Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up11

Risk factors of transient and permanent hypoparathyroidism after thyroidectomy: a systematic review and meta-analysis

BACKGROUND

Postoperative hypoparathyroidism (hypoPT) is a common complication following thyroid surgery. However, current research findings on the risk factors for post-thyroid surgery hypoPT are not entirely consistent, and the same risk factors may have different impacts on transient and permanent hypoPT. Therefore, there is a need for a comprehensive study to summarize and explore the risk factors for both transient and permanent hypoPT after thyroid surgery.

MATERIALS AND METHODS

Two databases (PubMed and Embase) were searched from inception to 2024. The Newcastle-Ottawa Scale was used to rate study quality. Pooled odds ratios were used to calculate the relationship of each risk factor with transient and permanent hypoPT. Subgroup analyses were conducted for hypoPT with different definition-time (6 or 12 months). Publication bias was assessed using Begg's test and Egger's test.

RESULTS

A total of 19 risk factors from the 93 studies were included in the analysis. Among them, sex and parathyroid autotransplantation were the most frequently reported risk factors. Meta-analysis demonstrated that sex (female vs. male), cN stage, central neck dissection, lateral neck dissection, extent of central neck dissection (bilateral vs. unilateral), surgery [total thyroidectomy (TT) vs. lobectomy], surgery type (TT vs. sub-TT), incidental parathyroidectomy, and pathology (cancer vs. benign) were significantly associated with transient and permanent hypoPT. Preoperative calcium and parathyroid autotransplantation were only identified as risk factors for transient hypoPT, while preoperative PTH was a protective factor. Additionally, node metastasis and parathyroid in specimen were associated with permanent hypoPT.

CONCLUSION

The highest risk of hypoPT occurs in female thyroid cancer patients with lymph node metastasis undergoing TT combined with neck dissection. The key to preventing postoperative hypoPT lies in the selection of surgical approach and intraoperative protection.

Low serum iPTH at the end of surgery is the earliest predictor of postoperative hypocalcemia after total thyroidectomy

BACKGROUND

The most frequent complication of total thyroidectomy remains hypocalcemia due to low postoperative levels of serum intact parathyroid hormone (iPTH). The purpose of this study was to investigate the role of decreased iPTH at the end of surgery in predicting hypocalcemia. In addition, we examined the percentage decrease of iPTH as potential indicator of hypocalcemia.

METHODS

We retrospectively collected the data of patients who underwent total thyroidectomy for benign and malignant diseases at our institution between 2010 and 2022. The iPTH level was measured before and at the end of surgery, and serum calcium levels on the first postoperative day. Demographic, clinical, and biochemical characteristics of patients with low iPTH were compared with patients with normal iPTH levels using ANOVA for continuous variables and χ2-tests for categorical variables. Multivariable logistic regression analysis evaluated the association of iPTH at the end of surgery and the relative reduction of iPTH with postoperative hypocalcemia.

RESULTS

The mean age of the 607 patients in this study was 55.6 years, and the female-to-male ratio was 5:1. Goiter was the most common indication for surgery (N = 382, 62.9%), followed by Graves' disease (N = 135, 22.2%). The mean preoperative iPTH was 49.0 pg/ml, while the mean postoperative iPTH was 29.3 pg/ml. A total of 197 patients (32.5%) had an iPTH level below normal, 77 patients (39%), had iPTH levels of 10-15.0 pg/ml and 120 patients (61%) of < 10.0 pg/ml at the end of surgery. Among all patients, 124 (20.4%) developed hypocalcemia on the first postoperative day. The mean percentage of decrease of iPTH was highest among patients with iPTH < 10 pg/ml (76.9%, p < 0.01); this group of patients had also the highest rate of postoperative hypocalcemia on day one (45.0% vs. 26.0% vs 12.2%, p < 0.01).

CONCLUSIONS

Measurement of iPTH at the end of total thyroidectomy predicts patients who are at risk for postoperative hypocalcemia. The combination of low serum iPTH with a decrease in iPTH level of ≥ 50% may improve prediction of hypocalcemia compared to iPTH levels alone allowing for early calcium substitution in these patients at high risk of developing postoperative hypocalcemia.

TSH receptor autoantibody levels post-total thyroidectomy in Graves' ophthalmopathy: a meta-analysis

BACKGROUND

TSH receptor autoantibodies (TRAbs) are pathognomonic for Graves' disease and are thought to also underly the pathogenesis of Graves' ophthalmopathy (GO). A decline in TRAb levels has been documented post-total thyroidectomy (TTx) in GO, however with conflicting correlations with disease outcomes. The aim of the study was to compare the effectiveness of TTx to other treatment modalities of Graves' disease and examine whether the lowering of TRAbs is associated with GO improvements.

METHOD

We searched electronic databases including Medline, Embase, Scopus, and Web of Science until 31 September 2022 using a broad range of keywords. Patients with GO undergoing TTx with measurements of both TRAbs and progression of the disease using a validated GO scoring system were included. Fourteen studies encompassing data from 1047 patients with GO met our eligibility criteria. The PRISMA guidelines were followed, and five studies had comparable data that were suitable for a meta-analysis.

RESULTS

The Cochrane Risk of Bias tool for RCTs showed low risk of bias across most domains. The pooled odds ratio showed that more patients significantly had normalized TRAb levels post-TTx as compared to other interventions (OR: 1.36, 95% CI: 1.02-1.81, p = 0.035). But, there was no significant difference in GO improvement post-TTx as compared with other intervention groups.

CONCLUSIONS

This meta-analysis shows that TRAb levels may decline largely post-TTx, but may not predict added improvements to the progression of GO. Thus, future studies with uniform designs are required to assess the minimal significant GO improvements.

Outcomes of Surgical Treatment for Graves' Disease: A Single-Center Experience of 216 Cases

BACKGROUND

The role of surgery in the treatment of Graves' disease (GD) needs to be revisited. The aims of the present retrospective study were to evaluate the outcomes of the current surgical strategy as a definitive treatment of GD at our center and to explore the clinical association between GD and thyroid cancer.

METHODS

A patient cohort of 216 cases from 2013 to 2020 was involved in this retrospective study. The data of the clinical characteristics and follow-up results were collected and analyzed.

RESULTS

There were 182 female and 34 male patients. The mean age was 43.9 ± 15.0 years old. The mean duration of GD reached 72.2 ± 92.7 months. Of the 216 cases, 211 had been treated with antithyroid drugs (ATDs) and hyperthyroidism had been completely controlled in 198 cases. A total (75%) or near-total (23.6%) thyroidectomy was performed. Intraoperative neural monitoring (IONM) was applied to 37 patients. The failure of ATD therapy (52.3%) was the most common surgical indication, followed by suspicion of a malignant nodule (45.8%). A total of 24 (11.1%) patients had hoarseness after the operation and 15 (6.9%) patients had transient vocal cord paralysis; 3 (1.4%) had this problem permanently. No bilateral RLN paralysis occurred. A total of 45 patients had hypoparathyroidism and 42 of them recovered within 6 months. Sex showed a correlation with hypoparathyroidism through a univariate analysis. A total of 2 (0.9%) patients underwent a reoperation because of hematomas. A total of 104 (48.1%) cases were diagnosed as thyroid cancer. In most cases (72.1%), the malignant nodules were microcarcinomas. A total of 38 patients had a central compartment node metastasis. A lateral lymph node metastasis occurred in 10 patients. Thyroid carcinomas were incidentally discovered in the specimens of 7 cases. The patients with concomitant thyroid cancer had a significant difference in body mass index, duration of GD, gland size, thyrotropin receptor antibodies and nodule(s) detected.

