Thyroidectomy For Graves Research Articles

Change of surgical strategy for Graves' disease from subtotal thyroidectomy to total thyroidectomy: a single institutional experience.

The extent of thyroidectomy in Graves' disease remains controversial. In our institution, long-term euthyroidism without thyroxin replacement therapy has been the aim, and it has long been the standard surgical procedure used to treat Graves' disease in many institutions, including our hospital. Based our several clinical studies, it was concluded that subtotal thyroidectomy is not suitable as a standard surgical procedure for the treatment of Graves' disease. In 2009, the surgical strategy for Graves' disease was changed from subtotal thyroidectomy to total thyroidectomy in our hospital. In this study, how surgical complications have changed after this modification was examined. The subjects were 1,476 patients with Graves' disease treated by thyroidectomy between 2006 and 2014. There were 1,119 females and 357 males with a median age of 39 years. A total of 660 patients underwent bilateral subtotal thyroidectomy (ST group), and 816 patients underwent total thyroidectomy (TT group). Both transient hypocalcemia and prolonged hypocalcemia were observed significantly more frequently in the TT group than in the ST group (p < 0.001). Total thyroidectomy was identified as risk factors for prolonged hypocalcemia on multivariate analysis. In conclusion, total thyroidectomy is a reliable and effective therapy for controlling hyperthyroidism in terms of controlling of hyperthyroidism. However, it should be noted that total thyroidectomy resulted in increased rate of prolonged hypocalcemia. Surgeons should try to reduce the surgical complication rate as much as possible.

Comparison of Intra-Operative Vital Sign Changes during Total Thyroidectomy in Patients with Controlled and Uncontrolled Graves' Disease.

Thyroid storm (TS) is a life-threatening emergency endocrine condition. Thyroid hormones should be normalized before thyroidectomy is performed in patients with Graves’ disease. However, thyroid hormone levels are inevitably high in patients undergoing surgery. This study analyzed differences in vital sign changes during thyroidectomy between patients with controlled and uncontrolled Graves’ disease and assessed thyroid hormone cutoffs for TS. Preoperative levels of the thyroid hormones free T4 (FT4), T3, and thyroid stimulating hormone (TSH) were retrospectively analyzed in patients who underwent total thyroidectomy for Graves’ disease. Patients were divided into those with uncontrolled Graves’ (UG) disease, defined as preoperative TSH <0.3 µIU/mL and FT4 >1.7 ng/dL, those with controlled Graves’ (CG) disease, those with extremely uncontrolled Graves’ (EUG) disease, defined as TSH <0.3 µIU/mL and FT4 >3.4 ng/dL, and finally, those without EUG (non-EUG). The 29 patients with Graves’ disease included 12 with CG group and 17 with UG. FT4 and T3 concentrations were significantly higher in the UG group. There were no differences in vital sign and anesthetic agent. These 29 patients could also be divided into those with (n = 4) and without EUG (n = 25). The mean age was lower (21.5 vs. 40.9 years, p < 0.001) and the mean operation time was shorter (121.4 vs. 208.8 min, p = 0.003) in the EUG group. Requirements for anesthetic agents were greater in the EUG group. Mean FT4 concentration in the EUG group was 3.8 ng/dL, and there were no changes in vital signs during surgery. Vital sign change during thyroid surgery was not observed in patients with uncontrolled Graves’ disease up to the twice upper normal limit of T4 level.

To admit or not to admit? Experience with outpatient thyroidectomy for Graves’ disease in a high-volume tertiary care center

BackgroundOutpatient 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. MethodsThe 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. ResultsMean 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%. ConclusionsOutpatient total thyroidectomy is safe and effective with acceptable morbidity in the Graves' patient.

Unmasking of Neuropsychiatric Manifestations after Total Thyroidectomy for Graves' Disease.

Unmasking of Neuropsychiatric Manifestations after Total Thyroidectomy for Graves' Disease.

