Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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306 Surgery and Healing in the Developing World
Table 12). An analysis of 45 such patients who exhibited this regrowth is seen in
Table 8. In this subgroup of 45 patients who exhibited this goiter regrowth, it was
noted that the planimetry was reduced to half of the pretreatment measurements
within six months of injection. Of those studied at three years follow-up, the goiter
had returned to preoperative size, a significant change in each direction.
That hormone levels remained in the normal range during regrowth of goiter
shows the better compensation of thyroid hypertrophy when iodine has been repleted.
In the absence of adequate iodine, pituitary TSH stimulation of goiter formation
could mitigate severe hypothyroidism but could never completely compensate bringing
thyroid hormone levels to normal without sufficient iodine substrate. Following
Lipiodol injection, this deficiency was relatively corrected and the compensation is
reflected in thyroid hormone levels holding near normal, even while goitrogenesis
reflects the extra effort expended in maintaining them near normal.
Despite these morphologic markers of improvement in most of the patients, the
subgroup that experienced goiter regrowth posed a new medical problem. A goiter,
even a massively enlarged goiter that hangs down between the breasts in front of the
manubrium, may be inconvenient and cosmetically disfiguring, but these complaints
were minimized in this population. There was little functional derangement caused
by an exophytic goiter. However, if such an enlarged gland shrank, retreated into the
thoracic inlet, and then regrew, compromise to the airway and food passages became
a real and increasing problem. As a consequence, patients were selected from the
subgroup of those exhibiting intrathoracic regrowth and offered thyroidectomy for
reduction of the morphologic as well as functional consequences of goiter regrowth.
Thyroidectomy for Selected Patients with Goiter Regrowth
After Iodine Repletion
Carrying out a major operation in the conditions of a remote bush makeshift
operating room might appear to be a formidable undertaking because of this
low-technology environment. Previous reports suggested that it was possible for
successful surgical therapy to be undertaken in remote settings35 including the environment
created at Assa. 36 Furthermore, the morphologic manifestation of goiter
may be even more immediately life-threatening than the functional consequences in
hypothyroidism if respiratory obstruction ensues. 37
With the special challenges of tropical surgical conditions, subtotal thyroidectomy
was undertaken in a select group of patients (Table 9). As it may be helpful
and instructive in how an effective low-technology operating room environment
may be improvised under such circumstances. Instruments and surgical sheeting
were prepared in a pressure autoclave heated over a wood fire for which both firewood
and water were gathered from the forest by family members. The operating
room light consists of a solar panel on the thatched roof which trickle charges a
storage battery wired to a used automobile headlamp. Using local and regional anesthesia
in this very patient and long-suffering population, cervical block was used in
the majority of patients and intubation with draw-over ether in ambient air. Inhalation
anesthesia was used in some with difficult airway compromise. Rigorously adhering
to surgical principles while improvising appliances as needed, 38 subtotal
thyroidectomy was safely undertaken in a group of 38 patients.
Pretreatment with oral Lugol’s iodine solution was used to help decrease the
hypervascularity of these iodoprival glands. Patients who are profoundly iodine deficient
have a very high probability of serious hemorrhage from the hypervascular