Treatment of Graves' disease: the advantages of surgery

Hemodynamic Instability during Thyroidectomy in Graves' Disease

BACKGROUND

The aim of this study was to investigate the changes in vital signs and hemodynamic status that occur in patients during the intraoperative course of thyroidectomy in Graves' Disease (GD).

METHODS

A total of 71 patients were included in the study. Patients were directed to surgery when they had large goiters with compressive symptoms or suspicious nodules, were pregnant or lactating, were unresponsive or intolerant to antithyroid drugs (ATDs), or expressed a preference to have surgery. All patients scheduled for operations underwent surgery while in the euthyroid state.

RESULTS

Hemodynamic instability was observed in 18 patients during thyroidectomy. Disease duration, sample weight, and thyroid-stimulating hormone receptor antibodies (TRAb) levels were found to be effective on hemodynamic instability. Logistic regression analysis revealed an 11-fold increase in the instability risk in patients with a period of disease shorter than 21 months (P = 0.037). A TRAb value >11.5 increased the risk by 235fold (p < 0.001).

CONCLUSION

High levels of TRAb values and new onset of disease with shorter periods of ATDs use may be risk factors for hemodynamic instability during thyroidectomy. Patients with larger thyroid glands are at greater risk for instability during surgery. Those risks should be taken into account during surgery, and the surgical and anesthetic management of the patient should be made more carefully in concordance with the anesthesia team.

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.

Management of Graves’ Hyperthyroidism: More Than a Century of Progression

Context: There are three therapeutic modalities for the management of Graves’ disease (GD), including thyroid surgery, radioactive iodine (RAI), and antithyroid drugs (ATDs). We aimed to briefly review the history of these treatment strategies and their advantages and disadvantages. Evidence Acquisition: We searched PubMed for English language articles using pertinent search terms. Results: Each treatment modality for GD is accompanied by several advantages and disadvantages. Nowadays, ATDs are the most commonly prescribed therapy for GD worldwide. The lack of well-designed, large RCTs comparing three different treatments for hyperthyroidism concerning various short-term and long-term outcomes has led to remarkable uncertainty in the preference of each of these treatments, as is evident in relevant guidelines from different societies. Recently, the efficacy and safety of long-term use of ATDs have been documented. Conclusions: Pros and cons of each therapeutic modality for Graves’ hyperthyroidism should be taken into account during the physician-patient discussion to select the primary treatment. Considering recent data about the long-term efficacy and safety of ATDs, it seems that the appropriate selection of Graves’ patients for long-term ATD therapy can be a new avenue in the treatment and even cure of GD.

Impact of surgery versus medical management on cardiovascular manifestations in Graves disease

BACKGROUND

Graves disease is well known to have multiple adverse effects on the cardiovascular system. We compared the cardiovascular outcomes after surgical intervention versus medical treatment in patients with Graves disease.

METHODS

We performed a retrospective study of all Graves disease patients with a cardiovascular comorbidity who underwent either surgical or medical management (N = 151). Perioperative biochemical and cardiovascular outcomes from the surgical versus the medical groups were analyzed.

RESULTS

Of 151 patients, 69 (45.6%) patients underwent total thyroidectomy and 82 (54.3%) patients received medical treatment. Hypertension resolved in 44.7% of the patients from the surgical group vs 18% in the medical group (P = .03). Tachyarrhythmias, including atrial fibrillation and tachycardia, improved in 85.9% of patients in the surgical group vs 66% in the medical group (P = .01). All cardiovascular manifestations examined, hypertension, tachyarrhythmias, and heart failure, improved in 69% of patients in the surgical group and 42.6% of patients in the medical group during the follow-up period (P < .01).

CONCLUSION

Surgical treatment offers a significant and rapid clinical improvement of cardiovascular manifestations in Graves disease patients, such as hypertension, tachyarrhythmias, and heart failure. Surgery should be considered and recommended in Graves disease patients with known cardiovascular manifestations.

