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Elkhoury D, Patel P, Sastry S, Tajik A, Elkhoury C, Montalbano M. Advancing Preoperative Strategies for Thyroidectomy in Graves' Disease: A Narrative Review. Cureus 2023; 15:e48156. [PMID: 38046703 PMCID: PMC10693191 DOI: 10.7759/cureus.48156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/05/2023] Open
Abstract
Graves' disease is an autoimmune disorder characterized by thyroid-stimulating antibodies that can potentially lead to thyrotoxicosis, goiter, skin disease, and eye disease. Available treatment options for Graves' disease include management with antithyroid drugs (ATDs), thyroid ablation with radioactive iodine (RAI), and surgical thyroid gland removal. For individuals unable to reach a normal thyroid hormone level, promptly considering a thyroidectomy is essential. Preoperative strategies to achieve a euthyroid state prevent thyroid storms and minimize postoperative complications and are therefore crucial. While variations in professional guidance exist, this review focuses on standard medical interventions as well as compares respective guidelines set forth by the American Thyroid Association, the European Thyroid Association, the American Association of Clinical Endocrinology, and the American Association of Endocrine Surgeons. There is consensus among these organizations underscoring the importance of rendering patients euthyroid prior to surgery and the use of ATDs. Most guidelines recommend screening for vitamin D deficiency as well as endorse thyroidectomy as the preferred treatment option for hyperthyroidism with skilled surgeons. Nevertheless, discrepancies do become apparent in aspects such as potassium iodide (SSKI) course duration and preoperative dexamethasone administration. By understanding these differing approaches, healthcare professionals can more effectively manage Graves' disease prior to surgery, resulting in improved patient outcomes and enhanced surgical success.
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Affiliation(s)
- David Elkhoury
- Anatomical Sciences, St. George's University School of Medicine, Saint George's, GRD
| | - Pruthvi Patel
- Anatomical Sciences, St. George's University School of Medicine, Saint George's, GRD
| | - Saalini Sastry
- Anatomical Sciences, St. George's University School of Medicine, Saint George's, GRD
| | - Alireza Tajik
- Anatomical Sciences, St. George's University School of Medicine, Saint George's, GRD
| | - Christina Elkhoury
- Health Sciences, Trident University International, Chandler, USA
- Molecular Pharmacology and Toxicology, University of Southern California, Los Angeles, USA
| | - Michael Montalbano
- Anatomical Sciences, St. George's University School of Medicine, Saint George's, GRD
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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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Chiapponi C, Schmidt M, Faust M. Potassium Iodide Tablets Instead of a Saturated Solution Preoperatively for Reaching Euthyroidism Quickly in Refractory Graves' Disease. Cureus 2021; 13:e15854. [PMID: 34327081 PMCID: PMC8301294 DOI: 10.7759/cureus.15854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 11/05/2022] Open
Abstract
The optional use of a saturated solution of potassium iodide in the immediate preoperative period to reach euthyroidism is included both in the American Thyroid Association (ATA) and in the European Thyroid Association (ETA) guidelines for the treatment of Graves' disease (GD). The recent literature though, shows that it does not translate to more clinically meaningful differences in surgical outcome. In our experience, potassium iodide should not be seen as a means for reducing operative time or complications; it is an effective way for reaching euthyroidism quickly. Herein, we describe three selected cases in which concentrated potassium iodide 65 mg tablets - instead of a saturated solution - were administered for thyroid blocking preoperatively, as recommended in the event of a nuclear emergency. One of the patients was pregnant. After oral treatment with potassium iodide 130 mg daily (two pills), euthyroidism was reached in all three cases within 24 hours. There were no side effects and surgery was performed without complications. Although the current literature did not report a significant benefit concerning operative time and complications, in our opinion preoperative potassium iodide plays an important role in selected cases for reaching euthyroidism preoperatively quickly. Potassium iodide 65 mg tablets, which are recommended in case of a nuclear emergency, are a very effective alternative to saturated solutions, which are not always quickly available and generally need to be administered over seven to 10 days.
