Interviewer: What to expect during and after thyroid cancer surgery. Surgical oncologist, Dr. Jason Hunt, walk us through the process.
Thyroid Cancer Surgery
Dr. Hunt: So day of surgery, you'll meet your surgeon, and you'll meet your anesthesiologist. These are surgeries that are done under general anesthesia. So you're asleep for this procedure. You then go back to the operating room. One of the worst things about the operating room is it's really cold in the room. So we try to give patients warm blankets to keep them comfortable. Your anesthesiologist will be the one who'll help to keep you safe and help to keep you obviously asleep for the whole procedure.
Surgical Procedure: Lobectomy and Nerve Preservation
For performing a lobectomy, typically we try to make a pretty small incision. So those incisions are usually about two inches or less in size. We go in, we remove that half of the thyroid gland.
We have to work around a lot of important structures, and the biggest one is there's something called the recurrent laryngeal nerve or we can call it the nerve to the voice box. You know, and that's oftentimes, if you're worried, that's the big one that people are worried about because if that nerve is injured, I don't know if this will come through on the mic, but you sound like this. You get a breathy voice if that happens. And now, sometimes that can happen because the cancer has grown into the nerve, or sometimes that can happen because during surgery we have to push the nerve out of the way from the thyroid and it can be inadvertently stretched or damaged in that process. Now, how often does that happen? Well, fortunately, it's not very common. There's about a 2% chance of temporary weakness of the voice, and it's about 1% that that would be a permanent problem.
Interviewer: And that's something you don't necessarily know before you go in for surgery, whether it's grown into that?
Dr. Hunt: No.
Dr. Hunt: No, not always. I mean, sometimes patients come in and say, "You know, my voice is weak." And then we actually take a little camera, it's about the size of a large piece of spaghetti, and we actually go through the nose with this camera and look at their voice box. But if a patient otherwise is normal, sometimes we get in there and we still find that the cancer is involving the nerve. So that's one of those unfortunate things. We talked a lot about it before. There are things we can do during surgery. Sometimes we will monitor the movement of the vocal cords with a special type of tube. So when they're intubated, we place a special tube that can kind of monitor the movement of the vocal folds.
And if it happens, there are some things that can be done to make it better. We have some voice specialists who can do collagen injections to the voice box, and sometimes we do nerve grafts. And so we can get the voice back to near normal with some of those other treatments.
Potential Risks and Complications of Thyroid Surgery
The other thing we have to talk about is there's a small risk of bleeding. There is a small risk of an infection with this surgery. And then there are these little glands that live near the thyroid called parathyroid glands. And the parathyroid glands control your calcium levels. And there are two of them on each side. They otherwise have nothing to do with the thyroid. Now this is another advantage of taking out half the thyroid versus all of it because you only need one out of the four. So if we just stick to half the thyroid, then there is a 0% chance that you'll get calcium problems. Versus if we have to take all of it out, then there is a small chance of having some calcium issues postoperatively or after surgery.
So after we take that thyroid out, we close up the incision. If we take half the thyroid out, typically we do this as same-day surgery, meaning you go home the same day. If we take all of the thyroid gland out, then some of those can go home the same day, but some will need to stay overnight for that surgery.
Interviewer: Okay. And that incision is that going to . . . Am I going to have a scar afterward, or . . .
Dr. Hunt: You know, yeah, there's not a scarless incision here, but we . . . Obviously this is where we operate all the time, so we . . . It tends to heal up pretty well being a thin line, and that's another reason why we try to make this incision smaller, just so it's not as big of a scar. We do have some management of scars afterward, so patients can do things such as try to avoid sun exposure on their scars. There are some, you know, vitamin E oil is a common thing that we recommend. And then also sometimes you can use some silicone strips on the scar that'll help to decrease the scarring.
Interviewer: Yeah. And where is that on the neck again that you make that incision?
Dr. Hunt: In the lower portion of the neck, in the middle. So kind of about an inch above your collarbone, in the midline of the neck.
Post-Surgery Care and Recovery
Interviewer: So after surgery, what can a patient expect in terms of recovery time before they can go back to kind of their normal life?
Dr. Hunt: Yeah. So, you know, this is . . . we have to move some muscles around when we do this surgery. So I tell patients it's more like a muscle strain than severe pain. For most patients nowadays, we actually do this without the use of narcotics postoperatively. So we have patients take Tylenol, and ibuprofen, alternating the two. And I would say for 95% of these cases, we do not need to use narcotics, which means quicker recovery, and less downtime.
