From the Guidelines
Surgery for Graves' disease (thyroidectomy) is indicated when patients fail medical therapy, have severe ophthalmopathy, are pregnant and cannot tolerate antithyroid drugs, have large goiters causing compressive symptoms, or develop thyroid nodules suspicious for malignancy. The indications for Graves' surgery can be broken down into several key categories:
- Medical therapy failure, which includes intolerance to antithyroid medications like methimazole (typically 5-30 mg daily) or propylthiouracil (typically 100-300 mg daily), recurrent hyperthyroidism after completing a 12-18 month course of medication, or poor medication adherence 1.
- Severe ophthalmopathy, which can be debilitating and requires prompt treatment to prevent long-term damage.
- Pregnancy, where antithyroid drugs may be contraindicated or poorly tolerated, making surgery a necessary option.
- Large goiters causing compressive symptoms, which can lead to respiratory distress and other complications if left untreated.
- Thyroid nodules suspicious for malignancy, which require prompt surgical intervention to prevent the spread of cancer.
Before surgery, patients should achieve a euthyroid state using antithyroid medications to prevent thyroid storm during the procedure 1. Total or near-total thyroidectomy is typically performed, requiring lifelong levothyroxine replacement therapy afterward (usually starting at 1.6 mcg/kg/day). The surgical approach offers immediate and definitive control of hyperthyroidism by removing the hyperactive thyroid tissue that produces excess thyroid hormones due to thyroid-stimulating immunoglobulins binding to TSH receptors. It is essential to note that the most common significant complications of thyroidectomy are hypoparathyroidism and recurrent laryngeal nerve injury, which occur with higher frequency after total thyroidectomy 1. However, in the hands of experienced surgeons, these complications can be minimized.
From the Research
Indications for Graves' Surgery
The indications for Graves' surgery, also known as thyroidectomy, in patients with Graves' disease include:
- Large goiter causing compressive symptoms 2, 3, 4
- Suspicious or malignant thyroid nodules 2, 3, 5
- Significant ophthalmopathy, including Graves' orbitopathy 2, 3, 6
- Intolerance, ineffectiveness, or recurrence after anti-thyroid drug treatment 3, 6
- Radioiodine therapy contraindicated 3
- Women planning a pregnancy within 6 months 3
- Patient preference, often due to misconception of radioactive substances or confidence in surgical outcomes 4
Surgical Options
The surgical options for Graves' disease include:
- Subtotal thyroidectomy, which was the standard operation for much of the twentieth century 2
- Total thyroidectomy, which has been increasingly performed over the past 20 years and is now considered the preferred option for the surgical treatment of Graves' disease, with a nearly 0% recurrence rate, predictable postoperative hypothyroidism, and a low complication rate comparable to subtotal thyroidectomy when performed by high-volume thyroid surgeons 2, 3, 4
Preoperative Management
Preoperative management is essential to optimize surgical outcomes, and includes:
- Pretreatment with anti-thyroid drugs to achieve the euthyroid state and avoid the risk of precipitating thyroid storm during surgery 3
- Beta-blockers, such as propranolol, to control hyperthyroid symptoms 3
- Saturated solution of potassium iodide or potassium iodine, given for a short period prior to surgery, to reduce thyroid hormone release and thyroid gland vascularity and decrease intra-operative blood loss 3