Surgical treatment of hyperthyroidism: a ten-year experience

Outcomes of Radioactive Iodine Versus Surgery for the Treatment of Graves’ Disease: a Systematic Review and Meta-analysis

Graves’ disease (GD) is a systemic autoimmune disorder mainly affecting the thyroid gland. During GD management, the principal target is to control the hyperthyroid state. There have been three rather similarly effective modalities: medical therapy with antithyroid drugs (ATD), radioactive iodine (RAI), or surgical excision of the thyroid tissue (thyroidectomy). Defining the relative risks and benefits of each of the two potential definitive treatment options (RAI or thyroidectomy) is crucial for creating evidence-based therapy algorithms. This systematic review and meta-analysis aimed to compare the outcomes of these two treatment options. This is a systematic review and meta-analysis that analyzed the studies comparing RAI and thyroidectomy to treat GD. Studies were obtained by searching on Scopus, the Cochrane Central Register of Controlled Trials, and PubMed central database. The surgically treated group showed significantly lower failure rates, non-significantly lower cardiovascular morbidities, non-significantly higher complication rates, and significantly lower mortality rates. The RAI-related complications were mostly the development or worsening of Graves’ ophthalmopathy. This review and meta-analysis comparing surgery and radioactive iodine for the treatment of Grave’s disease from 16 well-conducted trials has shown that although surgery viz., total thyroidectomy was less frequently utilized for the treatment of Grave’s disease, it controlled the symptoms with greater success and without any worsening of Grave’s ophthalmopathy.

Current Strategies for Tracheal Replacement: A Review

Airway cancers have been increasing in recent years. Tracheal resection is commonly performed during surgery and is burdened from post-operative complications severely affecting quality of life. Tracheal resection is usually carried out in primary tracheal tumors or other neoplasms of the neck region. Regenerative medicine for tracheal replacement using bio-prosthesis is under current research. In recent years, attempts were made to replace and transplant human cadaver trachea. An effective vascular supply is fundamental for a successful tracheal transplantation. The use of biological scaffolds derived from decellularized tissues has the advantage of a three-dimensional structure based on the native extracellular matrix promoting the perfusion, vascularization, and differentiation of the seeded cell typologies. By appropriately modulating some experimental parameters, it is possible to change the characteristics of the surface. The obtained membranes could theoretically be affixed to a decellularized tissue, but, in practice, it needs to ensure adhesion to the biological substrate and/or glue adhesion with biocompatible glues. It is also known that many of the biocompatible glues can be toxic or poorly tolerated and induce inflammatory phenomena or rejection. In tissue and organ transplants, decellularized tissues must not produce adverse immunological reactions and lead to rejection phenomena; at the same time, the transplant tissue must retain the mechanical properties of the original tissue. This review describes the attempts so far developed and the current lines of research in the field of tracheal replacement.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS/DESIGN

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative analysis of radioactive iodine versus thyroidectomy for definitive treatment of Graves disease

BACKGROUND

Management of Graves disease includes antithyroid drugs, ¹³¹I therapy, or thyroidectomy. Our aim was to review our institutional experience with definitive treatments for Graves disease.

METHODS

This was a retrospective review of patients undergoing ¹³¹I therapy (n = 295) or thyroidectomy (n = 103) for Graves disease (2003-2015). Demographic, clinical, pathology, and outcome data were collected from institutional databases.

RESULTS

¹³¹I therapy patients were older (39.1 years vs 33.4 years, P = .001). There was no difference in the presence of ophthalmopathy between groups. A larger proportion of children received thyroidectomy than ¹³¹I therapy (17.1% vs 9.2%, P = .026). The success rate of the first ¹³¹I therapy dose was 81.4%. Overall success rate, including additional doses, was 90.1%. Rapid turnover of iodine correlated with ¹³¹I therapy failure (58.3% rapid turnover failure vs 14.9% non-rapid turnover failure, P < .05). All surgical patients underwent total or near-total thyroidectomy. ¹³¹I therapy complications included worsening thyrotoxicosis (1%) and deteriorating orbitopathy (0.7%). Operative complications were higher than ¹³¹I therapy complications (P < .05) but were transient. There was no worsening orbitopathy or recurrent Graves disease among surgical patients.

