Dunhill Procedure Research Articles

The Prevalence of Incidental Thyroid Carcinoma in Patients Who Underwent Thyroidectomy for Multinodular Goiter

The incidence of an incidental carcinoma following surgical treatment for MNG varies from 3 to 16%. The aims of this study are to determine the incidence of an incidental thyroid carcinoma (ITC) in patients with multinodular goiter (MNG) and to evaluate the primary surgical treatment modality for these patients. Between January 2010 and July 2015, a total of 3311 patients who underwent surgery for goiter were retrospectively evaluated. Demographic characteristics of the patients, previous medical history, thyroid hormone profiles, thyroid ultrasonography findings, fine-needle aspiration biopsy (FNAB) findings, thyroid scintigraphy findings, surgical techniques, early postoperative complications, and histopathological diagnoses were recorded. The patients were divided into two groups: those who were incidentially diagnosed with a thyroid carcinoma (ITC group; n = ?) and those with MNG (MNG group; n = ?). Of 3311 patients, FNAB was performed in 1524 (46%) patients. Of these, 1790 underwent total thyroidectomy (TT) or near total thyroidectomy (NTT), 1066 underwent bilateral subtotal thyroidectomy (BSTT), 354 underwent the Dunhill procedure, and 101 underwent unilateral lobectomy (ULL) due to the presence of unilateral MNG. Postoperative histopathological examinations revealed an incidental thyroid carcinoma (ITC) in 283 (8.54%) patients, papillary carcinoma in 201 patients (201/3311, 6%), follicular cancer in 68 patients (68/3311, 2%), medullary cancer in 13 patients (13/3311, 0.3%), follicular carcinoma in four patients (4/923, 0.4%), and anaplastic cancer in one patient (1/3311, 0.03%). Our study results suggest that TT should be the primary surgical treatment modality to avoid the complications of a complementary thyroidectomy.

Thyroid surgery for Graves' disease and Graves' ophthalmopathy.

