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Eltelety AM, Terris DJ. Minimally invasive thyroid and parathyroid surgery: modifications for low-resource environments. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2022. [DOI: 10.1186/s43163-022-00341-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
AbstractMinimally invasive thyroidectomy (MIT) and parathyroidectomy (MIP) are gaining popularity in the current surgical practice. The need for specific equipment and technology is an obstacle in the low-resource environment. This article provides simple and practical guidance for surgeons practicing in low-resource environments to help them attain quality surgical practice, maintain patient safety, preserve available resources, and achieve the best outcomes.
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Safi M, Alhelfy S. Intracapsular total thyroidectomy experience and outcome for benign thyroid diseases. MEDICAL JOURNAL OF BABYLON 2022. [DOI: 10.4103/mjbl.mjbl_92_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tsai SH, Chien SC, Nguyen PA, Chien PH, Ma HP, Asdary RN, Wang YC, Humayun A, Huang CL, Iqbal U, Jian WS. Incidences of Hypothyroidism Associated With Surgical Procedures for Thyroid Disorders: A Nationwide Population-Based Study. Front Pharmacol 2020; 10:1378. [PMID: 31920634 PMCID: PMC6920095 DOI: 10.3389/fphar.2019.01378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/29/2019] [Indexed: 11/13/2022] Open
Abstract
Background and Aim: Limited information available about different types of thyroid surgeries with risk for postoperative hypothyroidism. This study aimed to investigate the risk of developing early and late-onset postoperative hypothyroidism in patients with thyroid disorders. Methods: We used a large cohort data from the Taiwan National Health Insurance Research Data Base (NHIRDB) and identified 9,693 (9, 348) patients from January 1998 to December 2010, admitted for thyroid disorder surgeries. We used the surgical procedures time as the index date. Our observational retrospective cohort study excluded the subjects diagnosed with hypoparathyroidism and hypothyroidism before any surgeries. We analyzed the data using the Cox regression model to calculate the hazard ratio. Result: Postoperative hypothyroidism associated with bilateral-total (HR, 4.27; 95% CI, 3.32-5.50), one-side total and another subtotal (HR, 3.16; 95% CI, 2.59-3.86), bilateral-subtotal (HR, 1.65; 95% CI, 1.37-1.98), and unilateral-total (HR, 1.17; 95% CI, 0.95-1.44) surgical procedures. The time intervals for thyroid disorders were 320 cases developed postoperative hypoparathyroidism in eight weeks, 480 cases the second month, and 1000 cases in the first year after surgery. Conclusion: Findings suggest that thyroidectomy was associated with transient postoperative hypothyroidism in thyroid disorder patients. The bilateral-total surgical procedure was strongly associated with temporary postoperative hypothyroidism.
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Affiliation(s)
- Shin-Han Tsai
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan.,Emergency Department, Shuang-Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shuo-Chen Chien
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Phung-Anh Nguyen
- International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan
| | - Po-Han Chien
- Department and Graduate Institute of Business Administration, National Taiwan University, Taipei, Taiwan
| | - Hon-Ping Ma
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan.,Emergency Department, Shuang-Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Rahma Novita Asdary
- Master Program in Global Health and Development, PhD Program in Global Health and Health Security, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Yao-Chin Wang
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan.,Department of Emergency, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Ayesha Humayun
- Department of Public Health and Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Chen-Ling Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Usman Iqbal
- International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan.,Master Program in Global Health and Development, PhD Program in Global Health and Health Security, College of Public Health, Taipei Medical University, Taipei, Taiwan.,Department of Public Health and Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Wen-Shan Jian
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
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Limonard EJ, Bisschop PH, Fliers E, Nieveen van Dijkum EJ. Thyroid function after subtotal thyroidectomy in patients with Graves' hyperthyroidism. ScientificWorldJournal 2012; 2012:548796. [PMID: 22448136 PMCID: PMC3290451 DOI: 10.1100/2012/548796] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 12/06/2011] [Indexed: 11/17/2022] Open
Abstract
Background. Subtotal thyroidectomy is a surgical procedure, in which the surgeon leaves a small thyroid remnant in situ to preserve thyroid function, thereby preventing lifelong thyroid hormone supplementation therapy. Aim. To evaluate thyroid function after subtotal thyroidectomy for Graves' hyperthyroidism. Subjects and Methods. We retrospectively reviewed the medical records of all patients (n = 62) who underwent subtotal thyroidectomy for recurrent Graves' hyperthyroidism between 1992 and 2008 in our hospital. Thyroid function was defined according to plasma TSH and free T4 values.
Results. Median followup after operation was 54.6 months (range 2.1–204.2 months). Only 6% of patients were euthyroid after surgery. The majority of patients (84%) became hypothyroid, whereas 10% of patients had persistent or recurrent hyperthyroidism. Permanent recurrent laryngeal nerve palsy and permanent hypocalcaemia were noted in 1.6% and 3.2% of patients, respectively. Conclusion. In our series, subtotal thyroidectomy for Graves' hyperthyroidism was associated with a high risk of postoperative hypothyroidism and a smaller, but significant, risk of persistent hyperthyroidism. Our data suggest that subtotal thyroidectomy seems to provide very little advantage over total thyroidectomy in terms of postoperative thyroid function.
