1 MS, FRCS (Ed), FRCS (Eng), FICS, FIMSA, FAIS, FTASc, FAES Prof. S. VITTALMS, FRCS (Ed), FRCS (Eng), FICS, FIMSA, FAIS, FTASc, FAESEmeritus ProfessorSurgical EndocrinologyThe Tamil Nadu Dr.MGR Medical UniversityPast ChairmanRoyal College of Surgeons of Edinburgh – Indian ChapterSurgical TutorRoyal College of Surgeons of EdinburghPast PresidentInternational College of Surgeon – Indian SectionThe Association of Surgeons of IndiaFounder PresidentIndian Association of Endocrine SurgeonsChief Surgeon – Sree Sai Krishna Hospital, Chennai
5 Emil Theodor Kocher was awarded the Nobel Prize in 1909 for his work on the physiology, pathology and surgery of the thyroid glandFather of Thyroid SurgeryEstablished the Kocher Institute in Berne
6 Thyroid Secretes two principal hormones Thyroxine (T4) Triiodothyronine (T3)
7 Thyroid HormonesAlmost all circulating T3 & T4 are bound to TBG , TBPA or albumin.It is only the free (unbound) hormones are metabolically active. T3 formed mainly by peripheral deiodination of T4 to T3, is the biologically active hormone.
15 Graves DiseaseCaused by an activating autoantibody that targets the TSH receptorAutoimmuneGeneticStressEnvironmental
16 OpthalmopathyInfiltrative ophthalmopathy causing exopthalmos and ophthalmoplegiaImmunologically mediatedTRAb binds to retro-orbital tissueSecretion of Hydrophilic glycosoaminoglycansProptosis causes symptoms of Exposure KeratitisStrong linkage with smoking
17 Exophthalmos May precede, coincide or succeed Clinical Graves Disease May not appear at allMay be the only manifestation of Graves DiseaseMay be unilateral or bilateral
33 Surgery Large goitres Retrosternal goitres Pregnant or lactation Reproductive age groupChildren below 16 yearsCoexistent suspicious nodulesSevere intolerance to antithyroid medicationGraves OpthalmopathyTotal or Near Total Thyroidectomy
34 Preoperative preparation Euthyroid at the time of surgeryAntithyroid drugsBeta BlockersIodine
35 Advantages of Surgery Immediate cure of disease Controlled hypothyroidismAdequate management of coexisting malignancyCan be offered to pregnant patients or those patients desiring pregnancy within months of treatment
36 Radioiodine Ablation Patient not in the reproductive age group Serious ComorbidityRecurrence following surgery
37 Radioiodine AblationProduces the ablative effects of surgery but not the complications of surgeryDose mci of I 131Majority [around 80%] respond well with a single dose.Another 10%-15% respond with 2nd dose.5% of cases may need a 3rd dose.
38 Toxic MNG Plummers Disease Older individuals Long history of MNG More prevalent in iodine deficient areasPathogenesis – Somatic mutation IN TSH receptor activation leading to constitutive receptor activation and upregulation of cyclic AMP
39 Toxic MNG Cardiovascular symptoms more prominent Diagnosis T3 alone can be elevated in some cases (T3 Thyrotoxicosis)Radioactive Iodine Scan – Increased Uptake and heterogenous pattern with focal areas of increased uptake corresponding to hyperfunctioning nodules.
42 Toxic Nodule Autonomous Nodule Younger age group One of the most frequent causes of Isolated T3 ThyrotoxicosisRadioactive Iodine uptake shows increased uptake over nodule with evidence of suppressed uptake throughout the remainder of the gland
45 Should patients with Solitary Toxic Nodule and those with Toxic Multinodular Goitre be treated differently?Does the presence of subclinical hyperthyroidism affect the treatment outcome?
46 Do patients with a large thyroid gain greater benefit from thyroidectomy? Are compression symptoms an indication for surgery?
47 What is the risk of malignancy in patients with Plummer’s disease? Is there an optimal treatment dose or regimen for Radioiodine ablation?
48 Is percutaneous ethanol ablation a useful treatment modality ? What is the best cost-effective strategy for the treatment of Plummer’s disease?
49 Special SituationsThyrotoxicosis and pregnancyThyroid storm
50 Thyrotoxicosis and Pregnancy Propylthoiuracil preferred over ImidazolesLowest possible dose of PTU must be usedRadioiodine absolutely contraindicatedSurgery – Second trimester
51 Thyroid StormThe clinical manifestations of thyroid storm are consistent with marked hypermetabolism resulting in multiorgan dysfunctionMortality between % even for treated patientsExaggeration or accentuation of the signs and symptoms of thyrotoxicosis
52 Thyroid Storm Fever greater than 38 C Marked diaphoresis Tachycardia, Atrial fibrillation and Cardiac failureSevere diarrhoeaAgitation, confusion and delirium, progressing to frank psychosis, stupor and coma
53 DiagnosisEarly diagnosis and treatment are the most important determinants in the successful management of thyroid stormEssentially a clinical diagnosisThere are no differences in the results of TFT in patients with thyroid storm when compared with patients who have symptomatic hyperthyroidism
54 TreatmentBlockage of the release and effects of circulating thyroid hormonesSupportive careIdentification and treatment of precipitating event
55 TreatmentPropylthiouracil(PTU) given as a loading dose of 600 mg followed by mg every 4 hours orally, rectally or via nasogastric tubeInorganic iodideLugols Iodine – 5-8 drops 6 HourlySaturated solution of Potassium Iodide drops 6 HourlySodium Ipodate – g 12 Hourly ivBeta BlockersPropranolol – mg orally 6 Hourly or 1 -5 mg iv 6 HourlyEsmolol - Ultrashort acting especially useful in the management of thyroid storm
56 Treatment Supportive Care Hyperthermia - Antipyretics - Alcohol sponge, ice packsCorrection of dehydrationSteroids – Dexamethasone or Hydrocortisone ivTreatment of precipitating eventAntibiotics
57 HyperthyroidismThyrotoxicosisTypes of Toxic goitreUltrasound and Nuclear Scans will aid in determining the etiologyMedical treatment
58 Definite treatment with Surgery or Radioactive Iodine is recommended for Graves disease, Toxic MNG AND Toxic AdenomaSpecial Circumstances
59 Gelette Burgess “In the last ten years, if you have not changed your technique or acquired a new technique,Check Your Pulse,Chances are you may be Dead “Gelette Burgess
60 “The purpose of life is the expansion of happiness” “ Very little is needed to make life happy”“ If you want happiness for a lifetime – help thenext generation”