Thyroidectomy

Thyroidectomy is a surgical operation to remove one of the most important endocrine glands of the body - the thyroid gland (glandula thyreoidea). The extent of surgical intervention - removal of part or all of the gland - depends on the specific diagnosis. [1]

Indications for the procedure

This operation is indicated:

• In malignant tumors, that is thyroid cancer - differentiated, medullary, follicular, papillary, anaplastic, and adenocarcinoma; [2]
• in case of metastases to the thyroid gland of tumors of other localization;
• in the presence of diffuse toxic goiter (bazedema) of multinodular character, leading to the development of thyrotoxicosis. Goiter excision is also called strumectomy;
• patients with follicular thyroid adenoma or a large cystic mass that makes breathing and swallowing difficult.

Preparation

Preparation for such surgeries starts from the moment the decision on its necessity is made. It is clear that in order to make an appropriate diagnosis, each patient underwent a comprehensive examination of the thyroid gland (with aspiration biopsy) and examination of regional lymph nodes.

It is also important to determine the location of parathyroid glands, as their localization may be non-orthotopic (they may be located at the top of the posterior thyroid gland or far from the neck - in the mediastinum). An ultrasound or CT scan of the neck is performed.

Before the planned removal of the thyroid (complete or partial), the condition of the heart and lungs must be checked - with the help of an electrocardiogram and chest X-ray. Blood tests are taken: general, biochemical, for coagulation. The doctor gives recommendations on the medications taken by the patient (some drugs are temporarily canceled).

The last meal before surgery, as recommended by anesthesiologists, should be at least 10 hours before the operation.

Technique of the thyroidectomy

According to indications, radical or total thyroidectomy - removal of the entire gland performed for surgical treatment of cancer - may be performed. The operation is performed under general (endotracheal) anesthesia, and its duration averages about two to three hours.

Technique of traditional subfascial thyroidectomy: a transverse incision (7.5-12 cm in length) of the skin, subcutaneous tissues, sterno-iliac muscles and the parietal leaflet of the cervical fascia is made - along the anatomical horizontal fold in the front of the neck (above the jugular); by crossing and ligating the appropriate vessels, the blood supply to the gland is stopped; the thyroid gland is exposed and separated from the cartilages of the trachea; displacement of the gland allows isolation of the recurrent laryngeal nerve; parathyroid glands are identified (to protect them from accidental damage and not to disrupt the blood supply); after isolation of the gland from the fascial capsule, its excision is performed; the edges of the capsule are joined with sutures; the place where the gland was located is closed with a visceral sheet of the internal fascia of the neck; the surgical wound is sutured with the installation of drainage (which is removed after 24 hours) and the application of a sterile dressing.

If malignancy is present, radical extrafascial thyroidectomy is used - complete extracapsular removal of one lobe, isthmus and 90% of the contralateral lobe (leaving no more than 1 g of gland tissue). Patients with a large tumor, as well as medullary thyroid cancer may require thyroidectomy with lymphodissection or lymphadenectomy, i.e. Removal of lymph nodes of the neck affected by metastases. Depending on their localization, bilateral excision is performed - thyroidectomy with lateral lymphodissection or removal of the upper and anterior mediastinal nodes - thyroidectomy with central lymphodissection.

If not the entire gland is removed, but more than half of each lobe, including the isthmus, this is subtotal thyroidectomy (resection), used in cases of goiter or solitary nodules of a benign nature. When the tumor is small (e.g., isolated papillary microcarcinoma) or the nodule is solitary (but suspicious of its benign nature), only the affected lobe of the gland and isthmus may be removed - hemithyroidectomy. And removal of isthmus tissue between the two lobes of the gland (isthmus glandulae thyroideae) in case of small tumors located on it is called isthmusectomy.

The so-called final thyroidectomy is performed when a patient has undergone thyroid surgery (subtotal resection or hemithyroidectomy) and there is a need to remove the second lobe or the remaining part of the gland.

In some cases, it is possible to perform endoscopic surgery, which uses a special set of instruments for thyroidectomy. During this intervention, an endoscope is inserted through a small incision in the neck; carbon dioxide is pumped in to improve the view, and all necessary manipulations (visualized on the monitor) are performed with special instruments through a second small incision. [3]

Contraindications to the procedure

If the patient has acute infectious diseases, relapse of chronic disease, as well as medically uncompensated coagulopathy (poor blood clotting) removal of the thyroid gland is contraindicated.

Consequences after the procedure

Both the overall condition after thyroidectomy and its short- and long-term consequences depend largely on the patients' diagnosis and the extent of the surgical procedure performed.

Although the procedure is considered safe (the mortality rate after it is reported to be no more than seven deaths per 10,000 surgeries), many patients report that their lives are forever changed after a thyroidectomy.