CONCLUSION

Surgical treatments for GD were effective, with a relatively low incidence of complications at this high-volume center. Concomitant thyroid cancer is one of the most important surgical indications for GD patients. Careful ultrasonic screening is necessary to exclude the presence of malignancies and to determine the therapeutic plan.

Accumulation of Experience and Newly Developed Devices Can Improve the Safety and Voice Outcome of Total Thyroidectomy for Graves’ Disease

Total thyroidectomy (TT) in patients with Graves’ disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves’ disease who received TT. Forty-six patients received surgery during 1990–1999 (Group A), and 44 patients received surgery during 2010–2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range (p = 0.015) and jitter (p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves’ disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.

Treatment of Grave’s Disease in Adults

Graves disease is an autoimmune disease, with a genetic susceptibility, activated by environmental factors like stress, iodine excess, infections, pregnancy and smoking. It is caused by thyroid stimulating immunoglobulin (TSI) or thyroid stimulating antibody (TSAb) and is the most common cause of hyperthyroidism with an incidence of 21 per 100,000 per year. Treatment of Graves disease includes antithyroid drugs such as methimazole and propylthiouracil, radioactive iodine therapy and thyroidectomy. Methimazole, an antithyroid drug that belongs to the thioamides class, is usually the first line of treatment due to lower risk of hepatotoxicity compared to propylthiouracil. Radioactive iodine therapy is reserved for those patients who do not respond to antithyroid drugs or have contraindication or adverse effects generated by antithyroid drugs, and thyroid surgery is an option in people with thyroid nodular disease with suspected malignancy or large goiters such as predictors of poor response to antithyroid drugs and radioactive iodine therapy. Multiple factors influence the management of patients with Graves disease including patient and physician preferences, access to medical services and patients features such as age, complications and comorbidities.

Total versus near-total thyroidectomy in Graves' disease: a systematic review and meta-analysis of comparative studies

Background

Total thyroidectomy (TT), near-total thyroidectomy (NT), and subtotal thyroidectomy (ST) are three surgical procedures for Graves' disease (GD) patients, but most previous studies have only evaluated the complications of TT versus ST or TT/NT versus ST; there is not a meta-analysis of NT versus TT, so whether NT is superior to TT for GD patients still unclear.

Methods

We comprehensively searched PubMed, Embase, Web of Science, and the Cochrane Library, without restriction to region, publication type, or language, on 10 June, 2020. We conducted this systematic review and meta-analysis of all included studies assessing the two surgical procedures.

Results

In total, 528 cases were identified from two randomized controlled trials (RCTs) and three retrospective studies. The incidence of permanent hypoparathyroidism after NT was lower than with TT [odds ratio (OR), 0.22; 95% confidence interval (CI), 0.06-0.80; P=0.02], and there was no statistical difference in the recurrence of hyperthyroidism (OR, 0.33; 95% CI, 0.01-8.12; P=0.50) and other postoperative complications (P>0.05).

Conclusions

NT for GD was superior to TT regarding permanent hypoparathyroidism, but there was no significant difference in preventing recurrent hyperthyroidism, as well as the other postoperative complications.

Current approach to surgical management of hyperthyroidism

Hyperthyroidism is a set of disorders that involve excess synthesis and secretion of thyroid hormones by the thyroid gland, which leads to thyrotoxicosis. The most common forms of hyperthyroidism include diffuse toxic goiter (Graves' disease), toxic multinodular goiter (Plummer disease), and a solitary toxic adenoma. The most reliable screening measure of thyroid function is the thyroid-stimulating hormone (TSH) level. Options for treatment of hyperthyroidism include: antithyroid drugs, radioactive iodine therapy (the preferred treatment of hyperthyroidism among US thyroid specialists), or thyroidectomy. Massive thyroid enlargement with compressive symptoms, a suspicious nodule, Graves' orbitopathy, and patient preference are indications for surgical treatment of thyrotoxicosis. This paper reviews the current literature and controversies on the surgical approach to the management of hyperthyroidism.

Short-Term Outcomes of Surgery for Graves' Disease in Germany

BACKGROUND

Surgical treatment of Graves' disease (GD) has a potentially increased incidence of postoperative hypoparathyroidism, recurrent laryngeal nerve palsy (RLNP) and bleeding. The aim of this study was to evaluate the current extent of surgery for the treatment of GD and its safety as a short-term outcome.

METHODS

Patients who underwent thyroid resection for GD were identified from the prospective StuDoQ/Thyroid registry. Patient data were retrospectively analyzed regarding demographics, surgical procedures and perioperative outcomes. Statistics were performed with Student's t-test or Fisher's exact test and multivariate Cox regression analysis. The level of statistical significance was set at p < 0.05.

RESULTS

A total of 1808 patients with GD with a median age of 44 (range 14-85) years were enrolled in a 25-month period by 78 departments, of which 35.7% (n = 645) had an endocrine orbitopathy and 0.1% (n = 6) had thyrotoxic crisis. Conventional open surgery was used in 98.6% of cases and minimally invasive or remote-access approaches were used in 1.4%. Total thyroidectomy was performed in 93.4% of cases (n = 1688). Intraoperative neuromonitoring (IONM) was used in 98.9% (n = 1789) of procedures. In 98.3% (n = 1777) at least one parathyroid gland was visualized and in 20.7% (n = 375) parathyroids were autografted. The rates of unilateral and bilateral transient RLNP were 3.9% (n = 134/3429 nerves at risk) and 0.1% (n = 4/3429 NAR). The rates of transient RLNP tended to be higher when intermittent IONM was used compared to continuous IONM (4.1% vs. 3.4%, p < 0.059). The rate of transient postoperative hypoparathyroidism was overall 29% (n = 525/1808). Multivariate analysis revealed fewer than 300 thyroid resections and fewer than 15 thyroid resections for GD per year, male sex, BMI > 30, autotransplantation of parathyroid glands and previous bilateral thyroid surgery as independent risk factors for postoperative temporary hypoparathyroidism. Reoperations for bleeding (1.3%) were rare.

CONCLUSION

Total thyroidectomy with IONM is safe and currently the most common surgical therapy for GD in Germany. Postoperative hypoparathyroidism is the major complication which should be focused on.

Total Versus Near-total Thyroidectomy in Graves Disease: Results of the Randomized Controlled Multicenter TONIG-trial

BACKGROUND

Previous data suggest that the incidence of hypoparathyroidism after surgery for Graves disease (GD) is lower after subtotal thyroidectomy compared to total thyroidectomy (TT). The present study evaluated the incidence of postoperative hypoparathyroidism after near-total (NTT) versus TT in GD.

METHODS/DESIGN

In a multicenter prospective randomized controlled clinical trial, patients with GD were randomized intraoperatively to NTT or TT. Primary endpoint was the incidence of transient postoperative hypoparathyroidism. Secondary endpoints were permanent hypoparathyroidism, transient recurrent laryngeal nerve palsy (RLNP), reoperations for bleeding, inadvertently removed parathyroid glands, and recurrent hyperthyroidism after 12 months.

RESULTS

Eighteen centers randomized 205 patients to either TT (n = 102) or NTT (n = 103) within 16 months. According to intention-to-treat postoperative transient hypoparathyroidism occurred in 19% (20/103) patients after NTT and in 21% (21 of 102) patients after TT (P = 0.84), which persisted >6 months in 2% and 5% of the NTT and TT groups (P = 0.34). The rates of parathyroid autotransplantation (NTT 24% vs TT 28%, P = 0.50) and transient RLNP (NTT 3% vs TT 4%, P = 0.35) was similar in both groups. The rate of reoperations for bleeding tended to be higher in the NTT group (3% vs 0%, P = 0.07) and the rate of inadvertently removed parathyroid glands was significantly higher after NTT (13% vs 3%, P = 0.01). An existing endocrine orbitopathy improved in 35% and 24% after NTT and TT (P = 0.61). Recurrent disease occurred in only 1 patient after TT (P = 0.34).