Exosomes as Mediators of Cell-to-Cell Communication in Thyroid Disease

Exosomes are a type of extracellular vehicle, formed by budding cell membranes, containing proteins, DNA, and RNA. Concentrated cargoes from parent cells are enveloped in exosomes, which are cell specific and may have functions in the recipient cell, reflecting a novel physiological and pathological mechanism in disease development. As a transmitter, exosomes shuttle to different cells or tissues and mediate communications among these organelles. To date, several studies have demonstrated that exosomes play crucial roles in disease pathogenesis and development, such as breast and prostate cancer. However, studies investigating connections between exosomes and thyroid disease are limited. In this review, recent research advances on exosomes in thyroid cancer and Graves' disease are reviewed. These studies suggest that exosomes are involved in thyroid disease and appear as impressive potentials in thyroid therapeutic areas.

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.

The value of total thyroidectomy as the definitive treatment for Graves' disease: A single centre experience of 594 cases

PURPOSE

Thyroidectomy is the preferred approach as the definitive treatment for Graves' disease. The outcomes for total thyroidectomy in a large series of 594 patients, who were observed in the last decade, will be presented in this study.

METHODS

The study concerned a retrospective review of 594 patients, undergoing a total thyroidectomy for Graves' disease. The incidence of complications and outcomes on hyperthyroidism and correlated symptoms resolution were also evaluated.

RESULTS

The mean age of the patients was of 44.7 ± 12.7 years and 456 patients (76.7%) were females. The mean gland weight was 67.3 ± 10.8 g (range: 20-350 g) and, in 397 patients (66.8%), the gland weighed >40 g. The mean operative time was 125 ± 23.1 min (range: 65-212 min). Temporary and permanent hypocalcaemia developed in 241 (40.6%) and 3 patients (0.5%), respectively. Temporary and permanent recurrent laryngeal nerve palsy were recorded in 31 (5.2%) and 1 patients (0.16%) respectively. No patient developed a thyroid storm. On multivariate analysis, patient age ≤50 years (Odds ratio: 1; 95% Confidence Interval: 0.843-0.901) and thyroid weight >40 g (Odds ratio: 1; 95%, Confidence Interval: 0.852-0.974), were mainly associated with the occurrence of complications.

CONCLUSION

This high-volume surgeon experience demonstrates that total thyroidectomy is a safe and effective treatment for Graves' disease. It is associated with a very low incidence rate of post-operative complications, most of which are transitory; therefore, it offers a rapid and definitive control of hyperthyroidism and its related symptoms.

The Role of Surgery in Autoimmune Conditions of the Thyroid

The two most common autoimmune conditions of the thyroid include chronic lymphocytic (Hashimoto's) thyroiditis and Graves' disease. Both conditions can be treated medically, but surgery plays an important role. Hashimoto's thyroiditis and Graves' disease are mediated by autoantibodies that interact directly with the thyroid, creating inflammation and impacting thyroid function. Patients may develop large goiters with compressive symptoms or malignancy requiring surgical intervention. In addition, there are several surgical indications specific to Hashimoto's and Graves' Disease.

Treatment of adult Graves' disease

Treatment strategy in Graves' disease firstly requires recovery of euthyroid status by antithyroid therapy. Treatment modalities, precautions, advantages and side-effects are to be discussed with the patient. No particular treatment modality has demonstrated superiority. Pregnancy or pregnancy project affects choice of treatment and monitoring. Graves' orbitopathy is liable to be aggravated by iodine-131 treatment and requires pre-treatment assessment. Iodine-131 treatment aims at achieving hypothyroidism. Thyroid surgery for Graves' disease should preferably be performed by an expert team. In case of recurrence of hyperthyroidism, the various treatment options should be discussed with the patient. Empiric treatment of thyroid dermopathy uses local corticosteroids in occlusive dressing.

To admit or not to admit? Experience with outpatient thyroidectomy for Graves' disease in a high-volume tertiary care center

BACKGROUND

Outpatient thyroidectomy is increasingly performed. Thyroidectomy for Graves' disease, however, has greater risk of periprocedural complications, limiting use of same-day procedures. We sought to demonstrate that these patients may be managed with ambulatory surgery.

METHODS

The experience of one endocrine surgeon with thyroidectomy for Graves' was examined from January 2016-November 2017. Forty-one patients met criteria. Patient demographics, perioperative parameters, and postoperative outcomes including emergency department utilization and readmission were recorded.

RESULTS

Mean age was 31.5 ± 17.0 years, with 80% females. Mode ASA score was 3, and median operative time was 77 minutes (43-132). Complications included transient hypocalcaemia in 12%, and temporary laryngeal nerve palsy in 9.7%, with no permanent complications. Two patients were admitted immediately postoperatively for non-medical reasons. Thirty-day emergency rdepartment visits were noted in 9.7%, with subsequent readmission of 7%.

