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Asian SURGICAL MANAGEMENT OF THYROTOXICOSIS Journal of Surgery ©Excerpta Medica Asia Ltd

Thyrotoxicosis — Surgical Management in the Era of Evidence-based Medicine: Experience in Western India with 752 Cases

S.K. Bhansali1 and H.B. Chandalia,2 1Department of Surgery and 2Department of Endocrinology, Jaslok Hospital and Research Centre, Mumbai, India.

The three modalities of treatment of thyrotoxicosis, antithyroid therapy (ATT), radio-iodine (I131) therapy and surgery are not cause-specific. In this paper, we describe our evolving experience with 752 thyrotoxic patients who underwent surgery during the last 40 years and discuss the current scenario with evidence-based data and observations wherever possible. Thyroidectomy was performed in 428 patients with Grave’s disease (GD), 299 patients with toxic multinodular , and 25 with toxic solitary nodules (TSN). Whereas 289 patients with GD had surgery for failed ATT, the other 139 had primary surgery for controversial or debatable indications such as poor socio-economic status, desire for early pregnancy, poor drug compliance and severe ophthalmopathy. Preoperatively, all patients were administered carbimazole or propylthiouracil. Non-selective β-blocker propranolol and Lugol’s iodine were routinely given. In the 25 patients with TSN, hemithyroidectomy was performed. In all others, subtotal thyroidectomy (STT), was performed leaving behind 4 to 8 g of thyroid tissue: a larger amount was left behind in those with higher antithyroid antibody titres. During the last decade, 80 patients received near total thyroidectomy (NTT), mainly to minimize recurrence of thyrotoxicosis and to ameliorate severe eye signs. Because of our increasing experience, no significant increase in postoperative morbidity was encountered with NTT compared to STT. Transient hoarseness was observed in 53 patients with STT and only in two patients with NTT. Three patients with STT and one with NTT developed permanent hoarseness due to recurrent laryngeal nerve palsy; voice in these four was normalized by intraglottic injection of Teflon paste 6 months after the operation. In patients undergoing STT, transient hypoparathyroidism was encountered in 63, and permanent hypoparathyroidism in five. The corresponding figures for NTT were 12 and one, respectively. Of the 500 patients monitoned for 1 year or more, was observed in 135 and recurrent thyrotoxicosis in nine. In the same group of 500, exophthalmos was ameliorated in 130 of the 265 with positive eye signs. Nineteen glands exhibited features of severe Hashitoxicosis with marked destruction of acini and considerable lymphoid aggregates and follicles. Carcinoma was observed in three other thyroid glands. (Asian J Surg 2002;25(4):291–9)

NTRODUCTION Address reprint request to Dr. Shirish K. Bhansali, I 81, Valentina, Naoroji Gamadia Road, Thyrotoxicosis is a clinical syndrome, the hallmark of Mumbai 400 026, India. which is accelerated metabolism. It is due to a group of Tel: [91 22] 364 1284 Fax: [91 22] 363 1106 diseases, the common ones being Grave’s disease (GD), E-mail: [email protected] toxic multinodular goitre (TMNG) and toxic solitary Date of acceptance: 30th June 2002 nodule (TSN). An autoimmune disorder, as yet ill-defined, is a common denominator of all these. The treatment of

Asian Journal of Surgery 291 BHANSALI AND CHANDALIA these patients, which aims to lower their thyroid hormone Of the 428 patients with GD, 250 had exophthalmos levels to normal, is, so far, not cause specific. None of the and/or other occular signs, whereas only 71 of the 324 three modalities of treatment, including antithyroid drugs, with nodular goitre had ophthalmopathy. Three patients radiotherapy with I131 or surgery, achieve a predictable had unilateral proptosis and two had asymmetrical and permanent euthyroid status. In this paper, we describe bilateral protrusion of the eye balls. and discuss our evolving experience of surgery with 752 Twenty-three patients had significant cardiac problems, thyrotoxic patients in Mumbai (Bombay), Western India, of which 14 had . Seven patients suffered and discuss current trends in the management of these from bronchial asthma. Six patients were undergoing patients. psychiatric treatment. Raised antithyroglobulin or antimicrosomal antibody titres were observed in 122 of PATIENTS AND METHODS the 200 patients for whom these were determined.