Graves' disease is an autoimmune disease caused by the production of auto-antibodies against the thyroid-stimulating hormone receptor, which stimulates follicular cell production of thyroid hormone. It is the commonest cause of hyperthyroidism and may cause considerable morbidity with increased risk of cardiovascular and respiratory adverse events. Five per cent of people with Graves' disease develop moderate to severe Graves' ophthalmopathy. Thyroid surgery for Graves' disease commonly falls into one of three categories: 1) total thyroidectomy, which aims to achieve complete macroscopic removal of thyroid tissue; 2) bilateral subtotal thyroidectomy, in which bilateral thyroid remnants are left; and 3) unilateral total and contralateral subtotal thyroidectomy, or the Dunhill procedure. Recent American Thyroid Association guidelines on treatment of Graves' hyperthyroidism emphasised the role of surgery as one of the first-line treatments. Total thyroidectomy removes target tissue for the thyroid-stimulating hormone receptor antibody. It controls hyperthyroidism at the cost of lifelong thyroxine replacement. Subtotal thyroidectomy leaves a thyroid remnant and may be less likely to lead to complications, however a higher rate of recurrent hyperthyroidism is expected and revision surgery would be challenging. The choice of the thyroidectomy technique is currently largely a matter of surgeon preference, and a systematic review of the evidence base is required to determine which option offers the best outcomes for patients. To assess the optimal surgical technique for Graves' disease and Graves' ophthalmopathy. We searched the Cochrane Library, MEDLINE and PubMed, EMBASE, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The date of the last search was June 2015 for all databases. We did not apply any language restrictions. Only randomised controlled trials (RCTs) involving participants with a diagnosis of Graves' disease based on clinical features and biochemical findings of hyperthyroidism were eligible for inclusion. Trials had to directly compare at least two surgical techniques of thyroidectomy. There was no age limit to study inclusion. Two review authors independently extracted and cross-checked the data for analysis, evaluation of risk of bias and establishment of 'Summary of findings' tables using the GRADE instrument. The senior review authors reviewed the data and reconciled disagreements. We included five RCTs with a total of 886 participants; 172 were randomised to total thyroidectomy, 383 were randomised to bilateral subtotal thyroidectomy, 309 were randomised to the Dunhill procedure and 22 were randomised to either bilateral subtotal thyroidectomy or the Dunhill procedure. Follow-up ranged between six months and six years. One trial had three comparison arms. All five trials were conducted in university hospitals or tertiary referral centres for thyroid disease. All thyroidectomies were performed by experienced surgeons. The overall quality of the evidence ranged from low to moderate. In all trials, blinding procedures were insufficiently described. Outcome assessment for objective outcomes was blinded in one trial. Surgeons were not blinded in any of the trials. One trial blinded participants. Attrition bias was a substantial problem in one trial, with 35% losses to follow-up. In one trial the analysis was not carried out on an intention-to-treat basis.Total thyroidectomy was more effective than subtotal thyroidectomy techniques (both bilateral subtotal thyroidectomy and the Dunhill procedure) at preventing recurrent hyperthyroidism in 0/150 versus 11/200 participants (OR 0.14 (95% CI 0.04 to 0.46); P = 0.001; 2 trials; moderate quality evidence). Total thyroidectomy was also more effective than bilateral subtotal thyroidectomy at preventing recurrent hyperthyroidism in 0/150 versus 10/150 participants (odds ratio (OR) 0.13 (95% confidence interval (CI) 0.04 to 0.44); P = 0.001; 2 trials; moderate quality evidence). Compared to bilateral subtotal thyroidectomy, the Dunhill procedure was more likely to prevent recurrent hyperthyroidism in 20/283 versus 8/309 participants (OR 2.73 (95% CI 1.28 to 5.85); P = 0.01; 3 trials; low quality evidence). Total thyroidectomy compared with subtotal thyroidectomy conferred a greater risk of permanent hypocalcaemia/hypoparathyroidism in 8/172 versus 3/221 participants (OR 4.79 (95% CI 1.36 to 16.83); P = 0.01; 3 trials; low quality evidence). Effects of the various surgical techniques on permanent recurrent laryngeal nerve palsy and regression of Graves' ophthalmopathy were neutral. One death was reported in one study in year three of follow-up. No study investigated health-related quality of life or socioeconomic effects. Total thyroidectomy is more effective than subtotal thyroidectomy (both bilateral subtotal thyroidectomy and the Dunhill procedure) at preventing recurrent hyperthyroidism in Graves' disease. The type of surgery performed does not affect regression of Graves' ophthalmopathy. There was some evidence that total thyroidectomy compared with subtotal thyroidectomy conferred a greater risk of permanent hypocalcaemia/hypoparathyroidism, which however, was not seen in comparison with bilateral subtotal thyroidectomy. Permanent recurrent laryngeal nerve palsy did not seem to be affected by type of thyroidectomy. Health-related quality of life as a patient-important outcome measure should form a core determinant of any future trial on the effects of thyroid surgery for Graves' disease.

Comparison of the results of total thyroidectomy and Dunhill operation in surgical treatment of multinodular goiter.

Multi-nodular goiter (MNG) is one of the commonest thyroid gland disease. Surgery is an important treatment option in the presence of indications. There are several alternative procedures for thyroid gland operation such as subtotal thyroidectomy (STT), near-total thyroidectomy (NTT), hemi-thyroidectomy plus subtotal resection (Dunhill procedure), and total thyroidectomy (TT), but the surgical procedure of choice is still under discussion. In this study, 173 consecutive patients with multi-nodular goiter underwent thyroid operation in the department of surgery of Pursina Hospital in Rasht-Iran, using two different methods: Dunhill operation and total thyroidectomy. Outcome assessment was performed 4days after surgery, 2weeks, 1, 2, 10, and 20month after surgery. Preoperative assessment, seroma, recurrent laryngeal nerve palsy, hypocalcaemia rates, and rates of other postoperative complications, final pathology, and recurrence were compared in two methods. Due to the high incidence of malignancy in this survey, TT can be the method of choice for MNG surgery. Also, TT will be more beneficial in the surgical treatment of benign thyroid disorders, especially those which are bilateral or extended to substernal space or which presented with compression symptoms.

Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis.

