Thyroid surgery: what treatment at Clinique Charcot in Lyon?

At the Charcot clinic , certain thyroid abnormalities can now be operated on transorally , a minimally invasive laparoscopic technique still in its infancy in France.

Called TOETVA (for Transoral Endoscopic Thyroidectomy Vestibular Approach) or TOT, transoral or buccal thyroidectomy is a technique imported from Asia.

Convinced of the interest of this technique which leaves no visible scar and developed by Dr Anuwong in Bangkok, it will allow in the future to bring a notable aesthetic gain with an identical gesture.

The suites are generally simple with 24 hours of hospitalization, sometimes at the cost of a few cervical bruises disappearing in a few days. There are certain specificities which will be explained to you during the pre-operative consultation .

Of course, some complications remain identical to so-called “conventional” surgery.

The thyroid is part of the body’s endocrine system.

It is a gland often described as having a butterfly shape. In a normal state, it weighs between 10 and 20 grams and measures 4 to 6 cm high by 2 to 6 cm wide. These data evolve according to the morphology of each

The thyroid gland is located in the middle of the neck, in front of the trachea.

We usually describe it with two oval lobes, the right lobe and the left lobe, and a central part called the isthmus.

It is an endocrine gland, which means that it secretes hormones (T3 – T4).

The manufacture of these hormones requires the presence of iodine, which is usually provided by food.

The complex system of regulation of this gland is dependent on another gland: the pituitary gland. Located in the brain, the pituitary stimulates thyroid function through a hormone called TSH.

The amount of hormones in your blood is constantly regulated to meet the body’s needs.

Thyroid hormones are necessary for the proper functioning of the body and its regulation. In the event of removal of the thyroid gland, it will be necessary to replace these hormones by a replacement therapy.

Thyroid hormones are involved in the regulation of the heart, the intestine, in the production of heat, as well as in the metabolism, ie the transformation of fats, but also sugars and proteins.

The most frequent modes of discovery can be:

• carrying out a biological assessment (blood test for dosage of your thyroid hormones) requested by your attending physician;
• the occurrence of clinical manifestations, as a rule, related to the production in excess, or to a lack of thyroid hormones;
• the discovery of a cervical mass with increase in the volume of the neck or the palpation of one or more balls in the neck.

All of these circumstances will require a more or less complete assessment, coordinated by your attending physician. This assessment is most often based on a biological assay of TSH, T3 and T4. A cervical ultrasound is requested. Your attending physician may be able to be supported by an endocrinologist, a doctor specializing in hormonal problems.

The thyroid nodule can be unique or integrated into a multi-nodular goiter (enlargement of the thyroid).

The operative indications are precise and established collectively with, beforehand, the need for a complete ultrasound assessment. When the nodule measures more than 8-10 mm, it is necessary to perform a cytopuncture for cytological analysis.

Depending on the result of this analysis and the ultrasound, a simple monitoring could be put in place. It will be coordinated by your endocrinologist. In the event of a large nodule or doubt about a possible cancer on the results of the puncture, partial or total thyroid surgery may be offered to you.

This is a choice that will be discussed during your consultation with your endocrinologist, then with your surgeon.

Goiter is the increase in size of your thyroid. It is most often associated with the presence of numerous nodules in the two thyroid lobes.

You have most often been monitored for several months or years by your attending physician or your endocrinologist through biological check-ups and successive ultrasounds.

A< strong> thyroid surgery< /strong> may be indicated in the event of an increase in the size of the goiter and nodules, in the event of a possible suspicious character during a puncture or during the appearance of compressive signs causing difficulty in breathing or swallowing.

There may be an associated dysregulation of the production of thyroid hormones with an increased thyroid in size and presenting numerous nodules to which is associated a hyper production of hormones which can then make discussion of surgery. This is a hyperfunctional goiter.

There are several variants of thyroid cancer, the most common variant of which is differentiated papillary thyroid cancer.

This type of cancer has an excellent prognosis. It will require surgery with or without the removal of lymph nodes, depending on the preoperative assessment.

After the operation, it is common to receive a specific treatment called radiation therapy. It consists of the administration of radioactive iodine in a specialized center during a short hospital stay.

There are specific recommendations concerning the management of differentiated thyroid cancers. The most suitable gesture will be explained to you during your consultation with your surgery.