CONCLUSIONS

Outpatient total thyroidectomy is safe and effective with acceptable morbidity in the Graves' patient.

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.

Total thyroidectomy as a method of choice in the treatment of Graves' disease - analysis of 1432 patients

Background

Graves’ disease represents an autoimmune disease of the thyroid gland where surgery has an important role in its treatment. The aim of our paper was to analyze the results of surgical treatment, the frequency of microcarcinoma and carcinoma, as well as to compare surgical complications in relation to the various types of operations performed for Graves’ disease.

Methods

We analysed 1432 patients (221 male and 1211 female) who underwent surgery for Graves’ disease at the Centre for Endocrine Surgery in Belgrade during 15 years (1996–2010). Average age was 34.8 years. Frequency of surgical complications within the groups was analyzed with nonparametric Fisher’s test.

Results

Total thyroidectomy (TT) was performed in 974 (68%) patients, and Dunhill operation (D) in 221 (15.4). Carcinoma of thyroid gland was found in 146 patients (10.2%), of which 129 (9%) were a microcarcinoma. Complication rates were higher in the TT group, where there were 31 (3.2%) patients with permanent hypoparathyroidism, 9 (0.9%) patients with unilateral recurrent nerve paralysis and 10 (1.0%) patients with postoperative bleeding. Combined complications, such as permanent hypoparathyroidism with bleeding were more common in the D group where there were 2 patients (0,9%), while unilateral recurrent nerve paralysis with bleeding was more common in the TT group where there were 3 cases (0,3%).

Conclusions

Frequency of complications were not significantly statistically different in relation to the type of surgical procedure. Total thyroidectomy represents a safe and efficient method for treating patients with Graves’ disease, and it is not followed by a greater frequency of complications in relation to less extensive procedures.

Total Thyroidectomy as Primary Definitive Treatment for Graves’ Hyperthyroidism

The objective of this study was to compare the results of total thyroidectomy (TT) for hyperthy-roidism secondary to Graves’ disease (GD) with TT for other benign thyroid diseases to determine if TT should be considered more often as first-line therapy for GD. Seven hundred eighty patients underwent TT for benign disease: 203 for GD, 56 for other hyperthyroidisms, and 521 for other benign diseases from March 1, 2003, to December 31, 2009. The perioperative results of these three groups were compared for demographics, blood loss, operative time, complications, and hospitalization. There were no significant differences among the three groups except the patients with GD were more likely to be younger (42 vs 56 vs 57 years; P < 0.001), have more blood loss (154 vs 99 vs 110 mL; P = 0.05), and were more likely to develop permanent hypoparathyroidism (1.0 vs 1.8 vs 0%; P = 0.03) when compared with other causes of hyperthyroidism and other benign thyroid diseases. Permanent recurrent laryngeal nerve injury did not occur in the GD group (0 vs 0 vs 0.4% nerves at risk; P = 0.69) with transient recurrent laryngeal nerve injury occurring in 1.7 versus 2.7 versus 3.1 per cent nerves at risk ( P = 0.35). The lack of a euthyroid state preoperatively had no influence on surgical outcomes or complications. Eighty percent of the TTs for GD were done as same-day outpatient procedures. TT offers a safe, low-risk, and rapid cure for GD to justifiably be considered as a reasonable first-line therapy in selected patients with Graves’ hyperthyroidism.

Feasibility and safety of minimal-incision thyroidectomy for Graves' disease: a prospective, single-center study

BACKGROUND

The role of minimally invasive surgery in Graves' disease is still controversial. The aim of this study was to compare the clinical outcomes of patients undergoing minimal-incision thyroidectomy with those undergoing conventional thyroidectomy for Graves' disease.

METHODS

A prospective study was performed on 148 patients undergoing total thyroidectomy. Seventy-one patients underwent minimal-incision thyroidectomy and 77 underwent conventional thyroidectomy. Minimal-incision thyroidectomy was proposed if the thyroid volume was ≤ 50 mL.

