Effect of lugol solution on thyroid gland blood flow and microvessel density in the patients with Graves' disease

Perchlorates in the treatment of hyperthyroidism and thyrotoxicosis: a comprehensive review

INTRODUCTION

Perchlorates are ionic inhibitors antagonizing iodine transport into thyrocytes, hampering thyroid hormone synthesis. Nevertheless, perchlorates are not considered as first-line treatment in hyperthyroidism and thyrotoxicosis as compared to other pharmacological and non-pharmacological interventions.

AIM

Reassessing the therapeutic role of perchlorates in hyperthyroidism and thyrotoxicosis throughout a systematic review of the Literature.

METHODS

Guidelines were searched and examined to summarize current recommendations on the use of perchlorates in the management of hyperthyroidism. Randomized and non-randomized clinical trials were also searched and reviewed to summarize the efficacy/effectiveness and safety of perchlorates in hyperthyroidisms and thyrotoxicosis.

RESULTS

The management of specific forms of hyperthyroidism was considered, including Graves' disease (GD) in non-pregnant adults, hyperthyroidisms in pregnancy, iodine media contrast-induced hyperthyroidism, amiodarone-induced hyperthyroidisms, and thyroid storm. Most of the reported studies had remarkable limitations in terms of study design (non-controlled trials, lack of blinding), low number of participants, and the lack of clinically relevant endpoints, such as cardiovascular events, cardiovascular mortality, and teratogenicity. Overall, perchlorates could be considered a second-line treatment after thionamides, radioiodine, and total thyroidectomy in both GD and hyperthyroidisms in pregnancy. The therapeutic potential of perchlorates alone or in combination with other agents could be considered a second-line treatment of iodine-related hyperthyroidisms and thyroid storm.

CONCLUSION

Despite the low level of evidence, perchlorates could be considered in such specific forms of thyroid disorders, including iodine-induced hyperthyroidism and thyroid storm.

Preoperative preparation for Graves' disease

Thyroidectomy is always regarded as the crucial treatment for Graves' disease, especially in cases of poor efficacy or excessive side effects of antithyroid- drugs and 131I radioiodine therapy. To decrease the incidence of hemorrhage, thyroid storms and other severe complications during the perioperative period, surgeons explore different therapies to prepare for thyroidectomy. We performed a review of preoperative preparation with a focus on the Graves' disease population. Most of the previous schemes are effective, which contributes to the smooth operation of patients, but there is no unified standard for preoperative preparation. This review aims to summarize the preoperative preparation of Graves' disease and the latest developments. Prospective studies with longer follow up-up periods are required to select appropriate preoperative regimens based on personal thyroid statements and to identify target populations of benefit.

Case report: Impact of hyperthyroidism on psychotic symptoms in schizophrenia comorbid with Graves' disease

Introduction

Auditory hallucinations are the most common type of hallucinations observed in schizophrenia; however, visual hallucinations are not uncommon. In Graves' disease, depression, hypomania, and psychosis can occur. While the association between Graves' disease and psychosis has been explored, understanding of the specific impact of thyroid dysfunction severity on psychiatric symptom severity is limited. Here, we present a case report of a patient with schizophrenia comorbid with Graves' disease whose psychotic symptoms were impacted by hyperthyroidism.

Case

The patient was a 32-year-old Japanese woman who presented with auditory and visual hallucinations, agitation, and pressured speech. The patient was diagnosed with schizophrenia comorbid with Graves' disease and thyroid storm. The patient's psychotic symptoms were found to be associated with fluctuations in thyroid hormone levels, and visual hallucinations were observed only during thyroid storms. Treatment involved dexamethasone, potassium iodide, bisoprolol fumarate, and methimazole for thyrotoxicosis, and a blonanserin transdermal patch, paliperidone, and paliperidone palmitate for psychotic symptoms. The patient's auditory and visual hallucinations improved with antipsychotic treatment and decreased thyroid hormone levels.

Conclusion

This case highlights the importance of monitoring thyroid function in patients with schizophrenia, particularly those with comorbid Graves' disease. The correlation between psychiatric symptoms and thyroid hormone levels was demonstrated on an individual level over time, with symptoms worsening as thyroid hormone levels increased. Additionally, our case suggests that abnormally high thyroid hormone levels may trigger visual hallucinations in individuals with schizophrenia. Further studies are needed to elucidate the underlying mechanisms and potential treatment implications of this association.

Non-thionamide antithyroid drug options in Graves' hyperthyroidism

INTRODUCTION

The thionamide anti-thyroid drugs namely carbimazole, methimazole, and propylthiouracil, have been the predominant therapy modality for Graves' hyperthyroidism for over 60 years. Although these agents have proven efficacy and favorable side-effect profiles, non-thionamide alternatives are occasionally indicated in patients who are intolerant or unresponsive to thionamides alone. This review examines the available non-thionamide drug options for the control of Graves' hyperthyroidism and summarizes their clinical utility, efficacy, and limitations.

AREAS COVERED

We reviewed existing literature on mechanisms, therapeutic utility, and side-effect profiles of non-thionamide anti-thyroid drugs. Established non-thionamide agents act on various phases of the synthesis, release, and metabolism of thyroid hormones and comprise historical agents such as iodine compounds and potassium perchlorate as well as drug repurposing candidates like lithium, glucocorticoids, beta-blockers, and cholestyramine. Novel experimental agents in development target key players in Graves' disease pathogenesis including B-cell depletors (Rituximab), CD40 blockers (Iscalimab), TSH-receptor antagonists, blocking antibodies, and immune-modifying peptides.

EXPERT OPINION

Non-thionamide anti-thyroid drugs are useful alternatives in Graves' hyperthyroidism and more clinical trials are needed to establish their safety and long-term efficacy in hyperthyroidism control. Ultimately, the promise for a cure will lie in novel approaches that target the well-established immunopathogenesis of Graves' disease.

Approach to the Patient: Management and the Long-term Consequences of Graves' Disease in Children

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.

Graves' disease treated by complementary medicine leading to thyroid storm: A case report

Background:

Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis and can be precipitated by several factors. We described a thyroid storm precipitated by a long-term treatment using homeopathic medicine containing iodine.