Measurement of serum parathyroid hormone during the early postoperative period as a predictor of clinical hypocalcaemia

Aim – to assess the risk of postoperative hypoparathyroidism and hypocalcaemia depending on the parathyroid hormone (PTH) blood levels in the early postoperative period in patients underwent thyroid surgery of different volume. Materials and methods. The results of serum PTH and ionized calcium (Ca++) levels in 305 patients operated on thyroid gland were analyzed. They included: thyroidectomy for Graves' disease (76 patients), hemithyroidectomy for nodular goiter (12 patients), hemithyroidectomy with lymphadenectomy for suspected cancer (19 patients), thyroidectomy for multinodular goiter (24 patients), thyroidectomy with lymphadenectomy for multinodular goiter, suspected or proven thyroid cancer (174 patients). According to the degree of clinical manifestations of hypocalcaemia, patients were divided into 4 groups: 1 – absence of obvious clinical manifestations, 184 (60.33%), 2 – mild form, 62 (20.33%), 3 – medium severity, 36 (11.8%), 4 – severe form, 23 (7.54%). Results and Discussion. The increase in the degree of clinical manifestations of hypocalcaemia correlated with the decrease in mean level of PTH and Ca++ in serum. Thus, patients of group 1 (184) had an average PTH level of 25.86 pg/ml (range: 14.23 – 51.39 pg/ml), and the mean level of Ca++ blood was 1.16 mmol/l (1.0 – 1.26 mmol/l). Patients of 2 group demonstrated the average level of PTH 12.92 pg/ml (8.12 – 16.36 pg/ml), and the average level of Ca++ 0.98 mmol/l (0.92 – 1.05 mmol/l). Patients of 3 group had average PTH levels of 7.67 pg/ml (4.54 – 11.19 pg/ml), Ca++ 0.84 mmol/l (0.78 – 0.97 mmol/l); and patients with severe form – PTH 3.42 pg/ml (0.2 – 6.38 pg/ml), Ca++ 0.68 mmol/l (0.62 – 0.83 mmol/l). The mean blood levels of PTH and Са++ decrease depending on the degree of clinical manifestations of hypocalcaemia. With an increase in the volume of surgical intervention, the number of cases of iatrogenic hypoparathyroidism and hypocalcaemia increased: hemithyroidectomy with lymphadenectomy resulted with hypocalcaemia in 4 patients (21.05%), thyroidectomy for multinodular goiter – in 8 (33.3%), thyroidectomy with lymphadenectomy – in 73 (41.95%), and thyroidectomy for Graves' disease – in 36 cases (47.36%). All patients of group 1 (184 patients) who had no clinical manifestations of hypoparathyroidism demonstrated PTH at lower border of normal figures (14.23 pg/ml and higher), and were candidates for safe early discharge from the hospital (2-3 day). Conclusions. Measurement of PTH level in the early postoperative period helps to identify patients with a high risk of postoperative hypoparathyroidism. The more than 15 pg/ml level of PTH in such patients allows to exclude the development of hypocalcaemia and shorten the patient's stay in the hospital, contributes to safe discharge.

TSH-Receptor Antibodies Decline with a Half-Life of Several Months after Thyroidectomy For Graves’ Disease

Clinical ThyroidologyVol. 28, No. 1 SummariesTSH-Receptor Antibodies Decline with a Half-Life of Several Months after Thyroidectomy For Graves’ DiseaseJerome M. HershmanJerome M. HershmanSearch for more papers by this authorPublished Online:15 Jan 2016https://doi.org/10.1089/ct.2016;28.16-17AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"TSH-Receptor Antibodies Decline with a Half-Life of Several Months after Thyroidectomy For Graves’ Disease." Clinical Thyroidology, 28(1), pp. 16–17FiguresReferencesRelatedDetails Volume 28Issue 1Jan 2016 InformationCopyright 2016 American Thyroid Association, Inc.To cite this article:Jerome M. Hershman.TSH-Receptor Antibodies Decline with a Half-Life of Several Months after Thyroidectomy For Graves’ Disease.Clinical Thyroidology.Jan 2016.16-17.http://doi.org/10.1089/ct.2016;28.16-17Published in Volume: 28 Issue 1: January 15, 2016PDF download

Clinical Indicators of Surgical Thyroidectomy in Graves’ Disease

ABSTRACT Pathognomonic clinical triad of Graves’ disease are diffusely enlarged goiter, exophthalmos, and acropachy. Thyroidectomy appears to be ideal treatment for this condition in comparison to radioiodine. How to cite this article Bhargav PRK. Clinical Indicators of Surgical Thyroidectomy in Graves’ Disease. World J Endoc Surg 2016;8(3):220.

