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Endocrine Surgery

Endocrinology Center Innsbruck

Team of doctors:
OA Dr. M. Eberwein
Dr.in Katharina Esswein

Special consultation hour:
Tuesday 09:30 -14:00
Tel. +43 (0)50 504 50010

 

In the special consultation hour we treat diseases of the hormone producing glands (thyroid, parathyroid, adrenal gland, pancreas, the NET/GEP tumors and genetically caused, hormonal tumor syndromes).

Benign thyroid diseases (benign goiter)
The thyroid gland (de.wikipedia.org/wiki/thyroid gland) is a butterfly-shaped organ or hormone-producing gland. It lies horseshoe-shaped in front of the windpipe and is connected to it by a ligament (grubber band, berry ligament). The thyroid gland produces the thyroid hormones (T3, T4), which have a stimulating effect on all organ functions! Therefore, an excess of thyroid hormones stimulates all organ functions, whereas an underactive thyroid gland slows down all organ functions. Pathological enlargement of the thyroid gland is called goitre (goiter). The most common thyroid disease to be operated on is nodular goiter with suspected presence of thyroid carcinoma. One of the known causes of goiter is an iodine deficiency in the diet, which has been successfully combated for decades by adding iodine to table salt. However, many patients have suffered a relative iodine deficiency in childhood or have grown up under iodine deficiency. Recent findings show that the nodular goiter often has a family (genetic) basis. By eliminating the iodine deficiency, the size growth of the nodules is no longer as pronounced.

Knotenstruma (Struma multinodosa)
Here, there are several nodes of different size in the thyroid gland. They can be up to 10 cm in diameter and larger. With many nodes in the thyroid gland, it is difficult to examine each node for malignancy. In addition, a nodular goiter can have a cosmetic effect and also constrict the trachea and esophagus.

Minimally invasive thyroid surgery with corresponding indication. The indication for minimally invasive thyroid surgery is usually in nodules smaller than 3 cm, with the exclusion of thyroiditis, no evidence of malignancy and no previous thyroid surgery. This operation is performed at our clinic with great success. The operation is possible with minimal tissue mobilization (small lateral skin incision of 1.5 cm length).

Cold node, suspicion of thyroid carcinoma
If a cold node has been described in your case, this means that this node cannot produce thyroid hormone. In our latitudes about 10% of cold nodules are malignant. At present, there is no method by which a malignancy can be excluded with certainty before the operation. For this reason, cold nodes should be operated on. Smaller cold nodules can easily be removed by minimally invasive surgery. In the case of a cold nodule or if the preliminary examinations give rise to the suspicion of malignancy, the thyroid lobe in question is usually removed and a so-called "frozen section" examination is performed. While you are still under anaesthesia, the removed thyroid tissue is sent to the Institute of Pathology where it is examined histologically (fine tissue) for malignancy. In about 70% - 80% (i.e. not in all cases) the correct diagnosis can be made by frozen section. Without exception, every tissue that has been examined by frozen section is thoroughly examined in further tissue examinations. If a malignant tumor of the thyroid gland has been diagnosed either already in the frozen section during the operation or in a few cases only after the always performed detailed tissue examination, a complete removal of the thyroid gland and the cervical lymph nodes is connected.

If the thyroid gland is overactive, surgery is performed in certain cases. In a so-called "multifocal autonomy", the hyperthyroidism is caused by several hormone-producing nodes. In these cases, only the operation shows a corresponding success.
In the case of an autonomous adenoma, there is only one node which leads to hyperthyroidism. Radioiodine therapy is an alternative method in this case. The so-called Graves' disease is an autoimmune disease in which antibodies are directed against the thyroid gland and stimulate it to a continuous excessive hormone production. In half of the patients, the eyeballs protrude (orbitopathy). In case of very large strumen, intolerance of the necessary medication, in women under 40 years of age and children, radioiodine therapy is not recommended in this disease, but thyroid surgery.

Thyroid cancer (thyroid carcinoma)
Papillary and follicular thyroid carcinoma. In differentiated thyroid carcinomas, a total thyroidectomy with central and also lateral functional lymphadenectomy is performed because of many advantages for the outcome. The most important advantage of total thyroidectomy in thyroid carcinoma is the better effectiveness of the subsequent radioiodine therapy. Further advantages are the possible removal of additional tumor foci, since papillary carcinoma occurs in up to 50% multicenter (several tumor foci in the thyroid); thyroglobulin is only useful as a tumor marker if a total thyroidectomy is performed (benign SD tissue also secretes thyroglobulin), etc. Only in the case of occult (not intraoperatively diagnosed by rapid incision) microcarcinoma (definition: tumor diameter less than 1 cm, no exceeding of the thyroid capsule, tumor completely removed), no subsequent completion thyroidectomy (removal of thyroid remnants) or radioiodine therapy is required. If, however, the microcarcinoma is diagnosed intraoperatively by means of rapid incision, a total thyroidectomy with central lymphadenectomy is recommended (allows for subsequent radioiodine therapy in any case, but is only considered for high-risk microcarcinomas).

