Thyroid surgery for Graves' disease and Graves' ophthalmopathy

The challenges experienced by patients in the early period after thyroidectomy and the effects on sleep quality

BACKGROUND

Thyroidectomy, a standard surgical procedure, can lead to various postoperative issues that can significantly affect a patient's sleep quality. This study, addressing a topic of significant importance to thyroid surgery and patient care, engages healthcare professionals, researchers, and academics, providing crucial insights into the challenges faced by patients in the early period after thyroidectomy and their effects on sleep quality.

OBJECTIVE

The primary aim of this study was to investigate the prevalence of postoperative issues experienced by patients in the early period after thyroidectomy and their influence on sleep quality.

METHODS

This descriptive and prospective study, conducted with a sample of 104 thyroidectomy patients hospitalized in a university's Ear, Nose, and Throat clinic between 2021 and 2023, employed a comprehensive set of tools for data collection. These tools included a questionnaire, Visual Analog Scale for pain and nausea, Symptom Severity Scale, and Richard Campbell Sleep Scale, ensuring a thorough investigation into the prevalence of postoperative issues and their influence on sleep quality.

RESULTS

The most frequently reported postoperative issues were pain, difficulty swallowing, sore throat, dry mouth, nausea-vomiting, tingling, hoarseness, Chvostek's sign, tremors (tetany), Trousseau's sign, and bleeding. Analysis of the pre-and postoperative Richard Campbell Sleep Scale scores revealed a significant decrease in sleep quality post-surgery, particularly in patients experiencing sore throat, difficulty swallowing, pain, Chvostek's sign, and Trousseau's sign.

CONCLUSIONS

Our study has revealed that patients' three most commonly reported problems after thyroidectomy are pain, difficulty swallowing, and sore throat. Importantly, these issues significantly impact sleep quality, underscoring the need for effective management to improve patient recovery. This study enhances our understanding of postoperative issues after thyroidectomy and inspires improved clinical practices in managing these challenges.

Advancing Preoperative Strategies for Thyroidectomy in Graves' Disease: A Narrative Review

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.

Sex-specific risk factors associated with graves' orbitopathy in Korean patients with newly diagnosed graves' disease

OBJECTIVE

To assess sex-specific risk factors for Graves' orbitopathy (GO) in newly diagnosed Graves' disease (GD) patients.

METHODS

A retrospective cohort study was conducted using the National Health Insurance Service's sample database, which consisted of 1,137,861 subjects from 2002 to 2019. The international classification of disease-10 codes was used to identify those who developed GD (E05) and GO (H062). A multivariable Cox proportional hazards model was used to estimate the effect of risk factors on GO development.

RESULTS

Among 2145 male and 5047 female GD patients, GO occurred in 134 men (6.2%) and 293 women (5.8%). A multivariable Cox regression model revealed that GO development was significantly associated with younger age (HR = 0.84, 95% CI = 0.73-0.98), low income (HR = 0.55, 95% CI = 0.35-0.86), and heavy drinking (HR = 1.79, 95% CI = 1.10-2.90) in men, and with younger age (HR = 0.89, 95% CI = 0.81-0.98), lower body mass index (HR = 0.55, 95% CI = 0.33-0.90), high total cholesterol (HR = 1.04, 95% CI = 1.01-1.06), hyperlipidaemia (HR = 1.37, 95% CI = 1.02-1.85), and lower statin dose (HR = 0.37, 95% CI = 0.22-0.62) in women. There was no association between smoking and GO development in both men and women.

CONCLUSIONS

The risk factors for GO development were sex-dependent. These results show the need for more sophisticated attention and support considering sex characteristics in GO surveillance.

TSH receptor autoantibody levels post-total thyroidectomy in Graves' ophthalmopathy: a meta-analysis

BACKGROUND

TSH receptor autoantibodies (TRAbs) are pathognomonic for Graves' disease and are thought to also underly the pathogenesis of Graves' ophthalmopathy (GO). A decline in TRAb levels has been documented post-total thyroidectomy (TTx) in GO, however with conflicting correlations with disease outcomes. The aim of the study was to compare the effectiveness of TTx to other treatment modalities of Graves' disease and examine whether the lowering of TRAbs is associated with GO improvements.

