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There are numerous questions that patients tend to ask before deciding to undergo a surgery :

What is the thyroid gland and what is its function?

The thyroid gland is one of the most important endocrine glands of the human organism and even its most minor disorder causes a series of problems. It is the gland that is situated in the area that is called “Adam’s apple” in layman’s terms. Its shape resembles that of a butterfly and there are two lobes to be discerned (the left and the right lobe).

The thyroid gland produces hormones, which are transported by the blood and affect the function of many of the body’s organs. A disorder in the hormones destabilises the metabolism of our cells, with adverse consequences for the function of the heart, the blood circulation, bowel function, skeletal development, brain function, the cycle and fertility of a woman etc.

What is a goitre?

Any swelling of the thyroid is called a goitre.

What are the symptoms of thyroid diseases?

The symptoms may be due to either over-activity (Hyperthyroidism), or underactivity (Hypothyroidism) of the thyroid gland. Moreover, in relatively large swellings of the thyroid there may be symptoms due to pressure exerted on neighbouring organs.

Practically though, in most cases damages to the thyroid do not cause obvious symptoms, while they continue to develop without outward warning signs to the patient.

When there are symptoms, depending on the type of the disorder of the gland’s function, we may have some of the following, such as swelling of the neck, a feeling of discomfort in the neck, tachycardia, irregular arrhythmias, nervousness, being emotional, emotional instability, shaking of the extremities, changing of the body’s weight, irregularities in the defecation, disturbance of the menstrual cycle, an occasional difficulty in swallowing food, hoarseness in the voice, coughing, a chocking sensation, difficulty in breathing and many other symptoms.

How can I check my thyroid?

A thyroid check can be done with a combination of blood tests (measuring of the T3, T4 and TSH hormones) and imaging procedures (thyroid ultrasound and scintigraphy).

Both types of examinations are required, as on the one hand we derive information regarding the functioning of the gland from the blood tests, while form the necessary imaging procedures the morphology of the thyroid gland can be discerned. Many patients, for instance, having already a series of normal hormonal blood tests, undergo an ultrasound for the first time, which– to their astonishment – reveals a significant damage.

What is a nodule?

Nodules are little tumours that grow on the thyroid, usually created due to an unknown cause. Simplistically, we could liken the image of the small nodules to hazelnuts in a hazel chocolate bar. There may be one or more nodules, small or large; they are often not visible or detectable through clinical palpation and are usually discover by accident through an ultrasound. The presence of nodular lesions is, most of the times, followed by a physiological test of the hormones in the blood.

What does nodule puncture do?

Fine Needle Aspiration (FNA) biopsy is a technique that was first described in Sweden, almost half a century ago, for the evaluation of swellings in the thyroid gland. It is based on the removal of cells from the thyroid via the needle, with or without local anaesthesia, and their further examination under a microscope.

 

The findings of the examination may be characterized as benign, malignant, suspect of malignancy or insufficient for diagnosis.

Fine Needle Aspiration is a frequently used method for examining thyroid nodules, providing important information, however the information as to whether we have to do with a benign nodule or cancer is based on the examination of a very small sample of cells and cannot offer us the certainty that the neighbouring cells are not cancer as well.

Η FNA (βιοψία με βελόνη) είναι μία συχνά χρησιμοποιούμενη μέθοδος στη διερεύνηση των όζων του θυρεοειδούς, προσφέρει σημαντικές πληροφορίες, ωστόσο η πληροφορία για το αν πρόκειται για καλοήθη όζο ή καρκίνο βασίζεται στην εξέταση ενός πολύ μικρού δείγματος κυττάρων και δεν μπορεί να μας προσφέρει τη βεβαιότητα ότι και τα γειτονικά κύτταρα δεν είναι καρκίνος.

My nodule remains at roughly the same size, can I rest easy?

A nodule, for example, of over 10 mm contains hundreds of millions of cells. If a person simply monitors it or is taking pharmaceutical treatment without achieving a noticeable reduction of the dimensions of this lesion, which may be displaying some suspicious characteristics, then the option of surgery should be discussed. A pathological focus (a nodule that, perhaps, despite the treatment, has not been noticeably reduced or has not disappeared) remaining in the organism allows at any given moment for the mutation to cancer.

