Abstract and Introduction
National and international guidelines about thyroid surgery seem to be moving more and more towards less radical surgical procedures but everyday practice does not seem to always align with them. We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.
Objective: The ain of this study was to describe thyroid surgery and to identify the factors leading to either a total or a partial thyroidectomy regardless of the severity of the thyroid disease.
Summary Background Data: National and international guidelines about thyroid surgery seem to be moving more and more toward less radical surgical procedures but everyday practice does not seem to always align with them.
Methods: We based this nationwide retrospective cohort study on a national database that compiles discharge abstracts for every admission for thyroidectomy to French acute healthcare facilities (PMSI database 2010 to 2019).
Results: In this study, 375,810 patients (male: 23%; age = 53 ± 15 years) had a thyroidectomy (partial: 28%) for cancer (17%), hyperthyroidism (16%), nonfunctioning goiter (64%), or other (3%). We noticed a global trend toward more partial thyroidectomy (P < 0.001) with a significant increase in the proportion of lobectomy in the post-ATA recommendations' period (P < 0.001) as well as in the "French Levothyrox crisis" period, in which we saw an unexpected rise of adverse events notifications associated with the marketing of a new formula of Levothyrox (P < 0.001) amid widespread media coverage. In a multivariate analysis, we also identified that complete resection was more frequently performed in centers with a caseload >40/year [P < 0.001, odds ratio (OR) = 1.48], for obese patients (body mass index >30 kg/m2; P < 0.001, OR = 1.42), and according to the indication of surgery (OR benign = 1, OR cancer = 2.25, OR hyperthyroidism = 4.13).
Conclusion: We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.
Thyroid nodules have long been known of and were even described in antiquity. Palpable thyroid nodules affect 6% of females and 1% of males, and can be identified by ultrasound screening in up to 50% of patients. In the past, because of the lack of physiological and anatomical knowledge of the thyroid gland at the time, few treatments were available, whereas surgery was reserved for emergency cases, mostly compressive or hyperfunctioning goiters, but with high mortality rates. Many surgical procedures were attempted over the years, usually with poor outcomes. A pivotal report by Kocher and Billroth on the common negative consequences of total thyroidectomy (eg, bleeding, infection, hypothyroidism) led to the development of partial thyroidectomy, with an aim to decrease postoperative complications in thyroidectomy. Then, as the surgical technique became safer and the postoperative complications were brought under control, there was a strong tendency to again favor total thyroidectomy, mostly to reduce the rate of recurrence, whether for benign or malignant disease. In parallel with the development of thyroid surgery, new medical treatments (hormone supplementation and synthetic antithyroid drugs) and diagnostic techniques (such as ultrasound and fine needle aspiration) gradually became more widespread and more commonly utilized throughout the 20th century, leading to a gradual change in indications and practice in the guidelines. Nowadays, we notice there is an increasing call for thyroid parenchymal sparing, supported by hormone therapy noncompliance and decreased risk, and a desire to avoid over-treatment, leading to partial surgeries being proposed, even with oncological indications,[5,6] and to the administration of less invasive treatments, such as percutaneous techniques or radioiodine therapy, for benign hyperfunctioning or not-hyperfunctioning tumors.
In terms of real-life surgery, the distribution of partial and total thyroidectomy seems mysterious, leading to the question as to whether there are other factors influencing the surgeons' and patients' choice of surgery besides the guidelines? In particular, does the procedure feasibility, social or medical environment, or any social event impact those choices? Consequently, the objective of this study was to identify the factors influencing the partial thyroidectomy rate, independent of the thyroid pathology or tumor characteristics.
Annals of Surgery. 2021;274(5):829-835. © 2021 Lippincott Williams & Wilkins