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Li J, Austin J, Douglas RS, Nallasamy S. Pediatric hyperthyroidism and thyroid eye disease management. J AAPOS 2023; 27:123-128. [PMID: 37182650 DOI: 10.1016/j.jaapos.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/14/2023] [Accepted: 02/20/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Joy Li
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Juliana Austin
- Department of Pediatrics, Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, University of Southern California, Los Angeles, California
| | - Raymond S Douglas
- Division of Oculoplastic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sudha Nallasamy
- The Vision Center at Children's Hospital Los Angeles, Los Angeles, California; USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California.
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2
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Salman MA, Assal MM, Salman A, Elsherbiney M. Outcomes of Radioactive Iodine Versus Surgery for the Treatment of Graves’ Disease: a Systematic Review and Meta-analysis. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03692-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Abstract
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.
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3
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Rivkees SA. Approach to the Patient: Management and the Long-term Consequences of Graves' Disease in Children. J Clin Endocrinol Metab 2022; 107:3408-3417. [PMID: 36184734 DOI: 10.1210/clinem/dgac573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Indexed: 02/13/2023]
Abstract
In children, Graves' disease (GD) is the most common cause of hyperthyroidism. Most pediatric patients with GD will not go into lasting remission, even following many years of antidrug therapy. Thus, most pediatric patients will require radioactive iodine (RAI) or surgery. When antithyroid drugs are used, methimazole is the drug of choice. When methimazole is used in children, up to 20% will have minor adverse reactions and serious adverse events occur in up to 1%. RAI is an effective form of therapy when the thyroid size is less than 80 g. Because of concerns of whole-body radiation exposure, it is recommended that RAI be avoided in children under 5 years of age, and dosages less than 10 mCi be used between 5 and 10 years of age. Surgery is an effective treatment in children if performed by a high-volume thyroid surgeon. Because of the scarcity of high-volume pediatric thyroid surgeons, a multidisciplinary approach using pediatric surgeons and endocrine surgeons can be considered. Whereas there is a trend toward long-term antithyroid drug therapy in adults, for several reasons, this approach may not be practical for children. Determining the optimal treatment for the pediatric patient with GD, requires consideration of the risks and benefits relating to age and likelihood of remission.
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Affiliation(s)
- Scott A Rivkees
- School of Public Health, Brown University, Providence, RI 02912, USA
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4
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Cohen O, Ronen O, Khafif A, Rodrigo JP, Simo R, Pace-Asciak P, Randolph G, Mikkelsen LH, Kowalski LP, Olsen KD, Sanabria A, Tufano RP, Babighian S, Shaha AR, Zafereo M, Ferlito A. Revisiting the role of surgery in the treatment of Graves' disease. Clin Endocrinol (Oxf) 2022; 96:747-757. [PMID: 34954838 DOI: 10.1111/cen.14653] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 01/06/2023]
Abstract
Graves' disease (GD) can be managed by antithyroid drugs (ATD), radioactive iodine (RAI) and surgery. Thyroidectomy offers the highest success rates for both primary and persistent disease, yet it is the least recommended or utilized option reaching <1% for primary disease and <25% for persistent disease. Several surveys have found surgery to be the least recommended by endocrinologists worldwide. With the development of remote access thyroidectomies and intraoperative nerve monitoring of the recurrent laryngeal nerve, combined with current knowledge of possible risks associated with RAI or failure of ATDs, revaluation of the benefit to harm ratio of surgery in the treatment of GD is warranted. The aim of this review is to discuss possible reasons for the low proportion of surgery in the treatment of GD, emphasizing an evidence-based approach to the clinicians' preferences for surgical referrals, surgical indications and confronting traditional reasons and concerns relating to the low referral rate with up-to-date data.
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Affiliation(s)
- Oded Cohen
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ohad Ronen
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Avi Khafif
- A.R.M. Center of Otolaryngology-Head and Neck Surgery, Assuta Medical Center, Affiliated with Ben-Gurion University of the Negev, Tel Aviv, Israel
| | - Juan P Rodrigo
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, Oviedo, Spain
| | - Ricard Simo
- Department of Otorhinolaryngology, Head and Neck Surgery, Head and Neck and Thyroid Oncology Unit, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Pia Pace-Asciak
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Randolph
- Division of Otolaryngology-Endocrine Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts, USA
| | - Lauge H Mikkelsen
- Department of Pathology, Eye Pathology Section, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Luiz P Kowalski
- Department of Head and Neck Surgery, University of Sao Paulo Medical School, AC Camargo Cancer Center, Sao Paulo, Brazil
- Department of Head and Neck Surgery and Otorhinolaryngology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - Kerry D Olsen
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia-Ips Universitaria, Medellín, Colombia
- CEXCA Centro de Excelencia en Enfermedades de Cabeza y Cuello-Clínica Las Vegas-Quirón, Medellín, Colombia
| | - Ralph P Tufano
- Multidisciplinary Thyroid and Parathyroid Center, Head and Neck Endocrine Surgery, Sarasota Memorial Health Care System, Sarasota, Florida, USA
- Division of Otolaryngology-Endocrine Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Madison, USA
| | - Silvia Babighian
- Department of Ophthalmology, Ospedale Sant'Antonio, Azienda Ospedaliera, Padova, Italy
| | - Ashok R Shaha
- Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Mark Zafereo
- Department of Head & Neck Surgery, Anderson Cancer Center, Houston, Texas, USA
| | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
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5
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Quintanilla-Dieck L, Khalatbari HK, Dinauer CA, Rastatter JC, Chelius DC, Katowitz WR, Shindo ML, Parisi MT, Kazahaya K. Management of Pediatric Graves Disease: A Review. JAMA Otolaryngol Head Neck Surg 2021; 147:1110-1118. [PMID: 34647991 DOI: 10.1001/jamaoto.2021.2715] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The incidence of Graves disease (GD) is rising in children, and adequate care of these patients requires a multidisciplinary approach. Whether patients are seen in the context of endocrinology, nuclear medicine, or surgery, it is important to know the nuances of the therapeutic options in children. Observations Given the rarity of GD in children, it is important to recognize its various clinical presenting signs and symptoms, as well as the tests that may be important for diagnosis. The diagnosis is typically suspected clinically and then confirmed biochemically. Imaging tests, including thyroid ultrasonography and/or nuclear scintigraphy, may also be used as indicated during care. It is important to understand the indications for and interpretation of laboratory and imaging tools so that a diagnosis is made efficiently and unnecessary tests are not ordered. Clinicians should be well-versed in treatment options to appropriately counsel families. There are specific scenarios in which medical therapy, radioactive iodine therapy, or surgery should be offered. Conclusions and Relevance The diagnosis and treatment of pediatric patients with GD requires a multidisciplinary approach, involving pediatric specialists in the fields of endocrinology, ophthalmology, radiology, nuclear medicine, and surgery/otolaryngology. Antithyroid drugs are typically the first-line treatment, but sustained remission rates with medical management are low in the pediatric population. Consequently, definitive treatment is often necessary, either with radioactive iodine or with surgery, ideally performed by experienced, high-volume pediatric experts. Specific clinical characteristics, such as patients younger than 5 years or the presence of a thyroid nodule, may make surgery the optimal treatment for certain patients.