Seven hundred and fifty-two patients who had suffered MODALITY OF INITIAL THERAPY from thyrotoxicosis and underwent treatment during the period of September 1962 to August 2001 were studied. The following factors or criteria influenced initial For comparison and discussion of results, the patients therapy: were divided into two groups according to the period of (a) age; treatment: the first group was treated during 1962–1981, (b) reproductive status and potential (including, the pres- and the second group, during1982–2001. Various aspects ence or absence of pregnancy, and the desire for early of data are described. Wherever required, data have been pregnancy); analyzed by calculating the “Standard Error of Difference (c) morphology of the thyroid gland; (SED)” between the two groups. (d) severity of thyrotoxicosis; (e) displacement and/or compression of the trachea, if Demographic data any, and a possible dry cough due to tracheal irritation; (f) mediastinal extension, if any (especially in those with Patients with GD (with or without thyromegaly) polynodular goitre); outnumbered those with toxic nodular goitre (Table 1). (g) cardiac and other medical problems; There was a preponderance of young patients in the third, (h) degree of ophthalmopathy; fourth and fifth decades of life, with a female to male ratio (i) socioeconomic status, especially given the costly of approximately 5:1. Eleven patients were pregnant at antithyroid drug therapy with a potential of 40% to the time of presentation. 50% recurrence;

Table 1. Age and goitre by morphology in 752 patients

Morphology

Age (years) Grave’s disease Nodular goitre Total

No significant goitre Diffuse goitre Multinodular goitre Solitary nodule

10–19 1 22 27 1 51 20–29 3 101 49 1 154 30–39 8 123 121 7 259 40–49 13 106 50 7 176 50–59 8 35 26 7 76 60–69 1 6 21 1 29 ≥ 70 0 1 5 1 7 Total 34 394 299 25 752

292 Vol 25 • No 4 • October 2002 SURGICAL MANAGEMENT OF THYROTOXICOSIS

(j) psychological make-up; the operation to all patients to reduce vascularity and (k) predicted compliance to treatment; and friability of the gland. (l) patient’s preference to any particular modality of therapy. INTRAOPERATIVE CONSIDERATIONS Surgery as the initial treatment was performed in 454 patients, as follows: For the uncommon STN, a hemithyroidectomy was (1) 299 patients with TMNG; performed. In patients with GD with a solitary nodule (2) 25 patients with TSN (elderly patients with a solitary ‘cold’ (hypointense) on isotope scan, a subtotal (STT) or nodule, and without tracheal displacement and/or near total thyroidectomy (NTT) was the procedure of compression and without cosmetic disfigurement were choice. In all patients with GD (with or without treated with I131 after carcinoma was excluded by fine thyromegaly) and in all patients with TMNG, STT was needle aspiration cytology); performed, leaving behind a remnant of about 4–8 g of (3) 139 with GD in whom one or more of the following thyroid tissue. If the patient had a high preoperative titre factors were present (many of these are, to an extent, of antithyroglobulin/antimicrosomal antibodies, an debatable indications for primary surgery); additional 2 to 3 g of thyroid tissue was preserved. (a) desire for early pregnancy (if antithyroid therapy is However, during the last decade, 80 patients underwent the selected modality of therapy, it is continued for NTT leaving behind only 1–2 g of thyroid tissue (or the 12–18 months and pregnancy should be delayed Dunhill procedure of total lobectomy on one side and for at least 2–3 years from the start of the therapy near total lobectomy on the opposite side), as the operation to prevent recurrence); of choice. (b) very young children below the age of 15 years; The external laryngeal branch (ELN) of the superior (c) poor socio-economic status; laryngeal nerve (SLN) was demonstrated (in the majority (d) severe ophthalmopathy; of patients) by entering the avascular space of Reeve’s (e) cosmetically unacceptable goitre; medial to the upper pole of the gland, which was (f) pregnancy, especially the first trimester (surgery is then retracted laterally. Ligation and division of the the best expedient in these); individual branches of superior thyroid artery and the (g) psychological aberration, leading to poor drug corresponding veins further safeguarded the ELN from compliance; and damage. (h) patient’s insistence for surgery. The trunk of the inferior thyroid artery was ligated in Surgery as a secondary treatment was performed in continuity well lateral to the thyroid gland. The recurrent 298 patients with GD (of whom 291 had relapsed after laryngeal nerve (RLN) was identified in more than 80% of or during antithyroid drug therapy; four were resistant the cases. The branches of inferior thyroid artery were to these and three were allergic to the thiourea drug then ligated and divided close to the gland. The identified group). nerve was followed until its entry into the larynx, without lifting it from its bed. This entry point was usually within PREOPERATIVE REGIMEN 3 mm of the ligament of Berry. The dissection of the thyroid gland was kept close All patients were administered an antithyroid drug to the glandular capsule to minimize damage to the (carbimazole 10 mg t.i.d. or q.i.d. or propylthiouracil parathyroid glands. In the early years, the thyroid 500 mg t.i.d.). Since 1970, the non-selective β-blocker gland was resected after clamping with straight, fine propranolol was also administered (for rapid control of haemostasis. But during the last 10 years, these clamps autonomic manifestations). One to two weeks of this have been substituted with pre-resection haemostatic therapy was deemed adequate for patients with mild to sutures of an absorbable material. One of the parathyroid moderate thyrotoxicosis but in those with severe disease, glands was excised accidentally in 11 patients. The