バセドウ病に対する内視鏡補助下甲状腺全摘術

バセドウ病に対する内視鏡補助下甲状腺全摘術

Comparative Effectiveness of Replacement Therapy with L-thyroxine in Women with Postoperative and Autoimmune Hypothyroidism

Objective. To compare the lipid profile, psychoemotional features, cognitive function, quality of life in women receiving adequate replacement therapy with levothyroxine for postoperative hypothyroidism and autoimmune (Hashimoto's) hypothyroidism.Methods. 121 women (18-45 y.o.) with primary hypothyroidism receiving levothyroxine for more than one year participated in the study. 66 women with autoimmune hypothyroidism, 55 - with hypothyroidism after subtotal thyroidectomy for Graves' disease. The scores for the Short-Form 36, Hospital Anxiety and Depression Scale, symptoms of hypothyroidism, Inventory of memory and attention, TSH, free T3, free T4 and lipid profiles were analyzed. Results. There were no significant differences between groups in the age, BMI, TSH, fT3, fT4 levels. The total cholesterol was higher in patients with postoperative hypothyroidism in comparison to autoimmune hypothyroidism ( р = 0,041). The levels of social functioning and mental health that reflect mental component of health were lower in patients with autoimmune hypothyroidism than with postoperative hypothyroidism ( p = 0,038, p = 0,019, respectively). The anxiety was higher in the same group ( p = 0,004). There was no difference in memory and attention levels. The anxiety level was higher in autoimmune hypothyroidism and “low-normal” TSH (0,4 - 2 µU/L) than in postoperative hypothyroidism and the same TSH ( p = 0,016). Also in the group with postoperative hypothyroidism and “low-normal” TSH the cholesterol and prevalence of hypercholesterolemia were higher than in autoimmune hypothyroidism ( p = 0,017; р = 0,013). Conclusion. In young women with compensated autoimmune hypothyroidism the mental component of health is lower and the anxiety - higher than in postoperative hypothyroidism. Even in stable compensation of postoperative hypothyroidism the cholesterol level is higher comparing to the patients with autoimmune thyroiditis. And even in “low-normal” TSH level in this group the prevalence of hypercholesterolemia is 47%.

Thyroidectomy for Graves' Disease: A Feasibility Study of the Robotic Transaxillary Approach

Introduction: Graves' disease (GD) is considered a relative contraindication for endoscopic approaches to the thyroid gland, due to a larger gland size and increased vascularity. Methods: A retrospective analysis of a single surgeon's experience was performed. We included all patients who underwent thyroidectomy for the treatment of GD over a 3-year period. Results: Twenty-five patients with GD were identified. Twelve of them underwent robotic thyroidectomy and 13 patients underwent conventional thyroidectomy. Age, gender, and BMI were similar in both groups (p > 0.05). The conventional approach allowed for resection of larger thyroid volumes (147.3 ± 153.6 ml), as compared to the robotic approach (62.3 ± 47.8 ml, p = 0.08). The average total operative times were similar in both groups (p = 0.98). There was no difference with respect to intraoperative blood loss (p = 0.49), duration of hospital stay (p = 0.38), and complication rates (p = 0.99). Conclusion: Robotic thyroidectomy is feasible and can be safely performed in appropriately selected patients with GD.

