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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 277-280

Feasibility of total thyroidectomy for management of benign thyroid disease


Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assuit, Egypt

Date of Submission04-Mar-2019
Date of Decision01-May-2019
Date of Acceptance01-Sep-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Abd Al-Kareem Elias
Lecturer of General Surgery, Department of General Surgery, Faculty ofMedicine, Al-Azhar University, Assuit, 33515
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_38_19

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  Abstract 


Objectives The aim of this study is to evaluate the outcome of total thyroidectomy (TT) for the management of benign thyroid disease.
Background The extent of thyroid resection in benign thyroid disease is controversial revolving around the potential risk of hypoparathyroidism and nerve injury. The potential advantage of TT is one stage removal of incidental thyroid cancer and low risk of goiter recurrence.
Patients and methods This prospective study was done at Al-Azhar University Hospitals from October 2016 to April 2019. One hundred patients who underwent TT for clinically benign thyroid disease were enrolled. All patients were subjected to clinical evaluation, neck ultrasonography, vocal cord examinations, and investigations. Follow-up was done for all patients for 6 months.
Results Of the 100 patients who were included in the study, 27 have Graves’ disease versus 73 have non-Graves’ disease, the age group range from 35 to 65 years old. The rate of transient hypocalcemia and temporary recurrent laryngeal nerve palsy was 25.9 versus 6.8% and 3.7 versus 2.7%, respectively. One patient suffered from postthyroidectomy bleeding in Graves’ group, and incidental thyroid cancer was found in two cases.
Conclusion TT for benign thyroid disease can avoid reoperation for incidental thyroid cancer, recurrent nodular goiter, recurrent toxic goiter, and can eliminate any subsequent risk of malignant change in the residual thyroid gland.

Keywords: benign thyroid disease, neck ultrasonography, thyroid surgery, toxic nodular goiter, total thyroidectomy


How to cite this article:
AboAmra M, Elias AA. Feasibility of total thyroidectomy for management of benign thyroid disease. Al-Azhar Assiut Med J 2019;17:277-80

How to cite this URL:
AboAmra M, Elias AA. Feasibility of total thyroidectomy for management of benign thyroid disease. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 6];17:277-80. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/277/271677




  Introduction Top


Total thyroidectomy (TT) for several benign thyroid diseases, a trend that is gaining adherences in the last two decades, emphazised on the concept of tissue ablation rather than function preserving surgery for nonmalignant thyroid diseases [1]. The introduction of capsular dissection and increasing experience with TTs had led many surgeons to believe that TT is a more preferable operation for the management of benign thyroid disease. Some authors argue that it is feasibility owing to the high incidence of permanent nerve injury and hypoparathyroidism especially when the posteromedial aspect is nodular free [2] The rate of complications associated with TT such as recurrent laryngeal nerve injury and postthyroidectomy hypocalcemia did not differ significantly from that associated with subtotal thyroidectomy. These findings indicate that TT is an acceptable surgical alternative in benign thyroid diseases. Among surgeons, there is always controversy about the recurrence rates after subtotal thyroidectomy. Many surgeons fear that enhanced postoperative recurrence and reoperation after subtotal thyroidectomy is achieved at the expense of low recurrence rates known after TT [3]. Thyroid hormone replacement therapy is necessary after TT which is no longer consider as a disadvantage [4]. Incidental thyroid carcinomas discovered at the definitive histological examination after TT encourage the procedure as a good alternative practice [5].

The aim of this study was to evaluate the safety and efficacy of TT for the management of benign thyroid disease.


  Patients and methods Top


The present prospective study was conducted in the Department of General Surgery, Al-Azhar University Hospital (Assuit Branch) from October 2016 to April 2019. One hundred patients clinically diagnosed to have benign thyroid disease met the inclusion criteria (multinodular goiter, Graves’ disease after adverse effects or failure of medical treatment, toxic nodular goiter, and thyroiditis). All patients gave in writing an informed consent and ethics committee approval was obtained. The demographic data such as age, sex, clinical diagnosis, and perioperative parameter were collected. Patients in Graves’ group received preoperative Carbimazole (an antithyroid drug) and beta blockers; after the achievement of euthyroid state, all patients underwent TT.

