Management of Graves' orbitopathy in Latin America: an international questionnaire study compared with Europe

CONTEXT

Management of Graves' orbitopathy (GO) and dysthyroid optic neuropathy (DON) continues to be challenging. Other surveys have been successful in elucidating trends in GO management. Knowledge of current practice by members of the Latin American Thyroid Society (LATS) who manage patients with GO was targeted by distribution of a questionnaire. We compared our results with a previously reported European Thyroid Association (ETA) survey.

OBJECTIVES

To determine how endocrinologists in Latin America access and treat patients with GO and compare the results with the same European survey.

RESULTS

One hundred and two responders representing endocrinologists from 10 countries participated in the survey. Most (57%) participate in a multidisciplinary setting for GO management. Access to a surgeon for orbital decompression was available only 'within months' according to 48.3% of responders. Despite suspected DON, 32.4% were reluctant to recommend urgent referral to an eyecare physician. Steroids were preferred as the first-option therapy by 88.2% of responders (by intravenous route by 57.8% of these). The presence of diabetes reduced the use of steroids to 64.7% (P < 0.001) and increased the use of other immunosuppressive agents (from 1% to 9.8%, P < 0.01). Development of cushingoid features resulted in a reduction in steroid use to 40.2% (P < 0.001), with increased preference for irradiation (from 23.5% to 52.9%, P < 0.001) and nonsteroidal immunosuppressive drugs (from 1% to 10.8%, P < 0.01), along with a nonsignificant trend to higher indication of orbital surgery (from 24.5% to 34.3%).

CONCLUSION

Some potential deficiencies in the diagnosis and management of DON and hyperthyroidism were observed in our survey, highlighting the need for improvement in specialist education and the quality of care offered to patients with GO in Latin America.

Sequential defunctionalization followed by thyroxine supplementation as preoperative preparation of hyperthyroid patients undergoing thyroidectomy

BACKGROUND

Preparing hyperthyroid patients for thyroid surgery with a combination of antithyroid drugs and thyroxine has long been controversial because this combination usually results in only partial inhibition of thyroid function. We therefore used large doses of antithyroid drugs to completely inhibit the synthesis of thyroxine and render the thyroid gland defunctionalized. We then administered physiologic doses of thyroxine to inhibit thyroid-stimulating hormone secretion. We have named this treatment "sequential thyroid defunctionalization followed by thyroxine supplementation."

METHODS

Four hundred and seventy-one hyperthyroid patients seen at our hospital were divided into experimental and control groups. The control group was treated preoperatively with antithyroid drugs and iodine preparation. The experimental group was further divided into four subgroups and treated with "sequential thyroid defunctionalization followed by thyroxine supplementation". Each of the four subgroups received different doses of antithyroid drugs and thyroxine for differing time periods. Thyroid function was assessed at each stage of treatment, as were operative blood loss volumes and postoperative complications.

RESULTS

Compared to the control group, the four experimental groups showed less thyroid congestion and surface varices at surgery. Patients in subgroup A also had thyroid glands that were almost histologically normal. The mean operative blood loss volume of the experimental group was less than that of the control group (326 +/- 163) ml in the control group; (196 +/- 57) ml in subgroup A; (230 +/- 71) ml in subgroup B; (240 +/- 80) ml in subgroup C; and (312 +/- 97) ml in subgroup D). The postoperative complication rate of the experimental group was 8.64% (21/243) whereas that of the control group was 17.54% (40/228).

CONCLUSIONS

Sequential thyroid defunctionalization followed by thyroxine supplementation is effective in reducing the bleeding volume and postoperative complication rate in selected hyperthyroid patients undergoing thyroidectomy.

Autonomously functioning thyroid nodule treated with radioactive iodine and later diagnosed as papillary thyroid cancer

The malignancy risk is low in hot thyroid nodules verified by scintigraphy. We present a rare case of papillary carcinoma, initially treated as an autonomous hot nodule. Case report. A 36-year old male patient with a hot thyroid nodule and subclinical hyperthyroidism was treated with 10mCi 131 I. On admission, both 99mTc and 131 I thyroid scintigraphic imaging revealed a hot nodule at the right lobe accompanied by lower uptake in the remaining thyroid tissue. After treatment, there was a progressive increase in the nodule size; a fine needle aspiration biopsy was thus performed which showed findings compatible with papillary thyroid cancer. The patient was referred to our department for further management. Total thyroidectomy with right central neck dissection was performed. The pathologic examination showed that the whole nodule (1.5 cm diameter) was a columnary type papillary thyroid cancer.

