[The role of intraoperative ultrasound in surgery for benign nodular goiter]. / Die Wertigkeit des intraoperativen Ultraschalls bei der benignen Knotenstruma.

BACKGROUND: In treating benign nodular goiter, selective surgery taking into account morphology and function is better than standard subtotal resection for reducing the frequency of nodules in the thyroid remnant. Intraoperative ultrasound (IOPUS) may additionally influence operative radicality and also the incidence of remaining nodules. METHODS: One hundred consecutive patients with benign nodular goiter were operated on with IOPUS; the specimens were compared with results of preoperative ultrasound and intraoperative palpation. Of these patients, 80 were reinvestigated after 3+/-1.6 years. A series of 80 patients with the same operative strategy but without IOPUS was used as control group, having been reinvestigated sonographically 1 year postoperatively, and was compared to the IOPUS group with respect to operative procedures, size of remnants, and sonography of lesions in thyroid remnants. RESULTS: In 35% of the thyroid lobes, preoperatively undetected nodules could be identified additionally by IOPUS, which also provided information on extent and structure in a further 20%. It resulted in the indication for more radical surgery in 24% and greater tissue preservation in 10%. Compared to surgery without IOPUS, IOPUS-guided surgery was more radical (total lobectomy in 40% vs 24%, nonresected lobes in 16% vs 26%, P<0.05) and showed a lower incidence of nodules in remnants at follow-up (2.5% vs 12.5%, P<0.05). CONCLUSIONS: With IOPUS, more nodules are detectable, size and structure of the remnants are optimized, and the number of nodular lesions in thyroid remnants is lower. Thus, an even lower risk of recurrence can be expected for long-term follow-up. All in all, the routine use of IOPUS can be advocated, with maintenance of the selective operative strategy.

Differentiated operative therapy of thyroid autonomy (Plummer's disease).

The operative therapy of the autonomous thyroid deals almost exclusively with nodular goiters. There are only rare situations with purely diffuse autonomy in surgical patients. The endpoint of operative therapy is permanent elimination of clinically relevant autonomous function and thereby irreversible abolition of thyrotoxicosis, even in their latent form. Clinically relevant autonomous function normally ist linked to nodular structures of different size and different distribution, so that this aim corresponds automatically with the aim of complete removal of nodular structures, both in autonomous and in non-autonomous goiters. Function is best preserved by leaving a homogenous remnant of considerable size. In different particular clinical situations (for example pregnancy, suspicion of malignancy, recurrent goiter, intrathoracic goiter, thyrotoxic crisis, Marine-Lenhart-syndrome) the basic principal of operative strategy is varied according to the respective situations. Unsatisfactory operative results are mainly caused by incomplete removal of nodules, based on insufficient surgical performance of morphological and functional diagnostics, which is related to operative uniformity. An operative strategy, which ist "fitted to morphology" and "regarding function" and which we call "selective strategy", in our opinion ist highly appropriate, to avoid remnant nodules and remnant autonomy and to preserve an normal remnant, even in different position and of different size. This selective surgery ist applicable both to autonomous and non-autonomous goiter. Compared with the classic subtotal, uniform procedure the incidence of remnant nodules is reduced from about 50% to about 5 %. Remnant autonomy is almost excluded, when mistakes are avoided (about 1%). The incidence of recurrent goiter and recurrent thyrotoxicosis is lowered to under 5%--but up to now there are too few reliable long-term follow-up studies. The selective surgery strategy demands flexibility regarding operative tactics, which can be simply classified into 5 basic situations, which we relate to the operative procedure per thyroid lobe. It requires experience and competence in carefully dissecting and--when necessary--manipulating the recurrent laryngeal nerve und the parathyroid glands. Under these conditions it is followed by a comparatively low rate of complications (permanent recurrent laryngeal nerve paralysis and hypoparathyroidism under 1%, respectively). Thus, the old dilemma of thyroid surgery can be solved, which consists of radical operation with higher morbidity and lower frequency of recurrent disease on the one hand and more limited operative procedures with fewer complications but more frequent recurrencies on the other hand.