Case presentation:

A 55-year-old Italian woman was admitted to our Sub-Intensive Care Unit with the diagnosis of congestive heart failure and thyrotoxicosis. She has been diagnosed with Graves’ disease two years before; she refused conventional therapy and in the preceding six months had been using phytotherapeutic and homeopathic medicine. We found serum and urine iodine levels consistent with severe intoxication by iodine (serum iodine: 42100 mcg/L and urinary iodine: 4223 mcg/L, respectively). After a few hours, the patient went into cardiac arrest. She was subjected to invasive ventilation, dialyzed with continuous veno-venous hemofiltration and treated with vasoactive amines.

Conclusion:

The high level of iodemia manifested in our patient - around a thousand times greater than the normal range and itself associated with fatal outcomes - was caused by long-term homeopathic treatment. This long-term treatment has two consequences: first, iodine load-precipitated hyperthyroidism in thyroid storm, and secondly, it prevents us from treating patients with inorganic iodide.

Efficacy and safety of preoperative preparation with Lugol's iodine solution in euthyroid patients with Graves' disease (LIGRADIS Trial): Study protocol for a multicenter randomized trial

Background

Currently, both the American Thyroid Association and the European Thyroid Association recommend preoperative preparation with Lugol's Solution (LS) for patients undergoing thyroidectomy for Graves’ Disease (GD), but their recommendations are based on low-quality evidence. The LIGRADIS trial aims to provide evidence either to support or refute the systematic use of LS in euthyroid patients undergoing thyroidectomy for GD.

Methods

A multicenter randomized controlled trial will be performed. Patients ≥18 years of age, diagnosed with GD, treated with antithyroid drugs, euthyroid and proposed for total thyroidectomy will be eligible for inclusion. Exclusion criteria will be prior thyroid or parathyroid surgery, hyperparathyroidism that requires associated parathyroidectomy, thyroid cancer that requires adding a lymph node dissection, iodine allergy, consumption of lithium or amiodarone, medically unfit patients (ASA-IV), breastfeeding women, preoperative vocal cord palsy and planned endoscopic, video-assisted or remote access surgery.

Between January 2020 and January 2022, 270 patients will be randomized for either receiving or not preoperative preparation with LS. Researchers will be blinded to treatment assignment. The primary outcome will be the rate of postoperative complications: hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, surgical site infection or death. Secondary outcomes will be intraoperative events (Thyroidectomy Difficulty Scale score, blood loss, recurrent laryngeal nerve neuromonitoring signal loss), operative time, postoperative length of stay, hospital readmissions, permanent complications and adverse events associated to LS.

Conclusions

There is no conclusive evidence supporting the benefits of preoperative treatment with LS in this setting. This trial aims to provide new insights into future Clinical Practice Guidelines recommendations.

Trial registration

ClinicalTrials.gov identifier: NCT03980132.

Thyroidectomy for Graves' Disease Predicts Postoperative Neck Hematoma and Hypocalcemia: A North American cohort study

Objective:

Examine the association of Graves’ disease with the development of postoperative neck hematoma.

Design:

A cohort of patients participating in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016 to December 31, 2018.

Setting:

A North American surgical cohort study.

Methods:

17 906 patients who underwent thyroidectomy were included. Propensity score matching was performed to adjust for differences in baseline covariates. Multivariate logistic regression was used to ascertain the association between thyroidectomy for Graves’ disease and risk of postoperative adverse events within 30 days of surgery. The primary outcome was postoperative hematoma. Secondary outcomes were postoperative hypocalcemia and recurrent laryngeal nerve injury.

Results:

One-to-three propensity score matching yielded 1207 patients with mean age (SD) of 42.6 (14.9) years and 1017 (84.3%) female in the group with Graves’ disease and 3621 patients with mean age (SD) of 46.7 (15.0%) years and 2998 (82.8%) female in the group with indications other than Graves’ disease for thyroidectomy. The cumulative 30-day incidence of postoperative hematoma was 3.1% (38/1207) in the Graves’ disease group and 1.9% (70/3621) in other patients. The matched cohort showed that Graves’ disease was associated with higher odds of postoperative hematoma (OR 1.65, 95% CI 1.10-2.46) and hypocalcemia (OR 2.04, 95% CI 1.66-2.50) compared with other indications for thyroid surgery. There was no difference in recurrent laryngeal nerve injury among the 2 groups.

Conclusions:

Patients with Graves’ disease undergoing thyroidectomy are more likely to suffer from postoperative hematoma and hypocalcemia compared to patients undergoing surgery for other indications.

Effect of preoperative potassium iodide administration on Graves' disease surgery: a propensity score analysis

BACKGROUND

Preoperative administration of a saturated solution of potassium iodide (SSKI) is recommended in the guidelines for the management of hyperthyroidism due to Graves' disease. Studies addressing its effect on complications after thyroidectomy are inconclusive.

METHODS

Retrospective multicenter Propensity Score study of patients undergoing total thyroidectomy for Graves' disease, from January 2013 to September 2019 in two tertiary centers in Madrid, Spain. Patients were given SSKI prior to surgery or not according to surgeons' preferences. Electronic clinical records were reviewed searching: baseline characteristics surgical variables, pathological findings, and postoperative complications.

RESULTS

Ninety patients were analyzed: 44 received SSKI and 46 were not given SSKI. No significant differences were found in the main postoperative complications with or without SSKI: transient hypoparathyroidism (40.9% vs. 50%), permanent hypoparathyroidism (6.8% vs. 13%), transient recurrent laryngeal nerve (RLN) palsy (2.3% vs. 8.7%), definitive RLN palsy (2.3% vs. 2.2%), or cervical hematoma (2.3% vs. 4.3%).

CONCLUSION

Preoperative administration of SSKI had no impact on postoperative complications after thyroidectomy for Graves' disease.

Preoperative Potassium Iodide Treatment in Patients Undergoing Thyroidectomy for Graves' Disease-Perspective of a European High-Volume Center

BACKGROUND

Potassium iodide (KI) treatment affects the vascularity of the thyroid gland and therefore may improve intraoperative visualization of essential structures. However, clear evidence for its usage is lacking, and its implementation in patients suffering from Graves' disease is becoming rare. The objective of this retrospective study was to assess the impact of KI treatment on the intraoperative course and the outcome of patients undergoing thyroidectomy for Graves' diseases.

METHODS

The study included 442 patients: 125 patients (28.3%) who received a preoperative treatment with KI ("Group KI") and 317 patients (71.7%) without a KI therapy ("Group No-KI"). Indication for KI treatment was a thyroid bruit (82.5%), as well as hyperthyroidism refractive to medical treatment with antithyroid drugs (17.4%).