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Affiliation(s)
- Costanza Chiapponi
- General, Abdominal, Tumor and Transplant Surgery, University Hospital of Cologne, Cologne, DEU.,Endocrine Surgery, Evangelisches Klinikum Köln Weyertal, Cologne, DEU
| | - Matthias Schmidt
- Clinic of Nuclear Medicine, University Hospital of Cologne, Cologne, DEU
| | - Michael Faust
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University Hospital of Cologne, Cologne, DEU
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Vidinov KN, Stoinov Y. Do we really Need Lugol Solution in the Era of Energy Devices for the Preoperative Management of Patients with Graves’ Disease? JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2019. [DOI: 10.5799/jcei/5904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Akram S, Elfenbein DM, Chen H, Schneider DF, Sippel RS. Assessing American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease. J Surg Res 2019; 245:64-71. [PMID: 31401249 DOI: 10.1016/j.jss.2019.07.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/30/2019] [Accepted: 07/12/2019] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Siddique Akram
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dawn M Elfenbein
- Division of Endocrine Surgery, Department of Surgery, University of California - Irvine Health, Irvine, California
| | - Herbert Chen
- Department of Surgery, University of Alabama - Birmingham, Birmingham, Alabama
| | - David F Schneider
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rebecca S Sippel
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Smithson M, Asban A, Miller J, Chen H. Considerations for Thyroidectomy as Treatment for Graves Disease. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2019; 12:1179551419844523. [PMID: 31040734 PMCID: PMC6482648 DOI: 10.1177/1179551419844523] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/26/2019] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Mary Smithson
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar Asban
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jason Miller
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
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Tsai CH, Yang PS, Lee JJ, Liu TP, Kuo CY, Cheng SP. Effects of Preoperative Iodine Administration on Thyroidectomy for Hyperthyroidism: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2019; 160:993-1002. [PMID: 30721111 DOI: 10.1177/0194599819829052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Chung-Hsin Tsai
- 1 Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan.,2 Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Po-Sheng Yang
- 1 Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan
| | - Jie-Jen Lee
- 1 Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan
| | - Tsang-Pai Liu
- 1 Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan.,2 Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Chi-Yu Kuo
- 1 Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan
| | - Shih-Ping Cheng
- 1 Department of Surgery, MacKay Memorial Hospital and Mackay Medical College, Taipei, Taiwan.,3 Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Corvilain B, Hamy A, Brunaud L, Borson-Chazot F, Orgiazzi J, Bensalem Hachmi L, Semrouni M, Rodien P, Lussey-Lepoutre C. Treatment of adult Graves' disease. ANNALES D'ENDOCRINOLOGIE 2018; 79:618-635. [PMID: 30193753 DOI: 10.1016/j.ando.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Bernard Corvilain
- Department of Endocrinology, Erasme University Hospital, université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Hamy
- Service de chirurgie viscérale et endocrine, CHU d'Angers, 49000 Angers, France
| | - Laurent Brunaud
- Service de chirurgie, unité de chirurgie endocrinienne, thyroïdienne et métabolique, unité multidisciplinaire de chirurgie de l'obésité, université de Lorraine, CHU Nancy, hôpital Brabois adultes, 11, allée du Morvan, 54511 Vandœuvre-les-Nancy, France
| | - Françoise Borson-Chazot
- HESPER EA 7425, hospices civils de Lyon, fédération d'endocrinologie, université Claude-Bernard Lyon 1, 69008 Lyon, France
| | - Jacques Orgiazzi
- CERMEP-imagerie du vivant, université Claude-Bernard Lyon 1, Lyon, France
| | - Leila Bensalem Hachmi
- Service d'endocrinologie à l'Institut national de nutrition de Tunis, faculté de médecine de Tunis, Tunisia
| | | | - Patrice Rodien
- Service EDN, centre de référence des maladies rares de la thyroïde et des récepteurs hormonaux, CHU d'Angers, 49000 Angers, France.
| | - Charlotte Lussey-Lepoutre
- Service de médecine nucléaire, Inserm U970, Sorbonne université, groupe hospitalier Pitié-Salpétrière, 75013 Paris, France
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To admit or not to admit? Experience with outpatient thyroidectomy for Graves' disease in a high-volume tertiary care center. Am J Surg 2018; 216:985-989. [PMID: 30007745 DOI: 10.1016/j.amjsurg.2018.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/05/2018] [Accepted: 07/08/2018] [Indexed: 11/23/2022]
Abstract
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.
