thyroid surgery for graves’ disease

• US guided FNA Bx – suspicious for papillary thyroid carcinoma • Surgery – 5/15/2008 total thyroidectomy same day, under local regional block • Path – papillary and follicular variant

Thyroid Surgery for Graves’

Disease

Alexander Shifrin, MD Department of Surgery Jersey Shore University Medical Center

Case # 1

• 30 y.o female with 5 year history of Graves’ disease

• Treated with PTU x 2 years, came off, developed more

symptoms of hyperthyroidism plus dermatitis

• Restarted on Methimazol, feels better

• Unable to come off medications

• Unable to get pregnant

• Came for advice on therapy options?

• Surgery – total

thyroidectomy (same day,

under local/regional block)

• Path – multinodular goiter,

chronic thyroiditis c/w

Graves’ disease

2 weeks post op

Case # 1

• 43 yo f with Graves x 8 years C/o inability to perform day-by-day functions (stopped her martial arts, unable to catch her breath, palpitations, anxiety).

• Unable to come off of anti-thyroid meds

• Developed 2cm, solid right thyroid

nodule (US 3/2008)

• FNA Bx – negative for malig cells

• Fam Hx – neg; No h/o radiation

• Surgery – total thyroidectomy (same

day, under local/regional block)

• Path – follicular variant of papillary

thyroid carcinoma, 1 cm, no LN 2 weeks post op

Case # 3

• 57 y.o female with 7 year history of Graves’ disease

• Treated with Methimazol, can not come off of meds

• f/u US (1/2008) - developed multinodular goiter with solid 3.8

cm cold nodule on Uptake scan + increased uptake throughout the rest of the thyroid (43% @ 24hr)

• compressive symptoms: swallowing, breathing difficulties in

supine position

• Came for second opinion?

• US guided FNA Bx – suspicious for papillary thyroid carcinoma

• Surgery – (5/15/2008) total thyroidectomy (same day, under

local regional block)

• Path – papillary and follicular variant of papillary thyroid

carcinoma, 1.8 x 1.6 cm

Case # 4

• 54 yo female, h/o Graves’ for 4 years.

• Suffered of severe, panic disorder with intolerable anxiety

attacks, which precluded her daily life activities; problems with people relationship, lost her job because of it Anxiety was

worse when she was off thyroid meds.

• Symptoms of difficulty swallowing solid – “stack in her throat”,

hoarseness, shortness of breath

• Thyroid US – MNG; Nuclear Med Thyroid Uptake - c/w Graves’.

• TFT’s – wnl on Methimazol

• Meds: Methimazol, Propronalol, Lexapro, Xanax

• Fam Hx: Mother – thyroidectomy for goiter, breast Ca Cousin –

thyroid Ca

Case # 4

• Came for consultation with her friend – unable to control her

panic attacks, so her friend can speak for her Very emotional, constantly crying.

• Surgery – total thyroidectomy

• Path – multinodular goiter

• Follow-up in two weeks:

- panic attacks resolved

- stopped taking Xanax since surgery

only on Lexapro

- able to control her life, can deal with

problems without tears and emotion

- compressive symptoms resolved

(swallowing, breathing problems)

2 weeks post op

Toxic diffuse goiter

• Robert James Graves – in the English-speaking world

• Carl Adolph von Basedow - in continental Europe

Graves’ disease: facts

• Autoimmune disorder with an unpredictable clinical course.

• Symptoms directly related to hormone excess

• Manifestations in connective tissue: Graves´ ophthalmopathy

and dermopathy

• annual incidences: 40 per 100,000 in the US

• 4 to 6 times more common in females, mostly between age 20

to 50.

• 1% to 5% of patients with GD are children (peak at age 11 to 14

years)

Graves disease: facts

• strong hereditary and genetic component

• Smoking is weakly associated with GD but strongly with the

development of Graves ophtalmopathy

• thyroid receptor antibodies activates the thyrotropin receptor

(TSHR), leading to synthesis and production of thyroid

hormones in the follicular cells and infiltration of lymphocytes

in the thyroid

1 Antithyroid medication

2 Radioactive iodine ablation (131I)

3 Thyroidectomy

Indications vary based on geographical location:

• Radioactive iodine ablation preferred in the US

• Europe and Asia - antithyroid drugs or surgery are

favored

Treatment options

Absolute indications for

surgery include the

following:

• Presence of GD and an associated suspicious or

malignant thyroid nodule

• Pregnancy, not controlled with antithyroid

medication

• Local compressive symptoms

• Children before age 5 yo

Is radioactive iodine safe?

No data for small dose (Graves’) but there are date for iodine dose in patients treated for thyroid cancer.

The Risk of Second Primary Malignancies up to Three Decades

after the Treatment of Differentiated

Thyroid Cancer

Brown AP,Tward JD J Clin Endocrinol Metab 2008 Feb;93(2):504-15

• METHODS: 30,278 patients with differentiated thyroid cancer (from

1973 to 2002) from centers participating in the NCI Surveillance, Epidemiology, and End Results program

• Median follow-up - 103 months (2-359 months).