RESULTS

All patients underwent total thyroidectomy. Permanent vocal cord paresis and permanent hypoparathyroidism were similar in both groups. KI treatment was associated with a significantly longer operative time (142 vs. 128 min, p < 0.001) and a significant higher weight of the thyroid gland. KI treatment did not impact duration of hospital stay or occurrence of secondary hemorrhage.

CONCLUSIONS

The complication rate of this study population with clinically severe GD was very low-which may be caused by pre-treatment of patients. The complementary option of a potassium iodide treatment before surgery remains a possibility and should be implemented individually.

Current approach to surgical management of hyperthyroidism

Hyperthyroidism is a set of disorders that involve excess synthesis and secretion of thyroid hormones by the thyroid gland, which leads to thyrotoxicosis. The most common forms of hyperthyroidism include diffuse toxic goiter (Graves' disease), toxic multinodular goiter (Plummer disease), and a solitary toxic adenoma. The most reliable screening measure of thyroid function is the thyroid-stimulating hormone (TSH) level. Options for treatment of hyperthyroidism include: antithyroid drugs, radioactive iodine therapy (the preferred treatment of hyperthyroidism among US thyroid specialists), or thyroidectomy. Massive thyroid enlargement with compressive symptoms, a suspicious nodule, Graves' orbitopathy, and patient preference are indications for surgical treatment of thyrotoxicosis. This paper reviews the current literature and controversies on the surgical approach to the management of hyperthyroidism.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Diagnosis and Management of Graves' Disease in Thailand: A Survey of Current Practice

Background

The data on clinical practice patterns in the evaluation and management of Graves' disease (GD) are limited in Asia. The aims of this survey were to report the current practices in the management of GD in Thailand and to examine any international differences in the management of GD.

Methods

Members of the Endocrine Society of Thailand who were board certified in endocrinology (N = 392) were invited to participate in an electronic survey on the management of GD using the same index case and questionnaire as in previous North American and European surveys.

Results

One hundred and twenty responses (30.6%) from members were included. TSH receptor antibody measurement (29.2%), thyroid ultrasound (6.7%), and isotopic studies (5.9%) were used less frequently to confirm the etiology compared with those in North American and European surveys. Treatment with an antithyroid drug (ATD) was the preferred first choice of therapy (90.8%). Methimazole at 10–15 mg/day with a beta-blocker was the initial treatment of choice. The preferred ATD in pregnancy was propylthiouracil in the first trimester and methimazole in the second and third trimesters, which was similar to the North American and European surveys.

Conclusion

Ultrasound and isotopic studies will be requested only by a small proportion of Thai endocrinologists. Higher physician preference for ATD is similar to Europe, Latin America, and other Asian countries. Geographical differences in the use of ATD, radioactive iodine, and thyroidectomy exist.

Effect of Addition of Thyroxine in the Treatment of Graves' Disease: A Systematic Review

Graves' disease is the most common cause of hyperthyroidism. Antithyroid drugs, radioiodine ablation, and surgery are the main treatments. Research has demonstrated that adding thyroxine to antithyroid therapy can improve the remission rate, and many similar studies have been conducted subsequently. The purpose of this systematic review was to investigate whether adding thyroxine to various treatments for Graves' disease has a clinical benefit in remission/relapse rate, stable thyroid function, occurrence of Graves' ophthalmopathy, etc. A total of 27 studies were included, and the risk of research bias was moderate to high. We discuss the role of thyroxine both in pharmacological and non-pharmacological therapeutic regimens. Overall, the available evidence does not support the indiscriminate addition of thyroxine to various treatments for Graves' disease, especially in combination with oral antithyroid drugs. Further clinical studies are required to explore the indications of thyroxine addition in the treatment of Graves' disease.

Assessing American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease

BACKGROUND

The American Thyroid Association (ATA) issued specific preoperative preparatory guidelines for patients undergoing thyroidectomy for treatment of Graves' disease. Our goal is to determine if compliance with these guidelines is associated with better outcomes.

METHODS

A retrospective review of a prospectively maintained database identified 228 patients with Graves' disease who underwent total thyroidectomy between August 2007 and May 2015. Patients treated in compliance with ATA guidelines were compared with those not in full compliance with the current preparatory guidelines.

RESULTS

At the time of surgery, 52% of all patients followed ATA guidelines. Patients who were prepped per ATA guidelines had fewer episodes of intraoperative tachycardia (0.3 versus 4.5, P = 0.04) but had no difference in peak systolic blood pressure or in number of episodes of systolic blood pressure > 180 mmHg. ATA prepped and nonprepped patients had similar mean operating room time and length of stay. ATA prepped and nonprepped patients had similar complication rates, including transient hypocalcemia (30.4% versus 25.5%, P = 0.45), prolonged hypoparathyroidism (0.98% versus 4.3%, P = 0.15), hoarse voice (10.8% versus 7.5%, P = 0.42), permanent recurrent laryngeal nerve paralysis (2.9% versus 2.1%, P = 0.71), and hematoma (2.9% versus 0%, P = 0.09).

CONCLUSIONS

Our data suggest that compliance with ATA guidelines for thyroidectomy preparation is not essential for a successful surgical outcome. Although preparation per the guidelines decreased the frequency of intraoperative tachycardia, it did not impact intraoperative hypertension, operating room time, or postoperative complications.

Propylthiouracil-induced agranulocytosis as a rare complication of antithyroid drugs in a patient with Graves' disease

INTRODUCTION

Graves' disease (GD) is an autoimmune disorder characterized by hyperthyroidism. Antithyroid drugs (ATDs) are available as therapy. Agranulocytosis is a rare but potentially fatal complication of this therapy. In this study, we report agranulocytosis induced by propylthiouracil (PTU) in a patient with GD and the difficulties of clinical management.

CASE

RNBA, male, 30 years old, with GD, treated with propylthiouracil (PTU). He progressed with pharyngotonsillitis. Then, PTU was suspended and antibiotic, filgrastim, propranolol, and prednisone were initiated. Due to the decompensation of hyperthyroidism, lithium carbonate, dexamethasone, and Lugol's solution were introduced. Total thyroidectomy (TT) was performed with satisfactory postoperative progression.

DISCUSSION

We describe here the case of a young male patient with GD. For the treatment of hyperthyroidism, thioamides are effective options. Agranulocytosis induced by ATDs is a rare complication defined as the occurrence of a granulocyte count <500/mm3 after the use of ATDs. PTU was suspended, and filgrastim and antibiotics were prescribed. Radioiodine (RAI) or surgery are therapeutic alternatives. Due to problems with ATD use, a total thyroidectomy was proposed. The preoperative preparation was performed with beta-blocker, glucocorticoid, lithium carbonate, and Lugol solution. Cholestyramine is also an option for controlling hyperthyroidism. TT was performed without postoperative complications.

