Surgical goiter

SURGICAL GOITER HOIW MODERN METHODS OF PREPARATION, ANESTHESIA AND TECHNIC IMPROVED THE SURGICAL RESULTS AND REDUCED MORTALITY TO AN ALMOST NEGLIGIBLE PERCENTAGE*

HAVE

JOSEPH L. DECOURCY, M.D. CINCINNATI, OHIO

B

EFORE discussing the purely surgical phases of exophthalmic and toxic adenomatous goiter, it may be we11 to mention brief4 y a few of the embryoIogic and anatomic facts that have a bearing on surgica1 pathoIogy. The thyroid pouch, the precursor of the thyroid gland, is the first parenchymatous organ to appear in the human ceIIs of the embryo. As th e epithelial pouch multiply, a mass is formed, which graduaIIy descends through the developing muscles of the base of the tongue in front of the epigIottis and primitive Iarynx to the upper part of the trachea. In the descent, the pouch is drawn out into a tube-Iike form, known as the thyrogIossa1 duct, which is normaIIy obliterated during feta1 Iife. The mass is now solid, but spaces appear and later become fiIIed with vascuIar and Iymphoid tissue, which uItimateIy spIits the thyroid epitheIium into Iayers of about two celIs in thickness. The concomitant deveIopment of the Iarynx divides the thyroid into two Iobes connected by an isthmus. A IittIe Iater, the layers of ceIIs become separated by a cIear substance; finaIIy, a capsule of fibrous connective tissue gradualIy enveIops the mass. The deveIoped gland lies across the trachea, to which it is Ioosely attached. The Iobes are convex externaIIy and concave internaIIy; the upper poIes are conica and the Iower rounded. The mean weight of the gIand is about 26.1 I gm. The right Iobe is usuaIIy the larger and is aIso situated higher in the neck than the Ieft. SURGICAL

PROBLEMS

Without further discussion of the anatomy, physioIogy and pathoIogy of the * From the SurgicaI Section, DeCourcy

thyroid gland, I wish to consider the surgica1 aspects of the probIem of goiter together with the preoperative and postoperative care, form of anesthesia, surgical technic and resuIts of thyroidectomy. PREOPERATIVE

USE

OF

IODINE

The use of iodine in any form of Graves’ disease was formerIy supposed to be contraindicated, because it was beIieved that its use increased the severity of the symptoms and might, in fact, be responsibIe for the deveIopment of exophthalmic from simpIe goiter. PIummer, of the Mayo CIinic, in 1922 began the use of Lugol’s soIution as a preoperative measure in the treatment of exophthamic goiter. Ten minims of LugoI’s soIution were given three times a day for the first ten days and continued up to the time of operation and throughout the postoperative reaction, even though the period before operation might be proIonged for several weeks. After the postoperative reaction, I o minims daiIy were given as a routine for eight weeks. If a crisis occurs, PIummer advises the administration of 50 to IOO minims in divided doses orally or by rectum within one or two hours. By this preoperative use of LugoI’s soIution, the surgica1 mortaIity was reduced from 3.5 per cent to I per cent and th e preoperative mortahty from 2.4 to 3, to 0.2 to 0.3 per cent. From this time (1922) to 1926, various other observers (Boothby, Mason, Starr and Means, Read, Clute, MerkIe and HeImhoIz, and Hoist and Lunde [rg29]) empIoyed iodine in the preoperative treatment of goiter and found it beneficia1. There is still, however, great diversity of opinion as to the manner in which Lugol’s soIution acts; but there is ampIe

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cIinica1 evidence that its preoperative use in exophthaImic goiter is a safe and which controls the beneficia1 measure, symptoms, Iowers the metabolic rate and Iessens the hazards of operation. When such preoperative treatment is administered, at operation the thyroid gIand is found to be edematous. When the gIand is sectioned, a watery fluid exudes freeIy from the incised surfaces. This condition is not found in those cases not treated with LugoI’s soIution or in the ordinary coIIoid goiter. This observation has Ied me to beIieve that the beneficial effects of preoperative iodine medication are due to a rapid formation of coIIoid materia1 in the thyroid gIand, which is depIeted of its norma iodine content. Back pressure from this formation resuIts not onIy on the ceIIs and acini but aIso on the thin-waIled veins surrounding the acini, and it is this back pressure that causes the passive edema found at operation. The edema of the gIand in turn renders the secreting ceIIs inactive, and the absorption of toxic substances is thus prevented; hence, the improvement in the patient’s condition. However, the temporary nature of the improvement can be accounted for by the fact that new bIood vesseIs are formed and the oIder ones accommodate themseIves to the changed condition. Absorption then recurs and the patient becomes toxic, even though coIIoid formation in the gIand may stiI1 persist. Marine, who has studied the effects of administration of iodine experimentaIIy, has reached a simiIar concIusion. At the DeCourcy Clinic, it is our practice in cases of hyperpIastic and adenomatous goiter to administer IO drops of Lugol’s soIution three times a day for from two to four weeks preceding the operation, depending upon the degree of cIinica1 improvement and the change in the gIand itseIf, as checked by metaboIic readings. In cases of severeIy toxic adenomatous goiter with cardiac instabiIity or decompensation, patients are pIaced in bed in the hospita1 and given a course

