title: State of the art: surgery for endemic goiter--a plea for individualizing the extent of resection instead of heading for routine total thyroidectomy.
abstract: BACKGROUND
  During the past 150 years of nodular goiter surgery, the pendulum has been swinging from limited to more extensive forms of thyroidectomy and all the way back reflecting the challenges of striking a balance between surgical morbidity and disease recurrence.
  
  
  OBJECTIVE
  This article aimed at providing guidance for individualizing decisions using a risk-oriented surgical approach to endemic goiter based on literature review and personal experience.
  
  
  CONCLUSIONS
  The following arguments favor total thyroidectomy: (a) Endemic goiter involves the entire thyroid gland; (b) Increasing standardization and specialization supported by better visualization, surgical devices, and intraoperative parathyroid hormone assays have decreased surgical morbidity; (c) One third of goiter patients require completion thyroidectomy for incidental thyroid cancer; (d) Recurrent goiter is frequently seen on ultrasonography after subtotal thyroidectomy; (e) Thyroid hormone replacement is well tolerated and inexpensive. Important counter-arguments include: (a) Restoration of iodine sufficiency does not reverse nodular goiter nor can the growth of individual nodules be predicted; (b) To gather the annual case load necessary to achieve improved outcomes, surgeons need to "super-specialize", which may not be viable globally; (c) Many incidental cancers are detectable through high-resolution ultrasonography, fine needle aspiration cytology, and frozen section during thyroidectomy; (d) Not all recurrent goiters require reoperations; (e) Thyroid hormone replacement is not available and affordable everywhere.
  
  
  CONCLUSIONS
  The higher surgical morbidity associated with total thyroidectomy, notably recurrent laryngeal nerve palsy and hypoparathyroidism, calls for individualizing the extent of resection for endemic goiter as a new standard of care instead of heading for routine total thyroidectomy.
authors.affiliation: Department of General, Visceral and Vascular Surgery, Medical Faculty, University of Halle-Wittenberg, University Hospital, Ernst-Grube-Str. 40, 06097, Halle/Saale, Germany. henning.dralle@uk-halle.de
authors.forename: Henning
authors.initials: H
authors.lastname: Dralle
authors.forename: Kerstin
authors.initials: K
authors.lastname: Lorenz
authors.forename: Andreas
authors.initials: A
authors.lastname: Machens
mesh_terms: D005260:Female; D006043:Goiter, Endemic / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D007037:Hypothyroidism / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology; D008297:Male; D011183:Postoperative Complications / Q000503:physiopathology; D057285:Precision Medicine / Q000379:methods*; D011379:Prognosis; D018570:Risk Assessment; D055502:Secondary Prevention; D012720:Severity of Illness Index; D013963:Thyroid Hormones / Q000627:therapeutic use; D013965:Thyroidectomy / Q000009:adverse effects* / Q000379:methods*; D016896:Treatment Outcome; D014826:Vocal Cord Paralysis / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology
chemical_list: D013963:Thyroid Hormones