RESULTS

There were no significant differences in the operative time between minimal-incision thyroidectomy and conventional thyroidectomy. The length of skin incision was significantly shorter in the minimal-incision thyroidectomy than that in the conventional thyroidectomy group. The incidence of postoperative complications was similar in the 2 groups. Patients undergoing minimal-incision thyroidectomy experienced significantly less postoperative pain and were more satisfied with the cosmetic result than patients who underwent conventional thyroidectomy.

CONCLUSIONS

Minimal-incision thyroidectomy is a feasible and safe option for the surgical treatment of selected patients with Graves' disease.

Is subtotal thyroidectomy a cost-effective treatment for Graves disease? A cost-effectiveness analysis of the medical and surgical treatment options

BACKGROUND

The 3 treatment options for Graves disease (GD) are antithyroid drugs (ATDs), radioactive iodine (RAI), and thyroid surgery. We hypothesized that thyroid surgery is cost-effective for Graves disease when compared to RAI or ATD.

METHODS

Cost-effectiveness analysis was performed to compare operative strategies to medical treatment strategies for GD. The decision model, based on a reference case, included treatment outcomes, probabilities, and costs derived from literature review. Outcomes were weighted using quality of life utility factors, yielding quality-adjusted life years (QALYs). The uncertainty of costs, probabilities, and utility estimates in the model were examined by univariate and multivariate sensitivity analysis and Monte Carlo simulation.

RESULTS

The subtotal thyroidectomy strategy produced the greatest QALYs, 25.783, with an incremental cost-effectiveness ratio of $26,602 per QALY, reflecting a gain of 0.091 QALYs at an additional cost of $2416 compared to RAI. Surgery was cost-effective when the initial postoperative euthyroid rate was greater than 49.5% and the total cost was less than $7391. Monte Carlo simulation showed the subtotal thyroidectomy strategy to be optimal in 826 of 1000 cases.

CONCLUSION

This study demonstrates that subtotal thyroidectomy can be a cost-effective treatment for GD. However, a 49.5% initial postoperative euthyroid rate was a necessary condition for cost-effective surgical management of GD.

Functional capacity of the thyroid autograft and heterograft: An experimental study

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.

Total thyroidectomy: a safe and effective treatment for Graves' disease

BACKGROUND

Thyroidectomy as a first line treatment for Graves' disease is rarely utilized in the US. The purpose of this study was to analyze the safety and efficacy of thyroid surgery among patients with Graves' disease.

METHODS

Fifty-six patients with Graves' disease underwent thyroid surgery between May 1994 and May 2008 at a single academic institution. Preoperative, intraoperative, and postoperative variables were analyzed.

RESULTS

A total of 58 surgeries were performed: 55.1% (n = 32) total thyroidectomy, 41.3% (n = 24) subtotal/lobectomy, 3.4% (n = 2) completion thyroidectomy. The average gland weight was 47.3 ± 10.8 gm, with 70% weighing > 30 gm. Reasons for having thyroid surgery were persistent disease despite medical therapy (46.6%), patient preference (24.1%), multinodular goiter/cold nodules (20.3%), failed RAI (radioactive iodine) treatment (16%), and opthalmopathy (12.1%). Of those patients that failed prior RAI therapy, the only factor that was predictive of failure was disease severity, as demonstrated by a markedly elevated initial free-T4 value (11.8 ± 4.5 ng/dL, P = 0.04). Transient symptomatic hypocalcemia occurred in 10.7% (n = 6) of patients, and one patient (1.8%) had symptomatic hypocalcemia lasting > 6 mo. There were no permanent recurrent laryngeal nerve injuries. There was no difference in overall complication rates between patients based on surgical procedure (subtotal versus total thyroidectomy), preoperative RAI treatment, or gland size. Recurrences occurred in 6% of the subtotal thyroidectomy group and 0% of the total thyroidectomy group (P = 0.008).

CONCLUSION

Thyroidectomy for patients with Graves' disease can be performed with very low complication rates and when a total thyroidectomy is performed, there is almost no risk of recurrence.

Endoscopic subtotal thyroidectomy: the procedure of choice for Graves' disease?

BACKGROUND

The aim of this study was to evaluate the feasibility and outcomes of endoscopic subtotal thyroidectomy for Graves' disease.

METHODS

From August 1998 to April 2008, a total of 100 patients with benign thyroid diseases underwent endoscopic thyroidectomy via the breast approach. Among these patients, 42 underwent subtotal thyroidectomy for Graves' disease.