Medullary thyroid carcinoma (MTC) A special form of differentiated thyroid carcinoma is medullary thyroid carcinoma (approx. 4 - 7% of all thyroid carcinomas). MTC has an excellent tumor marker in calcitonin. Understandably, MTC does not show radioiodine uptake, since it originates from the parafollicular C-cells. Typical for MTC is an early systemization (spread via lymph and bloodstream) with mainly cervical lymph node metastases and also hematogenic bone and liver metastases. This means that a cure for MTC can only be achieved in the preclinical stage. Since calcitonin is an organ-specific tumor marker, calcitonin screening is of great importance. Serum Calcitonin can be falsely positive in patients with renal insufficiency, smokers or patients older than 60 years. In patients with basal elevated calcitonin, stimulation of the secretion of calcitonin is always performed (pentagastrin test). All patients with stimulation also have a C-cell pathology (C-cell hyperplasia, MTC). 25% of MTC occur familial and are diagnosable by appropriate genetic testing (mutation in the RET protooncogene, chromosome 10). Since a RET mutation has a 100% penetrance for the development of MTC (however, the transformation of C-cell hyperplasia to MTC proceeds at different rates depending on the different mutation), a prophylactic thyroidectomy is recommended in the presence of the mutation. For these reasons, it is essential to perform a genetic examination on every patient with MTC, as he or she could be a so-called "index patient". Familial MTC can occur in isolation ("familial MTC-only") or be associated with multiple endocrine neoplasia type IIa (MTC, bilateral pheochromocytomas, hyperparathyroidism) or type IIb (MTC, bilateral pheochromocytomas, neurofibromas, marfanoid habitus). Since radioiodine therapy is not effective and percutaneous radiotherapy and chemotherapy are also ineffective, surgery (total thyroidectomy and systematic prophylactic lymphadenectomy) is of great importance.

Anaplastic carcinoma Anaplastic carcinoma is diagnosed less and less frequently. Like follicular carcinoma, it is highly associated with iodine deficiency. The prognosis is very poor. Many endocrine surgeons regard anaplastic thyroid carcinoma as a non-surgical disease. Occasionally, anaplastic thyroid carcinoma does not grow infiltratively but rather displaces it, which can lead to an indication for surgery. In most cases, however, the operation is limited to obtaining a tissue sample and creating a tracheostoma.

Lymphoma
The primary lymphoma of the thyroid gland always develops at the base of Hashimoto's thyroiditis. Clinically the lymphoma presents itself like the anaplastic carcinoma as a very fast growing goiter.

Insular Carcinoma
This carcinoma lies prognostically between differentiated and anaplastic carcinoma. It was formerly known as the so-called "proliferating goiter of Langhans".

Metastases
In generalized metastatic tumors, metastases are found in the thyroid gland in 9% of cases. Clinically relevant metastases are usually only found in renal cell carcinoma. A hemithyroidectomy is usually sufficient.

Hämangioendotheliom: extremely rare.

Prophylactic surgery for RET mutations (medullary SDCa)
If in patients with medullary thyroid carcinoma and proven germline mutation their relatives also have the same mutation, prophylactic thyroidectomy is recommended under certain conditions from a defined age, since penetration almost always reaches 100% in patients with mutation.

Preliminary examinations for thyroid gland surgery - nuclear medical preliminary examination (thyroid outpatient clinic
- preliminary internal examination (for patients older than 40 years)
- laryngological examination (vocal cord function) by ENT physician

Neuromonitoring
For 15 years now, intraoperative electrical neuromonitoring has been used very successfully at our clinic. The monitoring is always used, even during minimally invasive operations. Only an anatomical structure, which is clearly identified, can be protected accordingly. With this method the vocal cord nerve can be located acoustically and its anatomical integrity can be checked. It is very helpful in recurrent operations and carcinomas and is also of great importance in the training situation.

Hyperparathyroidism
The parathyroid glands are hormone-producing glands about the size of a grain of rice, which are located very close to the thyroid gland. Usually there are two such parathyroid glands on each side of the thyroid gland (a total of four parathyroid glands).

Parathormon
The parathormone is produced by the parathyroid glands. As the name suggests, these are located in the area of the thyroid gland. Normally one has four parathyroid glands. The parathyroid hormone causes an increase in the blood calcium level through several mechanisms. The most important mechanism is the release of calcium from the large calcium depot of the skeleton. In a healthy person, the parathyroid hormone is released into the bloodstream when the blood calcium level is reduced in order to normalize it. If there is an overactive parathyroid gland, the parathyroid hormone is constantly being released from one or more parathyroid glands.

