Thyroid Surgery

Your doctor may recommend that you consider thyroid surgery for 4 main reasons:

  1. You have a nodule that might be thyroid cancer.
  2. You have a diagnosis of thyroid cancer.
  3. You have a nodule or goiter that is causing local symptoms – compression of the trachea, difficulty swallowing or a visible or unsightly mass.
  4. You have a nodule or goiter that is causing symptoms due to the production and release of excess thyroid hormone – either a toxic nodule, a toxic multinodular goiter or Graves’ disease.

The extent of your thyroid surgery should be discussed by you and your thyroid surgeon and can generally be classified as a partial thyroidectomy or a total thyroidectomy. Removal of part of the thyroid can be classified as:

  1. Hemi-thyroidectomy or thyroid lobectomy – where one lobe (one half) of the thyroid is removed;
  2. Isthmusectomy – removal of just the bridge of thyroid tissue between the two lobes; used specifically for small tumors that are located in the isthmus.
  3. total or near-total thyroidectomy is removal of all or most of the thyroid tissue.

The recommendation as to the extent of thyroid surgery will be determined by the reason for the surgery. For instance, a nodule confined to one side of the thyroid may be treated with a hemithyroidectomy. If you are being evaluated for a large bilateral goiter or a large thyroid cancer, then you will probably have a recommendation for a total thyroidectomy. However, the extent of surgery is both a complex medical decision as well as a complex personal decision and should be made in conjunction with your endocrinologist and surgeon.

Your surgeon will explain the planned thyroid operation, such as lobectomy (hemi) or total thyroidectomy, and the reasons why such a procedure is recommended.

For patients with papillary or follicular thyroid cancer, many, but not all, surgeons recommend total or near-total thyroidectomy when they believe that subsequent treatment with radioactive iodine might be necessary. For patients with larger (>1.5 cm) or more invasive cancers and for patients with medullary thyroid cancer, local lymph node dissection may be necessary to remove possibly involved lymph node metastases.

A hemithyroidectomy may be recommended for overactive solitary nodules or for benign onesided nodules that are causing local symptoms such as compression, hoarseness, shortness of breath or difficulty swallowing. A total or near – total thyroidectomy may be recommended for patients with Graves’ Disease or for patients with large multinodular goiters.

 

What are the risks of thyroid surgery?

 

In experienced hands, thyroid surgery is generally very safe. Complications are uncommon, but the most serious possible risks of thyroid surgery include:

  1. bleeding in the hours right after surgery that could lead to acute respiratory distress;
  2. injury to a recurrent laryngeal nerve that can cause temporary or permanent hoarseness, and possibly even acute respiratory distress in the very rare event that both nerves are injured;
  3. damage to the parathyroid glands that control calcium levels in the blood, leading to temporary, or more rarely, permanent hypoparathyroidism and hypocalcemia.

These complications occur more frequently in patients with invasive tumors or extensive lymph node involvement, in patients undergoing a second thyroid surgery, and in patients with large goiters that go below the collarbone into the top of the chest (substernal goiter).

Overall the risk of any serious complication should be less than 2%.

 

Thyroid Replacement after Surgery

Depending on how much of the thyroid is removed, you may or may not require thyroid replacement after surgery.

If half (hemi) thyroidectomy is performed, there is an 80% chance you will not require a thyroid pill UNLESS you are already on thyroid medication for low thyroid hormone levels (e.g. Hashimoto’s thyroiditis) or have evidence that your thyroid function is on the lower side in your thyroid blood tests.

If you have your entire gland removed (total thyroidectomy) or if you have had prior thyroid surgery and now are facing removal of the remaining thyroid (completion thyroidectomy) then you have no internal source of thyroid hormone remaining and you will definitely need lifelong thyroid hormone replacement.

When someone is first started on thyroid hormone the initial dose is carefully selected based on information such as a person’s weight, age, and other medical conditions. The dose will then need to be adjusted by a physician to keep the thyroid function normal. The physician will make sure the thyroid hormone dose is correct by performing a physical examination and checking TSH levels.

There are several brand names of thyroid hormone available. Although these all contain the same synthetic T4, there are different inactive ingredients in each of the brand names. In general, it is best for you to stay on the same brand name. If a change in brand name is unavoidable, you should be sure your physician is aware of the change, so that your thyroid function can be re-checked. If your pharmacy plan changes your thyroid hormone to a generic preparation, it is important for you to inform your physician.

Thyroid hormone is easy to take. Because it stays in your system for a long time, it can be taken just once a day, and this results in very stable levels of thyroid hormone in the blood stream. When thyroid hormone is used to treat hypothyroidism, the goal of treatment is to keep thyroid function within the same range as people without thyroid problems. Keeping the TSH level in the normal range does this. The best time to take thyroid hormone is probably first thing in the morning on an empty stomach. This is because food in the stomach can affect the absorption of thyroid hormone. However, the most important thing is to be consistent, and take your thyroid hormone at the same time, and in the same way, every day. If you are taking several other medications, you should discuss the timing of your thyroid hormone dose with your physician. Sometimes taking your thyroid hormone at night can make it simpler to prevent your thyroid hormone from interacting with food or other medications.

Do not stop your thyroid hormone without discussing this with your physician. Most thyroid problems are permanent, and therefore most patients require thyroid hormone for life. If you miss a dose of thyroid hormone, it is usually best to take the missed dose as soon as you remember. It is also safe to take two pills the next day; one in the morning and one in the evening. It is very important that your thyroid hormone and TSH levels are checked periodically, even if you are feeling fine, so that your dose of thyroid hormone can be adjusted if needed.

 

References:

American Thyroid Association