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 thyroidectomy was performed in Baghdad circa 500 BC, but it was not until Emile Theodor Kocher refined his operative technique in the nineteenth century that it became accepted as a mainstream operative procedure. Due to the intricate relationship of numerous important functional structures in the neck, thyroidectomy was still fraught with life altering, and sometimes life threatening, complications. Despite this, surgical intervention for thyroid disease remains as one of the pillars of treatment with 80,000 thyroidectomies being performed in the United States annually . We reviewed the surgical anatomy of the thyroid gland along with its relations to the parathyroid glands, recurrent and external laryngeal nerves in a prior chapter in this book. Anatomic variations were discussed as well as tips and tricks to identify these important structures at the time of surgery. The indications for thyroidectomy together with the necessary pre- operative assessment including history, examination, thyroid function tests, ultrasound and fine needle aspiration cytology will be reviewed. The role of Computerised Tomography scan, radionucleotide scanning and Magnetic Resonance Imaging will be mentioned. Traditional thyroid surgery involved the use of cold steel. In this era, bleeding was a major concern as the vessels are numerous and thin walled and they may retract to make control difficult. With the introduction of monopolar and bipolar diathermy operative time has decreased. Operative time and blood loss are even shorter now with the use of ultrasonic dissectors . Other tools including nerve stimulators will be discussed and the data analysed. Recent advances in surgical equipment has fostered an evolution of the traditional thyroidectomy technique using sub-platysmal flaps. Considering that cosmesis remains one of the main indications for this operation, we have witnessed the introduction of video assisted thyroidectomy and robotic thyroidectomy. These minimally invasive techniques are explored, including their cost-benefit ratios and learning curves. We also discuss modifications of the traditional open technique including the retrograde sub-capsular approach that facilitates preservation of the external branch of the superior laryngeal nerve when removing large bulky glands. We also strive to discuss means to prevent complications, treat them and look at the long term outcomes.Thyroidectomy: Surgical Procedures, Potential Complications and Post-Operative Outcomes, 1 edited by Kimberly Rodolfo, 08/2014: chapter 5: pages 61-90; , ISBN: 978-1-63321-440-8
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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