTT group.

DISCUSSION

All studies had unclear risk of bias for blinding of the participants and personnel and high risk of bias for certain selective reporting. This meta-analysis did not show any clear benefit or harm of either procedure (TT vs LTT) for goiter recurrence and re-operation rates (for both recurrence and incidental thyroid cancer). However, re-operation for goiter recurrence was significantly higher in the LTT group based on a single RCT. Evidence suggests increased rates of temporary hypoparathyroidism with TT but there was no difference in the rate of RLN palsy and permanent hypoparathyroidism between the two methods. The overall quality of evidence was low to moderate.

Minimally invasive thyroid and parathyroid surgery: modifications for low-resource environments

Minimally invasive thyroidectomy (MIT) and parathyroidectomy (MIP) are gaining popularity in the current surgical practice. The need for specific equipment and technology is an obstacle in the low-resource environment. This article provides simple and practical guidance for surgeons practicing in low-resource environments to help them attain quality surgical practice, maintain patient safety, preserve available resources, and achieve the best outcomes.

Giant multinodular goiter for 24 years; hidden in a village in Western Nepal

Here, we present the case of a giant multinodular goiter with retrosternal extension in an old lady with dyspnea for 3 months. The patient was treated with microscopic‐assisted total thyroidectomy without any postoperative complications.

Risk factors for postoperative morbidity after thyroid surgery in a PROSPECTIVE cohort of 1500 patients

BACKGROUND

Postoperative hypocalcaemia, recurrent laryngeal nerve palsy and postoperative bleeding are the most frequent postoperative complications after thyroid surgery, and therefore often used as quality indicators of thyroid surgery. We aimed to assess postoperative morbidity in a high-volume endocrine surgery unit, and to detect which factors are associated with higher risks.

METHODS

Prospective surgical cohort in a high-volume tertiary referral centre for endocrine surgery in xxx. The first 1500 patients operated with hemi or total thyroidectomy during 2010-2019 were included. Postoperative hypocalcaemia, recurrent laryngeal nerve palsy and postoperative bleeding were assessed in relation to pre- and peri-operative characteristics using multivariable logistic regression analyses, expressed as odds ratios and 95% confidence intervals.

RESULTS

Overall, 1043 patients (69.5%) received a total thyroidectomy and 457 (30.5%) a hemithyroidectomy. Permanent hypocalcaemia occurred in 3.1%, permanent recurrent laryngeal nerve palsy in 1.8% and surgical reintervention for bleeding in 2.6%. Younger age, female sex and cancer were risk factors for permanent hypocalcaemia. No clear risk factors could be identified for permanent nerve palsy. Female sex, high body mass index and heavier thyroids were protective against postoperative bleeding after total thyroidectomy.

CONCLUSIONS

Surgical experience in endocrine surgery seems beneficial for clinical outcomes and contributes to organizational efficiency. A low complication risk can be obtained by trained high-volume endocrine surgeons, yet the risk is not negligible.

Patient satisfaction following thyroidectomy in surgical mission: a prospective study

BACKGROUND

Surgical volunteer mission is a well-recognized approach for reducing the burden of surgical disease worldwide. The aim of this study was to evaluate safety and patient satisfaction of thyroid surgery in the context of surgical mission carried out in Bohol Province, Philippines.

METHODS

This was a prospective study involving consecutive patients undergoing thyroid surgery in the surgical mission held in 2018. Informed consent was obtained from the patients. Safety defined as observed serious postoperative complication rate as compared to its expected based on American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was the primary endpoint, whereas patient satisfaction rated on a 5-point Likert scale was the secondary endpoint. Expected serious complication rate was calculated using the surgical risk calculator of NSQIP. Thyroid surgery included partial resections, hemi-, subtotal, and total thyroidectomies.