T3, T4, thyroid stimulating hormore (TSH) and recent free glands were sliced into eight to 10 parts, which thyroxine levels were assessed serially to ensure the were implanted into the sternomastoid muscle (after restoration of euthyroid status prior to surgery. Lugol’s histological verification on a frozen section of one of iodine (10 drops per day) was given for 1 week prior to the slices).

Asian Journal of Surgery 293 BHANSALI AND CHANDALIA

POSTOPERATIVE MANAGEMENT intravenous glucose. One patient with a progressive neck haematoma required re-exploration. For comparison, Serum calcium levels were determined 2, 5 and 15 the patients were divided into two groups, one group days and 3 months after surgery; the schedule was treated during 1962–1981 and the other during 1982– modified if a patient exhibited hypoparathyroidism. T3, 2001. Tables 2 and 3 summarize recurrent nerve paresis T4 and TSH were determined 2 months, 6 months and and hypoparathyroidism, both transient and permanent, 1 year after surgery unless the patient developed hy- in relation to to the type of thyroidectomy (hemithy- pothyroidism earlier than this time frame. roidectomy, STT and NTT) and to the period of treatment. The three patients requiring semi-emergency surgery Transient RLN paresis recovered completely in 4 to were administered corticosteroids, β-blockers and Lugol’s 16 weeks. In three of the four patients with permanent iodine postoperatively to prevent . unilateral RLN palsy, the quality of voice was normalized by intraglottic injection of Teflon paste (Ethicon, RESULTS Edinburgh, Scotland) 4 to 6 months after surgery (waiting for at least 4 months was deemed mandatory, as recovery There was no mortality in the series. Two patients from neuropraxia usually occurs by the fourth month). developed postoperative thyroid crises, which were Two patients had mild, but permanent, voice change successfully treated with β-blockers, steroids, iodine and without RLN palsy. This voice change may have been

Table 2. Recurrent nerve palsy

Recurrent nerve palsy (no. of cases)

Break-up by period

Total no. of cases 1962–1981 1982–2001 Total

Operation 1962–1981 1982–2001 Transient Permanent Transient Permanent Transient Permanent

HT 14 11 0 0 0 0 0 0 STT 380 267 31* 2** 22* 1** 53 3 NTT 0 80 – – 2 1 2 1 Total 394 358 31 1 24 2 55 4

* SED 2.19 (not significant). ** SED 0.51 (not significant). HT = hemithyroidectomy; STT = subtotal thyroidectomy; NTT = near total thyroidectomy.

Table 3. Hypoparathyroidism

Hypoparathyroidism (no. of cases)

Break-up by period

Total no. of cases 1962–1981 1982–2001 Total

Operation 1962–1981 1982–2001 Transient Permanent Transient Permanent Transient Permanent

HT 14 11 00 00 00 STT 380 267 35* 3** 28* 2** 63 5 NTT 0 80 –– 12 1 12 1 Total 394 358 35 3 40 3 75 6

*SED 2.39 (not significant). **SED 0.69 (not significant). HT = hemithyroidectomy; STT = subtotal thyroidectomy; NTT = near– total thyroidectomy.

