Introduction

This information sheet is meant to help you to remember and understand the conversation that we had about your illness and my advice that you should have surgery.

Being anxious is a healthy defence mechanism, but if the anxiety produces symptoms such as panic attacks, sleeplessness, or prevents you from making a decision, you should talk again with me and your family doctor. The level of knowledge  in these notes will be enough for most people but if you need more information I can show you where to find it. On the Internet, www.endocrinesurgeons.org.au is a good start.

If you are planning to talk to me further, it is helpful to write down your questions, and to bring a friend or family member, who can remember things you might forget.

Uncertainty and decision making

Deciding to have surgery is always a big step and you should feel confident to go ahead; if you don't you should let me know. Like travelling in an aeroplane, having an operation is usually safe but can rarely end up with serious complications causing death, or permanent severe disabilities. With those risks in mind we only recommend an operation if the condition being treated is  significant or there is a risk of serious illness if the condition is not treated

I always consider the option of not operating, and discuss what alternatives there are. If you are not sure about what could be done as an alternative to surgery you should talk to me again.

All patients are entitled to have the option of another opinion or to have another surgeon treat them and we are happy to arrange another surgeon to see you, if you are not confident that I am the right surgeon to treat you. All surgeons consider these requests as a routine part of professional life and we are happy to help with making other appointments and forwarding your results to other doctors. Sometimes this means having another doctor treat the condition and sometimes this makes the patient more confident to continue under my care.

Anaesthesia

Anaesthetics have transformed painful and dangerous surgery into a safe treatment that is done with the patient unaware until they wake in the recovery room. This work is done by colleagues who have had training and experience in this specialty. The procedure and risks of anaesthesia will be discussed with you by that specialist before the operation and if you have other medical problems or need to ask some detailed questions, an appointment can be made for you to visit the anaesthetic clinic.

Complications

All operations, even small ones can have complications. All surgeons have a few complications, and these can happen even when the operation went well. The only way to be absolutely certain of not having a complication is not to have surgery at all. When a problem arises, we try to recognise it as early as possible and take steps to correct the problem.

Public or Private Arrangements

If you come in to hospital as a public patient, you will not be charged for the costs involved in your care. The registrar (a doctor who is training to be a consultant surgeon) will do those parts of the operation suitable for their level of training under my supervision and I will perform those parts of the case that I consider need a consultant. This arrangement recognises that my skill and experience was developed in the same way so that when I am too old to continue, there will be a new generation of surgeons to take my place. Simple operations are done by the registrar with me available to assist or take over if there are problems. More difficult procedures are done with me assisting to supervise all steps and to take over for the most difficult parts. The most complicated operations are performed by me with the registrar assisting. Our first priority is to ensure that all operations are done to the highest possible standard.

If you elect to be a private patient, either in a public or a private hospital, then most of your operating will be done by me although surgery is a team process, where some cutting stitching and retracting is shared between two pairs of hands to make the operation safer and more efficient.

When you elect to be a private patient, there will be a bill from the hospital for your ward care, medications, and theatre fees, for any disposable equipment, and fees from the surgeon, anaesthetist, assistant surgeon, and pathologist, and some other specialists from time to time. Medicare and health funds cover part of the fees, but there will probably be some gap payments that you will need to pay yourself. My secretary can give you an estimate of costs in writing.

Private patients in public hospitals have the same access to the waiting list as public patients.

The indications for total thyroidectomy:

1. Thyroid enlargement to the point where there are symptoms of obstruction to swallowing, breathing, speaking or a constant cough, or pain in the lower neck
2. Thyroid overactivity where there is a need for medication to control thyroid hormone levels, and other types of control are less effective, or where cardiac drugs produce thyroid overactivity but are beneficial for control cardiac rhythm (amiodarone Cordarone)
3.  Suspicion of thyroid cancer or the development of thyroid cancer of a type that is best treated with total removal of the thyroid
4. Enlargement that produces an unacceptable cosmetic appearance. This is usually best judged by the patient
5. Genetic thyroid diseases that may lead to the development of thyroid cancer in the future where pre-emptive surgery reduces the risk of cancer spreading
6. Painful thyroid conditions that rarely do not settle with time or have not responded to treatment or where the side effects of medical treatment are unacceptable
7. Benign thyroid conditions which by needing repeated investigation such as needle biopsy over time are proving a source of anxiety and inconvenience for the patient
8. A condition which is mainly on one side of the thyroid but which is very likely to develop within a short time on the other side as well. Most patients in this situation prefer to have only one operation, as repeat surgery carries a higher risk of complications