Finally, there is a rare variant of cancer called medullary thyroid cancer. This cancer is linked to a genetic mutation and affects the C cells of your thyroid. Medullary thyroid cancer is diagnosed by a blood test: the calcitonin assay.

This examination will usually be requested from you before any thyroid surgery to eliminate its presence because its diagnosis is essentially made through this blood test, in the aftermath, quite frequently, of non-contributory punctures. It is a very specialized treatment that cannot be superimposed on the usual form of differentiated thyroid cancer.

In some cases, your thyroid gland is no longer regulated by TSH. It begins to function autonomously, causing dysfunction and hyperproduction of thyroid hormones. This mainly occurs in two cases:

• either the presence of a single so-called “hot” thyroid nodule for which a thyroid lobectomy (removal of half of the thyroid) is often indicated and which will allow healing;
• or an autoimmune disease called Graves’ disease . In this case, there is a hyper production of antibodies leading to an increase in the volume of the thyroid, a hyper production of hormones, and, sometimes, the appearance of ocular manifestations called proptosis. For this disease, medical treatment is indicated in the first place and for a period of 12 to 18 months. Thyroid surgery is indicated in case of resistance to treatment, in case of relapse, in case of desire for pregnancy or if there is residual goiter after treatment. In all cases, before any surgery, it is necessary to be euthyroid, ie with a normal hormonal balance, most often obtained with the help of medical treatment over several weeks. The total ablation of the thyroid is then the indicated gesture.

You are going to meet your surgeon after having had the opinion of your general practitioner and/or your endocrinologist. During the consultation, you are asked to bring the hormonal assessment carried out (=result of your blood test), the thyroid ultrasound and any imaging results (scanner, scintigraphy, etc.).

During the consultation, you will go over the various pre-operative elements with your surgeon and choose, with his explanations, the most suitable type of surgery: most generally, the removal of half or all of the thyroid gland.

In the case of tumoral pathologies, the need for the realization of a curage could be evoked. This involves removal of the lymph nodes, either in contact with the thyroid, or in contact with the jugular vein and the carotid artery. This procedure is called a jugulo-carotid dissection.

Each time, the surgical decision and the type of intervention will be adapted to your pathology.

Once the decision has been made, you will be referred to a fellow anesthesiologist who will ensure that the intervention, and especially the general anesthesia, does not pose a problem in your case. You will then be explained the modalities of this anesthesia.

Usually, the instructions are to fast for 6 hours before any general anesthesia. More specifically, it will be a question of following the instructions which will be given to you by the anesthesiologist and which will be the most appropriate in your particular situation.

If you take medication on a daily basis, again your anesthetist will be your contact and will explain to you which treatments to take and which not to take before the operation. They may want you to take some of your medications the morning of the procedure, with plenty of water. If you are taking medication to thin your blood, discuss this with your surgeon and anesthesiologist.

The Charcot clinic team welcomes you during admission, most often the morning of the operation and checks the administrative formalities. Health professionals ensure that there is no new information and that the instructions given before the intervention (shower, fasting, etc.) have been followed. You will be asked the same questions repeatedly.

You will then be taken to the procedure room in the operating theatre. Here, your surgeon and your anesthesiologist, surrounded by their team, welcome you. They in turn carry out the usual checks (identity, compliance with instructions, etc.).

Once general anesthesia has started, you will be placed on your back, with your head slightly extended. Helped by a nurse, the surgeon will position the surgical fields before starting.

To perform a thyroidectomy, it is necessary to make a horizontal incision in the cervical region, at neck level, which will be adapted to the size of your thyroid and, most often, made in a natural fold to obtain the most suitable aesthetic result possible thereafter.

All cervical procedures are performed using MIN monitoring. This is a device for monitoring the proper functioning of recurrent nerves.

At the end of the procedure, the incision is closed using a suture, called an intradermal suture, which is resorbable and does not require any nursing care afterwards, or even with glue and, more rarely, with staples.

Monitoring is then carried out in the recovery room. Once awake, you will go back to your room for post-operative monitoring. A nurse makes sure there is no pain, nausea or vomiting. She will be there to answer your first questions. Do not hesitate to share any symptoms to adapt your treatments, in particular analgesics or anti-nausea.

During this phase, you will gradually come to your senses. You will be served a snack and your surgeon will visit you during the day to make sure you are well. On this occasion, he will give you all the explanations regarding your intervention and to give you the first post-operative instructions.

