Thyroid Surgery in Eldoret, Kenya

Michael G. Moore, MD, Susan R. Cordes, MD, Aaron C. Moberly, MD, Edward C. Weisberger, MD, Gregory Randolph, MD Over the past two years, we have sent a team of head-and-neck surgeons, nurses, and anesthesiologists to work alongside the local staff at the Moi University Referral and Teaching Hospital (MURTH,) Eldoret, Kenya.  This year, our physician group included Academy members Susan R. Cordes, MD, Edward C. Weisberger, MD, and Michael G. Moore, MD, as well as our chief resident, Aaron C. Moberly, MD. We thank the Alcon Foundation for Dr. Moberly’s travel grant. Our trips have carried with them tremendous opportunities, along with humbling challenges. The surrounding population lives in what most developing countries would consider extreme poverty, with a mean per capita income of less than $400/year.  Medical care requires cash payment at the time of service, and health insurance and government aid are usually not available. The majority of thyroid pathology encountered in the region is endemic multinodular goiter, primarily due to iodine deficiency.  Some with hyperfunctioning glands are initially treated medically with carbimazole and/or propranolol, while many other, euthyroid patients desire thyroidectomy for indications such as dyspnea, dysphagia, and cosmesis. Pre-operative assessment usually involves history and physical exam, followed by thyroid function tests and a thyroid ultrasound.  For individuals where there is a suspicion for malignancy or significant substernal extension, a CT of the neck with intravenous contrast is often performed. (Note that radioactive iodine is not provided in this region, allowing for contrast to be administered.) While cytology is available, it is frequently omitted as time-consuming and unreliable. Fortunately, even in developing countries, adequate equipment is usually available to perform safe thyroid surgery. On our trip, we had standard surgical instruments and monopolar and bipolar electrocautery, and even brought a donated nerve stimulator that allowed for nerve confirmation through direct palpation of the posterior cricoarytenoid muscle contractions.  The true dilemmas came when deciding on the extent of surgery, based on the social and economic limitations the patients encounter in the post-operative period. It is unrealistic for most of the individuals who attended our annual surgical camp to take regular medications, such as thyroid hormone replacement or calcium and vitamin D supplementation.  Consequently, technical modifications must be made to minimize the risk of post-operative hypothyroidism and hypoparathyroidism. This applies not only to patients with benign disease but also to those with well differentiated thyroid cancer.  In the latter population, since radioactive iodine therapy is not available, complete removal of all benign thyroid tissue may not be necessary. One patient managed by our group was found to have an aggressive thyroid cancer in the setting of a large recurrent goiter, manifesting as a right-sided vocal-fold paralysis pre-operatively.  Intra-operatively, it was noted that the left recurrent laryngeal nerve coursed through the capsule of the tumor, but could be dissected free, resulting in an anatomically intact but paretic nerve. This, combined with the tracheal narrowing created by the longstanding goiter, made it most appropriate for the patient to receive a tracheostomy.  Despite the obvious benefit of airway security, this individual will face additional challenges associated with caring for a tracheostomy in a social and medical environment poorly equipped for such care. Aspects of perioperative management are different as well.  Passive drains made out of sterile glove fingers are substituted for closed suction drains.  Hypocalcemia is followed more through symptom reporting and bedside testing (Chvostek’s test) than by laboratory assessment. Continuous oxygen saturation monitors are not available on the wards, and patients are usually paired two to a bed.  Following discharge, patients often return to clinic for suture removal and pathology review (when available), but will frequently not come back for additional visits due to limitations in resources and travel. Such obstacles highlight the need for thorough consideration of all aspects of each patient’s care to determine management. All told, during our seven clinical days, we screened 110 individuals and performed 46 head-and-neck procedures, including 17 thyroidectomies. On top of providing patient care, we were fortunate to work alongside the otolaryngologists and other MURTH physician and nursing staff, and were immersed in the rich culture of the surrounding community. These warm interactions brought extra reward to an already fulfilling trip, and as we look to the future, our collaboration with our Kenyan colleagues will be central to successful management of these challenging patients. b Note: The extent of thyroid surgery and other aspects of thyroid surgical care as they relate not only to the patient’s diagnosis but also to regional resources are the subject of an International Goiter Surgery panel after the AAO-HNSF Annual Meeting & OTO EXPO.