Total Thyroidectomy for Differentiated Thyroid Cancer:Primary Compared With Completion ThyroidectomyAnjali Mishra and Saroj Kanta Mishra

From the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road,Lucknow 226014, India

Eur J Surg 2002; 168: 283–287

ABSTRACTObjective: To analyse morbidity after completion total thyroidectomy compared with primary total thyroidectomy in aspecialist thyroid surgery centre.Design: Retrospective study.Setting: Tertiary referral hospital, India.Patients: Medical records of 143 patients who had total thyroidectomy between January 1990 and December 1999. 95 hadprimary thyroidectomies and 48 were completion thyroidectomies.Main outcome measures: Complication rate in both groups.Results: The groups were comparable in respect of clinicopathological variables. Residual tumour was found in 19/48 (40%).After completion thyroidectomy, transient hypoparathyroidism and transient recurrent laryngeal nerve palsy were recorded in8/48 (17%) and 2/48 (4%), respectively. No permanent hypoparathyroidism or permanent recurrent laryngeal nerve palsy wasrecorded in the completion thyroidectomy group.Conclusions: Completion thyroidectomy can be done with acceptable morbidity in a specialist thyroid surgery centre. Fear ofincreased morbidity after the procedure should not deter surgeon from doing this operation or referring the patients to aspecialist centre.

Key words: morbidity, hypoparathyroidism , recurrent laryngeal nerve palsy.

INTRODUCTION

Total thyroidectomy is gradually being accepted as thetreatment of choice for differentiated thyroid cancer(4, 17), mainly because of the development of safesurgical techniques resulting in lower morbidity(5, 10, 20). Although the importance of the extent ofsurgery can be debated on the basis of the age of thepatients, and the size and grade of the primary lesion,once the diagnosis is made in one lobe many physiciansthink that a completion thyroidectomy should beconsidered to achieve total surgical ablation of thyroid(3, 6, 9, 16). Completion thyroidectomy not only dealswith residual carcinoma in the opposite lobe, but alsofacilitates 131I whole-body scanning, allowing for thediagnosis and treatment of unrecognised metastaticcarcinoma (6, 10, 16). Some think that when doneearly, it may result in signi�cantly fewer recurrences inlymph nodes and elsewhere and that it improvessurvival (10). However, the morbidity after completionthyroidectomy is reported to be many times more thanthe primary procedure (11, 18), only a few studiesreporting comparable morbidity for these two proce-dures (8). As a protocol at our centre, we recommendpatients for completion thyroidectomy if they arereferred to us after subtotal thyroidectomy or the

diagnosis of thyroid cancer is con�rmed after hemi-thyroidectomy. We undertook this study to �nd out themorbidity after completion total thyroidectomy and tocompare its results with those of primary totalthyroidectomy.

PATIENTS AND METHODS

We studied the medical records of 143 patients whohad total thyroidectomy between January 1990 andDecember 1999, 95 of whom had primary thyroidec-tomy and 48 completion thyroidectomy. The preopera-tive investigations included estimation of serum con-centrations of thyroxine (T4) and thyroid stimulatinghormone (TSH), calcium, and indirect laryngoscopy.When we contemplated completion thyroidectomy weassessed the extent of the remnant by radioiodine scan.Computed tomograms or magnetic resonance imageswere taken when the disease appeared to be extensiveor in�ltrating locally. Clinicopathologica l details andcomplications in both groups were noted. Postoperativelaryngoscopy was done if there was any suspicion ofnerve injury. The examination was repeated at sixweeks and six months in patients with nerve palsy.Symptomatic postoperative hypocalcaemia was mana-

Ó 2002 Taylor & Francis. ISSN 1102–4151 Eur J Surg 168

ORIGINAL ARTICLE

ged by intravenous infusion of calcium followed byoral calcium carbonate (median dose elemental cal-cium 2 g) and vitamin D3 for periods varying from 6weeks to 6 months.

Total thyroidectomy and completion thyroidec-tomies were done by previously described techniques(1, 13). Brie�y, the capsular dissection technique wasused for total thyroidectomy. The external branch ofthe superior laryngeal nerve was saved by individualligation of vessels in the upper pole. An attempt wasmade to follow the course and preserve both recurrentlaryngeal nerves and four parathyroids. However, wetook care not to dissect the parathyroids out of theirfatty envelopes. The blood supply to the parathyroidswas preserved by ligating the individual branches ofthe inferior thyroid artery on the capsule of the thyroid.When there was inadvertent injury to the parathyroid

glands or their blood supply, they were autotrans-planted in the sternocleidomastoid muscle on the sameside. Four patients had one or more parathyroidautotransplants. Completion thyroidectomy was doneby a lateral approach. After raising subplatysmal �aps,the sternocleidomastoid was mobilised to expose theinternal jugular vein. The middle thyroid vein wasligated and divided and the thyroid lobe dissected fromthe overlying strap muscles. The parathyroids and therecurrent laryngeal nerves were identi�ed and dis-sected from the thyroid lobe. The ligament of Berrywas ligated and divided. The vessels in the superiorpole and inferior thyroid veins were dealt with as in aprimary operation. The thyroid lobe was dissected offthe trachea and larynx from the lateral to the medialside. The same procedure was followed on the otherside if the patient requires bilateral dissection. Com-

Table I. Characteristics of primary and completion thyroidectomy groupsFigures are no. (%).