The size of a nodule does not constitute a defining criterion to diagnose malignancy. Some of its ultrasound characteristics, such as the calcifications, the boundaries, the vascularity and in general the morphology of a nodule may be grounds for suspicion of neoplasia. There are many patients that decided to undergo surgery due to a large (e.g. 2.5 cm) nodule and in the end the biopsy “absolved” the large nodule, but found multiple cancerous foci in other, seemingly insignificant, of few millimetres, nodules.

I have undergone one or more nodule punctures, which showed no malignancy. Can I safely assume that I do not have cancer?

Punctures suck out a small number of cells from specific points of the nodules and usually it is the larger nodules that are punctured because this is easier for the one performing the examination.

Very often however, patients with one or many “clean” pre-surgical fine needle aspiration biopsies, do have, in the end, after the surgery, a biopsy positive for cancer. This is explained by the needle finding itself just few millimetres beside the cancerous focus and the correct diagnosis failed to be made.

Therefore, the F.N.A. result has simply indicatory and not proving value. The certainty that there is cancer or not can only be provided by a biopsy of a thyroid that has been excised and examined.

Why should I undergo an operation, since I do not feel any symptoms?

A symptom is something completely different than a disease. The fact that we, subjectively, do not feel any discomfort at present, has absolutely nothing to do with the disease, from which, objectively and proven, we maybe ailing and which continuously worsens.

The particularity of thyroid diseases especially is that when they finally start causing symptoms, then the destruction of the gland has already advanced. Thyroid cancer causes absolutely no symptom, until it has developed enough so that lymph nodes or distant metastases become detectable.

When should I undergo an operation? Is it something urgent?

Due to the often asymptomatic and insidious route of the thyroid diseases, the earlier someone removes an affected thyroid gland from his organism, the better. The continued presence of a large nodule in the thyroid despite the pharmaceutical treatment, allows for the possibility of mutation, of a group of cells to malignancy, without absolutely no warning sign.

It sometimes happens that the histological report (the biopsy after the surgery) describes the cancer having invaded the capsule (the enclosure) of the thyroid gland and having branched out to the lymph nodes. This may be happening, despite the different information provided by the usual ultrasound. And then we have in front of us “inconsolable” patients that blame themselves for the detrimental delay of the surgery.

When is a thyroid operation advisable?

A surgical operation is needed when the pharmaceutical treatment fails – within a reasonable timeframe – to counter the problem (functional, morphological or combination thereof) or when it is from the beginning it is deemed ineffective, or when there are or going to be cases of pressing on the adjacent anatomical elements (oesophagus, trachea, nerves of the larynx) and – especially in our times – when there is a suspicion of malignancy, something which is common unfortunately during the last years.

Is it possible that the physicians’ opinions differ regarding whether an operation is necessary?

There are international guidelines regarding whether the removal of the thyroid gland is appropriate. Based on these guidelines, but also based on the clinical history of the patient and the clinical judgement of the Endocrinologist for each case individually, an operation is decided upon.

As in many cases, in Medical Science, there are “grey zones” in diagnosis and treatment. In these cases there should be an exhaustive conversation, between the doctor and the patient, as to which is the ideal treatment. The pros and cons of the conventional and the surgical treatment should be analysed by the Endocrine Surgeon.

In the daily operation of the Endocrine Surgery Practice, it is sometimes ascertained that precious time is wasted for the patient, until he undergoes surgery. Sometimes an undiagnosed cancer has already reached the edge of the thyroid, breaking through its capsule, and is ready to invade the lymph nodes.

The hesitation of the patient to undergo surgery, the seeking of the opinion of many doctors until “they tell us what we want to her, which is: do not go into surgery”, as well as the insistence on an ineffective pharmaceutical treatment, beyond a reasonable timeframe, are the most common causes of the surgical treatment, with usually adverse effects for the patient.

If it is believed that I am at a “grey zone” with regard to whether or not I should undergo an operation, whom can I discuss my problem with?

Initially with the Endocrinologist, but also with the Endocrine Surgeon, who is the most competent in informing regarding the patient about the relevant  surgical risks.

