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

Elisabeth Maurer,Knut A Böttcher,Antonia Hammer,Heinz J Buhr,Joachim Jähne,Katharina Schwarz,Theresia Weber,Kerstin Lorenz,Hinrich Köhler,Cornelia Dotzenrath,Christian Vorländer,Carsten Klinger,Moritz Von Frankenberg,Detlef K Bartsch,Andreas Zielke

doi:10.3390/jcm9124014

Abstract

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.

Highlights

Graves’ disease (GD) is an autoimmune disorder caused by the production of auto-thyrotropin receptor antibodies against the thyroid-stimulating hormone (TSH) receptor [1]
A total of 79% (n = 1429) of patients with GD were operated in hospitals with more than 300 thyroid resections per year; only 4.9% (n = 88) of patients were operated on in hospitals with 100 or fewer thyroid resections per year
A total of 11 institutions enrolled more than patients, 7 institutions 31–50 patients and 9 institutions 21–30 patients with GD, whereas the remaining institutions operated on 20 or fewer patients with GD during the recruitment period (Table 1)

Summary

Introduction

Graves’ disease (GD) is an autoimmune disorder caused by the production of auto-thyrotropin receptor antibodies against the thyroid-stimulating hormone (TSH) receptor [1]. Different kinds of subtotal resections were the preferred surgical procedures for GD until approximately the 21st century [9] and three former RCTs reported lower rates of hypoparathyroidism after bilateral subtotal thyroidectomy than after total thyroidectomy [11,12,13]. A very recent randomized controlled multicenter trial comparing total and near-total thyroidectomy identified total thyroidectomy as preferred surgical procedure for the treatment of GD with regard to transient and permanent hypoparathyroidism, transient recurrent laryngeal nerve palsy (RLNP), and short-term recurrent hyperthyroidism [14]. 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. Postoperative hypoparathyroidism is the major complication which should be focused on

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