Surgical Treatment of Graves’ Disease: Evidence-Based Approach
ABSTRACT The optimal treatment of Graves disease (GD) is still controversial. Surgery is one treatment option along with radioactive iodine (RAI) and antithyroid medication. In this evidence-based review, we examine four issues: (1) Is surgery better than RAI or long-term antithyroid medication? (2) What is the recommended surgical approach? (3) How does the presence of Graves' ophthalmopathy (GO) influence the role of surgery? (4) What is the role of surgery in children with GD?
We conducted a systematic review of the literature using evidence-based criteria regarding these four issues.
(1) There are no recommendations reaching any grade of evidence for which treatment to choose for adults with GD. (2) Total thyroidectomy has complication rates equal to those seen with lesser resections but it has higher cure rates and negligible recurrence rates (Level I-IV data leading to a grade A recommendation). (3) Data support surgery when severe GO is present, but RAI combined with glucocorticoids may be equally safe (Level II-IV data, grade B recommendation). The extent of thyroid resection does not influence the outcome of GO (Level II data, grade B recommendation). (4) Based on the available data, definitive treatment can be advocated for children (Level IV data, grade C recommendation) using either RAI or surgery. No recommendation can be given as to whether RAI or surgery is preferred owing to the lack of studies addressing this issue. Increased cancer risk with RAI in children below the age of 5 years supports surgery in this setting (Level I data, grade A recommendation).
If surgery is considered for definitive management, evidence-based criteria support total thyroidectomy as the surgical technique of choice for GD. Available evidence also supports surgery in the presence of severe endocrine GO. Children with GD should be treated with an ablative strategy. Whether this is achieved by total thyroidectomy or RAI may still be debatable. Data on long-term cancer risk are missing or conflicting; and until RAI has proven harmless in children, we continue to recommend surgery in this group.
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ABSTRACT: The first reports of thyroid surgery can be traced back to the 12th century, when only crude operative methods and rudimentary anaesthetic techniques were available. Theodor Kocher revolutionized the thyroid- dectomy technique in 1877 by introducing meticulous dissection and better antisepsis techniques. In the 1890‟s William Halsted, Charles Mayo and George Crile popularized Kocher‟s techniques in the United States.Operative morbidity reduced further with technical refinements made by Thomas Dunhill who introduced capsular dissection in 1912 and Frank Lahey who popularized nerve preservation in 1938. By the late 20th century there were significant advances in pharma- cology, anaesthetic techniques and antisepsis. Coupled with refined operative techniques and meticulous dissection, thyroidectomy is now a safe operation with complication rates less than 1%. To ensure good outcomes, surgeons performing thyroidectomy must be acutely familiar with the anatomy, and common varations of the thyroid gland. In this chapter we review the gross anatomy of the gland, with special emphasis on the surgical importance of the structures encountered during a thyroidectomy. We discuss the anatomic basis of the operative techniques and the common variations that may be encountered when performing a thyroidectomy.Thyroidectomy: Surgical Procedures, Potential Complications and Post-Operative Outcomes, 1 edited by K Rodolfo, 08/2014: chapter 6: pages 91-116; , ISBN: 978-1-63321-440-8
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ABSTRACT: Graves' disease represents an autoimmune disease of the thyroid gland where surgery has an important role in its treatment. The aim of our paper was to analyze the results of surgical treatment, the frequency of microcarcinoma and carcinoma, as well as to compare surgical complications in relation to the various types of operations performed for Graves' disease. We analysed 1432 patients (221 male and 1211 female) who underwent surgery for Graves' disease at the Centre for Endocrine Surgery in Belgrade during 15 years (1996-2010). Average age was 34.8 years. Frequency of surgical complications within the groups was analyzed with nonparametric Fisher's test. Total thyroidectomy (TT) was performed in 974 (68%) patients, and Dunhill operation (D) in 221 (15.4). Carcinoma of thyroid gland was found in 146 patients (10.2%), of which 129 (9%) were a microcarcinoma. Complication rates were higher in the TT group, where there were 31 (3.2%) patients with permanent hypoparathyroidism, 9 (0.9%) patients with unilateral recurrent nerve paralysis and 10 (1.0%) patients with postoperative bleeding. Combined complications, such as permanent hypoparathyroidism with bleeding were more common in the D group where there were 2 patients (0,9%), while unilateral recurrent nerve paralysis with bleeding was more common in the TT group where there were 3 cases (0,3%). Frequency of complications were not significantly statistically different in relation to the type of surgical procedure. Total thyroidectomy represents a safe and efficient method for treating patients with Graves' disease, and it is not followed by a greater frequency of complications in relation to less extensive procedures.BMC Surgery 04/2015; 15(1):39. DOI:10.1186/s12893-015-0023-3 · 1.24 Impact Factor