A simple meeting and medical consultation, in a surgical practice, based on the personal, clinical and laboratory date of the patient, does not mean that it  necessarily leads to surgery.

What exactly do we excise during the operation?

In our times usually a “Total Thyroidectomy” is performed. Medical science used to believe that it was sufficient to remove only the part of the thyroid that bore the nodule. Frequently though, with this practice, the patient undergoes surgery again, either because his biopsy showed cancer, or because nodules reappeared in the part that remained inside.

In our era, the recommendation for “Partial” Thyroidectomy reoccurs which is considered sufficient in some cases.

By evaluating the data of each patient, taking into account the position of the Endocrinologist, a discussion with the patient takes place regarding the pros and cons of each treatment option and the appropriate type of operation is decided upon.

How safe is a thyroid operation?

Thyroidectomy is a surgical operation of medium gravity, which is performed safely in our times. The medical literature reports, as in every surgical operation, possible complications regarding respiration, speech, the need for taking calcium pills, post-operative haemorrhage, infection etc., which you can discuss with the doctor. These cases amount to a very small percentage.

It has been internationally proven that the operation being performed by a Specialised Surgeon in the Endocrine Surgery ward, in a Centre that offers modern infrastructure, minimises the possibility of any complication.

How long does the operation take?

The duration is 1-1½ hour. The scheduling of the surgery is made in such a way that it allows, for each patient individually, the performance of a complete, safe, radical and efficient surgical operation, without being pressured for time.

What kind of anaesthesia is required?

General anaesthesia. The Greek patients – in utter contrast with what is happening abroad – have an unjustified phobia regarding the procedure of anaesthesia. The science of Anaesthesiology has nowadays advanced by leaps and bounds, which with the assistance of advanced computers; monitors in full detail all the vital functions of the organism, providing safety of the highest order for the patient.

Mr Karvounis has incorporated into his team Anaesthesiologists with long experience and scientific interest in the surgical operations on the endocrine glands.

Who is the specialist for this operation – Is there a specialised surgeon for the thyroid?

A thyroid operation historically belongs, among many others, to the broad range of operations of a General Surgeon. The uniqueness of this “delicate procedure” to the neck and its possibly grave complications, demand a Specialised Endocrine Surgeon.

A very limited number of surgeons has specialised in the particular field and the performance of an operation by these surgeons has the best result, practically nullifying the possibility of complications.

Is there a special scientific team?

A special scientific team is headed by Mr Karvounis, with the aim of providing a high safety level at the rendering of medical and surgical services. The team is comprised of extensively trained associates, doing pioneer work in Greece, focusing on  the scientific upgrading of thyroid Surgery.

Excellent Anaesthesiologists, Registrars-Scientific associate Surgeons, Surgical Pathologists, Cytologists, Radiologists, E.N.T., Thoracic/Vascular/Neurosurgeons, Nuclear Medicine Physicians, Pathologists and Endocrinologists proudly comprise our large medical family.

Disposing of the technical know-how and the scientific authority, the competent human  resources are there to make the most of the latest developments in Surgery, taking care of your health in the best possible way.

Are there new techniques for the thyroid gland operation?

Thyroid surgery is nowadays performed in various ways, all around us. One can come across (too often unfortunately) the traditional surgical technique with the large incisions, the tubes, and the long recovery. At the same time one hears of the very latest techniques, with considerable limitations in their applicability, untested and lacking validation through time, which have not become widely accepted by the scientific community (significant reservations are maintained and discord is voiced).

Mr Karvounis, Surgeon, applies the minimally invasive thyroidectomy (minimally invasive surgery), which is the modern and pioneering technique that is applied internationally with absolute success, in specialised centres of endocrine surgery.

Instead of the traditional scalpel and scissors, the dissection, the detachment of the thyroid gland and at the same time the haemostasis are performed with the use of radiofrequency and ultrasonic rays (Ultracision). These are special, modern surgical tools that provide maximum accuracy and efficiency, without causing damage to the tissue and or even post-operative pain to the patient, as happens with the traditional technique.

Moreover, the speech of the patient is safeguarded through the use of neuromonitoring. It is the most revolutionary and impressively useful technique which warns the Surgeon and protects, to a great extent, the patient from having problems with their vocal cords.

