Surgical management of hyperthyroidism
- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
- Sonia L Sugg, MD
Sonia L Sugg, MD
- Professor of Surgery
- Division of Surgical Oncology and Endocrine Surgery, University of Iowa Carver College of Medicine
The treatment of hyperthyroidism consists of both symptomatic relief and decreasing the production of thyroid hormone. The use of surgery as definitive therapy for hyperthyroidism varies with the cause of the disease and the characteristics of the patient.
Indications for surgical management of hyperthyroidism and preoperative preparation are reviewed here. Thyroidectomy is reviewed in detail elsewhere (see "Initial and reoperative thyroidectomy"). Other treatment options are also discussed elsewhere. (See "Radioiodine in the treatment of hyperthyroidism" and "Treatment of toxic adenoma and toxic multinodular goiter" and "Graves' hyperthyroidism in nonpregnant adults: Overview of treatment", section on 'Choice of therapy'.)
The approach outlined below is consistent with Hyperthyroidism Management Guidelines from the American Thyroid Association (ATA) .
Graves' disease — Patients with Graves' disease can be treated with antithyroid drugs, radioiodine, or surgery. In the only randomized, prospective trial comparing these three therapies, each was equally effective in normalizing serum thyroid hormone concentrations within six weeks; after treatment, 95 percent or more of the patients were satisfied with their therapy . Therefore, the choice of therapy should involve active discussion between clinician and patient (table 1) . The therapeutic approach to Graves' hyperthyroidism is reviewed in more detail elsewhere. (See "Graves' hyperthyroidism in nonpregnant adults: Overview of treatment", section on 'Choice of therapy'.)
A patient may prefer surgery over other modalities because of a desire to avoid radioiodine, avoid the potential side effects of antithyroid drugs, and to obtain rapid correction of hyperthyroidism. In addition, the following patients with Graves' hyperthyroidism may be better served by surgery:
- Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343.
- Törring O, Tallstedt L, Wallin G, et al. Graves' hyperthyroidism: treatment with antithyroid drugs, surgery, or radioiodine--a prospective, randomized study. Thyroid Study Group. J Clin Endocrinol Metab 1996; 81:2986.
- Ross DS. Radioiodine therapy for hyperthyroidism. N Engl J Med 2011; 364:542.
- Katlic MR, Grillo HC, Wang CA. Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital. Am J Surg 1985; 149:283.
- Hauch A, Al-Qurayshi Z, Randolph G, Kandil E. Total thyroidectomy is associated with increased risk of complications for low- and high-volume surgeons. Ann Surg Oncol 2014; 21:3844.
- Adam MA, Thomas S, Youngwirth L, et al. Is There a Minimum Number of Thyroidectomies a Surgeon Should Perform to Optimize Patient Outcomes? Ann Surg 2016.
- Palit TK, Miller CC 3rd, Miltenburg DM. The efficacy of thyroidectomy for Graves' disease: A meta-analysis. J Surg Res 2000; 90:161.
- Barczyński M, Konturek A, Hubalewska-Dydejczyk A, et al. Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up. Br J Surg 2012; 99:515.
- Erbil Y, Ozluk Y, Giriş M, et al. Effect of lugol solution on thyroid gland blood flow and microvessel density in the patients with Graves' disease. J Clin Endocrinol Metab 2007; 92:2182.
- Baeza A, Aguayo J, Barria M, Pineda G. Rapid preoperative preparation in hyperthyroidism. Clin Endocrinol (Oxf) 1991; 35:439.
- Adlerberth A, Stenström G, Hasselgren PO. The selective beta 1-blocking agent metoprolol compared with antithyroid drug and thyroxine as preoperative treatment of patients with hyperthyroidism. Results from a prospective, randomized study. Ann Surg 1987; 205:182.
- Vickers P, Garg KM, Arya R, et al. The role of selective beta 1-blocker in the preoperative preparation of thyrotoxicosis: a comparative study with propranolol. Int Surg 1990; 75:179.
- Feek CM, Sawers JS, Irvine WJ, et al. Combination of potassium iodide and propranolol in preparation of patients with Graves' disease for thyroid surgery. N Engl J Med 1980; 302:883.
- Hughes OR, Scott-Coombes DM. Hypocalcaemia following thyroidectomy for treatment of Graves' disease: implications for patient management and cost-effectiveness. J Laryngol Otol 2011; 125:849.
- Pesce CE, Shiue Z, Tsai HL, et al. Postoperative hypocalcemia after thyroidectomy for Graves' disease. Thyroid 2010; 20:1279.
- Oltmann SC, Brekke AV, Schneider DF, et al. Preventing postoperative hypocalcemia in patients with Graves disease: a prospective study. Ann Surg Oncol 2015; 22:952.
- Kim WW, Chung SH, Ban EJ, et al. Is Preoperative Vitamin D Deficiency a Risk Factor for Postoperative Symptomatic Hypocalcemia in Thyroid Cancer Patients Undergoing Total Thyroidectomy Plus Central Compartment Neck Dissection? Thyroid 2015; 25:911.
- Antakia R, Edafe O, Uttley L, Balasubramanian SP. Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis. Thyroid 2015; 25:95.
- Testa A, Fant V, De Rosa A, et al. Calcitriol plus hydrochlorothiazide prevents transient post-thyroidectomy hypocalcemia. Horm Metab Res 2006; 38:821.
- Genser L, Trésallet C, Godiris-Petit G, et al. Randomized controlled trial of alfacalcidol supplementation for the reduction of hypocalcemia after total thyroidectomy. Am J Surg 2014; 207:39.
- Werga-Kjellman P, Zedenius J, Tallstedt L, et al. Surgical treatment of hyperthyroidism: a ten-year experience. Thyroid 2001; 11:187.
- Welch KC, McHenry CR. Total thyroidectomy: is morbidity higher for Graves' disease than nontoxic goiter? J Surg Res 2011; 170:96.
- Bellantone R, Lombardi CP, Raffaelli M, et al. Is routine supplementation therapy (calcium and vitamin D) useful after total thyroidectomy? Surgery 2002; 132:1109.
- Landry CS, Grubbs EG, Hernandez M, et al. Predictable criteria for selective, rather than routine, calcium supplementation following thyroidectomy. Arch Surg 2012; 147:338.
- Noordzij JP, Lee SL, Bernet VJ, et al. Early prediction of hypocalcemia after thyroidectomy using parathyroid hormone: an analysis of pooled individual patient data from nine observational studies. J Am Coll Surg 2007; 205:748.
- Erbil Y, Ozbey NC, Sari S, et al. Determinants of postoperative hypocalcemia in vitamin D-deficient Graves' patients after total thyroidectomy. Am J Surg 2011; 201:685.
- Cote V, Sands N, Hier MP, et al. Cost savings associated with post-thyroidectomy parathyroid hormone levels. Otolaryngol Head Neck Surg 2008; 138:204.
- Edafe O, Antakia R, Laskar N, et al. Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. Br J Surg 2014; 101:307.
- Graves' disease
- Toxic adenoma and toxic multinodular goiter
- EXTENT OF RESECTION
- PREOPERATIVE PREPARATION
- Management of hyperthyroidism
- - Beta blockers
- - Thionamide therapy
- - Patients unable to take a thionamide drug
- - Iodine
- Measures to prevent postoperative hypocalcemia
- FOLLOW-UP AND MONITORING
- Persistent hyperthyroidism
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS