Total thyroidectomy for Graves’ disease: Compliance with American Thyroid Association guidelines may not always be necessary

Abstract

Background Total thyroidectomy (TT) is the preferred surgical approach to Graves' disease (GD). Current American Thyroid Association (ATA) guidelines call for administration of potassium iodide (KI) and achievement of euthyroid state before operation. Small numbers and a mixture of surgical approaches spanning several decades hinder previous surgical series. We present the outcomes for TT at a single high-volume center. Methods A retrospective cohort study was conducted on 165 patients undergoing TT for GD from 7/2007 to 5/2012. Results Mean age was 43 years (Range: 17-78), and 128 patients (78%) were female. 95% of patients were on methimazole or propylthiouracil, and 42% remained hyperthyroid at time of surgery. Only 3 (2%) patients received KI. Mean operative time was 132 minutes (Range 59-271). Mean gland size and blood loss were 41 grams (Range 8-180) and 55 mL (Range 10-1050), respectively. No patient developed thyroid storm. Median follow-up was 7.5 months. Temporary and permanent hypocalcemia developed in 51 (31%) and two patients (1.2%), respectively. Temporary and permanent recurrent laryngeal nerve paresis occurred in 12 (7%) and one (0.6%) patient, respectively. Sixty-one (37%) patients experienced at least one complication. On multivariate analysis, patient age less than 45 years (OR 2.93, 95% CI 1.39-6.19) and obesity (OR 2.11, 95% CI 1.00-4.43) were associated with occurrence of complications. Conclusion This high-volume surgeon experience demonstrates no appreciable detriment to patient outcomes when ATA recommendations for routine use of KI and euthyroid state before thyroidectomy are not met. Transient hypocalcemia and hoarseness are frequent complications of TT for GD resolving within six months in most patients. Age less than 45 years and obesity are risk factors for post-operative complications.

Impact of potassium iodide on thyroidectomy for Graves' disease: Implications for safety and operative difficulty

“…Even though defined slightly differently in the studies by Shinall and colleagues, their observed rates of transient hypoparathyroidism (27–31%) were comparable to the group of patients not prepared with KI (26%) in the current study and substantially higher than the rate in the group that did receive KI (7%). 16,17 These data suggest that the lack of a perceived benefit from KI administration in those studies is likely related to the limitations of the control groups rather than KI truly having no impact.…”

“…They concluded that pre-operative KI was not necessary. 16 In a separate study looking exclusively at patients with Graves’ disease, Shinall and colleagues 17 found that noncompliance with American Thyroid Association recommendations for the preoperative preparation of patients with Graves’ disease (which includes KI administration) was not associated with increased complications but their study cohort only included 3 patients who received KI preparation 17 . Even though defined slightly differently in the studies by Shinall and colleagues, their observed rates of transient hypoparathyroidism (27–31%) were comparable to the group of patients not prepared with KI (26%) in the current study and substantially higher than the rate in the group that did receive KI (7%).…”

“…16,17 Yet neither of these latter studies compared outcomes to a group of Graves’ patients prepared for surgery with KI. 16,17 Ultimately, the impact of KI on the ease and safety of total thyroidectomy for Graves’ disease remains largely unknown. Therefore, we aimed to quantify the difficulty of total thyroidectomy for Graves’ disease based upon preoperative preparation with KI.…”

Successful Pretreatment Using Plasma Exchange before Thyroidectomy in a Patient with Amiodarone-Induced Thyrotoxicosis

“…No perioperative complications were observed, however, in 3 other studies of thyroidectomy in AIT (although in 1 of these, 71% of the patients were prepared for surgery using iopanoic acid) [8,9,11] . A recent retrospective analysis of 165 Graves disease patients who were treated with total thyroidectomy did not show a difference in surgery-related morbidity or mortality between the group that reached euthyroidism and the patients who still had hyperthyroidism (42%) preoperatively [12] . Nonetheless, TPE has been proposed as a safe and effective procedure for restoring euthyroidism and preparing patients for thyroidectomy in Graves disease, toxic multinodular goiter, and hyperthyroidism related to iodine excess [13,14] .…”

Randomized trial of a short course of preoperative potassium iodide in patients undergoing thyroidectomy for Graves' disease

“…Small studies utilizing thyroid scans (3) or ultrasound (4,5) have demonstrated decreased thyroid blood flow and decreased blood loss (5) in Graves' disease patients treated with a short (7-10 days) course of Lugol's solution. Although an iodide preparation is often used, and is recommended by the ATA guidelines for this purpose, it is by no means a modern standard of care (6,7). Our surgical practice used SSKI sporadically for Graves' patients rendered euthyroid by modern medications, and uniformly performed either Total -or near TotalThyroidectomy for this condition.…”