CONCLUSION

A higher proportion of pediatric Graves disease patients underwent thyroidectomy than ¹³¹I therapy. Rapid turnover suggested more effective initial management with operation than ¹³¹I therapy. Although transient operative complications were high, ¹³¹I therapy complications included worsening of Graves orbitopathy among those with pre-existing orbitopathy.

Hyperthyroidism

Hyperthyroidism is characterised by increased thyroid hormone synthesis and secretion from the thyroid gland, whereas thyrotoxicosis refers to the clinical syndrome of excess circulating thyroid hormones, irrespective of the source. The most common cause of hyperthyroidism is Graves' disease, followed by toxic nodular goitre. Other important causes of thyrotoxicosis include thyroiditis, iodine-induced and drug-induced thyroid dysfunction, and factitious ingestion of excess thyroid hormones. Treatment options for Graves' disease include antithyroid drugs, radioactive iodine therapy, and surgery, whereas antithyroid drugs are not generally used long term in toxic nodular goitre, because of the high relapse rate of thyrotoxicosis after discontinuation. β blockers are used in symptomatic thyrotoxicosis, and might be the only treatment needed for thyrotoxicosis not caused by excessive production and release of the thyroid hormones. Thyroid storm and hyperthyroidism in pregnancy and during the post-partum period are special circumstances that need careful assessment and treatment.

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.

Long-Term Effect of Surgery in Graves' Disease: 20 Years Experience in a Single Institution

The present study compared the long-term outcome of subtotal thyroidectomy (ST) to that of total thyroidectomy (TT) in Graves' disease (GD). Patients with GD requiring surgery were divided between two groups: ST and TT. Postoperative thyroid function (PoTF) changes, including hypothyroidism, euthyroidism, and hyperthyroidism, and surgical complications were analyzed 3 months and 2 years after surgery. During the study period, 350 GD patients underwent surgery, of whom 254 underwent ST and 96 underwent TT. In the ST group, the rates of hypothyroidism, euthyroidism, and hyperthyroidism were 92.5%, 6.7%, and 0.4%, respectively, after 3 months, and 86.1%, 8.6%, and 5.3%, respectively, after 2 years. No difference in the rate of surgical complication was observed between the ST and TT groups (p = 0.089). Most of the ST patients showed hypothyroidism after surgery, and euthyroidism was rare. The long-term outcome of ST included noticeable PoTF changes and recurrence of GD. These results suggest that TT should be considered as a treatment option in GD requiring surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of Graves' disease: an overview and comparison of clinical practice guidelines with actual practice trends

Over the last century, much has been learned about the pathogenesis, manifestations, and management of Graves' disease leading to the establishment of evidence-based clinical practice guidelines. The joint clinical practice guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists give recommendations on both the diagnosis and treatment of hyperthyroidism. A survey of clinicians performed that same year, however, revealed that current practices diverge from these recently published guidelines in multiple areas. These differences will need to be assessed serially to determine the impact of the guidelines on future clinical practice and perhaps vice versa.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Total thyroidectomy for Graves' disease: compliance with American Thyroid Association guidelines may not always be necessary

BACKGROUND

Total thyroidectomy (TT) is the preferred operative approach to Graves' disease. Current guidelines of the American Thyroid Association call for the administration of potassium iodide (KI) and achievement of euthyroid state before operation. Small numbers and a mixture of operative approaches spanning several decades hinder previous operative series. We present the outcomes for TT at a single high-volume center.

METHODS

A retrospective cohort study was conducted on 165 patients undergoing TT for Graves' disease from July 2007 to May 2012.