METHOD

We searched electronic databases including Medline, Embase, Scopus, and Web of Science until 31 September 2022 using a broad range of keywords. Patients with GO undergoing TTx with measurements of both TRAbs and progression of the disease using a validated GO scoring system were included. Fourteen studies encompassing data from 1047 patients with GO met our eligibility criteria. The PRISMA guidelines were followed, and five studies had comparable data that were suitable for a meta-analysis.

RESULTS

The Cochrane Risk of Bias tool for RCTs showed low risk of bias across most domains. The pooled odds ratio showed that more patients significantly had normalized TRAb levels post-TTx as compared to other interventions (OR: 1.36, 95% CI: 1.02-1.81, p = 0.035). But, there was no significant difference in GO improvement post-TTx as compared with other intervention groups.

CONCLUSIONS

This meta-analysis shows that TRAb levels may decline largely post-TTx, but may not predict added improvements to the progression of GO. Thus, future studies with uniform designs are required to assess the minimal significant GO improvements.

Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC)

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.

Thyroidectomy With or Without Nerve Identification: A Personal Experience and Technique

INTRODUCTION

Careful and precise dissection of the gland, away from the typical trajectory of the recurrent and external laryngeal nerves, poses a minimal or similar risk of nerve injuries compared to directly visualizing and identifying the nerves.

MATERIALS AND METHODS

In a randomized controlled study involving 150 patients with various thyroid disorders who underwent different surgical procedures (total, near total, and hemi thyroidectomy), the patients were randomly assigned into two groups using a coin toss. The first group (G1) consisted of 75 patients who underwent thyroidectomy with nerve visual identification, while the second group (G2) comprised 75 patients without the requirement of nerve visualization. The aim was to determine the method with a lower risk of complications.

RESULTS

The incidence of external laryngeal nerve palsy (ELNP) was found to be higher in G1 patients compared to G2 patients (5.3% vs 2%), while no cases of permanent recurrent laryngeal nerve (RLN) palsy were observed in either group. The frequency of total nerve injury was higher in G1, with 14 patients (10.2%), compared to G2, with eight patients (5.3%). However, there was no significant association between nerve identification and the rate of nerve injury (P value = 0.452). Among the different surgical procedures, total thyroidectomy for toxic goiter was the most common operation associated with transient external laryngeal nerve (TELN) injury and permanent external laryngeal nerve (PELN) injury.

CONCLUSION

 By employing meticulous dissection techniques in proximity to the thyroid capsule, experienced surgeons can effectively reduce the risk of nerve injury, even in the absence of direct nerve visualization.

Thyroid receptor β might be responsible for breast cancer associated with Hashimoto's thyroiditis: a new insight into pathogenesis

Breast cancer is the most common cancer affecting females worldwide. Often it is observed that women suffering from Hashimoto's thyroiditis exhibit a greater propensity towards development of breast cancer. The exact mechanism for the same is unknown. However, multiple experimental evidences suggest a significant role of thyroid receptor β (TR-β) in regulating cell growth and proliferation and thus play a potent role as a tumor suppressor in several cancers, including breast cancer. Thyroid receptor β shows anti-proliferative action through mediators like β-catenin, RUNX2, PI3K/AKT, and cyclin regulation. The present review explores the link between these pathways and how they may be dysregulated due to Hashimoto's thyroiditis. Further, we propose a new mechanism for cancer prognosis associated with Hashimoto's thyroiditis, which may lead to the development of TR-β targeting as a novel therapeutic approach.

[Definitive treatment of Graves' disease in children]

BACKGROUND

Hyperthyreoidism due to Graves' disease is a rare disorder in pediatric practice. There is 2 treatment options in Graves' disease: medical treatment and definitive treatment, including surgery and radioactive iodine. Each method has its advantages and disadvantages. If medical therapy is ineffective the choice between radical treatment method is raised: radioactive iodine or total thyroidectomy. In this research we analyze treatment outcomes in pediatric Graves' disease patients after different radical treatment methods.

AIM

Comparative analysis of radical treatment outcomes in pediatric patients with Graves' disease.