CONCLUSION

Thionamide-induced agranulocytosis is a rare complication. With a contraindication to ATDs, RAI and surgery are definitive therapeutic options in GD. Beta-blockers, glucocorticoids, lithium carbonate, iodine, and cholestyramine may be an adjunctive therapy for hyperthyroidism.

The effect of intrathyroidal versus intraperitoneal bevacizumab on thyroid volume and vasculature flow in a rat model

Background

Several clinical conditions increase thyroid gland vascularity, impacting surgical blood loss. Bevacizumab has been observed to reduce thyroid function, possibly through its effect on gland angiogenesis. This study aimed to determine if bevacizumab has any effect on thyroid vascularity as measured by gland volume and superior thyroid artery (STA) flow velocity in the normal rat thyroid.

Methods

Sixteen adult female Sprague-Dawley rats were placed under general anesthesia to measure baseline thyroid gland characteristics. A Vevo 2100 high-frequency ultrasound with 40 mHz transducer was used to obtain STA flow measurements and thyroid gland dimensions. Four rats served as controls. Six rats received intrathyroidal (IT) injections and 6 received intraperitoneal (IP) injections of bevacizumab (4-5 mg/kg). After two weeks ultrasound measurements were repeated.

Results

Pretreatment animals displayed similar thyroid volume and vascularity. Thyroid volume decreased (62.583 vs. 42.161, P=0.004) after IP administration of bevacizumab, and blood flow measurements did not change [peak velocity 75.896 vs. 76.7, P=0.96, average velocity 45.748 vs. 43.867, P=0.88, or resistivity index (RI) 30.345 vs. 25.32, P=0.60]. IT bevacizumab did not change thyroid volume (55.229 vs. 58.16, P=0.64). The average peak (73.191 vs. 100.589 cm/s, P=0.03) and mean (45.047 vs. 62.843 m/s, P=0.03) velocities were increased, but did not differ in the RI (0.619 vs. 0.632, P=0.82). No differences were noted on VEGF or CD 31 immunohistochemical analysis.

Conclusions

Single systemic administration of bevacizumab appears to decrease thyroid volume without an effect on STA flow, VEGF or CD31 staining. These preliminary findings support further study of pharmacologic intervention in thyroid conditions characterized by increased angiogenesis and vascularity, such as iodine deficiency, Graves disease, and hypothyroidism.

Considerations for Thyroidectomy as Treatment for Graves Disease

Hyperthyroidism is a clinical state that results from abnormally elevated thyroid hormones. Thyroid gland affects many organ systems; therefore, patients usually present with multiple clinical manifestations that involve many organ systems such as the nervous, cardiovascular, muscular, and endocrine system as well as skin manifestations. Hyperthyroidism is most commonly caused by Graves disease, which is caused by autoantibodies to the thyrotropin receptor (TRAb). Other causes of hyperthyroidism include toxic multinodular goiter, toxic single adenoma, and thyroiditis. Diagnosis of hyperthyroidism can be established by measurement of thyroid-stimulating hormone (TSH), which will be suppressed with either elevated free T4 and/or T3 (overt hyperthyroidism) or normal free T3 and T4 (subclinical hyperthyroidism). Hyperthyroidism can be treated with antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy. ATDs have a higher replacement rate when compared with RAI or thyroidectomy. Recent evidence has shown that thyroidectomy is a very effective, safe treatment modality for hyperthyroidism and can be performed as an outpatient procedure. This review article provides some of the most recent evidence on diagnosing and treating patients with hyperthyroidism.

Effects of Preoperative Iodine Administration on Thyroidectomy for Hyperthyroidism: A Systematic Review and Meta-analysis

OBJECTIVE

The current guidelines recommend that potassium iodide be given in the immediate preoperative period for patients with Graves' disease who are undergoing thyroidectomy. Nonetheless, the evidence behind this recommendation is tenuous. The purpose of this study is to clarify the benefits of preoperative iodine administration from published comparative studies.

DATA SOURCES

We searched PubMed, Embase, Cochrane, and CINAHL from 1980 to June 2018.

REVIEW METHODS

Studies were included that compared preoperative iodine administration and no premedication before thyroidectomy. For the meta-analysis, studies were pooled with the random-effects model.

RESULTS

A total of 510 patients were divided into the iodine (n = 223) and control (n = 287) groups from 9 selected studies. Preoperative iodine administration was significantly associated with decreased thyroid vascularity and intraoperative blood loss. Significant heterogeneity was present among studies. We found no significant difference in thyroid volume or operative time. Furthermore, the meta-analysis showed no difference in the risk of postoperative complications, including vocal cord palsy, hypoparathyroidism/hypocalcemia, and hemorrhage or hematoma after thyroidectomy.

CONCLUSION

Preoperative iodine administration decreases thyroid vascularity and intraoperative blood loss. Nonetheless, it does not translate to more clinically meaningful differences in terms of operative time and postoperative complications.

Comparison of Intra-Operative Vital Sign Changes during Total Thyroidectomy in Patients with Controlled and Uncontrolled Graves' Disease

Thyroid storm (TS) is a life-threatening emergency endocrine condition. Thyroid hormones should be normalized before thyroidectomy is performed in patients with Graves’ disease. However, thyroid hormone levels are inevitably high in patients undergoing surgery. This study analyzed differences in vital sign changes during thyroidectomy between patients with controlled and uncontrolled Graves’ disease and assessed thyroid hormone cutoffs for TS. Preoperative levels of the thyroid hormones free T4 (FT4), T3, and thyroid stimulating hormone (TSH) were retrospectively analyzed in patients who underwent total thyroidectomy for Graves’ disease. Patients were divided into those with uncontrolled Graves’ (UG) disease, defined as preoperative TSH <0.3 µIU/mL and FT4 >1.7 ng/dL, those with controlled Graves’ (CG) disease, those with extremely uncontrolled Graves’ (EUG) disease, defined as TSH <0.3 µIU/mL and FT4 >3.4 ng/dL, and finally, those without EUG (non-EUG). The 29 patients with Graves’ disease included 12 with CG group and 17 with UG. FT4 and T3 concentrations were significantly higher in the UG group. There were no differences in vital sign and anesthetic agent. These 29 patients could also be divided into those with (n = 4) and without EUG (n = 25). The mean age was lower (21.5 vs. 40.9 years, p < 0.001) and the mean operation time was shorter (121.4 vs. 208.8 min, p = 0.003) in the EUG group. Requirements for anesthetic agents were greater in the EUG group. Mean FT4 concentration in the EUG group was 3.8 ng/dL, and there were no changes in vital signs during surgery. Vital sign change during thyroid surgery was not observed in patients with uncontrolled Graves’ disease up to the twice upper normal limit of T4 level.

