Type of operation for multinodular goitre and solitary nodule

Abstract

Many countries and medical associations have developed guidelines for the management of benign thyroid conditions, including the surgical management of multinodular goitre and the non-toxic solitary thyroid adenoma. It is clearly stated in most guidelines that the aim of the surgical procedure is the safe and definite management of the thyroid pathology. Our aim is to provide evidence to support or reject different kinds of surgical procedures used for the management of non-toxic thyroid conditions i.e. multinodular goitre and solitary nodule. Thyroid nodules are common in the general population. Only 4–8% are clinically detectable, but US has shown the incidence to be 13–67%. Many studies have reported that malignancy can be found in 5% of these nodules. The aim of this paper is to present the facts, the pros and cons of each operation used for the management of these thyroid conditions, and provide evidence concerning the ideal procedure that combines safety with the most definite results. Despite the fact that most authors, experts and relevant medical associations currently consider total thyroidectomy (TT) as the gold standard for the management of benign goitre, there is still debate in the literature. It seems that when compared to less radical operations, TT has a lower recurrence rate, and hence a lower risk for complications associated with a reoperation. Moreover, in expert hands, it is equally as safe as less radical procedures in terms of permanent complications (i.e hypoparathyroidism and recurrent laryngeal nerve injury). Nevertheless, subtotal thyroidectomy (ST) has been found to be safer in terms of temporary complications since lower rates have been recorded. The incidence of “occult thyroid cancers” ranges from 3% to 16.6% (level II–III); therefore, if initial surgery is anything less than TT or near-total thyroidectomy, a reoperation is indicated. Obviously, the high recurrence rate along with the significant rate of occult thyroid cancers increases the need for necessary reoperations after a ST; as a result, associated morbidity increases. The incidence of occult cancer in benign solitary non-toxic nodules is 5%, irrespective of the size of the nodule. The literature describes two acceptable surgical options, each with its pros and cons: an upfront TT or a total lobectomy, and in the case of an occult cancer, a completion total thyroidectomy. Both approaches are acceptable to the surgical community and are included in the national guidelines.

• For benign non-toxic solitary nodules, a total lobectomy or a total thyroidectomy can be performed after a thorough discussion with the patient, presentation of the current literature data, presentation of the pros and cons of each procedure, and acquisition of informed consent from the patient for the procedure chosen.

• For benign multinodular non-toxic goitre, total thyroidectomy is the procedure of choice since

  • it may decrease the recurrence rate

  • it can decrease the reoperation rate

  • it can reduce the overall morbidity associated with a reoperation, and

  • it can successfully manage “occult” thyroid cancers

• The operation should be performed by an experienced surgeon to ensure that the incidence of permanent complications (i.e. RLN palsy and hypoparathyroidism) is lower than 1-2%.