A variety of measures have been proposed to reduce the incidence of post-thyroidectomy hypocalcemia. The aim of this study was to perform a systematic review and meta-analysis of preventive and other surgical measures on post-thyroidectomy hypocalcemia as reported in the literature. Comprehensive searches of the PubMed, EMBASE, and Cochrane databases were performed, and the quality of included papers was assessed using the Cochrane risk of bias tool or a modified Newcastle-Ottawa Scale (NOS). The results of all included studies were summarized, and meta-analyses were performed where appropriate. Thirty-nine randomized controlled trials (RCTs) and 37 observational studies were included. Measures studied included hemostatic techniques, extent of thyroidectomy and central neck dissection, surgical approach, calcium/vitamin D/thiazide diuretic supplements, parathyroid gland autotransplantation (PGAT) and intraoperative parathyroid gland (PG) identification, truncal ligation of inferior thyroid artery (ITA), preoperative magnesium infusion, and use of magnification loupes and Surgicel. Measures associated with significantly lower rates of transient hypocalcemia in meta-analysis were postoperative calcium and vitamin D supplementation compared to either calcium supplements alone (odds ratio (OR) 0.66; p=0.04) or no supplements (OR 0.34; p=0.007), and bilateral subtotal thyroidectomy (BST) compared to Hartley Dunhill (HD) procedure (OR 0.35; p=0.01). Meta-analyses did not demonstrate any measure to be significantly associated with a reduction in permanent hypocalcemia. This review identified postoperative calcium and vitamin D supplementation and bilateral subtotal thyroidectomy (over HD) as being effective in prevention of transient hypocalcemia. However, the majority of RCTs were of low quality, primarily due to a lack of blinding. The wide variability in study design, definitions of hypocalcemia, and methods of assessment prevented meaningful summation of results for permanent hypocalcemia.

Effectiveness of preventative and other surgical measures on hypocalcaemia following bilateral thyroid surgery: A systematic review and meta-analysis

Background: Hypocalcaemia following bilateral thyroid surgery is common and is associated with significant short and long term morbidity. The aim of this study was to perform a systematic review and meta-analysis of preventive and other surgical measures on post-thyroidectomy hypocalcaemia as reported in the literature. Methods: Comprehensive searches of PubMed, EMBASE, and Cochrane databases were performed and quality of included papers was assessed using the Cochrane risk of bias tool and a modified NewcastleOttawa Scale (NOS). The results of all included studies were summarised and meta-analyses were performed where appropriate. Results: 39 randomised controlled trials (RCTs) and 37 cohort studies were included. Measures studied included haemostatic techniques, extent of thyroidectomy and central neck dissection, surgical approach, calcium/vitamin D supplements, parathyroid gland auto-transplantation (PGAT) and intra-operative parathyroid gland (PG) identification, truncal ligation of inferior thyroid artery (ITA), and use of magnification loupes and surgical. Measures associated with significantly lower rates of transient hypocalcaemia in meta-analysis were postoperative calcium and vitamin D supplementation compared to either calcium supplements alone (odds ratio (OR) 0.66; 95 per cent confidence interval (CI) 0.45-0.98; p=0.05) or no supplements (OR 0.34; 95 per cent CI 0.15-0.75; p=0.007) and bilateral subtotal thyroidectomy (BST) compared to Hartley Dunhill procedure (HD) procedure (OR 0.35; 95 per cent CI 0.15-0.79; p=0.01). Meta-analyses did not demonstrate any measure to be significantly associated with a reduction in permanent hypocalcaemia. Conclusion: The review identified post-operative calcium and vitamin D supplementation and bilateral subtotal thyroidectomy (over HD) as being effective in prevention of transient hypocalcaemia. However, the majority of RCTs were of low quality, primarily due to lack of blinding. The wide variability in study design, definitions of hypocalcaemia and methods of assessment prevented meaningful summation of results for permanent hypocalcaemia.

The Surgical Treatment of Bilateral Benign Nodular Goiter

About 100,000 thyroid operations are performed in Germany each year. There is a current trend toward more radical surgery for bilateral euthyroid nodular goiter. In recent years, thyroid specialists and specialty guidelines have recommended total thyroidectomy, because it ensures that nodules will not recur and already provides an adequately radical excision in case an incidental carcinoma is found postoperatively on histological study of the specimen. An alternative method is unilateral hemithyroidectomy with contralateral subtotal resection (the Dunhill procedure). Selective literature review. Three randomized controlled trials (RCTs) have compared the longterm outcomes of different surgical methods. In addition, retrospective studies have been published, but their findings must be interpreted with caution because of limitations of method. When all of the data are considered, it appears that radical procedures are often not justified. According to the RCTs, nodules arose during long-term follow-up in 4.7-14% of patients who had undergone subtotal resection; yet, in the two more recent and methodologically more valid RCTs, surgery for recurrent goiter was needed in only 0-0.5% of patients treated with a Dunhill procedure and given adequate hormone supplementation. Most incidental carcinomas are papillary microcarcinomas; this entity is usually adequately treated with hemithyroidectomy. The reported complication rates of total thyroidectomy for permanent hypoparathyroidism in particular range from 0.5% (in specialized centers) to 10% (in a cross-sectional study) and thus seem higher than the corresponding rate for a Dunhill procedure (1-2%). Total thyroidectomy has significant risks and should only be performed if the indication has been critically assessed. Alternative methods such as the Dunhill procedure are often radical enough with a much lower rate of postoperative hypoparathyroidism; they remain an important option in thyroid surgery. Further RCTs with sufficient long-term follow-up are needed so that the different surgical methods can be reliably compared in detail.