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of digitaIis therapy. If there is neither irreguIarity of beat nor decompensation, 3 doses of standardized tincture of digitaIis of 30 minims each are given at intervaIs of eight hours. If cardiac arrhythmia is present, IO drops of tincture of digitaIis are administered three times a day unti1 compensation is restored. DigitaIis is usuaIIy discontinued about five days before operation and resumed immediateIy afterward. Jackson beIieves that the surgica1 treatment of exophthaImic goiter has been revoIutionized by the preoperative use of iodine; but he aIso points out the surgica1 risk, whiIe admitting the reduction of the surgica1 mortaIity to I or 2 per cent or Iess. Graham states that, while a11 the phenomena observed after the administration of iodine in toxic goiter are not understood and cannot be satisfactoriIy expIained, its preoperative use is justifiabIe because of the beneficial effects which have been abundantly proved by cIinica1 experience. The quantity of iodine necessary to effect the maximum of clinica improvement is determined IargeIy by the size of the thyroid gIand and the degree of active hypertrophy and hyperplasia at the time treatment is instituted. Excessive dosage over proIonged periods of time deprive the patient of the vaIuabIe therapeutic aid in preparing him for operation, unIess there has been an interva1 of at Ieast a month before its resumption as a preoperative measure. A thriI1 and bruit over the gIand are suflicient indications for resumption of treatment, and compIete invoIution of the thyroid indicates that sufficient iodine has been given and its further use will not IikeIy prove beneficia1. However, the drug shouId not be discontinued immediately preceding operation. It is doubIy important to insist upon preoperative rest and treatment with LugoI’s soIution when performing thyroidectomy on patients with psychoses, because of the danger of increasing the menta1 symptoms by a period of exacerb-

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484 ation that might otherwise ateIy after operation.

foIIow immedi-

ANESTHESIA

Good 7 judgment is required in the choice of a method of anesthesia in goiter operations, and a safe anesthesia is one of the most important factors in the Iowering of the mortaIity rate in such operations. The reIative freedom from postoperative hyperthyroid crises is attributed by Pemberton to the avoidance of proIonged genera1 anesthesia and the adoption of speciaI methods of anesthesia as we11 as to improvement in technic and the preoperative use of iodine. CriIe has adopted the use of nitrous oxide and oxygen with IocaI infiItration aImost as a routine in goiter surgery. Heyd and Smith have empIoyed recta1 anesthesia in cases of Graves’ disease of severe type. Recta1 anesthesia is aIso used in adenoma hyperthyroidism, but in a11 other goiters ethyIene gas is used. Pitkin has recommended the use of ephedrine combined with novocaine in bIock anesthesia as a safe and effectua1 anesthesia for thyroidectomy. WhiIe I have empIoyed spinocaine (Pitkin’s method) in over five hundred operations beIow and with satisfactory the diaphragm, resuIts, I am convinced of the superiority of nitrous oxide and oxygen anesthesia in goiter operations. Kocher compIetes the operation under IocaI anesthesia and attributes his Iow mortaIity to this method. BartIett beIieves the ideal anesthesia for goiter operations is novocaine infiItration and nitrous oxide or Iight ethyIene inhaIation. Gwathmey has stated that, when genera1 anesthesia is to be empIoyed, ether and chIoroform with oxygen by tube is probabIy the best method. I do not agree with this concIusion; but with his statement that “those who have never used oxygen with nitrous oxide, and who have acquired the technic of administering it aIone, wiI1 be surprised by the ease and Iatitude given by this combination,” I do agree. Some six thousand goiter operations