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Affiliation(s)
| | - Hedieh K Khalatbari
- Department of Radiology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle.,Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle
| | - Catherine A Dinauer
- Department of Pediatrics, Section of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey C Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Pediatric Thyroid Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston.,Pediatric Head and Neck Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston
| | - William R Katowitz
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maisie L Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland
| | - Marguerite T Parisi
- Department of Radiology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle.,Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia
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Shalaby M, Hadedeya D, Toraih EA, Razavi MA, Lee GS, Hussein MH, Weidenhaft MC, Serou MJ, Ibraheem K, Abdelgawad M, Kandil E. Predictive factors of radioiodine therapy failure in Graves' Disease: A meta-analysis. Am J Surg 2021; 223:287-296. [PMID: 33865565 DOI: 10.1016/j.amjsurg.2021.03.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/18/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND I-131 therapy is a common treatment modality for adults with Graves' Disease (GD). Utilizing meta-analysis, we examined patient specific factors that predict I-131 therapy failure. METHODS Literature search followed PRISMA. Comprehensive Meta-analysis (version 3.0) was used. Mantel-Haenszel test with accompanying risk ratio and confidence intervals evaluated categorical variables. Continuous data was analyzed using inverse variance testing yielding mean difference or standardized mean difference. Decision tree algorithms identified variables of high discriminative performance. RESULTS 4822 collective patients across 18 studies were included. Male sex (RR = 1.23, 95%CI = 1.08-1.41, p = 0.002), I-131 therapy 6 months after GD diagnosis (RR = 2.10, 95%CI = 1.45-3.04, p < 0.001) and history of anti-thyroid drugs (RR = 2.05, 95%CI = 1.49-2.81, p < 0.001) increased the risk of I-131 therapy failure. Elevated free thyroxine, 24-h radioactive iodine uptake scan ≥60.26% and thyroid volume ≥35.77 mL were also associated with failure. CONCLUSION Patient characteristics can predict the likelihood of I-131 therapy failure in GD. Definitive surgical treatment may be a reasonable option for those patients.
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Affiliation(s)
- Mahmoud Shalaby
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Deena Hadedeya
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Eman A Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Michael A Razavi
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Grace S Lee
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Mandy C Weidenhaft
- Department of Radiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Michael J Serou
- Department of Radiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Kareem Ibraheem
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mohamed Abdelgawad
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
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7
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Beck AC, Sugg SL, Weigel RJ, Belding-Schmitt M, Howe JR, Lal G. Racial disparities in comorbid conditions among patients undergoing thyroidectomy for Graves' disease: An ACS-NSQIP analysis. Am J Surg 2020; 221:106-110. [PMID: 32553518 DOI: 10.1016/j.amjsurg.2020.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies indicate that racial disparities exist in the presentation and outcomes of patients undergoing thyroidectomy for cancer and benign disease. We examined the relationship between race, pre-operative characteristics and outcomes in patients undergoing thyroidectomy for GD. METHODS Patients were identified from the 2013-2016 American College of Surgeons NSQIP database using ICD-9/10 codes consistent with diffuse toxic goiter. RESULTS AA patients were more likely to have an ASA classification of ≥3 (41% vs 30%, p < 0.001), a higher rate of CHF (2.1% vs 0.5%, p = 0.01), hypertension (46% vs 32%, p < 0.001) and dyspnea (10% vs 5%, p < 0.001) compared to Non-Hispanic Caucasians (NH-C) patients. Complications were higher in patients with ASA≥3 and CHF but not affected by race. CONCLUSIONS Analysis of a national database of thyroidectomy for GD revealed a higher burden of preoperative comorbidities in AA patients compared to other races, although race was not an independent predictor of outcomes.
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Affiliation(s)
- Anna C Beck
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, 200 Hawkins Drive, 1500 JCP, Iowa City, IA, 52242, USA
| | - Sonia L Sugg
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, 200 Hawkins Drive, 1500 JCP, Iowa City, IA, 52242, USA
| | - Ronald J Weigel
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, 200 Hawkins Drive, 1500 JCP, Iowa City, IA, 52242, USA
| | - Mary Belding-Schmitt
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, 200 Hawkins Drive, 1500 JCP, Iowa City, IA, 52242, USA
| | - James R Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, 200 Hawkins Drive, 1500 JCP, Iowa City, IA, 52242, USA
| | - Geeta Lal
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, 200 Hawkins Drive, 1500 JCP, Iowa City, IA, 52242, USA.
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8
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Sugino K, Nagahama M, Kitagawa W, Ohkuwa K, Uruno T, Matsuzu K, Suzuki A, Tomoda C, Y Hames K, Akaishi J, Masaki C, Ogimi Y, Yabuta T, Ito K. Change of surgical strategy for Graves' disease from subtotal thyroidectomy to total thyroidectomy: a single institutional experience. Endocr J 2019; 66:181-186. [PMID: 30568070 DOI: 10.1507/endocrj.ej18-0324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [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 remains controversial. In our institution, long-term euthyroidism without thyroxin replacement therapy has been the aim, and it has long been the standard surgical procedure used to treat Graves' disease in many institutions, including our hospital. Based our several clinical studies, it was concluded that subtotal thyroidectomy is not suitable as a standard surgical procedure for the treatment of Graves' disease. In 2009, the surgical strategy for Graves' disease was changed from subtotal thyroidectomy to total thyroidectomy in our hospital. In this study, how surgical complications have changed after this modification was examined. The subjects were 1,476 patients with Graves' disease treated by thyroidectomy between 2006 and 2014. There were 1,119 females and 357 males with a median age of 39 years. A total of 660 patients underwent bilateral subtotal thyroidectomy (ST group), and 816 patients underwent total thyroidectomy (TT group). Both transient hypocalcemia and prolonged hypocalcemia were observed significantly more frequently in the TT group than in the ST group (p < 0.001). Total thyroidectomy was identified as risk factors for prolonged hypocalcemia on multivariate analysis. In conclusion, total thyroidectomy is a reliable and effective therapy for controlling hyperthyroidism in terms of controlling of hyperthyroidism. However, it should be noted that total thyroidectomy resulted in increased rate of prolonged hypocalcemia. Surgeons should try to reduce the surgical complication rate as much as possible.
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Affiliation(s)
| | | | | | - Keiko Ohkuwa
- Department of Surgery, Ito Hospital, Tokyo, Japan
| | | | | | | | | | | | | | - Chie Masaki
- Department of Surgery, Ito Hospital, Tokyo, Japan
| | - Yuna Ogimi
- Department of Surgery, Ito Hospital, Tokyo, Japan
| | | | - Koichi Ito
- Department of Surgery, Ito Hospital, Tokyo, Japan
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9
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Kwon H, Kim JK, Lim W, Moon BI, Paik NS. Increased risk of postoperative complications after total thyroidectomy with Graves' disease. Head Neck 2018; 41:281-285. [PMID: 30537006 DOI: 10.1002/hed.25484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/27/2018] [Accepted: 07/19/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The effect of Graves' disease on the risk of postoperative complications in patients undergoing total thyroidectomy is unclear. METHODS The incidence of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism were analyzed between 165 patients with Graves' disease (GD group) and 1:1 matched patients with euthyroid states (control group). RESULTS The matched cohorts did not differ in age, sex, body mass index, pathologic diagnosis, and extent of operation. Excised thyroid weight was higher in the Graves' disease than in the control group (60.1 g vs 22.6 g; P < .001). Multivariate analysis showed that Graves' disease significantly increased risks of transient RLN injury (odds ratio [OR] = 4.7, 95% confidence interval [CI] = 1.5-15.5; P = .010) and transient hypoparathyroidism (OR = 2.8, 95% CI = 1.3-5.8; P = .007). Rates of permanent complications were comparable in the Graves' disease and control groups. CONCLUSIONS Graves' disease can be a predictive factor for postoperative RLN injury and hypoparathyroidism after total thyroidectomy.