Nodular Goiter

Roughly 100 000 patients undergo thyroid surgery in Germany every year. Total thyroidectomy is often performed for benign nodular goiter to prevent recurrence. In this issue of Deutsches Arzteblatt International. N. Rayes and coauthors summarize the available data on surgery for bilateral benign nodular goiter and conclude that alternative treatments such as the Dunhill procedure still have a role to play alongside total thyroidectomy, as they are sufficiently radical but have markedly fewer complications (1).

Endemik Guatr Bölgesindeki Multinodüler Guatr Tanısı ile Yapılan Tiroidektomilerde İnsidental Tiroid Karsinomu Sıklığı

Amaç: Bu çalışmanın amacı multinodüler guatrlı (MNG) hastalarda görülen insidental tiroid karsinomu sıklığını belirlemek ve bu hastalarda tercih edilen ameliyat yöntemlerini incelemektir. Gereç ve Yöntemler: Çalışmamızda MNG tanısıyla opere edilmiş 923 hastanın retrospektif incelenmesi ile hastalarımızdaki insidental tiroid karsinomu oranını saptadık ve bu hastaların tedavi protokollerini değerlendirdik. Bulgular: Çalışmaya alınan 923 hastanın 817'si (% 88) kadın, 106'sı (%12) erkek idi. Hastaların yaş ortalaması 48.72±11.32 yıl olarak bulundu. Beş yüz on dört (%55,6) hastaya ince iğne aspirasyon biyopsisi uygulandığı saptandı. Hastaların 435'ine bileteral total tiroidektomi ya da biletaral totale yakın tiroidektomi, 298'ine bilateral subtotal tiroidektomi, 99'una Dunhill prosedürü , 28'ine ise, olgular tek taraflı MNG olduğu için, tek taraflı lobektomi uygulandığı belirlendi. Postoperatif patolojik incelemede 42 (%4,55) hastada insidental tiroid karsinomu tespit edildi. Otuz yedi hastada papiller karsinom (37/923, %4,0), 4 hastada folliküler karsinom (4/923, %0,4) ve 1 hastada Hurtle hücreli karsinom (1/923, %0,1) saptandı. Sonuç: İnsidental tiroid kanseri oranı ihmal edilemeyecek kadar yüksektir. Bu sebeple tamamlayıcı tiroidektominin komplikasyonlarından korunmak için, ilk operasyonda bileteral total tiroidektomi tercih edilmelidir.

Bilateral Subtotal Thyroidectomy Versus Hemithyroidectomy Plus Subtotal Resection (Dunhill Procedure) for Benign Goiter: Long‐Term Results of a Prospective, Randomized Study

Two recent meta-analyses of mostly retrospective studies have shown high recurrence rates following subtotal resection of bilateral multinodular goiter. Therefore, many endocrine centers have changed their operative procedures in favor of thyroidectomy. Consequently, the rate of complications, especially hypoparathyroidism, has increased. Hemithyroidectomy plus subtotal resection (Dunhill operation) overcomes some disadvantages of bilateral subtotal resection (BST). We performed a prospective, randomized trial to compare the Dunhill operation (DO) and BST for benign goiters. Between October 1994 and March 1997, a total of 200 consecutive patients were randomized into two study groups. Primary outcome measure was the incidence of recurrent goiter. Secondary outcome measures were incidence of recurrent nerve palsy and hypoparathyroidism. In all patients, ultrasonography of the thyroid and measurement of serum calcium and parathyroid hormone were performed. Recurrent nerve function was analyzed by indirect laryngoscopy. Long term data (>10 years after surgery) were available in 70 DO patients and 65 BST patients. Mean follow-up was 11.3 ± 4.2 years (10-12 years). No differences were seen in the operating times, transient and permanent hypoparathyroidism, or recurrent nerve palsy. In the long-term, mean thyroid volumes were significantly lower in the DO group (3.5 ± 3.5 vs. 6.4 ± 6.5 ml, p = 0.01). One reoperation was required in the BST group because of recurrence versus none in the DO group. 68 of 70 (97 %) patients in group DO and 59 of 65 (91 %) in group BST had ongoing thyroid hormone therapy with no significant differences in mean dosages of L-thyroxine. The Dunhill operation and BST are safe procedures. In case of small remnants, clinically significant recurrence is a rare event especially after the Dunhill operation.

