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Zaat AS, Derikx JP, Zwaveling-Soonawala N, van Trotsenburg AP, Mooij CF. Thyroidectomy in Pediatric Patients with Graves' Disease: A Systematic Review of Postoperative Morbidity. Eur Thyroid J 2021; 10:39-51. [PMID: 33777818 PMCID: PMC7983567 DOI: 10.1159/000511345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 08/09/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Graves' disease (GD) is the most common cause of hyperthyroidism. In children, the overall relapse frequency after treatment with antithyroid drugs is high. Therefore, many pediatric GD patients eventually require thyroidectomy as definitive treatment. However, the postoperative complications of thyroidectomy in pediatric GD patients are poorly reported. OBJECTIVE To identify the frequency of short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients. METHODS A systematic review of the literature (PubMed and Embase) was performed to identify studies reporting short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients according to the PRISMA guidelines. RESULTS Twenty-two mainly retrospective cohort studies were included in this review evaluating short- and long-term morbidities in 1,424 children and adolescents. The frequency of transient hypocalcemia was 22.2% (269/1,210), with a range of 5.0-50.0%. The frequency of permanent hypocalcemia was 2.5% (36/1,424), with a range of 0-20.0%. Two studies reported high frequencies of permanent hypocalcemia, 20.0 (6/30) and 17.4% (9/52), respectively. The 20% frequency could be explained by low-volume surgeons in poorly controlled GD patients. Only 21 cases of permanent hypocalcemia were reported in the 1,342 patients included in the other 20 studies (1.6%). Transient and permanent recurrent laryngeal nerve injury were reported less frequently, with frequencies between 0-20.0 and 0-7.1%, respectively. Infection, hemorrhage/hematoma, and keloid development were only rarely reported as postoperative complications. CONCLUSION The results of this systematic review suggest that thyroidectomy is a safe treatment option for pediatric GD patients. The minority of patients will experience transient and benign morbidities, with hypocalcemia being the most common transient postoperative morbidity. Permanent postoperative morbidities are relatively rare.
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Affiliation(s)
- Annabel S. Zaat
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joep P.M. Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A.S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christiaan F. Mooij
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- *Christiaan F. Mooij, Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, NL–1105 AZ Amsterdam (The Netherlands),
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Azizi F, Takyar M, Madreseh E, Amouzegar A. Long-term Methimazole Therapy in Juvenile Graves' Disease: A Randomized Trial. Pediatrics 2019; 143:peds.2018-3034. [PMID: 31040197 DOI: 10.1542/peds.2018-3034] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recent studies show that long-term (LT) antithyroid drugs reduce relapse of hyperthyroidism in patients with Graves' disease. Our objective was to evaluate the effectiveness and safety of LT methimazole treatment and to compare remission rates in Graves' disease patients after LT and short-term (ST) therapy. METHODS In this randomized, parallel group trial, 66 consecutive patients with untreated juvenile Graves' hyperthyroidism were enrolled. After a median 22 months of methimazole treatment, 56 patients were randomly assigned to either continue low-dose methimazole treatment (n = 24, LT group) or to discontinue treatment (n = 24, ST group). Twenty-four patients in LT group completed 96 to 120 months of methimazole treatment. Patients in both groups were managed for 48 months after discontinuation of treatment. RESULTS Except for 3 cases of cutaneous reactions, no other adverse events were observed throughout 120 months of methimazole therapy. Serum free thyroxine, triiodothyronine, thyrotropin, and thyrotropin receptor antibody remained normal, and the required daily dosage of methimazole was gradually decreased from 5.17 ± 1.05 mg at 22 months to 3.5 ± 1.3 mg between 96 and 120 months of treatment (P < .001). Hyperthyroidism was cured in 92% and 88% of LT patients and in 46% and 33% of ST patients, 1 and 4 years after methimazole withdrawal, respectively. CONCLUSIONS LT methimazole treatment of 96 to 120 months is safe and effective for treatment of juvenile Graves' disease. The four-year cure rate of hyperthyroidism with LT methimazole treatment is almost 3 times more than that of ST methimazole treatment.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and