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Affiliation(s)
- Hyungju Kwon
- Department of Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Jong-Kyu Kim
- Department of Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Woosung Lim
- Department of Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Byung-In Moon
- Department of Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Nam Sun Paik
- Department of Surgery, Ewha Womans University Medical Center, Seoul, South Korea
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10
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De Luca F, Valenzise M. Controversies in the pharmacological treatment of Graves' disease in children. Expert Rev Clin Pharmacol 2018; 11:1113-1121. [PMID: 30417713 DOI: 10.1080/17512433.2018.1546576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Graves' disease (GD) is a disorder, in which auto-immunity against the thyroid- stimulating hormone (TSH) receptor is the pivotal pathogenetic element. This disease may have different clinical manifestations, the most common being thyrotoxicosis. Treatment of this condition differs according to its etiology, but there is currently no evidence-based therapeutic strategy which is universally adopted in all countries. Areas covered: a systematic review of the updates on the management of pediatric GD was performed using the Pubmed data base until March 2018. Systematic reviews with or without meta-analysis were analyzed using the following terms: Antithyroid drugs, Childhood, Hyperthyroidism, Radioactive iodine, Thyroidectomy. Expert commentary: As the best way to manage children with GD remains a matter of debate among pediatric endocrinologists, and there is currently no evidence-based therapeutic strategy which is universally adopted, we confirm that the original and prolonged treatment with anti-thyroid drugs (ATDs) remains the mainstay of treatment for juvenile hyperthyroidism. Alternative treatments include radioiodine (RAI) therapy or surgery (total thyroidectomy). We recommend individualizing the therapeutic approach, without prejudices toward radical therapies that become necessary in case of relapse, adverse effects or poor compliance to ATDs. The optimal approach depends on patient or family preference, and specific patient clinical features.
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Affiliation(s)
- Filippo De Luca
- a UOC Pediatria, Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
| | - Mariella Valenzise
- a UOC Pediatria, Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
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Brammen L, Riss P, Lukas J, Gessl A, Dunkler D, Li S, Leisser A, Rezar-Dreindl S, Eibenberger K, Selberherr A, Scheuba C, Papp A. Total thyroidectomy (Tx) versus thionamides (antithyroid drugs) in patients with moderate-to-severe Graves' ophthalmopathy - a 1-year follow-up: study protocol for a randomized controlled trial. Trials 2018; 19:495. [PMID: 30219088 PMCID: PMC6139165 DOI: 10.1186/s13063-018-2876-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 08/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background Graves’ disease (GD) is characterized by thyrotoxicosis and goiter and arises through circulating autoantibodies that bind to, and stimulate, the thyroid hormone receptor (TSHR). A temporal relation between the onset of hyperthyroidism and the onset of ophthalmopathy, a common extrathyroidal manifestation, has been demonstrated. Graves’ ophthalmopathy (GO) is typically characterized by an inflammation and expansion of the extraocular muscles and an increase in retroorbital fat. There are currently three forms of therapies offered for hyperthyroidism caused by Graves’ disease: antithyroid drugs (ATD) (thionamides), radioiodine ablation (RAI) and thyroidectomy (Tx). To date, there is no clear recommendation on the treatment of Graves’ disease and GO, mainly due to the individuality of the disease in each patient. The aim of the study is to examine the difference in the outcome of GO in patients with moderate-to-severe GO who receive Tx versus further ATD after suffering their first relapse of GO, or in which GO stays the same following the initial decrease in ATD therapy after 6 months. Methods/Design This prospective randomized clinical trial with observer-blinded analysis will analyze 60 patients with moderate-to-severe GO who receive Tx versus ATD without surgery. Main outcome variables include: muscle index measurements via ultrasound and thyroid antibody levels. Additional outcome variables include: Clinical Activity Score (CAScore), NOSPECS score, superonasal index measurements via ultrasound, and quality of life score. Discussion This study should allow for better therapeutic choices in patients with moderate-to-severe GO. In addition, it should demonstrate whether the outcome of GO in patients with moderate-to-severe GO is better in those who receive early Tx versus further ATD. Furthermore, this study will aim to establish a standard glucocorticoid scheme before and after Tx in patients with moderate-to-severe EO. Trial registration Eudra-CT: 2015–003515-38; Medical University of Vienna Protocol Record 1839/2015. Date of Ethics Committee approval: 19 January 2017. Registered on 27 January 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2876-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lindsay Brammen
- Section of Endocrine Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Philipp Riss
- Section of Endocrine Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria. .,Medical University Vienna, General Hospital Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
| | - Julius Lukas
- Department of Ophthalmology, Medical University Vienna, Vienna, Austria
| | - Alois Gessl
- Department of Internal Medicine- Section of Endocrinology, Medical University Vienna, Vienna, Austria
| | - Daniela Dunkler
- Section for Clinical Biometrics, CeMSIIS, Medical University Vienna, Vienna, Austria
| | - Shuren Li
- Department of Nuclear Medicine, Medical University Vienna, Vienna, Austria
| | - Asha Leisser
- Department of Nuclear Medicine, Medical University Vienna, Vienna, Austria
| | | | | | - Andreas Selberherr
- Section of Endocrine Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Christian Scheuba
- Section of Endocrine Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Andrea Papp
- Department of Ophthalmology, Medical University Vienna, Vienna, Austria
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12
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Comparative analysis of radioactive iodine versus thyroidectomy for definitive treatment of Graves disease. Surgery 2016; 161:147-155. [PMID: 27863789 DOI: 10.1016/j.surg.2016.06.066] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/27/2016] [Accepted: 06/03/2016] [Indexed: 11/20/2022]
Abstract
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.
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Rivkees SA. Controversies in the management of Graves' disease in children. J Endocrinol Invest 2016; 39:1247-1257. [PMID: 27153850 DOI: 10.1007/s40618-016-0477-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 04/22/2016] [Indexed: 12/19/2022]
Abstract
Graves' disease (GD) is the most prevalent cause of thyrotoxicosis in children. Because spontaneous and lasting resolution of this condition occurs in only a minority of patients, most pediatric patients with GD will need radioactive iodine treatment (131I) or thyroidectomy. Whereas the medication propylthiouracil (PTU) had been used in the past, only methimazole (MMI) should be now used in children, as PTU is associated with an unacceptable risk of liver failure. However, MMI may be associated minor and major side effects, which may be minimized using lower doses. An area of controversy involves the optimal duration of antithyroid drug (ATD) therapy. For some children, the prolonged use of antithyroid drugs is a valid approach, but for most, this will not increase the chance of remission. When 131I is administered, dosages should be greater than 150 uCi/gm of thyroid tissue, with higher dosages needed for larger glands. Considering that there will be low-level whole body radiation exposure associated with 131I, this treatment is viewed as controversial by some and should be avoided in young children. When surgery is performed, near-total or total thyroidectomy is the recommended procedure. Complications for thyroidectomy in children are considerably higher than in adults. Thus, an experienced thyroid surgeon is needed when children have surgery. Overall, when different treatment options for GD are considered, the benefits, risks and viewpoints of the family need to be considered and discussed in full.
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Affiliation(s)
- S A Rivkees
- Department of Pediatrics, University of Florida College of Medicine, Pediatrics - Chairman's Office, 1600 SW Archer Road - Room R1-118, Gainesville, FL, 32610-0296, USA.
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De Luca F, Salzano G, Zirilli G, Calafiore M, Corica D, Sferlazzas C. Management of hyperthyroidism in children. Expert Rev Endocrinol Metab 2016; 11:301-309. [PMID: 30058924 DOI: 10.1080/17446651.2016.1199953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Treatment of hyperthyroidism in children differs according to its etiology; in particular, the optimal therapy of Graves' disease (GD) remains a matter of debate and there is currently no evidence-based therapeutic strategy that is universally adopted in all the countries. Areas covered: The most recent treatment strategies in the different pediatric conditions which may be associated with hyperthyroidism. We searched PubMed and Cochrane (1990 to 2016) in order to identify articles to include in this review using the following terms: Hyperthyroidism, Childhood, Antithyroid drug therapy, Thyroidectomy, Radioactive iodine. Expert commentary: Although pharmacological therapy represents the first-line approach for GD children, we recommend to individualize, as much as possible, the overall therapeutic approach, with no prejudices towards radical therapies, particularly in the cases with frequent relapses. Clinical and laboratory preferential criteria for an individualized therapeutic approach to GD children are given. Treatment procedures for hyperthyroid children without GD are also discussed.