RESULTS

The resection was successfully completed endoscopically in 41 patients (98%). Overall, the mean operating time, mean blood loss, and mean resected thyroid weight were 277 minutes, 76 ml, and 49.9 g, respectively. As the resected thyroid weight increased, the operating time was significantly prolonged and the blood loss significantly increased. Morbidities included one permanent and one temporary case of recurrent laryngeal nerve palsy with hypocalcemia. A hypertrophic scar was seen in the right breast medial margin in three men. Thyroid function was classified as euthyroidism, hypothyroidism, and recurrent hyperthyroidism in 5, 34, and 3 patients, respectively. At 92 months of median follow-up, two patients had modest operation-associated symptoms: one with swallowing discomfort and another with paresthesia in the anterior chest wall at the time of discharge. However, both patients' symptoms disappeared within 36 months after surgery. Young women were highly satisfied, with an overall mean satisfaction rating of 9.3 points.

CONCLUSIONS

Although the endoscopic approach may be relatively contraindicated for large thyroid glands, endoscopic subtotal thyroidectomy via the breast approach is a safe, feasible procedure with excellent cosmetic benefits, and it may be the procedure of choice in carefully selected patients with Graves' disease.

Surgical management of Graves' disease -10-year prospective trial at a single institution

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.

Surgery versus radioiodine therapy as definitive management for graves' disease: the role of patient preference

BACKGROUND

Thyroidectomy is an option for the definitive management of Graves' disease. The aim of this study was to examine the role of patient preference for selecting surgery as definitive treatment.

PATIENTS AND METHODS

This is a retrospective cohort study comprising all patients (n = 63) presenting to a single surgeon for surgical management of Graves' disease over 3 years. Documented reasons for surgery were compared with accepted indications, as well as patients' perceptions as assessed by questionnaire.

RESULTS

The most frequent absolute indication was the presence of a large goiter (n = 8; 13%) or associated thyroid nodule (n = 6; 10%). Ophthalmopathy, a relative indication, comprised the largest single group overall (n = 18; 29%); however, a significant number of patients (n = 17; 27%) elected surgery in the absence of a recognized indication. There was strong concordance (73%) between the recorded indication and the patients' survey response. Overall, there was a high level of satisfaction with surgery with 88% of respondents giving a satisfaction score of 7 or greater on a visual analog scale (VAS) (0-10).

CONCLUSIONS

One-third of all patients electing surgery as definitive management do so in the absence of a specific indication. Overall, there is a high level of satisfaction with the decision for surgery as definitive management of Graves' disease.

The surgical management of Graves' disease

BACKGROUND

The historical aspects of the pathophysiology and treatment of Graves' disease are briefly discussed in this paper.

MATERIALS AND METHODS

The three treatment modalities of Graves' disease are anti-thyroid drug therapy, radioactive iodine therapy, and surgery. Although the majority of patients with Graves' disease in the U.S. are treated with radioactive iodine, surgery still plays an important role when patients cannot tolerate anti-thyroid drug therapy, when medical treatment is rejected by patients, or when surgery is deemed the fastest and safest route in managing the patient.

CONCLUSIONS

The indications for surgical management of Graves' disease are discussed with emphasis on available data supporting the extent of thyroid resection based on the incidences of hypothyroidism, recurrence of hyperthyroidism, recurrent laryngeal nerve injury and hypoparathyroidism.

Video-assisted subtotal or near-total thyroidectomy for Graves' disease

BACKGROUND

Surgery remains the treatment of choice for patients with Graves' disease. The purpose of the present study was to assess the usefulness and efficacy of video-assisted subtotal or near-total thyroidectomy in patients with Graves' disease.

METHODS

Between March 2000 and December 2004, 63 patients with Graves' disease underwent video-assisted subtotal, near-total or total thyroidectomy. Fifty-three patients (84 per cent) were considered for surgery after failure of antithyroid drug and radioiodine therapy, whereas the other ten patients were initially selected for surgical treatment based on their own preference. Treatment outcome was evaluated, including surgical complications, thyroid function, quality of life and patient satisfaction with the surgical result.

