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Effect of Changing Practice

Leigh Delbridge, MD; Ana I. Guinea, BSc(Psych); Tom S. Reeve, MD

Arch Surg. 1999;134:1389-1393.

Hypothesis  That changing practices in a single institution toward performing total thyroidectomy as the preferred option for the treatment of bilateral benign multinodular goiter (BMNG) can alter attitudes and practice within an entire region (Australia and New Zealand).

Design  (1) Single-institution study of patients with bilateral BMNG treated by thyroidectomy over a 40-year period, examining the changing pattern of use of bilateral subtotal thyroidectomy and total thyroidectomy in the initial surgical treatment of nodular goiter. (2) Mail survey of all endocrine surgeons (n = 75) in Australia and New Zealand, seeking information on their changing practice in the surgical treatment of BMNG.

Setting  Tertiary academic referral center.

Patients  A group of 3468 patients who underwent thyroidectomy for bilateral BMNG during the study period. Of these, 1838 had a subtotal thyroidectomy performed and 1251 had a total thyroidectomy as the primary surgical treatment.

Main Outcome Measures  The changing incidence of each type of thyroid procedure each year over the study period.

Results  Within our unit, bilateral subtotal thyroidectomy was the principal procedure performed until 1984, when total thyroidectomy became the preferred procedure. Our unit now treats 94% of these patients with total thyroidectomy. Secondary thyroidectomy for recurrent goiter initially increased over the years (with a lag period of 13 years), reflecting the numbers of subtotal procedures previously performed, and is now declining. This pattern has been reflected throughout Australia and New Zealand; 60% of practicing endocrine surgeons now perform total thyroidectomy as the preferred treatment for bilateral BMNG.

Conclusions  Total thyroidectomy is a safe and effective treatment for bilateral BMNG, and it is now the routine procedure throughout Australia and New Zealand. Its use has corresponded to a reduction in the need for secondary thyroidectomy for recurrent goiter.

From the Endocrine Surgical Unit, Department of Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia.

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