CONCLUSION

In the case of a small-sized toxic thyroid nodule, the possibility of malignancy cannot be totally ruled out. Suspicious hot nodules should be cytologically evaluated before radioactive iodine treatment to determine the existing malignancy risk. Fine needle aspiration biopsy should be performed in all hot thyroid nodules that increase in size after radioactive iodine treatment.

Parathyroid surgery without instant PTH or radioguided Sestamibi scan

BACKGROUND

Radioguided Sestamibi scan and instant PTH (iPTH) are being used in minimally invasive parathyroid surgery (MIP). Experienced surgeons cure over 90-95% of the patients with primary hyperparathyroidism.

PURPOSE/METHOD

To study the surgical results in treating hyperparathyroidism in a for profit community hospital lacking both iPTH and radioguided Sestamibi scan, we reviewed the patients operated from November 1, 2005 to October 31, 2006.

RESULTS

The study comprised 56 patients: 52 with primary hyper-parathyroidism, three with secondary hyperparathyroidism and one with tertiary hyperparathyroidism. The only localizing test utilized pre-operatively was the Sestamibi Scan. PTH was measured immediately before and after surgery but the results was received seven to ten days later. The affected glands were removed in all patients. Fifty of 52 (96%) of the patients with primary hyperparathyroidism, the three patients with secondary hyper-parathyroidism and the patient with tertiary hyperparathyroidism are normocalcemic with normal PTH levels. Two patients have persistent mild hypercalcemia. Associated conditions were three papillary carcinoma of the thyroid, three multinodular goiter, four had a single thyroid nodule, one had an adrenal tumor and three were reoperations.

CONCLUSION

Parathyroid surgery can be done safely and effectively in community hospitals without the utilization of radioguided Sestamibi scan and iPTH measurement.

Multifocal hyperfunctioning thyroid carcinoma without metastases

Hyperthyroidism due to thyroid carcinoma is rare, and most cases are caused by hyperfunctioning metastatic thyroid carcinoma rather than primary carcinoma. Among primary hyperfunctioning thyroid carcinoma, multifocal thyroid carcinoma is exceedingly rare, with the only one case being reported in the literature. Here, we describe the case of a 62-year-old woman with multifocal functioning thyroid carcinoma. Technetium-99m (99m Tc) scintigraphic imaging showed four hot areas in the thyroid gland. Histopathological examination of all four nodules revealed papillary carcinoma, corresponding to hot areas in the 99m Tc scintigram. DNA sequencing of the thyrotropin receptor (TSH-R) gene from all nodules revealed no mutation, indicating that activation of TSH-R was unlikely in the pathophysiogenesis of hyperfunctioning thyroid carcinoma in the present case.

[Study on thyroid defunctionalization method for the preoperative preparation of hyperthyroid operation]

OBJECTIVE

To set up and publicize the thyroid defunctionalization method for the preoperative preparation of hyperthyroid operation.

METHODS

476 hyperthyroid patients admitted in our hospital from March 1990 to February 2005 were studied by groups. They were divided randomly into a test group (244 patients), in which "preoperative preparation method of sequential thyroid defunctionalization" was applied to hyperthyroid patients, and based on the different drug dosages and treating terms used, further 4 subgroups (A, B, C and D) were divided to observe the treatment efficiency; And a control group (232 patients), in which antithyroid drugs and iodine preparation were applied preoperatively to cases. Thyroid functions in every stage of treatment were tested by radioimmunoassays (RIA), and operative bleeding volumes and postoperative complications were observed.

