Dr George Saada is exactly the right specialist when it comes to hormones, metabolism and the thyroid gland. So anyone dealing with tumors or recurrent cancer, including in the parathyroid glands, can rely on the high level of expertise of this proven specialist at Stadt Soest Hospital and his surgical skill. As an experienced visceral surgeon, Dr George Saada is familiar with all types of operations throughout the abdominal cavity – whether involving the stomach, abdominal wall, liver, pancreas, adrenal glands, spleen, intestines or esophagus. However, one area is clearly the focus of Dr Saada’s work: endocrinology, which fascinates him in all its facets.
Endocrinology? What exactly is that? To understand this better, it is worth looking at the Greek linguistic origins of the word. Endocrinology comes from Ancient Greek: ἔνδον endon, ‘inside’, κρίνειν krinein, ‘to secrete, to release’; it is therefore the ‘study of the morphology and function of glands with internal secretion (endocrine glands) and of hormones’. Endocrine glands are those hormone-producing glands that release their product internally, i.e. directly into the blood, and, unlike exocrine glands such as the salivary or sebaceous glands, have no excretory duct.
Hyper and hypo: on hyperthyroidism and hypothyroidism
Hormones are chemical messengers that determine a person’s rhythm and cycle. They regulate, for example, breathing, metabolism, salt and water balance, sexual functions and pregnancy. Many people are affected by hormonal fluctuations and changes, for example during the menopause, with some suffering from unusual weight loss or gain.
However, a genetic condition is also possible. “Patients with overt hyperthyroidism lose weight unintentionally. This leads to an increase in basal metabolic rate, accompanied by a reduction in fat mass, eventually muscle wasting, and ultimately a reduction in bone mass in the sense of osteoporosis,” begins Dr Saada in his discussion of the topic. “Being overweight can often be a symptom of an underactive thyroid. The main cause of weight gain in the context of hypothyroidism is a slowed metabolism due to a lack of hormones. The body requires less energy, i.e. fewer calories. If the same amount of food is consumed as before the condition, this energy is not used up. It is then stored in fat deposits, which result in weight gain and, not infrequently, obesity,” explains the specialist.
One might then conclude that an underactive thyroid always makes you put on weight. However, this is not the case, clarifies Dr Saada: “Studies have shown that in patients with overt hypothyroidism, the administration of thyroid hormones initially led to the elimination of excess water. However, fat mass remained more or less unchanged. In overweight children, it was shown that the hormones TSH (thyroid-stimulating hormone) and free T3 (triiodothyronine) also rise in proportion to the increase in BMI, the so-called body mass index. The hormone T4 (thyroxine) remains the same. It is therefore debated whether an increase in fat mass also leads to thyroid hormone resistance, similar to insulin resistance in diabetic patients.”
Fortunately, thyroid function can often be managed purely with medication, so that levels at least stabilize. But it doesn’t stop there – the patient does need to make a bit of an effort. “Once thyroid function has normalized, which is achieved by administering L-thyroxine in adequate doses, effective weight-loss measures such as diet and exercise can only then take effect. That is why you should only start these measures after four to six weeks of normalized thyroid levels; otherwise, you’ll become frustrated before you’ve even begun,” Dr Saada advises his patients.
When the thyroid gland needs to be removed …
Unfortunately, there are also thyroid conditions where only complete removal can help. This is the case, for example, with nodular changes in the thyroid, with so-called cold nodules that may be malignant – where a malignant thyroid condition is suspected or where a malignant thyroid tumor has been confirmed. Even in cases of hyperthyroidism – such as autonomous adenoma or Graves’ disease – where drug therapy is no longer effective or where radioiodine therapy is not feasible or not desired, complete removal is often the only solution.
One specific condition, however, is known as a thyrotoxic crisis. This refers to a life-threatening exacerbation of hyperthyroidism. If the thyroid gland is significantly enlarged and is pressing on neighboring organs, surgery is also required: this leads to difficulty swallowing or breathing, as well as a feeling of pressure or tightness in the throat.
