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Thyroid surgery

Surgery may be the only option for certain patients with thyroid abnormalities.


In general, an endocrinologist should be involved in the decision for a patient to have a thyroid surgery. Let the doctors at Houston Thyroid and Endocrine help you decide if a surgery is needed and manage the hypothyroidism that may occur afterwards. There are many reasons for a patient with thyroid problems to have a need for a thyroid surgery:
  1. Hyperthyroidism - only some cases
  2. Establish a final diagnosis of a mass in the thyroid gland when FNA biopsy is not definitive
  3. Thyroid cancer - differentiated thyroid cancer and thyroid lymphoma
  4. Improve the compressive symptoms of an enlarged thyroid
  5. Cosmetic removal of unsightly goiter
  6. Large substernal goiter

Three major types of thyroidectomy:

1. Total thyroidectomy-
This is removal of all thyroid tissue with preservation of the recurrent laryngeal nerve and parathyroids. Patients will almost always require treatment for hypothyroidism after this type of operation
2. Unilateral thyroidectomy-
This is when only one thyroid lobe is removed without surgical entry into the contralateral neck. Only a percentage of patients may need treatment for hypothyroidism afterwards, especially if there are already known to have Hashimoto's thyroiditis.
3. Isthmusectomy-
Only the middle portion of the thyroid is removed.


Note that removal of only the abnormal portion (nodule) of the thyroid like removing a scoop of ice cream is not possible, especially if the reason for surgery is possible thyroid malignancy in a thyroid nodule. An overnight stay is usually required. The length of stay in the hospital is determined by the extent of the surgery and if any complications arise. Recovery time can vary from a few days to a week. Final surgical pathology reports are usually available after 2 weeks.


Let us help you pick your surgeon. 

Complications are rare and are lower in patients undergoing surgery by high-volume surgeons:

The relationship between surgeon volume and patient outcomes has been studied extensively since 1990s. Institutional studies examining outcomes following thyroidectomy by high-volume surgeons have been published demonstrating overall safety. In one of the first studies examining the relationship between surgeon volume and thyroidectomy outcomes at a state level, Sosa et al.  found a strong association between higher surgeon volume and favorable patient outcomes, especially with regard to RLN injury and wound complications. This was especially pronounced for patients undergoing total thyroidectomy for thyroid cancer. Others have made similar observations. In a study of patients undergoing thyroidectomy in the Health Care Utilization Project Nationwide Inpatient Sample (HCUP-NIS), surgeons were divided into categories of low (<10 cases/year; encompassing 6072 surgeons), intermediate (10–100 cases/year; 11,544 surgeons), and high volume (>100 cases/year; 4009 surgeons) . Over 80% of thyroid resections were performed by low- and intermediate-volume surgeons. On average, high-volume surgeons had the lowest complication rates for patients who underwent total thyroidectomy for cancer at 7.5%; intermediate-volume surgeons had a rate of 13.4%, and low-volume surgeons, 18.9% (p < 0.001).

But even high-volume surgeons have a higher overall postoperative complication rate when performing total thyroidectomy compared with lobectomy. Using the HCUP-NIS, these authors found that high-volume thyroid surgeons had a complication rate of 7.6% following thyroid lobectomy but a rate of 14.5% following total thyroidectomy. For low-volume surgeons, the complication rates were 11.8% and 24.1%, respectively

1. Metabolic complications
Hypocalcemia due to surgical primary hypoparathyroidism- this a rare complication that is caused by either transient (up to 49%) or permanent damage (as high as 13%) to the parathyroid glands which control calcium levels in the body.
Hypothyroidism occurs in patients that undergo total thyroidectomy (100%) and occasionally in patients with partial thyroid surgery.
Anesthesia complications can occur in some patients.
2. Anatomic complications
Temporary (6%) or permanent damage (1% ) to the recurrent laryngeal nerve leads to hoarseness or loss of voice pitch control. Other rare complications include hematoma (<1.2%), seroma, Horner's syndrome (<0.2%), esophageal injury, tracheal injury.


References
1. Lee YS, Nam KH, Chung WY, Chang HS, Park CS Postoperative complications of thyroid cancer in a single center experience. J Korean Med Sci. 2010;25(4):541
2. Bentrem DJ, Rademaker A, Angelos P. Evaluation of serum calcium levels in predicting hypoparathyroidism after total/near-total thyroidectomy or parathyroidectomy. Am Surg. 2001;67(3):249
3. Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, Pelizzo MR, Pezzullo L Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg. 2004;28(3):271
4. SosaJA, BowmanHM, TielschJM, PoweNR, GordonTA, UdelsmanR1998 The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 228:320–330
5. DuclosA, PeixJL, ColinC, KraimpsJL, MenegauxF, PattouF, SebagF,TouzetS, BourdyS, VoirinN, LifanteJC 2012 Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMJ 344:d8041. 
6. LoyoM, TufanoRP, GourinCG 2013 National trends in thyroid surgery and the effect of volume on short-term outcomes. Laryngoscope 123:2056–2063
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