Clinicopathological features Primary thyroidectomy n = 95 Completion thyroidectomy n = 48

Mean age, years (SD) 41.4 (13.5) 39.6 (13.7)M:F 1:2.5 1 :2.4Hyperthyroid 5 (5) 2 (4)Retrosternal 2 (2) –Extra-thyroidal invasion 26 (27) 9 (19)Cervical lymph node dissection* 25 (26) 11 (23)Mediastinal lymph node dissection** 4 (4) 3 (6)

* Cervical lymph node dissection included lateral and central compartment nodes dissection.** Lymph node dissection was done through the cervical incision except for one case in each in each group, in which

sternal split was done.The two groups did not differ signi�cantly.

Table II. Histopathological detailsFigures are no. (%).

Primary thyroidectomy n = 95 Completion thyroidectomy n = 48

Type*Papillary carcinoma 69 (73) 34 (71)Follicular carcinoma 20 (21) 12 (25)Poorly differentiated carcinoma 6 (6) 2 (4)

TNM distributionTumour:

Tx – 20 (42)T1 12 (13) 4 (8)T2 35 (37) 7 (15)T3 19 (20) 6 (12)T4 29 (30) 11 (23)

Nodes 29 (30) 13 (27)Metastases 19 (20) 6 (13)

* 15/34 (44%) of specimens of papillary carcinoma, 2/12 of follicular carcinoma (17%), and 2/2 of poorly differentiatedcarcinoma had residual tumour at completion thyroidectomy. The two groups did not differ signi�cantly.

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pletion thyroidectomy was done 3 months after the �rstoperation in most cases. Statistical analysis was doneby the Student’s t and chi square tests.

RESULTS

The overall mean (SD) age was 41 (14) years. Theclinical details of patients are shown in Table I. Thegroups were comparable. The patients who hadcompletion thyroidectomy were mostly referred fromperipheral hospitals (92%). The primary operation inthese cases was hemithyroidectomy (n = 35), subtotalthyroidectomy (n = 3) or nodulectomy (n = 10). Onepatient had a unilateral recurrent nerve palsy whenreferred to our unit. The previously resected side had tobe reoperated on in 13 patients (27%) who had thyroidtissue left after the �rst operation as shown by imaging.Histopathological diagnosis was papillary carcinoma in103 cases (72%), follicular carcinoma in 32 (22%), andpoorly differentiated carcinoma in 8 (6%).

Residual tumour was found in 19 (40%) of 48specimens after completion thyroidectomy, in 15/34(44%) cases of papillary carcinoma, 2/12 of follicularcarcinoma, and 2/2 of poorly differentiated carcinoma(Table II). Three patients (6%) who had completionthyroidectomy had distant metastases at the time ofoperation and another 3 developed metastases later.

The overall morbidity after the 143 operationsincluded temporary hypocalcaemia (23%), permanent

hypocalcaemia (1%), temporary recurrent nerve palsy(3%), permanent nerve palsy (1%), haemorrhage (3%),tracheomalacia (5%), and wound infection (3%) (TableIII). The difference between the two groups was notsigni�cant. Furthermore, the incidence of temporaryhypoparathyroidism did not differ among the sub-groups who had (2/11) or did not have (6/37) lymphnode dissection (18% compared with 16%) and thosewho had (3/13) or did not have (5/35) bilateraldissection (23% compared with 14%) during comple-tion thyroidectomies. Recurrent laryngeal nerve palsywas recorded in none of the patients who had lymphnode dissection but in 2/37 patients who did not havelymph node dissection and in 2/35 who had unilateraldissection compared with none who had bilateraldissections. Both these patients had extrathyroidalinvasion by tumour.

DISCUSSION

Many authorities now consider total thyroidectomy tobe the treatment of choice for differentiated thyroidcancer (4, 17). With improvements in technique andincreasing specialisation in thyroid surgery manycentres have reported low complication rates after totalthyroidectomy (5, 10, 20). Comparable morbidity hasbeen found after less radical operations (7). Afterpartial ablation of a cancerous gland many surgeonsrecommend completion thyroidectomy because, be-

Table III. Complications of primary and completion total thyroidectomyFigures are no. (%).

