Temporary and permanent recurrent laryngeal nerve paralysis following thyroid surgery. Modifying factors: the educational status of the surgeon

17 of 525 patients (3.2%) showed an laryngoscopically established palsy of the recurrent laryngeal nerve after surgery for struma. The analysis of these operations, performed by five surgeons during or within three years after the period of surgical training, revealed that the operations performed under assistance of the senior surgeons were high grade selected (p = 0.026). Thus 14.8% of the operations performed because of simple goiter but only 4.8% of the operations performed because of thyroid cancer/recurrent goiter/extensive nodular goiter were assisted in this way. On the other hand it was necessary to call for help of a senior surgeon because of intraoperative difficulties in only 1.26% of the cases operated on for simple goiter, but in 19.6% of the more complex forms of goiter (p less than 0.001). The risk of recurrent laryngeal nerve palsy was nearly 10 times higher in the complex forms of goiter than in the simple forms (p less than 0.001). More extensive surgical training in the forms of complex goiters should be able to improve the results.     

Diagnosis and surgical treatment of diseases of the thyroid

The authors discuss the results of post-surgical examination of 451 patients with various diseases of the thyroid gland (toxic and euthyroid goiter, chronic thyroiditis). Besides other instrumental methods, thermography was conducted for establishing the diagnosis; it helps to determine the functional state of the thyroid gland. Females accounted for 88.4% of all patients who underwent operation. Most operations were performed for III degree goiter in patients whose ages ranged from 30 to 50. Surgery was conducted mostly on individuals with nodular forms (85.1%) and euthyroid goiter (73.6%); postoperative complications amounted to 1.7%.     

Thyroid carcinoma in intrathoracic goiter

Introduction: Most cases of intrathoracic goiter can be managed by cervical incision alone. A thoracic approach may be needed when adhesions or an anomalous blood supply are present or carcinoma is suspected. Patients and methods: Only 44 patients out of 5263 operated on for goiter needed a thoracic incision. A sternotomy was performed in 29 cases and a thoracotomy in 15; a malignancy was present in 9 cases. Symptoms, surgical approach, histology, survival and pTN staging of these 9 patients were reviewed and discussed; no perioperative mortality was observed. Discussion: A thoracic approach is more frequently needed for treatment of intrathoracic thyroid carcinoma as it offers a greater chance of radical excision and better control of intraoperative bleeding. Histologically, thyroid carcinoma in intrathoracic goiter is often anaplastic or rare and has a poor long-term survival rate when compared to cervical forms. Received: 2 February 1998 / Accepted: 23 June 1998     

Postoperative recurrence of a nodular goiter

Long-term results were followed up from 3 to 15 years in 649 patients with different morphological forms of the nodular goiter. Postoperative recurrent nodular goiter was diagnosed in 26.8% of the patients. The greater part of recurrences (87.4%) was nodular colloid goiter that was shown morphologically. Main part of the recurrences (69.1%) appeared after operations if the greater part of the thyroid gland was left--resection of a lobe and enucleation of the nodes. No recurrences were registered after thyroidectomy. The results of the investigation suggest that such operations as enucleation of a node and resection of a lobe with a node are thought to be inadequate.     

The results of the surgical treatment of thyroid diseases in children]

The results of surgical treatment of various forms of diseases of the thyroid gland in 254 children are analysed in follow-up periods of 12 months to 20 years. Functional compensation of the thyroid occurred in all patients with nodular forms of goiter who were subjected to operation which did not exceed hemithyroidectomy in volume. The analysis showed that operative treatment of children with the diffuse toxic form of goiter attended by the autoimmune component lead to hypothyroidism in 76.6% of patients, whatever the activity of the thyroid tissue, and a recurrence developed in 11.7% of those who were operated on. In children without the autoimmune component postoperative hypothyroidism was found in 48.6% of those examined, a recurrence was found in 3.2% of cases. The indications for operative treatment are specified, measures for the prevention of postoperative complications are listed.     