294 Vol 25 • No 4 • October 2002 SURGICAL MANAGEMENT OF THYROTOXICOSIS due to damage of the external laryngeal branch of phoid aggregates and/or follicles were found in the the SLN. thyroid glands of about 20% of the patients. Considerable Calcium deficiency (temporary as well as permanent) destruction of the acini with marked lymphoid aggregates was controlled by oral calcium and vitamin D3 and follicles (Hashitoxicosis) was reported in 19 glands. (supplemented initially by intravenous calcium gluconate). Three patients had carcinoma: papillary carcinoma in

In many patients, carefully monitored vitamin D3 injection one with GD; follicular carcinoma in one with TMNG (6 lac units) minimized the initial oral calcium doses. and in one with TSN. Five hundred patients were monitored for 6 months to 20 years. Hypothyroidism (manifesting after 1 to 3 months DISCUSSION and mostly within 6 to 12 months, postoperatively) was observed in 135 patients (of whom 38 had undergone The clinical syndrome of thyrotoxicosis can be caused NTT). Hypothyroidism was well controlled with levo- by many diseases, the two most common causes being thyroxine. Nine patients (all of whom had undergone STT) GD and toxic nodular goitre. GD is an organ-specific developed recurrent ; four were autoimmune disorder caused by antibodies to the TSH reoperated upon and five received an ablative dose of I131. receptors that are stimulatory in nature.1 The role of Of the 80 patients who had undergone STT, 38 developed autoimmunity in TMNG has yet to be elucidated. Kraiem postoperative hypothyroidism but none developed et al found thyroid-stimulating auto-immunoglobulin in recurrent thyrotoxicosis. The NTT enhanced chances of 42% of patients with TMNG.2 Patients with solitary nodules postoperative hypothyroidism but considerably reduced may have a hyperfunctioning or a cold solitary nodule in the possibility of recurrence of hyperthyroidism. Grave’s thyroid gland (the latter having a significantly Of the 500 patients, 265 had ophthalmopathy prior higher malignant potential). to treatment (Table 4). Exophthalmos decreased in 130 The relative frequency of GD vis-à-vis TMNG varies patients and remained unchanged in 134 patients. A single from series to series. In Japan, TMNG is rare and GD patient who developed malignant exophthalmos needed constitutes the bulk of cases of thyrotoxicosis,3 whereas Nafzigger’s orbital roof decompression to save the eyeball. in most surgical series from the USA and other countries, Steroids were administered to 22 patients with persistent GD constitutes approximately two-thirds of cases. In our ophthalmopathy; mild improvement was observed in 18, surgical series (current and past), toxic nodular goitre while there was no improvement in four patients. constituted almost 45% of the cases.4–6 Mishra7 from Lucknow, India and Dorairajan8 from Chennai, India, THYROID HISTOLOGY both report a preponderance of GD. The three available modalities of therapy include The characteristic histological changes of an overactive thionamides, radioactive iodine ablation and surgery. It but treated gland were observed. Thus, hyperplasia of is not within the scope of this discussion to analyze each cells, with multilayered acini, and a variable admixture modality — surgical treatment only is discussed in detail of colloid hyperinvolution, were evident. Excessive lym- here.

Table 4. Ophthalmopathy

Follow-up

Cause of thyrotoxicosis Total (no.) Ophthalmopathy Total Ophthalmopathy Ophthalmopathy (no.) (no.) improved after surgery

Grave’s disease 428 250 284 213 101 Toxic multinodular goitre 299 71 201 52 29 Toxic solitary nodule 25 0 15 – – Total 752 321 500 265 130

Asian Journal of Surgery 295 BHANSALI AND CHANDALIA

Indications for surgery ophthalmopathy scoring system, and advocated surgery in those patients with GD who have severe ophthalmo- Surgery may be carried out either as primary treat- pathy, as a means of ameliorating eye problems.18 They ment or as secondary therapy after failure of other modes found an improvement in about 70% of their cases. of management. A solitary nodule successfully treated by I131 becomes non-functional on the isotope scan by about 6 months Surgery as primary treatment after treatment, whereas those with limited response will retain some functional activity.19 Hence, if after I131 The indications are: therapy the solitary nodule exhibits activity on the iso- (a) TMNG; tope scan, it should be excised. (b) Solitary hyperfunctioning (toxic) nodule with thyrotoxicosis, especially in the young, or when there Semi-emergency surgery is tracheal compression or cosmetic disfigurement. Percutaneous ethanol injection therapy is being evalu- Semi-emergency surgery may be required for patients ated by Freitas;9 with severe tracheal compression/displacement.20 Early (c) A patient with GD with one or more of the following surgery is also recommended for those with severe features/factors (these indications may be debatable): physiological compromise (and those with amiodarone- (i) Cold solitary nodule, as chances of malignancy induced thyrotoxicosis) who do not respond to conserva- in this are high10,11 (though neither hyperthy- tive management.21 roidism per se nor I131 therapy increases risk of cancer); Preoperative treatment (ii) Large goitre, as the thyrotoxicosis is more likely to recur;12 Preoperatively, the thyroid function should be nor- (iii) Children; malized by administration of thyrostatic drugs; otherwise, (iv) Pregnancy;13 there is a risk of postoperative thyroid storm. (v) Desire for early pregnancy (as it is advisable to Propylthiouracil is the ideal drug for pharmacological avoid pregnancy for at least 2 years after starting preparation, as it not only inhibits synthesis of thyroid thyrostatic drugs); hormones, but also reduces the rate of peripheral conver-

(vi) Poor socio-economic status (antithyroid drugs sion of T4 to T3, unlike carbimazole, or its active meta- are expensive, treatment must be continued for bolite, methimazole.22 In India, the cost factor and lack at least 18 months and chances of recurrence are of readily available propylthiouracil often forces us 30%–45%);14–17 to use carbimazole. β-Blockers administered simultane- (vii) Patients with severe exophthalmos;18 and ously with antithyroid drugs quickly control hyper- (viii) Likelihood of poor compliance because of psy- sympathethomimetic manifestations. Bronchospasm and chiatric aberrations. gross left ventricular dysfunction contraindicate use of Patients with considerable tracheal compression or β-blockers. If β-blockade is decided upon, non-selective tracheal deviation require semi-emergency surgery. propranolol is preferred, as it also reduces elevated oxygen consumption by 50%,23 and also inhibits

Surgery as secondary treatment peripheral conversion of T4 to T3. We routinely administer Lugol’s iodine preoperatively Surgery as a secondary treatment is required for patients for 1 week. Chang et al, by studying blood volume flow with GD who relapse on/after thiourea administration with the help of pulsed Doppler ultrasonography,24 Burns, (or the rare ones who exhibit drug allergy or resistance). by resistance index studies25 and Woodcock and Recurrence is rare after prudently administered colleagues, by using duplex scanning of the thyroid,26 radioiodine.17 Antithyroid drugs, as well as I131 ablation, demonstrated normalization of blood flow in toxic goitre should be avoided in patients with severe ophthalmopathy, by administration of Lugol’s solution. The decrease in as eye problems deteriorate in a significant number of thyroid gland vascularity and friability limits intraoperative such patients.16,18 Frilling et al utilized an accurate bleeding and related problems.25

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In patients requiring semi-emergency surgery, steroids ligation of the ITA.40 Probably, the small end arteries from are administered pre-, intra- and postoperatively, in the trachea and oesophagus provide perfusion of the addition to the therapeutic measures outlined above, to parathyroid glands. Also neo-anastomotic branches minimize chances of postoperative thyroid crisis. Recently, between the parathyroid arteries and the thyroid remnant Mercado demonstrated that therapy with cholestyramine may also be effective in perfusion of parathyroid in these patients achieves a rapid decline in thyroid glands.41 The incidence of permanent hypocalcaemia hormone level by diminishing the increased enterohepatic ranges from 2% to 5%.42 circulation of .27 Hence, this drug, too, may be a useful adjuvant in semi-emergency situations. Extent of resection