RESULTS

Mean age was 43 years (range, 17-78), and 128 patients (78%) were female. A total of 95% of patients were on methimazole or propylthiouracil, and 42% remained hyperthyroid at time of TT. Only 3 (2%) patients received KI. Mean operative time was 132 minutes (range, 59-271). Mean gland size and blood loss were 41 g (range, 8-180) and 55 mL (range, 10-1050), respectively. No patient developed thyroid storm. Median follow-up was 7.5 months. Temporary and permanent hypocalcemia developed in 51 (31%) and 2 patients (1.2%), respectively. Temporary and permanent recurrent laryngeal nerve paresis occurred in 12 (7%) and one (0.6%) patient, respectively. Sixty-one (37%) patients experienced at least one complication. On multivariate analysis, patient age younger than 45 years (odds ratio 2.93, 95% confidence interval 1.39-6.19) and obesity (odds ratio 2.11, 95% confidence interval 1.00-4.43) were associated with the occurrence of complications.

CONCLUSION

This high-volume surgeon experience demonstrates no appreciable detriment to patient outcomes when recommendations of the American Thyroid Association for routine use of KI and euthyroid state before thyroidectomy are not met. Transient hypocalcemia and hoarseness are frequent complications of TT for Graves' disease, resolving within 6 months in most patients. Age younger than 45 years and obesity are risk factors for postoperative complications.

Is potassium iodide solution necessary before total thyroidectomy for Graves disease?

BACKGROUND

Potassium iodide (KI) has traditionally been used to reduce gland vascularity and diminish blood loss in patients undergoing thyroidectomy for Graves disease (GD). Current American Thyroid Association (ATA) guidelines (Recommendation 22) call for its routine administration in GD but avoidance in toxic multinodular goiter (TMNG).

METHODS

A retrospective review (July 2008-May 2012) of perioperative data was performed on 162 patients undergoing total thyroidectomy without preoperative KI and compared to 102 patients with TMNG. Statistical analysis included Student's t test, χ2 test, and multivariate linear regression.

RESULTS

Compared to TMNG patients, GD patients had a lower mean age (42.7 vs. 49.6 years, p<0.001) and were less likely to be obese (37 vs. 54%, p=0.047). No patients were provided KI in preparation. GD patients did not differ significantly from TMNG patients with respect to mean estimated blood loss (55.4 vs. 51.5 mL, p=0.773) or mean operative time (131.5 vs. 122.6 min, p=0.084). GD patients had a lower rate of transient hypocalcemia (31 vs. 49%, p=0.004), but the two groups did not statistically differ in rates of prolonged hypocalcemia, temporary recurrent laryngeal nerve (RLN) palsy, prolonged RLN paralysis, or hematoma formation.

CONCLUSIONS

Although current ATA recommendations for the management of GD call for routine use of KI before thyroidectomy, this large series demonstrates no appreciable detriment to patient outcomes when this goal is not met.

Total thyroidectomy for safe and definitive management of Graves' disease

Background:

The role of total thyroidectomy in the management of patients with Graves' disease remains controversial. However, there is increasing evidence to support the role of the procedure as a safe and definitive treatment for Graves' disease.

Method:

Patients were identified from a prospective thyroid database of the multidisciplinary thyroid clinic at Hull Royal Infirmary. All case notes were independently reviewed to confirm the data held on the database.

Results:

Over a 7-year period, the senior author has performed 206 total thyroidectomies for Graves' disease. The incidence of temporary recurrent laryngeal nerve palsy and hypoparathyroidism was 3.4 per cent and 24 per cent respectively. There was one case of permanent unilateral recurrent laryngeal nerve palsy, and 3.9 per cent of patients developed permanent hypoparathyroidism. There has been no relapse of thyrotoxicosis.

Conclusion:

In the context of a multidisciplinary thyroid clinic, total thyroidectomy should be offered as a safe and effective first-line treatment option for Graves' disease.

Management of Grave's disease is improved by total thyroidectomy

BACKGROUND

A retrospective analysis was performed on 267 consecutive patients with Graves' disease (GD). The principal aim of this study was to evaluate the risk for recurrence and complications when changing the surgical method from subtotal (ST) to total thyroidectomy (TT).