RESULTS

All patients were operated on using a video-assisted technique, with some modifications depending on time and experience. There were no conversions to open surgery. Three patients (5 per cent) had temporary recurrent laryngeal nerve palsy that recovered spontaneously. Most patients were satisfied with the surgical results, particularly regarding the placement of the surgical scars.

CONCLUSION

Video-assisted subtotal or near-total thyroidectomy is a safe and effective procedure for treatment of Graves' disease.

Should total thyroidectomy become the preferred procedure for surgical management of Graves' disease?

This study aims to evaluate our institution's experience with thyroidectomy for Graves' disease, with an emphasis on indications and long-term outcomes. The study cohort consisted of 103 patients (mean age 34.3 [+/-13.9] years), who underwent thyroidectomy for Graves' disease between 1991 and 2002. Clinical and follow-up data were obtained by retrospective review of medical records and by contacting treating physicians or patients. The most common surgical indications were patient preference (26%), cold nodule (24%), eye symptoms (20%), large goiter size (18%), allergy to antithyroidal medications (15%), and age younger than 16 years (14%). Thyroidectomies performed included 45 (total or near-total), 57 subtotal, and 1 lobectomy. Transient complications included hypocalcemia in 42 patients, and recurrent laryngeal nerve palsy in 5 patients. There was no difference in the frequency of hypocalcemia in patients undergoing total or subtotal resections. One patient developed permanent hypocalcemia and 2 permanent recurrent laryngeal nerve (RLN) injury. Only 3 patients who underwent subtotal resections remain off thyroxine and 2 developed recurrent hyperthyroidism approximately 17 and 54 months after surgery. Subtotal thyroidectomy is associated with a high rate of hypothyroidism and large remnants have potential for recurrence. Total or near-total thyroidectomy obviates these disadvantages and can be performed without increased complication rates, thus appearing to be the preferred extent of thyroidectomy for Graves' disease.

Hyperthyroidism: advantages and disadvantages of medical therapy

The most common causes of hyperthyroidism are Graves' disease, toxic nodular goiter, and iodine-induced hyperthyroidism. Hyperthyroidism can be treated medically with antithyroid drugs or radioactive iodine, or surgically. Multiple clinical factors must be weighed when choosing a treatment modality. All of the available forms of therapy have advantages and disadvantages, and treatment choices must be individualized.

Surgical treatment of Graves' disease in children

Thyroidectomy may be indicated in children with Graves' disease who have adverse reactions to antithyroid drugs or who relapse after antithyroid drug therapy. We investigated the characteristics of childhood Graves' disease from the standpoint of surgical outcome. Between 1989 and 1998, 1897 patients with Graves' disease underwent thyroidectomy and their thyroid function could be evaluated 2 to 3 years after thyroidectomy. The patients were divided into three groups according to age at thyroidectomy: 74 patients were 15 years old or less (children), 345 patients 16 to 20 years of age (adolescents), and 1478 patients 21 years of age or more (adults). The children included higher proportions of patients who had a large goiter (> 100 g), high thyrotropin-binding inhibitory immunoglobulin (TBII) level (> 50%), and small remnant thyroid (< 4 g). At 2 to 3 years after thyroidectomy, the overt recurrence rate of the children, adolescents, and adults was 9.5%, 4.9%, and 5%, respectively. The cumulative recurrence-free rate of the children, adolescents, and adults at 5 years after thyroidectomy was 82%, 90%, and 92%, respectively. Surgical complications were more frequently observed in children. Considering the aggressiveness of childhood Graves' disease, subtotal thyroidectomy with thyroid remnant less than 3 g is the procedure of choice for preventing recurrent hyperthyroidism.

Advantages and disadvantages of surgical therapy and optimal extent of thyroidectomy for the treatment of hyperthyroidism

Surgery is excellent therapy for hyperthyroidism, with no mortality,and few complications or recurrences. It achieves euthyroidism rapidly and consistently, avoids long-term risks of radioactive iodine and antithyroid medications, provides tissue for histology,renders childbearing immediately possible, and allows absolute titration of thyroid hormone. Advancements such as preoperative preparation and intraoperative parathyroid hormone monitoring have decreased risks greatly and improved outcomes. Hartley-Dunhill procedure is the treatment of choice. Patients should be rendered euthyroid before operation to decrease thyroid vascularity, to improve surgical planes, and to prevent life threatening thyroid storm. Patients must be monitored carefully for hypocalcemia, a potentially serious complication. Patients will require lifelong thyroid hormone replacement. Radioactive iodine ablation should be considered for disease recurrence after surgery.