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Affiliation(s)
- Filippo De Luca
- a Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
| | - Giuseppina Salzano
- a Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
| | - Giuseppina Zirilli
- a Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
| | - Mariarosa Calafiore
- a Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
| | - Domenico Corica
- a Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
| | - Concetta Sferlazzas
- a Department of Human Pathology of Adulthood and Childhood , University of Messina , Messina , Italy
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15
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Boostrom S, Richards ML. Total thyroidectomy is the preferred treatment for patients with Graves' disease and a thyroid nodule. Otolaryngol Head Neck Surg 2016; 136:278-81. [PMID: 17275554 DOI: 10.1016/j.otohns.2006.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 09/11/2006] [Indexed: 11/19/2022]
Abstract
Objective To identify the indications and outcomes of total thyroidectomy for Graves' disease in a North American cohort. Study Design and Setting Prospective database of 297 patients undergoing total thyroidectomy in a tertiary care center identified 49 patients with Graves'. Results There were 37 women and 12 men (mean age, 37.9 years). Common indications for surgery were: refusal of radioactive iodine (20%), thyroid storm (18%), a thyroid nodule (16%), failure of I131(14%), and ophthalmopathy (14%). Complications included: symptomatic hypocalcemia (14%), permanent hypoparathyroidism (0%), and symptoms of recurrent laryngeal nerve injury (0%). Graves' patients had more bleeding (117 mL versus 48 mL, P < 0.05). Clinical nodules were malignant in 38%. Papillary thyroid carcinoma occurred in 10% of patients, with 60% multifocal, and 60% lymph node metastases. Conclusion Total thyroidectomy for Graves' has minimal morbidity. Patients with Graves' and a thyroid nodule are at an increased risk for malignancy and should be treated with a total thyroidectomy.
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Affiliation(s)
- Sarah Boostrom
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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16
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Chen Y, Masiakos PT, Gaz RD, Hodin RA, Parangi S, Randolph GW, Sadow PM, Stephen AE. Pediatric thyroidectomy in a high volume thyroid surgery center: Risk factors for postoperative hypocalcemia. J Pediatr Surg 2015; 50:1316-9. [PMID: 25783304 DOI: 10.1016/j.jpedsurg.2014.10.056] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hypocalcemia is a common complication following thyroid surgery. We seek to report on our experience in pediatric thyroidectomy in a high volume thyroid surgery center and accurately assess the incidence of postoperative hypocalcemia. MATERIALS AND METHODS A retrospective review of patients aged 18 and younger who underwent thyroid surgery between 1992 and 2013. The primary endpoints were the occurrence of postoperative hypocalcemia as by defined as a nadir calcium <8.0mg/dL and being discharged on oral calcium supplementation, need for intravenous calcium and the occurrence of permanent hypoparathyroidism. RESULTS 171 patients who underwent 186 thyroid operations were analyzed. The average age was 15.4years with 82.3% female. The most common indications for surgery were nodular disease (74.7%) and hyperthyroidism (12.4%). 24 patients (12.9%) experienced postoperative hypocalcemia with 13 (7.0%) requiring intravenous calcium infusion. One patient (0.9%) experienced permanent hypoparathyroidism. Risk factors for postoperative hypocalcemia included total thyroidectomy (OR 7.39, p<0.01), central and bilateral lateral neck dissection (OR 22.26, p=0.01), Graves' disease (OR 3.99, p=0.02), and malignancy (OR 2.96, p=0.03). CONCLUSIONS Pediatric patients who undergo total thyroidectomy for underlying malignancy or Graves' disease and those who have more extensive nodal dissections are at increased risk of developing this postoperative hypocalcemia. These patients may benefit from more vigilant preoperative preparation and postoperative calcium and vitamin D supplementation.
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Affiliation(s)
- Yufei Chen
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Peter T Masiakos
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Randall D Gaz
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Richard A Hodin
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Sareh Parangi
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Gregory W Randolph
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
| | - Peter M Sadow
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Antonia E Stephen
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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17
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Bojic T, Paunovic I, Diklic A, Zivaljevic V, Zoric G, Kalezic N, Sabljak V, Slijepcevic N, Tausanovic K, Djordjevic N, Budjevac D, Djordjevic L, Karanikolic A. Total thyroidectomy as a method of choice in the treatment of Graves' disease - analysis of 1432 patients. BMC Surg 2015; 15:39. [PMID: 25888210 PMCID: PMC4422312 DOI: 10.1186/s12893-015-0023-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/19/2015] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Toplica Bojic
- Department for Endocrine Surgery and Breast Surgery, Clinic of General Surgery, Clinical Centre Nis, Bul. Dr Zorana Djindjica 48, 18000, Nis, Serbia.
| | - Ivan Paunovic
- Centre for Endocrine Surgery, Clinic of Endocrinology Diabetes and Metabolic Disease, Clinical Centre Serbia, Dr Subotica 13, 11000, Belgrade, Serbia.,University of Belgrade School of Medicine, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Aleksandar Diklic
- Centre for Endocrine Surgery, Clinic of Endocrinology Diabetes and Metabolic Disease, Clinical Centre Serbia, Dr Subotica 13, 11000, Belgrade, Serbia.,University of Belgrade School of Medicine, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Vladan Zivaljevic
- Centre for Endocrine Surgery, Clinic of Endocrinology Diabetes and Metabolic Disease, Clinical Centre Serbia, Dr Subotica 13, 11000, Belgrade, Serbia.,University of Belgrade School of Medicine, Dr Subotica 8, 11000, Belgrade, Serbia
| | - Goran Zoric
- Centre for Endocrine Surgery, Clinic of Endocrinology Diabetes and Metabolic Disease, Clinical Centre Serbia, Dr Subotica 13, 11000, Belgrade, Serbia
| | - Nevena Kalezic
- University of Belgrade School of Medicine, Dr Subotica 8, 11000, Belgrade, Serbia.,Centre for Anaesthesia and Resuscitation, Clinical Centre Serbia, Pasterova 2, 11000, Belgrade, Serbia
| | - Vera Sabljak
- University of Belgrade School of Medicine, Dr Subotica 8, 11000, Belgrade, Serbia.,Centre for Anaesthesia and Resuscitation, Clinical Centre Serbia, Pasterova 2, 11000, Belgrade, Serbia
| | - Nikola Slijepcevic
- Centre for Endocrine Surgery, Clinic of Endocrinology Diabetes and Metabolic Disease, Clinical Centre Serbia, Dr Subotica 13, 11000, Belgrade, Serbia
| | - Katarina Tausanovic
- Centre for Endocrine Surgery, Clinic of Endocrinology Diabetes and Metabolic Disease, Clinical Centre Serbia, Dr Subotica 13, 11000, Belgrade, Serbia
| | - Nebojsa Djordjevic
- Department for Endocrine Surgery and Breast Surgery, Clinic of General Surgery, Clinical Centre Nis, Bul. Dr Zorana Djindjica 48, 18000, Nis, Serbia.,University of Nis School of Medicine, Bul. Dr Zorana Djindjica 81, 18000, Nis, Serbia
| | - Dragana Budjevac
- Department for Endocrine Surgery and Breast Surgery, Clinic of General Surgery, Clinical Centre Nis, Bul. Dr Zorana Djindjica 48, 18000, Nis, Serbia
| | - Lidija Djordjevic
- Department for Endocrine Surgery and Breast Surgery, Clinic of General Surgery, Clinical Centre Nis, Bul. Dr Zorana Djindjica 48, 18000, Nis, Serbia
| | - Aleksandar Karanikolic
- Department for Endocrine Surgery and Breast Surgery, Clinic of General Surgery, Clinical Centre Nis, Bul. Dr Zorana Djindjica 48, 18000, Nis, Serbia.,University of Nis School of Medicine, Bul. Dr Zorana Djindjica 81, 18000, Nis, Serbia