RESULTS

Compared to the control group, the thyroid congestion and surface varices were alleviated in the test groups, in which the thyroid tissue of subgroup A most closed to euthyroidism histologically. The mean operative bleeding volume of test group was less than that of the control group. The bleeding volumes were (324.76 +/- 163.26) mL for the control group, (195.74 +/- 57.07) mL for the subgroup A, (230.00 +/- 70.81) mL for the subgroup B, (240.47 +/- 80.29) mL for the subgroup C and (314.75 +/- 96.46) mL for the subgroup D. There was no significant difference between the control group and subgroup D, but compared with the subgroup A, B, and C, there was the significant difference between control and treated subgroup (P < 0.05). The postoperative complication rate of the test group was 8.61% (21/244), while that of the control group was 17.24 (40/232). There was statistic difference between two groups (P < 0.005).

CONCLUSION

The key to "preoperative preparation method of sequential thyroid defunctionalization" is as follows: the synthesis of thyroxin should be fully inhibited to thyroid defunctionalized; sufficient exogenous thyroxin should be supplemented; the term of thyroid function compensation should be long enough. The "preoperative preparation method of sequential thyroid defunctionalization" can decrease perioperational complications effectively and operation risks.

Determination of remnant thyroid volume: comparison of ultrasonography, radioactive iodine uptake and serum thyroid-stimulating hormone level

Purpose:

We aimed to evaluate the accuracy of ultrasonography, radioactive iodine uptake and serum thyroid-stimulating hormone level in predicting the volume of remnant thyroid gland.

Methods:

Sixty-six thyroidectomy patients were divided into two groups according to their functional status, i.e. those operated upon for nontoxic multinodular goitre (group one) and those operated upon for hyperthyroidism (group two). Ultrasonography, radioactive iodine uptake and thyroid-stimulating hormone assay were performed in all patients during the first post-operative month. The two groups were subdivided according to the amount of remnant thyroid volume detected on ultrasonography: <2 ml, 2–5 ml and >5 ml.

Results:

The remnant thyroid volume was positively correlated with the radioactive iodine uptake (rs = 0.684, p = 0.0001). The increase in remnant thyroid tissue radioactive iodine uptake was significantly greater in the patients operated upon for hyperthyroidism compared with those operated upon for nontoxic multinodular goitre (p = 0.0001). There was a negative correlation between remnant thyroid volume and post-operative serum thyroid-stimulating hormone level (rs =  −0.865, p = 0.0001) and between remnant thyroid tissue radioactive iodine uptake and post-operative serum thyroid-stimulating hormone level (rs = −0.682, p = 0.0001).

Conclusion:

Ultrasonography is a more accurate measure of remnant thyroid volume than radioactive iodine uptake in patients operated upon for hyperthyroidism, compared with those operated upon for nontoxic multinodular goitre.

Safety and efficacy of surgical management of hyperthyroidism: 15-year experience from a tertiary care center in a developing country

BACKGROUND

Ideal management of toxic goiter still remains elusive. Though surgical management of toxic multinodular goiter (MNG) is well accepted, surgical treatment of Graves' disease (GD) is still controversial in view of the presumed increased incidence of complications. In this paper, we discuss the experience of the surgical management of hyperthyroidism at a specialized tertiary care endocrine center in a developing country, highlighting the minimal morbidity and satisfactory outcome in experienced hands.

MATERIALS AND METHODS

We retrospectively reviewed 325 consecutive patients with hyperthyroidism managed surgically from 1990 to 2005. The etiologic diagnoses were Graves' disease (185), toxic MNG (105), and autonomously functioning thyroid nodules (AFTN) (n = 35). The indications for surgery in Graves' patients were large goiter, relapse after antithyroid drug therapy (ATD), Graves' ophthalmopathy, and presence of nodule. The indications for surgery in toxic MNG were retrosternal extension (n = 15), compressive symptoms (n = 20), and large size (grade II). Among the AFTN nodule size, those greater than 4 cm (85%) formed the major indication for surgery. Subjects with GD and toxic MNG were subjected to subtotal thyroidectomy (n = 93 prior to 1995) or total thyroidectomy (n = 205 post-1995). Hemithyroidectomy was the procedure of choice in patients with AFTN.

