Prospective Evaluation of Surgical Management Strategy of Thyroid Diseases in Assiut University Hospitals, A Clinical Audit

Abstract
Background: Thyroid surgery is the mainstay of the treatment of surgical goiters. Treatment modalities for the surgical management of goiter include lobectomy, sub-total thyroidectomy, near-total thyroidectomy and total thyroidec-tomy.
Aim of Study: To compare current surgical management of thyroid diseases in Assuit University Hospital with man-agement guidelines, planning for improving our management of thyroid diseases and correct obstacles to achieve reduction in the morbidity and mortality result from thyroid diseases.
Patients and Methods: Our study included 60 patients who were admitted to General Surgery Department with any thyroid disease during a period of six months and managed surgically. All patients had neck ultrasound and FNAC was done for suspicious cases for malignancy. Benign solitary nodular goiter was managed by unilateral lobectomy and isthmusectomy. MNG was managed by total and sub-total throidectomy. Malignant goiter was managed according to cytology with total thyroidectomy being done for most cases. Controlled toxic goiter was managed by total or sub-total thyroidectomy. All cases were subjected to pre-and post-operative layrngoscopic examination for assessement of vocal cord mobility. Post-operative histopathology is amust in all cases.
Results: Mean age of the studied patients was 39.18±11.75 years with range between 15 and 63 years. Out of 60 patients, 49 (81.7%) patients were females and 11 (18.3%) patients were males. 17 (28.3%) of the studied had toxic manifestations and 15 (25%) patients were on anti-thyroid medications. Iodine deficiency was noticed in 9 (15%) patients while 7 (11.7%) patients had endemic goiter. Out of the studied patients, 5 (8.3%) patients had family history of thyroid disease.
Unilobar enlargement presented in 12 (20%) patients while 48 (80%) patients had Bilobar thyroid enlargement. Diffuse goiter presented in 4 (6.7%) patients and nodular goiter in 56 (93.3%) patients, 13 (21.7%) solit all patients were subjected to thyroid function tests (TSH, free T3 and T4) before and after thyroidectomy. It was noticed that there were significant improvement in level of TSH, free T3 and free T4 after thyroidectomy (p<0.05).
FNAC was done in 41 (68.3%) patients. Total thyroidec-tomy was performed in 43 (71.7%) patients while 10 (16.7%) and 7 (11.7%) patients had subtotal thyroidectomy and uni-lateral lobectomy with isthmusectomy respectively. The most frequent complications post-operatively were hoarseness of the voice and choking occurred in 18 (30%) and 16 (26.7%) patients respectively. Injury of RLN occurred in 5 (8.3%) patients.
All of those patients received replacement therapy and none of them received chemotherapy or iodine therapy.
Post-operative complications were frequent in those patients had total thyroidectomy where hoarseness of the voice, chocking and injury of recurrent laryngeal nerve oc-curred in 13 (30.2%), 12 (27.9%) and 5 (11.6%) patients respectively.
In case of subtotal thyroidectomy 4 (40%) patients had choking and 4 (40%) patients had hoarseness of the voice. Only one patient from those had unilateral thyroidectomy had post-operative complication in form of hoarseness of the voice.
Duration of surgeon experience was less than 5 years in majority of cases (56.7%) while in 16 (26.7%) and 10 (16.7%) patients duration of surgeon experience was 5-10 and more than 10 years respectively. With experience less than 5 years, post-operative complications were; 3 patients had R.L.N. injury, 12 patients had hoarseness of voice, and 10 patients had chocking. With surgical experience between 5 to 10 years, complications were; 2 patients had R.L.N. injury, 4 patients had hoarseness of voice, and 5 patients had chocking. While with experience more than 10 years, the complications were so minimal with only 2 patients had transient hoarseness of voice and chocking.
In case of controlled toxic goiter; 15 (75%), 3 (15%) and 2 (10%) patients had total, subtotal and unilateral thyroidec-tomy respectively. In case of simple goiter; 7 (58.3%) patients had total thyroidectomy, 4 (8.3%) patients had unilateral thyroidectomy and 1 (8.3%) patient had subtotal thyroidectomy.
21 (75%) patients from those with multinodular goiter had total thyroidectomy, 6 (21.4%) had subtotal thyroidectomy and 1 (3.6%) patient had unilateral thyroidectomy.
Conclusion: In our study, no major difference was noticed between our surigal management strategy of thyroid diseases and international guidelines. Pre-operative assessement was focused with neck U/S and FNAC being the most important investigations. Choice of the type of operation was based on the type of thyroid disease and the risk of post-operative complications was considered.post-operative complications in the form of RLN injury, hypothyroidism and hypo-parathyroidism were markedly decreased.