Treatment of adult Graves' disease

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

2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism

Graves' disease (GD) is a systemic autoimmune disorder characterized by the infiltration of thyroid antigen-specific T cells into thyroid-stimulating hormone receptor (TSH-R)-expressing tissues. Stimulatory autoantibodies (Ab) in GD activate the TSH-R leading to thyroid hyperplasia and unregulated thyroid hormone production and secretion. Diagnosis of GD is straightforward in a patient with biochemically confirmed thyrotoxicosis, positive TSH-R-Ab, a hypervascular and hypoechoic thyroid gland (ultrasound), and associated orbitopathy. In GD, measurement of TSH-R-Ab is recommended for an accurate diagnosis/differential diagnosis, prior to stopping antithyroid drug (ATD) treatment and during pregnancy. Graves' hyperthyroidism is treated by decreasing thyroid hormone synthesis with the use of ATD, or by reducing the amount of thyroid tissue with radioactive iodine (RAI) treatment or total thyroidectomy. Patients with newly diagnosed Graves' hyperthyroidism are usually medically treated for 12-18 months with methimazole (MMI) as the preferred drug. In children with GD, a 24- to 36-month course of MMI is recommended. Patients with persistently high TSH-R-Ab at 12-18 months can continue MMI treatment, repeating the TSH-R-Ab measurement after an additional 12 months, or opt for therapy with RAI or thyroidectomy. Women treated with MMI should be switched to propylthiouracil when planning pregnancy and during the first trimester of pregnancy. If a patient relapses after completing a course of ATD, definitive treatment is recommended; however, continued long-term low-dose MMI can be considered. Thyroidectomy should be performed by an experienced high-volume thyroid surgeon. RAI is contraindicated in Graves' patients with active/severe orbitopathy, and steroid prophylaxis is warranted in Graves' patients with mild/active orbitopathy receiving RAI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Babu MJ, Menon R, Jacob P. Preoperative Preparation of Hyperthyroidism for Thyroidectomy - Role of Supersaturated Iodine and Lithium Carbonate

INTRODUCTION

Thyroidectomy is effective and safe procedure for permanent cure of hyperthyroidism (HT). Iodine preparations are widely used before operation to prevent excess blood loss. Ideal regimen for refractory HT is debated. This retrospective case-control study is designed to study the efficacy of various regimens of preoperative preparations.

MATERIALS AND METHODS

Case records, anesthesia charts, and follow-up details of hyperthyroid patients undergoing thyroidectomy were reviewed and compared with an age- and sex-matched euthyroid patients operated during the same period. Iodine preparations were not used for preoperative preparation. Study group was subdivided based on preoperative regimens of anti-thyroid medications.

RESULTS

Of the 168 patients in the study group, procedure time, duration of hospital stay, and overall complication rate were high compared to euthyroid group. Operative blood loss was not high in the study group. There was no difference in rate of complications in the subgroups of the study cohort.

CONCLUSION

Iodine preparations are not mandatory in preoperative preparation of HT. Lithium carbonate is effective in preoperative preparation of refractory HT. Rate of postthyroidectomy complications is not different in patients receiving thionamides alone or in combination with β-blocker.

Lugol's solution and other iodide preparations: perspectives and research directions in Graves' disease

Lugol's solution and other preparations containing iodide have for almost a century been used as an adjuvant treatment in patients with Graves' disease planned for thyroidectomy. Iodide has been shown to decrease thyroid hormone levels and reduce blood flow within the thyroid gland. An escape phenomenon has been feared as the iodide effect has been claimed to only be temporary. Lugol's solution has many additional effects and is used in other settings beside the thyroid. Still, there are questions of its mode of action, which doses should be deployed, if it should be used preoperative in all thyroidectomies or only in a few selected ones if at all, what is its use in other forms of thyrotoxicosis besides Graves' disease, and what is the mechanism acting on the vasculature and if these effects are confined only to arterial vessels supporting the thyroid or not. This review aims to collate current available data about Lugol's solution and other iodide preparations in the management of Graves' disease and give some suggestions where more research is needed.

Methamphetamine Use With Subsequent Thyrotoxicosis/Thyroid Storm, Agranulocytosis, and Modified Total Thyroidectomy: A Case Report

Thyroid storm is a rare, potentially lethal condition involving collapse of the hypothalamic-pituitary-thyroid feedback loop. Thyroid storm carries a significant mortality rate, thus requiring prompt identification and treatment. A 47-year-old woman presented to the emergency department complaining of palpitations, shortness of breath, and emesis for 24 hours after using methamphetamine. Past medical history was significant for untreated hyperthyroidism. Physical examination revealed a prominent, palpable thyroid. The Burch-Wartofsky-Score was 35. Management for thyroid storm included propylthiouracil (PTU), super saturated potassium iodide, intravenous hydrocortisone, and propranolol. However, a rare drug reaction to PTU on day 3 resulted in agranulocytosis. Propylthiouracil was withheld and a modified total thyroidectomy performed on day 8 without complications and the patient discharged on day 10 with levothyroxine. Undertreated hyperthyroidism may predispose patients to catecholamine-induced thyrotoxicosis due to catecholamine hypersensitivity. With known methamphetamine use, methamphetamine toxicity and a methamphetamine-exacerbated thyroid storm need to be included in the differential diagnosis in a patient presenting with signs of thyrotoxicosis. In addition, treating patients with agranulocytosis from PTU with a modified total thyroidectomy using ligation of the vascular supply as the initial surgical step limits release of thyroid hormone into the blood stream during thyroidectomy and decreases the possibility of intra operative thyroid storm.

Impact of potassium iodide on thyroidectomy for Graves' disease: Implications for safety and operative difficulty

BACKGROUND

Potassium iodide often is prescribed prior to thyroidectomy for Graves' disease, but the effect of potassium iodide on the ease and safety of thyroidectomy for Graves' is largely unknown.