CONCLUSION

NTT for GD is not superior to TT regarding transient postoperative hypoparathyroidism.

Treatment of patients with Graves' disease and the appropriate extent of thyroidectomy

Graves' disease is an autoimmune disorder caused by thyroid stimulating auto-antibodies directed against the thyrotropin receptor on thyroid follicular cells. It is the most common cause of hyperthyroidism and is associated with cardiovascular, ophthalmologic and other systemic manifestations. Three treatment options are available for Graves' disease: anti-thyroid drugs, radioactive iodine and thyroidectomy. While thyroidectomy is the least common option used for treatment of Graves' disease, it is preferentially indicated for patients with a large goiter causing compressive symptoms, suspicious or malignant thyroid nodules or significant ophthalmopathy. The best operation for Graves' disease has been a matter of debate. The standard operation was a subtotal thyroidectomy for much of the twentieth century, however, over the past 20 years total thyroidectomy has been increasingly performed. Herein, we provide a historical perspective and review the current literature, including randomized controlled trials, systematic reviews and meta-analyses and conclude that total thyroidectomy is the preferred option for the surgical treatment of Graves' disease, with a nearly 0% recurrence rate, predictable postoperative hypothyroidism and a low complication rate comparable to subtotal thyroidectomy when performed by high-volume thyroid surgeons.

Considerations for Thyroidectomy as Treatment for Graves Disease

Hyperthyroidism is a clinical state that results from abnormally elevated thyroid hormones. Thyroid gland affects many organ systems; therefore, patients usually present with multiple clinical manifestations that involve many organ systems such as the nervous, cardiovascular, muscular, and endocrine system as well as skin manifestations. Hyperthyroidism is most commonly caused by Graves disease, which is caused by autoantibodies to the thyrotropin receptor (TRAb). Other causes of hyperthyroidism include toxic multinodular goiter, toxic single adenoma, and thyroiditis. Diagnosis of hyperthyroidism can be established by measurement of thyroid-stimulating hormone (TSH), which will be suppressed with either elevated free T4 and/or T3 (overt hyperthyroidism) or normal free T3 and T4 (subclinical hyperthyroidism). Hyperthyroidism can be treated with antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy. ATDs have a higher replacement rate when compared with RAI or thyroidectomy. Recent evidence has shown that thyroidectomy is a very effective, safe treatment modality for hyperthyroidism and can be performed as an outpatient procedure. This review article provides some of the most recent evidence on diagnosing and treating patients with hyperthyroidism.

Huge variations in definition and reported incidence of postsurgical hypoparathyroidism: a systematic review

PURPOSE

The reported incidence of post surgical hypoparathyroidism (HypoPT) varies greatly. Previous research suggests that the definition of HypoPT is not consistent in the literature. We therefore conducted a systematic review to investigate how HypoPT is defined and whether this definition, as well as the selected threshold for hypocalcemia affects the incidence.

METHODS

Using a predefined search string we identified all articles in PubMed reporting on the incidence of postsurgical HypoPT from 1st January 2010 to January 2017.

RESULTS

We identified 89 articles that employed 20 different definition of HypoPT. The incidence of HypoPT varied from 0.0% to 20.2%. The definitions were not associated with incidence of HypoPT. Use of prophylactic post-operative calcium supplements, however decreased the risk of HypoPT (p = 0.03), and there was a trend towards a lower risk of HypoPT when using a definition of hypocalcemia below lower limit of the reference range (p = 0.09).

CONCLUSION

The large number of definitions of HypoPT, as well as the huge variation in incidence point to a problem suggests that the awareness of HypoPT should be raised. Use of prophylactic post-operative calcium supplements may decrease risk of HypoPT. This, however, may be due to reverse causality as awareness of the risk of HypoPT may promote the use of calcium supplementation.

Change of surgical strategy for Graves' disease from subtotal thyroidectomy to total thyroidectomy: a single institutional experience

The extent of thyroidectomy in Graves' disease remains controversial. In our institution, long-term euthyroidism without thyroxin replacement therapy has been the aim, and it has long been the standard surgical procedure used to treat Graves' disease in many institutions, including our hospital. Based our several clinical studies, it was concluded that subtotal thyroidectomy is not suitable as a standard surgical procedure for the treatment of Graves' disease. In 2009, the surgical strategy for Graves' disease was changed from subtotal thyroidectomy to total thyroidectomy in our hospital. In this study, how surgical complications have changed after this modification was examined. The subjects were 1,476 patients with Graves' disease treated by thyroidectomy between 2006 and 2014. There were 1,119 females and 357 males with a median age of 39 years. A total of 660 patients underwent bilateral subtotal thyroidectomy (ST group), and 816 patients underwent total thyroidectomy (TT group). Both transient hypocalcemia and prolonged hypocalcemia were observed significantly more frequently in the TT group than in the ST group (p < 0.001). Total thyroidectomy was identified as risk factors for prolonged hypocalcemia on multivariate analysis. In conclusion, total thyroidectomy is a reliable and effective therapy for controlling hyperthyroidism in terms of controlling of hyperthyroidism. However, it should be noted that total thyroidectomy resulted in increased rate of prolonged hypocalcemia. Surgeons should try to reduce the surgical complication rate as much as possible.

Development of a core outcome set for amblyopia, strabismus and ocular motility disorders: a review to identify outcome measures

BACKGROUND

Core Outcome Sets (COS) are defined as the minimum sets of outcomes that should be measured and reported in all randomised controlled trials to facilitate combination and comparability of research. The aim of this review is to produce an item bank of previously reported outcome measures from published studies in amblyopia, strabismus and ocular motility disorders to initiate the development of COS.

METHODS

A review was conducted to identify articles reporting outcome measures for amblyopia, strabismus and ocular motility disorders. Using systematic methods according to the COMET handbook we searched key electronic bibliographic databases from 1st January 2011 to 27th September 2016 using MESH terms and alternatives indicating the different subtypes of amblyopia, strabismus and ocular motility disorders in relation to treatment outcomes and all synonyms. We included Cochrane reviews, other systematic reviews, controlled trials, non-systematic reviews and retrospective studies. Data was extracted to tabulate demographics of included studies, primary and secondary outcomes, methods of measurement and their time points.

RESULTS

A total of 142 studies were included; 42 in amblyopia, 33 in strabismus, and 68 in ocular motility disorders (one study overlap between amblyopia and strabismus). We identified ten main outcome measure domains for amblyopia, 14 for strabismus, and ten common "visual or motility" outcome measure domains for ocular motility disorders. Within the domains, we found variable nomenclature being used and diversity in methods and timings of measurements.

CONCLUSION

This review highlights discrepancies in outcome measure reporting within published literature for amblyopia, strabismus and ocular motility and it generated an item bank of the most commonly used and reported outcome measures for each of the three conditions from recent literature to start the process of COS development. Consensus among all stakeholders including patients and professionals is recommended to establish a useful COS.