• Risk was assessed for radioisotope therapy, gender, latency to

development of secondary cancer, and age at thyroid cancer

diagnosis.

The Risk of Second Primary Malignancies up

to Three Decades after the Treatment of

Differentiated Thyroid Cancer

Brown AP,Tward JD J Clin Endocrinol Metab 2008

Feb;93(2):504-15

RESULTS:

• 2158 patients developed a total of 2338 nonthyroid second

primary malignancies, significantly more than that in the

general population [P < 0.05]

• The increased risk was greater for the irradiated vs the

unirradiated cohort (P < 0.05)

• The greatest risk of second primary cancers occurred within 5

yr of diagnosis and was elevated for younger patients.

Why not go straight to the surgery?

Is surgery safe?

What are side effects and complications of the surgery?

Side effects/complications of the surgery

• 1-2 % risk or permanent RLN injury

(In non-thyroid specialized surgeon – up to 10-15% reported)

• ~15-20% risk of temporary hoarseness

• Up to 15-20% chances of the EBSRN injury – high pitched voice

• 1-2% risk of permanent hypoparathyroidism

Surgical Treatment of Graves' Disease: Evidence-Based

approach Stalberg P, at al World J Surg 2008 Mar 8

• The optimal treatment of Graves disease (GD) is still

controversial: antithyroid medication? vs radioactive iodine (RAI)? vs Surgery?:

• 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?

• METHODS: a systematic review of the literature using

evidence-based criteria regarding these four issues

Surgical Treatment of Graves' Disease: Evidence-Based

approach Stålberg P, at al World J Surg 2008 Mar 8

• RESULTS:

• 1) There are no preference in the treatment options for adults

• 2) Total thyroidectomy has same complication rates as subtotal,

but higher cure rates and negligible recurrence rates (grade A recommendation)

• 3) If severe GO is present, surgery or RAI combined with

glucocorticoids (grade B recommendation)

• 4) The extent of thyroid resection does not influence the outcome

of GO (grade B recommendation)

• 5) RAI or surgery advocated for children (grade C

recommendation - lack of studies)

• 6) Increased cancer risk with RAI in children below the age of 5

years supports surgery in this setting (grade A

recommendation)

Surgical Treatment of Graves' Disease: Evidence-Based

Approach Stålberg P, at al World J Surg 2008 Mar 8

• CONCLUSION:

• If surgery is considered - evidence-based criteria support total

thyroidectomy as the surgical technique of choice for GD

• Available evidence supports surgery in the presence of severe

GO.

• Children with GD should be treated with an ablative strategy

Whether total thyroidectomy or RAI - still 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

How get patient ready for the safe

surgery?

The effect of anti-thyroid drug treatment duration on thyroid gland microvessel density and intraoperative blood loss in patients with

Graves' disease.

Erbil Y et al Surgery 2008 Feb;143(2):216-25

• Preoperative preparation of the patient with Graves' disease is

crucial to avoid intraoperative or postoperative complications associated with anesthesia or surgery

• 43 patients were treated with Methimazole &/or Propylthiouracil,

preoperatively

• Thyroid blood flow was measured by Doppler, microvessel

density was assessed immunohistochemically

• CONCLUTION: Longer treatment duration had a 142-fold

decreased rate of intraoperative blood loss.

Effect of Lugol solution on thyroid gland blood flow and

microvessel density in the patients with Graves' disease.

Erbil Y et al J Clin Endocrinol Metab 2007 Jun;92(6):2182-9

• 36 patients were randomly assigned to or not to receive

preoperative treatment with Lugol solution

• Thyroid blood flow was measured by Doppler, microvessel

density was assessed immunohistochemically

• Lugol solution treatment resulted in a 9.33-fold decreased rate

of intraoperative blood loss

• CONCLUSION: Lugol decreased thyroid vascularity, and

intraoperative blood loss during thyroidectomy

Total or subtotal thyroidectomy?

Total or subtotal thyroidectomy?

• Equal rate of complications – RLN palsy (0.7% - 0.9%)

• Equal rate of transient hypocalcemia (9.6% - 7.4%)

• Equal rate of permanent hyporarathyroidism (0.9% - 1.0%)

• Total thyroidectomy – no recurrence

• Subtotal thyroidectomy – 7.9% recurrence

Palit Et al 2000 J Surg Res Witte et al 2000 WJ Surg

• Unpredictable rate of euthyroidism after subtotal (how mach to

leave?) up to 70% develops long term hypothyroidism

Michie 1975 Br J Surg

• Micropapillary thyroid carcinoma found in 8% of patients with

GD

Stalberg 2008 WJ Surg

Incidental thyroid carcinoma in patients with Graves' disease Phitayakorn R, Case Western, Cleveland Am J Surg 2008 Mar;195(3)