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Affiliation(s)
- E J Limonard
- Department of Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Järhult J, Andersson PO, Duncker L. Alternating from subtotal thyroid resection to total thyroidectomy in the treatment of Graves’ disease prevents recurrences but increases the frequency of permanent hypoparathyroidism. Langenbecks Arch Surg 2011; 397:407-12. [DOI: 10.1007/s00423-011-0886-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 11/29/2011] [Indexed: 11/28/2022]
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Karaman M, Tuncel A, Sheidaei S, Karabulut MH, Tatlıpınar A. Functional capacity of the thyroid autograft and heterograft: An experimental study. Head Neck 2011; 34:702-8. [PMID: 21739520 DOI: 10.1002/hed.21811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2011] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the functional capacity of thyroid autografts/heterografts in a guinea pig model. METHODS A total of 24 guinea pigs were divided into 4 groups. Group A had only a thyroidectomy incision, and group B had total thyroidectomy. We performed autotransplantation in group C and heterotransplantation in group D. We monitored the guinea pigs for an 8-week period, with weekly measurements of free triiodothyronine (fT3), free thyroxine (fT4), and thyroid-stimulating hormone (TSH). At the final stage, the autografts/heterografts were histologically examined. RESULTS In group B, fT3/fT4 showed a gradual decrease; however, an increase of TSH was noted. In groups C and D, fT3/fT4 showed a gradual decrease, followed by a gradual increase until euthyroid levels; an exact opposite was noted for TSH. In histologic examination, there were functional thyroid follicles in all animals of groups C and D. CONCLUSIONS The autotransplanted/heterotransplanted guinea pig's thyroid tissue provides adequate thyroid function.
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Affiliation(s)
- Murat Karaman
- Department of Otorhinolaryngology, Ümraniye State Hospital for Research and Training, Istanbul, Turkey.
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Basili G, Andreini R, Romano N, Lorenzetti L, Monzani F, Naccarato G, Goletti O. Recurrence of Graves' disease in thyroglossal duct remnants: relapse after total thyroidectomy. Thyroid 2009; 19:1427-30. [PMID: 19916864 DOI: 10.1089/thy.2009.0143] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Ectopic thyroid tissue can be found anywhere between the foramen cecum and the normal position of the thyroid gland, most commonly located in the anterior cervical area, the region of the thyroglossal duct. Although thyroid cancer has been described frequently in thyroglossal duct remnants, thyroid dysfunction related to this tissue is rare. We report a patient with recurrent Graves' disease arising in a thyroglossal duct remnant. SUMMARY A 40-year-old woman with a history of total thyroidectomy for Graves' disease, presented with a slowly enlarging midline neck mass in association with clinical signs of hyperthyroidism. Serum-free triiodothyronine (6.6 pg/mL) and serum-free thyroxine (2.2 ng/dL) were elevated (normal range, 2.3-4.2 pg/mL and 0.9-1.8 ng/dL, respectively), and thyroid-stimulating hormone was suppressed (<0.01 mIU/mL; normal range, 0.35-5.50 mIU/mL). Neck ultrasonography showed a solid mass, localized at the infrahyoid area; radionuclide scanning confirmed an increased uptake at the same level. A 4 cm solid mass was removed by the Sistrunk technique. Microscopic examination revealed marked follicular hyperplasia, with tall cells, small follicles, scant, and scalloped colloid, in association with patchy lymphocytic infiltrate consistent with Graves' disease. CONCLUSIONS There appears to be no reason why thyroid cells within thyroglossal duct remnants should not be influenced by the thyroid-stimulating immunoglobulins of Graves' disease. Thyrotoxicosis resulting from this must be very rare, however, as were unable to find reports of patients with thyrotoxicosis due to Graves' disease in thyroglossal duct remnants. Although some thyroid tissue can be found within the thyroglossal duct in 1.6% to 40% of normal adults, the risk of thyroid dysfunction from this is far too low to justify new therapeutic approaches.
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Affiliation(s)
- Giancarlo Basili
- General Surgery Unit, Health Unit 5 Pisa, Pontedera Hospital, Pontedera, Italy.