RESULTS

Patients with Graves' disease were younger in age, with shorter mean duration of goiter when compared with the other 2 groups. Eight percent of patients with Graves' disease without a clinically palpable nodule and 25% of those with nodules had associated differentiated carcinoma, including papillary, follicular, and medullary thyroid cancer. Four percent of patients with toxic MNG had malignancy. Complications included temporary hypocalcemia (24%), permanent hypocalcemia (3%), and permanent vocal-cord palsy (1%).

CONCLUSIONS

Surgery for hyperthyroidism has negligible mortality and acceptable morbidity in experienced hands. It is a definite option in selected cases. Immediate and permanent cure of hyperthyroidism is achieved, with no recurrences, after total thyroidectomy. The cosmetic outcome is good, with excellent patient satisfaction and acceptance.

Fifteen-year follow-up of thyroid function in lithium patients

OBJECTIVE

To study prospectively the course of clinically relevant thyroid dysfunction in a cohort of patients on long-term lithium treatment.

METHOD

Patients (no.=150) who had undergone a cross-sectional evaluation of their thyroid function in 1989, when they were at different stages of lithium treatment, were followed up for thyroid circulating thyroid antibodies, hypothyroidism, hyperthyroidism, and thyroidectomy, during a further period of lithium exposure of up to 15 yr.

RESULTS

Annual rates of newly developed circulating thyroid antibodies and hypothyroidism were 1.7 and 1.5%, respectively. Subjects with thyroid antibodies had a higher chance of requiring substitution treatment with levothyroxine for hypothyroidism compared with subjects with no evidence of thyroid antibodies (6.4% annual rate compared to 0.8%; relative risk: 8.4; 95% confidence interval: 2.9-24.0). One case of hyperthyroidism was observed over 976 patient-yr. Three patients underwent thyroidectomy during followup (two for multinodular goiter and one for multicentric papillary carcinoma).

CONCLUSIONS

Lithium may be associated with hypothyroidism in particular in the presence of circulating thyroid antibodies. Incidence of thyroid antibodies is comparable with that reported for the general population. Hyperthyroidism and thyroid cancer are rare.

Struma ovarii coincident with Hashimoto's thyroiditis: an unusual cause of hyperthyroidism

OBJECTIVE

To report the identification of struma ovarii in a patient with a history of struma ovarii and new hyperthyroidism.

DESIGN

Case report.

SETTING

Academic research hospital.

PATIENT(S)

A woman with hyperthyroidism who has struma ovarii coincident with Hashimoto's thyroiditis.

INTERVENTION(S)

Laparoscopic salpingo-oophorectomy.

MAIN OUTCOME MEASURE(S)

Measurement of thyroid hormone parameters before and after surgery.

RESULT(S)

After removal of the second struma ovarii, hyperthyroidism resolved.

CONCLUSION(S)

In a patient with two different causes of abnormal thyroid function, it is important to seek an encompassing clinical scenario.

Thyroid cancer in toxic and non-toxic multinodular goiter

BACKGROUND

Many authors have claimed that hyperthyroidism protects against thyroid cancer and believed that the incidence of malignancy is lower in patients with toxic multinodular goiter (TMG) than in those with non-toxic multinodular goiter. But in recent studies, it was reported that the incidence of malignancy with TMG is not as low as previously thought.

AIM

To compare the thyroid cancer incidence in patients with toxic and non-toxic multinodular goiter.

SETTINGS AND DESIGN

Histology reports of patients treated surgically with a preoperative diagnosis of toxic and non-toxic multinodular goiter were reviewed to identify the thyroid cancer incidence. Patients having a history of neck irradiation or radioactive iodine therapy were excluded from the study.

MATERIALS AND METHODS

We reviewed 294 patients operated between 2001-2005 from toxic and non-toxic multinodular goiter. One hundred and twenty-four of them were toxic and 170 were non-toxic. Hyperthyroidism was diagnosed by elevated tri-iodothyroinine / thyroxine ratios and low thyroid-stimulating hormone with clinical signs and symptoms. All patients were evaluated with ultrasonography and scintigraphy and fine needle aspiration biopsy.