METHODS

We conducted a prospective, cohort study of patients with Graves' disease undergoing thyroidectomy. For the first 8 months, no patients received potassium iodide; for the next 8 months, potassium iodide was added to the preoperative protocol for all patients. Outcomes included operative difficulty (based on the Thyroidectomy Difficulty Scale) and complications.

RESULTS

We included a total of 31 patients in the no potassium iodide group and 28 in the potassium iodide group. According to the Thyroidectomy Difficulty Scale, gland vascularity decreased in the potassium iodide group (mean score 2.6 vs 3.3, P = .04), but there were no differences in friability, fibrosis, or size of the thyroid or in overall difficulty of operation (P = not significant for all). Despite similar operative difficulty, patients prescribed potassium iodide were less likely to experience transient hypoparathyroidism (7% vs 26%, P = .018) and transient hoarseness (0% vs 16%, P = .009) compared with the no potassium iodide group.

CONCLUSION

Potassium iodide administration decreases gland vascularity, but does not change the overall difficulty of thyroidectomy. Preoperative use of potassium iodide solution was, however, associated with less transient hypoparathyroidism and transient hoarseness, suggesting that potassium iodide improves the safety of thyroidectomy for Graves' disease.

Preoperative management in patients with Graves' disease

Graves' disease is the most frequent cause of hyperthyroidism in iodine-sufficient geographical areas and is characterized by the presence in patients' serum of autoantibodies directed against the thyrotropin receptor (TRAb) that cause overproduction and release of thyroid hormones. Clinical presentation results from both hyperthyroidism and underlying autoimmunity. The diagnosis is based on characteristic clinical features and biochemical abnormalities. If serum thyrotropin (TSH) is low, serum free thyroxine (FT4) and free triiodothyronine (FT3) concentrations should be measured to distinguish between subclinical (with normal circulating thyroid hormones) and overt hyperthyroidism (with increased circulating thyroid hormones). Graves' disease is treated with any of three effective and relatively safe initial treatment options: antithyroid drugs (ATDs), radioactive iodine ablation (RAIU), and surgery. Total thyroidectomy is favored in several clinical situations, such as intolerance, ineffectiveness or recurrence after ATD treatment, radioiodine therapy contraindicated, documented or suspected thyroid malignancy, one or more large thyroid nodules, coexisting moderate-to-severe active Graves' orbitopathy, women planning a pregnancy within 6 months. Whenever surgery is selected as treatment, selection of an expert high-volume thyroid surgeons is fundamental and careful preoperative management is essential to optimize surgical outcomes. Pretreatment with ATDs in order to promptly achieve the euthyroid state is recommended to avoid the risk of precipitating thyroid storm during surgery. For the majority of patients, euthyroidism is achieved after few weeks of ATD treatment. Beta-blockers, such as propranolol, are often added effectively to control hyperthyroid symptoms. Saturated solution of potassium iodide (SSKI) or potassium iodine (Lugol's solution), given for a short period prior to surgery, in order to reduce both thyroid hormone release and thyroid gland vascularity, is beneficial to decrease intra-operative blood loss.

Uterine artery blood flow and microvessel density by vaginal color Doppler ultrasonography in embryo implantation failure

The purpose of this study was to investigate the clinical application of uterine artery blood flow parameters by vaginal color Doppler ultrasonography in patients with repeated embryo implantation failure and to examine the correlation between uterine artery blood flow parameters and microvessel density (MVD). We monitored the outcomes of in vitro fertilization and embryo transfer in eighty patients. We divided the patients into two groups: Pregnancy (successful pregnancy, n=50) and repeated implantation failure (more than two failures of in vitro fertilization-embryo transfer, n=30). The patients were subjected to vaginal color Doppler ultrasonography to measure endometrial thickness, peak systolic velocity/end diastolic velocity (S/D), pulsatility index (PI), resistance index (RI), and other uterine artery blood flow parameters. We found no significant differences in endometrial thickness (human chorionic gonadotropin endometrial thickness) and uterine artery blood flow parameters (S/D, PI) between the two groups. The RI value of endometrial blood flow was significantly higher in the repeated implantation failure group than that in pregnancy group. The endometrium MVD in the repeated implantation failure group was significantly lower than that of the pregnancy group. Spearman correlation analysis showed that S/D value of uterine artery blood flow in repeated implantation failure group was not correlated with MVD or uterine artery blood flow PI, but was positively correlated with RI. Endometrium MVD in patients with repeated implantation failure was significantly lower than that in patients with successful pregnancy during the implantation window. We also found a significant difference in uterine artery blood flow RI between the two groups. The uterine artery blood flow RI in patients with repeated implantation failure was positively correlated with MVD, which has clinical significance in predicting the outcome of embryo transfer.

Thyroidectomy for the treatment of Graves' thyrotoxicosis in thioamide-induced agranulocytosis and sepsis

A 51 year old man presented with sepsis in the setting of thioamide-induced agranulocytosis. Empiric broad-spectrum antibiotics was followed by directed narrow-spectrum antibiotics, and his neutrophil count recovered with support from granulocyte-colony stimulating factor (G-CSF) analogue transfusions. After a brief period of multi-modal therapy for nine days including potassium iodide (Lugol's iodine), cholestyramine, propanolol and lithium to temper his persisting hyperthyroidism, a total thyroidectomy was performed while thyroid hormone levels remained at thyrotoxic levels. Postoperative recovery was uncomplicated and he was discharged home on thyroxine. There is limited available evidence to guide treatment in this unique cohort of patients who require prompt management to avert impending clinical deterioration. This case report summarises the successful emergent control of thyrotoxicosis in the setting of thioamide-induced agranulocytosis complicated by sepsis, and demonstrates the safe use of multi-modal pharmacological therapies in preparation for total thyroidectomy.

LEARNING POINTS

Thioamide-induced agranulocytosis is an uncommon but potentially life-threatening complication of which all prescribers and patients need to be aware.A multi-modal preoperative pharmacological approach can be successful, even when thioamides are contraindicated, when needing to prepare a thyrotoxic patient for semi-urgent total thyroidectomy.There is not enough evidence to confidently predict the safe timing when considering total thyroidectomy in this patient cohort, and therefore it should be undertaken when attempts have first been made to safely reduce thyroid hormone levels.Thyroid storm is frequently cited as a potentially severe complication of thyroid surgery undertaken in thyrotoxic patients, although the evidence does not demonstrate this as a common occurrence.