Complications Primary thyroidectomy n = 95 Completion thyroidectomy n = 48

Temporary hypoparathyroidism 25 (26) 8 (17)Permanent hypoparathyroidism 1 (1) –Temporary recurrent laryngeal nerve palsy 3 (3) 2 (4)Permanent recurrent laryngeal nerve palsy 1 (1) –Haemorrhage 4 (4) 1 (2)Tracheomalacia 5 (5) 2 (4)Wound infection 3 (3) 1 (2)

The two groups did not differ signi�cantly.

Table IV. Percentage of postoperative complications after completion thyroidectomy in other publications

MorbidityDe Jong (6)(n = 100)

Chao (3)(n = 40)

Pezzullo (15)(n = 35)

Eroglu (8)(n = 59)

Pasieka (14)(n = 60)

Present series(n = 48)

Permanent hypoparathyroidism 0 2 3 1 2 0Temporary hypoparathyroidism 3 7 6 0 8 17Permanent recurrent laryngeal nerve palsy 0 2 3 0 0 0Temporary recurrent laryngeal nerve palsy 2 2 8 3 5 4

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sides dealing with residual tumour in the opposite lobe,which is reported in 23%–54% of cases, it allows thesubsequent recognition and treatment of metastaticdisease and offers young patients a potentially normallifespan (6, 8, 14, 15, 17). However, the permanentcomplication rate is higher after reoperations on thethyroid than after primary operations and one ofarguments for doing a total thyroidectomy as theprimary operation is to avoid reoperations (7, 11, 17–19).

Recently, many workers have shown completionthyroidectomy to be an ef�cient and safe operationwith a low complication rate provided that precise rulesare observed (3, 8, 15, 16). The incidence of permanenthypoparathyroidism varies from less than 1% to 3%and that of permanent recurrent laryngeal nerve palsyfrom nil to around 3% in various recently reportedseries (Table IV). However, many think that thoughacceptable, these are still higher than after primaryoperations (11). There are few reports that havecompared morbidity of primary and secondary opera-tions (2, 15, 18). Reeve et al. (18) found no permanentcomplications after primary operations for multinodu-lar goitre, but the incidence of complications was manytimes greater after secondary thyroidectomy (perma-nent hypoparathyroidism in 3.7% and permanentrecurrent laryngeal nerve palsy in 3.1%). SimilarlyBergamaschi et al. reported a signi�cantly higherincidence of hypoparathyroidism than after primaryoperations (2). However, Eroglu et al. (8) reportedpermanent hypoparathyroidism in 1/106 and transientunilateral recurrent laryngeal nerve palsy in 3/106patients who had total thyroidectomies, 59 of whichwere completion operations. In their experience, therisk of complication was not signi�cantly differentbetween primary total thyroidectomy and completionthyroidectomy.

Higher morbidity after total thyroidectomy is attri-butable to extent of resection, surgeon’s experience,hyperthyroidism, malignancy, retosternal goitres, andassociated lymph node dissection (2, 20). Bergamaschiet al. found completion and total thyroidectomy withnode dissection increased the rates of permanenthypoparathyroidism and temporary recurrent laryngealnerve palsy (2). However, in our series the complica-tion rate did not differ in patients who had lymph nodedissection.

With increasing con�dence in technique surgeonsare now using completion thyroidectomy in children aswell (12). Miccoli et al. evaluated the usefulness ofcompletion total thyroidectomy in children withthyroid cancer secondary to nuclear accidents andconcluded that completion thyroidectomy facilitatedthe diagnosis and treatment of recurrent thyroid cancerand metastases in lung or lymph nodes in 11/18 of the

patients in whom residual differentiated thyroid carci-noma had not previously been recognised (12).

In our experience using a lateral approach forcompletion thyroidectomy, it is relatively easy todissect the untouched side after hemithyroidectomy(1). Though the incidence of complications were notsigni�cantly different, dissection on the ipsilateral sidein patients who had had either nodulectomy or subtotalthyroidectomy is technically more dif�cult and a smallamount of thyroid tissue as revealed on postoperative131I scan is almost always left behind.

CONCLUSION

We had previously shown that at a specialist centrededicated to thyroid surgery the complication rate oftotal thyroidectomy was no greater in the hands oftrainees than in those of consultants (13). The presentstudy shows that completion thyroidectomy can bedone with acceptable morbidity in a specialist thyroidsurgery centre. We recommend it for the managementof differentiated thyroid cancer, and fear of increasedmorbidity should not be used as an argument against itsroutine use.

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Submitted August 1, 2001; submitted after revision January20, 2002; accepted February 7, 2002

Address for correspondence:S. K. Mishra, M.D., ProfessorDepartment of Endocrine SurgerySanjay Gandhi Postgraduate Institute of Medical SciencesRaebareli RoadLucknow 226014IndiaFax: ‡91522 440999/440017E-mail: skmishra@sgpgi.ac.in

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