- Email: [email protected]
Total thyroidectomy in the treatment of angina pectoris
TOTAL THYROIDECTOMY IN THE TREATMENT OF ANGINA PECTORIS LATE RESULTS IN FOURTEEN JOHN
ROBERTS
PHILLIPS,
M.D.
AND
Visiting Surgeon, MemoriaI HospitaI and St. Joseph’s Infirmary HOUSTON,
A
GREAT number of tota thyroidectomies have been done for patients suffering from angina pectoris or congestive heart faihrre since the introduction of this pIan by BIumgart, Levine and BerIin. Sufficient time has now eIapsed for the immediate resuIts to be recorded. The primary probIem is reaIIy a medica one, for onIy by carefu1 study and seIection of cases can the best uItimate resuIts be obtained. We wish to add to the Iiterature a report of our experiences with fourteen tota thyroidectomies which were done for angina pectoris. Each patient in the series had been given every advantage of medica management and had reached the state of invaIidism. Each patient was carefuIIy watched and studied so that not onIy the physica condition but aIso the cardiac and renaI status was known. AI1 had renaI functions within norma Iimits. There was evidence of coronary scIerosis in a11 the cases and in one there was evidence of two smaI1 heaIed infarcts. The presence of a heaIed infarct has not been considered a contraindication to surgery. The basa1 metaboIic reading is very important, since it is not advisabIe to recommend tota abIation if the rate is beIow minus hfteen. In this series the metabolic readings were a11 within norma Iimits. The angina1 syndrome may be improved by eIevating the metaboIism in some of the cases with a Iow basal rate and a Iow bIood pressure. The mechanism is an improvement in the coronary circuIation. We beIieve that the Iessening of adrena effect is responsibIe for the dramatic
CASES
GIBBS MILLIKEN,
M.D.
Visiting Physician, MemoriaI HospitaI Joseph’s Infirmary
and St.
TEXAS
reIief of pain in the angina pectoris cases, and a separate expIanation of the resuIts obtained in decompensated hearts must rest in the Iowered metaboIic demand, a Iimit which the damaged heart can suppIy. The Iowering of the basa1 metaboIic IeveI is not an immediate phenomenon, but occurs about four to six weeks after the tota abIation has been done. The patients have been prepared by being pIaced in the hospita1 for two or three days previous to operation in order that they may become adapted to the surroundings. A sedative is given the night before and the morning of the operation. The surgery has been done by one of us (J. R. P.). The operations have been performed under IocaI anesthetic suppIemented by a IittIe ethyIene gas; in two cases the operation was done entireIy under IocaI anesthesia. The operation is not difficuIt and can be done in forty-five minutes to one hour. Every particIe of the gIand must be removed; otherwise there wiI1 be a regeneration of the remaining part and the temporary benefit wiI1 be lost. In addition, the recurrent IaryngeaI nerves must not be injured. However, the anatomic reIation of these nerves has been so we11 worked out that this danger is minimaI. There has been no cord paraIysis in this series. The parathyroids, as a usua1 thing, are not greatIy endangered; at Ieast one has been demonstrated in every case. There was a transient parathyroid tetany in one case, which was easiIy controIIed by caIcium, cod Iiver oiI and parathormone. AI1 the patients were operated on more than eighteen months ago, the first one
I 26
American
journal
of~urgery
PhilIips,
MiIIiken-Thyroidectomy
on ApriI 12, 1934. There were nine men and five women in the series, their ages varying between 40 and 70 years. These patients stand tota remova very weI1, the genera1 operative risk being between 5 and IO per cent. There were two operative deaths in the series. The first occurred in a man, aged 70, who had a marked coronary scIerosis and had had two previous attacks of occIusion. His death was due to an acute occIusion, as shown at post-mortem examination. The second was fn a man, aged 56, whose death was the resuIt of a cerebra1 emboIus from aortic arterioscIerotic uIcerations. There have been seven exceIIent resuIts and two cases with good resuIts. Five patients are Iiving over two years after operation. One individua1 had exceIIent resuIts for one year, but has had two attacks of coronary occIusion since that time. Another died six weeks after operation of coronary occIusion. StiII another died seventeen months after operation of coronary occIusion, though he had had fair resuIts before his death. Since surgica1 myxedema does not begin to manifest itseIf unti1 four to six weeks after the whoIe thyroid is removed, there is no need for thyroid extract unti1 that time. These patients take one tenth grain of active thyroid substance two or three the times each day, which overcomes greater portion, but not a11 the myxedema. One patient, aIthough with a we11 marked myxedema, has had no distressing symptoms and consequentIy takes no thyroid extract. Two patients have had very interesting experiences foIIowing tota thyroidectomy. The first, a man who two years ago had a tota remova for severe angina, about six weeks ago presented himseIf with a ruptured gangrenous appendix. He was operated on for this and had a very easy postoperative convaIescence. The second, a woman who twenty-one months ago had a tota remova for congestive faiIure with and carried angina, has since conceived
JaNvARY, 1939
the pregnancy to term without decompensation or pain. Her baby is now five months oId and is perfectIy normaI. -i-Nallle
4s
Occupation
Date of Operation
ResuIt
M.L. R .. . . . H. C. H L. T. P.. . . . .