For each patient:
  • Complete history and examination.
  • Investigations:
    1. Routine investigations such as complete blood picture, random blood sugar, liver and kidney function.
    2. Thyroid function test, free T3, free T4, and TSH.
    3. Serum calcium level preoperative and postoperative (third and fifth day).
    4. Thyroid ultrasound and thyroid scanning.
    5. The laryngeal examination was done for vocal cord assessment.
    • Exclusion criteria:
    1. Nodular goiter confined to one lobe.
    2. Recurrent goiter.
    3. Recurrent toxicity after RAI ablation in Graves’ disease.
    4. Malignant goiter.
  • Surgical technique. Under general anesthesia, the patient lies supine on the operative table, which tilted 15 degrees upward at the head. A sandbag pillow is placed between the shoulder blades with the neck extended, thus making the gland more prominent. Low collar incision was extending laterally and it made about 1-inch above the suprasternal notch. The upper flap raised upward to the level of the cricoid cartilage and the lower flap dissected downward to the suprasternal notch. The midline raphe between the strap muscles is divided longitudinally with exposure and opening of the pretracheal fascia. A plane of dissection between the strap muscles superficially and thyroid capsule deeply. Each thyroid lobe is turned and mobilized medially after ligation and division of the middle thyroid vein. The superior thyroid pedicle is ligated within the upper pole to avoid external laryngeal nerve injury. Inferior thyroid artery was dissected and ligated. The parathyroid glands should be identified before resectioning of the thyroid gland; also, excessive use of diathermy should be avoided. The recurrent laryngeal nerve should be identified as it passes between the inferior thyroid artery branches and then pass into the tracheoesophageal groove. The nerve passes into the larynx behind the inferior cornu of the thyroid cartilage. Absolute hemostasis is ensured and the wound is closed with suction drainage of the deep cervical space. Histopathology for all thyroid specimens was done.


Follow up

All patients were followed up at 1, 3, and 6 months. At each visit, clinical examination, serum calcium level, and TSH were carried out.

Evaluation of recurrent laryngeal nerve status just after surgery by an otolaryngologist was done to asses vocal cord mobility by direct laryngoscopy. The patient is considered to have temporary recurrent laryngeal nerve palsy (RLNP) when there is hoarseness of voice associated with evident vocal cord paralysis at laryngoscopy during the first 6 months; if the condition persists for more than 6 months we consider the patients developed permanent RLNP.

Evaluation of the parathyroid function was checked immediately at the third postoperative day and every follow-up visit by measurement of serum calcium level. Patients will consider having temporary hypoparathyroidism when the calcium level is less than 8.0 mg/dl in two sequent samples at least for 3 days, if the condition persists for more than 6 months, we consider the patients developed permanent hypoparathyroidism. The hypocalcemic patient was treated by supplementary oral calcium (1–4 g) daily. Vitamim D was added when serum calcium levels were less than 7.5 mg/dl. The supplementation continues until normalization of serum calcium levels.

Postthyroidectomy bleeding is defined as a hematoma that requires immediate wound exploration and good hemostasis.

The primary endpoint was to evaluate the safety and efficacy of TT for the management of benign thyroid disease. The secondary endpoint was to evaluate the safety and efficacy of TT for Graves’ disease.

Statistical analysis

The Anderson–Darling test was used to test the result for normality and for homogeneity variances prior to further statistical analysis. Categorical variables were described by number and percent, where continuous variables were described by the mean and SD. χ2 test between categorical variables where compared between continuous variables by the paired test. A two-tailed P value less than 0.05 was considered statistically significant. All analyses were performed with the IBM SPSS 20.0 software (IBM, Armonk, New York, United State).


  Results Top


Our study aimed at comparing TT for treatment of benign thyroid diseases in both Graves’ and non-Graves’ disease. The study was carried out on 100 patients (72 female patients and 28 male patients) with benign thyroid diseases in the age group range from 35 to 65 years. Preoperative diagnosis on the basis of physical, laboratory, and thyroid ultrasound was as follows: 27 patients have Graves’ disease, 60 patients have a multinodular goiter involving both lobes, five patients have toxic nodular goiter, and eight patients have thyroiditis ([Table 1]). All patients were managed via TT with estimation of serum calcium level preoperatively and third day postoperatively and on each visit. Seven (25.9%) patients suffered from post-TT temporary hypocalcemia in Graves’ group, one (3.7%) of them remained permanently hypocalcemia versus five (6.8%) patients in the non-Graves’ group suffered from temporary hypocalcemia. All of them improved during follow-up. One (3.7%) patient suffered from temporary unilateral RLNP in Graves’ group, improved 1 month postoperatively versus two (2.7%) patients suffered from temporary unilateral RLNP in non-Graves’ group, complete recovery during the first month and fortunately bilateral RLNP was not reported in both groups. One patient suffered from postthyroidectomy bleeding in Graves’ group managed by wound reexploration and ligation of bleeding vessels. Histopathological examination shows incidental thyroid cancer was found in two (2%) cases, one in each group.
Table 1 Indication for thyroidectomy

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  Discussion Top


TT has been documented as the most effective treatment for benign thyroid disease, both in pathology ablation and in its recurrence (12–40% for nodular goiter and 15–30% for Graves’ disease) [6],[7]. Several surgeons have been proposed the reoperation for the recurrent disease over previous adhesion and disturbed anatomy carries a significant potential risk of permanent damage of recurrent laryngeal nerve and parathyroid gland injury; therefore, TT has been widely adopted [8].

