Removal of diffuse toxic goiter is the main method of treating this pathological condition, despite the existence of conservative methods of treatment and radioiodine therapy. Non-surgical methods of treatment may be ineffective when the process is started, the individual characteristics of the patient may exclude the use of the main drugs used for conservative treatment, and the return of the disease is practically guaranteed.

However, the operation associated with the removal of part of the thyroid gland, like any surgical intervention, has its own risks. The surgical intervention itself is considered technically difficult: the close location of vital anatomical structures, the presence of an adhesive process, as well as a large number of thin-walled, but sufficiently full-blooded vessels, require a great deal of experience from the surgeon.

Disease classification and its influence on the choice of treatment

There are several classification options, but they are all based on the same signs: the size of the thyroid gland, the possibility of its palpation and visual detection. The World Health Organization has established three degrees of diffuse toxic goiter:

• 0 degree – the presence of a goiter cannot be determined either by palpation or during examination;
• 1 degree – on examination, deviations from the norm are invisible, however, an enlargement of the gland is determined by palpation;
• 2 degree – pathology is detected both by palpation and visually.

The classification of the disease according to Nikolaev is somewhat more detailed:

• degree 0 – it is not possible to identify the gland either on examination or on palpation;
• the first degree – on palpation, it is possible to detect the isthmus;
• the second degree – the gland can be seen during swallowing, its lobes are detected by palpation;
• third degree – an increase in the glands is visible on examination;
• fourth degree – a clear deformation of the neck is found;
• fifth degree – the thyroid gland reaches enormous size.

And also there are three degrees of severity of the disease, which are set in terms of heart rate, disorders of the nervous and cardiovascular systems, and also take into account weight loss.

Indications and contraindications for surgery

It is believed that the removal of diffuse toxic goiter of the thyroid gland is required in the following cases:

• moderate or severe severity of the disease – if it is impossible to achieve the normal level of thyroid hormones with drug therapy; 
• large goiter;
• retrosternal goiter;
• disease in childhood and adolescence, provided that it is impossible to achieve a euthyroid state with the help of drugs;
• having heart rhythm problems, such as atrial fibrillation.

Surgical intervention is impossible in case of the presence of pathology of other organs and systems in the stage of decompensation, since this casts doubt on the patient’s survival both during the operation and in the early postoperative period. 

And also it is impossible to remove the goiter in case of various infectious diseases, in the presence of a focus of chronic infection, as well as if the goiter is complicated by psychosis.

Features of surgery

The most common technique for performing an operation for diffuse toxic goiter is subtotal subfascial resection according to Nikolaev. The advantage of this technique is to minimize the possibility of damage to the laryngeal nerves, as well as to minimize the absorption of hormones after the goiter is removed . 

After the operation, the patient has a certain amount of thyroid tissue, which in some cases avoids lifelong replacement therapy, but at the same time there is a risk of recurrence of the disease. 

Another option for surgery is the complete removal of the gland. It is used more often for oncological pathology of the thyroid gland, but it can also be used for diffuse toxic goiter. After removing the goiter in this way, there is a high risk of postoperative complications, as well as the risk of damage to the nerves and their plexuses. Patients are forced to take thyroid hormones for life, but there are no relapses after its complete removal.

Possible problems in the postoperative period

The high density of the location of the anatomical structures, as well as their small size, make such an operation quite difficult. The most common undesirable consequences are:

• Hypothyroidism It develops after complete removal of the gland, however, hypothyroidism is also possible with subtotal resection. The most striking manifestations of hypothyroidism are bradycardia, manifestations of the nervous system, as well as an increase in body weight and edema.
• Hypoparathyroidism. Occurs when the parathyroid glands are unintentionally removed during surgery. The most striking manifestations of this condition will be convulsive syndrome, as well as a pronounced decrease in the level of calcium in the blood plasma.
• Postoperative bleeding. This complication develops due to abundant vascularization and high blood flow intensity of both healthy thyroid tissues and pathologically altered ones. But also the development of bleeding is facilitated by the abnormal location of the vessels of the thyroid gland.