STATISTICAL ANALYSIS USED

Significance of the various parameters was calculated by using ANOVA test.

RESULTS

The incidence of malignancy was 9% in the toxic and 10.58% in the non-toxic multinodular goiter group. Any significant difference in the incidence of cancer and tumor size between the two groups could not be detected.

CONCLUSIONS

The incidence of malignancy in toxic multinodular goiter is not very low as thought earlier and is nearly the same in non-toxic multinodular goiter.

Percutaneous Laser Ablation in the Treatment of Toxic and Pretoxic Nodular Goiter

OBJECTIVE

To report data regarding treatment with use of percutaneous laser ablation (PLA) in autonomously functioning thyroid nodules (AFTN).

METHODS

We treated 18 patients (10 women and 8 men, 31 to 80 years old) who presented with a single hyperfunctioning thyroid nodule (8 patients) or a multi-nodular goiter (10 patients) with clearly hyperfunctioning areas on a thyroid scintiscan. In 5 cases, free thyroxine (FT4) and free triiodothyronine (FT3) levels were high, and in these patients and a further 9 patients with cardiovascular symptoms, methimazole therapy was initiated to restore euthyroidism. The total number of PLA sessions ranged from 1 to 5 (median, 3). Thyroid-stimulating hormone, FT4, FT3, thyroglobulin, and antithyroglobulin and anti-thyroid peroxidase antibodies were measured by a commercial kit the day after PLA treatment, then weekly during the first month, and monthly thereafter. The Student t test was used for statistical analyses, and data are reported as mean values +/- SE.

RESULTS

After each PLA session, there was a transient and mild increase in FT4 and FT3-5.2% to 18.1% (mean, 11.1 +/- 0.69%) (P<0.001) in patients not treated with methimazole and 4.0% to 8.3% (mean, 5.9 +/- 0.31%) (P<0.001) in patients treated with methimazole-relative to values before treatment; however, these values never reached the range of hyperthyroidism. In addition, thyroglobulin showed a remarkable increase after 24 hours- 115% to 390% (mean, 266.0 +/- 12.7%) (P<0.001). Thyroid-stimulating hormone increased in all cases and reached normal values in all patients with single AFTN and in 5 patients (50%) with multinodular goiter within 3 months after PLA. At 1-year follow-up, the decrease in nodular volume was 24% to 72% (mean, 59.3 +/- 8.2%; P<0.001).

CONCLUSION

Our data show that PLA can be a useful treatment in AFTN and particularly in single toxic nodules. Possible elective indications are patients who refuse surgical or radioiodine treatment and patients with cardiovascular comorbidity who need rapid restoration of the euthyroid state and who cannot tolerate the discontinuation of antithyroid drugs for radioiodine treatment.

[Thyroid diseases in sub-Saharan Africa]

