Chapter 6: Endocrine Surgery

Introduction

Prior to the late 1800’s, the function of endocrine glands was unknown. Surgeons excised the thyroid gland for severe goiters, but operative mortality was over 40% due to massive hemorrhage.¹ Outcomes for patients who survived the operation were ambiguous, but as neither antisepsis nor the existence of parathyroid glands was recognized, it was unclear whether postoperative mortality reflected infection or organ failure.²

Major advances in the mid-19th century, namely, the advent of effective anesthesia, adoption of aseptic technique, and the invention of hemostatic forceps, enabled significant strides in thyroid surgery. Swiss surgeon Theodor Kocher (1841–1917) refined the operation over the course of his 40-year career and approximately 5000 thyroidectomies, reducing mortality rates to 0.5%.³ Crucially, Kocher also characterized the vital role of the thyroid gland in metabolism and organ function. At the behest of a referring physician, Kocher reexamined a girl he had previously performed a total thyroidectomy on 9 years earlier, and found her to be cretinoid. This prompted him to initiate follow-up on 102 of his postthyroidectomy patients (the largest reported single-surgeon series at the time) and review an additional 134 cases collected from 15 colleagues in Germany and Switzerland. He catalogued in detail the clinical features and outcome of each patient, and coined the term cachexia strumipriva (decay resulting from lack of goiter).² His work represents a milestone in surgery, as a classic example of a surgical audit and investigation into the long-term effects of a procedure. For his groundbreaking work on the physiology, pathology, and surgery of the thyroid gland, Kocher was awarded the Nobel Prize in 1909, and is considered the father of endocrine surgery.

Thyroid and parathyroid surgery today boasts very low complication rates in experienced hands. The more common disease entities requiring surgical interventions, such as well-differentiated thyroid cancer and primary hyperparathyroidism, have excellent long-term survival and cure rates.^4,5 A comparison of different treatment approaches in a prospective randomized controlled fashion would, therefore, require a prohibitively high number of subjects, as demonstrated by Carling et al in a feasibility study concerning prophylactic central lymph node dissection for papillary thyroid cancer.⁶ Given these considerations, as well as the rarity of many endocrine disorders, the majority of published reports in the field of endocrine surgery are retrospective in nature. Without good randomized clinical trials, surgeons rely on clinical practice guidelines developed and endorsed by reputable professional societies such as the American Thyroid Association, American Association of Endocrine Surgeons, and American Association of Clinical Endocrinologists. We will review several of these guidelines in this chapter.

The modern age of clinical practice guidelines began in 1992 with an Institute of Medicine report advocating for “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific circumstances.”⁷ Clinical practice guidelines aim to create consistent practice patterns based on the best available evidence. Guidelines are formulated according to ...