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Sugino K, Ito K, Nagahama M, Kitagawa W, Shibuya H, Ito K. Surgical management of Graves' disease -10-year prospective trial at a single institution. Endocr J 2008; 55:161-7. [PMID: 18250542 DOI: 10.1507/endocrj.k07e-013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The extent of thyroidectomy in Graves' disease is still controversial. In our institution, long term euthyroidism without thyroxine replacement therapy has been aimed and, thus, subtotal thyroidectomy has been employed. We prospectively studied whether the surgical outcome was improved by a strategy of leaving smaller thyroid remnants. Between 1989 and 1998, 1897 patients with Graves' disease were treated by subtotal thyroidectomy and their thyroid function could be determined 2 to 3 years after thyroidectomy. The 10-year period was divided into 3 parts, '89-'91 (Period 1, n = 690), '92-'94 (Period 2, n = 587) and '95-'98 (Period 3, n = 620). Different maximum thyroid remnant sizes were prospectively established for each period: up to 7 g left in Period 1, up to 6 g in Period 2 and up to 5 g in Period 3. Thyroid function 2 to 3 years after thyroidectomy and the occurrence of surgical complications were compared among the three groups. The relapse rate for Period 1, Period 2, and Period 3 was 14.1%, 12.6%, and 10.9%, respectively, and the rate of euthyroidism decreased and rate of hypothyroidism increased from period to period. Surgical complications increased in Periods 2 and 3. For preventing relapse, the strategy of reducing the thyroid remnant is effective. Subtotal thyroidectomy leaving 3-4 g remnant tissue is a suitable surgical option for Graves' disease.
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H. Malabu U, Alfadda A, A. Suliman R, A. Al-Rube K, D. Al-Ruha A, A. Fouda M, A. Al-Maat M, A. El-Bakr A. Surgical Management of Graves` Hyperthyroidism in Saudi Arabia: A Retrospective Hospital Study. JOURNAL OF MEDICAL SCIENCES 2007. [DOI: 10.3923/jms.2007.1061.1064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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10
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Hypothyroidism following Hemithyroidectomy for Benign Nontoxic Thyroid Disease. EAR, NOSE & THROAT JOURNAL 2007. [DOI: 10.1177/014556130708600517] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hypothyroidism following hemithyroidectomy for benign nontoxic thyroid disease is an underappreciated phenomenon. Up until recently, it was common practice for physicians to place post-hemithyroidectomy patients on thyroid suppression therapy during the immediate postoperative period. That practice began to fall out of favor as a result of two developments: (1) the publication of data that put into question the efficacy of levothyroxine therapy for preventing recurrent disease or thyroid growth and (2) a heightened awareness of the morbidity associated with levothyroxine. We conducted a retrospective chart-review study of 58 patients with benign nontoxic thyroid disease who had undergone hemithyroidectomy from 1994 through 2003 at one institution. Of these 58 patients, 14 (24.1%) had become hypothyroid after surgery, including 7 who had been so diagnosed 1 month postoperatively and 6 at 2 months. The remaining 44 patients were euthyroid. The mean preoperative serum thyroid-stimulating hormone (TSH) levels in the hypothyroid and the euthyroid groups were 2.39 and 1.07 μIU/ml, respectively—a statistically significant difference (p < 0.0001). A tissue diagnosis consistent with chronic inflammation (lymphocytic thyroiditis or Hashimoto's thyroiditis) was found in 50.0% of the hypothyroid patients, compared with only 6.8% of the euthyroid patients—again, a significant difference (p < 0.001). No significant difference was seen between the two groups with respect to age, sex, or the weight of the resected gland. We conclude that hypothyroidism after hemithyroidectomy is not an uncommon occurrence. Apparent risk factors include a high mean preoperative serum TSH level and tissue pathology consistent with chronic inflammation. It may be wise to follow patients with these identifiable risk factors more closely during the postoperative period; monitoring should include scheduled serial serum TSH draws.
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Moreno P, Gómez JM, Gómez N, Francos JM, Ramos E, Rafecas A, Jaurrieta E. Subtotal Thyroidectomy: A Reliable Method to Achieve Euthyroidism in Graves’ Disease. Prognostic Factors. World J Surg 2006; 30:1950-6. [PMID: 17006611 DOI: 10.1007/s00268-005-0770-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Pablo Moreno
- Servicio de Cirugía General y Digestiva, Ciudad Sanitaria y Universitaria de Bellvitge, Barcelona, Spain.
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Bakiri F, Hassaïm M, Bourouba MS. Subtotal Thyroidectomy for Benign Multinodular Goiter: A 6-Month Postoperative Study of the Remnant’s Function and Sonographic Aspect. World J Surg 2006; 30:1096-9. [PMID: 16736342 DOI: 10.1007/s00268-005-0570-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The purpose was to evaluate the thyroid function after subtotal thyroidectomy. METHODS One hundred and nineteen patients operated on for multinodular benign goiter were included in this prospective study. Results of the surgical treatment were evaluated 6 months after operation by thyroid-stimulating hormone (TSH) assay and cervical echography. RESULTS Thyroid-stimulating hormone levels correlated inversely (r=-0.78) with the thyroid remnant volumes. Forty-seven patients presented with a hypoechoic aspect of the remnant. Isoechoic and hypoechoic remnant volumes were similar; however, 46 of the 47 patients with a hypoechoic remnant (97.9%) had TSH levels higher than 5 mU/l vs. 39 of the 72 patients (54.2%) with an isoechoic aspect. No predictive factor for the occurrence of this hypoechoic feature was found. CONCLUSIONS After sub-total thyroidectomy for benign multinodular goiter, the volume of the remnant is not the only determinant of the occurrence of postoperative hypothyroidism. The appearance of a hypoechoic aspect of the remnant is also a strong predictive factor for such an outcome. In this case the occurrence of hypothyroidism is quite constant whatever the volume of the thyroid remnant. Since this evolution toward a hypoechoic aspect of the remnant is unpredictable, our results are an additional argument in favor of total thyroidectomy for benign multinodular goiter.
