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

Systematic Review and Meta-Analysis: Recurrent Laryngeal Nerve Variants and Their Implication in Surgery and Neck Pathologies, Using the Anatomical Quality Assurance (AQUA) Checklist

INTRODUCTION

The recurrent laryngeal nerve (RLN) is the structure responsible for sensory and motor innervation of the larynx, and it has been shown that its lesion due to a lack of surgical rigor led to alterations such as respiratory obstruction due to vocal cords paralysis and permanent phonation impairment. The objectives of this review were to know the variants of the RLN and its clinical relevance in the neck region.

METHODS

This review considered specific scientific articles that were written in Spanish or English and published between 1960 and 2022. A systematic search was carried out in the electronic databases MEDLINE, WOS, CINAHL, SCOPUS, SCIELO, and Latin American and Caribbean Center for Information on Health Sciences to compile the available literature on the subject to be treated and was enrolled in PROSPERO. The included articles were studies that had a sample of RLN dissections or imaging, intervention group to look for RLN variants, or the comparison of the non-recurrent laryngeal nerve (NRLN) variants, and finally, its clinical correlations. Review articles and letters to the editor were excluded. All included articles were evaluated through quality assessment and risk of bias analysis using the methodological quality assurance tool for anatomical studies (AQUA). The extracted data in the meta-analysis were interpreted to calculate the prevalence of the RLN variants and their comparison and the relationship between the RLN and NRLN. The heterogeneity degree between included studies was assessed.

RESULTS

The included studies that showed variants of the RLN included in this review were 41, a total of 29,218. For the statistical analysis of the prevalence of the RLN variant, a forest plot was performed with 15 studies that met the condition of having a prevalence of less than 100%. As a result, the prevalence was shown to be 12% (95% CI, SD 0.11 to 0.14). Limitations that were present in this review were the publication bias of the included studies, the probability of not having carried out the most sensitive and specific search, and finally, the authors' personal inclinations in selecting the articles.

DISCUSSION

This meta-analysis can be considered based on an update of the prevalence of RLN variants, in addition to considering that the results show some clinical correlations such as intra-surgical complications and with some pathologies and aspects function of the vocal cords, which could be a guideline in management prior to surgery or of interest for the diagnostic.

Time to Symptom Resolution After Total Thyroidectomy for Graves' Disease

INTRODUCTION

Total thyroidectomy (TT) has been shown to be a safe and effective treatment for Graves' disease. However, the time course for improvement of symptoms has not been defined.

METHODS

With an institutional review board approval, we prospectively gathered survey data of all patients (n = 79) undergoing TT for Graves' disease at a single institution from 2019 to 2021. After informed consent was obtained, patients completed surveys preoperatively and at 2 wk followed by monthly postoperative visits/phone calls. Patient demographics and survey results were collected and analyzed. Symptom recovery time was evaluated using Kaplan-Meier analysis.

RESULTS

A total of 50 patients completed the survey on postoperative follow-up (response rate 63%). Average age was 38 y (range 12-80 y) and 88% of patients were female. The most common preoperative symptoms were fatigue (90%) and heat/cold intolerance (88%). Tremor (median time to resolution: 1 wk; interquartile range [IQR] 1-3), diarrhea (median 1 wk [IQR 1-3]), and palpitations (median 1 wk [IQR 1-3]) resolved the most rapidly followed by eye symptoms (median 3 wk [IQR 1-6]), heat/cold intolerance (median 3 wk [IQR 3-30]), memory deficits (median 3 wk [IQR 1-undefined]), and fatigue (median: 3 wk [IQR 1-14]). There were no significant differences in time to resolution of symptoms by gender or age (less than versus 40 y and older). Those with uncontrolled Graves' had more severe symptoms but no difference in time to resolution from the euthyroid Graves' patients.

CONCLUSIONS

Many Graves' disease symptoms improve rapidly following TT, with a median time to improvement of less than 1 mo.

Narrative review of management of thyroid surgery complications

Currently, thyroid surgery is the most common and safe operation worldwide. However, thyroidectomy is still not free from the risks of complications and death due to the anatomical structure and physiological function particularity of the thyroid gland. Postoperative complications affect the life quality and life safety of patients after surgery. The common complications include hypoparathyroidism (HP), recurrent laryngeal nerve (RLN) injury, injury to the external branch of the superior laryngeal nerve (EBSLN), postoperative bleeding (PB), thoracic duct injury, laryngeal edema, tracheospasm, tracheal injury, and esophageal injury. A severe complication, such as dyspnea, asphyxia, or thyroid crisis, might cause the death of the patient. Therefore, every thyroid surgeon's responsibility is to remain alert and aware of the occurrence of various intraoperative and postoperative complications and exercise effective prevention and treatment. This is closely related to the advancement in thyroid disease research, the increase in local anatomy knowledge, the standardization of surgical approaches, the improvement in operating skills, the application of new technologies, and the emphasis on specialty training. In addition, many complications that effect patients are much better tolerated if the patient has appropriate expectations of what the complications are and how to treat them. Open communication between surgeon and patient optimizes the potential negative effects that complications may have on patients' quality of life. This paper discusses the prevention, recognition and therapy of intraoperative and postoperative complications in thyroid surgery.

