Retrospective evaluation of subtotal and total thyroidectomy in Graves' disease with and without endocrine ophthalmopathy

Abstract

A retrospective analysis was performed in 173 consecutive patients with Graves' disease (GD) with the principal aim of evaluating the influences of subtotal (N = 157) and total (N = 19) thyroidectomy on postoperative recurrence rates, endocrine ophthalmopathy (EO) and thyrotropin receptor antibody (TSH-R-ab) titres. Postoperatively recurrent disease, identified by increased thyroid hormone levels, occurred in 32 patients (20%) who underwent subtotal resection. These recurrences were associated with over-representation of preoperative EO (p < 0.001) as well as high TSH-R-ab levels postoperatively (p < 0.05-0.01). Subtotal and total resections were followed by an aggravation of preoperative EO in nine (16%) and one (6%), and by a development of EO in two and none of the patients, respectively. Persistently elevated TSH-R-ab titers during thyrostatic therapy became close to normalized in seven (32%) and 15 (88%) of the patients undergoing subtotal or total thyroidectomies, respectively, which illustrates a thyroid tissue dependency of the autoantibody production. Among the total material of 173 patients, altogether 75 cases exhibited persistent or progressive EO and/or TSH-R-ab elevation after more than 1 year of preoperative thyrostatic treatment. In this group, recurrent GD or aggravated EO occurred in 23 (39%) of those operated with subtotal resection and in one (6%) of those undergoing total thyroidectomy (p < 0.05). The results thus indicate that EO, particularly at the time of surgery, and prevailing TSH-R-ab titers are associated with an increased risk of recurrent GD and suggest that patients exhibiting these characteristics should benefit from total rather than subtotal thyroidectomy.

Changes in Serum TSH Receptor Antibody (TRAb) Values in Patients with Graves' Disease after Total or Subtotal Thyroidectomy

“…They were significantly higher in the TT group than the ST group at 1, 3, 5, and 7 years after surgery, and the proportions were up to 70.4% at 6 months and 83.3% at 1 year. A relation between TRAb and endocrine opthalmopathy, and the probability of improving eye involvement by TT, were also reported by several authors [5,26,39]. As the number of patients who underwent TT for endocrine opthalmopathy was small (n = 22), we could not evaluate the influence of TT on opthalmopathy in this study.…”

“…The continuation of a high (elevated) TRAb value or an increased TRAb value after surgery may cause hyperthyroidism recurrence [3,4]. In addition, previous studies demonstrated that a high TRAb value is linked to endocrine opthalmopathy [5,6], or risk for intrauterine death, and fetal or neonatal hyperthyroidism in pregnant women with Graves' disease [7][8][9][10][11][12].…”

“…There are 2 surgical methods for Graves' disease: total thyroidectomy (TT) and subtotal thyroidectomy (ST). ST is usually chosen for Graves' disease therapy, but 5-15% of patients have recurrent thyrotoxicosis after surgery [1], which is more likely to occur in patients with high serum TRAb values before surgery [15] and severe eye involvement [5]; such patients should therefore undergo TT rather than ST [1]. Although the surgical outcomes and their relation to serum TRAb values have been demonstrated by several authors [3,4,[14][15][16][17][18][19][20][21][22][23][24], there have been only a few reports concerning the surgical outcome of TT for Graves' disease [5,[25][26][27].…”

Management of Graves' Ophthalmopathy: Reality and Perspectives

“…Eye disease worsened in 9 of 56 patients (16%) treated by subtotal thyroidectomy and 1 of 17 (6%) patients treated by total thyroidectomy, who had preoperative clinically evident ophthalmopathy, while new ophthalmopathy developed in 2 of 101 patients (2%) treated by subtotal thyroidectomy and 0 of 2 patients treated by total thyroidectomy (227). Thus, as a whole, progression of ophthalmopathy occurred in 12 patients (7%), more frequently among those who had clinically evident eye disease before surgery (227). No substantial effect on GO was observed by Miccoli et al (228) in 140 surgically treated Graves' patients, independently of the extent of thyroid resection.…”

“…Winsa et al (227) recently evaluated retrospectively a large series of 173 Graves' patients who underwent either subtotal (n ϭ 157) or total (n ϭ 19) thyroidectomy. Eye disease worsened in 9 of 56 patients (16%) treated by subtotal thyroidectomy and 1 of 17 (6%) patients treated by total thyroidectomy, who had preoperative clinically evident ophthalmopathy, while new ophthalmopathy developed in 2 of 101 patients (2%) treated by subtotal thyroidectomy and 0 of 2 patients treated by total thyroidectomy (227).…”