Postoperative endocrine function in patients with surgically treated thyrotoxicosis

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.

Comparison of different thyroidectomy techniques for benign thyroid disease

Extent of thyroidectomy in the management of benign thyroid disease remains controversial. In this clinical study, three different thyroidectomy techniques were compared by means of the complication, short period recurrence and L-thyroxin requirement rates. Two hundred consecutive patients who had bilateral subtotal thyroidectomy (BST) (n = 71), unilateral total lobectomy + contralateral subtotal lobectomy (Dunhill Procedure (DP)) (n = 71), or total thyroidectomy (TT) (n = 58) for benign thyroid disorders were included in this study. One patient was re-operated due to bleeding in BST group. Wound infection was observed in 1 patient both in BST and DP group and 2 patients in TT group. Temporary hypocalcaemia was seen in 14 (19.7%) of BST group, in 19 (26.7%) of DP group, and in 14 (24.1%) patients of TT group (p>0.05). Transient recurrent laryngeal nerve palsy developed in 1 patient both in DP and TT group. One patient of DP group had secondary thyroidectomy due to postoperative diagnosis of papillary carcinoma. There was no significant difference in the mean durations of hospitalization between the groups. Mean postoperative follow-up periods were 27.7 months (6-56), 34.8 months (8-55), 26.5 months (6-54) in BST, DP and TT groups, respectively. While all patients were administered L-thyroxin in TT group, 26 (36.6%) patients in DP group and 34 (47.8%) patients in BST group needed no L-thyroxin supplementation and L-thyroxin requirement rates were not different in either group. We think that total thyroidectomy should be adopted for benign thyroidal diseases, because its complications are no different than those for BST and DP. If individual factors and patient's preference are not in favor of lifelong L-thyroxin supplementation, however, DP may be carried out for benign thyroidal diseases instead of BST.

Hyperthyroidism

Hyperthyroidism is a pathological syndrome in which tissue is exposed to excessive amounts of circulating thyroid hormone. The most common cause of this syndrome is Graves' disease, followed by toxic multinodular goitre, and solitary hyperfunctioning nodules. Autoimmune postpartum and subacute thyroiditis, tumours that secrete thyrotropin, and drug-induced thyroid dysfunction, are also important causes. The diagnosis of hyperthyroidism is generally straightforward, with raised serum thyroid hormones and suppressed serum thyrotropin in almost all cases. Appropriate treatment of hyperthyroidism relies on identification of the underlying cause. Antithyroid drugs, radioactive iodine, and surgery are the traditional treatments for the three common forms of hyperthyroidism. Beta-adrenergic blocking agents are used in most patients for symptomatic relief, and might be the only treatment needed for thyroiditis, which is transient. The more unusual causes of hyperthyroidism, including struma ovarii, thyrotropin-secreting tumours, choriocarcinoma, and amiodarone-induced thyrotoxicosis are, more often than not, a challenge to diagnose and treat.

Perioperative management of the thyrotoxic patient

Preoperative thyrotoxicosis is a potentially life-threatening condition that requires medical intervention before surgery. Most patients are undergoing thyroidectomy for persistent thyrotoxicosis, usually Graves' disease, either having contraindications to or failing medical therapy. Fewer patients are undergoing nonthyroidal surgery that is likely urgent or emergent. The choice of treatment depends on the time available for preoperative preparation, the severity of the thyrotoxicosis, and the impact of any current or previous therapies. Generally treatment is directed at a combination of targets in the thyroid hormone synthetic, secretory, and peripheral pathway with concurrent treatment to correct any decompensation of normal homeostatic mechanisms. Thionamides are the preferred initial treatment unless contraindicated, but do require several weeks to render a patient euthyroid. beta-Blockers should always be used unless absolutely contraindicated because they improve thyrotoxic symptoms especially of the cardiovascular system. Other agents including iodine and steroids can be used if rapid preparation is required or more severe thyrotoxicosis is present. The goal of therapy is to render the patient as close as possible to clinical and biochemical euthyroidism before surgery. Overall, the morbidity and mortality of adequately prepared patients is low.

