Type of operation for toxic adenoma, toxic multinodular goitre and Graves’ Disease

Abstract

Many countries and medical associations have developed guidelines for the management of benign thyroid conditions, including the surgical management of toxic thyroid goitres and the toxic solitary thyroid adenoma. Our aim is to provide evidence to support or reject different kind of operations used for the management of toxic thyroid conditions i.e. toxic goitre and toxic solitary nodule. Hyperthyroidism affects 1.2% of the general population. The main cause is Graves’ Disease (50–80%) followed by the toxic multinodular goitre (TMNG), toxic adenoma (TA) and, finally, thyroiditis (10%). Management includes antithyroid medications, iodine ablation (I¹³¹) and surgical resection of the gland. According to the American thyroid association, if surgical management is selected, it is highly recommended to proceed with a total or near-total thyroidectomy in order to minimize the recurrences. This kind of operation is associated with an almost 0% recurrence rate as opposed to subtotal thyroidectomy which is associated with an 8% recurrence rate at 5-year follow-up. The incidence of malignancy in patients with Graves’ disease is less than 2%. In about one-third of patients, there will be regression of the disease. For the patients who are under medical or surgical management, the recurrence rate is almost 50% if only antithyroid medications are used, 21% after I¹³¹ ablation, and 5% after surgery. The evidence from the literature shows that TT is associated with a lower recurrence rate and the same incidence of permanent serious complications. ST is associated with a lower rate of temporary hypoparathyroidism. In terms of the development of ophthalmopathy, both the comparison of RCT and non-RCT showed no significant difference between the two approaches. For the management of the toxic thyroid lesions, most guidelines recommend the following:

• Solitary toxic thyroid nodule - the recommended operation is unilateral total thyroid lobectomy.

• This operation is associated with less than 1% treatment failure and only 2.3% hypothyroidism.

• Toxic multinodular goitre - it is recommended to proceed with total or near-total thyroidectomy.

• The incidence of malignancy is 3%-9%, hence, this operation is adequate for such lesions; the recurrence rate is less than 1% and the patient becomes euthyroid soon after surgery.

• For the benign toxic solitary nodule, a total lobectomy can be performed.

• For the benign toxic multinodular goitre, total thyroidectomy is the procedure of choice since it may decrease the recurrence rate, can decrease the reoperation rate, can reduce the overall morbidity associated with a reoperation, and can successfully manage “occult” thyroid cancers

• The operation should be performed by an experienced surgeon so as to ensure that the risk of permanent complications (i.e. RLN palsy and hypoparathyroidism) is less than 1–2%.