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Affiliation(s)
- Fawzy Bakiri
- Service d'Endocrinologie, Hôpital Bologhine, Bains-Romains, 16060 Algiers, Algeria.
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Chi SY, Hsei KC, Sheen-Chen SM, Chou FF. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy Versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves? Disease. World J Surg 2005; 29:160-3. [PMID: 15650802 DOI: 10.1007/s00268-004-7529-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2005] [Indexed: 10/26/2022]
Abstract
To reduce the chance of recurrent hyperthyroidism, two methods of subtotal thyroidectomy were performed and compared. From January 1998 to December 2002, 340 patients were operated on with subtotal thyroidectomy. They were prospectively randomized into two groups. Group A included 166 patients and group B 174 patients. Group A patients had a 2.5 x 1 x 1 cm thyroid remnant on each side and group B patients had a 2.5 x 1 x 1 cm remnant on one side plus total lobectomy on the other side. Thyroid function tests including T(3), T(4), TSH, and antimicrosomal antibody (AMA) were checked preoperatively and in the follow-up period of 3 months, and later up to 26.4 +/- 1.1 months (mean +/- SE). The age, sex, duration of oral medicine, and blood loss of the two groups were not significantly different during surgery and the follow-up period. The operative time was less in group A (113 +/- 3.3 minutes) than that in group B (131 +/- 3.2 minutes) (p < 0.001). In the long-term follow-up period, recurrent hyperthyroidism was noted in 15 patients in group A and 3 patients in group B. The difference was significant (p = 0.003). Hypothyroidism was noted in 35 of the group A patients and in 46 of the group B patients. The differences between the two groups regarding hypothyroidism was not significant (p = 0.181). Multivariate logistic regression analysis revealed preoperative titers of AMA > or = 6400, which was the only factor affecting the incidence of hypothyroidism in the later follow-up period. In consideration of hypothyroidism, recurrent hyperthyroidism, and postoperative complications, subtotal thyroidectomy with total lobectomy plus subtotal lobectomy provides a better outcome than bilateral subtotal lobectomy.
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Affiliation(s)
- Shun-Yu Chi
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital at Kaohsioung, 123 Ta Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan
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Sivanandan R, Ng LG, Khin LW, Lim THD, Soo KC. Postoperative endocrine function in patients with surgically treated thyrotoxicosis. Head Neck 2004; 26:331-7. [PMID: 15054736 DOI: 10.1002/hed.10389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Endocrine function after surgery for thyrotoxicosis is difficult to predict. The operative morbidity and long-term thyroid function of patients surgically treated for thyrotoxicosis is presented, and factors postulated to affect long-term function are correlated with outcome. METHODS The clinical records of 289 consecutive patients who underwent surgery for thyrotoxicosis were reviewed. Indications for surgery, intraoperative findings, postoperative complications, and endocrine status 1, 2, and 5 years after surgery were analyzed. Sex, age, duration of medical treatment, weight of thyroid removed and preserved, and antimicrosomal/antithyroglobulin antibody status were correlated with outcome 5 years after surgery. RESULTS The incidence of permanent recurrent laryngeal nerve injury and hypocalcemia were 0.7% and 1.7%. The cumulative hypothyroid and hyperthyroid rates for the first, second, and fifth postoperative years were 13.8% and 3.5%, 14.5% and 4.8%, and 15.6% and 8.0%. All the prognostic variables analyzed did not achieve a significant correlation with outcome at 5 years by univariate and multivariate age- and sex-adjusted relative risk. CONCLUSIONS Failure from hypothyroidism develops early; recurrent hyperthyroidism increases with the number of years of follow-up. Patients undergoing subtotal thyroidectomy warrant long-term follow-up because of the inability to accurately predict postoperative function with consistently reliable prognostic factors.
