Lang, HHB

Journal of Thyroid Disorders & Therapy

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Title What should the correct extent of thyroidectomy  be in adeveloping area where goiter is an endemic problem?Author(s) Lang, HHBCitation Journal of Thyroid Disorders and Therapy, 2017, v. 6 n. 1, p.1000e128:1-2Issued Date 2017URL http://hdl.handle.net/10722/239584Rights Creative Commons: Attribution 3.0 Hong Kong LicenseWhat Should the Correct Extent of Thyroidectomy be in a Developing AreaWhere Goiter is an Endemic Problem?Brian Lang Hung-Hin*Department of Surgery, University of Hong Kong, Hong Kong SAR, China*Corresponding author: Brian Lang Hung-Hin, Divison Chief, Department of Surgery, University of Hong Kong, Hong Kong SAR, China, Tel: +8522255 4232; E-mail:blang@hku.hkReceived date: February 15, 2017; Accepted date: February 16, 2017; Published date: February 23, 2017Copyright: © 2017 Lang BH. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,distribution, and reproduction in any medium, provided the original author and source are credited.EditorialExtent of thyroidectomy has always been a highly debated topicamong thyroid surgeons, regardless of whether it is performed for abenign or malignant thyroid condition. Although lobectomy orsubtotal thyroidectomy have long been favored because they havealways been perceived as a procedure resulting in fewer recurrentlaryngeal nerve (RLN) injuries, hypocalcemia and hemorrhage/hematoma [1] than total thyroidectomy, over the last 10-15 years,many surgeons have preferred doing a total thyroidectomy when thedisease has involved both thyroid lobes (i.e. bilateral multinodulargoiter) [2]. The rationale behind this change is the fact that withimproving surgical techniques and experience, total thyroidectomy canbe performed as safely as lobectomy or subtotal thyroidectomy [3].Furthermore, total thyroidectomy virtually eliminates the future risk ofremnant recurrence and risky reoperations [4]. In a large retrospectiveanalysis of over 2000 patients who either had a total thyroidectomy orbilateral subtotal thyroidectomy, the authors found the latter procedureresulted in a significantly higher rate of completion thyroidectomywhile the rate of permanent complications was not significantlydifferent between the two procedures [5]. Based on these findings, theyrecommended total thyroidectomy for bilateral multinodular goiter toprevent recurrence and to eliminate the necessity for early completionthyroidectomy in case of a final diagnosis of thyroid carcinoma.However, in the recent few years, this practice of doing routine totalthyroidectomy has been increasingly questioned. In a large populationstudy using the National Inpatient Sample from 2003 to 2009, amongall adult patients who underwent a total thyroidectomy or lobectomyfor benign or malignant conditions, the authors found there was asignificantly increased risk of complications after total thyroidectomycompared to lobectomy (20.4 vs. 10.8%: p<0.0001) [6]. This increasedrisk was also observed among the more-experienced, high-volumesurgeons (i.e. surgeons performing >99 thyroid operations per year).Given that the majority of thyroid operations in the United States arenow being done by lower volume surgeons (i.e. <10 thyroid operationsper year), this implied the actual (or unreported) risks of RLN injuriesand hypocalcemia might actually be significantly higher on the wholethan many published single institution series [7]. This shift towardsthyroid conservatism has also partly reflected in the most updatedAmerican Thyroid Association guidelines on thyroid nodules anddifferentiated thyroid cancer [8] where even for patients with thyroidcancer >1cm and <4 cm without high-risk factors, lobectomy is now arecommended alternative to total thyroidectomy. Therefore, in recentyears, the pendulum have swung back in favor of doing a lesser extentprocedure initially over a total thyroidectomy.In the current issue of Thyroid Disorder Therapy, Burali et al.indirectly addressed this issue by reviewing their operative experiencein North Uganda [9]. Over a period of 3 and half years, as part of themission supported by “Centri Salute Globale”, the authors performedover 200 thyroid operations and of these, 137 were eventually