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Nair GC, C. Babu MJ, Menon R, Jacob P. Preoperative Preparation of Hyperthyroidism for Thyroidectomy - Role of Supersaturated Iodine and Lithium Carbonate. Indian J Endocrinol Metab 2018; 22:392-396. [PMID: 30090733 PMCID: PMC6063166 DOI: 10.4103/ijem.ijem_3_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Gopalakrishnan C. Nair
- Endocrine Surgery Division of General Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Misha J. C. Babu
- Division of Endocrine Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Riju Menon
- Endocrine Surgery Division of General Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Pradeep Jacob
- Endocrine Surgery Division of General Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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12
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Does Surgery Without Lugol’s Solution Pretreatment for Graves’ Disease Increase Surgical Morbidity? World J Surg 2018; 42:2123-2126. [DOI: 10.1007/s00268-017-4443-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Calissendorff J, Falhammar H. Lugol's solution and other iodide preparations: perspectives and research directions in Graves' disease. Endocrine 2017; 58:467-473. [PMID: 29075974 PMCID: PMC5693970 DOI: 10.1007/s12020-017-1461-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/17/2017] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
- Jan Calissendorff
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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14
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Randle RW, Bates MF, Long KL, Pitt SC, Schneider DF, Sippel RS. Impact of potassium iodide on thyroidectomy for Graves' disease: Implications for safety and operative difficulty. Surgery 2017; 163:68-72. [PMID: 29108701 DOI: 10.1016/j.surg.2017.03.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/03/2017] [Accepted: 03/29/2017] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Reese W Randle
- Department of Surgery, University of Wisconsin, Madison, WI.
| | - Maria F Bates
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Kristin L Long
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Susan C Pitt
- Department of Surgery, University of Wisconsin, Madison, WI
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Calissendorff J, Falhammar H. Rescue pre-operative treatment with Lugol's solution in uncontrolled Graves' disease. Endocr Connect 2017; 6:200-205. [PMID: 28325735 PMCID: PMC5434745 DOI: 10.1530/ec-17-0025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/21/2017] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Jan Calissendorff
- Department of EndocrinologyMetabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of EndocrinologyMetabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
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Hope N, Kelly A. Pre-Operative Lugol's Iodine Treatment in the Management of Patients Undergoing Thyroidectomy for Graves' Disease: A Review of the Literature. Eur Thyroid J 2017; 6:20-25. [PMID: 28611944 PMCID: PMC5465802 DOI: 10.1159/000450976] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/21/2016] [Indexed: 11/19/2022] Open
Abstract
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.
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Comment on article entitled "Randomized trial of a short course of preoperative potassium iodide in patients undergoing thyroidectomy for Graves' disease". Am J Surg 2017; 213:1194. [PMID: 28049563 DOI: 10.1016/j.amjsurg.2016.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 12/04/2016] [Indexed: 10/20/2022]
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1312] [Impact Index Per Article: 164.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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Abstract
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.
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Affiliation(s)
- Simone De Leo
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Sun Y Lee
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Lewis E Braverman
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
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Randomized trial of a short course of preoperative potassium iodide in patients undergoing thyroidectomy for Graves' disease. Am J Surg 2016; 213:805-809. [PMID: 27769543 DOI: 10.1016/j.amjsurg.2016.07.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/15/2016] [Accepted: 07/06/2016] [Indexed: 12/31/2022]
Abstract
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.