MATERIALS AND METHODS

Retrospective and prospective one-center research of 122 patients with Graves' disease after radical treatment (between 2016 and 2021)RESULTS: The mean age was 13.5±3,5 year at the moment of examination. Patients were divided into 2 groups due to the radical treatments method: 1 group (n=60) were children after surgical treatment, 2 group (n=62) - after radioactive iodine. The mean dose of medical treatment in these groups did not reliably differ (p=0,06), duration of the medical treatment was reliably longer in patients after radioactive iodine (p=0,024). Graves' orbitopathy was diagnosed in 58 patients (47,5%) and met equally often in both groups, but active stage of Graves' orbitopathy was diagnosed only in patients from the 1st group. Thyroid size was reliable bigger in patients from the 1st group (p=0,004), and thyroid gland nodes were diagnosed only in patients from 1st group (p=0,0007).

CONCLUSION

RI can be considered an effective and safe treatment for GD. The effectiveness of RI depends on the volume of the thyroid gland; according to the results of the constructed ROC curve, the risk of repeated RI is higher with a volume of more than 55 cm3. Also radioactive iodine is undesirable if there is signs of ophatalmopathy due to its possible deterioration. According to the results of the study hypoparathyroidism after surgical treatment was diagnosed in 20%, recurrent laryngeal nerve injury was diagnosed after surgical treatment in 5% of patients. In patients with identified nodular goiter according to the results of ultrasound, surgical treatment is preferable due to the impossibility of excluding thyroid cancer.

Study protocol to develop a core outcome set for thyroid dysfunction to bridge the unmet needs of patient-centred care

INTRODUCTION

Thyroid dysfunctions (TD) are common medical conditions affecting all global populations. Improved healthcare leading to increasing survival rates and delayed diagnosis rendered significant burden of the disease in the increasing number of patients with TD with comorbid illnesses. Therefore, reducing the burden of TD and improving the quality of care are crucial. Existing poor-quality data that guide evidence-based decisions only provide a fragmented picture of clinical care. The different outcomes across studies assessing the effectiveness of treatments impede our ability to synthesise results for determining the most efficient treatments. This project aims to produce a core outcome set (COS), which embeds the multiple complex dimensions of routine clinical care for the effectiveness studies and clinical care of adult patients with TD.

METHODS AND ANALYSIS

This mixed-method project has two phases. In phase 1, we will identify a list of patient-reported and clinical outcomes through qualitative research and systematic reviews. In phase 2, we will categorise the identified outcomes using the Core Outcome Measures in Effectiveness Trials taxonomy of core domains and the International Classification of Functioning, Disability and Health. We will develop questionnaires from the list of outcomes identified from each domain for the two-round online Delphi exercise, aiming to reach a consensus on the COS. The Delphi process will include patients, carers, researchers and healthcare participants. We will hold an online consensus meeting involving representatives of all key stakeholders to establish the final COS.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Ethics Committee for Research Involving Human Subjects, Universiti Putra Malaysia and the Research Ethics Committee, National University of Malaysia. This proposed COS in TD will improve the value of data, facilitate high-quality evidence synthesis and evidence-based decision-making. Furthermore, we will present the results to participants, in peer-reviewed academic journals and conferences.

REGISTRATION DETAILS

Core Outcome Measures in Effectiveness Trials (COMET) Initiative database registration: http://www.comet-initiative.org/studies/details/1371.

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.

Adverse effects of chronic steroid use following thyroidectomy

BACKGROUND

Prior to thyroid surgery, a subset of patients chronically uses steroids to manage medical conditions such as Grave's disease, auto-immune conditions, or organ transplantation. Existing literature describes adverse effects of prolonged steroid use on surgical outcomes, however there remains a paucity of data investigating the specific effects of steroid use on postoperative outcomes after thyroidectomy. This study aims to identify complication risks steroid users are predisposed to after thyroidectomy.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program Database (ACS-NSQIP) was queried to identify and isolate all patients who had undergone thyroidectomy procedures by Current Procedure Terminology codes from 2005 through 2018. Univariate analysis was performed to compare steroid uses and non-steroid users. Coarsened exact matching was utilized to homogenize the two cohorts based on demographics and preoperative comorbidities.