METHODS

Information from 267 consecutive patients operated on for GD between 2000 and 2006 was collected at Uppsala University Hospital (143) and Falun County Hospital (128). There were 229 women and 38 men. Four patients were operated on twice. A total of 40 STs and 229 TTs were performed. Results were compared to those of a previous cohort from the same hospital, with a majority of STs (157/176) performed from 1980 to 1992.

RESULTS

The risk for relapse of GD was reduced from 20 to 3.3 % after the shift from ST to TT. In terms of surgical complications, 2.2 % demonstrated permanent vocal cord paralysis and 4.5 % had persistent hypocalcemia, not significant when compared to the previous cohort. In spite of TT, there were four recurrences, all due to remnant thyroid tissue high up at the hyoid bone. Changing the surgical method did not affect postoperative progression of dysthyroid ophthalmopathy (DO, 7.0 vs. 7.5 %). There were no differences in outcome with respect to which hospital the patients had their operation.

CONCLUSION

Change from ST to TT dramatically reduced the risk for recurrence of GD without increasing the rate of complications. TT is not more effective than ST in hampering progression of DO as has been advocated by some. Careful surgical dissection up to the hyoid bone is necessary to avoid recurrence.

What is the best definitive treatment for Graves' disease? A systematic review of the existing literature

BACKGROUND

The management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists for Graves' disease (GD) include any of the following modalities: (131)I therapy, antithyroid medication, or thyroidectomy. No in-depth analysis has been performed comparing the treatment options, even though a single treatment option seems to be universally accepted.

METHODS

A systematic review of the literature was performed to examine contemporary literature between 2001 and 2011 evaluating the management options of GD. We compiled retrospective and prospective studies analyzing surgery and radioactive iodine. Outcomes of interest included postoperative hypothyroidism, euthyroidism, and persistent or recurrent hyperthyroidism without supplementation. Success was defined as postoperative euthyroidism or hypothyroidism. Failure was defined as persistent or recurrent hyperthyroidism.

RESULTS

Of the 14,245 patients, 4,546 underwent surgery [3,158 patients had subtotal thyroidectomy (STT) and 1,388 had total thyroidectomy (TT)] and 9,699 had radioactive iodine. The radioactive iodine group consisted of 2,383 patients receiving 1-10 mCi, 1,558 patients receiving 11-15 mCi, 516 patients receiving >15 mCi, and 5,242 patients receiving an unspecified amount. Surgery was found to be 3.44 times more likely to be successful than radioactive iodine (p < 0.001). STT and TT were found to be 2.33 and 94.45 times more likely to be successful than radioactive iodine (p < 0.001), respectively.

CONCLUSIONS

On the basis of the outcomes analyzed, surgery appears to be the most successful in the management of GD, with TT being the preferred surgical option.

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.

Medical management of thyroid eye disease

Thyroid eye disease (TED) is the most common cause of orbital disease in adults. The immunologic pathogenesis of TED has been an area of active research and considerable progress has resulted in an expansion of therapeutic options. Although surgical intervention may be required, a majority of TED patients can be managed with medical therapies. Of medical therapies, glucocorticoids remain the agent of choice in the control of TED activity. The objective of this review is to discuss the paradigm and options in medical management of TED.

Recurrence of Graves' disease in thyroglossal duct remnants: relapse after total thyroidectomy

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.

Treatment options for Graves disease: a cost-effectiveness analysis

BACKGROUND

First-line treatment for Graves disease is frequently 18 months of antithyroid medication (ATM). Controversy exists concerning the next best line of treatment for patients who have failed to achieve euthyroidism; options include lifelong ATM, radioactive iodine (RAI), or total thyroidectomy (TT). We aim to determine the most cost-effective option.

STUDY DESIGN

We performed a cost-effectiveness analysis comparing these different strategies. Treatment efficacy and complication data were derived from a literature review. Costs were examined from a health-care system perspective using actual Medicare reimbursement rates to an urban university hospital. Outcomes were measured in quality-adjusted life-years (QALY). Costs and effectiveness were converted to present values; all key variables were subjected to sensitivity analysis.