Ultrasonic method of study and puncture biopsy in diagnosing thyroid nodules

Results of diagnosis of thyroid nodes in 404 patients are analyzed. Ultrasonic examination and US-assisted puncture biopsy were carried out before operations. Their results were compared with ones of morphologic study performed after surgery. Solitary nodes were diagnosed in 171 (42.3%) patients, multiple--in 233 (57.7%). The most specific ultrasonic symptoms of different forms of thyroid nodes were revealed. Thyroid cancer is imaged as hypoechogenic node with clear and unclear contour, heterogeneous structure, multiple zones of hyperechogenicity and calcification. Adenomas are presented as isoechogenic homogenic nodes with clear border and cystic cavities. Colloid nodes picture is the same. Rathen often different morphologic forms of nodes are similar, thus ultrasonic examination permits to detect morphologic structure of nodes hypothetically only. Sensitivity of puncture biopsy for goiter, adenomas and cancer was 87.1, 92.9 and 69.7% respectively. Cancer was not diagnosed before surgery in 30.3% cases when colloid goiter or adenomas were suspected. In these cases small cancer was located amidst colloid nodes and didn't differ by ultrasonic symptoms. Diagnosis of malignant tumor in nodular goiter was highly precise. Morphologic form of cancer was verified cytologically in majority of cases.     

Nodular forms of goiter as a cause of cancer of the thyroid gland

The experience with diagnosis and treatment of struma maligna in 267 (5.5%) of the 4876 patients operated on for nodular forms of goiter is summarized. In the diagnosis, the puncture biopsy was widely used. Extrafascial resection of the thyroid gland with subsequent replacement therapy with thyroidin is a method of choice.     

结节性甲状腺肿合并甲状腺癌25例

目的：探讨结节性甲状腺肿中甲状腺癌的临床特征和预后。方法：回顾性分析手术治疗结节性甲状腺肿合并甲状腺癌２５例临床资料。结果：２５例结节性甲状腺肿合并甲状腺癌,男６例,女１９例,年龄１２～６５（３６．８±１３．１）岁,占同期手术治疗３９５５例结节性甲状腺肿的０．６３％。术前、术中诊断甲状腺癌的占３２％,６８％为术后病理检查发现。甲状腺微小癌占４８％。结论：结节性甲状腺肿合并甲状腺癌预后较好。不能简单地认为结节性甲状腺肿是良性病变而忽略对其的处理,也不应过分强调甲状腺癌在治疗结节性甲状腺肿中的地位随意放宽手术指征,或扩大手术。     

Surgical treatment of recurrent goiter

The authors have analyzed and generalized their 20-years experience with surgical treatment of 247 patients with recurrent goiter. Among them 48 patients had recurrent toxic goiter and 199 patients had nontoxic goiter. Postoperative complications developed in 8.3% of the patients with recurrent toxic goiter and in 6% of the patients with nontoxic goiter. The overall postoperative lethality was 1.2%. Operative treatment is recommended by the authors for recurrent toxic and nontoxic goiter, conservative treatment with radioactive iodine is thought to be expedient for a repeated recurrence. For preventing recurrences of toxic and nontoxic goiter after the first operation the administration of small does of the thyroid hormones is considered to be expedient during 1.5-2 months.     

Necessity for additional incisions with the cervical collar incision to remove retrosternal goiters

Purpose  Retrosternal goiters (RSGs) can be removed transcervically, but additional incisions are sometimes necessary. We examined the factors determining the need for additional incisions to remove an RSG goiter, based on our experience and on an algorithm. Methods  Among 499 patients who underwent surgery for a goiter, 52 (10.4%) had an RSG removed via a collar incision. Additional incisions were necessary in 11 patients (21% of those with an RSG and 2.2% overall): a partial sternotomy in 4, total sternotomy in 5, and right thoracotomy in 2. Results  Recurrent nerve paralysis developed in two patients and one patient had a tracheal laceration. There was no mortality. A diagnosis of adenomatous goiter was confirmed in all patients. Conclusions  Additional incisions can be made if thyroidectomy cannot be done transcervically and if the goiter extends to the level of the aortic arch. If the thyroid gland extends below the aortic arch and the lateral diameter of the goiter is greater than 10 cm, a partial sternotomy may be required. Total sternotomy is needed when an RSG extends caudally to the azygos vein, if it is located in the retrotracheal or retroesophageal space, or if it is recurrent or ectopic. Coexisting lung disorders and goiters extending to the left atrium also require thoracotomy.     