Primary hyperparathyroidism Primary hyperparathyroidism (hyperparathyroidism of the parathyroid gland) is one of the most common hormonal diseases besides diabetes. Apart from a few inherited forms of primary hyperparathyroidism, the cause is unknown. The symptoms are sometimes relatively uncharacteristic (bone pain, fatigue, exhaustion), especially in the early stages of parathyroidism, so that parathyroid hyperfunction is not considered. Only if the disease persists for a longer period of time, more severe bone changes (10% of patients already suffer bone fractures with minor injuries), kidney stones, but also diffuse calcifications of the kidney or even functional limitations of the kidney without calcifications can occur. The development of stomach and duodenal ulcers is promoted by the constantly elevated calcium level in the blood. Furthermore, the adequate calcium level in the blood is important for the function of nerve and muscle cells. A constantly elevated blood calcium level can therefore impair the function of the nerve cells and muscles. Many patients complain of fatigue and poor performance or have psychological problems such as depression etc. (endocrine psychosyndrome). In recent years, studies have shown that patients with parathyroid hyperthyroidism suffer more frequently from cardiovascular problems (heart attack, cerebral infarction, circulatory disorders of the extremities, etc.).

Single gland disease Since with 90 - 95% probability only one of the 4 parathyroid glands is pathologically changed, in the vast majority of cases only this one changed parathyroid gland must be removed.

Multiple glandular disease Double adenomas: of four glands, two glands may be pathologically altered in 2 - 4% of cases.four-gland disease (hyperplasia): in about 6 - 7% of cases with primary hyperparathyroidism, all four parathyroid glands are pathologically altered. In these cases three whole and half parathyroid glands are removed. Most frequently, parathyroid hyperfunction is detected by chance when serum calcium is elevated. If the serum calcium level is elevated, parathyroid hyperfunction should be considered in any case and the parathyroid hormone should be determined. If the parathyroid hormone and serum calcium are elevated, the diagnosis is already relatively certain. The further complete clarification, which in all cases should also include a determination of the calcium in the 24-hour urine, is usually carried out by an internist or endocrinologist.
Since patients with parathyroid hyperthyroidism get symptoms within five years, and many of the organ damages are not reversible (vascular calcification, kidney calcification, bone damage) and on the other hand the procedure can be performed minimally invasive (1.5 cm skin incision) in about 90% of cases, the recommendation is to operate on every patient. In mild forms of parathyroid hyperthyroidism, however, the urgency is not great.

If the biochemical diagnosis is sufficiently confirmed and the doctor recommends surgery, we will suggest the following procedure:
1. Discussion of the existing findings and further examinations and possibly already fixing the date of the operation Your doctor will make an appointment for this in our consultation hours for endocrine surgery.
2. What other examinations are necessary (if you have decided to have surgery)? Since the parathyroid glands are only about the size of a grain of rice in normal size, they cannot be visualized with the usual imaging procedures such as ultrasound or computer tomography (all structures in the body smaller than 1 cm are difficult to image). A pathologically altered gland is also only 1.5 cm in size on average. In addition, it is not known which of the four glands is the pathologically altered one.
Furthermore, the glands may not be in a typical position, but can be very variable from the base of the skull to the pericardium (ectopic position). For this reason, we perform a preoperative localization diagnosis by means of a nuclear medical examination (MIBI-SPECT) and computer tomography.
These examinations take about half a day and can be performed on an outpatient basis! For this examination you should come fasting. A cannula is inserted into the vein. You will be placed on an appropriate vacuum mat and both examinations will be performed at intervals of 1-3 hours! You can then go home again. A special computer will then superimpose all the data with pinpoint accuracy! This examination was developed in Innsbruck and currently provides the best prediction of where the altered parathyroid gland is located. This examination is also a prerequisite for minimally invasive surgery.
3. If desired, these findings can be discussed with you before the surgery
4. If the date of the operation has been fixed, your family doctor should refer you to an ENT specialist who will check the vocal cord function! Please take the written findings with you to the hospital!
5. the family doctor should also refer you to an internist who will perform the laboratory findings, lung x-rays etc.! Please also take these written findings with you to the operation.