RESULTS

TT was the most cost-effective strategy, resulting in a gain of 1.32 QALYs compared with RAI (at an additional cost of 9,594 US dollars) and an incremental cost-effectiveness ratio of 7,240 US dollars/QALY. RAI was the least costly option at 23,600 US dollars but also provided the least QALY (25.08 QALY). Once the cost of TT exceeds 19,300 US dollars, the incremental cost-effectiveness ratio of lifelong ATM and TT reverse and lifelong ATM becomes the more cost-effective strategy at 15,000US dollars/QALY.

CONCLUSIONS

This is the first formal cost-effectiveness study in the US of the optimal treatment for patients with Graves disease who fail to achieve euthyroidism after 18 months of ATM. Our findings demonstrate that TT is more cost effective than RAI or lifelong ATM in these patients; this continues until the cost of TT becomes > 19,300 US dollars.

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.

Extensive Thyroidectomy in Graves’ Disease

BACKGROUND

The best surgical treatment for hyperthyroidism caused by Graves' disease remains a controversial subject.

METHODS

Seven hundred fourteen consecutive patients underwent total or near-total thyroidectomy for Graves' disease in a 13-year period. In a first analysis, postoperative rates of suffocating hematoma, wound infection, recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, and persistence or recurrence of hyperthyroidism, were studied and compared with the same parameters in 4,426 patients who underwent bilateral thyroid gland resection for other conditions. A second analysis identified factors associated with postoperative complications among Graves' disease patients.

RESULTS

Comparing Graves' disease patients with patients who had bilateral thyroid resection for other conditions, the transient morbidity rate was 13.3% versus 8.2% (p < 0.0001), with 10.2% versus 5.0% (p < 0.0001) hypoparathyroidism, 2.2% versus 1.7% (p = 0.35) RLN palsy, 1.7% versus 0.9% (p < 0.05) suffocating hematoma, and 0.3% versus 0.4% (p = 0.67) wound infection, respectively. Permanent morbidity rate was 2% versus 2.2% (p = 0.72), including 0.4% versus 0.6% RLN palsy and 1.5% versus 1.7% hypoparathyroidism. Among the Graves' disease patients, univariate analysis revealed that those who experienced postoperative complications had a higher weight resected thyroid gland (odds ratio = 1.5; 95% CI, 1.0-2.3) and a higher rate of total thyroidectomy (24.4% versus 19.5%, odds ratio = 2.2; 95% CI, 1.4-3.4) than patients without complications. In the multivariable model, these two factors remained independent. There was no recurrence of hyperthyroidism with a median followup of 6.7 years (interquartile range 4.1 to 10.1 years). Persistent hyperthyroidism developed in three patients.

CONCLUSIONS

Total or near-total thyroidectomy is an effective and safe treatment for Graves' disease when performed by an experienced surgeon.

Optimisation of thyroid hormone replacement using an automated thyroid register

The high prevalence of thyroid dysfunction requires an efficient and effective means of monitoring and adjustment. We compared the current network of 12,524 patients with thyroid dysfunction with register data prior to 1991 to examine the precision of thyroxine replacement in patients with hypothyroidism and assess locally changing trends in treatment of hyperthyroidism. Since 1991, due to the associated adverse effects of a suppressed thyroid-stimulating hormone (TSH) (<0.03 mU/l), the network has facilitated a significant reduction in the proportion of thyroxine-treated patients with TSH suppression from 58.5% before 1991 to 9.2 +/- 3.8% thereafter. Since 1991, there has been an increased use of radioiodine by 14.3% [95% confidence interval (95% CI): 10.6-17.8] and a reduced use of thyroidectomy by 12.3% (95% CI: 8.8-15.8) to treat hyperthyroid patients compared with before 1991. Between the two treatments, there were no differences in subsequent rates of hypothyroidism or mean thyroxine dosage.