44 46 49
CIothier Merchant Contractor
&IZ-34 5-2634 5-28-34
A. M.. . .I. K.
51 70
Merchant Ranchman
6-2-34 6-25-34
C. A. I=.
50 40
Theater Housewife
8-17-34 10-9-34
...,..
50
Farmer
1-21-35
48 35 25 59 45 56
Housewife Housewife Housewife Housewife PIumber Ranchman
...
.
.
w. H. . . . . . . . Mrs.
N. T..
Mrs. L. H..
..
Mrs. M. B. .,. Mrs. B. E.G. Mrs. E. F.. J. C. N E. K. N..
.... ...
8-19-35 9-30-35 9-30-35 ICI-15-35 lo-~3-35 2-5-36
Excellent. Good. Good-died 12-10-35. coronary occlusion. months after 17 operation. ExceIIent. Died immediately after operation, caronary occlusion. Excellent. Fair-excellent for one year. two attacks since. Relief for six weeks. death due to corenary occlusion. Good. Excellent. ExceIIent. Excellent. Excellent. Died. cerebral emboIus.
Not one in our series feeIs that he or she is cured. AI1 of them Iive we11 within their pain range, yet each one is better and wouId gIadIy repeat the measure if necessary. They are a11 rehabiIitated cardiac invaIids. The present IeveI of improved status fuIIy justifies the use of tota abIation of the thyroid gIand in properIy seIected cases of angina pectoris. SUMMARY
A series of fourteen patients, who had had tota thyroidectomies at Ieast two years previousIy, is reported. AI1 of these patients were suffering from angina pectoris of the most severe form. AI1 showed some degree of coronary scIerosis and several presented definite evidence of cardiac infarction. We feeI, from the evidence presented, that whiIe none of these patients may be considered cured, the present IeveI of improved status fuIIy justifies the use of tota abIation of the thyroid gIand in properIy seIected cases of angina pectoris.
ROBERTS
PHILLIPS,
M.D.
AND
Visiting Surgeon, MemoriaI HospitaI and St. Joseph’s Infirmary HOUSTON,
A
GREAT number of tota thyroidectomies have been done for patients suffering from angina pectoris or congestive heart faihrre since the introduction of this pIan by BIumgart, Levine and BerIin. Sufficient time has now eIapsed for the immediate resuIts to be recorded. The primary probIem is reaIIy a medica one, for onIy by carefu1 study and seIection of cases can the best uItimate resuIts be obtained. We wish to add to the Iiterature a report of our experiences with fourteen tota thyroidectomies which were done for angina pectoris. Each patient in the series had been given every advantage of medica management and had reached the state of invaIidism. Each patient was carefuIIy watched and studied so that not onIy the physica condition but aIso the cardiac and renaI status was known. AI1 had renaI functions within norma Iimits. There was evidence of coronary scIerosis in a11 the cases and in one there was evidence of two smaI1 heaIed infarcts. The presence of a heaIed infarct has not been considered a contraindication to surgery. The basa1 metaboIic reading is very important, since it is not advisabIe to recommend tota abIation if the rate is beIow minus hfteen. In this series the metabolic readings were a11 within norma Iimits. The angina1 syndrome may be improved by eIevating the metaboIism in some of the cases with a Iow basal rate and a Iow bIood pressure. The mechanism is an improvement in the coronary circuIation. We beIieve that the Iessening of adrena effect is responsibIe for the dramatic
CASES
GIBBS MILLIKEN,
M.D.
Visiting Physician, MemoriaI HospitaI Joseph’s Infirmary
and St.