Thyroid gland diseases vary according to the environment. In sub-Saharan Africa, they are also influenced by population isolation and the absence of food self-sufficiency, both factors affecting the onset and persistence of iodine-deficiency goiters. More cosmopolitan diseases are now added to these thyroid disorders. Women are mainly affected (94.2%), most often with euthyroid goiters (54.7%), followed by Graves disease (13.1%), hypothyroidism (8.8%), thyroiditis (6.6%), toxic multinodular goiters (6.6 %) and unclassified goiters (10%) [Gabon]. The paucity of laboratories specializing in endocrinology and of nuclear medicine facilities, the delay in diagnosis that results in compressive or recurrent goiters, and endemic goiters are all typical in Africa. In children and adolescents, death rates increase with congenital or acquired thyroiditis as with delayed physical or mental development. In this environment, thyroiditis can also be pregnancy-related. Very recent surveys show a prevalence of endemic goiters of 28.6% in the community of Sekota, Ethiopia, 64-70% in Sahel-Sudan (population aged 10-20 years), 20-29% in KwaZulu-Natal (school children), 14.3-30.2% in Namibia (school children), 0.21% (congenital hypothyroidism or cretinism) in Plateau State, Nigeria, 55.2% at Zitenga, Burkina Faso (210 persons 0-45 years), and 10% in Hararé and Wedza, Zimbabwe (newborn TSH >10.1 microIU/mL). The prevalence of goiters is 43.6% in children emigrating from Ethiopia to Israel. Millet from semi-arid zones contains apigenin at a concentration of 150 mg/kg and luteolin at 350 mg/kg, both of which can interfere with thyroid function. The harmful effects of cassava (also known as manioc) are better known: milling cassava reduces its goitrogenic potential. In addition to iodine deficiency, selenium deficiency, and the effect of the thiocyanates in cassava, ion concentrations in soil and drinking water appear to play a role. The proportion of thyroid surgery indicated for hyperthyroidism has tripled, now accounting for 18.5% of all such operations. This disorder is found today in subjects older than 50 years, mainly from rural areas, and caused most often by Graves disease (25 of 51 cases). Graves disease in young women can cause serious problems during pregnancy; in such cases assessment of the minimal effective dose of antithyroid agents is essential. Carbimazole leads to remission in 61% of cases of Graves disease. Hypothyroidism can be auto-immune and often in patent forms because of insufficient screening in Africa: 24 cases in Dakar (1984) and 37 others noticed by us (1998). Single-nodule tumors were assessed in 89 patients in Khartoum: they were found to be simple goiters in 72% of cases, follicular adenoma in 13.5%, cancer in 13.5% (with 6 of the 12 cases follicular, 5 papillary, and 1 anaplastic). The sex ratio for thyroid cancer in Ouagadougou is 0.22, thus mainly women. It affects mainly women in their 30s. Thyroid cancer at Ibadan was found to be papillary carcinoma in 45.3% of cases; follicular forms were seen in 44.5% and this series includes 5% of medullary cancers (7 cases), with a mean age of 34 years. Already 4 other cases from Francophone sub-Saharan Africa have been noticed. Iodine deficiency is suggested to play a role because follicular cancer in southern Africa accounts for up to 55% of thyroid cancers. Thyroid cancers in Algeria are associated with low socioeconomic status and characterized by a high prevalence of cancers discovered at an advanced stage and of anaplastic carcinomas. Oral potassium iodate is recommended: 30 mg of iodate a month or 8 mg every two weeks. Iodized oil has been recommended by some authors, as well as a combination of iodine and sugar, and the iodation of drinking water; these are in addition to the proposed methods of opening up areas by new infrastructure). In conclusion, thyroid disease is due predominantly to iodine deficiency and goitrogenic products, but we also note the increasing emergence of hyperthyroidism, especially Graves disease, atrophic auto-immune hypothyroidism, and thyroid cancer. The insufficiency of infrastructure in transportation, endocrinology, and nuclear medicine are a public health challenge for the third millennium.

[Hyperthyroidism in surgery at the Teaching Hospital Yalgado Ouedraogo Burkina Faso. About 95 cases]

The authors pay in a retrospective study, 95 cases of hyperthyroidism, listed in the teaching hospital Yalgado Ouedraogo of Ouagadougou from January 2000 to June 2005. These hyperthyroidism represent 39% of the thyroid affections, with a female prevalence (97%), 32 years of average age, the urban source of the patients (90% of the cases) and the importance of self medication (73%). They stress the importance of sonography, allowing a classification in diffuse goiter (44%) and multi nodular (56%). They insist on a good preparation of the patient before the intervention and on the interest of the sub total thyroïdectomy. They estimate that a correct binding of the vessels, the dissection of recurring, the visualization and the dissection of parathyroid and their vascular pedicle should make it possible to reduce the post-operative complications: null morbidity and death rate 12.5%.

100 consecutive thyroidectomies performed by a single surgeon in an upstate South Carolina teaching hospital: an outcome analysis

An experienced surgeon in a community hospital with surgical resident participation can perform thyroid surgery safely. An outcome analysis of 100 consecutive thyroidectomies showed a 1.2% incidence of permanent recurrent nerve injury and no cases of permanent hypo-parathyroidism. Temporary hypocalcemia was common (in total thyroidectomy patients) but was easily treated with oral calcium supplementation. Total thyroidectomy is an acceptable treatment for hyperthyroidism in those patients who are unable or unwilling to receive Radioiodine ablation.