Carcinomas in the remnant thyroid after thyroidectomy for Graves' disease: report of a case

Title Carcinomas in the remnant thyroid after thyroidectomy for Graves' disease: report of a case Author(s) Yamanouchi, Kosho; Minami, Shigeki; Hayashida, Naomi; Sakimura, Chika; Hayashi, Tomayoshi; Kinoshita, Naoe; Ueki, Ikuko; Kuroki, Tamotsu; Eguchi, Susumu Citation Acta medica Nagasakiensia, 58(2), pp.63-66; 2013 Issue Date 2013-08 URL http://hdl.handle.net/10069/33824 Right NAOSITE: Nagasaki University's Academic Output SITE

Erratum to: Thyroxine vs thyroxine plus triiodothyronine in treatment of hypothyroidism after thyroidectomy for Graves’ disease

Erratum to: Thyroxine vs thyroxine plus triiodothyronine in treatment of hypothyroidism after thyroidectomy for Graves’ disease

Odd thyroid function tests results: interference versus non-compliance

Despite the advent modern immunoassays, particularly with regards to TSH measurements, clinicians still encounter seemingly inexplicable results of thyroid function tests, for instance raised concentrations of free hormones (free T4 and/or free T3) in the setting of high, or at least not suppressed TSH concentrations. Though cases of TSH-oma or thyroid hormone resistance do exist, they are in fact rare, while some “strange” thyroid function tests results can be commonly explained either by a laboratory error or patient’s non-compliance with L-thyroxine treatment. In the latter case, a patient might deny any compliance problems, while a combination of raised TSH accompanied by an increased free T4 (±free T3) concentration is typically observed. This is usually a result of taking some extra doses of L-thyroxine prior to blood test, in order to catch up for previously missed doses. Confirmation of non-compliance is essential, as it avoids the need for lengthy and costly investigations in order to rule out malabsorption problems, assay interference or genuine cases of thyroid hormone resistance/TSH-oma. There are some strategies that help to demonstrate non-compliance, such as monitoring of thyroid function tests after controlled administration of high dose of L-thyroxine. An example of a case of a non-compliant hypothyroid patient after thyroidectomy for Graves’ disease will be presented, as well as a strategy that helped to elucidate this problem. I will also present the data on the efficacy of once weekly L-thyroxine administration in comparison to daily L-thyroxine administration protocol. Such approach might be sometimes applied in order to deal with some cases of persistent non-compliance with L-thyroxine treatment. Nevertheless, there are cases where abnormal results of thyroid function tests persist, even though patient’s non-compliance has been ruled out. In such cases, assay interference, typically caused by the presence of heterophilic antibodies, must be suspected. These antibodies, usually directed against rodent antigens, are actually quite common, but most modern assays contain blocking antibodies that eliminate this problem in the majority of cases. If, however, the titre of such antibodies is extremely high, this may lead to abnormal test result. It should be mentioned that heterophilic antibody interference is not limited to results of thyroid function tests, but it may affect all other hormonal assays that involve the use of antibodies (e.g. sex steroid assays, etc) as well as other assays, for instance measurements of cardiac troponins. The likelihood of presence of high titre of heterophilic antibodies is increased in the setting of an augmented propensity for generation of autoantibodies, particularly in cases of coexistent rheumatoid disorders (such as rheumatoid arthritis). In cases of suspected assay interference, a clinician must decide in the first instance, whether obtained results fit the clinical picture. I shall endeavour to present a case of suspected heterophilic antibodies interference and I will also describe strategies to deal with such problems. The last, but not least I will also mention recently described cases of assay interference caused by the presence of macro-TSH particles, that may result in abnormal TSH measurements in a manner similar to macroprolactin.

Author's reply: Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up (Br J Surg 2012; 99: 515–522)

Author's reply: Randomized clinical trial of bilateral subtotal thyroidectomy <i>versus</i> total thyroidectomy for Graves' disease with a 5-year follow-up (<i>Br J Surg</i> 2012; 99: 515–522)

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up (Br J Surg 2012; 99: 515–522)

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up (Br J Surg 2012; 99: 515–522)

Takotsubo cardiomyopathy complicating thyroidectomy for Graves’ disease.

Takotsubo cardiomyopathy complicating thyroidectomy for Graves’ disease.

