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01.03.2012 | Letter to the Editor | Ausgabe 3/2012

Langenbeck's Archives of Surgery 3/2012

State of the art: surgery for endemic goiter

Zeitschrift:
Langenbeck's Archives of Surgery > Ausgabe 3/2012
Autor:
P. V. Pradeep
Wichtige Hinweise

Response: Balancing the pros and cons for subtotal and total thyroidectomy

We appreciate Dr. Pradeep’s comments on our recent review on endemic goiter surgery (1). Our review embarked on balancing the pros and cons for subtotal (ST) and total thyroidectomy (TT) to provide guidance for individualizing decisions using a risk-oriented surgical approach to endemic goiter. To illustrate the magnitude of surgical risk in various clinical scenarios, we extrapolated data from the largest population-based study involving 16,448 consecutive thyroid operations with 29,998 operated thyroid sites performed at 63 community hospitals and six university medical centers (2). On balance, the arguments do not support an indiscriminate “one-size-fits-all” approach to total thyroidectomy, for the following reasons:
(a) TT entails a greater risk for hypoparathyroidism and RLN palsy than ST (2–8). As a matter of fact, the loss of parathyroid hormone production and secretion is difficult to replace in full and more expensive to follow up upon, whereas functional loss of one vocal cord tends to recover spontaneously. Postoperative hypoparathyroidism, the manifestation of which is also determined by the extent of preoperative vitamin D deficiency (9), occurs more often after TT because of the parathyroid glands’ proximity to the thyroid capsule, their delicate blood supply, and the variability of the glands’ anatomic position in the neck.
(b) Many goiters that develop after ST, although technically operable, do not require reoperation. Older patients in particular often will not live long enough to see the thyroid remnant recur.
(c) Although bilateral RLN palsy has been given little, if any, prominence in the medical literature, it remains a prominent source of malpractice claims owing to its grave functional and social ramifications (10).
(d) Training general surgeons well in TT is critical but necessitates an adequate institutional case load (11–14). To narrow the surgical divide between community hospitals and expert institutions, expert institutions are called upon to train general surgeons in performing total thyroidectomies at minimal morbidity. Although these training programs are important, they cannot alter the economic and social disparities between rural and metropolitan areas.
Because TT has an inherently greater risk of surgical morbidity than ST, an individualized, risk-oriented surgical approach to endemic goiter is warranted that carefully weighs all relevant factors. ‘Individualization’ in this context is not meant to be taken as an excuse for performing an inappropriate thyroid operation, or for not referring a patient to an expert institution if reasonably feasible.
Henning Dralle, Kerstin Lorenz, Andreas Machens
Department of General, Visceral and Vascular Surgery, University Hospital and Medical Faculty, University of Halle-Wittenberg, Halle (S), Germany, email: henning.dralle@uk-halle.de
References
1. Dralle H, Lorenz K, Machens A. State of the art: surgery for endemic goiter—plea for individualizing the extent of resection instead of heading for routine total thyroidectomy. Langenbecks Arch Surg 2011. doi:10.​1007/​s00423-011-0809-4.
2. Dralle H, Sekulla C, Haerting J, Timmermann W, Neumann HJ, Lippert H, Gastinger I, Brauckhoff M, Gimm O. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2004; 136: 1310–132.
3. Agarwal G, Agarwal V. Is total thyroidectomy the surgical procedure of choice for benign multinodular goiter? An evidence-based review. World J Surg 2008; 32: 1313–1324.
4. Moalem J, Suh I, Duh QY. Treatment and prevention of recurrence of multinodular goiter: an evidence-based review of the literature. World J Surg 2008; 32: 1301–1312.
5. Karamanakos SN, Markou KB, Panagopoulos K, Karavias D, Vagianos CE, Scopa CD, Fotopoulou V, Liava A, Vagenas K. Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2043 procedures. Hormones 2010; 9:318–325.
6. Dralle H, Sekulla C. Schilddrüsenchirurgie: Generalist oder Spezialist? Zentralbl Chir 2005; 130: 428–433.
7. Bergenfelz A, Jansson S, Kristoffersson A, Martensson H, Reihner E, Wallin G, Lausen L. Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg 2008; 393; 667–663.
8. Thomusch O, Sekulla C, Dralle H. Rolle der totalen Thyreoidektomie im primären Therapiekonzept der benignen Knotenstruma. Chirurg 2003; 74: 437–443.
9. Kirkby-Bott J, Markogiannakis H, Skandarajah A, Cowan M, Fleming B, Palazzo F. Preoperative vitamin D deficiency predicts postoperative hypocalcemia after total thyroidectomy. World J Surg 2011; 35: 324–330.
10. Dralle H, Lorenz K, Machens A. Verdicts on malpractice claims after thyroid surgery: emerging trends and future directions. Head & Neck 2011 (in press).
11. Stavrakis AI, Ituarte PHG, Ko CY, Yeh MW. Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery. Surgery 2007; 142: 887–899.
12. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998; 228: 320–330.
13. Sosa JA, Wang TS, Yeo HL, Mehta PJ, Boudourakis L, Udelsman R, Roman SA. The maturation of a specialty: workforce projections for endocrine surgery. Surgery 2007; 142: 876–883.
14. Chen H, Hardacre JM, Martin C, Udelsman R, Lillemoe KD. Do future general surgery residents have adequate exposure to endocrine surgery during medical school? World J Surg 2002; 26: 17–21.

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