There may be one or more factors that are important in any one patient. Every patient will react to their own illness in a different way so we use this list as a guide to making the decision about whether surgery is necessary and how much surgery is needed

General Complications of Surgery

When patients undergo surgery there is a risk of having a heart attack or stroke, of developing kidney or lung failure. Generally these conditions are more likely if there is already evidence of a pre-existing illness, which is why your past history is noted in detail. If you have forgotten some part of the history, you can ring my rooms to fill in any gaps.

We take precautions with any major operation (squeezing the blood out of the legs during surgery, stockings to compress the leg veins and blood thinning injections) to minimise the risk of blood clots forming in the legs and pelvic veins. If these travel to the lungs they can occasionally be life threatening. You must make sure that if you or your family have a blood clot history, or if you have had leg immobilisation prior to surgery to let me know.

Hospitals harbour some infections that are resistant to many and sometimes all antibiotics. The risk of infection of this type is greater if you need to stay longer, have a long complex procedure, or have a depressed immune system or other medical problems like diabetes. All hospitals that I use have systems to reduce the risk of this type of problem.

There are a few very rare but serious complications that can happen after surgery which simply cannot be predicted. Usually surgeons record these complications as case reports but would expect never to see them more than once in their working life. Of course this is not much comfort to the patient who has suffered the complication! Remember that these problems do not affect more than a few percent of patients, and often can be recognised and treated.

Complications Specific to Thyroid surgery

The larynx (the organ for speaking) lies just above the thyroid and there are nerves to make the vocal cords move for speech, to avoid food going "down the wrong way" and for coughing which run very close to the thyroid from above and below.

It is important to avoid injury to these nerves during thyroid surgery. We may check the vocal cord function before or after your operation with a flexible telescope through the nose (nasopharyngoscopy).  Temporary hoarseness affects about 10% of patients but is due to nerve damage in only half. Wound swelling, and vocal cord bruising from the anaesthetic tube are other causes.

Permanent paralysis of one nerve is uncommon (about 0.5%) and the nerve may take up to 2 years to recover, although often the other vocal cord can be strengthened to do the work for both sides. Very rarely (mostly with advanced thyroid cancer) both nerves do not work and a tracheostomy (breathing tube in the neck) is necessary, in some cases permanently. It is unusual for thyroid patients not to be able to use their voice to the same level as before.

Voice weakness and voice fatigue (losing the voice after prolonged speaking) are common symptoms that usually improve over six months. This can be due to the upper nerve to the larynx being damaged, and this may affect up to 30% of patients but is usually mild.

We recommend using the voice as much as is comfortable as the larynx muscles like muscles in the arms and legs recover better if they are being exercised. This exercise is not always popular with other family members! If there are voice problems, we like to know from patients early after discharge from hospital as we plan voice rehabilitation and may ask a speech pathologist for help. If your work involves a lot of speaking we may recommend "light voice duties" to help with recovery.

Thyroid Hormone replacement after surgery

When the whole thyroid is removed, replacement of thyroid hormone (a chemical made in the thyroid and released into the blood stream) is necessary to remain healthy. This hormone is given in the form of thyroxine (trade name Oroxine) which is a tablet form of the same chemical that is called T4 in the blood test that you may have had recently.

This hormone is needed to maintain important metabolic (a bit like the accelerator pedal in a car) function. Usually 100 to 150 mcg (ug or micrograms) per day is enough. We test this with a blood test 6 weeks after surgery and 6 monthly afterwards. The level is usually easy to maintain and the dose needed may gradually get less as you grow older.