Prognosis of small thyroid cancer in patients with Graves' disease

Background

To find the best ways to follow up patients with small thyroid cancer (STC; 1 cm or less in diameter) and concomitant Graves' disease, this study examined whether such patients had the same excellent prognosis as those with STC without Graves' disease.

Methods

Between 1970 and 1996, 2199 patients were diagnosed as having STC by pathology after thyroidectomy. Of those, 509 patients (33 males and 476 females, mean age 43·5 years) underwent thyroidectomy for Graves' disease. Control patients with STC without Graves' disease were matched for age, sex, treatment year and tumour size (33 males and 476 females, mean age 44·0 years).

Results

Patients with STC and Graves' disease had a longer disease-free survival than those with STC alone (99 and 93 per cent at 20 years' follow-up, respectively; P &lt; 0·001). The Cox's proportional hazard analysis showed that concomitant Graves' disease and age at surgery are more significant factors for predicting disease-free survival than surgical procedures.

Conclusion

Patients who undergo thyroidectomy for Graves' disease and are found to have STC have an excellent prognosis and longer disease-free survival than patients with STC alone.

Thyroidectomy remains an effective treatment option for Graves’ disease

BACKGROUND

Recent experience with thyroidectomy for Graves' disease is limited. We report our current experience with thyroidectomy for Graves' disease at a tertiary hospital.

METHODS

A prospective database showed 48 patients who underwent surgery for Graves' disease from April 1993 to June 2005.

RESULTS

All patients had typical symptoms of Graves' disease. Twenty-three patients had ophthalmopathy. Indications for surgery were failed medical therapy (n = 24), presence of a dominant nodule (n = 12), or refusal of radioiodine (n = 12). Surgery included total thyroidectomy (n = 46) or subtotal thyroidectomy (n = 2). The incidence of cancer was 17%. Long-term follow-up data were available for 44 patients. No patients had recurrence of hyperthyroidism or cancer. Follow-up evaluation of 20 patients with ophthalmopathy showed the condition had either stabilized or resolved.

CONCLUSIONS

Total thyroidectomy for Graves' disease offers rapid and durable control of hyperthyroidism, provides appropriate treatment for patients with coexisting cancer, and can stabilize or reverse ophthalmopathy.

Results of surgery for toxic multinodular goiter

PURPOSE

We analyzed the clinical and histological features of patients operated on for toxic multinodular goiter (TMG) to determine the clinical profile and evaluate the surgical results.

METHODS

We reviewed 672 patients who underwent surgery for multinodular goiter (MG), 112 (17%) of whom had hyperthyroidism, and analyzed the epidemiological, clinical, and surgical variables.

RESULTS

The patients with TMG tended to be older than those with nontoxic MG, with a greater evolution time of the goiter and a higher rate of positive antithyroid antibodies. In the multivariate analysis, the only feature characteristic of TMG, as opposed to nontoxic MG, was the evolution time. Morbidity was 34%, representative of the fact that that most of the patients were seen before the establishment of our endocrine surgical unit. The hyperthyroid symptoms resolved in all patients, but 4 of 17 patients who underwent partial surgical resection showed signs of relapse within a follow-up period of 98 +/- 71 months.

CONCLUSIONS

TMG is characterized by a long evolution time and is most effectively treated by total thyroidectomy, which achieves complete remission from symptoms, without relapse, and is necessary if there is associated carcinoma. However, the incidence of complications may be high if this procedure is not carried out by surgeons with experience in endocrine surgery.

