The centre for
Thyroid, Parathyroid and Adrenal Surgery

The thyroid gland is located below the larynx and surrounds the trachea. This small, butterfly-shaped organ fulfils a vital role, being responsible for the production, storage and release of thyroid hormones. These hormones regulate numerous metabolic processes as well as the energy balance of the body’s cells. If half the thyroid gland needs to be removed (hemithyroidectomy), the body’s supply of thyroid hormones is in most cases provided by the remaining half. Removal of the whole thyroid gland requires the use of hormone replacement therapy.

^{Fig.1: Location of the thyroid gland in the neck}

Goitre

A goitre refers to an enlarged thyroid gland. In the past, goitre was very common in Switzerland due to a deficiency of iodine in the diet. Since iodine is a fundamental component of the thyroid hormone, iodine deficiency leads to a lack of effective thyroid hormone in the body. The body detects this deficiency and reacts by stimulating the growth of the thyroid gland. Uncontrolled thyroid growth or changes in the thyroid gland happen on a much smaller scale today. Sometimes the glandular changes are not visible and can only be felt by hand or possibly only detected by ultrasound. Nowadays these changes are interpreted as benign tumours of the thyroid gland, which are caused by mutations in the genetic material of the cells. Small nodules on the thyroid are common in young women.

Thyroid nodules

If isolated nodules or lumps occur in the thyroid gland, these require further investigation. Formation of nodules in the thyroid gland is very common and is due to excessive production of thyroid hormone. This causes uncontrolled but benign growth of thyroid cells.


^{Fig. 2: Ultrasound examination of the thyroid gland}

In the vast majority of cases, thyroid nodules are benign. However, as they increase in size and take up more space, these benign changes can displace neighbouring organs. If a malignant condition is suspected and if there are large nodules causing displacement, surgery is necessary.

Thyroid cancer

The worldwide incidence of thyroid cancer is increasing. One of the reasons for the increasing number of cases nowadays is the much more frequent use of ultrasound, CT and MRI. Not infrequently these investigations, often performed for a different reason, reveal smallish nodules in the thyroid gland that then prove to be thyroid cancer. Previously these findings went undetected. Unfortunately, however, there is also an increasing number of cases of advanced stages of thyroid cancer, the cause of which as yet remains unclear. Various environmental influences are postulated.

Radioactive radiation is a clear risk factor. For example, people who lived in the vicinity of Chernobyl have a much higher risk.

Diagnosis and symptoms

Just like breast cancer in the breast, a worrying nodule in the neck can suddenly become apparent. Thyroid cancer, which affects women considerably more often than men, usually does not cause any pain. In these cases an ultrasound scan and puncture of the nodule are required to confirm the diagnosis.

The right therapy

Predominantly the treatment involves a surgery. In most cases the thyroid gland must be removed completely. In early stages, however, the healthy half of the thyroid gland can be left in the body. Only the lobe in which the cancer nodule is located must be removed.

Surgery for thyroid cancer

Thyroid surgery is high-precision work. Thank to neuromonitoring it is possible to spare the laryngeal nerve, which is responsible for the mobility of the vocal folds. When the tip of the detection probe approaches the nerve, an acoustic signal is heard, and a deflection is visible on the surgical monitor. This instrument has undergone constant improvement over the years and prevents injury to this important nerve. It is equally important that the parathyroid glands are spared. The surgical challenge of thyroidectomy, as it is known, is to preserve the blood supply as far as possible to these four tiny glands that lie on the thyroid capsule and are responsible for calcium metabolism. A state-of-the-art infrared camera for intraoperative use has recently become available to us for this purpose, allowing better visualization of the blood supply to the parathyroid glands during surgery and enabling the thyroid tissue to be identified as such. Initial studies indicate that the parathyroid glands are better spared with the use of this camera. Essentially, anatomical knowledge and a precise operating technique are the main factors for avoiding surgical complications. This requires the surgeon to undertake a certain minimum number of thyroidectomies each year. The hospital stay is about three days. The missing thyroid hormones are replaced immediately postoperatively by a daily tablet. While early stages of cancer can be cured by surgery alone, in advanced cases additional radioiodine therapy is recommended. The remaining thyroid cells and in particular cancer cells that are not visible to the surgeon’s eye are destroyed by the radioiodine therapy.

Prospects of a cure / Prognosis

Fortunately, papillary thyroid carcinoma, by far the most common thyroid carcinoma in Switzerland, is less aggressive than other forms of cancer. The cure rate for thyroid gland cancer in Switzerland is over 95%.

Hyperthyroidism (overactive thyroid)

The increased production of thyroid hormones by individual nodules (autonomous adenoma) or by the thyroid gland as a whole (Graves’ disease) causes an overactive thyroid. Typical symptoms include weight loss, a fast pulse and restlessness. In this situation, it is important for an endocrinologist to be involved in the treatment. Drug treatment to restrict the thyroid gland will be indicated. However, surgery is often necessary for definitive treatment of symptoms.

Hypothyroidism (underactive thyroid)

Hypothyroidism (underactive thyroid) is a deficiency of thyroid hormones, often associated with autoimmune disease or thyroid inflammation. This deficiency leads to various complaints such as fatigue, sensitivity to cold, constipation and muscle weakness. It is treated by administering thyroid hormones in the form of medication.