The prescription is inexpensive and there are 200 tablets in a bottle. We give various combinations of 50, 100, and 200 mcg tablets. The dose lasts a few days in the blood stream so missing a dose and catching up occasionally is not a problem. Most people get in to a routine of taking the tablet on getting up in the morning. Thyroxine is absorbed through the intestine and the absorption can be affected by binding to calcium in calcium tablets and vitamin supplements containing calcium. Milk and soy products have large amounts of calcium which can have this effect. We advise taking thyroxine on an empty stomach one hour before any of these products are consumed.

You should not adjust the dose according to how you feel as the effect of changing the dose is delayed. If you are forgetful, the chemist has a dispenser with the days of the week marked on it, so you can set out your week's medication and take it regularly.

There is quite a lot of discussion on the Internet about the use of T3 (trade name Tertroxine). This is a manufactured form of the hormone that is measured in the blood as T3. The thyroid makes about 15 times more T4 as T3 but in the cells where thyroid hormone works T3 is the active hormone. 80% of T3 is made by converting T4 from the bloodstream to T3 (outside the thyroid) and this is exactly what hapens after the thyroid is removed.

Alternative (Non-medical) Opinions about thyroid hormone replacement

Some non-medical web sites claim that patients do not feel "normal" unless they take both T3 and T4, however there is no convincing evidence that this is the case for more than 1% of patients taking thyroxine alone after total thyroidectomy. There is a rare situation called "thyroid hormone resistance" due to reduced conversion of T4 to T3,  where taking T3 appears beneficial, and there are a few patients who seem to feel better taking both T4 and T3 but most patients do not need this added complication to their daily routine to remain healthy and active. Tertroxine (T3) is available for such cases and is expensive, but is subsidised with an authority prescription for the appropriate indication, by the pharmaceutical benefits scheme (PBS).

Recently, claims have been made that patients taking thyroid hormone should use a natural dried thyroid extract from slaughtered pigs, and that the manufacturer of synthetic thyroid hormone has conspired to criticise this recommendation on the grounds that its monopoly for the sale of thyroid hormone might be threatened. It is also claimed that this mixture of thyroid hormones might be more natural and healthy for patients and have less allergic reactions despite having all the animal proteins. Without strict regulation regarding the strength and purity of this product, and confidence in the continuity of supply, in a setting where there is concern about the transmission of disease from animals to humans,  I  recommend the chemically identical synthetically produced quality controlled gluten-free thyroxine (Oroxine). Doctors stopped using thyroid hormone extract for the reasons I have just given, early in the 20th century.

Parathyroid glands and Calcium

The parathyroid glands are located on both sides of the neck, so an operation on one thyroid lobe usually puts only half these glands at risk. As a result, the problems described below are rarely experienced, unless you have already had one thyroid lobe removed, or we need to remove both thyroid lobes.

Behind the thyroid there are four tiny glands only 5 mm in length. These glands have the same blood supply as the thyroid, and even with very careful surgery, they can be injured. If this happens then the important parathyroid hormone (PTH) may fall, leading to low levels of calcium in the blood. As calcium is an important mineral for bones and for muscles and nerves, a fall in calcium can lead to a loss of bone substance or osteoporosis although this is a long term complication.

More immediately low calcium causes numbness, cramps, and pins & needle symptoms. These are easily fixed by giving calcium either in a drip or in tablet form, and to bring the level up if very low, Vitamin D. About 25% of patients have some form of fall in calcium after surgery to remove both lobes of the thyroid (total thyroidectomy). Patients who have had previous thyroid surgery or Graves' disease are more susceptible.

About 1 in 50 patients need long term calcium and Vitamin D (Rocaltrol) replacement, but are usually otherwise healthy. There may be an increased risk of developing cataracts, so an eye check and measurement of bone strength may be needed Vitamin D is not used in pregnancy, and calcium tablets are large so not always popular with patients who have trouble with tablets. Chewable and dissolvable forms are available. Several serves of dairy food or calcium enriched food may substitute for some calcium tablets.

If we are worried about the health of one or more parathyroid glands we may implant them into the right sternomastoid muscle (the large diagonal muscle on the front of the neck). Here they develop a new blood supply like a skin graft and work well after 6 weeks. If there is a temporary problem this is usually better within 2-3 weeks but sometimes takes 6-12 months to settle. Hypoparathyroidism (lack of parathyroid function) does not usually interfere with normal daily living or work.