• 93 pt - thyroidectomy for Graves' disease,

• 2 pt (2.2%) had an incidental papillary carcinoma

• The prevalence of incidental thyroid cancer was 3.6% and 6.2%

in patients with nontoxic nodular goiter and toxic multinodular goiter, respectively - no statistical difference

Total thyroidectomy is the preferred treatment for patients with Graves' disease and a thyroid nodule Boostrom S University of

Texas Otolaryngol Head Neck Surg 2007 Feb;136

• 49 prospective pt - thyroidectomy for Graves' disease,

• Papillary thyroid carcinoma in 10% (60% multifocal, 60% lymph

node metastases)

• CONCLUSION : Total thyroidectomy for Graves' has minimal

morbidity Patients with Graves' and a thyroid nodule are at an increased risk for malignancy and should be treated with a total thyroidectomy

Instruments and Technique

Why the thyroid surgery is safer at these

days?

Chose the right tools:

1) surgeon 2) instruments / technology

“Surgeon volume as a predictor of outcomes in inpatient and

outpatient endocrine surgery.” Stavrakis A, at al Endocrine Surgical Unit and Center for Surgical Outcomes and

Quality, VA System, Los Angeles Surgery 2007 Dec;142(6):887

• the effect of surgeon volume on clinical and economic

outcomes for thyroid, parathyroid, and adrenal surgery were examined (New York and Florida state discharge data (2002))

• Surgeons were grouped by annual endocrine operative

volume: Group A: 1 to 3 operations; B: 4 - 8; C: 9 - 19; D: 20 - 50; E: 51 - 99; and F: >100

• Complications, length of stay, and total charges were analyzed

• CONCLUSION: Surgeon volume correlates inversely with

complication rates, length of stay , and total charges The

lowest complication rates are achieved by surgeons

performing >or=100 endocrine operations annually

The importance of surgeon experience for clinical and economic outcomes from thyroidectomy Sosa JA, Udelsman R at alAnn

Surg 1998 Sep;228(3) The Johns Hopkins University

• Surgeons were categorized by volume of thyroidectomies over

the 6-year study period: A (1 to 9 cases), B (10 - 29), C (30 -

100), and D (>100)

• 5860 patients (Maryland hospital discharge data base)

• relation between surgeon caseload and in-hospital

complications, length of stay, and total hospital charges were analyzed

• Results: highest-volume surgeons had the shortest length of

stay (1.4 days for gr B vs 1.9 days for gr A) and the lowest

complication rate (5.1 % for gr B vs 8.6% for gr A)

• Length of stay and complications were more determined by

surgeon experience than hospital volume.

• Individual surgeon experience was significantly associated

with complication rates and length of stay for thyroidectomy

Effect of hospital volume of thyroidectomies on

outcomes following substernal thyroidectomy.

World J Surg 2008 May;32(5):740-6.

Pieracci FM, Fahey TJ, Cornell University

• Volume of thyroidectomies was divided into low (<33 per year),

middle (33-99 per year), and high (>/=100 per year)

• Outcome: hospital length of stay, recurrent laryngeal nerve

injury, hypoparathyroidism, bleeding, respiratory failure, blood transfusion, and mortality

• total of 1153 pt: 372 (32.2%) were performed at low-volume

centers, 388 (33.7%) at middle-volume centers, and 393 (34.0%)

at high-volume centers (the New York State Statewide Planning and Research Cooperative System database )

• Results: complication rate and mortality rate were significantly associated with volume They were decreased when surgery occurred at hospitals that perform a high volume of

thyroidectomies

Chose the right instruments

VERY OLD INSTRUMENTS –

Ancient Roman Surgical Instruments

Pompeii, Italy, 1st Century A.D

Old instruments & techniques

Multiple ties

bovi Multiple clamps JP drain

New devices & technology

Harmonic FOCUS device

Randomized controlled trial of harmonic scalpel use during

thyroidectomy Miccoli at al Arch Otolaryngol Head Neck Surg

2006 Oct;132(10):1069-73

• OBJECTIVE: To compare operative factors, postoperative

outcomes, and surgical complications of thyroidectomy when using the harmonic scalpel (HS) vs conventional hemostasis (CH).

• DESIGN: 100 patients Single-blind, randomized controlled trial

• INTERVENTION: total thyroidectomy with either the HS or CH

• CONCLUSIONS: Use of the HS reduce postoperative pain,

drainage volume, and transient hypocalcemia in patients

undergoing thyroidectomy Shorter operative times and

improved outcomes might justify the cost of the HS compared with that of CH

NIM Nerve monitoring

for selected high-risk thyroidectomies

• For reoperative thyroidectomy

to monitor recurrent laryngeal nerve

• For professions requiring voice

or speech (singers and teachers) – to monitor external branch of the superior laryngeal nerve

Chan W, Surgery, Dec 2006 Snyder, Surgery, Dec 2005

Thyroid surgery under local anesthesia

“Thyroidectomy Using Local Anesthesia:

a report of 1,025 cases over 16 years.”

K Spanknebel, J Chabot, M DiGiorgi,

K Cheung, S Lee, J Allendorf, P