For Doctors

HISTORY- Emil Kocher’s Pioneering Achievements

Emil Theodor Kocher

Theodor Kocher was a pioneering surgeon of the last half of the nineteenth century. His major discoveries were in the field of surgery of the thyroid gland. The contributions of Theodor Kocher had a great impact on thyroid surgery.

Theodor Kocher was born on August 25, 1841, at Berne. When he was 31 years old He was appointed professor of Surgery and Head of the University Clinic in Berne. He held this position until retirement. He was a student of Billroth and Langenbeck. He had a particular interest in infections, especially in the prevention of surgical infections.

Kocher’s publication Mobilisierung des Duodenum (Mobilisation of the Duodenum), published in 1902 is a contribution known to all surgeons today. In this study of the mobilisation of the duodenum, he described a new method for the reduction of dislocations of the shoulder. Around 1850, thyroid surgery was performed on vital indications only. Surgeons considered the function of the gland a complete mystery. The mortality for thyroid surgery was as high as 40%. The reason for death was usually uncontrollable bleeding or infection. In 1883, the mortality decreased to 13%. Kocher performed more than seven thousand thyroid operations by 1901. The mortality decreased steadily from 14% in 1884 to 2.4% in 1889 and 0.18% in 1898. He was awarded the Nobel prize in medicine in 1909 for his achievement in this field.

Kocher's studies on one of his patients, a eleven year old girl, who was operated on in 1874, led to the understanding on post operative myxoedema. This girl had a successful removal of her thyroid, but after the surgery, she became very tired, showed no signs of initiative and became cretinoid. She remained small and had an ugly and idiotic appearance in contrast to her sister.

He also pioneered post op substitution of thyroid hormone.

Kocher married Marie Witchi. Theodor Kocher died at Berne on July 27, 1917.

Recent Advances: Studies in Thyroid Carcinoma.

The commonest thyroid carcinoma is the papillary variety and this is now considered to include many variants. These are follicular, tall cell, sclerosing, oxyphilic and muco-epidermoid types .The tall cell variant of papillary carcinoma was first described by Hawk & Hazard in 1976. It behaves more aggressively. These subtypes have a worse prognosis than the classical type. Papillary microcarcinoma of the thyroid is the most common form of thyroid cancer. This usually remains clinically silent until found at autopsy or during surgery. This may present with cervical lymphadenopathy with or without palpable thyroid nodules. The cervical nodes may be clinically cystic. Lesions of 10 mm size(some studies 15mm) are included as papillary micro carcinoma. Variants include encapsulated papillary carcinoma, circumscribed micro carcinoma and occult sclerosing carcinoma. Unlike carcinoma of the breast, thyroid carcinoma is less aggressive in younger age group. Total thyroidectomy is advocated.

Hurthle Cell Carcinoma

This accounts for less than 3% of thyroid malignancies and is considered a variant of follicular carcinoma. These involve both lobes and can also metastasise to nodes. Total thyroidectomy is the treatment of choice. Post-op thyroid suppression by thyroxine is often necessary.

Snippet: Fine Needle Aspiration Cytology

Fine Needle Aspiration Cytology(FNAC) of thyroid nodules is performed routinely for the preoperative assessment of patients with thyroid nodules. FNAC has become a very important diagnostic test. FNAC, however, continues to have some limitations when used as the sole preoperative diagnostic test and should never overrule good clinical judgement.

FNAC has become a widely accepted diagnostic test for the preoperative assessment of patients with solitary thyroid nodules. It is an accurate, safe and cost-effective method. When performed by an experienced cytopathologist, FNAC has largely replaced radio-isotope and sonographic imaging in preoperative evaluation.

The main purpose of performing FNAC is to distinguish those patients who have thyroid neoplasms that require operative intervention from others who need medical treatment. FNAC has clearly decreased the number of unnecessary thyroid operations. The reported false-positive rates of FNAC generally range from 1 % to 9% whereas the false-negative rate ranges from 0% to 3%.

It has some limitations. First in suspicious cytology, the accuracy is lower. It cannot say for sure in follicular malignancies. The imaging modalities are always required to quantify the nodule and nodal involvement.