Rescue pre-operative treatment with Lugol's solution in uncontrolled Graves' disease

BACKGROUND

Graves' disease is a common cause of hyperthyroidism. Three therapies have been used for decades: pharmacologic therapy, surgery and radioiodine. In case of adverse events, especially agranulocytosis or hepatotoxicity, pre-treatment with Lugol's solution containing iodine/potassium iodide to induce euthyroidism before surgery could be advocated, but this has rarely been reported.

METHODS

All patients hospitalised due to uncontrolled hyperthyroidism at the Karolinska University Hospital 2005-2015 and treated with Lugol's solution were included. All electronic files were carefully reviewed manually, with focus on the cause of treatment and admission, demographic data, and effects of iodine on thyroid hormone levels and pulse frequency.

RESULTS

Twenty-seven patients were included. Lugol's solution had been chosen due to agranulocytosis in 9 (33%), hepatotoxicity in 2 (7%), other side effects in 11 (41%) and poor adherence to medication in 5 (19%). Levels of free T4, free T3 and heart rate decreased significantly after 5-9 days of iodine therapy (free T4 53-20 pmol/L, P = 0.0002; free T3 20-6.5 pmol/L, P = 0.04; heart rate 87-76 beats/min P = 0.0007), whereas TSH remained unchanged. Side effects were noted in 4 (15%) (rash n = 2, rash and vomiting n = 1, swelling of fingers n = 1). Thyroidectomy was performed in 26 patients (96%) and one was treated with radioiodine; all treatments were without serious complications.

CONCLUSION

Treatment of uncontrolled hyperthyroidism with Lugol's solution before definitive treatment is safe and it decreases thyroid hormone levels and heart rate. Side effects were limited. Lugol's solution could be recommended pre-operatively in Graves' disease with failed medical treatment, especially if side effects to anti-thyroid drugs have occurred.

A Pediatric Case of Cowden Syndrome with Graves' Disease

Cowden syndrome (CS) is a rare dominantly inherited multisystem disorder, characterized by an extraordinary malignant potential. In 80% of cases, the human tumor suppressor gene phosphatase and tensin homolog (PTEN) is mutated. We present a case of a 17-year-old boy with genetically confirmed CS and Graves' disease (GD). At the age of 15, he presented with intention tremor, palpitations, and marked anxiety. On examination, he had macrocephaly, coarse facies, slight prognathism, facial trichilemmomas, abdominal keratoses, leg hemangioma, and a diffusely enlarged thyroid gland. He started antithyroid drug (ATD) therapy with methimazole and, after a 2-year treatment period without achieving a remission status, a total thyroidectomy was performed. Diagnosis and management of CS should be multidisciplinary. Thyroid disease is frequent, but its management has yet to be fully defined. The authors present a case report of a pediatric patient with CS and GD and discuss treatment options.

Pre-Operative Lugol's Iodine Treatment in the Management of Patients Undergoing Thyroidectomy for Graves' Disease: A Review of the Literature

OBJECTIVE

To undertake a review of the relevant English literature published on the pre-operative use of Lugol's iodine in the management of patients undergoing thyroidectomy for Graves' disease.

SEARCH STRATEGY

We reviewed all relevant papers found through Ovid Medline, PubMed, EMBASE and the American Thyroid Association website. Searches were limited to the English language only.

EVALUATION METHOD

The critical appraisal tool CASP was used to help analyse the papers. Following this, the evidence was ranked using the Harbour and Miller classification of hierarchy.

RESULTS

Four papers were deemed appropriate for analysis. The evidence contained within the review is considered weak. The literature available in the public domain regarding the use of iodinated solutions in the pre-operative period for those patients about to undergo thyroidectomy for Graves' disease is scant.

CONCLUSION

Having undertaken an extensive literature review, we are of the opinion that the evidence on which the American Thyroid Association's guidance on the use of preoperative Lugol's iodine is based is tenuous. There appears to be little in the way of sound clinical evidence that post-operative outcomes are any different following a course of Lugol's iodine. Given the lack of robust clinical evidence regarding the clinical need for iodine solution in the pre-operative period, it appears clear that a larger, prospective, randomised controlled trial of all relevant outcomes - clinical and scientific - is required to answer whether or not patient preparation with Lugol's iodine is in fact necessary prior to operative intervention for Graves' disease.

2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition)

Thyroid storm is an endocrine emergency which is characterized by multiple organ failure due to severe thyrotoxicosis, often associated with triggering illnesses. Early suspicion, prompt diagnosis and intensive treatment will improve survival in thyroid storm patients. Because of its rarity and high mortality, prospective intervention studies for the treatment of thyroid storm are difficult to carry out. We, the Japan Thyroid Association and Japan Endocrine Society taskforce committee, previously developed new diagnostic criteria and conducted nationwide surveys for thyroid storm in Japan. Detailed analyses of clinical data from 356 patients revealed that the mortality in Japan was still high (∼11%) and that multiple organ failure and acute heart failure were common causes of death. In addition, multimodal treatment with antithyroid drugs, inorganic iodide, corticosteroids and beta-adrenergic antagonists has been suggested to improve mortality of these patients. Based on the evidence obtained by nationwide surveys and additional literature searches, we herein established clinical guidelines for the management of thyroid storm. The present guideline includes 15 recommendations for the treatment of thyrotoxicosis and organ failure in the central nervous system, cardiovascular system, and hepato-gastrointestinal tract, admission criteria for the intensive care unit, and prognostic evaluation. We also proposed preventive approaches to thyroid storm, roles of definitive therapy, and future prospective trial plans for the treatment of thyroid storm. We hope that this guideline will be useful for many physicians all over the world as well as in Japan in the management of thyroid storm and the improvement of its outcome.

2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis

BACKGROUND

Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition.

METHODS

The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group.

RESULTS

Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded.

CONCLUSIONS

One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.

Effectiveness and Mechanism of Preoperative Lugol Solution for Reducing Thyroid Blood Flow in Patients with Euthyroid Graves' Disease

BACKGROUND

To reduce intraoperative and postoperative complications, using Lugol solution to preoperatively prepare patients with Graves' disease has (1) rapidly reduced the severity of thyrotoxicosis and (2) reduced the vascularity of the thyroid gland. The vascularity reduction normally accompanies reducing the severity of thyrotoxicosis. However, the effects and mechanism of Lugol solution for reducing blood flow have not been well investigated in the patients with euthyroid (normally functioning thyroid) Graves' disease.