Intraoperative considerations Until about a decade ago, the extent of resection performed was STT leaving behind 4–8 g of thyroid Intraoperative steps to safeguard the recurrent and tissue. However, with STT, recurrent thyrotoxicosis external laryngeal branch of the SLNs and parathyroid develops in 5% to 10% of patients.43–45 As a result, over glands have been outlined already in the initial part of the last decade, the trend is for NTT or total thyroidectomy this report. Reeve’s manoeuvre of lateralization of (TT).46 Recurrence is especially more frequently encoun- the superior pole of the thyroid gland followed by ligation tered in the very young patients with severe thyrotoxicosis, of the superior thyroid vessels safeguards the ELN.28 and those with normal levels of antithyroid antibodies. Routine identification of the RLN greatly decreases the Also, exophthalmos does not regress as well after STT as incidence of nerve injury,29 but is possible in less than after NTT/TT.18 85% of cases.30 Mono-lateral vocal cord hypomotility is Revision surgery (either TT or NTT) for recurrent deemed permanent if it lasts beyond 3–4 months: after thyrotoxicosis is associated with a higher morbidity than this interval, the quality of voice can be restored to near ab initio TT/NTTT.47 Per contra ab initio TT/NTT is not normality by injection of Teflon paste into the glottic associated with a higher morbidity than that associated region via a laryngoscope. Temporary hoarseness of with STT,32,42 provided TT (or NTT) is performed by an voice occurs in about 5% to 10% of cases and permanent experienced “high volume thyroid surgeon”.48 The hoarseness, in 0.5% to 1%.31,32 Maryland cross-sectional survey of 5,860 thyroidectomies Ligation of the trunk of inferior thyroid artery (ITA) after adjustment for case mix (age, race,co-morbidities, remains controversial. The advantage of initial trunk diagnosis, procedures, etc.) and hospital volume, showed ligation is that it produces a relatively bloodless field. that “highest volume thyroid surgeons” had the lowest Some surgeons postulate that ligation of the trunk of ITA complication rates for TT. Our analysis of the operation causes hypocalcaemia by devascularization of parathy- in two groups of two decades each does not show roid gland; they advocate ligation of only the branches of increased morbidity with NTT. A recent mail survey of the ITA near the thyroid capsule, thus, preserving the 75 endocrine surgeons in Australia and New Zealand blood supply to parathyroid glands.32 Nonetheless, this revealed that 60% of the surgeons perform TT, with view is not shared by others 33–35 including the current decreased incidence of recurrent thyrotoxicosis, and a author. Apart from ligation of the ITA, there are other reduction in the need for revision thyroidectomy.46 possible factors leading to hypocalcaemia, such as STT with video-surgical techniques and the use of the inadvertent excision of a parathyroid gland, infarction an ultrasound-activated scalpel (or shear) as a cutting- of the gland, autoimmune disorders and severe cum-coagulation device has been reported by Yamamoto thyrotoxicosis.36 An inadvertently excised parathyroid and colleagues.49 gland is best transplanted into the sternomastoid muscle37 after slicing (and confirming the presence of the gland on Postoperative complications frozen section histopathology), with a reported successful function at upwards of 75%.38,39 This precaution reduces Surgical mortality is practically nil. The fatalities are the incidence of permanent postoperative hypocalcaemia. usually due to associated cardiac and other co-morbidities. The high incidence (> 20%) of post-thyroidectomy The issue of recurrent thyrotoxicosis has already been temporary hypocalcaemia is not related to the truncal discussed. Whilst transient hypothyroidism is frequently