Changes in the choice of thyroidectomy for benign thyroid disease

There is an increasing trend towards performing more radical resections instead of a subtotal resection for benign thyroid disease. The aim of this study was to examine the effect of this change in practice on the surgical treatment of bilateral thyroid diseases in this unit. The data on 367 patients that underwent a bilateral thyroidectomy were categorized by dividing the operation types into 4 groups: (1) total thyroidectomy (TT), (2) near-total thyroidectomy, (3) Dunhill procedure, and (4) bilateral subtotal thyroidectomy. A statistically significant change in the choice of thyroidectomy occured during the study period (p < 0.001). TT has replaced subtotal thyroidectomy (STT; bilateral subtotal thyroidectomy and Dunhill procedure) as the preferred routine surgical procedure for bilateral benign thyroid diseases in this clinic. The permanent complication rates were similar for all surgical procedures. The rate of secondary thyroidectomy for both recurrence of multinodular goiter and incidental thyroid carcinoma were significantly higher in the STT groups, than the total in the TT and near-total thyroidectomy patients. Total or near total thyroidectomy procedures are now being increasingly employed to treat bilateral benign thyroid disease, and are as safe as the sub-total thyroidectomy procedures, which are more conservative and associated with significantly higher recurrence rates.

Alternating from subtotal thyroid resection to total thyroidectomy in the treatment of Graves’ disease prevents recurrences but increases the frequency of permanent hypoparathyroidism

This study aims to compare the results of three different surgical techniques in the treatment of Graves' disease. All patients operated on due to Graves' disease at a single institution between 1985 and 2009 were followed up for a median time of 152 months. The same endocrine surgeon operated altogether 265 patients; 111 with bilateral subtotal thyroid resection, 65 with lobectomy + unilateral subtotal resection (Dunhill's operation) and 99 with total thyroidectomy. Recurrence of thyreotoxicosis was seen in 11 (9.9%) patients operated on with bilateral thyroid resection, in two (3.1%) of those operated on with Dunhill's method and in none treated with total thyroidectomy. Permanent hypoparathyroidism was observed in 6% of the patients with total thyroidectomy, in 0.9% of those operated with bilateral subtotal resection and in none of the patients with Dunhill's procedure (p < 0.001). The frequency of permanent paresis of one recurrent laryngeal nerve was 2%, 0% and 1.5%, respectively, in the three different groups. At follow-up, thyroxine supplementation therapy was given to 81 (73%) of the patients treated with bilateral subtotal resection, to 58 (89%) of those treated with Dunhill's operation and to all of those treated with total thyroidectomy. It is concluded that surgical treatment of Graves' disease with Dunhill's procedure, leaving a remnant of 1-2 g, seems to minimize the risks of both recurrences and permanent hypoparathyroidism.

Quality of life is not influenced by the extent of surgery in patients with benign goiter

The surgical approach to benign goiter is becoming increasingly radical due to the risk of recurrent goiter. The aim of this prospective study was to evaluate the impact of surgery on health-related quality of life (HRQoL) of patients with benign goiter. HRQoL data from 115 patients with benign goiter were analyzed. Thirty-three patients (group 1) had a hemithyroidectomy. Sixty-five patients (group 2) had a so-called Dunhill operation (hemithyroidectomy + near-total thyroidectomy of the opposite side), and in 17 patients, a total resection of the goiter was performed. The validated HRQoL instrument, the EuroQol-5D, was applied to measure the health-related quality of life. With an overall complication rate of 10% and no permanent recurrent laryngeal nerve palsy, it was shown that surgery for benign goiter is safe. In the validated HRQoL questionnaire (EQ-5D), no significant variance could be found between different surgical procedures such as thyroidectomy, hemithyroidectomy, or Dunhill procedure. Further, no significant differences in QoL were found in EQ-5D questionnaire compared to normal population. Thyroid surgery can be done safely and without impairment of life quality, regardless of the extent of the operation.