And so as far as the downtime, we tell patients the day after surgery, you can get out of the house, you can go for walks. You know, we don't want you lifting anything heavy that might actually kind of bring bleeding, that might open up a blood vessel. So for about a week, we recommend no heavy lifting. And I tell patients, if you have a hardcore exercise routine, if you're a skier, you know, a biker, you probably want to not do that to kind of the same degree until two weeks.
Interviewer: Okay. So somebody who has say an office job or a desk job, they can go back to work, it sounds, pretty quickly. Maybe, somebody who is in physical labor would need to take a little bit more recovery time.
Dr. Hunt: Yeah, that's right. I mean, I've had some patients that'll go back to work the next day. I think that's probably a little soon, but, you know, usually within a couple of days you're good to go back to a desk job.
Interviewer: Yeah. I mean, right, take advantage of a little time off.
Dr. Hunt: That's right.
Interviewer: Hey, you just had thyroid cancer surgery.
Dr. Hunt: That's right. Yeah.
Interviewer: You get a day or two.
Dr. Hunt: Take some time for yourself.
Interviewer: Yeah. After surgery, is there additional therapy that the individual would need to take care of?
Dr. Hunt: You know, if we just take the half of the thyroid, then typically there's not, because typically if we do that, then we're saying it's a low-grade cancer that has a low likelihood of coming back and we don't give radioactive iodine. If we performed a total thyroidectomy, those are the patients that might need radioactive iodine, and we typically do that about six weeks later.
Follow-up and Surveillance after Thyroid Cancer Surgery
Interviewer: Okay. And then, when is your next visit beyond that, with your healthcare professional, just to monitor and make sure things are okay?
Dr. Hunt: Sure. Yeah. We usually see patients back about one to two weeks after surgery. And then, for a cancer diagnosis, most of those patients are going to get routine surveillance, looking for potential recurrence of cancer about every six months for the first two years, and then annually up till about five years. And what that looks like is typically an ultrasound of the neck and then some blood work.
Interviewer: Okay. So they could get that done, if they don't live near the center where they had their surgery, with their own local provider?
Dr. Hunt: Typically you do want to see an endocrinologist, though, to follow you on that. Yeah.
Side Effects and Health Considerations Post-Surgery
Interviewer: Okay. And then are there any sort of side effects or health problems that somebody should be aware of after surgery?
Dr. Hunt: The biggest one has to do with hormone replacement. I mean, we talked about kind of the risk of surgery, but the medication, the medical management side, if your thyroid has been removed, all of it, you have to be on a thyroid medication, one pill a day for the rest of your life. It's a really, really common medication. And doctors are pretty good about honing in on that and getting it to the right level. If you take half the thyroid, we need to check on that, because sometimes that half of the thyroid doesn't provide enough of the thyroid hormone. But for a lot of those, like I said earlier, about 70% of patients, half of that thyroid will provide all of your hormone needs. So you do need to get some blood tests to monitor that.
Hormone Replacement Therapy and Managing Thyroid Hormone Levels After Thyroid Surgery
Interviewer: What are the side effects of not having enough thyroid hormone production?
Dr. Hunt: Yeah, the thyroid, that's the motor of your body. So if your thyroid levels are low, you'll feel tired, and fatigued. You'll have weight gain. You can get hair loss. You can get some swelling around the eyes. So it is a really important medication. You know, if you're off of it for months and years, it can even affect your heart. So it is important to make sure that those levels have been adjusted appropriately.
Recurrence Risk and Monitoring Strategies
Interviewer: And then what are the chances of recurrence? And is there something I can do post-surgery to, you know, control that risk?
Dr. Hunt: Yeah, the chance for recurrence, if you have low-grade cancer, that recurrence rate is about 10%, and it typically would come back, say, in a lymph node or potentially it could come back in the other side of the thyroid gland. Taking all of the thyroid out doesn't significantly decrease that risk though. It's just a small amount. So we do recommend self-examination in the neck. If you feel any lumps or bumps, obviously you want to get those checked out. But really the big thing is getting these periodic ultrasound evaluations. Typically, that's going to find something well before you could ever feel it.
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