METHODS

Twenty-five patients with euthyroid Graves' disease being preoperatively treated with Lugol solution for 10 days were measured, at baseline and on the operative day, for (1) superior thyroid artery blood flow; (2) systemic angiogenic factor (VEGF); and (3) systemic inflammatory factor [interleukin (IL)-16].

RESULTS

All three parameters were significantly (p < 0.0001) lower after 10 days of Lugol solution treatment. The average reductions were blood flow: 60% (0.294 vs. 0.117 L/min), serum VEGF: 55% (169.8 vs. 76.7 pg/mL), and serum IL-16: 50% (427.2 vs. 214.2; pg/mL).

CONCLUSION

Lugol solution significantly reduced thyroid arterial blood flow, VEGF, and IL-16, even in patients with euthyroid Graves' disease. We recommend routine preoperative Lugol solution treatment for all patients with Graves' disease.

Hyperthyroidism

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

Randomized trial of a short course of preoperative potassium iodide in patients undergoing thyroidectomy for Graves' disease

BACKGROUND

A short course of potassium iodide (SSKI) has been traditionally used to prepare patients with Graves' disease for thyroidectomy. The rationale for this treatment has evolved over time; from control of hyperthyroidism to facilitating surgery by making the gland less friable and bloody.

METHODS

Randomized trial of preoperative SSKI vs no SSKI to test whether that is true.

RESULTS

Mean estimated blood loss in the SSKI group (62 mL) was less than in the control group (162 mL) as was the median estimated blood loss (50 vs 140 mL). Mean (142 vs 162 minutes) and median (138 vs 150 minutes) operative times were also less in the SSKI arm. Subjective difficulty of operation was similar. Multivariable comparisons of groups with analysis of covariance showed the SSKI group suffered a mean blood loss 35% of the no treatment group (P = .036), the 9.2% decrease in Operating Room (OR) time between the SSKI group and the no treatment group was not statistically different (P = .464).

CONCLUSIONS

SSKI given before operation in patients with Graves' disease reduces blood loss during thyroidectomy.

The effect of preoperative Lugol's iodine on intraoperative bleeding in patients with hyperthyroidism

AIM

To investigate the effect of preoperative Lugol's iodine on intraoperative bleeding in patients with hyperthyroidism.

MATERIAL AND METHODS

This controlled, randomized, prospective cohort was carried out on 40 patients who admitted for surgery due to hyperthyroidism. Cases were randomly assigned to receive either preoperative treatment with Lugol solution (Group 1) or no preoperative treatment with Lugol solution (Group 2). Group 3 (n = 10) consisted of healthy adults with no known history and signs of hyperthyroidism. Blood flow through the thyroid arteries of patients was measured by color flow Doppler ultrasonography. Free T3, free T4, TSH, thyroid volume and the resistance index of the four main thyroid arteries were measured in all patients.

RESULTS

There was not a significant difference between gender, preoperative serum thyroid hormone levels, or thyroid gland volumes between groups 1 and 2. The mean blood flow of the patients in Group 1 was significantly lower than values in Group 2. When age, gender, thyroid hormone, TSH, thyroid volume, blood flow, and Lugol solution treatment were included as independent variables, Lugol solution treatment (OR, 7.40; 95% CI, 1.02-58.46; p = 0.001) was found to be the only significant independent determinant of intraoperative blood loss. Lugol solution treatment resulted in a 7.40-fold decrease in the rate of intraoperative blood loss.

CONCLUSION

Preoperative Lugol solution treatment was found to be a significant independent determinant of intraoperative blood loss. Moreover, preoperative Lugol solution treatment decreased the rate of blood flow, and intraoperative blood loss during thyroidectomy.

Graves' disease: a review of surgical indications, management, and complications in a cohort of 59 patients

An analysis of 59 patients who underwent total thyroidectomy for the treatment of Graves' disease over a 6-year period was conducted in order to assess the current indications and identify any specific factors that may influence the patient's decision to opt for surgical treatment. A comparison of outcomes between the current study and a similar one from Hong Kong was also attempted. Patient preference was the most common reason for opting for surgery over radioactive iodine in both studies. Other indications for surgery, such as Graves' ophthalmopathy, patient refusal for radioactive iodine, large goitre with pressure symptoms, planning for pregnancy, young age, and intolerance to anti-thyroid drugs, were also similar in the two groups. There were no statistically significant differences in laryngeal nerve palsy between the two groups. The rates of permanent hypoparathyroidism in patients in Hong Kong and in the present study were 5.4% and 5.1%, respectively. No patient in either study had recurrent Graves' disease after total thyroidectomy. Our findings confirmed that patient preference is the leading indication for surgery, implicating a continuous misconception of radioactive substances and increasing confidence in surgical outcomes. In experienced hands, the risks of recurrent laryngeal nerve injury and permanent hypoparathyroidism remain minimal.

Clinical Pathway for Thyroidectomy

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

Preventing postoperative hypocalcemia in patients with Graves disease: a prospective study

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.

Preoperative Preparation with Lugol's Iodine in Thyroidectomy of Euthyroid Patients-Is it Really Mandatory?-An Otorhinolaryngologist's View

OBJECTIVE

To elucidate the necessity of Lugol's iodine in preoperative preparation of patients undergoing thyroidectomy.

MATERIALS AND METHODS

Hundred and five euthyroid patients who underwent surgery without preoperative preparation of patients with Lugol's iodine were enrolled in this retrospective study conducted during the period May 2009 to August 2013 in Teaching Hospital. Indication of surgery was ranging from suspected malignancy to cosmetic reasons and compressive features like dysphagia , dyspnoea and hoarseness of voice.

RESULTS

All patients were operated by the same surgeon where in hemi, total and subtotal thyroidectomies were performed without any usage of Lugol's iodine preoperatively. During the postoperative period the following events occurred, five patients (4.7%) had incurred recurrent laryngeal nerve palsy (RLNP) which was confirmed with postoperative indirect laryngoscopic examination and two patients (1.9%) with hypocalcemia (serum calcium less than 8mg/dl) which was managed conservatively and effectively. Among these five patients, three patients had (Right RLNP) and two patients had (Left RLNP) palsies. Of these four RLNP (3.8%) were temporary which improved with conservative management within 3weeks-6months duration and one (0.9%) was a permanent Rt RLNP with no improvement even after six months.

CONCLUSION

Hence, we conclude that it is not of much importance to use Lugol's iodine preoperatively in patients undergoing thyroidectomy. There does not appear any convincing evidence of advantages of preoperative preparation of patients with lugol's iodine in euthyroid state undergoing surgery.