Thyroidectomy

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

Indications for the procedure

This operation is shown:

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

Preparation

Preparation for such operations begins from the moment a decision is made about its necessity. It is clear that in order to establish 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 the parathyroid glands , since their localization may be non-orthotopic (they may be located at the top of the back of the 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 gland (complete or partial), the condition of the heart and lungs should be checked using an electrocardiogram and chest x-ray. Blood tests are taken: general, biochemical, clotting. The doctor makes recommendations regarding the medications taken by the patient (some medications are temporarily canceled).

The last meal before the operation, on the recommendation of anesthesiologists, should be at least 10 hours before it starts.

Technique of the thyroidectomy

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

The technique of traditional subfascial thyroidectomy: a transverse incision (7.5-12 cm long) of the skin, subcutaneous tissues, sternohyoid muscles and the parietal sheet of the cervical fascia is made - along the anatomical horizontal fold in front of the neck (above the jugular cavity); by crossing and ligating the corresponding vessels, the blood supply to the gland stops; the thyroid gland is exposed and separated from the cartilage of the trachea; displacement of the gland allows you to highlight the recurrent laryngeal nerve; parathyroid glands are identified (to protect them from accidental damage and not disrupt the blood supply); after the gland is isolated from the fascial capsule, its excision is performed; the edges of the capsule are connected with sutures; the place where the gland was located is closed by the visceral sheet of the internal fascia of the neck; the surgical wound is sutured with the installation of drainage (which is removed after a day) and the application of a sterile bandage.

In the presence of a malignant formation, radical extrafascial thyroidectomy is used - complete extracapsular removal of one lobe, isthmus and 90% of the contralateral lobe (no more than 1 g of gland tissue is left). Patients with a large tumor, as well as  medullary thyroid cancer,  may require thyroidectomy with lymph node dissection or lymphadenectomy, that is, the removal of metastasized lymph nodes in the neck. Depending on their localization, bilateral excision is performed - thyroidectomy with lateral lymph node dissection or with removal of the upper and anterior mediastinal nodes - thyroidectomy with central lymph node dissection.

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

The so-called final thyroidectomy is performed in cases where the patient has undergone an operation on the thyroid gland (subtotal resection or hemithyroidectomy), and it becomes necessary to remove the second lobe or the remaining part of the gland.

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

Contraindications to the procedure

If the patient has acute infectious diseases, recurrence of a chronic disease, as well as drug-resistant coagulopathy (poor blood clotting), removal of the thyroid gland is contraindicated.

Consequences after the procedure

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

Although this procedure is considered safe (mortality after it, according to some reports, is no more than seven cases per 10,000 operations), many patients report that their life after thyroidectomy has changed forever.

And the point is not that a scar or scar remains on the neck after a thyroidectomy, but 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 analogue of the T4 hormone - Levothyroxine (other names - L-thyroxine, Euthyrox,  Bagothyrox ). Patients should take it daily: in the morning on an empty stomach, and the correct dosage is checked by a blood test (6-8 weeks after the start of use).

As endocrinologists note, the development of secondary hypothyroidism after subtotal thyroidectomy is observed much less frequently: approximately in 20% of those operated on.

You should also know how a thyroidectomy affects the heart. First, postoperative hypothyroidism provokes a decrease in heart rate and an increase in blood pressure, causing pain in the heart, atrial fibrillation and sinus bradycardia.

Secondly, during the operation, the parathyroid glands can be damaged or removed along with the thyroid gland: the frequency of their accidental extirpation is estimated at 16.4%. This deprives the body of parathyroid hormone (PTH), which leads to a decrease in renal reabsorption and intestinal absorption of calcium. Thus, calcium after thyroidectomy may be insufficient, that is, hypocalcemia occurs, the symptoms of which may persist for six months after surgery. In the case of severe hypocalcemia, heart failure is observed with a decrease in the left ventricular ejection fraction and ventricular tachycardia.

One more question: is pregnancy possible after thyroidectomy? As you know, with hypothyroidism, the menstrual cycle and ovulation in women are disturbed. But taking Levothyroxine can normalize the level of thyroid hormones T3 and T4, so there is a chance of getting pregnant after removing the thyroid gland. And if pregnancy occurs, it is important to continue replacement therapy (adjusting the dosage of the drug) and constantly monitor the level of hormones in the blood.[4]

More information in the material -  The thyroid gland and pregnancy

Complications after the procedure

The most likely complications after this operation include:

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

In addition, after thyroidectomy in patients with Graves' disease, 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 the operation, patients are in the ward under the supervision of medical staff; to reduce swelling, the head of the bed should be raised.

For sore throat or painful swallowing, food should be soft.

It is imperative to observe hygiene, but the incision area, until it begins to heal, is forbidden to wet for two to three weeks. Therefore, you can take a shower (so that the neck remains dry), but you should refuse to take baths for a while.

Recovery will take at least two weeks, during which patients should limit physical activity as much as possible and not lift heavy things.

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

Patients undergo such tests after thyroidectomy: a blood test for

The level of pituitary thyrotropin (TSH) -  thyroid-stimulating hormone in the blood , on the serum content of parathyroid hormone (PTH), calcium and  calcitriol in the blood .

Determining the level of TSH after thyroidectomy allows you to avoid the development of hypothyroidism by prescribing hormone replacement therapy (see above). The established norm of TSH after thyroidectomy is from 0.5 to 1.5 mU/L.

Relapse after thyroidectomy

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

The definition of recurrence is based on clinical signs of the tumor, the presence / absence of signs of the tumor on x-ray imaging, on scanning with radioactive iodine or ultrasound after thyroidectomy, as well as tests for the level of  thyroglobulin 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 then once or twice a year. If thyroglobulin increases after thyroidectomy in cancer, it means that the malignant process could not be stopped.

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