Thyroidectomy Incisions and Scars

We pay particular attention to the wound from thyroid surgery, Just like every patient is different, every scar is also different. If your neck is long and thin and the thyroid is small, then the scar is usually about 6 cm along the collar line, but we make the scar longer to suit the conditions we find and so that surgery can be performed with good vision.

We sew all wounds up using a plastic surgical stitching technique that gives a good cosmetic result in most patients. Some people are prone to form a red raised up (hypertrophic) scar. This is seen more in young people with darker skin. The scar usually gets better with time but may take 6 to 18 months.

In Japan and other south east Asian countries some surgeons perform thyroid surgery telescopically through the axilla to avoid neck scars and this can also be performed robotically. I do not believe this surgery is easier or safer than with a scar in the neck. In some selected cases we perform one sided thyroid surgery through a small (2-3 cm) incision on one side. This is called minimal access surgery. I am happy to discuss this with you, but will always put safety before marginally improved cosmetic results.

If a scar is particularly hypertrophic and these can sometimes be itchy as well, we may ask a plastic surgeon to advise regarding treatment, but we usually wait 12 months before referring. Unsatisfactory scars affect perhaps 3% of patients. Some patients have numbness in the skin above the scar. In men this can be a problem with shaving. The numbness settles after about 6 months.

Local neck symptoms

Some patients experience a feeling of tightness in the neck. This symptom settles in most cases over 2 weeks but may take up to 6 months to subside. There may be a feeling of difficulty swallowing during that time and sometimes pain and an irritating cough. Patients who have a low thyroid hormone level are more prone to neck swelling and tightness and correction  of the low level with thyroid hormone may help. Rarely these symptoms can be persistent, but usually not severely disabling.

Bleeding complications

Bleeding is an uncommon complication after thyroid surgery. Blood transfusion is rarely required for thyroidectomy unless there are unusual problems. Even a small amount of blood collecting around the throat can cause swelling and breathing problems. For this reason we watch thyroid patients closely after their surgery to look for any signs of swelling.

Occasionally patients return to theatre as an emergency so we can release the blood that has collected, but the risk is less than 1% of all neck operations. We take particular steps during the operation and at the end to minimise the risk of bleeding. If there is coughing as the patient wakes up this will sometime cause bleeding.

It is important to stop aspirin, arthritis medicines and anti-platelet drugs at least 10 days before surgery. Warfarin treatment needs special arrangements. There are also some herbal medicines (particularly gingko biloba) that can interfere with blood clotting. If you are unsure, show me the details of any dietary supplement or natural remedy you are using.

We use small titanium clips to secure many of the blood vessels that run in to the thyroid. This technique enables us to secure very small arteries close to the nerves and parathyroid glands without "collateral" damage to these important structures. The clips are inert, do not rust and do not set off metal detectors, and do not move or heat up in strong magnetic fields used in Magnetic Resonance Imaging (MRI). Sometimes patients have neck X-rays after thyroid surgery and are alarmed when the report notes "surgical clips are seen in the neck", and think that instruments have been left there by mistake! These clips are used in most branches of surgery and do not produce adverse health problems. In the past surgeons used silk sutures which do not show up on X-ray, but had problems harbouring infection which we do not see with the titanium clips.

Recovery and return to normal life

Most patients recover quickly from their thyroid operation, and are well enough to leave hospital on the first or second day after surgery. We advise taking it easy at home for about 10-14 days after thyroidectomy. Some patients who feel unable to relax, or run their own business return to work after about 5 days. Occasionally the recovery time may be longer, for example if the voice is recovering, and we take this into consideration when providing a medical certificate.

As the neck muscles may be stiff, it is important not to drive until you can turn your head comfortably to have full vision of the inside lane and when reversing. Heavy housework should be avoided for 2 weeks, and really heavy manual work and heavy lifting above shoulder height avoided for 6 weeks. Contact sport should be avoided for 6 weeks but exercise to maintain fitness such as walking, running swimming and cycling can be started after 7-10 days. Recommencing sexual relations is best guided by individual patient comfort levels and common sense.

 

 

 

 

 

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