Humanitarian Goiter Surgery: Ethics and Best Practices in Low-Resource Settings

Program Description: Iodine deficiency has largely been eradicated in the developed world, but many lower resource countries demonstrate persistent iodine deficiency, goitrogen abundance, or both. In addition, some areas with high rates of thyroid malignancy have not had the resource capacity to fully address the need. Thus, surgical treatment of thyroid disease has comprised a significant proportion of head and neck related humanitarian surgery. This miniseminar, which is endorsed by the Humanitarian Efforts and Endocrine Surgery Committees, will be targeted to an audience of thyroid surgeons and those experienced in humanitarian surgery in low to medium resource settings. The presentations will be didactic, but with opportunity for discussion as well as audience interaction for the potentially controversial aspects. After introductory remarks, the audience will be queried for experience in humanitarian thyroid surgery and current management practices. The ethics of defining standard care with respect to resources and regional standards will be discussed. Evidence-based standards of thyroid surgery in the developed world will be contrasted to those in the variety of settings in which goiter surgery occurs in the developing world. The public health implications of goiter within the larger context of iodine deficiency will be discussed. Management of thyroid surgery in variable-resource settings will be presented in 3 components: 1) Pre-operative workup and patient selection will be discussed with respect to clinical presentation, diagnostic workup (labs and imaging), medical correction of hypothyroidism and iodine deficiency, and preoperative preparation. 2) Intraoperative management will be discussed including controversies in the use of technologies such as recurrent nerve monitoring and various cutting tools. 3) Postoperative management, including use of drains, hospital stay, calcium monitoring, thyroid supplementation, and long-term follow-up will be discussed. Complications of thyroid surgery in variable resource settings, including bleeding/ hematoma, recurrent nerve injury and hypoparathyroidism will be addressed as well as the need and risks for reoperation. In conclusion, a model for evidence-based standardization of thyroid surgery based on resource availability will be presented. The role of the thyroid surgeon as a conduit for population screening and treatment will be introduced. Research opportunities will be suggested, in particular with respect to greater understanding of a region’s iodine and goitrogen levels, medical management as an alternative to surgery, and measuring the impact of higher level management. The audience will again be queried to demonstrate a greater understanding of the topic and to determine if management opinions have been altered.

Educational Objectives: 1) Understand the challenges faced in performing thyroid surgery during international humanitarian mission work. 2) Discuss ethics in surgical decision-making in low-resource settings: what is the minimum standard of care? 3) Be able to tailor treatment plans to the patient and the environment within best practices.