| | - Miralireza Takyar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and
| | - Elham Madreseh
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and.,Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and
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Azizi F, Amouzegar A. Management of thyrotoxicosis in children and adolescents: 35 years' experience in 304 patients. J Pediatr Endocrinol Metab 2018; 31:159-165. [PMID: 29306930 DOI: 10.1515/jpem-2017-0394] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/12/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Diffuse toxic goiter accounts for about 15% of all childhood thyroid diseases. There is great controversy over the management of Graves' disease in children and adolescents. This article reports our experience in 304 children and juvenile patients with Graves' disease. METHODS Between 1981 and 2015, 304 patients aged 5-19 years with diffuse toxic goiter were studied, of whom 296 patients were treated with antithyroid drugs (ATD) for 18 months. Patients with persistent or relapsed hyperthyroidism who refused ablative therapy with surgery or radioiodine were managed with continuous methimazole (MMI) treatment. RESULTS In 304 patients (245 females and 59 males), the mean age was 15.6±2.6 years. After 18 months of ATD therapy, 37 remained in remission and of the 128 who relapsed, two, 29 and 97 patients chose surgery, continuous ATD and radioiodine therapy, respectively. Of the 136 patients who received radioiodine, 66.2% became hypothyroid. Twenty-nine patients received continuous ATD therapy for 5.7±2.4 years. The mean MMI dose was 4.6±12 mg daily, no serious complications occurred and all of them remained euthyroid during the follow-up. Less abnormal thyroid-stimulating hormone (TSH) values were observed in these patients, as compared to patients who were on a maintenance dose of levothyroxine after radioiodine induced hypothyroidism. CONCLUSIONS Original treatment with ATD and subsequent radioiodine therapy remain the mainstay of treatment for juvenile hyperthyroidism. Continuous ATD administration may be considered as another treatment modality for hyperthyroidism.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, I.R. Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, I.R. Iran
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Minamitani K, Sato H, Ohye H, Harada S, Arisaka O. Guidelines for the treatment of childhood-onset Graves' disease in Japan, 2016. Clin Pediatr Endocrinol 2017; 26:29-62. [PMID: 28458457 PMCID: PMC5402306 DOI: 10.1297/cpe.26.29] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose behind developing these guidelines: Over one decade ago, the “Guidelines for the
Treatment of Graves’ Disease with Antithyroid Drug, 2006” (Japan Thyroid Association
(JTA)) were published as the standard drug therapy protocol for Graves’ disease. The
“Guidelines for the Treatment of Childhood-Onset Graves’ Disease with Antithyroid Drug in
Japan, 2008” were published to provide guidance on the treatment of pediatric patients.
Based on new evidence, a revised version of the “Guidelines for the Treatment of Graves’
Disease with Antithyroid Drug, 2006” (JTA) was published in 2011, combined with the
“Handbook of Radioiodine Therapy for Graves’ Disease 2007” (JTA). Subsequently, newer
findings on pediatric Graves’ disease have been reported. Propylthiouracil (PTU)-induced
serious hepatopathy is an important problem in pediatric patients. The American Thyroid
Association’s guidelines suggest that, in principle, physicians must not administer PTU to
children. On the other hand, the “Guidelines for the Treatment of Graves’ Disease with
Antithyroid Drug, 2011” (JTA) state that radioiodine therapy is no longer considered a
“fundamental contraindication” in children. Therefore, the “Guidelines for the Treatment
of Childhood-Onset Graves’ Disease with Antithyroid Drug in Japan, 2008” required
revision.