The long-term outcomes of thyroid function after subtotal thyroidectomy for Graves' hyperthyroidism

BACKGROUND

Surgical management of Graves' disease (GD) is changing from subtotal to total thyroidectomy because the latter eliminates the risk of recurrence. However, to preserve thyroid function in a euthyroid state, subtotal thyroidectomy is still performed for GD in non-Western countries. Therefore, we designed a study to investigate the long-term outcomes in GD patients after subtotal thyroidectomy and the correlation between remnant weight and postoperative thyroid function.

MATERIALS AND METHODS

This was a retrospective cohort observation study. Between January 2005 and December 2011, 415 consecutive GD patients treated by subtotal thyroidectomy were enrolled. All data were collected from 385 patients who underwent bilateral subtotal thyroidectomy and 57 patients who underwent the Hartley-Dunhill operation. The median postoperative follow-up time was 72 months (range 12-144 months).

RESULTS

The mean weight of the preserved thyroid remnant was 5.1 g. Persistent or recurrent hyperthyroidism was observed in 119 (28.7%) patients. The median time of recurrence was 36 months (range 12-120 months). Hypothyroidism developed in over 50% of patients. A euthyroid state was achieved in only 19.3% of patients, and the rate did not increase significantly as remnant weight increased. Based on a Cox regression analysis, the remnant weight is an independent risk factor for persistent or recurrent hyperthyroidism (hazard ratio: 1.323, 95% confidence interval: 1.198-1.461, P < 0.001).

CONCLUSIONS

Subtotal thyroidectomy with the intent to maintain a euthyroid state is not an optimal surgical strategy for the definitive treatment of GD because the persistence or recurrence rate is high and the euthyroid rate is lower than expected.

Postoperative Outcomes in Graves' Disease Patients: Results from the Nationwide Inpatient Sample Database

BACKGROUND

Current surgical indications for Graves' disease include intractability to medical and/or radioablative therapy, compressive symptoms, and worsening ophthalmopathy. Total thyroidectomy for Graves' disease may be technically challenging and lead to untoward perioperative outcomes. This study examines outcomes in patients with Graves' disease who underwent total thyroidectomy and assesses its safety for this patient population.

METHODS

A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample database from 2006 to 2011. Total thyroidectomy performed in patients with Graves' disease, benign multinodular goiter (MNG), and thyroid cancer was identified. Demographic factors, comorbidities, and postoperative complications were evaluated. Chi-square, one-way analysis of variance, and risk-adjusted multivariable logistic regression were performed.

RESULTS

Of 215,068 patients who underwent total thyroidectomy during the study period, 11,205 (5.2%) had Graves' disease, 110,124 (51.2%) MNG, and 93,739 (43.6%) thyroid malignancy. Patients with Graves' disease were younger than MNG and thyroid cancer patients (M_age = 42.8 years vs. 55.5 and 51.0 years; p < 0.01). The Graves' disease group included a higher proportion of women (p < 0.01) and nonwhites (p < 0.01). Postoperatively, Graves' patients had significantly higher rates of hypocalcemia (12.4% vs. 7.3% and 10.3%; p < 0.01), hematomas requiring reoperation (0.7% vs. 0.4% and 0.4%; p < 0.01), and longer mean hospital stay (2.7 days vs. 2.4 and 2.2 days; p < 0.01) compared to MNG and thyroid cancer patients, respectively. On risk-adjusted multivariate logistic regression, Graves' disease was independently associated with a higher risk of vocal-cord paralysis (odds ratio [OR] = 1.36 [confidence interval (CI) 1.08-1.69]), tracheostomy (OR = 1.35 [CI 1.1-1.67]), postoperative hypocalcemia (OR = 1.65 [CI 1.54-1.77]), and hematoma requiring reoperation (OR = 2.79 [CI 2.16-3.62]) compared to MNG patients. High-volume centers for total thyroidectomy were independently associated with lower risk of postoperative complications, including in patients with Graves' disease.

CONCLUSIONS

Despite low overall morbidity following total thyroidectomy, Graves' disease patients are at increased risk of postoperative complications, including bleeding, vocal-cord paralysis, tracheostomy, and hypocalcemia. These risks appear to be lower when performed at high-volume centers, and thus referral to these centers should be considered. Total thyroidectomy may therefore be a safe treatment option for appropriately selected patients with Graves' disease when performed by experienced surgeons.

Epidemiology, management and outcomes of Graves' disease-real life data

PURPOSE

Treatment options in Graves' disease are clearly defined, but management practices and the perceptions of success are varied. The outcomes of treatment in large consecutive cohorts of Graves' disease have not been well characterised. The study describes the epidemiology, management strategies and medium term outcomes following anti-thyroid drug treatment, radio-iodine ablation and surgery in Graves' disease.

METHODS

All patients (n = 659) who received treatment for a new diagnosis of Graves' disease in secondary care over a 5 year period were included with a median (interquartile range) follow-up of 42.9 (29-57.5) months.

RESULTS

The age adjusted incidence of adult onset Graves' disease in Sheffield, UK was 24.8 per 100,000 per year. Excluding 35 patients lost to follow-up, 93.1% (n = 581) were controlled on anti-thyroid drug treatment. Of these, 73.6% went into remission following withdrawal of anti-thyroid drugs; 5.2% were still undergoing initial therapy; 13.3% lost control whilst on anti-thyroid drugs; and 7.9% went on to have either surgery or radio-iodine ablation whilst controlled on anti-thyroid drugs. Of the 428 patients who achieved remission, 36.7% relapsed. Of 144 patients who had radio-iodine ablation treatment, 5.6% relapsed and needed further treatment. Of 119 patients having surgery, 5.2% had long-term hypoparathyroidism and none had documented long-term recurrent laryngeal nerve palsy.

CONCLUSIONS

In the follow-up, 39.9% of patients underwent surgery or radio-iodine ablation with little morbidity. Up to two-thirds of patients who achieved remission did not relapse. Data on effectiveness and risks of treatments for Graves' disease presented in this study will help clinicians and patients in decision making.

Comparative Effectiveness of Treatment Choices for Graves' Hyperthyroidism: A Historical Cohort Study

BACKGROUND

The optimum therapy for Graves' disease (GD) is chosen following discussion between physician and patient regarding benefits, drawbacks, potential side effects, and logistics of the various treatment options, and it takes into account patient values and preferences. This cohort study aimed to provide useful information for this discussion regarding the usage, efficacy, and adverse-effect profile of radioactive iodine (RAI), antithyroid drugs (ATDs), and thyroidectomy in a tertiary healthcare facility.

METHODS

The cohort included consecutive adults diagnosed with GD from January 2002 to December 2008, who had complete follow-up after treatment at the Mayo Clinic, Rochester, Minnesota. Data on treatment modalities, disease relapses, and adverse effects were extracted manually and electronically from the electronic medical records. Kaplan-Meier analyses were performed to evaluate the association of treatments with relapse-free survival.

RESULTS

The cohort included 720 patients with a mean age of 49.3 years followed for a mean of 3.3 years. Of these, 76.7% were women and 17.1% were smokers. The initial therapy was RAI in 75.4%, ATDs in 16.4%, and thyroidectomy in 2.6%, while 5.6% opted for observation. For the duration of follow-up, ATDs had an overall failure rate of 48.3% compared with 8% for RAI (hazard ratio = 7.6; p < 0.0001). Surgery had a 100% success rate; 80% of observed patients ultimately required therapy. Adverse effects developed in 43 (17.3%) patients treated with ATDs, most commonly dysgeusia (4.4%), rash (2.8%), nausea/gastric distress (2.4%), pruritus (1.6%), and urticaria (1.2%). Eight patients treated with RAI experienced radiation thyroiditis (1.2%). Thyroidectomy resulted in one (2.9%) hematoma and one (2.85%) superior laryngeal nerve damage, with no permanent hypocalcemia.