Subtotal Thyroidectomy: A Reliable Method to Achieve Euthyroidism in Graves’ Disease. Prognostic Factors

BACKGROUND

Subtotal thyroidectomy is a widely accepted surgical procedure for Graves' disease. The purpose of this work is to evaluate functional long-term results and determine predictive prognostic factors of postoperative thyroid function.

STUDY DESIGN

This is a retrospective study conducted on 202 patients with Graves' disease undergoing subtotal thyroidectomy during the period 1979-2002. Predictive prognostic factors of final thyroid status were investigated by logistic ordinal regression, and probability of hypothyroidism during the years of follow-up was obtained by the Kaplan-Meier method.

RESULTS

Surgery controlled hyperthyroidism in 196 out of 202 patients (97%). The probability of hypo-, eu-, and hyperthyroidism at 5 years was 62.1%, 35.5%, and 2.4%, respectively. No statistical change in thyroid function occurred in the follow-up after 60 months. Multivariate analysis by a logistic ordinal regression analysis showed that weight of the remnant, age, and gender seemed to influence long-term thyroid function. The higher rates of euthyroidism were obtained when the remnant weight was between 6 and 8 g. No recurrence or persistence of hyperthyroidism occurred with remnant weights under 5 g.

CONCLUSIONS

Subtotal thyroidectomy controlled hyperfunction symptoms in 97% of our patients. Cure (euthyroidism) of Graves' disease patients should be attempted by leaving a thyroid tissue remnant between 6 and 8 g. Even more significant, our results suggest that euthyroidism rates could be improved by leaving a smaller remnant in elderly women and greater remnants in young men.

The use of LigaSure in patients with hyperthyroidism

BACKGROUND

Thyroidectomies of hyperthyroidic patients are known to be more blood-spattered than the operations performed for euthyroid nodular diseases and require careful hemostasis. Our purpose was to evaluate the efficacy of the use of LigaSure in patients with hyperthyroidism.

MATERIALS AND METHODS

Between January 2004 and October 2005, 100 patients underwent total or near-total thyroidectomy. Bipolar vessel ligation system (LigaSure) was the choice of modality for hemostasis in half of these patients, and the conventional suture ligation technique was used for the rest. The following data were evaluated non-randomized and prospectively in this study: patients demographics, thyroid pathology, operative duration, presence of complications, and the duration of the hospital stay. Comparisons of the data were evaluated by the Wilcoxon and chi-square tests.

RESULTS

Among the patients of the LigaSure group, 14 patients were detected to have hyperthyroidism (seven patients with Graves' disease and another seven patients with multinodular toxic goiter), while 36 patients were found to be euthyroidic. The durations of the operation time and of the hospital stay of the patients in the LigaSure group were significantly lower than the conventional thyroidectomy group (p<0.05). The complication rates of the LigaSure and conventional thyroidectomy groups were 4 and 6%, respectively (p>0.05).

CONCLUSIONS

The use of LigaSure as an operative technique in the treatment of Graves' disease and toxic goiter is a safe and effective modality that provides a shorter hospital stay and a shorter operation time as well.

Surgery for hyperthyroidism in Down syndrome: case report

Thyroid disorders are common in patients with Down syndrome (DS). In these patients, hyperthyroidism occurs much less frequently than hypothyroidism, but it is likely to be underestimated. We report a case of an adult man with DS and hyperthyroidism. After 2 years of antithyroid therapy in a special facility, he was referred to our center with recurrence of hyperthyroidism with leukopenia and elevations of liver enzymes 14 months after remission. The patient underwent subtotal thyroidectomy, with rapid preparation with inorganic iodine and prednisone. After thyroidectomy the patient was found to have hypothyroidism and was given thyroid replacement therapy. We also review the literature on the treatment options for hyperthyroidism with DS. We conclude that the role of surgery in the treatment of hyperthyroid patients with DS has yet to be defined.

