Endocrine Surgery

Thyroid, parathyroid glands and adrenal glands

The thyroid gland regulate, so to say, the energy balance of the body though the hormones Thyroxine (T4) and Triiodothyronine (T3). The symptoms of its hyperfunction (hyperthyroidism) are heart disease, high blood pressure, nervousness, diarrhea and heat sensation, hypothyroidism is manifested in fatigue, constipation and slowing of all metabolic processes.

The important hormone gland ("endocrine gland") is located on both sides of the neck around the trachea and immediately below the larynx. When enlarged, it can be seen as a „goiter“.

To cure many diseases of the thyroid gland an operation may be necessary:

  • Nodous goiter (Struma nodosa)
  • Hyperfunction of autoimmune thyroid disease (Graves' disease)
  • Cold nodes and tumors

Nodous struma

A nodous struma is the most common disorder of the thyroid gland. It develops as the result of iodine deficiency in the diet, this is why the iodation of the food salt is so important. When trying to absorb the sufficient amount of iodine, which is the most important building block of thyroid hormones, the thyroid gland increases. During this growth, the tissue is increasingly transformed into nodes. Starting from this point the disease can not be reversed by iodine intake.

The thyroid gland can finally become so large that it presses on the surrounding organs (trachea, esophagus) causing corresponding complaints (dyspnoea, dysphagia, feeling of pressure). Also, the nodes can become "autonomous", meaning that the "hot" nodules increase hormone production thus causing a thyroid gland overfunction.

Overfunction in autoimmune thyreopathy

Graves' disease is an autoimmune disease ("autoimmune thyroid disease"), the immune system of the body is directed against the thyroid gland cells. The result is the enlargement of the thyroid gland without nodes ("diffuse struma") often accompanied by considerable thyroid over-function.

Cold nodes and tumors

Behind a "cold node" a tumor can be ensconced. This is always an indication for an urgent surgical intervention. Most thyroid carcinomas (papillary and follicular carcinomas) can be treated using surgery and subsequent radio-iodine therapy with very good results, much better than tumors of other organs.

For the correct diagnosis, ultrasound, scintigram and the determination of the hormone values are necessary, sometimes also a puncture with cell examination or other blood tests.

The ultrasound examination shows the size and shape of the thyroid gland, i.e. the size, position and number of the nodes. The scintigram shows the functional state of the tissue and can thus can help distinguish between "warm" and "cold" nodes. Iodine-like weakly radioactive substance (technetium) is injected and then its accumulation in the thyroid gland is measured. In the case of a "cold node", no accumulation is detectable, although a node is ultrasoundable or even palpable. In the case of a "hot node", accumulation is particularly strong, often also suppressing of the remaining thyroid gland.

Treatment

The scope of the operation depends on the disease. In case of a nodous struma, it is important to remove all the nodes, which can often mean the removal of the entire thyroid gland or the affected lobe, but may require just the removal of individual nodes. Only this way can a recurrence be safely avoided.

A tissue examination during the operation ("frozen section analysis") to clarify whether a malignant tumor is present is not reliable with possible thyroid tumors. In the case of suspected tumors, and also in cold nodules, it is the rule to remove the whole affected part, to avoid a extremely risky resection of the vocal cord nerve a few days later. If the tumor is confirmed, only the other unaffected side has to be removed avoiding the risk.

Prior to thyroid gland operation, a possible over-function must be compensated by medication. In addition, a neck-nose-ear examination (of the vocal cord nerve) is necessary.

The operation can also be performed even in the case of large strums by a rather small cut at the neck. The wound is sutured from the inside with a dissolvable thread, so no threads need to be removed and the scar is hardly visible later.

In order to avoid injury to the vocal cord nerves, which run on both sides behind the thyroid gland, an experienced surgeon must know the exact placement of these nerves, and thus can spare them. For special precautions, we regularly conduct electrical nerve testing ("neuro-monitoring") during the surgery. Thus, the nerve can be identified, and its functional integrity can be confirmed. Extensive resections are thus possible with low risk. If, in rare cases, nerve damage occurs (hoarseness, weak voice), the nervous function recovers in most cases within a few months.

After the surgery, the patient usually recovers quickly, so that discharge is possible on the second day after the surgery. Sometimes tingling in the fingers occurs which is caused by a temporary parathyroid gland subfunction and can be treated with calcium. These complaints quickly disappear.

After the removal of big thyroid gland parts its subfunction is inevitable, which must be compensated by hormones (pills). However, the hormones are prescribed not after every operation. Whether to take them or at what dosage should be decided 4-6 weeks after the operation based on the hormone values (especially TSH).

The parathyroid glands do not lie "beside" but "behind" the thyroid gland. The four pinpoint size glands play an important role in calcium metabolism. Their hyperfunction ("hyperparathyroidism") can be caused by benign tumors on one of the glands, but also by the enlargement ("hyperplasia") of all four glands, e.g. in renal disease. In order to avoid serious sequelae (deseases of bones, pancreas, kidneys, etc.) an operation is necessary - the removal of the individual node or all four parathyroid glands (then with replantation of tissue into the limb).

Even a greatly enlarged parathyroid gland is often only pea-sized, and so our very special experience in such operations is the prerequisite for success.

The adrenal glands lie beside the kidneys, but have nothing else to do with them!

Operations on these important hormonal glands are rather rare. The indications often are tumors, usually benign. Such tumors must be examined. Some adrenal glands tumors may lead to hypertension and must be removed (after pretreatment with drugs), other ceses of overactivity may also constitute an operation indication. The necessary hormonal clarification must be done by endocrinologist (specialist for hormonal glands).

Despite the adrenal glands hiding behind the intestine, the pancreas and the large blood vessels, a laparoscopic operation is almost always possible.