CONCLUSIONS

RAI was the most commonly used modality within the cohort and demonstrated the best efficacy and safety profile. Surgery was also very effective and relatively safe in the hands of experienced surgeons. While ATDs allow preservation of thyroid function, a high relapse rate combined with a significant adverse-effect profile was documented. These data can inform discussion between physician and patient regarding choice of therapy for GD.

A new method of subtotal thyroidectomy for Graves' disease leaving a unilateral remnant based on the upper pole

BACKGROUND

The aim of this prospective randomized study was to evaluate the feasibility of subtotal thyroidectomy with leaving a unilateral remnant based on the upper pole.

METHODS

Patients who underwent the subtotal thyroidectomy and isthmusectomy leaving either a unilateral remnant based on the upper pole (Group I, 79 patients) or the bilateral dorsal thyroid tissue remained (Group II, 89 patients) were compared in operation time, blood loss, recurrence, and postoperative complications.

RESULTS

Among 168 patients analyzed, the operation time remained similar, but the blood loss, the reoperation time, and recurrence in Group I were much less than Group II. In addition, no postoperative hemorrhage occurred in Group I. Two patients (2.28%) in Group II underwent recurrent laryngeal nerve damages. Four patients (5.06%) in Group I and 3 patients (3.37%) in Group II experienced transient hypocalcemia. Recurrence only occurred in Group II.

CONCLUSION

In terms of blood loss, reoperation time, postoperative complication, and the recurrence, subtotal thyroidectomy with recurrent laryngeal nerves identification and the unilateral superior pole remnant of the gland provides a better outcome than subtotal thyroidectomy with bilateral dorsal thyroid tissue remnant.

The Preservation and Autotransplantation of the Parathyroid Glands in Total Thyroidectomy in Patients With Thyroid Cancer—A Strategy for Avoiding Permanent Hypoparathyroidism

Hypoparathyroidism is a complication that occurs after total thyroidectomy (TT) in patients with thyroid cancer. We tried to determine a strategy for avoiding permanent hypoparathyroidism. A total of 42 patients underwent TT for thyroid cancer between April 2009 and March 2014. One or more parathyroid glands (PGs) could be macroscopically preserved in all of the patients. First, we evaluated the association between the number of PGs that were macroscopically preserved and the postoperative course in 28 patients without autotransplantation. The number of preserved PGs was not associated with postoperative tetany or the serum levels of calcium or phosphorous on postoperative day 1, or the proportion of patients who needed to take calcium supplements or a vitamin D analog. However, only the patients with a single preserved PG required calcium supplementation for longer than 1 year (33.3%, P &lt; 0.05). Next, we compared the clinical course with PG autotransplantation in 16 patients in whom a single PG was preserved. Although the result was not statistically significant, only the patients without autotransplantation required calcium supplementation for longer than 1 year. To avoid permanent hypoparathyroidism after TT, it should be essential to preserve at least 2 PGs or to preserve 1 PG and perform autotransplantation.

Influence of change in surgical practice for benign thyroid disease on postsurgical outcome-Single-center experience in 1400 patients

PURPOSE

To evaluate the rate of surgical complications during the change from subtotal resection to hemithyroidectomy or thyroidectomy over a period of 17 years.

METHODS

All operations for benign goiter at our hospital were analyzed for the periods 1996-2002 (Group 1) and 2003-2012 (Group 2). The groups were compared for recurrent laryngeal nerve damage, hypocalcemia, and other surgical complications directly postoperatively.

RESULTS

In total, 1462 patients were operated on for goiter between 1996 and 2012. There were 1219 patients who underwent a primary thyroid operation, whereas 50 patients had surgery for recurrence. Postoperative histology revealed thyroid cancer in 193 patients (13.2%). In Group 1, 42.7% of all operated lobes were performed as lobectomies and 57.3% as subtotal resections; in Group 2, 74.4% were performed as lobectomies and 25.6% as subtotal resections. No differences were found for reduced vocal cord function (2.4% vs. 1.9%, p = 0.746) and recurrent laryngeal nerve paralysis in the postoperative laryngoscopy (2.9% vs. 1.8%, p = 0.675). Postoperative hypoparathyroidism was detected in 13.66% in Group 1 and in 19.80% in Group 2 after bilateral resections (p = 0.037). There was no difference in the rate of reoperations for cancer between both groups (43.4% vs. 52.1%, p = 0.182).

CONCLUSION

Surgical practice changed from subtotal to lobectomies for benign goiter over a period of 17 years without change in laryngeal nerve damage but with increasing rates of postoperative hypocalcemia.

Thyroid surgery for Graves' disease and Graves' ophthalmopathy

BACKGROUND

Graves' disease is an autoimmune disease caused by the production of auto-antibodies against the thyroid-stimulating hormone receptor, which stimulates follicular cell production of thyroid hormone. It is the commonest cause of hyperthyroidism and may cause considerable morbidity with increased risk of cardiovascular and respiratory adverse events. Five per cent of people with Graves' disease develop moderate to severe Graves' ophthalmopathy. Thyroid surgery for Graves' disease commonly falls into one of three categories: 1) total thyroidectomy, which aims to achieve complete macroscopic removal of thyroid tissue; 2) bilateral subtotal thyroidectomy, in which bilateral thyroid remnants are left; and 3) unilateral total and contralateral subtotal thyroidectomy, or the Dunhill procedure. Recent American Thyroid Association guidelines on treatment of Graves' hyperthyroidism emphasised the role of surgery as one of the first-line treatments. Total thyroidectomy removes target tissue for the thyroid-stimulating hormone receptor antibody. It controls hyperthyroidism at the cost of lifelong thyroxine replacement. Subtotal thyroidectomy leaves a thyroid remnant and may be less likely to lead to complications, however a higher rate of recurrent hyperthyroidism is expected and revision surgery would be challenging. The choice of the thyroidectomy technique is currently largely a matter of surgeon preference, and a systematic review of the evidence base is required to determine which option offers the best outcomes for patients.

OBJECTIVES

To assess the optimal surgical technique for Graves' disease and Graves' ophthalmopathy.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE and PubMed, EMBASE, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The date of the last search was June 2015 for all databases. We did not apply any language restrictions.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) involving participants with a diagnosis of Graves' disease based on clinical features and biochemical findings of hyperthyroidism were eligible for inclusion. Trials had to directly compare at least two surgical techniques of thyroidectomy. There was no age limit to study inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and cross-checked the data for analysis, evaluation of risk of bias and establishment of 'Summary of findings' tables using the GRADE instrument. The senior review authors reviewed the data and reconciled disagreements.