TEXAS
reIief of pain in the angina pectoris cases, and a separate expIanation of the resuIts obtained in decompensated hearts must rest in the Iowered metaboIic demand, a Iimit which the damaged heart can suppIy. The Iowering of the basa1 metaboIic IeveI is not an immediate phenomenon, but occurs about four to six weeks after the tota abIation has been done. The patients have been prepared by being pIaced in the hospita1 for two or three days previous to operation in order that they may become adapted to the surroundings. A sedative is given the night before and the morning of the operation. The surgery has been done by one of us (J. R. P.). The operations have been performed under IocaI anesthetic suppIemented by a IittIe ethyIene gas; in two cases the operation was done entireIy under IocaI anesthesia. The operation is not difficuIt and can be done in forty-five minutes to one hour. Every particIe of the gIand must be removed; otherwise there wiI1 be a regeneration of the remaining part and the temporary benefit wiI1 be lost. In addition, the recurrent IaryngeaI nerves must not be injured. However, the anatomic reIation of these nerves has been so we11 worked out that this danger is minimaI. There has been no cord paraIysis in this series. The parathyroids, as a usua1 thing, are not greatIy endangered; at Ieast one has been demonstrated in every case. There was a transient parathyroid tetany in one case, which was easiIy controIIed by caIcium, cod Iiver oiI and parathormone. AI1 the patients were operated on more than eighteen months ago, the first one
I 26
American
journal
of~urgery
PhilIips,
MiIIiken-Thyroidectomy
on ApriI 12, 1934. There were nine men and five women in the series, their ages varying between 40 and 70 years. These patients stand tota remova very weI1, the genera1 operative risk being between 5 and IO per cent. There were two operative deaths in the series. The first occurred in a man, aged 70, who had a marked coronary scIerosis and had had two previous attacks of occIusion. His death was due to an acute occIusion, as shown at post-mortem examination. The second was fn a man, aged 56, whose death was the resuIt of a cerebra1 emboIus from aortic arterioscIerotic uIcerations. There have been seven exceIIent resuIts and two cases with good resuIts. Five patients are Iiving over two years after operation. One individua1 had exceIIent resuIts for one year, but has had two attacks of coronary occIusion since that time. Another died six weeks after operation of coronary occIusion. StiII another died seventeen months after operation of coronary occIusion, though he had had fair resuIts before his death. Since surgica1 myxedema does not begin to manifest itseIf unti1 four to six weeks after the whoIe thyroid is removed, there is no need for thyroid extract unti1 that time. These patients take one tenth grain of active thyroid substance two or three the times each day, which overcomes greater portion, but not a11 the myxedema. One patient, aIthough with a we11 marked myxedema, has had no distressing symptoms and consequentIy takes no thyroid extract. Two patients have had very interesting experiences foIIowing tota thyroidectomy. The first, a man who two years ago had a tota remova for severe angina, about six weeks ago presented himseIf with a ruptured gangrenous appendix. He was operated on for this and had a very easy postoperative convaIescence. The second, a woman who twenty-one months ago had a tota remova for congestive faiIure with and carried angina, has since conceived
JaNvARY, 1939
the pregnancy to term without decompensation or pain. Her baby is now five months oId and is perfectIy normaI. -i-Nallle
4s
Occupation
Date of Operation
ResuIt
M.L. R .. . . . H. C. H L. T. P.. . . . .
44 46 49
CIothier Merchant Contractor
&IZ-34 5-2634 5-28-34
A. M.. . .I. K.
51 70
Merchant Ranchman
6-2-34 6-25-34
C. A. I=.
50 40
Theater Housewife
8-17-34 10-9-34
...,..
50
Farmer
1-21-35
48 35 25 59 45 56
Housewife Housewife Housewife Housewife PIumber Ranchman
...
.
.
w. H. . . . . . . . Mrs.
N. T..
Mrs. L. H..
..
Mrs. M. B. .,. Mrs. B. E.G. Mrs. E. F.. J. C. N E. K. N..
.... ...
8-19-35 9-30-35 9-30-35 ICI-15-35 lo-~3-35 2-5-36
Excellent. Good. Good-died 12-10-35. coronary occlusion. months after 17 operation. ExceIIent. Died immediately after operation, caronary occlusion. Excellent. Fair-excellent for one year. two attacks since. Relief for six weeks. death due to corenary occlusion. Good. Excellent. ExceIIent. Excellent. Excellent. Died. cerebral emboIus.
Not one in our series feeIs that he or she is cured. AI1 of them Iive we11 within their pain range, yet each one is better and wouId gIadIy repeat the measure if necessary. They are a11 rehabiIitated cardiac invaIids. The present IeveI of improved status fuIIy justifies the use of tota abIation of the thyroid gIand in properIy seIected cases of angina pectoris. SUMMARY
A series of fourteen patients, who had had tota thyroidectomies at Ieast two years previousIy, is reported. AI1 of these patients were suffering from angina pectoris of the most severe form. AI1 showed some degree of coronary scIerosis and several presented definite evidence of cardiac infarction. We feeI, from the evidence presented, that whiIe none of these patients may be considered cured, the present IeveI of improved status fuIIy justifies the use of tota abIation of the thyroid gIand in properIy seIected cases of angina pectoris.