A second safeguard for the integrity of the vocal chords is achieved through video-laryngoscopy during the extubation and waking of the patient.

A special, detailed operative preparation, sometimes undergoing the effort of marking them, aims at the checking and safeguarding of the adjacent parathyroid glands.

Exhaustive pre-operative, ultrasonic mapping of the neck, often with imaging re-checking, in the surgery room (portable sonography), provides the information for a more complete, successful neck dissection, in cases of malignancy.

Is there a thyroidectomy technique that does not include an incision to the neck?

During the last decades, a large number of surgical techniques for removing the thyroid gland have been described.

The desired, ideal surgical approach is the one that minimises, as much as possible, the exit opening of the gland (incision), is less bloody without necessitating a draining tube, has the smallest risk of injury to the elements adjacent to the thyroid, provides the surgeon with immediate access during an emergency situation (e.g. profuse and threatening haemorrhaging), affects the possibility of a proper, thorough cleaning of the gland and the metastatic lymph nodes, causes the minimum possible discomfort/pain post-operatively, ensures an uneventful and quick recovery, and is of affordable cost.

The patient has to be informed   about   the surgical technique by his doctor. However, it is simply noted that many techniques, no matter how “enticing” they are presented to be in medical conferences and posts on the internet, bring with them significant drawbacks, which have forced the international scientific community of endocrine surgeons, in its vast majority, not to adopt them in the current medical practice.

In spring 2018, Mr Karvounis travelled to the Singapore Academy of Medicine, where he underwent training in the pioneering technique of removing the thyroid through the mouth assisted by video camera. While being the only Greek participant in this international workshop, he was trained in performing the aforementioned technique, among top endocrine surgeons from all five continents.

Daily, Mr Karvounis, Surgeon, by monitoring closely the developments in endocrine surgery as well as the international literature, makes the performance of modern, minimally invasive, safe, uneventful, thorough, practically bloodless and aesthetically whole operation for his patients his priority.

How long must I be hospitalised for a thyroidectomy?

One day. The patient arrives at the Clinic in the morning, the surgery is performed and by midday the I.V. is removed. Immediately after surgery he can speak, move about and by midday receives stable food. Having no I.V. or other tube tin the neck, he can move about freely, remains in the Clinic for the night and exits in the morning of the next day.

When and how will I eat after the operation?

The patient starts receiving food approximately 3 hours after the surgery. Although his diet can be free, some patients prefer generally tender food for the first 24 hours; free diet after that.

Will I be able to speak after the operation?

Of course. Immediately after the surgery is over, the patient speaks normally.

Will there be a blood transfusion needed?

No, there will be no blood needed. No blood donor is required.

Will I have a drainage tube after the operation?

No, with the particular surgical technique – in the vast majority of the patients – we do not place a drainage tube.

Why do some people report hoarseness in their voice after the operation?

The anatomical position of the laryngeal nerves, which are responsible for the vocal chords, is adjacent to the thyroid gland. Depending on the mature of each patient’s issue there is a varying degree of difficulty and risk for the function of the vocal chords. Undergoing the operation at the experienced hands of a specialised Surgeon and through the use of the most modern technological equipment, minimises any possibility of voice disorder.

What about parathyroid glands and calcium balance?

The parathyroid glands are 4 small glands, at the size of a lentil, which, in the anatomical sense, neighbour the thyroid. Their function is linked with the calcium metabolism in our organism. Always depending on the nature of each patient’s problem, the identification and preservation of the parathyroid glands necessitates great care and detailed process on the part of the Surgeon. The specialised surgical technique that the Surgeon applies, in combination to the modern technological support, contributes to the calcium balance not being affected.

Is the patient in pain after the operation?

No, with the particular surgical technique, there is no pain. Actually, we do not even prescribe analgesics upon the patient’s discharge.

Will there be a scar on my neck?

Plastic reconstruction is applied at the end of the surgery. There are no sutures. Nothing is removed. The impressively small incision is done on the natural skin fold (where skin makes a fold by itself) yielding an aesthetically perfect result. Mr Karvounis has developed this technique in particular, and moreover, recommends special beauty products, which achieve cellular reconstruction and provide a beautiful and without scars skin.