[Celiac disease revealed by hypocalcemia complicating total thyroidectomy: a case report]

In order to illustrate a particular circumstance of diagnosis of celiac disease, we report the case of 54-year-old women with a history of thyroid enlargement with normal thyroid function and positive anti-peroxidase antibodies. Immediately after total thyroidectomy with preservation of the parathyroid glands, she developed tetany with total serum calcium level at 50mg/l. Intravenous calcium infusion increased the calcium level and led to resolution of hypocalcemia-induced signs but there was no result when calcium and vitamin D were taken orally. The diagnosis of malabsorption was very probable in light of the family history of celiac disease, the anemia and the hypoalbuminemia. The diagnosis was confirmed by antibodies assay and endoscopy. The PTH level was less than 1 pg/l and radiography showed signs of hyperparathyroidism. Gluten-free diet, calcium and vitamin D led to an improvement of serum calcium.

Síndrome del hueso hambriento relacionado con hipertiroidismo

Hungry bone syndrome is a common clinical entity which is accompanying of hypocalcemia, hypomagnesemia, and hipophosphatemia, results from an increase in bone formation. It is related to a pathological scenario which causes an imbalance between osteoclast-mediated bone resorption and osteoblast-mediates bone formation, favouring the latter. Its classic presentation occurs after parathyroidectomy in hyperparathyroydism's patients. Its clinical features are largely due to plasmatic calcium levels reduction. Hungry bone syndrome is frequent in hyperparathyroid's patients who have development bone disease before surgery. Even less frequent, it has also been described after thyroydectomy in patients with hyperthyroidism. We hereby report a case of hungry bone syndrome in one patient who suffers a Graves' disease. Then, we will provide a brief review of pathogenesis and therapeutic features.

[Improvement of thrombocytopenia with normalization of thyroid function in a patient with Graves disease]

A 39-year-old man was admitted to our hospital because of hyperthyroidism complicated with fever, atrial fibrillation with rapid ventricular response and congestive heart failure. Laboratory data revealed pancytopenia with a white blood cell count of 3360/microl, Hb 9.6 g/dl, and a platelet count of 88000/ul. After initiation of treatment with 30 mg of thiamazole daily, the patient's thyroid function improved but 4 weeks later, thiamazole induced agranulocytosis occurred and the drug was discontinued. After recovery from agranulocytosis, a subtotal thyroidectomy was performed, and the patient's pancytopenia rapidly improved. In this case, hyperthyroidism itself appeared to be closely related to the development of thrombocytopenia.

Results of Thyroidectomy in 101 Cats with Hyperthyroidism

OBJECTIVE

To describe outcome after thyroidectomy in hyperthyroid cats, with emphasis on peri- and postsurgical complications and recurrence.

STUDY DESIGN

Retrospective study.

ANIMALS

One hundred and one hyperthyroid cats.

METHODS

Diagnostic work-up included preoperative measurement of plasma calcium, sodium, potassium, urea, and creatinine concentrations, and thyroid scintigraphy. A modified intracapsular dissection technique was performed. Postoperatively, parathyroid gland function was evaluated by measuring plasma calcium concentration several times daily. Outcome was obtained by standard telephone questionnaire.

RESULTS

Thyroid scintigraphy revealed ectopic hyperplastic thyroid tissue (EHTT) in 9 cats. Preoperatively, 29 of 91 cats had hypokalemia. Two cats died within 3 days after surgery and 5 of 86 cats developed postoperative transient hypocalcemia. On histologic examination, thyroid carcinoma was identified in 3 of 88 cats. Hyperthyroidism recurred in 5 cats between 3 and 59 months; 4 of these cats had EHTT preoperatively. The difference in recurrence rate between hyperthyroid cats with and without EHTT was significant (P<.001).

CONCLUSION

Complications were uncommon after thyroidectomy performed by an experienced surgeon when combined with an anesthetic regimen associated with minimal adverse cardiovascular effects. Hyperthyroid cats with EHTT had a significantly higher chance of recurrence.

CLINICAL RELEVANCE

Thyroidectomy is associated with a low incidence of surgical complications and is an effective treatment for hyperthyroid cats when radioactive iodine therapy is not available. Preoperative thyroid scintigraphy is advised. Surgery is not recommended when EHTT is present, because of a higher chance of developing recurrent disease.