ATA Spells Out Goiter Surgery Indications, Optimal Management

Marlene Busko

July 14, 2015

An American Thyroid Association (ATA) statement describing how to assess patients with goiter and providing recommendations for ways to manage goiter surgery to minimize complications is now published online for open access.

Originally published in Thyroid in 2014, these are the first comprehensive recommendations for goiter surgery, lead author Amy Y Chen, MD, from the division of endocrine surgery, Emory University, Atlanta, Georgia, told Medscape Medical News.

The statement, which is restricted to benign goiters (enlargements of the thyroid gland), mainly covers "how to do this surgery safely — what needs to be done before surgery, during surgery, and immediately after surgery — to have the best outcomes," she said. The key message is that "with careful preparation and teamwork [between the surgical and anesthesia team], successful thyroid surgery can be achieved."

The guidelines were mandated by the ATA, and the writing group included four surgeons and an endocrinologist, Dr Chen noted.

Three main types of physicians are likely to initially see a patient with a goiter, she continued: primary-care physicians, endocrinologists, and, perhaps surprisingly, gynecologists (who are often women's primary-care providers).

"I've seen teenagers have large goiters, I've seen older folks — it's a wide range, mostly women," she explained.

Not All Goiters Need Surgery

According to Dr Chen, clinicians should be aware of several important points. First, "not all [benign] goiters need surgery."

Medical options for treating goiter include iodine replacement, thyroid-hormone replacement, thyroid-hormone suppressive therapy, and radioactive iodine treatment.

However, "it's important to realize that giving suppressive doses of thyroid-[hormone] replacement have not been shown to help prevent the growth of thyroid goiter," and patients should be monitored, so that if the goiter does grow suddenly, doctors should refer the patient for a biopsy, Dr Chen said.

In contrast to medical therapy, which may partially reduce goiter volume, surgery may provide definitive treatment.

Patients who have symptoms of dyspnea and/or dysphagia due to compression of the trachea or esophagus may need surgery the most, she noted. Several studies have demonstrated improved breathing and swallowing outcomes after surgery.

The statement describes recommended preoperative patient assessment, which includes evaluating symptoms of goiter (dyspnea, dysphagia, and dysphonia) and looking for signs on a physical examination.

In addition, thyroid-function tests are required: "TSH is an obligatory initial step in goiter evaluation," Dr Chen and colleagues write. In North America, thyroid ultrasound is the standard practice to evaluate an enlarged thyroid (thyromegaly). Cross-sectional computed tomography (CT) imaging is also helpful in determining the diameter of the trachea.

High-Volume Centers and Teams Have Best Outcomes

The surgical management of large goiters and substernal goiters is complex, and at least two studies have reported that improved outcomes are associated with high-volume teams and centers, Dr Chen and coauthors note.

Moreover, as with any thyroid surgery, "both intraoperative and postoperative complications can be serious." These complications include bleeding, airway distress, recurrent laryngeal nerve injury, and transient hypoparathyroidism.

Therefore, "appropriate preparation and evaluation of the extent of the disease, airway status, and medical condition is crucial."

And good communication between the surgeon and the anesthesiologist is especially important during induction and reversal of the anesthesia in goiter surgery.

"It's very important [for the thyroid surgeon] to work closely with the anesthesiologist, to be sure that you can control the airway [during intubation and extubation]…so that it is a safe procedure," Dr Chen emphasized.

Finally, in the initial postoperative period, the surgeon should be immediately available to manage any postoperative airway complications, the report stresses.

The authors report having no relevant financial relationships.

Thyroid. 2014;24:181-189. Article

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