Graves’ disease

The most common form of hyperthyroidism (overactive thyroid) is caused by a disease of the immune system, called Graves’ disease. It’s an autoimmune disease, which means that the immune system attacks the body’s own cells. In Graves’ disease, a receptor on the thyroid cell is not recognized by our immune system as being generated by the body itself. Antibodies are then produced (autoantibodies = anti-TSH Ab, anti-Tg Ab), which activate the receptor and lead to excessive hormone formation.

Diagnosis and symptoms

Typical symptoms are restlessness, rapid heartbeat, weight loss, sleep disorders and diarrhoea (= symptoms of hyperthyroidism). The disease often causes the eyeballs to protrude prominently, a symptom known as exophthalmos. There is also sometimes visible or palpable enlargement of the thyroid gland. An ultrasound examination and thyroid scintigraphy are the determining examinations.

The right treatment

The treatment of a first flare of Graves’ disease involves suppressing thyroid function by means of drugs, which often produces a temporary normalization of thyroid function. However, these drugs are not suitable for suppressing thyroid function over many years because they sometimes cause severe unwanted side effects. These thyrostatics, as they are known, should be discontinued after about 6 months of treatment. Only if the hyperactivity recurs following discontinuation of the drugs does the thyroid tissue have to be removed completely, since otherwise the autoimmune reaction cannot be interrupted.

Surgery is particularly suitable in the case of associated exophthalmos, an enlarged thyroid gland and in female patients wishing to have children. Alternatively, radiotherapy can be administered if the surgical risk is high.

Thyroidectomy (removal of the thyroid)

At the Pyramid Clinic, we currently offer conventional thyroid gland removal as well as the minimally invasive method. Both methods are safe and well proven. Minimally Invasive Video Assisted Thyroidectomy (MIVAT) is now the most widely used minimally invasive procedure in neck surgery. It is established as the preferred method for the removal of small thyroid glands and small nodules. Minor nodular changes of up to 2 cm in particular can be operated using a method that is painless, less invasive and cosmetically advantageous. Surgical access to the thyroid gland is achieved using the smallest possible horizontal skin incision to the neck of 2 to 3 cm.

In order to carry out the surgical processes, the surgeon introduces an endoscope that provides an enlarged display of the area onto a screen. This reveals the parathyroid glands and the laryngeal nerve, enabling them to be protected during surgery. Minimally invasive procedures are not only cosmetically more favourable - the smaller the incision, the less pain the patient will experience after the surgery and the shorter the recovery period.

Hyperparathyroidism (overactive parathyroid)

Hyperparathyroidism is the overactive function of one or more parathyroid glands. The four parathyroid glands are about the size of a lentil and are attached to the thyroid capsule. They are adjacent to the thyroid gland but have a completely different function, serving to regulate the balance of calcium in the blood. Problems arise if the parathyroid glands carry out their task too well. The parathyroid glands can then develop into independent hormone generators (parathyroid adenoma), and the body becomes flooded with parathyroid hormone (PTH). When PTH is released into the blood by the glands, the concentration of calcium in the blood increases as a result. Excessively high levels lead to a complex of symptoms that is often associated with severe fatigue, depression and reduced functioning. Muscle pain is also typical. This is very limiting and does not respond well to anti-inflammatory drugs.

The symptoms decrease after surgical removal of the parathyroid gland (parathyroidectomy) which was producing excess hormones. Patients often feel much more capable and fatigue decreases. They frequently describe a feeling of having had a heavy weight removed from their shoulders after the surgery. Chronic damage to the kidneys, blood vessels and bones is resolved when calcium metabolism returns to normal. Parathyroidectomies are regularly carried out using endoscopic assistance and a minimally invasive approach. The incision can be limited to a maximum of 2 cm and after a few months is hardly visible.

A highly specialised surgeon is required for successful parathyroid surgery. After resection of a parathyroid adenoma, normalisation of the PTH/calcium metabolism is assessed by collection of intraoperative blood samples and communicated to the surgical team in the operating theatre. In simple terms, the operation is successful if the PTH value drops by more than 50% after removal.

The Pyramid Clinic provides the surgeon with another valuable tool for monitoring the success of parathyroid surgery. With intraoperative fluorescence imaging using an infrared camera, overactive parathyroid tissue can be better distinguished from normal parathyroid tissue. This avoids a situation where the parathyroid tissue that is independently producing excess hormones remains in the body, which can lead to a recurrence of the disease.

Adrenal surgery

Surgery of the adrenal gland is rare – so the expertise of the surgeon is all the more important. The most frequent indications for surgical removal of the adrenal gland, also known as adrenalectomy, are large tumours (incidental tumours) and hormone-active tumours, so-called adenomas, which are mostly small in size. In the case of active tumours, comprehensive preoperative diagnostics by an experienced endocrinologist are of the utmost importance. The endocrinologist will coordinate the diagnostic imaging and interventional radiological procedures based on hormone results from laboratory tests. These days, adrenalectomies can almost always be performed laparoscopically.

Neuromonitoring

Using the latest generation of neuromonitoring (monitoring nerve function during surgery using electromyography), the risk of injury to the laryngeal nerves, which control vocal cord function, is reduced to a minimum.

Problems with temporary hoarseness after surgery can thus be significantly reduced. In order to avoid damage to the parathyroid glands, which are embedded in the surface of the thyroid gland, imaging is used during the procedure and care is taken to ensure there is no injury to their blood supply. The risk of postoperative hypocalcaemia is estimated based on a parathyroid hormone test on the first postoperative day and calcium substitution may be begun, depending on the result. Emergency readmission due to tetany (involuntary muscle contraction) can thus be eliminated.

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