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Sung TY, Lee YM, Yoon JH, Chung KW, Hong SJ. Long-Term Effect of Surgery in Graves' Disease: 20 Years Experience in a Single Institution. Int J Endocrinol 2015; 2015:542641. [PMID: 26064111 PMCID: PMC4443923 DOI: 10.1155/2015/542641] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/27/2015] [Accepted: 04/30/2015] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
| | - Yu-mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
| | - Jong Ho Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
| | - Ki-Wook Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
| | - Suck Joon Hong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Republic of Korea
- *Suck Joon Hong:
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Jevalikar G, Solis J, Zacharin M. Long-term outcomes of pediatric Graves' disease. J Pediatr Endocrinol Metab 2014; 27:1131-6. [PMID: 24945422 DOI: 10.1515/jpem-2013-0342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 05/16/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Remission rates with antithyroid drugs (ATDs) in pediatric Graves' disease (GD) are low. Very few studies report long-term follow-up of GD especially into adulthood. OBJECTIVES We studied long-term outcomes of pediatric onset GD, including a follow-up into adulthood and factors associated with need for definitive therapy. METHODS Sixty-five patients (57 females) with GD, with onset <18 years (median 13, range, 3.5-17) and duration ≥2 years (median 7; range, 2-22) since diagnosis, were included. Medical records were reviewed, and current details were recorded in a questionnaire by telephonic interview. RESULTS All patients were initially treated with ATDs. Fifty-three patients were treated for ≥2 years. Amongst these, outcomes included relapse after initial remission (n=38), failure of remission (n=8) and long-term remission, defined as remission lasting ≥4 years (n=6). One patient had carbimazole and surgery but died of hepato-renal failure secondary to systemic vasculitis. A total of 44/65 patients were managed with definitive treatment. Those needing definitive treatment had higher mean free T4 (54.6±23.7 vs. 39.5±20.5 pmol/L, p=0.02) and thyrotropin receptor antibody (TRAB) titers (34.1±19.3 vs. 13.8±9.9 IU/L p<0.0001). Long-term sequelae included need for thyroxine replacement (n=42, 64.6%), persistent goiter (12/62, 19.3%) and persistent ophthalmopathy (19/40, 47.5%). CONCLUSIONS Long-term remission rates of pediatric onset GD with ATDs are very low, especially with longer follow-up. Higher pretreatment free T4 and high TRAB titers predict need for definitive treatment.
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20
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Oltmann SC, Brekke AV, Schneider DF, Schaefer SC, Chen H, Sippel RS. Preventing postoperative hypocalcemia in patients with Graves disease: a prospective study. Ann Surg Oncol 2014; 22:952-8. [PMID: 25212835 DOI: 10.1245/s10434-014-4077-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypocalcemia occurs after total thyroidectomy (TT) for Graves disease via parathyroid injury and/or from increased bone turnover. Current management is to supplement calcium after surgery. This study evaluates the impact of preoperative calcium supplementation on hypocalcemia after Graves TT. METHODS A prospective study of patients with Graves disease undergoing TT was performed. Patients with Graves disease managed over a 9-month period took 1 g of calcium carbonate (CC) three times a day for 2 weeks before TT. Those managed the previous year without supplementation served as historic controls. Age-, gender-, and thyroid weight-matched, non-Graves TT patients were procedure controls. Patient demographics, postoperative laboratory values, complaints, and medications were reviewed. Parathyroid hormone (PTH)-based postoperative protocols dictated postoperative CC and calcitriol use. RESULTS Forty-five patients with Graves disease were treated with CC before TT, and 38 patients with Graves disease were not. Forty control subjects without Graves disease were identified. Age, gender, and thyroid weight were comparable. Preoperative calcium and PTH levels were equivalent. PTH values immediately after surgery, at postoperative day 1, and at 2-week follow-up were equivalent. Postoperative use of scheduled CC (p = 0.10) and calcitriol (p = 0.60) was similar. Postoperatively, patients with untreated Graves disease had lower serum calcium levels than pretreated patients with Graves disease or control subjects without Graves disease (8.3 mg/dL vs. 8.6 vs. 8.6, p = 0.05). Complaints of numbness and tingling were more common in nontreated Graves disease (26%) than in pretreated Graves disease (9%) or in control subjects without Graves disease (10%, p < 0.05). CONCLUSIONS Calcium supplementation before TT for Graves disease significantly reduced biochemical and symptomatic postoperative hypocalcemia. Preoperative calcium supplementation is a simple treatment that can reduce symptoms of hypocalcemia after Graves TT.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, Madison, WI, USA
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21
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Rivkees SA. Pediatric Graves' disease: management in the post-propylthiouracil Era. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2014; 2014:10. [PMID: 25089127 PMCID: PMC4118280 DOI: 10.1186/1687-9856-2014-10] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 06/04/2014] [Indexed: 12/19/2022]
Abstract
The most prevalent cause of thyrotoxicosis in children is Graves’ disease (GD), and remission occurs only in a modest proportion of patients. Thus most pediatric patients with GD will need treatment with radioactive iodine (RAI; 131I) or surgical thyroidectomy. When antithyroid drugs (ATDs) are prescribed, only methimazole (MMI) should be administered, as PTU is associated with an unacceptable risk of severe liver injury. If remission does not occur following ATD therapy, 131I or surgery should be contemplated. When 131I is administered, dosages should be greater than 150 uCi/gm of thyroid tissue, with higher dosages needed for large glands. Considering that there will be low-level whole body radiation exposure associated with 131I, this treatment should be avoided in young children. When surgery is performed near total or total-thyroidectomy is the recommended procedure. Complications for thyroidectomy in children are considerably higher than in adults, thus an experienced thyroid surgeon is needed when children are operated on. Most importantly, the care of children with GD can be complicated and requires physicians with expertise in the area.
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Affiliation(s)
- Scott A Rivkees
- Department of Pediatrics, University of Florida College of Medicine, 1600 SW Archer Road - Room R1-118, Gainesville, FL, USA
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22
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A systematic review and meta-analysis of total thyroidectomy versus bilateral subtotal thyroidectomy for Graves' disease. Surgery 2014; 155:529-40. [DOI: 10.1016/j.surg.2013.10.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 10/11/2013] [Indexed: 11/19/2022]
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Guo Z, Yu P, Liu Z, Si Y, Jin M. Total thyroidectomy vs bilateral subtotal thyroidectomy in patients with Graves' diseases: a meta-analysis of randomized clinical trials. Clin Endocrinol (Oxf) 2013; 79:739-46. [PMID: 23521078 DOI: 10.1111/cen.12209] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 01/29/2013] [Accepted: 03/18/2013] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Zhenying Guo
- Department of Surgical Pathology, Zhejiang Cancer Hospital, Hangzhou, China
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Shinall MC, Broome JT, Nookala R, Shinall JB, Kiernan C, Parks L, Solórzano CC. Total thyroidectomy for Graves' disease: compliance with American Thyroid Association guidelines may not always be necessary. Surgery 2013; 154:1009-15. [PMID: 24075271 DOI: 10.1016/j.surg.2013.04.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 04/26/2013] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Nashville, TN.