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Affiliation(s)
| | - Kanshi Minamitani
- Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | | | - Hidemi Ohye
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Shohei Harada
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Arisaka
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
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Chen PY, Chao CM, Wu TJ, Huang SM. Volume changes in remnant thyroid tissue after thyroidectomy in Graves disease. J Formos Med Assoc 2014; 113:629-33. [PMID: 25103076 DOI: 10.1016/j.jfma.2012.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 08/14/2012] [Accepted: 08/17/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND/PURPOSE Surgery is one of the treatment choices for Graves disease. The residual thyroid tissue may shrink or become larger. The object of this study was trying to find out what factors affect the residual thyroid gland volume change after thyroidectomy in Graves disease. METHODS We followed thyroid volume changes by ultrasonography in 101 patients with Graves disease who underwent one side lobectomy and another side subtotal thyroidectomy from 1996 to 2006. These patients were divided into three groups according to the residual thyroid size increasing, no change in size, and shrinking. We checked the factors as follows: age, body weight, thyroid-stimulating hormone (TSH) level, TSH-receptor antibody level, anti-thyroid peroxidase (TPO) antibody level, total thyroid volume before and after thyroidectomy, and degree of lymphocyte infiltration. RESULTS We found that young age and lower residual volume ratio were the most powerful two factors affecting remnant thyroid gland volume changing. We also found that there is no significant correlation between TSH levels and thyroid volume change, nor TSH-receptor antibody titer or thyroid volume change. CONCLUSION Age and residual volume ratio were the most powerful two factors in this study.
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Affiliation(s)
- Pei-Yin Chen
- National Cheng Kung University, College of Medicine and Hospital, Dou-Liou Branch, Yunlin, Taiwan, ROC
| | - Cheng-Min Chao
- National Yunlin University of Science and Technology, Yunlin, Taiwan, ROC
| | - Ta-Jen Wu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Shih-Ming Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC.
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Sato H, Minamitani K, Minagawa M, Kazukawa I, Sugihara S, Wataki K, Konda S, Inomata H, Sanayama K, Kohno Y, Sasaki N. Clinical features at diagnosis and responses to antithyroid drugs in younger children with Graves' disease compared with adolescent patients. J Pediatr Endocrinol Metab 2014; 27:677-83. [PMID: 24756042 DOI: 10.1515/jpem-2013-0288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 02/28/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate clinical manifestations, laboratory findings, and effects of antithyroid drugs in younger children with Graves' disease (GD). DESIGN A retrospective and collaborative study. SETTING Nine facilities in Chiba prefecture, Japan. PATIENTS We analyzed 132 children and adolescents with GD. The subjects were divided according to the median age into a group of young children (group I, 4.1-12.4 years, n=66) and an adolescent group (group II, 12.5-15.9 years, n=66). MAIN OUTCOME MEASURES Clinical manifestations, laboratory findings, incidence of adverse effects, and remission rates 5 years after initial therapy were assessed. RESULTS The mean height SD score of group I (1.0) was higher than that of group II (0.3, p<0.001). The mean BMI SD score of group I (-0.7) was lower than that of group II (-0.3, p<0.05). The most common presentations were goiter, sweating, and hyperactivity in group I, whereas the most common presentations were goiter, sweating, and easy fatigability in group II. Hyperactivity was more frequent in group I (56.7%) than in group II (37.9%, p<0.05). Liver dysfunction appeared more often in group I (14.3%) than in group II (1.9%, p<0.05). There was no difference in the appearance of adverse effects between the two groups. The remission rate was slightly lower in group I (23.1%) than in group II (31.3%), but was not significant. CONCLUSIONS Thyrotoxicosis had more influence on the growth and liver function in younger children.