Graves' disease with moderate-severe endocrine ophthalmopathy-long term results of a prospective, randomized study of total or subtotal thyroid resection

The optimal thyroid surgery to be performed in patients with Graves' disease and concomitant endocrine ophthalmopathy is a matter of debate. We randomly assigned 44 patients with moderate-severe eye signs in a trial of treatment with subtotal, leaving a small (approximately 2 g) thyroid remnant, or total thyroidectomy. At inclusion, the patients had been treated with antithyroid drugs, and corticosteroids been given to 12 (27%). All received postoperative thyroxine supplementation and were followed for 3 years at regular examinations. The eye disease improved in all cases, and throughout the study, the two groups did not differ with regard to subjective and objective eye symptoms and laboratory findings. At the study start, motility disturbances were present in 8 and 11 of the cases in the subtotal and total resection group and proptosis in 16 and 17, respectively. After 3 years, the corresponding data were 3 and 6 cases with motility defects and 16 and 15 cases with proptosis. Thyrotropin (TSH)-receptor antibody levels gradually fell and became nondetectable in 21 (49%). The surgical complication rate (permanent recurrent laryngeal nerve paresis and permanent hypoparathyroidism) was significantly higher in the total thyroidectomy group. The data indicate that in patients with Graves' disease and active endocrine ophthalmopathy, subtotal thyroidectomy, leaving a small thyroid remnant, will reduce the risk of surgical complications but not the beneficial effect of surgery.

A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy Versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves? Disease

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.

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.

Prevalence of thyroid cancer in hyperthyroidism treated by surgery

The reported prevalence of thyroid cancer with concurrent hyperthyroidism varies from 0.21% to 9.0%. This variability may be due to multiple factors, such as indications for surgery and histopathologic accuracy. However, this condition is not rare and its prevalence has increased in recent surveys, perhaps as a result of more detailed examinations. The aim of this retrospective study was to determine the prevalence of thyroid cancer in hyperthyroid patients at surgery. Forty-five patients, 34 women and 11 men, underwent surgery for hyperthyroidism in our department between 1989 and 2000. Ages ranged from 14 to 67 years. There were 42 cases of Graves' disease, one of functional multinodular goiter, and two of single toxic nodules. Forty-three patients underwent total thyroidectomy and two underwent total lobectomy. Six cases (13.3%) of thyroid cancer were found, two men and four women with ages ranging from 19 to 48 years. Final histologic examination revealed three papillary carcinomas, one follicular carcinoma, one follicular carcinoma combined with clear-cell carcinoma, and one clear-cell carcinoma. Thus, in our department, the prevalence of thyroid cancer in hyperthyroidism treated using surgery was 13.3%. Our study showed that even a single toxic nodule may occur with concurrent thyroid cancer. Careful evaluation of such patients is needed to exclude the presence of associated malignancy and to determine the most appropriate therapeutic plan.

Early complications of thyroid surgery: Analysis of 2100 patients

Background/Aims. Thyroid gland surgery today is not saddled with high incidence of main complications. Miscellaneous surgical institutions with different surgical approach, operative technique and radicality have published reports with great discrepancy in incidence of complications, analyzing them with different methods of diagnosis and result evaluation. In the same way it is well known that higher latitude of operative procedure gave better control of thyroid diseases, but it can be accompanied with more complications. All of that motivate us to analyze complications of operative treatment in our patients under well known criteria, with hypothesis that higher radicality of operative procedure do not increase incidence of complications, and that this incidence is in correlations with results published in world literature. Aim of this nonrandomized study was to analyze results of operative treatment for huge number of consecutively operated patients in our teaching hospital, to analyze and compare results according to group of diseases and operative procedures, and to compare final results with results published in the world literature. Methods. Complications of operative treatment were analyzed retrospectively for period 1988-1997 (Group I) and prospectively in period 1998-2002 (Group II). Operations were performed by 20 surgeons and 20 young surgeons during their education. We have analyzed only complications during first 30 days after operation. Results. In Group I there was 1425 patients with 1451 operations (192 thyroid malignances, 247 hyperthireosis, 98 reoperations, 13% thyreoidectomies and 14,8% lobectomies), with complication rate of 14,3%. Most common complication was recurrent laryngeal nerve injury in 9,3% patients or 6,3% according to number of exposed nerves (?nerve at risk?), then postoperative hypocalcemia with rate of 4,7% (persistent in 1,3%). In Group II in 675 patients there was 687 operations (96 thyroid malignances, 111 hyperthireosis, 35 reoperations, 36,6% thyreoidectomies and 25% lobectomies), with complication rate of 10,7%. Most common postoperative complication was hypocalcemia with 5% rate (persistent in 0,7%), then recurrent laryngeal nerve injury in 4,4% patients or 2,9% according to number of exposed nerves (?nerve at risk?). Incidence of recurrent laryngeal nerve injury in Group II is less frequent than in Group I, highly statistically significant (p<0,01), while for other complications there is no statistically significant difference. Totally for both groups there was 0,7% tracheotomies, postoperative bleeding in 1,1% of patients, wound haemathoma in 0,5%, wound infections in 0,9%, pneumonia in 0,5%, mortality 0,5% and most common cause of death (8/11) was problem with respiration, ?Airway obstruction?. In Group II complications were less frequent in total thyreoidectomies in relation to lobectomy with contra lateral subtotal lobectomy. In both groups and totally incidence of complications was higher in reoperations, in patients with more extensive operative procedure, in malignant diseases and hyperthyreosis. Conclusion. In thyroid gland surgery more extensive operative treatment with improved operative technique (micro dissection, recurrent laryngeal nerve visualization and parathyroid gland preservation), in our teaching hospital, do not have influence on incidence of postoperative complications, even recurrent laryngeal nerve injury was significantly less frequent. This results are in correlation with published results of similar hospitals around the world.

