Correspondence (reply): In Reply

Professor Wagner’s comment from a surgeon’s perspective shows that the recommendation for general thyroidectomy in bilateral nodular goiter is not generally accepted, and for good reasons. In our opinion, what is required is a differentiated approach to surgical therapeutic planning. In this setting, bilateral subtotal resection can make sense in the individual case scenario—as suggested by Professor Wagner—especially as the already cited retrospective study by Fikatas et al. showed that only 0.9% of patients in whom bilateral resection was undertaken that was adapted to the findings developed a clinically relevant recurrence in the long term (1). In the published prospective randomized studies the rate of repeat operations for recurrences after subtotal resection was also very low, at 1.5%. In many cases of bilateral goiter, one side, or one nodule, is found to be dominant. We think that in these cases the Dunhill procedure is superior to bilateral subtotal resection, especially in view of the possibly required re-operation at short notice, in cases where post-hoc histology confirmed the presence of cancer. In contrast to thyroidectomy, the Dunhill procedure was not associated with a much higher complication rate in the studies we cited in our article.

Wedig points out that the indication for surgery was probably too uncritical. This problem has recently been discussed in Deutsches Ärzteblatt (2). We agree with Wedig that even when less radical procedures than thyroidectomy are used the indication for surgery should not be expanded. Close cooperation between the treating endocrinologist and the endocrine surgeon is crucial in this setting. New insights also need to be considered, especially concerning the prognosis of differentiated thyroid cancers.

We would ask our readers to be lenient as we were not able to go into detail about all of the forms of laryngeal palsy mentioned by Professor Kruse. We are obviously aware that several laryngeal pathologies may occur after thyroid operations. Several presentations at the 2014 Congress of the German Surgical Society focused on this subject. A laryngostroboscopic analysis of 761 patients from 2009 showed a laryngeal complication rate of 42% after goiter surgery. Only 6% was associated with a surgery-related palsy of the laryngeal recurrent nerve (3). Since almost all published studies mention only recurrent nerve palsy, we were able overall to only use recurrent nerve palsy for comparative analyses that make sense.

It is worth pointing out that, when selecting the surgical technique for bilateral benign nodular goiter, a greater variety of therapeutic options should be available to choose from than just general thyroidectomy, and that one should proceed in a findings-oriented and patient-oriented manner in this setting.