[Is primary total thyroidectomy justified in benign multinodular goiter? Results of a prospective quality assurance study of 45 hospitals offering different levels of care].

INTRODUCTION: After subtotal resection of multinodular goiter, rates of up to 40% are reported for recurrent goiter in the long-term follow-up. Because of the increased morbidity of surgery for recurrent goiter, this study evaluated the preconditions that would justify total thyroidectomy as part of the primary therapy concept for benign multinodular goiter. MATERIAL AND METHODS: The Quality Assurance Study of Benign and Malignant Goiter covering the period from 1 January to 31 December 1998 assessed 5195 patients treated for benign goiter by primary bilateral resection. With respect to the extent of resection three groups were analyzed: bilateral subtotal resection (ST+ST, n=4580), subtotal resection with contralateral lobectomy (ST+HT, n=527), and total thyroidectomy (TT, n=88). RESULTS: The age of the patients was significantly higher (60.3 years) in the TT group than in the ST+ST (52.5 years) and ST+HT (55.6 years) groups. ASA classification grades III and IV were significantly more frequent in the TT group. The postoperative morbidity increased with the extent of resection. The rate of permanent recurrent laryngeal nerve (RLN) palsy was 0.8% for ST+ST, 1.4% for ST+HT, and 2.3% for TT and of permanent hypoparathyroidism 1.5% for ST+ST, 2.8% for ST+HT, and 12.5% for TT. Multivariate analysis showed that the extent of resection significantly increased the risk of RLN palsy (transient RR 0.5, permanent RR 0.4) and hypoparathyroidism (transient RR 0.2,permanent RR 0.08). The surgeon's experience (RR 0.6) and identification of the RLN (RR 0.5) reduced the risk of permanent RLN palsy. Additionally, the development of permanent hypoparathyroidism was reduced if at least two parathyroid glands (RR 0.4) were identified. CONCLUSION: Total thyroidectomy is associated with an increased rate of RLN palsies and hypoparathyroidism in comparison to less extensive thyroid surgery. In the hands of well-trained surgeons using an appropriate intraoperative technique, primary thyroidectomy is justified if the patient has an increased risk of recurrent goiter. Due to the increased postoperative morbidity after total thyroidectomy, subtotal thyroid resection based on the morphologic changes in the thyroid gland is still recommended as the standard treatment regimen for multinodular goiter.