Asian Journal of Surgery 297 BHANSALI AND CHANDALIA seen (possibly due to temporary devascularization of the 5. Bhansali SK, Shanbhag W, Joshi VR, et al. The enigma of management of hyperthyroidism. India J Surg 1974;36: thyroid remnant), the incidence of permanent 445–55. hypothyroidism varies, from 5% to 40% with STT43,44,50 6. Bhansali SK, Menon K, Agarwal SR. Surgery for hyperthy- With NTT, it is necessarily higher. Apart from the extent roidism – an Indian experience. Endocrine Surgery 1992;9: of surgery,50,51 other factors that influence the incidence 361–9. 7. Mishra SK. Personal Communication, 2002. of postoperative hypothyroidism are: (a) preoperative 8. Dorairajan N. Personal Communication, 2002. levels of antithyroglobulin and antimicrosomal antibodies, 9. Freitas JE. Therapeutic options in the management of toxic and (b) the extent of lymphocytic infiltration observed and nontoxic nodular goiter. Semin Nucl Med 2002;30: 52,53 54 88–97. histologically. Recently, Shimizu and colleagues 10. Alsanea O. Treatment of Grave’s disease: the advantages have reported successful auto-transplantation (in forearm of surgery. Endocrinol Metab Clin North Am 2002;29: muscles) of cryopreserved thyroid tissue (obtained at 321–7. thyroidectomy) to counter postoperative hypothyroidism; 11. McClellan DR, Francis GL. Thyroid cancer in children, pregnant women and patients with Grave’s disease. the auto-transplantation was carried out 18 months or Endocrinol Metab Clin North Am 1996;25:27–48. more after the initial surgery. It is possible that this 12. Ewins DL, McGregor AM. Medical aspects of . technique (or its refinement or modification, if need be) In: Lynn J and Bloom SR, eds. Surgical Endocrinology. Oxford: Butterworth Heinemann Ltd;1993:294–311. may benefit some patients with post-thyroidectomy 13. Martin F, Caporal R, Tran BA, Huy P. Role of Surgery in hypothyroidism. treatment of hyperthyroidism. Ann Otolaryngol Chir Cervicofa 1999;116:184–97. 14. Allanic H, Faucher R, Orgiazzi J, et al. Antithyroid drugs and Associated carcinoma Grave’s disease: a prospective randomised evaluation of the efficacy of treatment duration. J Clin Endocrinol Metab The incidence of carcinoma in TMNG and GD has 1990;90:675–9. been reported at around 1–7%.7,45,55 A solitary nodule 15. Kennedy JW, Caro JF. The ABC’s of managing hyperthyroidism in the older patient. Geriatrics 1996;51:22–4. developing in Grave’s thyroid, cold on isotope scan 16. Torring O, Tallstedt L, Wallin G, et al. Grave’s and echogenic on ultrasound, has a higher risk of hyperthyroidism: treatment with antithyroid drugs, surgery malignancy.11 or radio-iodine — a prospective randomized study. Thyroid study group. J Clin Endocrinol Metab 1996;81:Z986-Z993. 17. Solomon B, Glinoer D, Lagasse R et al. Current trends in the Eye changes management of Grave’s disease. J Clin Endocrinol Metab 1990;70:1518–28. 18. Frilling A, Goretzki PE, Grubenderf M, et al. The influence Eye changes will generally ameliorate or remain static of surgery on endocrine ophthalmopathy. World J Surg with the control of hyperthyroidism; but, on occasion, 1980;14:442–6. ophthalmopathy will progress despite thyroid ablation. 19. Maisey MN. Imaging of the thyroid. In: Lynn J, Bloom SR, Generally, patients with severe ophthalmopathy benefit eds, Surgical Endocrinology. Oxford: Butterworth Heinemann Ltd;1993:200–18. 16 more from surgical TT or NTT. The lack of predictable 20. G’anger PG, Guinea AI, Reeves TS, Delbridge Law. The effects of treatment on ophthalmopathy suggests that the spectrum of emergency admissions for thyroidectomy. Am thyrotoxicosis and ophthalmopathy in GD are, perhaps, J Emerg Med 1999;17:591–3. 21. Meurisse M, Gollogly L, Degauque C, et al. Iatrogenic two distinct auto-immune phenomena with a high degree thyrotoxicosis: casual circumstances, pathophysiology and of concurrence. principles of treatment — review of the literature. World J Surg 2000;24:1377–88. 22. Sutherland J, Robinson B, Delbridge L. Anaesthesia for REFERENCES amiodarone-induced thyrotoxicosis: a case review. Anaesth Intensive Care 2001;29:24–9. 1. Wall JR, Kuroki T. Immunologic factors in thyroid disease. 23. Jansson S, Lie-Karlsen K, Stenquist O, et al. Oxygen con- Med Clin Am 1985;69:913–36. sumption in patients with hyperthyroidism before and after 2. Kraiem Z, Glaser B, Yigla M, et al. Toxic multinodular goiter: treatment with beta blockade versus thyrostatic treatment: a a variant of autoimmune hyperthyroidism. J Clin Endocrinol prospective randomised study. Ann Surg 2001;233:60–4. Metab 1987;65:659–64. 24. Chang DCS, Wheeler MH, Woodcock JP, et al. The effect of 3. Ozaki O, Ito K, Kobayashi K, et al. Thyroid carcinoma in pre-operative Lugol’s iodine on thyroid blood flow in pa- Grave’s disease. World J Surg 1990;14:437–40. tients with Grave’s hyperthyroidism. Surgery 1987;102: 4. Bhansali SK, Menon K, Agarwal SR. Surgical treatment of 1055–61. hyperthyroidism – a Western Indian experience. Asian J Surg 25. Burns PN. Interpreting and analysing the Doppler 1994;17:90–5. examination. In: Taylor KJW, Burns PN, Wells PNT, et al,