RESULTS

A total of 153,595 thyroidectomies were initially included. After Coarsened exact matching, 116,861 patients were categorized as non-steroid users, and 2,965 as steroid users. The steroid cohort demonstrated significantly higher rates of any complication (P < 0.001) as well as overall surgical, cardiopulmonary, and renal complications. Individual complications such as superficial surgical site infections (P = 0.013), pulmonary embolism (P = 0.016), deep vein thrombosis (P = 0.011), progressive renal insufficiency (P = 0.006), and unplanned readmission (P = 0.026) were also increased.

CONCLUSIONS

Patients with chronic steroid use undergoing thyroidectomy are at an increased risk for surgical, cardiopulmonary, and renal complications. Further research on preoperative steroid management is necessary for optimizing outcomes in this population.

Total versus near-total thyroidectomy in Graves' disease: a systematic review and meta-analysis of comparative studies

Background

Total thyroidectomy (TT), near-total thyroidectomy (NT), and subtotal thyroidectomy (ST) are three surgical procedures for Graves' disease (GD) patients, but most previous studies have only evaluated the complications of TT versus ST or TT/NT versus ST; there is not a meta-analysis of NT versus TT, so whether NT is superior to TT for GD patients still unclear.

Methods

We comprehensively searched PubMed, Embase, Web of Science, and the Cochrane Library, without restriction to region, publication type, or language, on 10 June, 2020. We conducted this systematic review and meta-analysis of all included studies assessing the two surgical procedures.

Results

In total, 528 cases were identified from two randomized controlled trials (RCTs) and three retrospective studies. The incidence of permanent hypoparathyroidism after NT was lower than with TT [odds ratio (OR), 0.22; 95% confidence interval (CI), 0.06-0.80; P=0.02], and there was no statistical difference in the recurrence of hyperthyroidism (OR, 0.33; 95% CI, 0.01-8.12; P=0.50) and other postoperative complications (P>0.05).

Conclusions

NT for GD was superior to TT regarding permanent hypoparathyroidism, but there was no significant difference in preventing recurrent hyperthyroidism, as well as the other postoperative complications.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Retrospective Study of Tc-99m Thyroid Scan in Patients with Graves' Disease: Is There Significant Difference in Lobar Activity?

PURPOSE

Graves' disease (GD) is the most common cause of hyperthyroidism. It was reported that the right thyroid lobe is generally larger, and it is more likely to be affected by thyroid disorders. The aim of the current study is to verify preferential affection of one of the thyroid lobes and incidence of higher activity of either thyroid lobe in patients with GD through analysis of quantitative data of Tc-99m thyroid scan and possible relation of different thyroid lobar activity to gender, age, and total thyroid uptake (TTU) level.

MATERIALS AND METHODS

Retrospective analysis of quantitative data of Tc-99m thyroid scan in patients with GD was done. Total and lobar thyroid uptake levels were analyzed and correlated with age, gender, and TTU.

RESULTS

GD was reported in 222 patients, representing 76.6% of those with hyperthyroidism, women represent 70.3% of patients. The right thyroid lobe uptake (RLU) figures were significantly higher compared to the left in the whole group as well as in women and in young patients (<40 years). This significance was lost in men and in old patients. Equal lobar uptake was found in 11 patients. 138 patients (62.2%) had higher RLU, while the remaining 73 patients (32.8%) had higher left thyroid lobe uptake, with statistically significant difference. This significant difference was found in women and in young patients and was absent in men and old patients. There is an increase in the incidence of patients with higher RLU in association with an increase in TTU. All women with TTU >30% had higher RLU figures.

CONCLUSION

There is significant preferential thyroid lobar affection in favor of the right thyroid lobe in patients with GD, with significantly higher RLU figures and significantly more incidence of patients with higher right lobar activity. This significance is maintained in women and in young patients and lost in men and old patients. The incidence of higher right thyroid lobe activity also increases in association with increase in TTU. Our results emphasize the value of Tc99m thyroid scan in patients with GD, especially when surgery is the treatment of choice, helping to tailor suitable surgical procedure for each individual patient.