MAIN RESULTS

We included five RCTs with a total of 886 participants; 172 were randomised to total thyroidectomy, 383 were randomised to bilateral subtotal thyroidectomy, 309 were randomised to the Dunhill procedure and 22 were randomised to either bilateral subtotal thyroidectomy or the Dunhill procedure. Follow-up ranged between six months and six years. One trial had three comparison arms. All five trials were conducted in university hospitals or tertiary referral centres for thyroid disease. All thyroidectomies were performed by experienced surgeons. The overall quality of the evidence ranged from low to moderate. In all trials, blinding procedures were insufficiently described. Outcome assessment for objective outcomes was blinded in one trial. Surgeons were not blinded in any of the trials. One trial blinded participants. Attrition bias was a substantial problem in one trial, with 35% losses to follow-up. In one trial the analysis was not carried out on an intention-to-treat basis.Total thyroidectomy was more effective than subtotal thyroidectomy techniques (both bilateral subtotal thyroidectomy and the Dunhill procedure) at preventing recurrent hyperthyroidism in 0/150 versus 11/200 participants (OR 0.14 (95% CI 0.04 to 0.46); P = 0.001; 2 trials; moderate quality evidence). Total thyroidectomy was also more effective than bilateral subtotal thyroidectomy at preventing recurrent hyperthyroidism in 0/150 versus 10/150 participants (odds ratio (OR) 0.13 (95% confidence interval (CI) 0.04 to 0.44); P = 0.001; 2 trials; moderate quality evidence). Compared to bilateral subtotal thyroidectomy, the Dunhill procedure was more likely to prevent recurrent hyperthyroidism in 20/283 versus 8/309 participants (OR 2.73 (95% CI 1.28 to 5.85); P = 0.01; 3 trials; low quality evidence). Total thyroidectomy compared with subtotal thyroidectomy conferred a greater risk of permanent hypocalcaemia/hypoparathyroidism in 8/172 versus 3/221 participants (OR 4.79 (95% CI 1.36 to 16.83); P = 0.01; 3 trials; low quality evidence). Effects of the various surgical techniques on permanent recurrent laryngeal nerve palsy and regression of Graves' ophthalmopathy were neutral. One death was reported in one study in year three of follow-up. No study investigated health-related quality of life or socioeconomic effects.

AUTHORS' CONCLUSIONS

Total thyroidectomy is more effective than subtotal thyroidectomy (both bilateral subtotal thyroidectomy and the Dunhill procedure) at preventing recurrent hyperthyroidism in Graves' disease. The type of surgery performed does not affect regression of Graves' ophthalmopathy. There was some evidence that total thyroidectomy compared with subtotal thyroidectomy conferred a greater risk of permanent hypocalcaemia/hypoparathyroidism, which however, was not seen in comparison with bilateral subtotal thyroidectomy. Permanent recurrent laryngeal nerve palsy did not seem to be affected by type of thyroidectomy. Health-related quality of life as a patient-important outcome measure should form a core determinant of any future trial on the effects of thyroid surgery for Graves' disease.

Total or near-total thyroidectomy versus subtotal thyroidectomy for multinodular non-toxic goitre in adults

BACKGROUND

Total thyroidectomy (TT) and subtotal thyroidectomy (ST) are worldwide treatment options for multinodular non-toxic goitre in adults. Near TT, defined as a postoperative thyroid remnant less than 1 mL, is supposed to be a similarly effective but safer option than TT. ST has been shown to be marginally safer than TT, but it may leave an undetected thyroid cancer in place.

OBJECTIVES

The objective was to assess the effects of total or near-total thyroidectomy compared to subtotal thyroidectomy for multinodular non-toxic goitre.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, PubMed, EMBASE, as well as the ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was 18 June 2015 for all databases. No language restrictions were applied.

SELECTION CRITERIA

Two review authors independently scanned the abstract, title or both sections of every record retrieved to identify randomised controlled trials (RCTs) on thyroidectomy for multinodular non-toxic goitre for further assessment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed studies for risk of bias and evaluated overall study quality utilising the GRADE instrument. We calculated the odds ratio (OR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. A random-effects model was used for pooling data.

MAIN RESULTS

We examined 1430 records, scrutinized 14 full-text publications and included four RCTs. Altogether 1305 participants entered the four trials, 543 participants were randomised to TT and 762 participants to ST. A total of 98% and 97% of participants finished the trials in the TT and ST groups, respectively. Two trials had a duration of follow-up between 12 and 39 months and two trials a follow-up of 5 and 10 years, respectively. Risk of bias across studies was mainly unknown for selection, performance and detection bias. Attrition bias was generally low and reporting bias high for some outcomes. In the short-term postoperative period no deaths were reported for both TT and ST groups. However, longer-term data on all-cause mortality were not reported (1284 participants; 4 trials; moderate quality evidence). Goiter recurrence was lower in the TT group compared to ST. Goiters recurred in 0.2% (1/425) of the TT group compared to 8.4% (53/632) of the ST group (OR 0.05 (95% CI 0.01 to 0.21); P < 0.0001; 1057 participants; 3 trials; moderate quality evidence). Re-intervention due to goitre recurrence was lower in the TT group compared to ST. Re-intervention was necessary in 0.5% (1/191) of TT patients compared to 0.8% (3/379)of ST patients (OR 0.66 (95% CI 0.07 to 6.38); P = 0.72; 570 participants; 1 trial; low quality evidence). The incidence of permanent recurrent laryngeal nerve palsy was lower for ST compared with TT. Permanent recurrent laryngeal nerve palsy occurred in 0.8% (6/741) of ST patients compared to 0.7% (4/543) of TT patients (OR 1.28, (95% CI 0.38 to 4.36); P = 0.69; 1275 participants; 4 trials; low quality evidence). The incidence of permanent hypoparathyroidism was lower for ST compared with TT. Permanent hypoparathyroidism occurred in 0.1% (1/741) of ST patients compared to 0.6% (3/543) of TT patients (OR 3.09 (95% CI 0.45 to 21.36); P = 0.25; 1275 participants: 4 trials; low quality evidence). The incidence of thyroid cancer was lower for ST compared with TT. Thyroid cancer occurred in 6.1% (41/669) of ST patients compared to 7.3% (34/465)of TT patients (OR 1.32 (95% CI 0.81 to 2.15); P = 0.27; 1134 participants; 3 trials; low quality evidence). No data on health-related quality of life or socioeconomic effects were reported in the included studies.

AUTHORS' CONCLUSIONS

The body of evidence on TT compared with ST is limited. Goiter recurrence is reduced following TT. The effects on other key outcomes such as re-interventions due to goitre recurrence, adverse events and thyroid cancer incidence are uncertain. New long-term RCTs with additional data such as surgeons level of experience, treatment volume of surgical centres and details on techniques used are needed.

Thyroid surgery for treatment of Graves' disease complicated by ophthalmopathy: a comprehensive review

Graves' disease (GD) is an autoimmune disorder in which antibodies directed against thyroid-stimulating hormone receptors leads to thyrotoxicosis. Graves' ophthalmopathy, a condition that occurs in up to half of GD patients, is a cause of significant morbidity and is potentially vision threatening. Three treatment options are equally effective for uncomplicated GD and these include thyroid surgery (thyroidectomy), radioactive iodine thyroid ablation and antithyroid drugs. However, recent practice surveys suggest that surgery is the least favored GD treatment. When GD is complicated by moderate-to-severe Graves' ophthalmopathy, antithyroid drugs and surgery are recommended by current guidelines, and again the preference for thyroid surgery in these cases has remained low. This report aims to review current published data regarding thyroidectomy as a treatment for GD, and in particular, we focus on the effects of thyroidectomy on Graves' ophthalmopathy development and progression.

Surgical management of hyperthyroidism

AIMS

Hyperthyroidism includes several clinical and histopathological situations. Surgery is commonly indicated after failure of medical treatment. The aim of this study was to analyze the indications and complications of surgery as well as endocrine results.

MATERIALS AND METHODS

Patients operated on for hyperthyroidism between 2004 and 2012 were included in a retrospective study. Total thyroidectomy was performed for Graves' disease, toxic multinodular goiter and amiodarone-associated thyrotoxicosis; patients with toxic nodule underwent hemithyroidectomy. Pathologic analysis assessed surgical specimens; postoperative complications and resolution of hyperthyroidism were noted.