analyzed.With the lack of proper health support and medical personnel, theirreported surgical results were truly impressive. There were only 5(3.6%) complications directly from the surgery itself and there were noperioperative deaths in the period. The authors appropriately discussedthe rationale behind doing a lesser procedure (i.e. lobectomy orsubtotal thyroidectomy) over total thyroidectomy in North Ugandaand their arguments would seem well justified and appropriate. Thefirst argument relates to the enormous risk of hypothyroidism if a totalthyroidectomy was done instead of a lesser procedure. Given the poorunderstanding of thyroxine replacement after a total thyroidectomyand the difficulty in accessing affordable thyroxine in North Uganda,the choice of a subtotal thyroidectomy or a lobectomy was preferred.Although some patients may still need small amount of thyroxine aftera subtotal thyroidectomy or even a lobectomy, the effect ofhypothyroidism is certainly less life-threatening than someone whohas undergone a total thyroidectomy [10]. The second issue relates torisk of postoperative hypocalcemia. None of their patients experiencedsymptomatic hypocalcemia as a result of their surgery and this waspartly due to their preference towards a lesser procedure over a totalthyroidectomy. Therefore, there generally should not be one correctextent of thyroidectomy for benign multinodular goiter (or a “one fitsall” approach) but rather, thyroid surgeons should adapt their surgicalapproach depending on a multitude of factors including patientpreference, risks of complications and cultural and socio-economicfactors.References1. Kandil E, Krishnan B, Noureldine SI, Yao L, Tufano RP (2013)Hemithyroidectomy: a meta-analysis of postoperative need for hormonereplacement and complications. ORL J Otorhinolaryngol Relat Spec 75:6-17.2. Lang BH, Lo CY (2005) Total thyroidectomy for multinodular goiter inthe elderly. Am J Surg 190: 418-423.3. Delbridge L (2003) Total thyroidectomy: the evolution of surgicaltechnique. ANZ J Surg 73: 761-768.4. Snook KL, Stalberg PL, Sidhu SB, Sywak MS, Edhouse P, et al. (2007)Recurrence after total thyroidectomy for benign multinodular goiter.World J Surg 31: 593-600.5. Tezelman S, Borucu I, Senyurek Giles Y, Tunca F, Terzioglu T (2009) Thechange in surgical practice from subtotal to near-total or totalthyroidectomy in the treatment of patients with benign multinodulargoiter. World J Surg 33: 400-405.6. Hauch A, Al-Qurayshi Z, Randolph G, Kandil E (2014) Totalthyroidectomy is associated with increased risk of complications for low-and high-volume surgeons. Ann Surg Oncol 21: 3844-3852.Journal of Thyroid Disorders andTherapy Lang, Thyroid Disorders Ther 2017, 6:1DOI: 10.4172/2167-7948.1000e128Editorial OMICS InternationalThyroid Disorders Ther, an open access journalISSN:2167-7948Volume 6 • Issue 1 • 1000e1287. Bergenfelz A, Jansson S, Kristoffersson A, Mårtensson H, Reihnér E, et al.(2008) Complications to thyroid surgery: results as reported in a databasefrom a multicenter audit comprising 3,660 patients. Langenbecks ArchSurg 393: 667-673.8. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, et al.(2016) 2015 American Thyroid Association Management Guidelines forAdult Patients with Thyroid Nodules and Differentiated Thyroid Cancer:The American Thyroid Association Guidelines Task Force on ThyroidNodules and Differentiated Thyroid Cancer. Thyroid 26: 1-133.9. Burali G, Martin OD, Fiorini FR, Mannelli G, Giachetti R, et al. (2016)Total Thyroidectomy in North Uganda: A Cultural and SocioeconomicChallenge for an African Country. Thyroid Disorder Ther 5: 206.10. Lang BH, Wong CK, Wong KP, Chu KK, Shek TW (2017) Effect ofThyroid Remnant Volume on the Risk of Hypothyroidism AfterHemithyroidectomy: A Prospective Study. Ann Surg Oncol. Citation: Lang BH (2017) What Should the Correct Extent of Thyroidectomy be in a Developing Area Where Goiter is an Endemic Problem?.Thyroid Disorders Ther 6: e128. doi:10.4172/2167-7948.1000e128Page 2 of 2Thyroid Disorders Ther, an open access journalISSN:2167-7948Volume 6 • Issue 1 • 1000e128

What should the correct extent of thyroidectomy be in a developing area where goiter is an endemic problem?

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