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eds. Clinical Application of Doppler Ultrasound. 2nd Ed. 41. Curtis GN. The blood supply of the human parathyroids. New York: Raven Press;1995:217–28. Surg Gynecol Obstet 1990;51:805–9. 26. Woodcock JP, Owen GM, Shedden EJ, et al. Duplex scan- 42. De Toma G, Tedesco M, Gabriele R. et al. Total thyroidec- ning of the thyroid. Ultrasound Med Biol 1985;11:659–63. tomy in the treatment of multinodular (toxic) goiter. G Chir 27. Mercado M. Treatment of hyperthyroidism with a combina- 1995;16:373–6. tion of methimazole and cholestyramine. J Clin Endocrinol 43. Reid DJ. Hyperthyroidism and hypothyroidism complicat- Metab 1996;81:3191–3. ing the treatment of thyrotoxicosis. Br J Surg 1987;74:1000–2. 28. Aina EN, Hisham AN. External laryngeal nerve in thyroid 44 Torre G, Borgonouo G, Arezzo A, et al. Is euthyroidism the surgery. Recognition and surgical implications. Aust NZ J goal of surgical treatment of diffuse toxic goiter? Eur J Surg Surg 2001;7:212–4. 1998;164:495–500. 29. Farrar WB. Complications of thyroidectomy. Surg Clin North 45. Mittendorf EA, McHenry CR. Thyroidectomy for selected Am 1983;63:1353–61. patients with thyrotoxicosis. Arch Otolaryngol Head Neck 30. Sturniolo G, D’alia C, Tonate A, et al. The recurrent laryngeal Surg 2001;127:61–5. nerve related to thyroid surgery. Am J Surg 1999;177:485–8. 46. Delbridge L, Guinea AI, Reeve TS. Total thyroidectomy for 31. Lo CY, Kwok KF, Yuen PW. A prospective evaluation of bilateral benign multinodular goiter: Effect of changing recurrent laryngeal nerve paralysis during thyroidectomy. practice. Arch Surg 1999;134:1389–93. Arch Surg 2000;135:204–7. 47. Menegaux F, Turpin G, Dahman M, et al. Secondary thyroid- 32. Marchesi M, Biffoni M, Tartaglia F, et al. Total versus ectomy in patients with prior thyroid surgery for benign subtotal thyroidectomy in the management of multinodular disease: a study of 203 cases. Surgery 1999;126:479–83. goiter. Int Surg 1998;83:200–4. 48. Sosa JA, Bowman HM, Tielsgh JM, et al. The importance of 33. Falk SA, Birken EA, Baran DT. Temporary post-thyroidec- surgeon experience for clinical and economic outcomes for tomy hypocalcaemia. Arch Otolaryngol Head Neck Surg thyroidectomy. Ann Surg 1998;228:320–30. 1988;114:168–74. 49. Yamamoto M, Sasaki A, Asahi H, et al. Endoscopic subtotal 34. Ramus NI. Hypocalcaemia after subtotal thyroidectomy for thyroidectomy for patients with Grave’s disease. Surg Today thyrotoxicosis. Br J Surg 1984;71:589–90. 2001;31:1–4. 35. Nawrot I, Zajac S, Grzesivk W, et al. Effect of surgical 50. Okamoto T, Fujimoto Y, Obara T, et al. Retrospective technique in subtotal and bilateral thyroidectomy on risk of analysis of prognostic factors affecting the thyroid function postoperative parathyroid insufficiency development – our status after subtotal thyroidectomy for Grave’s disease. experience. Med Sci Monit 2002;6:564–6. World J Surg 1992;16:690–6. 36. Wingert DJ, Driessen SR, Ilopoulos JL, et al. Post thyroidec- 51. Gamez JM, Gomez N, Amat M, et al. Hypothyroidism after tomy hypocalcaemia: incidence and risk factors. Am J Surg iodine-131 or surgical therapy for Grave’s disease 1986;152:606–10. hyperthyroidism. Ann Endocrinol (Paris), 2000;61: 37. Olson JA Jr, Debenedetti MK, Baumann DS, Wells SA Jr. 184–91. Parathyroid autotransplantation during thyroidectomy. Re- 52. Sampat MB, Sirsat MV. The thyroid gland in hyperthyroidism. sults of long-term follow-up. Ann Surg 1996;223:472–80. Indian J Med Res 1972;60:855–8. 38. D’avanzo A, Parangi S, Morita E, et al. Hyperparathyroidism 53. Toft AD. Thyroid surgery for Grave’s disease. Br Med J 1983; after thyroid surgery and autotransplantation of histologically 286:740. normal parathyroid glands. J Am Coll Surg 2002;190:546–52. 54. Shimizu K, Kumita S, Kitamura Y, et al. Trial of autotrans- 39. Lo CY, Tam SC. Parathyroid autotransplantation during plantation of cryopreserved thyroid tissue for postoperative thyroidectomy. Documentation of graft function. Arch Surg hyperthyroidism in patients with Grave’s disease. J Am Coll 2001;36:1381–5. Surg 2002;194:14–22. 40. Cakmalki S, Aydintug S, Erdem E. Postthyroidectomy hypo- 55. Ruggieri M, Scocchera F, Genderini M, et al. Hyperthy- calcaemia: does arterial ligation play a significant role. Int roidism and concurrent carcinoma. Eur Rev Med Pharmacol Surg 1992;77:284–6. Sci 1999;3:265–8.

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