RESULTS

Two hundred patients from 15 to 83 years old were included. One hundred and eighty-eight underwent primary surgery and 12 were re-operated for recurrent goiter (6 with subtotal thyroidectomy for multinodular goiter 25 years previously; 6 with hemithyroidectomy for solitary nodule 15 years previously). Eighty-two patients suffered from toxic multinodular goiter, 78 from Graves' disease, 35 from solitary toxic nodules and 5 from amiodarone-associated thyrotoxicosis. Fourteen papillary carcinomas (including 11 papillary microcarcinomas) and 34 healthy parathyroid glands (17%) were identified in the pathological specimens. Postoperative complications comprised 4% permanent recurrent laryngeal nerve palsy (1 year follow-up), 9% hematoma requiring surgical revision, and 3% definitive hypocalcemia. Normalization of thyroid hormone levels was observed in 198 patients. Two recurrences occurred due to incomplete resection (1 case of Graves' disease and 1 intrathoracic toxic goiter that occurred respectively 18 and 5 months after resection). Postoperative complications were more frequent in multinodular goiter (23%) than in Graves' disease (13%) (ns: P>0.05).

CONCLUSION

Surgical management of hyperthyroidism enables good endocrinal control if surgery is complete. Patients need to be fully informed of all possible postoperative complications that could occur, especially vocal ones. Long-term follow-up is necessary to detect recurrence, which can occur more than 20 years after partial thyroidectomy surgery. Surgery allows early diagnosis of 12.5% of papillary carcinomas.

Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis

BACKGROUND

A variety of measures have been proposed to reduce the incidence of post-thyroidectomy hypocalcemia. The aim of this study was to perform a systematic review and meta-analysis of preventive and other surgical measures on post-thyroidectomy hypocalcemia as reported in the literature.

METHODS

Comprehensive searches of the PubMed, EMBASE, and Cochrane databases were performed, and the quality of included papers was assessed using the Cochrane risk of bias tool or a modified Newcastle-Ottawa Scale (NOS). The results of all included studies were summarized, and meta-analyses were performed where appropriate.

RESULTS

Thirty-nine randomized controlled trials (RCTs) and 37 observational studies were included. Measures studied included hemostatic techniques, extent of thyroidectomy and central neck dissection, surgical approach, calcium/vitamin D/thiazide diuretic supplements, parathyroid gland autotransplantation (PGAT) and intraoperative parathyroid gland (PG) identification, truncal ligation of inferior thyroid artery (ITA), preoperative magnesium infusion, and use of magnification loupes and Surgicel. Measures associated with significantly lower rates of transient hypocalcemia in meta-analysis were postoperative calcium and vitamin D supplementation compared to either calcium supplements alone (odds ratio (OR) 0.66; p=0.04) or no supplements (OR 0.34; p=0.007), and bilateral subtotal thyroidectomy (BST) compared to Hartley Dunhill (HD) procedure (OR 0.35; p=0.01). Meta-analyses did not demonstrate any measure to be significantly associated with a reduction in permanent hypocalcemia.

CONCLUSION

This review identified postoperative calcium and vitamin D supplementation and bilateral subtotal thyroidectomy (over HD) as being effective in prevention of transient hypocalcemia. However, the majority of RCTs were of low quality, primarily due to a lack of blinding. The wide variability in study design, definitions of hypocalcemia, and methods of assessment prevented meaningful summation of results for permanent hypocalcemia.

Thyroid thyrothymic extension: An anatomic study in a surgical series

BACKGROUND

The thyrothymic extension (TTE) is a variable projection from the inferior thyroid pole along the course of the thyrothymic ligament. Awareness of the TTE is critical to ensure complete total thyroidectomy. However, there is little mention of the TTE in the literature. The purpose of the present study was to investigate the frequency of the TTE in our surgical series.

METHODS

We conducted a prospective cohort study of 284 thyroid and parathyroid surgeries performed by a single surgeon.

RESULTS

A TTE was present in 138 of 414 evaluable thyroid lobes (33.3%), with no predilection for left or right. The TTE was bilateral in 57% of cases. In 5 cases, there was significant nodular enlargement of the TTE. The inferior parathyroid gland was closely associated with 8% of TTEs.

CONCLUSION

The TTE is a commonly encountered projection from the inferior thyroid pole. Awareness of the TTE is important to ensure complete total thyroidectomy.

Recent trends in thyroid surgery in Wales

INTRODUCTION

Our objective was to analyse trends in thyroid surgery in Wales over a recent 12-year period.

METHODS

Details of patients who underwent thyroid surgery across Wales from 1999 to 2010 were analysed from the Patient Episodes Database for Wales [n = 6570, 83% (5429) female, 86% (5634) benign thyroid disease]. We determined age-adjusted thyroidectomy rates from the European standard population and a Poisson regression model was fitted to assess temporal trends. Joinpoint regression was used to calculate annual percentage change (APC) in thyroidectomy rates.

RESULTS

An increase in thyroidectomy rates was observed for malignant disease [APC 4.5, 95% confidence interval (CI) 1.6-7.5] while surgery rates for benign disease declined over the period (APC -3.2, 95% CI -5.1 to -1.3). The use of total thyroidectomy rose from 17% (599/3501) in 1999-2004 to 30% (912/3069) in 2005-2010 (p < 0.001). Total thyroidectomies were performed in a higher proportion of males than females [26% (291/1141) vs. 22% (1220/5429), p = 0.03] and in a greater percentage of patients with malignant disease than benign [36% (337/936) vs. 21% (1174/5634), p < 0.001). General surgeons undertook 83% of thyroid surgery but with a growing involvement of ENT surgeons. Regional disparities were seen in the type of surgery offered to patients with benign thyroid disease.

CONCLUSION

The use of total thyroidectomy for benign and malignant thyroid disease has risen in Wales. The increase in surgeries performed for malignancy would support a rising incidence of thyroid cancer in the region. Regional disparities in choice of surgery for benign disease require further exploration.

Diagnosis and management of Graves disease: a global overview

Graves disease is an autoimmune disorder characterized by goitre, hyperthyroidism and, in 25% of patients, Graves ophthalmopathy. The hyperthyroidism is caused by thyroid hypertrophy and stimulation of function, resulting from interaction of anti-TSH-receptor antibodies (TRAb) with the TSH receptor on thyroid follicular cells. Measurements of serum levels of TRAb and thyroid ultrasonography represent the most important diagnostic tests for Graves disease. Management of the condition currently relies on antithyroid drugs, which mainly inhibit thyroid hormone synthesis, or ablative treatments ((131)I-radiotherapy or thyroidectomy) that remove or decrease thyroid tissue. None of these treatments targets the disease process, and patients with treated Graves disease consequently experience either a high rate of recurrence, if receiving antithyroid drugs, or lifelong hypothyroidism, after ablative therapy. Geographical differences in the use of these therapies exist, partially owing to the availability of skilled thyroid surgeons and suitable nuclear medicine units. Novel agents that might act on the disease process are currently under evaluation in preclinical or clinical studies, but evidence of their efficacy and safety is lacking.

Total thyroidectomy vs bilateral subtotal thyroidectomy in patients with Graves' diseases: a meta-analysis of randomized clinical trials

BACKGROUND

Conducting total thyroidectomy (TT) or subtotal thyroidectomy (ST) in patients with Graves' disease remains controversial. We performed a meta-analysis based on the published randomized controlled trials to evaluate the complications of TT vs ST.

METHODS

We searched multiple electronic databases for prospective, randomized, controlled trials related to safety and effectiveness of TT vs ST. Relative risk (RR) was estimated with 95% confidence interval (CI) based on an intention-to-treat analysis. We considered the following outcomes: recurrent hyperthyroidism, ophthalmopathy progression, temporary and permanent hypoparathyroidism, temporary and permanent recurrent laryngeal nerve palsy (RLNP) and post-operative bleeding.

