Outcomes After Urgent Thyroidectomy Following Rapid Control of Thyrotoxicosis in Graves' Disease are Similar to Those After Elective Surgery in Well-Controlled Disease

World J Surg. 2019 Dec;43(12):3051-3058. doi: 10.1007/s00268-019-05125-5.

Abstract

Background: Surgery for Graves' disease (GD) is usually performed after adequate control with medical treatment. Occasionally, rapid pre-operative optimization is required. The primary objective was to compare the outcomes of patients undergoing elective surgery for well-controlled GD with those undergoing rapid pre-operative treatment. We also propose a formal treatment protocol for future use.

Methods: A retrospective cohort study in a tertiary referral centre included 247 patients with well-controlled GD undergoing elective surgery and 19 patients with poorly controlled disease undergoing surgery after rapid optimization. The latter group did not respond well to thionamides (carbimazole and/or propylthiouracil) or had intolerance or side effects to thionamides and were treated with a range of non-thionamide drugs, including Lugol's iodine, cholestyramine, beta blockers and steroids (with or without thionamides), and closely monitored for 1-2 weeks before surgery. Outcome measures included thyroid storm, hypoparathyroidism and recurrent laryngeal nerve palsy.

Results: In total, 266 patients with male-to-female ratio of 1:6 and median (interquartile range) age of 39 (31-51) were included. Overall, long-term recurrent laryngeal palsy and hypoparathyroidism occurred in 1 (0.38%) and 13 (4.9%) patients, respectively. No patient had thyroid storm. There was no significant difference in hypoparathyroidism (p = 1), vocal cord palsy (p = 0.803) and post-operative bleeding (p = 0.362), between elective surgery and rapid optimization groups.

Conclusion: Rapid pre-operative treatment is effective, safe and is associated with similar outcomes compared to usual treatment. A rapid pre-operative optimization protocol is proposed.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use
  • Adult
  • Antithyroid Agents / therapeutic use
  • Elective Surgical Procedures
  • Emergencies
  • Female
  • Graves Disease / surgery*
  • Humans
  • Hypoparathyroidism / etiology
  • Iodides
  • Male
  • Middle Aged
  • Postoperative Complications
  • Retrospective Studies
  • Thyroidectomy / adverse effects
  • Thyroidectomy / methods*
  • Thyrotoxicosis / drug therapy*
  • Treatment Outcome
  • Vocal Cord Paralysis / etiology
  • Young Adult

Substances

  • Adrenergic beta-Antagonists
  • Antithyroid Agents
  • Iodides
  • Lugol's solution