Skip to main content
Log in

Totale Thyreoidektomie bei Knotenstruma

Total thyroidectomy for multinodular goiter

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Die Struma multinodosa ist eine häufige Erkrankung, deren Therapie eine zentrale Rolle im allgemein- und viszeralchirurgischen Alltag einnimmt. Auswertungen der nationalen DRG-Statistiken belegen, dass die totale Thyreoidektomie zunehmend partielle Resektionsstrategien ersetzt. Dieser Paradigmenwechsel wird wesentlich durch das Verständnis der Struma multinodosa als Erkrankung des gesamten Organs sowie der durch die totale Thyreoidektomie vermiedenen risikoreicheren Zweiteingriffe aufgrund von inzidentellen Schilddrüsenkarzinomen und Strumarezidiven bei gleichwertigen operativen Risiken begründet. Die vorliegende Evidenz stützt sich jedoch bezüglich der operativen Ergebnisse überwiegend auf zentrumspezifische Daten und weist hinsichtlich der postoperativen Auswirkungen der Hormonsubstitution sowohl nach totaler Thyreoidektomie als auch nach nichttotaler Thyreoidektomie große Lücken auf. Der Erhalt von funktionsrelevantem nicht pathologisch verändertem Schilddrüsengewebe behält daher als Therapiealternative seine Bedeutung. Bei Gewährleistung vergleichend niedriger Komplikationsraten und unter Berücksichtigung der Compliance, der Lebenssituation und des Patientenwunsches stellt die totale Thyreoidektomie jedoch den Regeleingriff zur Behandlung der beidseitigen Knotenstruma dar.

Abstract

Multinodular goiter is a frequent disease which plays a central role in the daily routine of general and visceral surgeons. Analyses of the national DRG statistics reveal that total thyroidectomy is increasingly replacing partial thyroid resections. This paradigm shift is substantiated by the comprehension of multinodular goiter as a disease affecting the whole organ as well as the fact that total thyroidectomy avoids high risk secondary interventions for incidental thyroid carcinomas and recurrent disease while offering comparable operative risks. However, the available evidence on operative results originates predominantly from thyroid centers and clinical data regarding long-term effects of thyroid hormone substitution following total as well as sub-total thyroidectomy are lacking. Therefore, the preservation of functionally relevant normal thyroid tissue retains its relevancy as an alternative treatment. If a comparably low operative risk can be guaranteed and considering the patient’s compliance, life situation and wishes, total thyroidectomy represents the optimal therapy for bilateral multinodular goiter.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6

Literatur

  1. Agarwal G, Aggarwal V (2008) Is total thyroidectomy the surgical procedure of choice for benign multinodular goiter? An evidence-based review. World J Surg 32:1313–1324

    Article  PubMed  Google Scholar 

  2. Baltisberger BL, Minder CE, Burgi H (1995) Decrease of incidence of toxic nodular goitre in a region of Switzerland after full correction of mild iodine deficiency. Eur J Endocrinol 132:546–549

    Article  CAS  PubMed  Google Scholar 

  3. Barczynski M, Konturek A, Hubalewska-Dydejczyk A et al (2010) Five-year follow-up of a randomized clinical trial of total thyroidectomy versus dunhill operation versus bilateral subtotal thyroidectomy for multinodular nontoxic goiter. World J Surg

  4. Bellantone R, Lombardi CP, Boscherini M et al (2004) Predictive factors for recurrence after thyroid lobectomy for unilateral non-toxic goiter in an endemic area: results of a multivariate analysis. Surgery 136:1247–1251

    Article  PubMed  Google Scholar 

  5. Bellantone R, Lombardi CP, Bossola M et al (2002) Total thyroidectomy for management of benign thyroid disease: review of 526 cases. World J Surg 26:1468–1471

