From the Guidelines
Total or near-total thyroidectomy is recommended after failure of medical management for several thyroid conditions, including confirmed thyroid cancer, as it effectively eliminates the diseased thyroid tissue while addressing symptoms that medical management failed to control. The choice between total (complete removal) and near-total thyroidectomy (leaving minimal thyroid tissue) depends on the underlying condition, with total thyroidectomy generally preferred for cancer cases 1. For example, in the case of differentiated thyroid cancer, total or near-total thyroidectomy is the initial treatment of choice, whenever the diagnosis is made before surgery, and the nodule is ≥1 cm, or regardless of the size if there is metastatic, multicocal or familial disease 1.
Some key points to consider when deciding on the type of surgery include:
- The extent of the disease and whether it is confined to the thyroid gland or has spread to surrounding tissues or lymph nodes
- The patient's overall health and ability to tolerate surgery
- The potential risks and benefits of each type of surgery, including the risk of complications such as hypoparathyroidism and recurrent laryngeal nerve injury
- The need for lifelong thyroid hormone replacement therapy after surgery, typically levothyroxine at a starting dose of 1.6 mcg/kg/day, with dose adjustments based on TSH levels measured 6-8 weeks after initiation 1.
In terms of specific conditions, total or near-total thyroidectomy may be recommended for:
- Graves' disease refractory to antithyroid medications (methimazole or propylthiouracil)
- Toxic multinodular goiter unresponsive to radioactive iodine therapy
- Large goiters causing compressive symptoms, suspicious thyroid nodules, and confirmed thyroid cancer
- Medullary thyroid carcinoma, where total thyroidectomy and bilateral central neck dissection (level VI) are indicated for all patients with tumors 1 cm or larger or who have bilateral thyroid disease 1.
Overall, the decision to perform a total or near-total thyroidectomy should be made on a case-by-case basis, taking into account the individual patient's condition, medical history, and preferences, as well as the potential risks and benefits of each type of surgery.
From the Research
Types of Surgery After Failure of Medical Management
The types of surgery recommended after failure of medical management of thyroid disease are total or near-total thyroidectomy.
- Total thyroidectomy is currently the preferred treatment for thyroid cancer, multinodular goitre, and Graves' disease 2, 3.
- Near-total thyroidectomy is also considered a suitable option, especially in cases where the risk of complications is high 4, 5.
- The choice between total and near-total thyroidectomy depends on various factors, including the patient's overall health, the severity of the disease, and the surgeon's expertise 2, 3.
Benefits of Total Thyroidectomy
Total thyroidectomy has several benefits, including:
- Immediate and permanent cure for benign thyroid diseases 2, 3
- Low incidence of postoperative complications, such as recurrent laryngeal nerve palsy and hypoparathyroidism 2, 3
- Elimination of the need for completion thyroidectomy in cases of incidentally diagnosed thyroid carcinoma 3
- Reduction in the rate of reoperation for recurrent disease 3
Comparison with Less Than Total Thyroidectomy
Less than total thyroidectomy procedures, such as subtotal thyroidectomy, partial thyroidectomy, and lobectomy, have a higher rate of nodular recurrence and require lifelong thyroxine supplementation 6.
- A study found that 68.2% of patients who underwent less than total thyroidectomy experienced recurrence of clinically important nodules, and only 11% underwent completion thyroidectomy 6.
- The study suggested that total thyroidectomy may be a more suitable option to avoid recurrence and reduce the need for frequent follow-ups and thyroxine replacement therapy 6.