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Shinall MC, Broome JT, Baker A, Solorzano CC. Is potassium iodide solution necessary before total thyroidectomy for Graves disease? Ann Surg Oncol 2013; 20:2964-7. [PMID: 23846785 DOI: 10.1245/s10434-013-3126-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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Abstract
Thyroidectomy is the most common endocrine surgical procedure being carried out throughout the world. Besides, many patients who have deranged thyroid physiology, namely hyperthyroidism and hypothyroidism, have to undergo various elective and emergency surgical procedures at some stage of their life. The attending anesthesiologist has to face numerous daunting tasks while administering anesthesia to such patients. The challenging scenarios can be encountered at any stage, be it preoperative, intra-op or postoperative period. Preoperatively, deranged thyroid physiology warrants optimal preparation, while anticipated difficult airway due to enlarged thyroid gland further adds to the anesthetic challenges. Cardiac complications are equally challenging as also the presence of various co-morbidities which make the task of anesthesiologist extremely difficult. Thyroid storm can occur during intra-op and post-op period in inadequately prepared surgical patients. Postoperatively, numerous complications can develop that include hemorrhage, laryngeal edema, nerve palsies, tracheomalacia, hypocalcemic tetany, pneumothorax, etc., The present review aims at an in-depth analysis of potential risk factors and challenges during administration of anesthesia and possible complications in patients with thyroid disease.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
| | - Vishal Sehgal
- Department of Internal Medicine, The Commonwealth Medical College Scranton, PA 18510, USA
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Excessive Decrease in Serum Magnesium After Total Thyroidectomy for Graves’ Disease Is Related to Development of Permanent Hypocalcemia. World J Surg 2012. [DOI: 10.1007/s00268-012-1843-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Hallgrimsson P, Nordenström E, Bergenfelz A, Almquist M. Hypocalcaemia after total thyroidectomy for Graves' disease and for benign atoxic multinodular goitre. Langenbecks Arch Surg 2012; 397:1133-7. [PMID: 22976368 DOI: 10.1007/s00423-012-0981-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 07/05/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Postoperative hypocalcaemia has been reported to be more common after total thyroidectomy (TT) for Graves' disease than after TT for benign atoxic multinodular goitre (MNG). The reasons for this potential association are not clear. In the present study, the frequency and risk factors of hypocalcaemia after TT for Graves' vs MNG were compared. METHODS Between January 1999 and October 2009, patients with first-time surgery for Graves' disease or MNG treated with a TT were included in the study. Postoperative hypocalcaemia was defined by symptoms, calcium levels and treatment with calcium and/or vitamin D analogues during postoperative hospital stay, at discharge, and at the 6-week and 6-month follow-ups. Outcomes were compared with Mann-Whitney, chi(2) and Fishers' exact test where appropriate and by multivariable logistic regression analysis. RESULTS There were 128 patients with Graves' disease and 81 patients with MNG. Patients with Graves' disease were younger than patients with MNG (median age, 35 vs 51 years, p < 0.001). Symptoms of hypocalcaemia were more common in patients with Graves' disease (p < 0.001; OR, 95 % CI 3.26, 1.48-7.14), but the frequency of biochemical hypocalcaemia, postoperative levels of parathyroid hormone (PTH) and treatment with calcium and vitamin D did not differ between groups of patients. CONCLUSION Apart from more frequent symptoms of hypocalcaemia in patients with Graves' disease, there was no difference in the overall frequency of biochemical hypocalcaemia, low levels of PTH and/or treatment with calcium and vitamin D.
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Affiliation(s)
- Páll Hallgrimsson
- Department of Surgery, Skane University Hospital, Lund University, S-221 85 Lund, Sweden.
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Genovese BM, Noureldine SI, Gleeson EM, Tufano RP, Kandil E. What is the best definitive treatment for Graves' disease? A systematic review of the existing literature. Ann Surg Oncol 2012; 20:660-7. [PMID: 22956065 DOI: 10.1245/s10434-012-2606-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Bradley M Genovese
- Division of Endocrine and Oncological Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
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Citgez B, Uludag M, Yetkin G, Yener F, Akgun I, Isgor A. Changes in the choice of thyroidectomy for benign thyroid disease. Surg Today 2012; 43:625-31. [DOI: 10.1007/s00595-012-0297-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 03/16/2012] [Indexed: 11/24/2022]
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Kim YS. Impact of preserving the parathyroid glands on hypocalcemia after total thyroidectomy with neck dissection. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:75-82. [PMID: 22880180 PMCID: PMC3412187 DOI: 10.4174/jkss.2012.83.2.75] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 05/16/2012] [Accepted: 06/04/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE The aims of this study were to determine the incidence and evaluate the risk factors for hypocalcemia after total thyroidectomy and to investigate how many parathyroid glands should be preserved to prevent postoperative hypocalcemia. METHODS From March 2007 to February 2011, a retrospective review of 866 patients who underwent total thyroidectomy and node dissection for thyroid cancer was performed. The incidence and predisposing factors for hypocalcemia were analyzed. Among them, a total of 191 cases had four of their parathyroid glands identified intraoperatively. These patients were then divided into one preserved parathyroid gland group (group I, n = 22) and two or more preserved parathyroid glands group (group II, n = 169). The incidence of hypocalcemia with regards to the number of preserved parathyroid glands was determined and the results between the two groups were compared. The total calcium, ionized calcium and parathyroid hormone levels were compared between the two groups. RESULTS The overall incidence of transient and permanent hypocalcemia was 9.2% and 0.5%, respectively. The decreased number of preserved parathyroid gland and increased number of removed central lymph node were the significant risk factors for developing postoperative hypocalcemia. In 191 cases identified with four parathyroid glands, the incidence of hypocalcemia was related to the number of preserved glands (group I, 22.7%; group II, 3.0%; P < 0.001). CONCLUSION The insufficient number of preserved parathyroid glands is the only cause of hypocalcemia after total thyroidectomy and node dissection. At least one preserved parathyroid gland may prevent postoperative permanent hypocalcemia.
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Affiliation(s)
- Yon Seon Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Peroni E, Angiolini MR, Vigone MC, Mari G, Chiumello G, Beretta E, Weber G. Surgical management of pediatric Graves' disease: an effective definitive treatment. Pediatr Surg Int 2012; 28:609-14. [PMID: 22543510 DOI: 10.1007/s00383-012-3095-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The optimal treatment for pediatric Graves' disease (GD) is controversial. Antithyroid drugs are often used initially, but they are associated with a high failure rate. Therefore alternative therapies have become important. In the present study, we analyze our institution's experience regarding the safety and efficacy of thyroid surgery among pediatric patients with GD. METHODS This is a retrospective chart review of 27 pediatric patients (age ≤ 18 years) with GD who underwent thyroid surgery between 1991 and 2009 at a single academic Institution. We recorded preoperative, intraoperative, and short-term postoperative data. RESULTS All 27 patients were initially treated with thionamides. The high rate of hyperthyroidism relapse after discontinuation of medical treatment, age < 5 years, adverse reaction to medical therapy, severe ophthalmopathy, and patient preference justified the final decision to proceed with surgery as definitive therapy. All patients underwent total thyroidectomy. We had no mortality; surgical complications were rare: 4 (14.8 %) cases of transient hypocalcemia, 1 (3.7 %) of permanent hypocalcemia, 3 (11.1 %) of transient RLN neuropraxia, and 2 (7 %) of keloid scar. No bleeding, permanent RLN palsy or relapse hyperthyroidism were reported. CONCLUSIONS Surgical therapy for pediatric GD performed by experienced thyroid surgeons is a safe, definitive and cost-effective treatment.
