Safety and efficacy of total thyroidectomy for differentiated thyroid carcinoma: a 20-year review.

Controversy continues to exist regarding the optimal extent of resection for differentiated thyroid carcinoma (DTC). Subtotal thyroidectomy has been advocated by some authors in expectation of lower complication rates, while others advocate total thyroidectomy to achieve better cure rates. To examine this issue, the medical records of 124 patients who underwent total thyroidectomy for DTC were retrospectively reviewed. Total thyroidectomy was the initial procedure in 115 patients, while nine patients had complete thyroidectomy following some type of subtotal resection. Concomitant procedures were performed in 47 patients. Ninety papillary, 20 mixed papillary-follicular variant, one Hürthle cell type, and 13 follicular carcinomas were performed. Tumors were bilateral or multicentric in 40 patients, with metastases present in one-third of patients at the same time of initial operation. Permanent hypoparathyroidism developed in two patients, and permanent ipsilateral recurrent laryngeal nerve palsy occurred in one patient, for an overall significant complication rate of 2.4 per cent. Tumor recurrence was noted at a mean of 19 months postoperatively in 14 patients. Ninety-six patients received adjuvant postoperative radioiodine therapy to ablate residual functioning thyroid tissue or suspected metastases. We conclude that total thyroidectomy as treatment for differentiated thyroid carcinoma carries a low rate of morbidity, treats occult contralateral disease, and should facilitate radioiodine scanning and ablation of residual functioning thyroid tissue or metastatic disease.

Carcinoma of the esophagus.

Carcinoma of the esophagus remains difficult to detect while it is localized to the mucosa. The ideal treatment is removal of all tissue that contains tumor. Usually reconstruction using the stomach is preferred over the use of gastric tubes, colon, and jejunum, although these will serve satisfactorily. Maximal palliation with relief of dysphagia is best achieved by removal of the obstructing lesion when possible, even if some tumor remains. When resection is not practical, bypass anastomoses proximal to the tumor occasionally may be used to relieve the obstruction and the associated dysphagia. Irradiation and chemotherapy may improve the results of therapy. To permit earlier detection, better screening tests are needed.

Primary malignant pulmonary tumors in the older patient.

The incidence of lung cancer, the most common visceral malignancy, is increasing in the elderly patient. Careful preoperative preparation and postoperative care will allow some of these patients to have surgical resections. Radiotherapy and chemotherapy offer benefits for those patients who cannot have a curative surgical resection.

Surgical treatment of gastroesophageal reflux.

Most investigators agree that the most important goal in correcting gastroesophageal reflux is restoring or developing a competent lower esophageal sphincter. Although the sphincter can be incompetent in its normal intra-abdominal position and rarely a patient may have a competent sphincter in the thorax, generally the sphincter is much more effective in the positive pressure abdominal position. The choice of operative technique will depend upon the abnormal conditions present and the general condition of the patient. The thoracic approach is elected if there is associated intrathoracic disease warranting surgical correction, such as diffuse spasm of the esophagus, achalasia, epiphrenic diverticulum, or a pulmonary lesion requiring biopsy and possible resection. Very obese patients, patients with recurrent hernias, and patients with shortened esophagus are better managed by the thoracic approach. Patients with an essentially normal esophagus are treated with a Mark IV Belsey procedure. If shortening of the esophagus is present, a combination Collis-Nissen technique with fixation below the diaphragm is preferable. The abdominal approach is indicated when there is another intraabdominal disease known or suspected warranting surgical correction. This approach is also useful for the thin or poor risk patient. Usually, through an abdominal incision, we elect to use a modified Nissen fundoplication, with fixation of the fundoplication to the median arcuate ligament or the right crus of the diaphragm. The crural sling is returned to normal dimensions with interrupted sutures. Reflux in the absence of an hiatal hernia initially is treated medically. If symptoms are significant and intractable, a competent lower esophageal sphincter is restored, or developed by the modified Nissen procedure just described. Most reflux strictures at the esophagogastric junction are reversible by dilatation and restoration of a competent sphincter. Firm, fixed, fibrous strictures occasionally cannot be safely dilated. These may be managed by a Thal procedure to correct the stricture and a Nissen fundoplication to prevent recurrent reflux.