Cervicogenic exophthalmos: Possible etiology and pathogenesis

BACKGROUND

Unilateral exophthalmos is often caused by inflammation, neoplasm, infection, metabolic disease, vascular disorder and several other less common conditions. Reflex sympathetic dystrophy related to unilateral exophthalmos has not been reported in the past literature.

CASE SUMMARY

We describe a 45-year-old female with unilateral exophthalmos caused by reflex sympathetic dystrophy and its unexpected spontaneous disappearance after a standard anterior cervical discectomy and fixation operation with two PEEK interbody cages and a plate. To our surprise, the patient’s left unilateral exophthalmos improved spontaneously in the morning on postoperative day 2-with no relapse, without any further medication, as of seven years. We have named this condition “cervicogenic exophthalmos.”

CONCLUSION

We would inform other clinicians that unilateral exophthalmos was caused not only by inflammation, vascular disorder, infection, neoplasm, or metabolic disease, but also by reflex sympathetic dystrophy related with cervicogenic spondylosis. To the best of our knowledge, ours is the first related case report and use of the term “cervicogenic exophthalmos” after reviewing previous literature.

Graves' Disease: Can It Be Cured?

Whether or not Graves' hyperthyroidism can be really cured, depends on the definition of "cure." If eradication of thyroid hormone excess suffices for the label "cure," then all patients can be cured because total thyroidectomy or high doses of ¹³¹I will abolish hyperthyroidism albeit at the expense of creating another disease (hypothyroidism) requiring lifelong medication with levothyroxine. I would not call this a "cure," which I would like to define as a state with stable thyroid stimulating hormone (TSH), free thyroxine, and triiodothyronine serum concentrations in the normal range in the absence of any thyroid medication. Surgery and radioiodine are unlikely to result in so-defined cures, as their preferable aim as stated in guidelines is to cause permanent hypothyroidism. Discontinuation of antithyroid drugs is followed by 50% recurrences within 4 years; before starting therapy the risk of recurrences can be estimated with the Graves' Recurrent Events After Therapy (GREAT) score. At 20-year follow-up about 62% had developed recurrent hyperthyroidism, 8% had subclinical hypothyroidism, and 3% overt hypothyroidism related to TSH receptor blocking antibodies and thyroid peroxidase antibodies. Only 27% was in remission, and might be considered cured. If the definition of "cure" would also include the disappearance of thyroid antibodies in serum, the proportion of cured patients would become even lower.

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.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease: a comparison of surgical results with open thyroidectomy

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) provides excellent cosmetic results from its potential for scar-free operation. The procedure has been applied successfully for Graves' disease by the authors of this work and compared with the standard open cervical approach to evaluate its safety and outcomes.

METHODS

From January 2014 to November 2016, a total of 97 patients with Graves' disease were reviewed retrospectively. Open thyroidectomy (OT) and TOETVA were performed in 49 patients and 46 patients, respectively. For TOETVA, a three-port technique through the oral vestibule was utilized. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device. Patient demographics and surgical variables, including operative time, blood loss, and complications, were investigated and compared.

RESULTS

TOETVA was performed successfully in all 45 patients, although conversion to open surgery was deemed necessary in one patient. All patient characteristics for both groups were similar. Operative time was shorter for the OT group compared to the TOETVA group, which totaled 101.97±24.618 and 134.11±31.48 minutes, respectively (P<<0.5). Blood loss was comparable for both groups. The visual analog scale (VAS) pain score for the TOETVA group was significantly lower than for the OT group on day 1 (2.08±1.53 vs. 4.57±1.35), day 2 (0.84±1.12 vs. 2.57±1.08) and day 3 (0.33±0.71 vs. 1.08±1.01) (P<<0.05). Transient recurrent laryngeal nerve (RLN) palsy was found in four and two cases of TOETVA and OT group, respectively. Transient hypocalcemia was found in ten and seven cases of TOETVA and OT group, respectively. No other complications were observed.

CONCLUSIONS

TOETVA is a feasible and safe treatment for Graves' disease in comparison to the standard open cervical approach. It is considered a viable alternative for patients who have been indicated for surgery with excellent cosmetic results.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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