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Sugino K, Ito K, Nagahama M, Kitagawa W, Shibuya H, Ohkuwa K, Yano Y, Uruno T, Akaishi J, Suzuki A, Masaki C, Ito K. Changes in the thyroid function of Graves' disease patients treated by subtotal thyroidectomy. Endocr J 2012; 59:1115-20. [PMID: 22971989 DOI: 10.1507/endocrj.ej12-0260] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The extent of thyroidectomy in Graves' disease is still a matter of controversy. Subtotal thyroidectomy has been used as the standard surgical procedure for Graves' disease in Japan, but high hyperthyroidism relapse rates have been reported. We retrospectively studied serial changes in the thyroid function Graves' disease patients after they had been treated by subtotal thyroidectomy and assessed whether subtotal thyroidectomy should be recommended as the standard surgical procedure for the treatment of Graves' disease. The subjects were 478 Graves' disease patients who underwent subtotal thyroidectomy at our institution between 1994 and 1997 and were followed up on a regular basis, and their thyroid function 2-3 years after surgery (the early period) and 8-10 years after surgery (the late period) was evaluated and compared. The evaluations in the late period showed that 57% of the euthyroid patients in the early period remained euthyroid, 30% had developed a relapse of hyperthyroidism, and 13 % had become hypothyroid. Approximately 80% of the patients who were overtly hyperthyroid or overtly hypothyroid in the early period remained so in the late period. During the entire periods 47 patients had subclinical hyperthyroidism and were followed up without any postoperative medication. Twenty (42.6%) of them developed overt hyperthyroidism, 11 (23.4%) experienced a spontaneous remission, and 16 (34%) continued to be subclinically hyperthyroid. Because thyroid function after subtotal thyroidectomy is unstable and reduces quality of life, subtotal thyroidectomy is concluded not to be suitable as a standard surgical procedure for the treatment of Graves' disease.
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Chao M, Jiawei X, Guoming W, Jianbin L, Wanxia L, Driedger A, Shuyao Z, Qin Z. Radioiodine treatment for pediatric hyperthyroid Grave's disease. Eur J Pediatr 2009; 168:1165-9. [PMID: 19421775 DOI: 10.1007/s00431-009-0992-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 04/28/2009] [Indexed: 11/25/2022]
Abstract
Grave's disease (GD) is an autoimmune disease in which excessive amounts of thyroid hormones circulate in the blood. Treatment for pediatric GD includes (1) antithyroid drugs (ATD), (2) radioiodine, and (3) thyroidectomy. Yet, the optimal therapy remains controversial. We collected studies from all electronically available sources as well as from conferences held in China. All studies using radioiodine and/or ATD and/or thyroidectomy were included. Information was found on 1,874 pediatric GD patients treated with radioiodine, 1,279 patients treated with ATD and 1,362 patients treated surgically. The cure rate for radioiodine was 49.8%; the incidence of hypothyroidism, 37.8%; of relapse, 6.3%; of adverse effects, 1.55%; and of drop outs, 0.6%. These data show that radioiodine treatment is safe and effective in pediatric GD with significant lower incidence of relapse and adverse effects but significantly higher incidence of hypothyroidism as compared with both ATD and thyroidectomy. For the time being, radioiodine treatment for pediatric GD remains an excellent first-line therapy and a good second-line therapy for patients with ATD failure, severe complications, or poor compliance.
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Affiliation(s)
- Ma Chao
- Department of Nuclear Medicine Affiliated Hospital, Qingdao University, Qingdao, Shandong Province, China.
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Sasaki A, Nitta H, Otsuka K, Obuchi T, Kurihara H, Wakabayashi G. Endoscopic subtotal thyroidectomy: the procedure of choice for Graves' disease? World J Surg 2009; 33:67-71. [PMID: 19009318 DOI: 10.1007/s00268-008-9783-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Akira Sasaki
- Department of Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan.
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Huang SA. Can hyperthyroidism relapse after antithyroid drug treatment be predicted in children with Graves disease? NATURE CLINICAL PRACTICE. ENDOCRINOLOGY & METABOLISM 2009; 5:74-75. [PMID: 19092786 DOI: 10.1038/ncpendmet1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 11/12/2008] [Indexed: 05/27/2023]
Affiliation(s)
- Stephen A Huang
- Harvard Medical School Children's Hospital Boston, MA 02115, USA.
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