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Takamura Y, Nakano K, Uruno T, Ito Y, Miya A, Kobayashi K, Yokozawa T, Matsuzuka F, Kuma K, Miyauchi A. Changes in serum TSH receptor antibody (TRAb) values in patients with Graves' disease after total or subtotal thyroidectomy. Endocr J 2003; 50:595-601. [PMID: 14614216 DOI: 10.1507/endocrj.50.595] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
TSH receptor antibodies (TRAb) are generally regarded as mediators of thyroid stimulation in Graves' disease. In addition, a high serum TRAb value during pregnancy is one of the risk factors for intrauterine death, prematurity, and fetal or neonatal hyperthyroidism. Recently, correlations between a high serum TRAb value and endocrine opthalmopathy were also suggested. Surgical resection of the thyroid is usually followed by a reduction of serum TRAb levels in variable degrees. The relation between the extent of the thyroidectomy and the degree of reduction is still controversial. In addition, the changes in the TRAb value after total thyroidectomy (TT) over a long period of time have never been studied. We studied the changes in serum TRAb values after TT and subtotal thyroidectomy (ST) for more than 7 years. Forty-one patients with Graves' disease underwent TT, and 99 patients underwent ST. The serum TRAb values and the ratio of the patients who achieved normal values among each group (normalization rates of TRAb) at 3 and 6 months, 1, 3, 5 and 7 years after surgery were compared between the TT group and ST group. The mean preoperative TRAb values were not significantly different between the TT and ST groups, and the mean TRAb values measured 3, 6 and 12 months after surgery were not significantly different between the groups. However, the TRAb values measured 3, 5 and 7 years after surgery were significantly (p<0.05) lower in the TT group than in the ST group (16.7 +/- 3.3% vs 28.0 +/- 2.6%, 12.6 +/- 3.4% vs 29.3 +/- 3.8%, 5.6 +/- 0.9% vs 25.4 +/- 4.1%, respectively). The normalization rates of TRAb were not significantly different between the groups until 1 year after surgery. However, the normalization rates 3, 5 and 7 years after surgery were significantly (p<0.05) higher in the TT group than in the ST group (65.7% vs 42.4%, 77.3% vs 46.7%, 100% vs 59.1%, respectively). The surgical complication rates of TT were similar to ST except for permanent hypoparathyroidism. TT is a treatment option for Graves' disease, especially in patients with a high TRAb value who wish to have children or who have Graves' opthalmopathy.
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Bhansali SK, Chandalia HB. Thyrotoxicosis--surgical management in the era of evidence-based medicine: experience in western India with 752 cases. Asian J Surg 2002; 25:291-9. [PMID: 12471001 DOI: 10.1016/s1015-9584(09)60194-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The three modalities of treatment of thyrotoxicosis, antithyroid therapy (ATT), radio-iodine (I131) therapy and surgery are not cause-specific. In this paper, we describe our evolving experience with 752 thyrotoxic patients who underwent surgery during the last 40 years and discuss the current scenario with evidence-based data and observations wherever possible. Thyroidectomy was performed in 428 patients with Grave's disease (GD), 299 patients with toxic multinodular goitre, and 25 with toxic solitary nodules (TSN). Whereas 289 patients with GD had surgery for failed ATT, the other 139 had primary surgery for controversial or debatable indications such as poor socio-economic status, desire for early pregnancy, poor drug compliance and severe ophthalmopathy. Preoperatively, all patients were administered carbimazole or propylthiouracil. Non-selective b-blocker propranolol and Lugol's iodine were routinely given. In the 25 patients with TSN, hemithyroidectomy was performed. In all others, subtotal thyroidectomy (STT), was performed leaving behind 4 to 8 g of thyroid tissue: a larger amount was left behind in those with higher antithyroid antibody titres. During the last decade, 80 patients received near total thyroidectomy (NTT), mainly to minimize recurrence of thyrotoxicosis and to ameliorate severe eye signs. Because of our increasing experience, no significant increase in postoperative morbidity was encountered with NTT compared to STT. Transient hoarseness was observed in 53 patients with STT and only in two patients with NTT. Three patients with STT and one with NTT developed permanent hoarseness due to recurrent laryngeal nerve palsy; voice in these four was normalized by intraglottic injection of Teflon paste 6 months after the operation. In patients undergoing STT, transient hypoparathyroidism was encountered in 63, and permanent hypoparathyroidism in five. The corresponding figures for NTT were 12 and one, respectively. Of the 500 patients monitored for 1 year or more, hypothyroidism was observed in 135 and recurrent thyrotoxicosis in nine. In the same group of 500, exophthalmos was ameliorated in 130 of the 265 with positive eye signs. Nineteen glands exhibited features of severe Hashitoxicosis with marked destruction of acini and considerable lymphoid aggregates and follicles. Carcinoma was observed in three other thyroid glands.
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Affiliation(s)
- S K Bhansali
- Department of Surgery, Jaslok Hospital and Research Centre, Mumbai, India.