Safety of surgical interventions on the thyroid gland and anesthesia against the background of thyrotoxicosis

Results of surgical treatment of 192 patients aged from 19 through 72 years were analyzed, they had euthyroid goiter, compensated and subcompensated forms of toxic goiter. A comparative assessment is given of sodium thiopental, propophol and sibazon for induction of general anesthesia according to their effects on the indices of central hemodynamics, thyroid status and subjective patient's comfort, as well as propranolol, thalinolol and esmolol as medicines for intraoperative correction of hemodynamic manifestations of thyrotoxicosis. The influence of surgical manipulations was assessed on main hemodynamic indices and the level of thyroid glands hormones. Attention is called to the main tasks of anesthesiologists responsible for anesthesiological maintenance of operation under conditions of compensated and subcompensated thyrotoxicosis.     

Long-term results of the surgical treatment of patients with multinodular euthyroid goiter

Long-term results of treatment of 280 patients operated for multinodal euthyroid goiter (MNEG) in surgical department of Endocrinology Research Center RAMS from 1983 to 1997 were studied. Hormonal examination of peripheral blood, ultrasonic examination of thyroid gland (TG) and zones of regional lymph outflow, thin-needle punch biopsy were used as special methods of investigation. Correlation between recurrence and histological form was studied. In cystic-colloid goiter with adenomatosis the recurrence of MNEG was revealed in 15 (34.1%) cases. In primary multiple TG adenomas of different types the number of recurrences was smallest--1 (3.3%) cases. There were no recurrences in cancer of TG in combination with cystic-colloid goiter or adenomas of TG. Recurrence of cystic-colloid goiter was revealed in 5 (5.7%) cases, different types of adenomas--in 5 (5.7%) cases. The smallest number of recurrences of MNEG was seen after maximum subtotal resection of TG--in 4 patients (7.7% of the patients with this volume of operation). In all the 12 cases of partial resection of TG the recurrence of different morphological forms of MNEG was revealed. Influence of thyroid therapy on remote recurrence rate in different form of MNEG was also studied. In cystic-colloid goiter (CCG) of different proliferation degree with adenomatosis the recurrence rate was not significantly different irrespective of hormonal therapy--29.4%, 37.5% and 36.4%, respectively, in adequate therapy, inadequate therapy and its absence, that testifies to small influence of thyroid therapy on reduction of recurrence rate in this group of patients. The highest recurrence rate in CCG and CCG with adenomas of TG was revealed in the group without thyroid therapy--30.8% and 35.7%, respectively.     

The so-called goiter of the accessory thyroid glands

In the period of 1954-1966, 74 patients were operated on for goiter of the accessory thyroid glands (GATG). Of them, in 45 in histologic investigation, papillary adenoma or microfollicular, less often parenchymatous, goiter were revealed, in 29--papillary cancer or papillary adenoma at the state of malignization. The long-term follow-up (up to 30 years) of the patients with reoperations for GATG recurrences, or subsequent development of a "goiter" has shown that GATG presented a metastasis of papillary thyroid cancer into the lateral lymph nodes of a neck. At operation, the revision of a thyroid gland with intervention on it is mandatory. The term GATG we haven't used from 1966.     

The “forgotten” goiter after total thyroidectomy

INTRODUCTION“Forgotten” goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy.PRESENTATION OF CASEWe report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves’ disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures.DISCUSSIONIn the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter.CONCLUSIONRetrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.     