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up (Br J Surg 2012; 99: 515–522)

Randomized clinical trial of bilateral subtotal thyroidectomy <i>versus</i> total thyroidectomy for Graves' disease with a 5-year follow-up (<i>Br J Surg</i> 2012; 99: 515–522)

Changes in the thyroid function of Graves’ disease patients treated by subtotal thyroidectomy

The extent of thyroidectomy in Graves' disease is still a matter of controversy. Subtotal thyroidectomy has been used as the standard surgical procedure for Graves' disease in Japan, but high hyperthyroidism relapse rates have been reported. We retrospectively studied serial changes in the thyroid function Graves' disease patients after they had been treated by subtotal thyroidectomy and assessed whether subtotal thyroidectomy should be recommended as the standard surgical procedure for the treatment of Graves' disease. The subjects were 478 Graves' disease patients who underwent subtotal thyroidectomy at our institution between 1994 and 1997 and were followed up on a regular basis, and their thyroid function 2-3 years after surgery (the early period) and 8-10 years after surgery (the late period) was evaluated and compared. The evaluations in the late period showed that 57% of the euthyroid patients in the early period remained euthyroid, 30% had developed a relapse of hyperthyroidism, and 13 % had become hypothyroid. Approximately 80% of the patients who were overtly hyperthyroid or overtly hypothyroid in the early period remained so in the late period. During the entire periods 47 patients had subclinical hyperthyroidism and were followed up without any postoperative medication. Twenty (42.6%) of them developed overt hyperthyroidism, 11 (23.4%) experienced a spontaneous remission, and 16 (34%) continued to be subclinically hyperthyroid. Because thyroid function after subtotal thyroidectomy is unstable and reduces quality of life, subtotal thyroidectomy is concluded not to be suitable as a standard surgical procedure for the treatment of Graves' disease.

Initial experience using robot- assisted transaxillary thyroidectomy for Graves’ disease

Graves' disease is the most common form of hyperthyroidism and surgery to remove the thyroid gland is a common treatment option for many of these patients. Interestingly, due to the enlarged gland size, their high vascularity, and the difficulty to control bleeding, many authors feel that Graves' disease remains a contraindication to current endoscopic techniques. We hypothesize that performing robotic subtotal thyroidectomy in Graves' disease settings could overcome the limitations of conventional endoscopic surgeries in the surgical management of this challenging thyroid disease. Prospective study in an academic hospital. Sixty-seven patients had robotic transaxillary thyroidectomy within a year. Of these, five cases (7%) were done for Graves' disease. There were three females and two males (mean age, 36 years). There were no conversions to laparoscopic or open surgery. The mean (SD) thyroid volume was 16.6 (3.2) ml. The mean (SD) operative time was 159 (17.8)min and docking time was 81 (20)min. Mean blood loss was 18 mL. All patients were discharged home in 24h. There were no perioperative or postoperative complications. There was no evidence of postoperative vocal cord palsy or paresis. We showed that robotic transaxillary thyroidectomy is feasible and can be safe and effective in patients with Graves' disease. To our knowledge, this is the first article describing this approach for Graves' disease. These findings, however, warrant additional investigation within future prospective clinical trials.

Changing trend in surgical indication and management for Graves' disease

Background Although thyroidectomy for Graves' disease (GD) is well established, surgical indications remain less well defined. This study aimed to evaluate the changes in surgical indication, type of resection, and surgical outcomes at a single institution. Methods A total of 346 patients who underwent thyroidectomy for GD were divided into 2 time periods: period 1 (1995–2001) and period 2 (2002–2008). Their surgical indication, type of resection, and surgical outcomes were compared. Results Patients in the earlier period were significantly younger, suffered more previous relapses, and were on a longer duration of antithyroid drugs before surgery. Graves' ophthalmopathy and refusal for radioactive iodine were the indications that changed significantly between the 2 periods. Total/near-total thyroidectomy was performed more commonly and resulted in a higher temporary hypoparathyroidism rate in the latter period ( P < .001). Conclusions Over the study period, significant changes in surgical indication, type of resection, and surgical outcomes were noted. Graves' ophthalmopathy became one of the most common surgical indications. Total thyroidectomy became the preferred surgery but that resulted in a higher temporary hypoparathyroidism rate.