TT has been recently recommended as a preferred surgical procedure for management of Graves’ disease in many centers owing to a reduction in the the recurrence rate and potential improvement of concomitant exophthalmos [9].

Post-TT general complications like wound infection, seroma formation, and hemorrhage that occur periodically are preventable and its treatment is easy. The goal is to perform such an operation without permanent complications conserving the integrity of the laryngeal nerves and parathyroid glands [10].

Our results reported the incidence of post-TT bleeding in one (1%) patient similar to the Barakat study who reported the incidence of postoperative hemorrhage in 1.11% out of 180 patients who underwent TT for nonmalignant thyroid disorder [2].

Vocal cord paralysis can be temporary and has an incidence ranging from 5.2 to 11.5% or permanent and has an incidence ranging from 0 to 3% [10],[11],[12]. In our study, the incidence of temporary RLNP in Graves’ disease was 3.7% ([Table 2]) and non-Graves’ group was 2.7% ([Table 3]) which was statistically nonsignificant and is comparable to that reported in the previous study [13],[14],[15]. However, the reported incidence of permanent RLNP was zero. Temporary vocal cord paralysis always results from traction over the thyroid lobe which leads to neuropraxia; therefore, temporary RLNP was observed.
Table 2 Comparison of complication results in Graves' group with other studies

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Table 3 Comparison of complication results in non-Graves' group with other studies

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In the present study, temporary hypoparathyroidism rate was 25.9% in Graves’ group and 6.8% in non-Graves’ group which was statistically significant, and in most cases, it is transient. The higher incidence rate may be due to the inflammatory process and high vascularity within the gland. However, the rate of permanent hypocalcemia is 0.4%. The rate of temporary hypocalcemia is reportedly 2–30% which was comparable to the result of the present study [11],[12],[13],[14],[15],[16]. Meticulous dissection over the thyroid capsule and ligation of inferior thyroid artery branches on the gland surface are important maneuvers to preserve these small parathyroid glands. It is also a good practice to immediately reimplant in the sternocleidomastoid any parathyroid that has been devascularized or inadvertently removed during dissection [17]. Incidental thyroid carcinomas would be occult carcinomas that have not yet metastasized and those discovered after thyroidectomy did not need further intervention. In our study, incidental thyroid cancer was found in two (2%) cases with agrees with the previous study [18].


  Conclusion Top


TT is a safe, effective, and is advocated for benign thyroid disease with a reduction of the rate of complication by meticulous surgical dissection.

TT for benign thyroid disease can avoid reoperation for incidental thyroid cancer, recurrent nodular goiter, recurrent toxic goiter, and to eliminate any subsequent potential hazard of malignant change in the residual thyroid gland.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Mohamed WB, Ahmed AE. Morbidity and mortality after total thyroidectomy for nonmalignant thyroid disorder: 10 years’ experience. Egypt J Surg 2016; 35:380.  Back to cited text no. 2
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AlTheyab FS, AlOnazi RN, AlHarbi IM, AlHarbi HM, AlSaigh S. Risk factors for post-operative thyroid related complications in patient undergoing thyroidectomy: a single center study. Egypt J Hosp Med 2018; 72:3918–3923.  Back to cited text no. 4
    
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Slijepcevic N, Zivaljevic V, Marinkovic J, Sipetic S, Diklic A, Paunovic I. Retrospective evaluation of the incidental finding of 403 papillary thyroid microcarcinomas in2466 patients undergoing thyroid surgery for presumed benign thyroid disease. BMC Cancer 2015; 15:330.  Back to cited text no. 5
    
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Cipolla C, Graceffa G, Calamia S, Fiorentino E, Pantuso G, Vieni S, Latteri M. The value of total thyroidectomy as the definitive treatment for Graves’ disease: a single centre experience of 594 cases. J Clin Transl Endocrinol 2019; 16:100183.  Back to cited text no. 9
    
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Rifaat M, Saber A, Hokkam EN. Total versus subtotal thyroidectomy for benign multinodular goiter: outcome and complications. J Curr Surg 2014; 4:40–45.  Back to cited text no. 10
    
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Kwon H, Kim JK, Lim W, Moon BI, Paik NS. Increased risk of postoperative complications after total thyroidectomy with Graves’ disease. Head Neck 2019 41: 281–285  Back to cited text no. 11
    
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Sugino K, Nagahama M, Kitagawa W, Ohkuwa K, Uruno T, Matsuzu K et al. Change of surgical strategy for Graves’ disease from subtotal thyroidectomy to total thyroidectomy: a single institutional experience. Endocr J 2018; 66:181–186.  Back to cited text no. 12
    
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Barczyński M, Konturek A, Hubalewska-Dydejczyk A, Gołkowski F, Nowak W. Ten-year follow-up of a randomized clinical trial of total thyroidectomy versus Dunhill operation versus bilateral subtotal thyroidectomy for multinodular non-toxic goiter. World J Surg 2018; 42:384–392.  Back to cited text no. 13
    
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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