Cervico-mediastinal extension of thyroid cancer

A surgical series of 30 cervico-mediastinal thyroid cancer patients operated on has been retrospectively reviewed. Results were compared with those obtained in patients operated on for benign cervico-mediastinal goiter and thyroid cancer confined to cervical region. Of 4688 thyroidectomies performed, 30 patients were operated on for thyroid carcinoma with cervico-mediastinal extension. There were 15 males and 15 females. The mean age was 67 years (range, 21-86 years). Patients with cervico-mediastinal cancer were significantly older than patients with benign cervico-mediastinal goiter (P < 0.0001). Time between onset of first symptoms and surgery was significantly longer in patients with cervico-mediastinal cancer than in those with benign cervico-mediastinal goiter (P < 0.0001) and cervical thyroid cancer. Signs and symptoms at the time of surgery were cervical mass in 28 patients (93%), cervical lymphadenopathy in 20 patients (66%), dyspnea in 21 (70%), dysphagia in 9 (30%), dysphonia in 2 (7%), and venous stasis in 1 (3%). None of the patients was asymptomatic. Total thyroidectomy with functional lymphectomy was performed in 16 cases. Seven of these patients were operated on in 2 stages. In 8 cases the operation was a debulking procedure, and in 6 it was a near-total thyroidectomy. Sternotomy was performed in two cases. A differentiated thyroid cancer was found in 21 patients (70%), medullary in 5 (17%) and undifferentiated in 4 (13%). The incidence of medullary carcinoma was significantly higher compared with cervical cancer (P < 0.008). Postoperative complications were higher than those occurring in benign cervico-mediastinal goiter and similar to those occurring in cervical cancer. The actuarial survival was similar to that of cervical cancer matched for age and sex. This analysis shows that the longer clinical history of goiter is related to its endothoracic development and its neoplastic transformation. This finding should further encourage surgeons to treat any cervico-mediastinal goiter as promptly as possible.     

Repeated surgeries on the thyroid gland in nodular euthyroid goiter

Medical histories of 214 patients hospitalized with diagnosis "recurrent nodular goiter" were studied retrospectively. Complex clinical, laboratory and instrumental examination was carried out in all the patients. Comparative analysis demonstrated that in the structure of recurrent goiter nodular colloid form dominated (84.1%), only in 42.1% cases repeated surgeries were indicated. Other patients (15.9%) were the ones underwent surgery for other thyroid diseases (hypertrophied form of autoimmune thyroiditis, follicular adenoma, thyroid cysts, thyroid cancer). Inadequate surgery and prophylactic therapy with iodine drugs were the main causes of recurrent goiter. Adequate iodine prophylaxis (potassium iodide 100-200 mg per day), complex examination of patients, correct indications for primary surgery and adequate surgical volume, valuable postoperative therapy (iodine drug, LT-4 if it is necessary) permit to reduce the risk of recurrent nodular (multiple-nodular, diffuse-nodular) goiter. Ways of researches for improvement of diagnosis, prophylaxis and treatment results of "recurrence nodular goiter" are projected.     

Early diagnosis, therapy, follow-up and survival in patients with thyroid malignancies

The Aim of the paper was to give a review of an early diagnosis, therapy, follow-up and survival rate of patients with thyroid malignancy (TM). The paper presented the algorithm of early diagnosis: clinical, scintigraphic and ultrasonographic examination together with fine needle biopsy, cytologic analysis of the smear and biopsy ex tempore of the clear and suspected thyroid node to malignancy. Therapy of all TM forms was mainly surgical: postsurgical treatment was dependent on the type of malignancy: radioiodine 131-I, radiologic treatment, chemotherapy and radioimmunotherapy, (the latest one being in the phase of a clinical research). Follow-up was in accordance with the protocol and it was necessary because it contributes to the survival rate. In the presentation of survival rate for differentiated and medullar carcinomas we gave our results and literature data, while for the other malignancies only data from literature were presented. CONCLUSION: Only an early diagnosis of the nodular goiter together with an up-to-date treatment can cure TM patients in a high percentage and prevent development of a terminal stage of the disease which is extremely severe in all forms of this malignancy.     