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Bilosi M, Binquet C, Goudet P, Lalanne-Mistrih ML, Brun JM, Cougard P. [Is subtotal bilateral thyroidectomy still indicated in patients with Grave's disease?]. ANNALES DE CHIRURGIE 2002; 127:115-20. [PMID: 11885370 DOI: 10.1016/s0003-3944(01)00689-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM OF THE STUDY To evaluate the morbidity and the functional results of subtotal bilateral thyroidectomy in patients (TST) with Graves' disease. PATIENTS AND METHOD A retrospective study was performed in 128 patients. They were 23 males and 105 females with a median age of 34 years (range: 14-68). Weight of remnant tissue was between 4 and 5 g. Thyroid functional status was evaluated, at 3 months and after a follow-up period ranged from 1 to 5 years, by measurement of serum concentration of free T4 and/or free T3 and TSH. RESULTS They were no post-operative death. Surgical complications were 2 vocal cord palsies and 17 hypocalcemia (inf. to 2 mmol/L). After a median follow-up of 2 years, they were no longer any cases of vocal cord dysfunction and no case of permanent hypoparathyroidism. Functional results were established in 118 patients: 46 patients had clinical hypothyroidism (39%), 64 patients had latent hypothyroidism or euthyroidism (54.2%), and 8 had recurrent hyperthyroidism (6.8%). CONCLUSION These results suggest that TST with a remnant mass inferior to 5 g provides a low level of recurrent hyperthyroidism and allows to give no drug therapy to half patients. In our opinion, TST is still indicated in Graves' disease.
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Affiliation(s)
- M Bilosi
- Service de chirurgie générale et endocrinienne, hôpital général, CHU Dijon, rue du Faubourg-Raines, 21000 Dijon, France
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Shimizu K, Kumita SI, Kitamura Y, Nagahama M, Kitagawa W, Akasu H, Oshina T, Kumasaki T, Tanaka S. Trial of autotransplantation of cryopreserved thyroid tissue for postoperative hypothyroidism in patients with Graves' disease. J Am Coll Surg 2002; 194:14-22. [PMID: 11800336 DOI: 10.1016/s1072-7515(01)01115-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Some patients with Graves' disease who select surgical therapy so they can discontinue antithyroid medication require lifelong levo-thyroxin (l-T4) replacement therapy because of irreversible postoperative hypothyroidism. The aim of this study was to enable the replacement of absent thyroid hormone through autotransplanted thyroid tissue that had been cryopreserved since the initial thyroid operation, and to release these patients from lifelong l-T4 administration. STUDY DESIGN At the time of subtotal thyroidectomy for Graves' disease, the surgical specimen was partially cryopreserved at -196 degrees C until it was used for autotransplantation. After obtaining sufficient informed consent, four patients with postoperative hypothyroidism underwent autotransplantation of cryopreserved thyroid tissues. These patients required 50 to 150 microg/day of l-T4 at 1.8, 3.4, 3.5, and 2.8 years after operation. For the transplantation, 2.5 to 3.5 g of cryopreserved thyroid tissue was autotransplanted into the forearm muscle of each patient. RESULTS In three of the patients, l-T4 administration could be discontinued and the clinical symptoms of hypothyroidism disappeared because of an improved serum thyroid-stimulating hormone level. Pathologic and immunohistochemical examinations of the thawed cryopreserved tissue demonstrated well-preserved thyroid structure and thyroglobulin-positive follicular cells and colloids, suggesting that the transplanted material was functional. In addition, 123I scintiscanning in patients 1 and 2 indicated an accumulation of radioactive iodine at the transplantation sites. One patient, who was able to discontinue l-T4 administration for 6 months, subsequently required l-T4 again because of recurrent hypothyroidism. BACKGROUND Despite a few remaining uncertainties that must be resolved before this procedure is optimized, autotransplantation of cryopreserved thyroid tissue promises to be a useful therapeutic procedure for treating permanent postoperative hypothyroidism in patients with Graves' disease.
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Affiliation(s)
- Kazuo Shimizu
- Nippon Medical School, Department of Surgery II, Tokyo, Japan
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Palit TK, Miller CC, Miltenburg DM. The efficacy of thyroidectomy for Graves' disease: A meta-analysis. J Surg Res 2000; 90:161-5. [PMID: 10792958 DOI: 10.1006/jsre.2000.5875] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgery for Graves' disease was largely replaced in the mid-1900s by radioiodine and antithyroid drugs, due to the belief that they were more safe and effective. Since then, thyroid surgery has improved with preoperative drug therapy and modern operative techniques. Recent clinical studies of thyroidectomy for Graves' disease may not reflect outcomes accurately because of small sample size, especially when estimating ideal thyroid remnant size. The purpose of this study was to combine modern clinical trials and use meta-analysis to determine the overall efficacy of both total (TT) and subtotal thyroidectomy (ST) for Graves' disease, compare thyroid function and complications rates of TT and ST, and determine ideal thyroid remnant size. METHODS Meta-analysis was performed on published studies in which patients underwent either TT or ST for Graves' disease. Meta-analysis was performed by weighted least-squares linear regression. P < 0.05 was considered significant. RESULTS There were 35 studies comprising 7241 patients. Mean follow-up was 5.6 years. Overall, persistent or recurrent hyperthyroidism occurred in 7.2% of patients. TT was performed on 538 patients and hypothyroidism occurred in all cases. ST was performed in 6703 patients, 59.7% of whom achieved euthyroidism, 25. 6% became hypothyroid, and 7.9% had either persistent or recurrent hyperthyroidism. Permanent recurrent laryngeal nerve injury occurred in 0.9% of TT patients and 0.7% of ST patients (P = NS). Permanent hypoparathyroidism occurred in 1.6% of TT patients and 1.0% of ST patients (P = NS). There was an 8.9% decrease in hypothyroidism and 6.9% increase in euthyroidism for each gram of thyroid remnant (P < 0.0001 each). CONCLUSIONS Overall, thyroidectomy successfully treated hyperthyroidism in 92% of patients with Graves' disease. There were no cases of hyperthyroidism following TT. ST achieved a euthyroid state in almost 60% of patients with an 8% rate of persistent or recurrent hyperthyroidism. There was no significant difference in complication rates between TT and ST.
