Thyroidectomy Surgery in Iran

            For many years, one of the main unresolved issues of thyroid surgery has been the choice of the extent of surgical intervention on the thyroid gland. At the same time, the complexity of compensation that occurs after surgery for hypothyroidism was the main obstacle to complete removal of the thyroid gland. For a long time, the lack of drugs, the impossibility of dosing accuracy in replacement therapy led to the difficult achievement of stable euthyroidism after surgery. This was the impetus for the choice of organ-preserving surgical tactics when performing operations on the thyroid gland.

Until the middle of the 20th century, the treatment of hypothyroidism involved the administration of animal thyroid extracts to patients. These preparations, in which it was practically impossible to accurately dose the content of thyroid hormones, could not sufficiently provide stable euthyroidism, and their administration itself was accompanied by significant difficulties. In 1913, Nobel Prize-winning American biochemist Edward Kelvin Kendall isolated, purified crystallized thyroxine and achieved a 100-fold increase in the concentration of hormones in thyroid extracts, which served as a turning point in the creation of modern thyroxin preparations. The creation of precisely dosed synthetic preparations of thyroid hormones radically changed the idea of ​​the treatment of thyroid diseases and led to a revolution in thyroidology, expanding the possibilities of thyroid surgery.

            In our region, until 1995, to compensate for postoperative hypothyroidism, an extract of the dried thyroid gland, thyroidin, was used, which was titrated only by the total iodine content, and most of the clinical presentations were formed in a period when there were no modern preparations of levothyroxine (L-T4). In this regard, in relation to any disease of the thyroid gland, there was a postulate that hypothyroidism is a severe complication of these diseases. The expansion of the possibility of performing operations on the thyroid gland obliged endocrinologists to develop strict indications for surgical methods for the treatment of thyroid diseases, in order to avoid excessive operational activity.

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Absolute indications for thyroidectomy are all forms of malignant tumors of the thyroid gland. Considering the situation of the post-Chernobyl period and the post-accident consequences, total thyroidectomy is recognized as the method of choice even for minimally invasive, highly differentiated thyroid carcinomas. Mandatory preoperative cytological verification of the diagnosis makes it possible to determine the scope of the planned surgical intervention. Performing a total thyroidectomy for highly differentiated thyroid carcinomas opened up opportunities for effective treatment of metastases with 131I isotopes and made it possible to achieve favorable treatment results.

            Most often, surgical interventions on the thyroid gland are performed for nodular goiter. It should be noted that modern thyroidology has a wide range of diagnostic methods (ultrasound, cytological, hormonal, radiological) that make it possible to determine the pathogenetic and morphological basis of the disease before treatment and, in most cases, avoid surgical intervention, recognizing the minimum oncological risk of detected focal changes in the thyroid gland. In most cases, nodular goiter is represented by colloidal, to varying degrees, proliferating goiter (up to 90%), which is subject to observation and conservative treatment. Operative interventions of an organ-preserving nature in multinodular colloid proliferating goiter usually lead to a relapse of the disease, and there must be good objective reasons for thyroidectomy.

            Indications for surgical treatment in patients with nodular goiter are:

cytologically confirmed carcinomas;

neoplasms suspicious of a malignant nature;

cases of complex cytomorphological diagnosis (follicular and B-cell tumors – the frequency of malignancy in this group reaches 30%);

local compression syndrome of the neck organs with large benign neoplasms;

thyrotoxicosis with nodular and multinodular goiter of large size.

The most debatable issue is the choice of the volume of surgical intervention in Graves’ disease (diffuse toxic goiter). Before the pathogenesis of Graves’ disease was elucidated, the ideology of surgical treatment of this disease was as follows: in a patient with thyrotoxicosis, an increase in the size of the thyroid gland was most often detected, and in order to normalize the level of thyroid hormones, part of the organ must be removed. The most common operation was and still is – subtotal resection of the thyroid gland according to O.V. Nikolaev. Later it became obvious that Graves’ disease is a systemic autoimmune disease that develops as a result of the production of antibodies to the thyroid-stimulating hormone receptor (AT-rTSH), and leaving a part of the thyroid gland during subtotal resection is leaving a target for stimulating antibodies in the body, which leads to relapse. thyrotoxicosis. Therefore, the only predictable outcome and goal of surgical treatment for Graves’ disease is the removal of the entire thyroid gland. In this regard, according to modern concepts of recent times, hypothyroidism has ceased to be considered as a complication of surgical intervention in Graves’ disease and has actually become the goal of treatment.

            According to the literature of recent years, subtotal resections of the thyroid gland for Graves’ disease are logically (based on the pathogenesis of the disease) and practically unjustified. In most foreign clinics, the operation of choice for Graves’ disease, the “gold standard”, has become thyroidectomy.

            In the last decade, a large number of works devoted to the problem of hypothyroidism have appeared, which have transformed our views on thyroid diseases. First of all, this is due to the introduction of modern thyroid hormone preparations into clinical practice. Against the background of taking these drugs, hypothyroidism becomes for the patient not a disease, but a way of life that practically does not imply any special restrictions. Modern precisely dosed synthetic preparations of levothyroxine (L-T4) do not differ in structure from human thyroxine (T4) and make it possible to easily and effectively maintain stable euthyroidism against the background of their administration only once a day.

           The prerequisites for this are factors such as:

The only vital function of the thyroid gland is the production of thyroid hormones;

The daily rhythm of secretion of thyroid hormones is practically absent (the variation from day to day is less than 15%), and therefore, the daily intake of levothyroxine (L-T4) in the same dose easily models their endogenous production;

The stability of the body’s need for thyroid hormones (rare situations in which a change in the selected dose of L-T4 is required are pronounced changes in body weight, pregnancy and the parallel administration of certain drugs);

High bioavailability of L-T4 when taken orally;

Long plasma half-life of L-T4 (about 7 days);

The presence of an exact criterion (TSH level), which fully reflects the quality of hypothyroidism compensation for a long period (about 2-3 months);

Relative cheapness of L-T4 preparations;

The quality of life of patients with hypothyroidism who constantly receive L-T4 replacement therapy practically does not differ significantly from that of those without hypothyroidism.

            The goal of substitution therapy for hypothyroidism is to maintain a stable level of thyroid hormones in the body that meets physiological needs. The main indicator to assess the adequacy of replacement therapy for hypothyroidism is the level of TSH, determined by methods with high functional sensitivity.