Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Metabolic Maladaptation
Table 8. Goiter planimetry was reduced in half for 43 patients who
subsequently regrew back to original 6 at 3 years follow-up
Pre-Lipiodol 6 Months Post-Lip 36 Months Post-Lip
36 +/- 15 cm 18 +/- 10 cm 36 +/- 12 cm
(n = 45) (n = 25) (n = 17)
p .001 p .001 p .001
Not all 45 patients had reached three year followup at time data were analyzed, and ten
were lost to followup.
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glands and should not be operated without iodine pretreatment. Patients who are
cretins are fragile in the perioperative period, and it is recommended that they be
brought to euthyroid function by thyroid hormone replacement. Following iodine
and hormone supplementation, the preoperative patients that have been prepared
for surgery undergo subtotal thyroidectomy leaving 20 to 30 grams thyroid remnants
(approximating the size of a normal thyroid) attached to an intact blood supply
with care that parathyroid circulation be undisturbed and the recurrent laryngeal
nerves identified and protected. Using this technique, the thyroid function was preserved
with removal of up to a kilogram of redundant gland with close follow-up
observation during recovery for a period of 48 hours for airway protection.
The results of thyroidectomy appeared satisfactory for most patients with surgical
mortality reflecting the fragility of some of these patients. While one of the
goiter patients was awaiting treatment in the absence of the surgical team, death
occurred from airway collapse in this patient with a compressive goiter. A second
death occurred from hyperthyroidism, made possible by iodine repletion in
“Jod-Basedow’s syndrome”. Jod-Basedow’s syndrome is hyperthyroidism acquired
in a previously hypothyroid patient when iodine is “fuel added to the fire.” In the
hypothyroid patient with iodine deprivation, some autonomy may take over in thyroid
hormone synthesis by this enlarged thyroid that allows escape from pituitary
control. But, no synthesis of thyroid hormone can be achieved until iodine repletion.
In a rare few patients this permits a flare of overproduction of thyroid hormone
over-riding the pituitary shutdown of TSH usually seen in hyperthyroidism.
Assessing the Outcome of Intervention in Morphologic
Changes
Changes in form were dramatic in many of the measurements made. Thyroid
hormone levels uniformly increased and remained elevated with TSH suppressed
through the longitudinal follow-up. Goiters shrank remarkably following depot iodine
but regrew on later continuing measurement. Some of these patients selected
underwent operation for reduction in risk of this structural compromise to their
airway.
The changes in function were even more remarkable than those changes noted
in form. No more dramatic change was observed in the morphology of patients with
already established goiter or cretinism than one very encouraging fact very early on
in the study: in comparison with the control group, there was not one cretin born in
the group of women treated by iodine repletion! The control arm of this investiga-
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