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Affiliation(s)
- T K Palit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA
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Moreno Pérez D, Borrás Pérez V, López Siguero J. Hipertiroidismo en neonatos de madres tiroidectomizadas por enfermedad de Graves. An Pediatr (Barc) 2000. [DOI: 10.1016/s1695-4033(00)78638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
The objective of this study was to find the factors responsible for hypothyroidism after subtotal thyroidectomy for Graves' disease. Two hundred five patients who were operated on from July 1989 to December 1997 were studied. The mean age of patients was 33.4+/-11.0 (mean +/- SD) years, and 175 (85.4%) were female. Patients were prepared with an antithyroid drug and Lugol's solution preoperatively. Triiodothyronine (T3), thyroxine (T4), thyrotropin (TSH), thyrotropin-binding immunoglobulins (TBII) antimicrosomal antibodies (AMA = 100x 4(M-1)), and antithyroglobulin antibodies (ATA = 100x4(T-1)) were measured 1 week before patients were operated on. Operations were performed according to the standard procedure with 2.5x1x1 cm of thyroid tissue remaining on each side before approximating the thyroid capsule and pretracheal fascia. Hypothyroidism was defined by patients with overt hypothyroidism in laboratory data, and or with T4 to maintain T3 and T4. Two hundred two patients were checked 3 months after being operated on. Latent hyperthyroidism was found in 22, euthyroidism in 55, latent hypothyroidism in 91, hypothyroidism in 34 (16.8%) and none were in overt hyperthyroidism. After a follow-up period of 26.9+/-15 (mean +/- SD) months, 199 patients were reevaluated. Overt hyperthyroidism was found in 2 patients, latent hyperthyroidism in 12, euthyroidism in 97, latent hypothyroidism in 72, and hypothyroidism in 16 (8%). Factors having possible effects on hypothyroidism after longterm follow-up were analyzed. Patient's age, gender, body surface, premedicative T3 and T4, preoperative ATA, and TBII, and the weight of removed thyroid had no effect on the occurrence of hypothyroidism. Preoperative AMA levels, and finding more than 10 lymphoid infiltrations per 10 low-power fields (x40) were significantly different between the hypothyroid and nonhypothyroid groups. A high level of preoperative AMA was the only factor independently causing overt hypothyroidism in the follow-up period. Patients with high preoperative AMA levels have a higher risk of hypothyroidism if only 2.5x1x1 cm remnants are left on each side.
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Affiliation(s)
- F F Chou
- Department of Surgery, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung Hsien, Taiwan, ROC.
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Hermann M, Roka R, Richter B, Freissmuth M. Early relapse after operation for Graves' disease: Postoperative hormone kinetics and outcome after subtotal, near-total, and total thyroidectomy. Surgery 1998. [DOI: 10.1016/s0039-6060(98)70014-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ozaki O, Ito K, Mimura T, Sugino K, Ito K. Factors affecting thyroid function after subtotal thyroidectomy for Graves' disease: case control study by remnant-weight matched-pair analysis. Thyroid 1997; 7:555-9. [PMID: 9292942 DOI: 10.1089/thy.1997.7.555] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In order to determine whether there are any predictive factors, other than the amount of remnant thyroid tissue, for subsequent thyroid function after subtotal thyroidectomy for Graves' disease, thyroid function was assessed in 329 patients 3 years after surgery, and a case control study was carried out in euthyroid, hyperthyroid, and hypothyroid groups by remnant-weight matched-pair analysis. Factors that affected thyroid function 3 years after surgery were thyroid gland infiltration by lymphocytes and the thyrotropin binding inhibiting immunoglobulin (TBII) value in the hyperthyroid and euthyroid groups, and the free triiodothyronine (FT3) value at the time of surgery and lymph follicle formation in the thyroid gland in the hypothyroid and euthyroid groups. It is concluded that no single factor studied at surgery, other than the amount of remnant tissue, can predict thyroid function after subtotal thyroidectomy for Graves' disease.