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Quimby AE, Wells ST, Hearn M, Javidnia H, Johnson-Obaseki S. Is there a group of patients at greater risk for hematoma following thyroidectomy? A systematic review and meta-analysis. Laryngoscope 2016; 127:1483-1490. [DOI: 10.1002/lary.26195] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2016] [Indexed: 11/09/2022]
Affiliation(s)
| | - Simon T. Wells
- Faculty of Medicine; University of Ottawa; Ontario Canada
| | - Matthew Hearn
- Department of Otolaryngology-Head and Neck Surgery; University of Ottawa; Ontario Canada
| | - Hedyeh Javidnia
- Department of Otolaryngology-Head and Neck Surgery; University of Ottawa; Ontario Canada
- The Ottawa Hospital; Ottawa Ontario Canada
| | - Stephanie Johnson-Obaseki
- Department of Otolaryngology-Head and Neck Surgery; University of Ottawa; Ontario Canada
- The Ottawa Hospital; Ottawa Ontario Canada
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Schneider DF, Mazeh H, Oltmann SC, Chen H, Sippel RS. Novel thyroidectomy difficulty scale correlates with operative times. World J Surg 2015; 38:1984-9. [PMID: 24615607 DOI: 10.1007/s00268-014-2489-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate a new thyroidectomy difficulty scale (TDS) for its inter-rater agreement, correspondence with operative times, and correlation with complications. METHODS We developed a four item, 20-point TDS. Following cases where two board-certified surgeons participated, each surgeon completed a TDS, blinded to the other's responses. Paired sets of TDS scores were compared. The relationship between operative time and TDS scores was analyzed with linear regression. Multiple regression evaluated the association of TDS scores and other clinical data with operative times. RESULTS A total of 119 patients were scored using TDS. In this cohort, 22.7% suffered from hyperthyroidism, 37.8% experienced compressive symptoms, and 58.8% had cancer. The median total TDS score was 8, and both surgeons' total scores exhibited a high degree of correlation. Overall, 87.4% of the two raters' total scores were within one point of each other. Patients with hyperthyroidism received higher median scores than euthyroid patients (10 vs. 8, p < 0.01). Similarly, patients who suffered a complication had higher scores than those without complications (10 vs. 8, p = 0.04). TDS scores demonstrated a linear relation with operative times (R2 = 0.36, p < 0.01). Cases with a score of ≥14 took 41.0% longer compared to cases with scores of ≤5 (p < 0.01). In the multiple regression analysis, TDS scores independently predicted the operative time (p < 0.01). CONCLUSION The TDS is an accurate tool whose scores correlate with more difficult thyroidectomies as measured by complications and operative times.
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Affiliation(s)
- David F Schneider
- Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, K3/738, Clinical Science Center, 600 Highland Avenue, Madison, WI, 53792, USA,
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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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Muldoon BT, Mai VQ, Burch HB. Management of Graves' disease: an overview and comparison of clinical practice guidelines with actual practice trends. Endocrinol Metab Clin North Am 2014; 43:495-516. [PMID: 24891174 DOI: 10.1016/j.ecl.2014.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the last century, much has been learned about the pathogenesis, manifestations, and management of Graves' disease leading to the establishment of evidence-based clinical practice guidelines. The joint clinical practice guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists give recommendations on both the diagnosis and treatment of hyperthyroidism. A survey of clinicians performed that same year, however, revealed that current practices diverge from these recently published guidelines in multiple areas. These differences will need to be assessed serially to determine the impact of the guidelines on future clinical practice and perhaps vice versa.
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Affiliation(s)
- Becky T Muldoon
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Vinh Q Mai
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Henry B Burch
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Endocrinology Division, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Mok VM, Oltmann SC, Chen H, Sippel RS, Schneider DF. Identifying predictors of a difficult thyroidectomy. J Surg Res 2014; 190:157-63. [PMID: 24750986 DOI: 10.1016/j.jss.2014.03.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/05/2014] [Accepted: 03/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS. METHODS A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P<0.05) variables from a univariate analysis. RESULTS A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P=0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P=0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P=0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23-15.36, P=0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28-9.66, P=0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06-6.42, P=0.037) were independently associated with DT. CONCLUSIONS Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.
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Affiliation(s)
- Valerie M Mok
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Sarah C Oltmann
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Herbert Chen
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
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