Autoimmune thyroid diseases: etiology, pathogenesis, and dermatologic manifestations

Autoimmune thyroid disease (AITD) including Graves' disease, Hashimoto's thyroiditis, and idiopathic hypothyroidism (atrophic Hashimoto's thyroiditis) is of vital concern to the dermatologist. This article reviews the cutaneous manifestations of Graves' disease and Hashimoto's thyroiditis. Recognition of dermatologic manifestations of AITD may alert practitioners to investigate for these disorders. The immune response involved in the pathogenesis of AITD is detailed. Current understanding of the role of genetic and environmental factors, antigens, and apoptosis are elaborated. The future holds exciting insight into the etiology, pathogenesis, and treatment of AITD.

Graves disease in childhood: a review of the options for diagnosis and treatment

While diagnosing Graves disease in childhood and adolescence does not usually present specific problems, the treatment of hyperthyroidism is still controversial. In particular, with regard to the use of radioiodine therapy, strategies vary between many European and North American pediatric endocrinology centers. After the diagnosis is made, antithyroid drug treatment with methimazole (thiamazole), carbimazole, or propylthiouracil should be performed with caution, in particular, because of severe adverse effects, such as agranulocytosis or hepatitis, that are found in up to 1% of patients. Antithyroid drug treatment should not be continued long-term, particularly since definitive remission cannot be expected in more than 30-40% of patients. In contrast, the risk of severe adverse effects is still present, and the risk of thyroid carcinoma increases with time and appears to be considerably higher than after radioiodine treatment. To a great extent, the success of surgery depends on the skills of a trained surgeon. The question of whether to perform total or subtotal thyroidectomy is yet to be resolved. Surgery should be considered in patients with a large thyroid gland (>80g), severe ophthalmopathy, and a lack of remission on antithyroid drug treatment. Success rates have increased to up to 97%, while severe adverse effects (laryngeal nerve palsy, hypoparathyroidism) occur in approximately 4% of patients. Mortality is below 0.1%. Radioiodine treatment in children >5 years of age does not appear to be associated with an increased risk of thyroid carcinoma; however, long-term data are lacking. Compared with the surgical approach, success rates are lower, particularly if low doses of radioiodine are used. In general, adverse effects are less prevalent than in patients who have undergone surgery.

Inflammatory thyroid disorders

Inflammatory thyroid disorders encompass a broad spectrum of diseases that are generally self-limited, and relatively easy to diagnose and manage. Autoimmune subtypes are by far the most commonly encountered diagnoses and create the most confusion because of simultaneous overlap and the potential for interconversion among the subtypes. The otolaryngologist will frequently see these disorders and provide valued consultative care and surgical intervention as needed.

Thyrotoxicosis--surgical management in the era of evidence-based medicine: experience in western India with 752 cases

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.

Thymic hyperplasia presenting as anterior mediastinal mass in 2 patients with Graves disease

Graves disease is an autoimmune thyroid condition characterized by the production of autoantibodies against the thyrotropin receptor. The autoantibodies mimic the effect of the hormone on thyroid cells, which stimulates autonomous production of thyroxine and triiodothyronine. It has been hypothesized that cross-reactivity of autoantibodies may result in Graves ophthalmopathy and dermopathy. A seldom-recognized feature of Graves disease is thymic hyperplasia. We report 2 patients with Graves disease and incidentally discovered anterior mediastinal masses presumed to be thymic hyperplasia. In both cases, these masses regressed spontaneously after treatment of hyperthyroidism.

[Ablative therapy for immune hyperthyroidism in patients with ophthalmopathy]

The influence of ablative treatment of Graves' disease on the course of endocrine ophthalmopathy is discussed controversially. Data are inhomogeneous, because some studies were performed retrospectively, some prospectively, because of different follow up periods and different patient groups. In principal near total resection seems to influence endocrine ophthalmopathy in a positive way, due to the removal of thyroid antigen. Most studies also demonstrate that treatment using radioiodine has a negative influence on ophthalmopathy, because the course of disease is worsening in up to one third of patients. There is also consensus that treatment of Graves' disease with radioiodine should be performed only by concomitant administration of glucocorticoids. The early administration of L-thyroxine after radio-iodine therapy of Graves' disease seems to have a positive influence on the course of disease, whereas additional treatment with methimazole has no positive influence on endocrine ophthalmopathy.