[Prospective study of early predictive factors of permanent hypocalcemia after bilateral thyroidectomy]

AIM OF THE STUDY

The aim of this prospective cohort study was to identify the early criteria potentially predictive for outcome of permanent hypocalcemia after thyroidectomy.

PATIENTS AND METHODS

Serum calcium (Ca) et phosphorus (Ph) were measured daily until discharge in 2035 consecutive patients undergoing bilateral thyroidectomy. In all patients experiencing postoperative hypocalcemia, defined as a Ca < 8.0 mg/dl on two consecutive days, parathyroid hormone was measured prior initiation of calcium therapy et discharge (early PTH), et blood sample was also obtained 7 to 14 days after discharge for Ca et Ph measurements (delayed Ca et Ph). These patients were then followed up until complete resolution of hypocalcemia or at least one year. Those still needing substitutive therapy to maintain normocalcemia one year after surgery were considered to have permanent hypocalcemia. Correlation of outcome with clinical characteristics, postoperative Ca et Ph levels, early PTH, et delayed Ca et Ph were examined with univariate analysis et multivariate logistic regression.

RESULTS

Postoperative hypocalcemia occurred in 153 patients (7.5%) and spontaneously recovered in all but 7 patients (0.3%). Delayed Ca, and delayed Ph were found to be predictive for outcome of hypocalcemia by univariate analysis (p < 0.01). Relative risk to develop permanent hypocalcemia was 15 for patients with early PTH < 12 pg/ml, 52 when delayed Ph was > 4.0 mg/dl, and 121 when delayed Ca was < 8.0 mg/dl. None of the 113 patients with delayed Ca > or = 8.0 mg/dl and delayed Ph < or = 4.0 mg/dl developed permanent hypocalcemia, in contrast to 1 out of 31 patients (3%) with delayed Ca > 8.0 mg/dl or delayed Ph > 4.0 mg/dl, and 6 out of 9 patients (66%) with delayed Ca < 8.0 mg/dl and delayed Ph > 4.0 mg/dl. Both delayed Ca and delayed Ph appeared as independent factors predicting outcome of hypocalcemia at one year with multivariate logistic regression analysis.

CONCLUSION

Delayed serum calcium and phosphorus levels, when measured one week after starting calcium therapy but prior to administration of any vitamin D analogs, accurately predict outcome of hypocalcemia after thyroidectomy. Patients with delayed Ca under 8.0 mg/dl and/or delayed Ph above 4.0 mg/dl are at high risk to develop permanent hypocalcemia.

[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.

Trial of autotransplantation of cryopreserved thyroid tissue for postoperative hypothyroidism in patients with Graves' disease

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.