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Affiliation(s)
- O Ozaki
- Surgical Department, Ito Hospital, Tokyo, Japan
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Miccoli P, Vitti P, Rago T, Iacconi P, Bartalena L, Bogazzi F, Fiore E, Valeriano R, Chiovato L, Rocchi R, Pinchera A. Surgical treatment of Graves' disease: subtotal or total thyroidectomy? Surgery 1996; 120:1020-4; discussion 1024-5. [PMID: 8957489 DOI: 10.1016/s0039-6060(96)80049-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The extent of thyroidectomy in Graves' disease is still controversial. We compared the outcome of two groups of patients with Graves' disease who underwent total and subtotal thyroidectomy, respectively. METHODS One hundred forty patients were treated by subtotal (ST, n = 80) or total thyroidectomy (TT, n = 60) between 1988 and 1994 for a large goiter or recurrence of hyperthyroidism after antithyroid drugs. Surgical complications, relapse of hyperthyroidism, and serum levels of antibodies were evaluated. RESULTS Thyroid-stimulating hormone receptor and thyroperoxidase antibodies significantly decreased in 44 of 60 and in 27 of 60, respectively, of TT patients and in 65 of 80 and 8 of 80, respectively, of ST patients. Thyroid-stimulating hormone antibody levels increased in three ST patients who had relapse of hyperthyroidism and in no TT patients; thyroperoxidase antibodies increased in nine ST patients (four with relapse of hyperthyroidism) and in no TT patients. Vocal cord palsy occurred in two ST (2.5%) and in 1 TT (1.7%) patients; hypoparathyroidism occurred in three ST (3.8%) and in two (3.3%) TT patients. CONCLUSIONS Total thyroidectomy does not present more complications with respect to subtotal thyroidectomy, but it avoids the worsening of thyroid humoral autoimmunity and the relapse of hyperthyroidism. Thus it could represent the treatment of choice in Graves' disease.
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Affiliation(s)
- P Miccoli
- Department of Surgery, University of Pisa, Italy
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Sugino K, Mimura T, Ozaki O, Kure Y, Iwasaki H, Wada N, Matsumoto A, Ito K. Early recurrence of hyperthyroidism in patients with Graves' disease treated by subtotal thyroidectomy. World J Surg 1995; 19:648-52. [PMID: 7676715 DOI: 10.1007/bf00294748] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Prerequisites for surgical treatment of Graves' disease are that it can be done safely and that it is associated with a low incidence of recurrent hyperthyroidism. Early recurrence is especially undesirable. We studied 728 patients with Graves' disease treated by subtotal thyroidectomy using multivariate analysis in order to determine the factors related to early recurrence. The following factors were analyzed: age, sex, duration of medical treatment, weight of resected thyroid tissue, thyroid remnant size, preoperative level of thyroid-stimulating hormone (TSH) binding inhibitory immunoglobulin (TBII), and antimicrosomal hemagglutination antibody (MCHA). "Early recurrence" was defined as TSH suppression observed within the first year after surgery and continuing for at least 6 months. A total of 106 patients (14.6%) had early recurrence. Statistical analyses were performed by the chi-square test for univariate analysis and a logistic model for multivariate analysis. Significant factors were thyroid remnant size, MCHA, and TBII. These results indicated that TBII and MCHA are related to early recurrence of hyperthyroidism, and smaller remnant size is recommended for patients with a high MCHA titer or a high TBII level (or both) in order to avoid early recurrence.
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Sugino K, Mimura T, Ozaki O, Iwasaki H, Wada N, Matsumoto A, Ito K. Management of recurrent hyperthyroidism in patients with Graves' disease treated by subtotal thyroidectomy. J Endocrinol Invest 1995; 18:415-9. [PMID: 7594234 DOI: 10.1007/bf03349738] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
If the aim of surgical treatment for Graves' disease is not permanent hypothyroidism, it is difficult to avoid recurrent hyperthyroidism completely. The management of recurrent hyperthyroidism, however, is neither easy nor obvious. Improvement in the sensitivity of TSH assay has allowed the diagnosis of latent hyperthyroidism. Little is known about the clinical course of latent hyperthyroidism. We studied the management and outcome of recurrent hyperthyroidism in patients with Graves' disease treated by subtotal thyroidectomy. Between January 1988 and August 1991, 1115 patients with Graves' disease were treated by surgery. Postoperative thyroid function was evaluated by free T3, free T4 and TSH measurements. One hundred seventy-five patients with suppressed TSH secretion for at least 6 months were categorized as having recurrent hyperthyroidism. Eighty patients (45.1%) also had elevated thyroid hormone levels, (group 1). The remaining 95 patients (54.9%) had normal thyroid hormone levels with suppressed TSH values (group 2). In group 1, 58 patients were treated with antithyroid drug (ATD), 12 with iodine and 10 with radioiodine (RI). Remission of Graves' disease was obtained in 22 patients (11 by ATD, 1 by iodine and 10 by Ri). On the other hand, patients in group 2 were followed up without medication, and spontaneous remission was observed in 21 of theln (22.1%). It was difficult to induce remission of overt recurrent Graves' disease by ATD or iodine. In contrast spontaneous remission could be obtained in some patients with postoperative latent hyperthyroidism.
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