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Affiliation(s)
- Elena Peroni
- Department of Pediatric Endocrinology, San Raffaele Hospital, Vita-Salute San Raffaele University, Via Olgettina, 60, Milan, Italy.
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Disparity in the management of Graves' disease observed at an urban county hospital: a decade-long experience. Am J Surg 2012; 204:199-202. [PMID: 22317948 DOI: 10.1016/j.amjsurg.2011.10.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 10/12/2011] [Accepted: 10/12/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to determine whether health care disparities exist in management of Graves' disease. METHODS Patients treated for Graves' disease from 1999 to 2009 were divided into medical and surgical treatment groups. A comparative analysis of age, sex, race, health insurance, and income was completed. Address and/or zip code were geocoded and median income was determined from census data. RESULTS A total of 634 patients were treated for Graves' disease; 535 (84%) medically and 99 (16%) surgically. Mean age (40 ± 15 vs 43 ± 11 y), percentage of women (84% vs 91%), and racial distribution were similar in the 2 groups (P > .05). In the surgical group, median income was lower ($31,530 vs $34,404; P = .07) and 52% of patients were uninsured compared with 30% of patients treated medically (P < .0001). CONCLUSIONS A disproportionate number of uninsured patients underwent thyroidectomy for Graves' disease. Social and economic factors may have a role in determining definitive therapy for Graves' disease.
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Limonard EJ, Bisschop PH, Fliers E, Nieveen van Dijkum EJ. Thyroid function after subtotal thyroidectomy in patients with Graves' hyperthyroidism. ScientificWorldJournal 2012; 2012:548796. [PMID: 22448136 PMCID: PMC3290451 DOI: 10.1100/2012/548796] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 12/06/2011] [Indexed: 11/17/2022] Open
Abstract
Background. Subtotal thyroidectomy is a surgical procedure, in which the surgeon leaves a small thyroid remnant in situ to preserve thyroid function, thereby preventing lifelong thyroid hormone supplementation therapy. Aim. To evaluate thyroid function after subtotal thyroidectomy for Graves' hyperthyroidism. Subjects and Methods. We retrospectively reviewed the medical records of all patients (n = 62) who underwent subtotal thyroidectomy for recurrent Graves' hyperthyroidism between 1992 and 2008 in our hospital. Thyroid function was defined according to plasma TSH and free T4 values.
Results. Median followup after operation was 54.6 months (range 2.1–204.2 months). Only 6% of patients were euthyroid after surgery. The majority of patients (84%) became hypothyroid, whereas 10% of patients had persistent or recurrent hyperthyroidism. Permanent recurrent laryngeal nerve palsy and permanent hypocalcaemia were noted in 1.6% and 3.2% of patients, respectively. Conclusion. In our series, subtotal thyroidectomy for Graves' hyperthyroidism was associated with a high risk of postoperative hypothyroidism and a smaller, but significant, risk of persistent hyperthyroidism. Our data suggest that subtotal thyroidectomy seems to provide very little advantage over total thyroidectomy in terms of postoperative thyroid function.
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Affiliation(s)
- E J Limonard
- Department of Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Barczyński M, Konturek A, Hubalewska-Dydejczyk A, Gołkowski F, Nowak W. Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up11. Br J Surg 2012; 99:515-22. [DOI: 10.1002/bjs.8660] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2011] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The extent of thyroid resection in Graves' disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves' disease and mild active ophthalmopathy.
Methods
Participants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves' ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism.
Results
Two hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5-year follow-up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves' ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury.
Conclusion
TT for Graves' disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. Registration number: NCT01408368 (http://www.clinicaltrials.gov).
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Affiliation(s)
- M Barczyński
- Third Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - A Konturek
- Third Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | | | - F Gołkowski
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - W Nowak
- Third Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
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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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Järhult J, Andersson PO, Duncker L. Alternating from subtotal thyroid resection to total thyroidectomy in the treatment of Graves’ disease prevents recurrences but increases the frequency of permanent hypoparathyroidism. Langenbecks Arch Surg 2011; 397:407-12. [DOI: 10.1007/s00423-011-0886-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 11/29/2011] [Indexed: 11/28/2022]
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Orgiazzi J. Traitement de la maladie de Basedow : problématiques actuelles. Presse Med 2011; 40:1155-62. [DOI: 10.1016/j.lpm.2011.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 09/23/2011] [Accepted: 09/27/2011] [Indexed: 11/25/2022] Open
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Abstract
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, tumors that secrete thyrotropin, and drug-induced thyroid dysfunction, are also important causes.<br /> <br />
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Affiliation(s)
- Mala Sharma
- Department of Internal Medicine and Division of Cardiology, New York Medical College, Valhalla, NY 10595, USA
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Hypocalcaemia following thyroidectomy for treatment of Graves’ disease: implications for patient management and cost-effectiveness. The Journal of Laryngology & Otology 2011; 125:849-52. [DOI: 10.1017/s0022215111001332] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground:No consensus exists on optimal treatment for Graves’ disease once anti-thyroid medication fails to induce remission. Total thyroidectomy is a more cost-effective treatment than radioactive iodine or life-long anti-thyroid medication, but hypocalcaemia is an important complication, leading to longer hospital admissions and increased prescription costs. This study aimed to compare the relative risk of hypocalcaemia requiring medical treatment for patients with Graves’ disease.Methods:Prospective cohort study of patients undergoing total thyroidectomy for Graves’ disease and for multinodular goitre, calculating serum calcium levels 24-hours post-operatively and prescription rates.Results:Mean corrected calcium concentrations 24 hours post-operatively were 2.05 mmol/l for Graves’ disease patients and 2.14 mmol/l for multinodular goitre patients (p = 0.003). Biochemical hypocalcaemia developed in 92 per cent (n = 34) of Graves’ disease patients and 71 per cent (n = 43) of multinodular goitre patients (p = 0.012). Graves’ disease patients were more likely to be prescribed calcium supplementation pre-discharge (p = 0.037).Conclusion:Total thyroidectomy for Graves’ disease carries an increased risk of hypocalcaemia at 24 hours, and of calcium supplementation pre-discharge. Graves’ disease patients should be informed of the increased risk of hypocalcaemia associated with total thyroidectomy, and this risk must be factored into future cost-effectiveness analysis.
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Feliciano DV, Lyons JD. Thyroidectomy Is Optimal Treatment for Graves' Disease. J Am Coll Surg 2011; 212:714-20; discussion 720-1. [DOI: 10.1016/j.jamcollsurg.2010.12.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 12/22/2010] [Indexed: 10/18/2022]
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Yuan L, Yang J. Radioiodine treatment in pediatric Graves' disease and thyroid carcinoma. J Pediatr Endocrinol Metab 2011; 24:877-83. [PMID: 22308835 DOI: 10.1515/jpem.2011.399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Graves' disease (GD) is the most common cause of hyperthyroidism in pediatric patients. Most pediatric thyroid cancer is differentiated thyroid cancer (DTC). The two diseases can be treated using different methods, such as antithyroid drug, radioactive iodine (RAI), and surgery for GD and surgery and RAI for DTC. RAI can be used to treat pediatric GD and DTC. In the article, we reviewed the RAI application in pediatric GD and DTC.