RESULTS

Four trials with 674 patients (342 with TT, 332 with ST) were analysed. Although the overall rates of ophthalmopathy progression were similar between TT and ST (RR 0·92, 95% CI = 0·50-1·71; P = 0·80), TT was associated with a significant reduction in recurrent hyperthyroidism (RR 0·14, 95% CI = 0·05-0·41; P < 0·01). The pooled RR of post-operative bleeding for TT was similar to that for ST (RR 0·32, 95% CI = 0·05-1·96; P = 0·22). However, comparing with ST, the RR of temporary hypoparathyroidism was significantly higher for TT (RR 2·66, 95% CI = 1·89-3·73; P < 0·01). There was no significant difference in permanent hypoparathyroidism (RR 2·30, 95% CI = 0·78-6·76; P = 0·13), temporary (RR 1·08, 95% CI = 0·47-2·48; P = 0·85) and permanent RLNP (RR 1·54, 95% CI = 0·41-5·73; P = 0·52) between the two groups.

CONCLUSIONS

With regard to ophthalmopathy progression, post-operative bleeding, permanent hypoparathyroidism, temporary and permanent RLNP, TT is consistent with ST in patients with Graves' disease. However, TT is associated with a reduced incidence of recurrent hyperthyroidism and results in an increase in temporary hypoparathyroidism. Therefore, TT should be proposed for the treatment of Graves' disease.

Prophylactic central neck dissection for papillary thyroid cancer

BACKGROUND

Prophylactic central neck dissection (CND) for papillary thyroid cancer (PTC) remains controversial. The aim of this study was to examine whether prophylactic CND for PTC affected long-term survival and locoregional control.

METHODS

This was a retrospective cohort study of patients who underwent total thyroidectomy (TT) with bilateral prophylactic CND. They were compared with patients who had TT without CND. Personalized adjuvant radioiodine treatment was used in both groups. Primary outcomes were overall and disease-specific survival, and locoregional control. Secondary outcomes were number of patients with negative serum thyroglobulin levels, and morbidity.

RESULTS

Of 640 patients with PTC included in this study, 282 (treated in 1993-1997) had TT without CND and 358 (treated in 1998-2002) underwent TT with CND. The 10-year disease-specific survival rate for patients who had TT without CND was 92·5 per cent compared with 98·0 per cent in patients with CND (P = 0·034), and the locoregional control rate was 87·6 and 94·5 per cent respectively (P = 0·003). In multivariable analysis, extrathyroidal extension was an independent predictive factor for locoregional recurrence (odds ratio 12·47, 95 per cent confidence interval 6·74 to 23·06; P < 0·001), whereas CND was an independent predictive factor for improved locoregional control at 10 years after surgery (odds ratio 0·21, 0·11 to 0·41; P < 0·001). No differences were seen in the rates of permanent hypoparathyroidism or recurrent laryngeal nerve injury between the groups.

CONCLUSION

Bilateral prophylactic CND for staging of the neck in PTC, followed by personalized adjuvant radioiodine treatment, improved both 10-year disease-specific survival and locoregional control, without increasing the risk of permanent morbidity.

REGISTRATION NUMBER

NCT01510002 (http://www.clinicaltrials.gov).

Coexistence of papillary thyroid cancer with Hashimoto thyroiditis

Aims

Conflicting data have been reported with regard to Hashimoto thyroiditis (HT) and risk of malignancy. The aim of this study was to evaluate coexistence of papillary thyroid cancer (PTC) with HT.

Patients and methods

This is a retrospective cohort study in which HT was diagnosed in 452 (F/M ratio = 405:47, median age 53.5 ± 12.1 years) of 7,545 patients qualified for thyroidectomy throughout the years 2002 to 2010. Pathological reports were reviewed to identify prevalence of PTC in HT vs. non-HT patients.

Results

PTC was diagnosed in 106 of 452 (23.5 %) HT patients vs. 530 of 7,093 (7.5 %) non-HT patients (p < 0.001). Metastases to level VI lymph nodes were observed in 81 of 106 (76.4 %) patients with PTC in HT vs. 121 of 530 (22.8 %) patients with PTC in non-HT disease (p < 0.001).

Conclusions

HT was associated with a threefold increase of PTC prevalence as compared to other non-HT thyroid diseases, and the spread of PTC to level VI lymph nodes was four times more frequent in HT than in non-HT patients.

Hypocalcaemia after total thyroidectomy for Graves' disease and for benign atoxic multinodular goitre

PURPOSE

Postoperative hypocalcaemia has been reported to be more common after total thyroidectomy (TT) for Graves' disease than after TT for benign atoxic multinodular goitre (MNG). The reasons for this potential association are not clear. In the present study, the frequency and risk factors of hypocalcaemia after TT for Graves' vs MNG were compared.

METHODS

Between January 1999 and October 2009, patients with first-time surgery for Graves' disease or MNG treated with a TT were included in the study. Postoperative hypocalcaemia was defined by symptoms, calcium levels and treatment with calcium and/or vitamin D analogues during postoperative hospital stay, at discharge, and at the 6-week and 6-month follow-ups. Outcomes were compared with Mann-Whitney, chi(2) and Fishers' exact test where appropriate and by multivariable logistic regression analysis.

RESULTS

There were 128 patients with Graves' disease and 81 patients with MNG. Patients with Graves' disease were younger than patients with MNG (median age, 35 vs 51 years, p < 0.001). Symptoms of hypocalcaemia were more common in patients with Graves' disease (p < 0.001; OR, 95 % CI 3.26, 1.48-7.14), but the frequency of biochemical hypocalcaemia, postoperative levels of parathyroid hormone (PTH) and treatment with calcium and vitamin D did not differ between groups of patients.

CONCLUSION

Apart from more frequent symptoms of hypocalcaemia in patients with Graves' disease, there was no difference in the overall frequency of biochemical hypocalcaemia, low levels of PTH and/or treatment with calcium and vitamin D.

Changes in the thyroid function of Graves' disease patients treated by subtotal thyroidectomy

The extent of thyroidectomy in Graves' disease is still a matter of controversy. Subtotal thyroidectomy has been used as the standard surgical procedure for Graves' disease in Japan, but high hyperthyroidism relapse rates have been reported. We retrospectively studied serial changes in the thyroid function Graves' disease patients after they had been treated by subtotal thyroidectomy and assessed whether subtotal thyroidectomy should be recommended as the standard surgical procedure for the treatment of Graves' disease. The subjects were 478 Graves' disease patients who underwent subtotal thyroidectomy at our institution between 1994 and 1997 and were followed up on a regular basis, and their thyroid function 2-3 years after surgery (the early period) and 8-10 years after surgery (the late period) was evaluated and compared. The evaluations in the late period showed that 57% of the euthyroid patients in the early period remained euthyroid, 30% had developed a relapse of hyperthyroidism, and 13 % had become hypothyroid. Approximately 80% of the patients who were overtly hyperthyroid or overtly hypothyroid in the early period remained so in the late period. During the entire periods 47 patients had subclinical hyperthyroidism and were followed up without any postoperative medication. Twenty (42.6%) of them developed overt hyperthyroidism, 11 (23.4%) experienced a spontaneous remission, and 16 (34%) continued to be subclinically hyperthyroid. Because thyroid function after subtotal thyroidectomy is unstable and reduces quality of life, subtotal thyroidectomy is concluded not to be suitable as a standard surgical procedure for the treatment of Graves' disease.