    Article  PubMed  Google Scholar 

  6. Berchtold R, Studer H, Teuscher J (1983) Current surgery of goiter. Chirurgie 109:187–199

    CAS  PubMed  Google Scholar 

  7. Brauer VF, Paschke R (2004) Die Knotenstruma. Die molekulare Entstehung – Konsequenzen für die Therapie? Zentralbl Chir 129:356–362

    Article  CAS  PubMed  Google Scholar 

  8. Clark OH (1988) Total thyroidectomy: the preferred option for multinodular goiter. Ann Surg 208:244–245

    Article  CAS  PubMed  Google Scholar 

  9. Colak T, Akca T, Kanik A et al (2004) Total versus subtotal thyroidectomy for the management of benign multinodular goiter in an endemic region. ANZ J Surg 74:974–978

    Article  PubMed  Google Scholar 

  10. De Toma G, Tedesco M, Gabriele R et al (1995) Total thyroidectomy in the treatment of multinodular toxic goiter. G Chir 16:373–376

    Google Scholar 

  11. Delbridge L (2003) Total thyroidectomy: the evolution of surgical technique. ANZ J Surg 73:761–768

    Article  PubMed  Google Scholar 

  12. Delbridge L, Guinea AI, Reeve TS (1999) Total thyroidectomy for bilateral benign multinodular goiter: effect of changing practice. Arch Surg 134:1389–1393

    Article  CAS  PubMed  Google Scholar 

  13. Derwahl M, Studer H (2000) Multinodular goitre: ‚much more to it than simply iodine deficiency’. Baillieres Best Pract Res Clin Endocrinol Metab 14:577–600

    Article  CAS  PubMed  Google Scholar 

  14. Destatis (2007) Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) Operationen und Prozeduren der vollstationären Patientinnen und Patienten in Krankenhäusern – Ausführliche Darstellung. In:Statistisches Bundesamt

  15. Destatis (2006) Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) Operationen und Prozeduren der vollstationären Patientinnen und Patienten in Krankenhäusern – Ausführliche Darstellung. In: Statistisches Bundesamt

  16. Destatis (2008) Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) Operationen und Prozeduren der vollstationären Patientinnen und Patienten in Krankenhäusern – Ausführliche Darstellung. In: Statistisches Bundesamt

  17. Dralle H (2009) Identification of the recurrent laryngeal nerve and parathyroids in thyroid surgery. Chirurg 80:352–363

    Article  CAS  PubMed  Google Scholar 

  18. Dralle H (2007) Inzidentalome der Schilddrüse. Überdiagnostik und -therapie gesunder Schilddrüsenkranker? Chirurg 78:677–686

    Article  CAS  PubMed  Google Scholar 

  19. Enderlen E, Hotz G (1918) Beiträge zur Anatomie der Struma und zur Kropfoperation. Z Angew Anat 3:57–79

    Google Scholar 

  20. Escobar-Morreale HF, Botella-Carretero JI, Gomez-Bueno M et al (2005) Thyroid hormone replacement therapy in primary hypothyroidism: a randomized trial comparing L-thyroxine plus liothyronine with L-thyroxine alone. Ann Intern Med 142:412–424

    CAS  PubMed  Google Scholar 

  21. Foster RS Jr (1978) Morbidity and mortality after thyroidectomy. Surg Gynecol Obstet 146:423–429

    PubMed  Google Scholar 

  22. Gemsenjager E (1973) Die selektive Strumektomie. Schweiz Rundsch Med Prax 62:492–496

    CAS  PubMed  Google Scholar 

  23. Gemsenjager E (1993) Zur Strumachirurgie von Kocher bis heute. Schweiz Med Wochenschr 123:207–213

    CAS  PubMed  Google Scholar 

  24. Gemsenjager E, Heitz PU, Staub JJ et al (1983) Surgical aspects of thyroid autonomy in multinodular goiter. World J Surg 7:363–371