Dr Saada first explains the preparatory measures in the event of surgery: “Following appropriate pre-operative preparation, patients are admitted as inpatients on the day of the operation. The incision in the lower neck area – the cervical incision – is marked while the patient is standing. The operation, which can take one to two hours, is performed under general anesthesia. Once the entire organ has been exposed, the diseased tissue is removed on one side or both sides. In doing so, I take great care to preserve the vocal cord nerves and the parathyroid glands.”
Dr Saada explains the next steps in the operating theater step by step: “To minimize complications as much as possible, I use fine instruments, magnifying glasses and a special neuro-monitoring device. This is used to check and monitor the function of the vocal cord nerves throughout the entire operation. Due to the delicate dissection, bleeding during the operation is minimal, and there is no need for a blood transfusion or autologous blood. The wound is closed with a self-dissolving suture, which does not need to be removed.”
The healing process is generally quick, which is encouraging. This means that the patient is able to eat and drink again on the day of the operation. “On the first day after the operation, a blood sample is taken to check calcium levels, and an ENT specialist checks the function of the vocal cords. One to three days after the operation, following a final consultation regarding the histological findings, patients can be discharged home,” says Dr Saada, describing the post-operative course.
“How much thyroid tissue needs to be removed depends on the specific condition. The extent of the operation can therefore range from the partial removal of a thyroid lobe to the complete resection of the entire thyroid gland. Generally, an extensive operation is necessary if malignancy is suspected. In some cases, the removed tissue is examined for malignancy by the pathologist during the operation using a frozen section analysis,” adds Dr Saada.
If the thyroid gland is missing, a replacement is needed
Naturally, the function of the thyroid gland must be replaced in the event of its removal or partial removal. “Following a complete bilateral removal of the thyroid gland or where residual parenchyma – that is, cells of the connective tissue – amounts to less than two milliliters, we recommend replacement therapy with the drug L-thyroxine. The dosage depends on body weight, and the medication is taken daily early in the morning on an empty stomach,” explains Dr Saada, continuing: “Following unilateral removal of the thyroid gland and residual parenchyma of less than eight to ten milliliters, we recommend replacement and growth-inhibiting therapy with the preparation Thyronajod, a combination of levothyroxine sodium and potassium iodide. The dosage is also weight-adjusted. Following a conservative resection of the thyroid or where residual parenchyma exceeds ten milliliters, growth-inhibiting therapy with iodide alone is generally recommended. Here too, the dosage is weight-adjusted.”
It is recommended that an initial laboratory check-up be carried out six weeks after the operation. This involves assessing the metabolic status in order to adjust the dosage of the replacement hormones accordingly. Further hormone checks should then take place at three-monthly intervals during the first year following the operation.
Trigger for hyperthyroidism: Graves’ disease
The autoimmune disease Graves’ disease triggers hyperthyroidism. This means that antibodies are produced that target the thyroid cells. These antibodies are therefore also called autoantibodies, as they are directed against the body’s own cells. This manifests as weight loss, palpitations or irregular heartbeat, insomnia and general nervousness. At the same time, it can lead to eye problems and the formation of a goiter. In some patients, there is also a visual change around the eyes. Anyone thinking of the famous comedian Marty Feldmann, for example, may well picture his strikingly protruding eyes.
Fortunately, Graves’ disease responds well to drug treatment. “Generally speaking, when treating hyperthyroidism, a conservative attempt at drug therapy with thyrostatic agents is often recommended and favored over surgery or radioiodine therapy for a period of twelve to around eighteen months,” explains Dr Saada, sharing his experience.