And it's not that there is a scar or scar on the neck after thyroidectomy, but the fact that when the entire thyroid gland is removed, the body still needs thyroid hormones that regulate many functions, metabolic processes and cellular metabolism. Their absence causes hypothyroidism after thyroidectomy. Therefore, treatment after thyroidectomy will be required in the form of lifelong replacement therapy with a synthetic analog of the T4 hormone, the drug Levothyroxine (other names include L-thyroxine, Euthyrox, Bagothyrox). Patients should take it daily: in the morning on an empty stomach, and the correct dosage is checked by blood tests (6-8 weeks after the start of use).

As noted by endocrinologists, the development of secondary hypothyroidism after subtotal thyroidectomy is observed much less frequently: approximately 20% of operated patients.

You should also be aware of the effects of thyroidectomy on the heart. First, postoperative hypothyroidism provokes a decrease in heart rate and an increase in blood pressure, causing heart pain, atrial fibrillation and sinus bradycardia.

Secondly, the parathyroid glands may be damaged or removed together with the thyroid gland during surgery: the incidence of accidental extirpation is estimated at 16.4%. This deprives the body of parathyroid hormone (PTH), which causes a decrease in renal reabsorption and intestinal absorption of calcium. Thus, calcium after thyroidectomy may be in inadequate amounts, i.e., hypocalcemia occurs, the symptoms of which may persist for six months after surgery. In case of severe hypocalcemia, heart failure with decreased left ventricular ejection fraction and ventricular tachycardia is observed.

Another question is whether pregnancy is possible after thyroidectomy. It is known that in hypothyroidism menstrual cycle and ovulation in women is disturbed. But the reception of Levothyroxine can normalize the level of thyroid hormones T3 and T4, so there are chances to get pregnant after removal of the thyroid gland. And if pregnancy occurs, it is important to continue substitution therapy (adjusting the dosage of the drug) and constantly monitor the level of hormones in the blood. [4]

More information in the material - Thyroid and Pregnancy

Complications after the procedure

The most likely complications from this surgery include:

• bleeding in the first hours after surgery;
• Neck hematoma, which occurs within 24 hours after the procedure and is manifested by thickening, swelling and pain of the neck under the incision, dizziness, shortness of breath, and a wheezing sound when breathing in;
• airway obstruction, which may lead to acute respiratory failure;
• temporary hoarseness of voice (due to irritation of the recurrent laryngeal nerve or the external branch of the superior laryngeal nerve) or permanent hoarseness (due to damage);
• uncontrollable coughing when speaking, difficulty breathing, or the development of aspiration pneumonia are also caused by damage to the recurrent laryngeal nerve;
• pain and a lumpy feeling in the throat, difficulty swallowing;
• pain and stiffness in the neck (which can last from a few days to a few weeks);
• The development of infectious inflammation, in which the temperature rises after thyroidectomy.

In addition, after thyroidectomy in patients with basalgia, fever with body temperature up to +39°C and palpitations may occur as a result of a thyrotoxic crisis requiring intensive care.

Care after the procedure

After surgery, patients stay in a room under the supervision of nursing staff; the head of the bed should be elevated to reduce swelling.

If you have a sore throat or painful swallowing, food should be soft.

Hygiene is essential, but the incision area must not be wet for two to three weeks until it starts to heal. Therefore, you can shower (so that the neck remains dry), but bathing should be avoided for a while.

Recovery will require at least two weeks, during which time patients should limit physical activity as much as possible and avoid lifting heavy weights.

Because the area around the incision puts you at an increased risk of sunburn, it is recommended that you use sunscreen before going outdoors for a year after surgery.

Patients undergo the following tests after thyroidectomy: blood tests for

Pituitary thyrotropin (TSH) levels - thyroid hormone in the blood, on serum levels of parathyroid hormone (PTH), calcium and calcitriol in the blood.

Determination of TTH level after thyroidectomy allows avoiding the development of hypothyroidism by prescribing hormone replacement therapy (see above). The established norm of TTH after thyroidectomy is from 0.5 to 1.5 mU/dL.

Recurrence after thyroidectomy

Unfortunately, thyroid cancer recurrence after total thyroidectomy remains a serious problem.

Recurrence is determined on the basis of clinical signs of tumor, presence/absence of tumor on X-ray, radioactive iodine scan or ultrasound after thyroidectomy, and tests for thyroglobulin levels in the blood, which is considered an indicator of disease recurrence. Its level should be determined every 3-6 months for two years after thyroidectomy, and once or twice a year thereafter. If thyroglobulin increases after thyroidectomy for cancer, it means that the malignant process has not been stopped.

According to the Instruction on the establishment of disability groups (Ministry of Health of Ukraine, Order No. 561 of 05.09.2011), patients are established disability after thyroidectomy (group III). The criterion is defined in the following wording: "total thyroidectomy with subcompensated or uncompensated hypothyroidism with adequate treatment".