    Article  CAS  PubMed  Google Scholar 

  25. Giacomelli L, Gagliarducci E, Guerriero G et al (2003) Multinodular goiter as an organ disease: study of continual nodulogenesis. Biological bases indicating total thyroidectomy. Ann Ital Chir 74:155–158

    PubMed  Google Scholar 

  26. Gough IR, Wilkinson D (2000) Total thyroidectomy for management of thyroid disease. World J Surg 24:962–965

    Article  CAS  PubMed  Google Scholar 

  27. Grussendorf M, Vaupel R, Reiners C et al (2005) The LISA trial – a randomized, double-blind, placebo-controlled four-arm study of 1,000 patients with nodular goiter in Germany. Study design and first results of feasibility. Med Klin 100:542–546

    Article  Google Scholar 

  28. Hampel R, Bennohr G, Gordalla A et al (2010) Urinary iodide excretion in adults in Germany 2005 meets WHO target. Exp Clin Endocrinol Diabetes (in press)

  29. Harrer P, Broecker M, Zint A et al (1998) Thyroid nodules in recurrent multinodular goiters are predominantly polyclonal. J Endocrinol Invest 21:380–385

    CAS  PubMed  Google Scholar 

  30. Jonklaas J, Davidson B, Bhagat S et al (2008) Triiodothyronine levels in athyreotic individuals during levothyroxine therapy. JAMA 299:769–777

    Article  CAS  PubMed  Google Scholar 

  31. Kraimps JL, Marechaud R, Gineste D et al (1993) Analysis and prevention of recurrent goiter. Surg Gynecol Obstet 176:319–322

    CAS  PubMed  Google Scholar 

  32. Kulacoglu H, Dener C, Ziraman I et al (2000) Thyroxine prophylaxis after bilateral subtotal thyroidectomy for multinodular goiter. Endocr J 47:349–352

    Article  CAS  PubMed  Google Scholar 

  33. Lefevre JH, Tresallet C, Leenhardt L et al (2007) Reoperative surgery for thyroid disease. Langenbecks Arch Surg 392:685–691

    Article  PubMed  Google Scholar 

  34. Liu Q, Djuricin G, Prinz RA (1998) Total thyroidectomy for benign thyroid disease. Surgery 123:2–7

    CAS  PubMed  Google Scholar 

  35. Martina B, Staub JJ, Gemsenjager E (1992) Long-term follow-up after thyroidectomy: incidence of recurrent goiter and functional results. Schweiz Med Wochenschr 122:1753–1757

    CAS  PubMed  Google Scholar 

  36. Miccoli P, Antonelli A, Iacconi P et al (1993) Prospective, randomized, double-blind study about effectiveness of levothyroxine suppressive therapy in prevention of recurrence after operation: result at the third year of follow-up. Surgery 114:1097–1101; discussion 1101–1092

    CAS  PubMed  Google Scholar 

  37. Mishra A, Agarwal A, Agarwal G et al (2001) Total thyroidectomy for benign thyroid disorders in an endemic region. World J Surg 25:307–310

    Article  CAS  PubMed  Google Scholar 

  38. Misiakos EP, Liakakos T, Macheras A et al (2006) Total thyroidectomy for the treatment of thyroid diseases in an endemic area. South Med J 99:1224–1229

    PubMed  Google Scholar 

  39. Moalem J, Suh I, Duh QY (2008) Treatment and prevention of recurrence of multinodular goiter: an evidence-based review of the literature. World J Surg 32:1301–1312

    Article  PubMed  Google Scholar 

  40. Muller PE, Schmid T, Spelsberg F (1998) Total thyroidectomy in iodine-deficient goiter – an effective treatment alternative? Zentralbl Chir 123:39–41

    CAS  PubMed  Google Scholar 

  41. Ozbas S, Kocak S, Aydintug S et al (2005) Comparison of the complications of subtotal, near total and total thyroidectomy in the surgical management of multinodular goitre. Endocr J 52:199–205

