Raymon Grogan, MD, Assistant Professor of Surgery and Endocrine Surgery, Director, Endocrine Surgery Research at the University of Chicago talks about a new procedure to remove the thyroid that won’t leave a visible scar on the patient.
Interview conducted by Ivanhoe Broadcast News in October 2017.
I want to ask you about Graves’ Disease, the disease that Mary has. What kind of impact does that have on patients?
Dr. Grogan: It has a significant impact on patients, particularly with their quality of life as well as physiologically with lots of impairments in daily function; eye problems, weight loss typically, all types of things that can cause problems with Graves’.
Solutions, treatments for that?
Dr. Grogan: There are three main ways to treat it. One is with radioactive iodine therapy which shrinks the gland and basically keeps it from producing more thyroid hormone. There is surgery, which removes the thyroid gland and obviously removes the thyroid hormone as well. The third option is to stay on medications called anti-thyroidals which basically just try to regulate the amount of thyroid hormone that the thyroid is producing.
With the surgery in the past, what has been the procedure? Has that pretty much always been open to the neck, is it considered major surgery?
Dr. Grogan: It’s a well-known operation; it’s been done for a very long time, since the turn of the century. And since that time it’s been done through the open technique. Typically these days we make somewhere between a four and a six centimeter incision for a normal size thyroid, a few inches in length. It has always been done in that open fashion for at least a hundred years.
When the thyroid comes out, when the gland comes out, what’s the benefit for the patient, what happens for the patient when the gland is no longer there?
Dr. Grogan: It depends on why we’re doing the operations. There are several reasons to need to take the thyroid out. Graves’ obviously is one of them; in that particular case the benefit is that the excess thyroid hormone is no longer in the body. And so the thyroid hormone production can be stabilized with the use of thyroid hormone replacement pill. We also do this operation for people with cancers, we do it for people who have large thyroids that are compressing their airway causing difficulties breathing and swallowing. There are people who have nodules that we can’t tell if they are a cancer or not, those people need to have their thyroid removed. There are several reasons for needing a thyroidectomy.
Talk to me about the new way of performing the procedure.
Dr. Grogan: One way you can think about it is basically applying laparoscopic techniques to the thyroid gland. Similar to the way we do laparoscopic gallbladder surgery, laparoscopic colon surgery, laparoscopic appendix surgery; we’re just taking those same techniques, concepts and principle and applying that to the thyroid gland is how you can think about it in some ways.
Walk me through how you approach it and how the surgery is performed?
Dr. Grogan: The first thing we do is we make three small incisions on the inside of the lower lip. Those incisions are placed in the midline and then on each corner of the mouth in order to allow us to gain access to the neck with the laparoscopic instruments. Once the incisions are made we then tunnel down underneath the skin on top of the mandible but under the skin and open up a flap of tissue called a subplatysmal plain. That flap is the same flap that we make in the open operation, it’s almost exactly the same actually. So the amount of dissection that is done for the new operation is actually very similar to the traditional approach. Once that flap of skin, the subplatysmal flap is opened we then can see the same anatomy that we see from the traditional approach, and we go from there. The only difference is it’s viewed from top down as opposed to kind of middle or bottom up.
What’s the benefit to the patient for having the surgery performed this way?
Dr. Grogan: Well right now the main benefit is the lack of a visible scar. There still is a scar, it just happens to be on the inside of the mouth. Those scars even on the inside of the mouth tend to heal up so well that after about a year you can’t even find them. There’s no data to indicate that this new approach is any safer than the previous approach or gives you any better outcomes in regards to the amount of or the ability to remove the thyroid or anything like that. So as of now the main benefit is just the lack of a visible scar.
Who are the best candidates for this procedure as opposed to the traditional procedure?
Dr. Grogan: We have several limitations on the operation right now because it’s new and most of that revolves around size. Size depends on what the indications for surgery are. For example, someone who has a cancer; the current size limitation is two centimeters cancers. For someone who has a benign nodule of the thyroid that could be six centimeters. But for someone with Graves’ for example, we would look at the entire length of the thyroid lobe if they don’t have any nodules in it and that cut-off currently is about ten centimeters in size.
Can you talk to me about Mary’s case?
Dr. Grogan: Sure. She had Graves’ disease which as we’ve been speaking about is excess thyroid hormone production. And as we said there are three ways to treat that. Not everyone who has Graves’ disease gets eye involvement. But if you do have eye involvement with Graves’ disease, surgery is really the only way to treat it. The reason for that is because radioactive iodine can actually exacerbate the eye problems. So that’s why she was sent to see me because it was indicated due to the eye problems. Once I spoke with her in the clinic we evaluated her based on her size of her thyroid gland as well as any other indications that she may have, such as not wanting to have a scar on the neck. In her case she was very concerned about the scar, worried about the idea that she could have excess scarring of the skin which some people have, which can cause the scar to be much thicker than normal, in a normal healing situation. Because of those reasons she was very interested in the new approach to the surgery and so that’s why we talked to her about it and explained to her the details of the surgery and offered it to her.
This is also for parathyroid removal?
Dr. Grogan: That’s correct. So this operation actually is adminable to any surgery in the central neck as of now. For the most part that means thyroid and parathyroid surgery. Parathyroid surgery would be the other indication currently for this operation. That’s a totally different set of diseases that obviously involve the parathyroid glands as opposed to the thyroid glands.
What set of diseases for my background?
Dr. Grogan: There are three types of parathyroid disease. There’s primary, secondary and tertiary. As of now we’re only operating on people with primary hypoparathyroidism who have a well-localized parathyroid adenomas, single parathyroid adenomas. The consequences of hypoparathyroidism is osteoporosis, kidney stones, fatigue, memory fog, constipation, abdominal cramping pain. Some people can have difficulty sleeping at night and other things like that.
What percentage of patients have the procedure done this way?
Dr. Grogan: Right now the percentages of the number of people we are currently doing is very low because this is a new operation. We’re only offering it obviously to the very select people who are candidates for the surgery based on size and some other criteria for the parathyroids. We actually lifted the data from our practice however to say if we applied even these strict criteria how many people in our current practice would be eligible for this operation and it turns out about fifty percent. So that’s an interesting finding because a lot of people think that this is a niche operation that’s going to be applicable to only a very small number of patients. However when we look at it there’s actually about fifty percent of the people that we operate on that are eligible for this operation. To get into context of the practice that we have here, my partner and me, it is a relatively complex practice. It includes a lot of people who have already had operations. A lot of people who have very large nodules and thyroids. A lot of people who have metastatic disease to the neck and things like that. All those people aren’t even eligible for this operation and so even in a complicated type of practice you still have fifty percent of them eligible. So if you were extrapolate that out to the general population who is having thyroid and parathyroid surgery actually a fairly large number of people we believe will probably be eligible to have it done this way.
Is there anything I didn’t ask you that you want to make sure that people know?
Dr. Grogan: Probably just that it’s still a very new operation, this operation was started in Asia roughly three or four years ago in its current form. It actually experimentally started prior to that in Europe up to about eight, ten years ago now. But it was essentially perfected about three years ago and it only came to the United States about a year and a half ago. So there are very few centers that are currently doing this operation, which is probably a good thing. It requires a lot of setup, it requires a lot of support from the surgery department where it’s being done in terms of nursing power, surgical expertise, anesthesia expertise. It’s not something that should be done routinely by everyone right now until we have more information about it to make sure that it’s going to be safe in everyone’s hands and not just safe in people who just perform a lot of this kind of operation.
END OF INTERVIEW
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