Minimally invasive parathyroid surgery:in about 90% of cases, parathyroid surgery can be performed minimally invasive (in case of single gland disease) The minimally invasive surgery (approx. 1.5 cm skin incision) requires two prerequisites: first, a reliable localization diagnosis, second, the intraoperative parathyroid hormone assay, see below). After successful parathyroid surgery, many patients have a so-called "hungry bone syndrome" with recalcification tetania in postoperative hypocalcaemia. The more severe the skeletal damage was preoperatively, the more pronounced the postoperative hypocalcaemia. When the suppressed remaining parathyroid glands start secreting parathyroid hormone again, serum calcium levels increase. The nadir of hypocalcaemia is usually on the 3rd postoperative day.
Classic bilateral neck exploration:if no clear adenoma can be localized in preoperative localization diagnostics (very rare), bilateral neck exploration (until a few years ago gold standard) must be performed
Subtotal parathyroidectomy in reactive hyperparathyroidism: Patients with reactive hyperparathyroidism are usually affected by disease of all four parathyroid glands. The surgical therapy in our clinic is subtotal parathyroidectomy (removal of 3 ½ parathyroid glands) with cryopreservation. If parathyroid function is insufficient postoperatively, cryopreserved tissue can be implanted into the forearm under local anesthesia. 

Localization diagnostics using image fusion (CT-MIBI-SPECT-image fusion): in Innsbruck, image fusion (combination of a specially designed CT with a MIBI-Spect) was developed together with Radiology I and Nuclear Medicine. This method was performed preoperatively with very good success in all patients. Both examinations are performed on the so-called "blue bag", which is a vacuum mattress. By fixing the body with this vacuum mattress and the possibility of superimposing both examinations, a so-called "virtual neck exploration" can be performed. It is possible to locate the pathological parathyroid gland very precisely preoperatively, which is one of the prerequisites for the minimally invasive procedure! (Picture!). When comparing our data with those of the usual localization diagnostics (MIBI-Spect, ultrasound) in literature, image fusion is clearly superior and therefore the best method for localization of enlarged parathyroid glands at present! (Link to Ann Surg work?). 
Intraoperativer Parathormonassay (Schnell-PTH): the parathyroid hormone has a half-life of only 2-3 minutes with normal kidney function. This allows intraoperative measurement of the parathyroid hormone and decision-making, as the measurement result is available after about ten minutes (Quick-PTH). Before the era of minimally invasive surgery, bilateral neck exploration was the gold standard. Until all parathyroid glands were found intraoperatively, the surgeon did not remove any parathyroid gland. It was up to the surgeon to assess whether a parathyroid gland was enlarged or not. Only the enlarged parathyroid gland was removed. Since the introduction of the intraoperative PTH assay, the parathyroid gland, which was pathologically suspected in the preoperative localization diagnosis, is extirpated! If the parathyroid hormone level drops by 50% ten minutes after extirpation compared to the level before the anaesthesia, there is a specificity of 99% that all pathological parathyroid tissue has been removed!  
How does the operation day proceed? You should not eat or drink anything after 10 p.m. the day before the surgery. On the day of the surgery, about one hour before the surgery, the so-called pre-operative preparation will be performed at your place. You will be injected with the medication prescribed by the anesthesiologist. Antithrombosis stockings will also be applied. The day before the operation, an injection is injected into the subcutaneous fatty tissue to prevent thrombosis. After the operation you will be taken to the recovery room, where respiratory and circulatory functions will be monitored for a few hours. Pain and nausea are common on the day of surgery. However, these complaints can be treated very well. On the evening of the day of the operation, you can already drink fluids.
How long must I stay in the clinic?The following day you can eat as usual and also get up. If the thyroid gland was operated on minimally invasively, you can go home after checking the vocal cord function. 
However, if you have had minimally invasive surgery on the parathyroid gland, you cannot go home yet. After removal of the overactive parathyroid gland, it takes several days until the remaining parathyroid glands, which are suppressed until the operation, resume their function and produce parathormone. Until this is the case, the serum calcium level may be reduced to a mirror image of the normal level, as the calcium is now re-integrated into the bone. This can lead to cramps in the fingers (recalcification tetany, or so-called "hungry bone syndrome"). In this situation it may be necessary to administer calcium intravenously, so you should stay at the clinic for a few days. Usually the calcium level increases on the 3rd postoperative day!
Are there alternatives to surgery? Actual alternatives to surgery are not yet available. The instillation of alcohol into the parathyroid glands has not proven to be effective, since a high percentage of patients suffered damage to the vocal cord nerve.
Do I have to make further follow-up checks?Further endocrinological controls should be performed in any case. The first control of parathyroid function is performed during the inpatient stay, the next three months after the operation.
Can hyperparathyroidism also be caused by a malignant parathyroid tumor?In a maximum of 1% of patients, parathyroid hyperfunction is caused by a malignant tumor of the parathyroid gland. If the blood levels of parathyroid hormone are excessively high, parathyroid carcinoma must be considered.
Can the disease reoccur? If parathyroid tissue remains in the body, parathyroid hyperthyroidism can of course occur again. However, this is an extremely rare event in practice.