    Article  PubMed  Google Scholar 

  42. Pappalardo G, Guadalaxara A, Frattaroli FM et al (1998) Total compared with subtotal thyroidectomy in benign nodular disease: personal series and review of published reports. Eur J Surg 164:501–506

    Article  CAS  PubMed  Google Scholar 

  43. Patane S, Marte F, Sturiale M (2009) Endogenous subclinical hyperthyroidism and cardiovascular system: Time to reconsider? Int J Cardiol

  44. Pears J, Jung RT, Gunn A (1990) Long-term weight changes in treated hyperthyroid and hypothyroid patients. Scott Med J 35:180–182

    CAS  PubMed  Google Scholar 

  45. Phitayakorn R, Mchenry CR (2008) Follow-up after surgery for benign nodular thyroid disease: evidence-based approach. World J Surg 32:1374–1384

    Article  PubMed  Google Scholar 

  46. Reeve TS, Delbridge L, Cohen A et al (1987) Total thyroidectomy. The preferred option for multinodular goiter. Ann Surg 206:782–786

    Article  CAS  PubMed  Google Scholar 

  47. Seiler CA, Vorburger SA, Burgi U et al (2007) Extended resection for thyroid disease has less operative morbidity than limited resection. World J Surg 31:1005–1013

    Article  PubMed  Google Scholar 

  48. Shiffman MA (1998) Total thyroidectomy for multinodular goiter. Int Surg 83:182

    CAS  PubMed  Google Scholar 

  49. Tekin K, Yilmaz S, Yalcin N et al (2010) What would be left behind if subtotal thyroidectomy were preferred instead of total thyroidectomy? Am J Surg (in press)

  50. Tezelman S, Borucu I, Senyurek Giles Y et al (2009) The change in surgical practice from subtotal to near-total or total thyroidectomy in the treatment of patients with benign multinodular goiter. World J Surg 33:400–405

    Article  PubMed  Google Scholar 

  51. Thomusch O, Sekulla C, Dralle H (2003) Is primary total thyroidectomy justified in benign multinodular goiter? Results of a prospective quality assurance study of 45 hospitals offering different levels of care. Chirurg 74:437–443

    Article  CAS  PubMed  Google Scholar 

  52. Tigas S, Idiculla J, Beckett G et al (2000) Is excessive weight gain after ablative treatment of hyperthyroidism due to inadequate thyroid hormone therapy? Thyroid 10:1107–1111

    Article  CAS  PubMed  Google Scholar 

  53. Torre GC, Borgonovo G, Arezzo A et al (1996) Recurrent goiter: analysis of 134 reinterventions. Ann Ital Chir 67:357–363

    CAS  PubMed  Google Scholar 

  54. Tunca F, Senyurek YG, Terzioglu T et al (2009) Impact of total versus subtotal thyroidectomy on calcium metabolism and bone mineral density in premenopausal women. J Laryngol Otol 123:434–438

    Article  CAS  PubMed  Google Scholar 

  55. Vaiman M, Nagibin A, Hagag P et al (2008) Subtotal and near total versus total thyroidectomy for the management of multinodular goiter. World J Surg 32:1546–1551

    Article  PubMed  Google Scholar 

  56. Wahl RA, Rimpl I (1998) Selective (= morphology and function dependent) surgery of nodular struma: relationship to risk of recurrent laryngeal nerve paralysis by dissection and manipulation of the nerve. Langenbecks Arch Chir Suppl Kongressbd 115:1051–1054

    CAS  PubMed  Google Scholar 

  57. Walsh JP (2002) Dissatisfaction with thyroxine therapy – could the patients be right? Curr Opin Pharmacol 2:717–722

    Article  CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to T.J. Musholt.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Musholt, T. Totale Thyreoidektomie bei Knotenstruma. Chirurg 81, 603–611 (2010). https://doi.org/10.1007/s00104-009-1880-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-009-1880-z

Schlüsselwörter

Keywords

Navigation