Goiter

have been performed at DeCourcy Clinic during the past ten years, and severa methods of anesthesia have been used. Five hundred patients were operated upon under IocaI anesthesia. The skin incision, the cutting of muscIes and the division of the capsuIe couId be satisfactoriIy accompIished; but, when the gIand was eIevated from its bed and the capsuIe stripped back, there was aImost invariabIy compIaint by the patient of a sensation of being strangIed. WhiIe no pain is feIt in many instances, the psychic shock is aIways undesirabIe, the time consumed for the operation is usuaIIy twice as Iong as under genera1 anesthesia, and the nervous tension suffered by the surgeon is considerabIe. Ether by the open drop method was given to patients who objected to IocaI anesthesia; but it had the disadvantage of a stage of excitement, deep narcosis, postoperative nausea, and disagreeabIe effects upon the surgeon and his assistants. LocaI infiItration combined with nitrous oxide induction and Iight ether sequence was found quite satisfactory for a time. About five years ago, however, I began the use of nitrous oxide and oxygen anesthesia for a11 goiter operations and soon discovered that this method has many advantages. Anesthesia is induced rapidIy and recovery is aImost immediate, the patient usuaIIy becoming conscious before Ieaving the operating tabIe. Vomiting and retching are reduced to a minimum, and the danger of postoperative hemorrhage is aImost compIeteIy obviated. The dosage of the anesthetic agent can be reguIated to suit the needs of the patient. Injury to nerves can be detected readiIy by the respiratory rate and crowing inspiration which occurs under this Iight anesthesia. There is no excess of mucus and suficient rigidity is present to prevent the faIIing backward of the tongue and consequent obstruction of respiration. Anesthesia can be deepened quickIy, if necessary, and the patient can aIso be brought back to a safe IeveI by administration of pure oxygen under direct pressure. WhiIe nitrous oxide and oxygen anes-

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thesia with proper preIiminary medication appears to me to be the method of choice for thyroidectomy, the anesthetist shouId be skilIed in both IocaI and genera1 anesthesia and prepared to administer such anesthetic agents as wiII produce a weIIbaIanced anesthesia with a minimum of untoward resuIts prior to, during and foIIowing the operation. TECHNIC

OF

OPERATION

Without doubt, the successfu1 treatment of toxic goiter must be by thyroidectomy. MedicaI measures are generaIIy of onIy temporary avai1. They find their greatest fieId of usefuIness in preoperative and postoperative care. GentIeness of manipuIation is of first importance in surgica1 technic. In fact, the actua1 steps in the operation are overshadowed in importance by preoperative and postoperative medication with LugoI’s soIution and the choice of the anesthetic. In miIder cases, a one-stage biIatera1 partia1 Iobectomy may be performed. A low, transverse coIIar incision, foIIowing the wrinkIe of the neck, Ieaves an inconspicuous scar, which women may hide compIeteIy by wearing a neckIace. The wound may be cIosed without drainage if there is no oozing. In very Iarge hyperpIastic thyroids, especiaIIy in gangrenous, a two-stage operation is desirabIe. The thyroid gIand is exposed and, after poIar Iigation, singIe partia1 Iobectomy performed. If the patient’s condition permits, the operation is compIeted twenty-four to forty-eight hours Iater. In a11 cases, if thyrotoxicosis is to be reIieved compIeteIy, not Iess than fourfifths of the entire gIanduIar substance must be removed. During the course of the operation, the principa1 accidents against which we must guard incIude primary or secondary hemorrhage, surgica1 shock, coIIapse of the trachea, injury to the parathyroid gIands or to the recurrent IaryngeaI nerves, and air emboIism through the large veins of the neck. With carefu1 technic, these

Goiter accidents troubIe.

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are not

POSTOPERATIVE

IikeIy

of Surgery

to cause

TREATMENT

AND

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serious RESULTS

There is a remarkabIe improvement in the convaIescence of patients who have been treated preoperativeIy with Lugol’s soIution, absence of tachycardia, muscuIar tremor, restIessness and fever. In a11 toxic cases, the patient is given 30 minims of Lugol’s soIution rectaIIy, as soon as he is returned to bed, and the dose repeated in about eight hours. In severe cases of exophthaImic goiter, a third dose may be required; but this is rareIy necessary when the patient has been prepared pro;erIy. FIuids are given subcutaneousIv and encouraged by mouth, if they dye not cause nausea. In the adenomatous gIand, iodine has not been of especia1 vaIue in the preoperative treatment but has been of distinct vaIue postoperativeIy. In a series of 388 operations, 92 per cent of which were upon patients with toxic goiter, there was but one death. This reduces the mortaIity for the year (1929) to g per cent, a notabIe improvement over severa years ago. Six cases of hyperpIastic goiter were compIicated by diabetes meIIitus. The patients were prepared for operation by administration of LugoI’s soIution and insuIin and a restricted carbohydrate diet unti1 they were sugar-free. The operations were performed without diffIcuIty and convaIescence was uneventfu1. Operation aIone is not a cure for these patients. The after-care is most important. Iarge doses of iodine, SkiIIfuI nursing, warmth and sedatives are necessary. The inteIIigent co6peration of the patient not onIy for months, but for years, is an essentia1 for a favorabIe prognosis. THYROIDECTOMY DISTURBANCE WITH

FOR IN

MENTAL

ASSOCIATION

GOITER

BerkeIey and FoIIis observed a marked resembIance between the symptoms of exophthaImic goiter and those of the catatonic form of dementia precox. During the prodroma1 stage of catatonia, there was a