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Affiliation(s)
- Leilei Yuan
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Pesce CE, Shiue Z, Tsai HL, Umbricht CB, Tufano RP, Dackiw APB, Kowalski J, Zeiger MA. Postoperative hypocalcemia after thyroidectomy for Graves' disease. Thyroid 2010; 20:1279-83. [PMID: 20950255 DOI: 10.1089/thy.2010.0047] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND It is believed that patients who undergo thyroidectomy for Graves' disease are more likely to experience postoperative hypocalcemia than patients undergoing total thyroidectomy for other indications. However, no study has directly compared these two groups of patients. The aim of this study was to determine whether there was an increased incidence or severity of postoperative hypocalcemia in patients who underwent thyroidectomy for Graves' disease. METHODS An institutional review board-approved database was created of all patients who underwent thyroidectomy from 1998 to 2009 at the Johns Hopkins Hospital. There were a total of 68 patients with Graves' disease who underwent surgery. Fifty-five patients who underwent total thyroidectomy were randomly selected and served as control subjects. An analysis was conducted that examined potential covariates for postoperative hypocalcemia, including age, gender, ethnicity, preoperative alkaline phosphatase level, size of goiter, whether parathyroid tissue or glands were present in the specimen, and the reason the patient underwent surgery. Specific outcomes examined were calcium levels on postoperative day 1, whether or not patients experienced symptoms of hypocalcemia, whether or not Rocaltrol was required, the number of calcium tablets prescribed upon discharge, whether or not postoperative tetany occurred, and calcium levels 1 month after discharge. RESULTS Each outcome was analyzed using a logistic regression. Graves' disease patients had a significantly (p-value < 0.001) higher odds of greater number of calcium tablets prescribed upon discharge. Further, 6 of 68 patients with Graves' disease and no patient in the control group were readmitted with tetany (p = 0.033). There was a trend, though not significant, toward patients with Graves' disease having a higher prevalence of hypocalcemia the day after thyroidectomy and 1 month later. CONCLUSIONS Patients with Graves' disease are more likely to require increased dosages of calcium as well as experience tetany postoperatively than patients undergoing total thyroidectomy for other indications. This suggests that patients operated upon for Graves' disease warrant close followup as both inpatients and outpatients for signs and symptoms of hypocalcemia.
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Affiliation(s)
- Catherine E Pesce
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Eisenberg MC, Santini F, Marsili A, Pinchera A, DiStefano JJ. TSH regulation dynamics in central and extreme primary hypothyroidism. Thyroid 2010; 20:1215-28. [PMID: 21062194 PMCID: PMC2974848 DOI: 10.1089/thy.2009.0349] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Thyrotropin (TSH) changes in extreme primary hypothyroidism include increased secretion, slowed degradation, and diminished or absent TSH circadian rhythms. Diminished rhythms are also observed in central hypothyroid patients and have been speculated to be a cause of central hypothyroidism. We examined whether TSH secretion saturation, previously suggested in extreme primary hypothyroidism, might explain diminished circadian rhythms in both disorders. METHODS We augmented and extended the range of our published feedback control system model to reflect nonlinear changes in extreme primary hypothyroidism, including putative TSH secretion saturation, and quantified and validated it using multiple clinical datasets ranging from euthyroid to extreme hypothyroid (postthyroidectomy). We simulated central hypothyroidism by reducing overall TSH secretion and also simulated normal TSH secretion without circadian oscillation, maintaining plasma TSH at constant normal levels. We also utilized the validated model to explore thyroid hormone withdrawal protocols used to prepare remnant ablation in thyroid cancer patients postthyroidectomy. RESULTS Both central and extreme primary hypothyroidism simulations yielded low thyroid hormone levels and reduced circadian rhythms, with simulated daytime TSH levels low-to-normal for central hypothyroidism and increased in primary hypothyroidism. Simulated plasma TSH showed a rapid rise immediately following triiodothyronine (T(3)) withdrawal postthyroidectomy, compared with a slower rise after thyroxine withdrawal or postthyroidectomy without replacement. CONCLUSIONS Diminished circadian rhythms in central and extreme primary hypothyroidism can both be explained by pituitary TSH secretion reaching maximum capacity. In simulated remnant ablation protocols using the extended model, TSH shows a more rapid rise after T(3) withdrawal than after thyroxine withdrawal postthyroidectomy, supporting the use of replacement with T(3) prior to (131)I treatment.
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Affiliation(s)
- Marisa C Eisenberg
- Biocybernetics Laboratory, Department of Computer Science, University of California, Los Angeles, California, USA.
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Raffaelli M, Bellantone R, Princi P, De Crea C, Rossi ED, Fadda G, Lombardi CP. Surgical treatment of thyroid diseases in elderly patients. Am J Surg 2010; 200:467-72. [PMID: 20887839 DOI: 10.1016/j.amjsurg.2009.12.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 12/08/2009] [Accepted: 12/08/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND We evaluated the safety of thyroid surgery in elderly patients, in whom surgical procedures usually are considered more hazardous than in younger patients. METHODS The medical records of all the patients who were aged 70 years or older who had undergone thyroid surgery between January 1998 and June 2008 were reviewed. RESULTS A total of 320 patients were included. The preoperative diagnosis was multinodular goiter in 171 cases, toxic goiter in 59 cases, suspicious or indeterminate thyroid nodule in 60 cases, and thyroid carcinoma in 30 patients. Total thyroidectomy was performed in 283 patients, thyroid lobectomy in 15 patients, and a completion thyroidectomy was performed in 22 patients. The final histology showed thyroid cancer in 86 patients and benign disease in 234. CONCLUSIONS Thyroid surgery in patients aged 70 years or older is safe and the relatively high rate of thyroid carcinoma and toxic goiter may justify an aggressive approach.
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Affiliation(s)
- Marco Raffaelli
- Division of Endocrine Surgery-Department of Surgery, Università Cattolica del Sacro Cuore, L. go A. Gemelli 8, 00168 Rome, Italy.
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Abstract
BACKGROUND Cumulative sum (CUSUM) analysis gives visual feedback on performance. It requires agreed benchmarks to compare binary outcomes. This process has not previously been applied to thyroidectomy. The objective of this study was to determine if CUSUM analysis can be employed to give feedback on performance of thyroidectomy. METHODS A literature review to define the CUSUM analysis key performance indicators for thyroidectomy was performed. The key performance indicators for thyroid surgery were hematoma (return to theater for evacuation), hypocalcemia (corrected calcium <2.0 mmol/L), and vocal cord palsy (postoperative hoarseness with nasal endoscopic confirmation). Pre- and postoperative laryngoscopy was not routinely performed by all surgeons. Permanent was defined as duration longer than 6 months. A prospective audit of 216 patients undergoing thyroidectomy between January 2003 and December 2006 at the Geelong Hospital was completed. CUSUM charting of outcomes was performed after agreeing by consensus the boundaries of acceptable and unacceptable performance. RESULTS Aggregate analysis of outcomes demonstrated acceptable performance across all clinical indicators. The incidence of temporary/permanent hypocalcemia and vocal cord palsy were 24%/2.6% and 3.2%/0.65%, respectively. About 1.39% of patients required evacuation of hematoma. CUSUM plotting of outcomes demonstrated acceptable performance. CONCLUSIONS There is some variation of how standard outcome indicators for thyroidectomy are measured in the literature. A prospective audit using aggregate outcomes and CUSUM analysis has demonstrated that the performance of thyroid surgery at the Geelong Hospital was acceptable. These indicators and our methods of analysis could be used to monitor the performance of thyroid surgery at other hospitals.
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Total Thyroidectomy for Nodular, Benign Thyroid Diseases in Terms of Larynx Function Examinations - Is it a New Treatment Standard? POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Own Experience in Treatment of Autoimmune Goiter in the Last Decade. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Total Thyroidectomy Is Superior to Subtotal Thyroidectomy for Management of Graves’ Disease in the United States. World J Surg 2009; 34:1261-4. [PMID: 20033406 DOI: 10.1007/s00268-009-0337-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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