A Reasonable Amount of Preserved Thyroid Tissue in Thyroidectomy for Multi-nodular Nodular Goiter

Objective: The Dunhill procedure gave us an idea to develop a more objective way to preserve thyroid remnant when performing subtotal lobectomy. We want to study whether a modified ”Dunhill procedure” can decrease the recurrence rate and not increase the complication rate when we perform the procedure for treatment of multiple nodular goiter. Methods: 269 patients took part in this study. 266 patients had bilateral multiple nodular goiter and 3 patients had bilateral multiple nodular goiter combined with a cyst. One hundred and thirty five (135) patients in group A were operated on with a modified ”Dunhill procedure”. One hundred and thirty four (134) patients in group B were operated on by bilateral subtotal thyroidectomy with 3-4gm of thyroid remnant on each side. Results: Recurrent nodular goiter occurred in 1 case in group A and 8 cases in group B. The difference was statistically significant (p=0.016) between the two groups. No recurrent laryngeal nerve injury occurred in group A or B intraoperatively. Transient cord palsy was found in 5 patients each in groups A and B. The incidence of temporary nerve palsy was identical (almost identical) in both groups. No patient needed calcium supplement 6 months after surgery. The numbers of patients who needed thyroxine during the follow-up period or still took thyroxine at the last follow up between the two groups were not significantly different. Conclusion: We conclude that our modified ”Dunhill procedure” could be a considerable method in the treatment of multiple nodular goiter from the viewpoint of a decreased recurrence and without increased hypothyroidism or other complications.

Surgical treatment of thyrotoxicosis: a local institution's perspective

Objective: The most optimal form of thyroidectomy for thyrotoxicosis is controversial. Geographical factor, possibly due to the difference in iodine intake, can profoundly influence the therapy outcomes. The results of different forms of thyroidectomy in a local hospital for thyrotoxicosis is presented. Their pros and cons were evaluated.Methods: From January 1995 to December 2001, 69 patients with toxic goitres treated surgically were retrospectively studied. The factors potentially affecting the postoperative thyroid function were also analysed.Results: The mean follow‐up duration was 22.6 ± 17.2 months. The incidence of permanent vocal cord palsy and hypoparathyroidism were 0 and 2.9%, respectively. Remission, hypothyroidism, and recurrent hyperthyroidism occurred in 39, 52.5 and 8.5% respectively, of patients who have undergone either subtotal thyrodiectomy or Dunhill procedure (hemithyroidectomy plus contralateral subtotal lobectomy). Only the size of the remnant was found to be a significant factor of postoperative hypothyroidism (P = 0.048).Conclusion: Subtotal thyroidectomy or Dunhill procedure are efficacious in treating thyrotoxicosis with acceptable incidence of operative complications and recurrent hyperthyroidism. A significant portion of patients were rendered euthyroid without the need of thyroxine replacement.

Frühoperation als Behandlungsmaßnahme der thyreotoxischen Krise

Thyroid storm is a rare disease, occurring in less than 1% of all thyrotoxicoses. Diagnosis and therapy still have serious problems. We review 14 patients who were operated on between 1992 and 1999 because of thyroid storm. All of the ten women and four men, aged 27 to 77 years, had an underlying thyroid disease. Autonomies were found in seven, Grave's disease in four, and a nodular goiter in three patients. The precipitating events were in five patients an antiarrhythmic therapy with amiodarone, on three occasions application of contrast medium, two times omission of antithyroid drugs and in one patient severe hyperglycemia with acidosis. In three patients no triggering factor was discovered. All patients were treated with high-dose antithyroid therapy. On admission, four patients were graded as stage-one thyroid crisis, three patients had stage-two and seven patients stage-three disease. All patients were operated on within 18 h of admission. Surgical procedure was in seven cases a bilateral subtotal resection, four times thyroidectomy, and in three patients a Dunhill procedure. After the operation, 12 patients improved rapidly. Two 77 and 74-year-old women died 1 or 2 days after the operation, respectively, one from heart failure and the other from multiple organ failure. Both had been diagnosed as thyrotoxic crisis stage three. Early operation should be adopted as a standard option in thyroid storm that cannot be controlled medically. Best results are achieved if the operation is done at stage one or two of the disease.