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similarity of menta1 symptoms to those occurring in Graves’ disease. There were also tachycardia, loss of weight, excessive sweating, fine tremor of the fingers, quick pupiIIary reff exes, vasomotor weakness and menstrua1 anomaIies. The thyroid gIand was not usuaIIy enIarged, but was of a soft mushy consistency and contained occasiona hard noduIes. The administration of iodine, iodothyrine or desiccated thyroid extract caused a temporary cessation of stupor. These observers performed partia1 thyroidectomy in IO cases of catatonia; 4 of these patients recovered their menta1 equiIibrium and 3 improved sIowIy but progressiveIy with no tendency towards reIapse. Other investigators (KanaveI, WinsIow and Weinberg) have confirmed the work of BerkeIey and FoIIis. It must be understood, of course, that there is no attempt to ascribe an etioIogic reIationship of disturbances of the thyroid gIand to the average case of dementia precox; but, in occasiona cases, there is a cIose relationship between dementia precox and thyroid disease. During the past five years, I have operated upon 14 insane patients with Graves’ disease, 12 of whom have made compIete menta1 recoveries and remained norma to date. In 13 of these patients, there was a hyperpIastic goiter.

Goiter

DECEMBER,1930

MentaI improvement seIdom occurs immediateIy after thyroidectomy but is more commonIy gradua1, during a period of from severa months to a year. The coexistence of menta1 disease with exophthaImic goiter does not contraindicate operative procedures, but makes them more advisabIe, since they offer a fair prospect of menta1 recovery. CONCLUSIONS I. The successfu1 treatment of toxic goiter and the safe one, because it spares the heart and nervous system undue stimuIation, is by thyroidectomy. 2. Modern methods of surgica1 treatment have not onIy improved resuIts but aIso greatIy Iessened the mortaIity, to Iess than x per cent at the DeCourcy CIinic. 3. Of first importance is preoperative and postoperative use of LugoI’s soIution. 4. Second in importance is the choice of the anesthetic. I regard nitrous oxide and oxygen, administered by a skiIIed anesthetist, as the procedure of choice. 5. By way of technic, extreme gentIeness in handIing the gIand at operation and the use of a two-stage operation in severe cases are essentia1. 6. In mentaIIy disturbed patients having toxic goiters, thyroidectomy offers a fair prospect of recovery from menta1 symptoms.

REFERENCES BERKELEY, H. J., and FOLLIS, R. An investigation into the merits of thyroidectomy and thyroIecithin in the treatment of catatonia. Am. Med. Psycbol. AWL, 15: 283, 1908. DECOURCY, J. L. The Prevention of post-operative thyrotoxicosis by post-operative iodinization, Ann. Surg., 83: 768, 1926. DECOURCY, J. L. Pre-operative use of compound SOIUtion of iodine in exophthaImic goiter. Ann. Surg., 86: 871, 1927. DECOURCY, J. L. ControIIabIe spina anesthesia. AM. J. SURG., 5: 620, 1928. DECOURCY, J. L. Thyroidectomy anesthesia. AM. J. SURG., 5: 170, 1928. DECOURCY, J. L. Mortality of operations upon the thyroid gland. Ann. Surg., 89: 203, 1929. DECOURCY, J. L. Thyroidectomy in mentaIIy disturbed with exophthaImic goiter: report of tweIve cases in which psychosis was relieved by operation. Am J. SURG., 6: 21, 1929. DECOURCY, J. L. Thyroidectomy in mentaIIy disturbed patients with exophthaImic goiter. J. Neru. @ Ment. Dis., 68: 384, 1928.

J. L. Toxic goiter and menta1 disease: reIief of psychosis in thyrotoxic patients by thyroidectomy. Arch. Surg., 17: 296, 1928. DECOURCY, J. L. ExophthaImic goiter: symptoms. Boston M. w S. J., 197: 1305, 1928. EHERX, E. M. SurgicaI Diseases of the Thyroid GIand. Phila., Lea, 1929. GRAHAM, A. Pre-operative iodine therapy in toxic goiter, indications and Iimitations. AM. J. SURG., 2: 354, 1927. HEYD, C. G., and SMITH, A. M. Recta1 anesthesia (Gwathmey) in exophthalmic goiter. AM. J. SURG., 7: 9 (JuIy), 1929. JACKSON, A. S. The diagnosis and treatment of diseases of the thyroid gland. AM. J. SURG., 2: 228, 1927. MARINE, D. Iodine in the treatment of diseases of the thyroid pIand. Medicine, 6: 127, 1927. MAYO, C. H., and PLUMMER, H. S. The Thyroid GIand. St. Louis, Mosby, 1926, pp. 74-75. PITKIN. G. P. A safe and effectua1 anesthesia for thyroidectomies. J. M. S. New Jersey, 24: 603, DECOURCY,

1927.