It is quite often according to our patients that a few days after the surgery are asked by their unsuspecting friends: “Where did you scrape yourself”, instead “when did you have surgery”, due to the microscopic, imperceptible scar! 

Weeks or months after surgery, the patient himself has to greatly insist to convince the person that he is talking to that he indeed underwent surgery, as the latter sees no scar.

When can I go back to work?

Whenever you want. The recovery is rapid and there is no pain. Many of our patients return to their job, the following day of their discharge. Depending on the nature of their employment, some desire sick leave. In the latter case, the doctor, in conjunction with the patient, determine the desired length of the sick leave.

Might the issue recur after the operation?

No. The total thyroidectomy operation aims at removing the entire thyroid gland. Therefore there is no recurrence.

In case of malignancy, the patient is monitored for the rare possibility of the appearance of a relapse/metastasis in the future.

The thoroughness of the operation is a main attribute of successful surgery for the Endocrine Surgeon.

Our surgical team, under the direction of Mr Karvounis, has as one of its core values that a through clearing constitutes an affirmation challenge for the Surgeon that practices diligently thyroid Surgery.

What happens if the biopsy after the operation shows malignancy?

Thyroid cancer is one of the “best cancers” of the human organism. Its most common type (papillary Ca) has excellent prognosis at a very high percentage. Most of the patients with this type of thyroidal cancer will live deep into old age, as long as they have removed it from their organism in time.

What about radioactive iodine therapy?

In the case of a biopsy positive for cancer following a thyroidectomy, depending on the details of the histological examinations, the Endocrinologist decides regarding the therapeutic application of Iodine or not.

Having no relation to typical chemotherapy and radiotherapy that are applied in other types of cancer, in the case of thyroid malignancy the intake of radioactive iodine pills and some scintigraphic measurements from the Nuclear Medicine Physician are enough. It is usually recommended avoiding contact with infants and pregnant women for a few days.

There is no reason why the patient should worry (in advance) regarding Iodine intake. This is a process that might be needed some weeks after the surgery, or it might not. The decision will be exclusively taken when we have in front of us the final findings of the biopsy.

A timely, safe and thorough surgical operation is the first and most important step in the treatment approach of a malignancy in the thyroid.

Will I get fat after the surgery?

No. Having surgically removed the damaged thyroid gland from your organism, you will receive a replacement therapy. This means that you Endocrinologist will administer the required dosage for your organism. Very soon, after the necessary calibration of the dosing regimen, you will become euthyroid. This translates to a perfectly normal function of your organism, for which there is no reason for metabolic change and thus weight gain.

Will my life change after the surgery?

Millions of people have undergone a thyroidectomy operation and post-operatively take a thyroxine pill daily. This regulates the organism perfectly right, having a totally normal life. The presence of an ailing thyroid where the normal part of the gland would produce one amount of hormone, the damaged area of the gland would produce another and your Endocrinologist would administer in the form of a pill yet a possibly different one, is a delicate balance that is easy to upset, while the surgical removal of the gland provides a permanent solution.

Will fertility and/ or a woman’s cycle be negatively affected after the surgery?

On the contrary, the hormonal balance that is achieved through the perfectly controlled hormone dose in the form of a pill that is administered after the surgery, ensures a smooth menstrual cycle.

Moreover, ladies that are scheduling to give birth either naturally or through techniques of assisted reproduction are often referred, before pregnancy, to Mr Karvounis, Endocrine Surgeon, for the removal of an ailing, overactive thyroid. On many occasions, our medical team received later the happy news of our patient having given birth successfully!

What is the procedure for a thyroidectomy operation?

The procedure has been very simplified, so that there isn’t even the slightest inconvenience for the patient. For all our associates, it is a routine procedure, which – in a friendly environment – aims at approaching each patient as a separate case, in a responsible and scientifically sound manner.

An initial surgical assessment is carried out in the premises of the clinic or a detailed communication over the telephone and eventual check of the results of the examinations sent via fax or e-mail. The operation with hospitalisation of less than 24 hours follows and then, optionally, after one week, a surgical re-evaluation at the premises of the Clinic.

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EVANGELOS KARVOUNIS
EVANGELOS KARVOUNIS MD, PhD, FACS