Use and abuse of iodine in the management of goiter

The answers to this questionnaire reveal that 96 per cent of the physicians suggest the use of iodine in the form of Lugol's solution (10 drops weekly) or one 10 mg. idostrone tablet weekly, alone or with dessicated thyroid extract in the treatment of colloid goiter.Eighty-eight per cent find it necessary to correct mild diffuse (exophthalmic) goiter by subtotal thyroidectomy, and another 8 per cent suggest surgery if the condition is not cured in a reasonable period of time with iodine medication.The opinion is practically unanimous (99 per cent) that nontoxic nodular (adenomatous) goiter should not be treated with iodine medication. As many as 79 per cent of the physicians agree that the promiscuous administration of iodine produces activation or toxicity in this type of goiter.In toxic goiter, we note the greatest abuse in the use of iodine medication. Almost 90 per cent of the patients treated by goiter surgeons have had previous iodine medication, which produces an increase in the operative risk, and a very definite increase in the morbidity, especially since stage operations are often necessary in order to prevent an increased mortality. Practically all postoperative thyroid crises occur in patients who have had long continued iodine medication before consulting the goiter surgeon.     

Surgical diseases of thyroid gland

Medical reports of 8,768 patients with various diseases of thyroid gland were analyzed. There were 1,563 (17.8) male and 7,201 (82.2%) female patients aged 6 to 86 years. One-nodular goiter was diagnosed at 13.85% patients, multinodular goiter - at 67.2%, diffuse toxic goiter - at 5.85%, thyreotoxic adenoma - at 4.91%, Hashimoto's thyroiditis - at 8.16% patients. Thyroid cancer was revealed at 1.56 patients with nodular goiter, at 8.45% - with multinodular goiter, at 2.72% - with diffuse toxic goiter, at 3.71% - with thyreotoxic adenoma, and at 27.09% patients with Hashimoto's thyroiditis. Totally thyroid cancer was diagnosed at 741 (8.45%) patients including 71.12% papillary cancer, 26.47% follicular cancer and 2.42% medullar (anablastic) cancer. Some patients had metastases. It is concluded that all the patients with goiter should be operated. At diffuse toxic goiter the surgical treatment is indicated at the patients with recurrences or after 6 - 12 months of conservative treatment without clinical improvement.     

Surgical management of mediastinal goiter: risk factors for sternotomy

BACKGROUND AND AIMS: Mediastinal goiter constitutes an indication for surgical management. The procedure can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The objective of the investigation was to analyze the prevalence and therapeutic results in patients with mediastinal goiter and to assess factors that affect the need of performing sternotomy in the course of mediastinal goiter surgery. MATERIAL AND METHODS: In the years 1984-2004, i.e., over 21 years, 11,849 patients with various types of goiter were operated on in the department. Mediastinal goiter was detected in 88 (0.76%) individuals. The analyzed material included 64 (72.7%) females and 24 (27.3%) males. The age of the patients ranged between 19 to 81 years, with the mean age of 61 +/- 13 years of life. The material was statistically analyzed. Risk factors for sternotomy were assessed using the multidimensional logistic regression method. RESULTS: The highest percentage of mediastinal goiter was noted in patients operated on due to recurrent goiter (3.86%). Goiter situated in the anterior mediastinum was noted in 61 (69.3%) individuals, while 27 (30.7%) patients demonstrated goiter located in the posterior mediastinum; of the latter, nine were previsceral and 18 retrovisceral. In the majority of cases, these were primarily cervical goiters, which descended from the neck to the mediastinum (53 patients). Aberrant adenomas were diagnosed in 32 (36.4%) individuals. Four patients presented with the superior cava vein syndrome. Primary goiters evaluated intraoperatively with blood supply originating from the mediastinal vessels were observed in 12 (13.6%) cases. In 27 (30.7%) patients, sternotomies were necessary. In the majority of cases, these were individuals with goiters showing additional blood supply originating from the mediastinal vessels, patients with aberrant adenomas in the mediastinum, especially in recurrent goiters, or else subjects with goiters situated in the posterior mediastinum as compared to anterior mediastinal goiters. No postoperative mortality during stay in a hospital was noted. CONCLUSIONS: Surgical management of patients with mediastinal goiter is the therapeutic modality that requires considerable experience of the surgical team, performed in specialized centers, and appropriate preoperative diagnostic management. Statistically significant risk factors for sternotomy are as follows: recurrent goiter, primary mediastinal goiter, posterior mediastinal location of goiter, and the presence of an aberrant adenoma situated in the mediastinum.