“Thionamides are most commonly used; these inhibit thyroid peroxidase and, consequently, thyroid hormone synthesis. Thyroid peroxidase is important for the production of thyroid hormones, as it controls the oxidative iodination of the tyrosine residues in thyroglobulin. The therapeutic effect of thyrostatic drugs, also known as thyroid blockers, only becomes apparent once the body has broken down the hormones, with a latency period of at least six to eight days. An initial laboratory check of thyroid function parameters, with a possible dose adjustment of the thyrostatic drugs, should take place approximately two weeks after the start of treatment. The intervals between further laboratory checks depend on the therapeutic effect and the course of the treatment. “Once euthyroidism, i.e. normal thyroid function, has been achieved, the maintenance dose should be gradually reduced,” says Dr Saada, describing the not-entirely-straightforward course of treatment.
Graves’ disease is the most common cause of hyperthyroidism worldwide, primarily affecting middle-aged people, with women being significantly more likely to develop the condition than men.
Unfortunately, side effects are often unavoidable
“In addition to allergic skin reactions, changes in liver function and blood counts are also observed. Therefore, liver function tests and blood counts should be routinely monitored during metabolic check-ups. Due to their significant potential for side effects, thyrostatic drugs are only of limited suitability for long-term therapy. In the event of cardiac reactions such as palpitations or arrhythmias, and particularly in patients with relevant risk factors and pre-existing conditions, additional treatment with beta-blockers is recommended,” says Dr Saada, highlighting the specific aspects of treatment.
This is because, following drug therapy, symptoms of Graves’ disease spontaneously subside in up to half of all cases. Dr Saada makes a distinction regarding the prognosis for recovery: “In cases of large Graves’ goitres exceeding forty milliliters, a high detection rate of TSH receptor antibodies – the so-called TRAK values, which occur in young patients up to around twenty years of age and in smokers – the likelihood of a long-term remission is low. In such cases, therefore, the question arises as to whether early definitive treatment is warranted. This is generally also indicated in cases of intolerance to thyrostatic therapy, severe side effects, and recurrent hyperthyroidism that can no longer be managed with standard treatments. Ablative therapy is carried out via surgery or radioiodine therapy. When performed correctly, both radioiodine therapy and surgery are very effective”.
Another peculiarity in the world of hormones: Cushing’s syndrome
Cushing’s syndrome, also known as hypercortisolism, is a condition characterized by a complex of various symptoms. What these symptoms have in common is that they are influenced by an excess of the hormone cortisol. Cortisol is produced in the adrenal cortex – it is known as a stress hormone, which is produced in high quantities by the body, particularly when a person is exposed to extreme stress. Typically, patients develop a ‘moon face’ and a ‘buffalo hump’ as symptoms. Susceptibility to infection increases, as does blood pressure, and muscle weakness and a constant feeling of thirst may occur.
Doctors refer to this as a “syndrome” when several symptoms are present at the same time.
“With Cushing’s syndrome, a distinction must be made between secondary and primary syndrome, with eighty per cent of all patients suffering from secondary Cushing’s disease. The main symptoms of Cushing’s syndrome are: a red, rounded face, significant fat accumulation in the abdominal area, high blood pressure, a testosterone deficiency, osteoporosis, muscle weakness and hirsutism – which is the term for excessive hair growth,” explains Dr Saada. There are between 80 and 240 new cases per year in Germany, with women being affected about three times as often as men. The condition usually appears around the age of 40.
There are two different ways to diagnose Cushing’s syndrome. Dr Saada mentions diagnosis via laboratory tests and via imaging – such as ultrasound, CT, MRI of the adrenal glands and, if necessary, a cranial MRI to rule out a tumor on the pituitary gland.
Surgery for Cushing’s syndrome is performed when the excessive cortisol release stems from an adrenal adenoma that produces cortisol – or from both adrenal glands. If an adrenal gland needs to be removed due to Cushing’s syndrome, drug therapy with hydrocortisone is required. Following bilateral adrenalectomy – the term for the removal of the adrenal glands – additional fludrocortisone must be administered.
Hormones are therefore vital for our bodies. Thank you very much, Dr Saada, for the interview and the insight into the various treatment options for this condition. It is both encouraging and enlightening!