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.

Cross-sectional investigation of serum creatine kinase concentration in Graves disease patients treated with oral antithyroid drugs

Elevated serum creatine kinase (CK) concentration was reported in some Graves disease patients during the treatment with oral antithyroid drugs (ATD). The pathogenesis of this abnormal biochemical value was considered to be related to the therapeutic drug. However, the relevant epidemiological investigation was absent.Overall, 416 patients with Graves disease treated with oral ATDs were recruited from December 2017 to October 2019. Clinical characteristics such as the patient's medical history and therapeutic regimen were collected. Serum CK concentration and thyroid function were measured. Statistical analysis was adopted to clarify the relationship between serum CK level and these clinical parameters.Elevation of serum CK concentration was emerged in 13.5% patients who were treated with oral ATDs. The proportion was significantly higher among men than among women (19.5% vs 10.8%). There was no correlation between increased serum CK concentration and age. More than 60% of serum CK elevations occurred within 6 months after taking oral ATDs. Free triiodothyronine and free thyroxine are negatively correlated with serum CK concentration. The correlation coefficients are respectively -0.222 (P < .05) and -0.234 (P < .05). There is positive correlation between thyroid stimulating hormone and serum CK concentration. The correlation coefficient is 0.405 (P < .05). There was no statistical correlation between drug dosage and increased serum CK level.Increased serum CK level is a common adverse reaction of oral ATDs. It generally develops early after starting treatment. The cause of this adverse reaction is not clear. It is speculated that elevation of serum CK level is related to the fluctuation of thyroid function.

[Role and effectiveness of radioactive-iodine therapy for the treatment of Grave's disease]

The treatment of Graves' disease is based on three therapies: medical treatment with synthetic antithyroid agents, surgery and radioactive-iodine therapy. The purpose of our study was to study the role and effectiveness of radioactive-iodine therapy for the treatment of Graves' disease. We conducted a retrospective, descriptive study of the epidemiological, clinical, paralclinical and therapeutic features of 54 patients with Graves' disease managed and treated with iodine-131 as well as of their short- and medium-term remission rate. The sex ratio was 0.45. The average age of patients was 38,33 ± 12.7 years. The most common functional signs were weight loss, tremors and palpitations. Mean FT4 was 54,51 ± 19,56 ng/dl (ranging from 8,90 and 100). Mean TSHus was 0,074 ± 0,29 µIU/ml. Synthetic antithyroid drugs were used in 49 patients; 83,67% of cases had persistent hyperthyroidism. Radioactive-iodine therapy was used as first-line therapy in 9,3% of cases and as second-line therapy in 90,7% of cases. Mean activity was 13,29 mCi ± 1,46 ranging from 10 to 15 mCi. The first assessment of hormonal status was performed after an average post-treatment period of 1,91 months; 29 patients (53,7%) achieved remission (eu- or hypo-thyroidism). After a 12 month-follow-up, patients' course was marked by remission in 88,88% of cases (euthyroidism in 14,8% and hypothyroidism in 74% of cases). Radioactive-iodine therapy is an effective treatment for Graves' disease. High radioactive iodine dose provides high remission rate.

The effect of dexamethasone on pain control after thyroid surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

The effect of dexamethasone on postoperative pain after thyroid surgery remains controversial. We conduct a systematic review and meta-analysis to explore the influence of dexamethasone versus placebo on postoperative pain after thyroid surgery.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through May 2020 for randomized controlled trials (RCTs) assessing the effect of dexamethasone versus placebo on postoperative pain after thyroid surgery. This meta-analysis is performed using the random-effect model.

RESULTS

Eight RCTs involving 734 patients are included in the meta-analysis. Overall, compared with control group for thyroid surgery, dexamethasone shows significantly reduced pain scores (SMD = - 0.82; 95% CI - 1.08 to - 0.56; P < 0.00001), number of required analgesics (OR = 0.18; 95% CI 0.11-0.31; P < 0.00001), analgesic consumption (SMD = - 0.38; 95% CI - 0.63 to - 0.13; P = 0.003), nausea and vomiting (OR = 0.38; 95% CI 0.17-0.86; P = 0.02), as well as rescue antiemetics (OR = 0.40; 95% CI 0.20-0.79; P = 0.008).

CONCLUSIONS

Perioperative dexamethasone is effective to reduce the pain, nausea and vomiting after thyroid surgery.