The duration of the intervention can vary, as a rule, from one hour to a few hours. The surgical act varies according to the complexity of your pathology. At the end of the operation, a drain can be left in place to avoid the risk of hematoma.

If a lobo-isthmectomy has been proposed to you (partial removal), this will most often be carried out on an outpatient basis, ie with admission in the morning and discharge in the evening.

When you leave, your prescription will include pain treatment, instructions regarding your scar, and, most often, a hormonal assessment (TSH, T3, T4) to be carried out within a month. It is rare to consider, from the outset, the establishment of a replacement treatment with thyroid hormones.

In the case of total thyroidectomy, outpatient surgery is currently not recommended in France. Most often, hospitalization lasts 24 hours. In some cases, it can last up to 4 or 5 days in the event of abnormal blood calcium levels (see Complications section).

Thyroid operations are common. The technique is precise and carried out by operators trained and trained in its specificity. However, as with any procedure, some complications may arise.
Some are common to all surgical procedures (superficial hematoma or scar infection): they affect less than 0.5% of procedures.
Others are more specific to thyroid surgery:

• compressive hematoma of the neck which may require emergency re-intervention due to the risk of respiratory discomfort and whose appearance generally occurs within the first 24 hours;
• voice disorders or difficulty swallowing which can be immediate, or appear secondarily. Most of the time, these disorders are due to recurrent nerve irritation. Usually, these disorders are transient and may require speech therapy. If in doubt, an ENT consultation will be prescribed. Exceptionally and in the event of bilateral involvement, the occurrence of a postoperative respiratory disorder may require the performance of an additional procedure to improve breathing;
• Dysfunction of the parathyroid glands may be responsible for postoperative hypocalcaemia (lower calcium in the blood). Hypocalcemia causes tingling around the lips, tingling of the extremities and in the complete forms of attacks of tetany. These symptoms are treated by the administration of calcium sometimes in association with vitamin D. Usually limited in time, a long-term substitution is exceptional. This type of complication is increased in the event of lymph node dissection (in certain cases of thyroid cancer);
• pain or stiffness in the spine usually relieved by physiotherapy and related to the position during the procedure. The list of complications described is not exhaustive. Your surgeon may need to modify the initial course of the operation. Indeed, the local modifications discovered during the intervention or the appearance of an unexpected complication can lead him to leave the initial protocol. Its goal: to remedy the difficulties encountered.
  At all times, your surgeon will weigh the benefits and risks of your current intervention.

The postoperative course is usually very simple.

As a general rule, you will leave the clinic with a prescription for analgesics, a postoperative check-up and a work stoppage.

Concerning the other aspects of your recovery, we will give you all the indications concerning the local care to bring to your scar to obtain the most beautiful aesthetic aspect. We will recommend local massages. Also, it would be better for your skin to avoid any form of sun exposure for several months. In most cases, the result is very satisfactory.

Some patients may experience cervical discomfort related to their position in the operating room. Do not hesitate to inform your surgeon or anesthesiologist of any cervical fragility so that all precautions can be implemented. Postoperatively, simple stretching movements can be beneficial to speed up your recovery.

Finally, your work stoppage may vary depending on the procedure performed and your profession. Do not hesitate to discuss this issue with your surgeon.

You will see your surgeon again in consultation, after one month, with your biological check-up.

You must contact your endocrine surgeon at Clinique Charcot in the event of:

• cervical swelling that you think is abnormal;
• difficulty breathing or swallowing;
• persistent fever;
• drainage at the level of the scar or disunity;
• or any other manifestation that seems abnormal to you.

Indeed, it is a surgery whose post-operative consequences are generally simple.
If in doubt, do not hesitate to contact us.

L-T4 (or Levo-thyroxine) being a synthetic hormone, it is the same as the natural hormone. Thus, it can be combined with all other treatments with little drug interaction.

The possible undesirable effects are in most cases related to a hormonal imbalance, testifying to hypothyroidism or hyperthyroidism.

The monitoring of the treatment is set at regular intervals by your attending physician or your endocrinologist. To do this, a simple biological assessment with the TSH assay is sufficient to adapt your treatment.

Once the right dosage has been found, you will be able to live completely normally provided that you respect the daily intake of the drug.

If you forgot to take your tablet, that’s okay. Under no circumstances should you take a double dose! On the contrary, it is necessary to resume the treatment, at the usual dose. Indeed, there is, permanently, a reserve of thyroid hormones in your organism.