RESULTS

Thirty-eight patients underwent thyroidectomy performed by 4 surgeons in 2018 mission. Mean age of the patients was 40.6±11.3 years. Male to female ratio was 2:36. Goiter was the indication for surgery in 33 (86.8%) patients, whereas 5 (13.2%) patients were operated for thyroid malignancy. Postoperative serious complication and reoperation occurred in 1/38 (2.6%) for hematoma on first postoperative day. Expected and observed serious complication rates did not differ (1.1% vs. 2.6%; P=0.385). Ninety-seven percent of patients were satisfied with outcomes of surgery.

CONCLUSIONS

This prospective cohort study found thyroid surgery performed within a surgical mission to be safe. Patient satisfaction rate was 97%. Further research is needed to develop and validate patient satisfaction assessment tools in surgical missions.

Hemithyroidectomy for benign euthyroid asymmetric nodular goitre

BACKGROUND

There is no consensus on the optimal surgery extent for patients with benign euthyroid asymmetric nodular goitre (AMNG).

METHODS

We reviewed medical literature using the PubMed engine to address the following issues: definition and prevalence, rationale for hemithyroidectomy, long-term outcomes, follow-up, revision surgery and image-guided thermal ablation of contralateral benign thyroid nodules following hemithyroidectomy for AMNG.

RESULTS

In total, 102 articles were found in MEDLINE using a keyword search strategy; subsequently, we selected 36 articles with clinical pertinence.

CONCLUSIONS

AMNG is a common clinical and surgical problem. Depending on the extent of the disease and individual surgeon preferences, either unilateral or bilateral thyroidectomy can be performed. Hemithyroidecomy can be considered for some patients with AMNG and the low risk of recurrent disease as a safer alternative to total thyroidectomy but it requires life-long follow-up, is associated with a higher recurrence risk and a need for revision thyroidectomy in selected subjects.

Nontoxic Multinodular Goitre and Incidental Thyroid Cancer: What Is the Best Surgical Strategy?-A Retrospective Study of 2032 Patients

OBJECTIVES

A discussion with regard to the most optimal surgical procedure in nontoxic multinodular goitre (NTMNG). We assessed and compared three main types of operations in 2032 patients with NTMNG.

METHODS

This is a retrospective study of 2032 patients operated on in one center due to NTMNG. The observation period was 48 to 120 months (mean and SD: 87 ± 20).

RESULTS

The early complications included uni- and bilateral recurrent laryngeal nerve paralysis (URLNP, BRLNP), overt tetany (OT), and postoperative bleeding (POB). We observed after TT, STT, and DO URLNP: 15 (1.73%), 3 (0.64%), and 2 (0.28%), respectively (p < 0.05); BRLNP: 3 (0.34%), 2 (0.43%), and 0 (0.0%), respectively (p = 0.25); OT: 42 (4.84%), 6 (1.29%), and 9 (1.28%), respectively (p < 0.0001); and POB: 11 (1.26%), 4 (0.86%), and 3 (0.42%), respectively (p = 0.209). Persistent complications we observed after TT, STT, and DO are the following: URLNP: 9 (1.03%), 3 (0.64%), and 1 (0.14%), respectively (p = 0.086); BRLNP: 1 (0.11%), 1 (0.21%), and 0 (0.0%), respectively (p = 0.51); and OT: 11 (1.26%), 2 (0.43%), and 2 (0.28%), respectively (p = 0.052). Incidental thyroid cancer (ITC) was recognized after TT, STT, and DO in 18 (2.07%), 21 (4.52%), and 11 (1.56%), respectively (p = 0.039). Recurrent goitre (RG) was observed in 1 (0.11%) after TT, 3 (0.64%) after STT, and 2 (0.28%) after DO (p = 0.234).

CONCLUSIONS

Performing less radical surgery in NTMNG is associated with a significantly lower risk of early and late URLNP and OT. In the case of BRLNP (early and persistent) and POB, no statistically significant differences are seen. The occurrence of ITC is higher following more radical surgeries. Less radical surgery is connected with a higher risk of RG.