Accumulation of Experience and Newly Developed Devices Can Improve the Safety and Voice Outcome of Total Thyroidectomy for Graves’ Disease

Cheng-Hsun Chuang,Feng-Yu Chiang,Ling-Feng Wang,Chih-Chun Wang,Pi-Ying Chang,Ching-Feng Lien,Tzu-Yen Huang,Che-Wei Wu,I-Cheng Lu,Tzer-Zen Hwang,Yi-Chu Lin,Gianlorenzo Dionigi,Chih-Feng Tai

doi:10.3390/jcm11051298

Abstract

Total thyroidectomy (TT) in patients with Graves’ disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves’ disease who received TT. Forty-six patients received surgery during 1990–1999 (Group A), and 44 patients received surgery during 2010–2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range (p = 0.015) and jitter (p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves’ disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.

Highlights

Graves’ disease is the most common cause of persistent hyperthyroidism
In Group B, recurrent laryngeal nerve (RLN) were routinely identified and preserved by visualization with the adjunct of intermittent intraoperative neuromonitoring (IONM), and parathyroid glands (PGs) were preserved in situ whenever possible
The two groups significantly differed in the number of patients with at least one PG autotransplantation; forty (87.0%) patients in Group A and twenty-two (50.0%) patients in Group B had at least one PG autotransplantation (p = 0.001)

Summary

Introduction

Graves’ disease is the most common cause of persistent hyperthyroidism. The annual prevalence rate is approximately 20 to 30 cases per 100,000 individuals, and the lifetime prevalence rates in women and men are 3% and 0.5%, respectively [1]. The suggested indications for surgical treatment of Graves’ disease include large goiters, lesions causing tracheal compression, moderate-to-severe ophthalmopathy, current pregnancy or breastfeeding, poor control of hyperthyroidism after radio-iodine ablation or after anti-thyroid drug therapy, and suspected malignancy of a coexisting nodule [3]. Subtotal thyroidectomy leaves 4 to 7 g of thyroid and provides patients with adequate thyroid function without requiring thyroxin replacement Another advantage is that the procedure reduces the risk of hypoparathyroidism [4]. TT is a preferred surgical treatment option because of several advantages, including (1) low recurrence rate, (2) rapid and reliable control of hyperthyroidism and its related symptoms, (3) radical resection of coexisting malignant thyroid tumor, (4) optimal release of airway compression, (5) absence of side-effects such as those in radio-iodine and anti-thyroid drug therapy, and (6) possible elimination of further progression of ophthalmopathy [7–9]

Methods

Results

Discussion

Conclusion