Sequential defunctionalization followed by thyroxine supplementation as preoperative preparation of hyperthyroid patients undergoing thyroidectomy

Department II of General Surgery West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
Chinese medical journal (Impact Factor: 1.05). 11/2008; 121(20):2010-5.
Source: PubMed


Preparing hyperthyroid patients for thyroid surgery with a combination of antithyroid drugs and thyroxine has long been controversial because this combination usually results in only partial inhibition of thyroid function. We therefore used large doses of antithyroid drugs to completely inhibit the synthesis of thyroxine and render the thyroid gland defunctionalized. We then administered physiologic doses of thyroxine to inhibit thyroid-stimulating hormone secretion. We have named this treatment "sequential thyroid defunctionalization followed by thyroxine supplementation."
Four hundred and seventy-one hyperthyroid patients seen at our hospital were divided into experimental and control groups. The control group was treated preoperatively with antithyroid drugs and iodine preparation. The experimental group was further divided into four subgroups and treated with "sequential thyroid defunctionalization followed by thyroxine supplementation". Each of the four subgroups received different doses of antithyroid drugs and thyroxine for differing time periods. Thyroid function was assessed at each stage of treatment, as were operative blood loss volumes and postoperative complications.
Compared to the control group, the four experimental groups showed less thyroid congestion and surface varices at surgery. Patients in subgroup A also had thyroid glands that were almost histologically normal. The mean operative blood loss volume of the experimental group was less than that of the control group (326 +/- 163) ml in the control group; (196 +/- 57) ml in subgroup A; (230 +/- 71) ml in subgroup B; (240 +/- 80) ml in subgroup C; and (312 +/- 97) ml in subgroup D). The postoperative complication rate of the experimental group was 8.64% (21/243) whereas that of the control group was 17.54% (40/228).
Sequential thyroid defunctionalization followed by thyroxine supplementation is effective in reducing the bleeding volume and postoperative complication rate in selected hyperthyroid patients undergoing thyroidectomy.

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    • "Numerous factors contribute towards causing haemorragic complications, such as the technique used for haemostasis, the drainage, and the haemorragic risk factors presented by the individual patient including the hyperthyroidism causing thyroid congestion, tumescence, and increasing thyroid blood supply [12] [13]. "
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    ABSTRACT: Means to prevent and control intra- or postoperative bleeding remain a topic of utmost importance in thyroidectomy. In this randomised clinical trial, we used adrenaline spraying to see if it helps bleeding control and reduces drainage and hematoma formation after thyroidectomy. After total thyroidectomy, 1 mg/ml adrenaline solution in 10 ml saline was sprayed all over the operation area by a syringe in 40 patients of "Adrenaline (+) Group". In the other 40 patients in "Adrenaline (-) Group", only standart total thyroidectomy was performed. Drainage amounts of 24 hours were recorded. Among 80 patients, 66 (82.5%) were female and 14 (17.5%) were male. The daily drainage amounts of the Adrenaline (+) Group were found statistically significantly lower than the Adrenaline (-) Group (p<0.05). In both of the groups, thyroid volumes were significantly correlated with the drainage amounts. "p" values were 0.008 and <0.001 in Adrenaline (+) and Adrenaline (-) Groups, respectively. Preliminary experience using adrenaline has been encouraging and it is useful as an adjunct to thyroid surgery in order to prevent hemorrhagia and give up drain placement. But prospective randomized trials using adequate patient numbers are still needed to validate efficacy and safety.
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    ABSTRACT: Preoperative preparation of the hyperthyroid patient for thyroidectomy is imperative to avoid perioperative complications due to severe thyrotoxicosis. The mainstay of preparation is the administration of anti-thyroid drugs (ATD). When ATDs cause adverse reactions, an alternative regimen to prepare the patient for definitive management is crucial. We present the case of a 35-year-old Filipino female with Graves’ disease who developed methimazole-induced agranulocytosis. She refused to undergo radioactive iodine (RAI) therapy. She was admitted for thyroidectomy with elevated thyroid hormone levels. She was rapidly prepared for thyroidectomy using high-dose steroid, beta-adrenergic blocker, propylthiouracil (PTU) and Lugol’s solution. The patient’s free thyroxine level decreased after 8 days of treatment, without complications. She then underwent an uneventful subtotal thyroidectomy. In conditions with very limited options, although contraindicated, administration of another ATD may be the last alternative for patients who developed agranulocytosis.
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