Surgery still has a role in Graves' hyperthyroidism.

Abstract

A recent survey of American thyroidologists defining their management of a 43-year-old woman with hyperthyroid Graves' disease and a thyroid weighing 40 to 50 grams revealed that 69% recommended iodine 131 therapy, 30% prolonged antithyroid drug therapy, and only 1% operation. If the patient was younger or had a larger thyroid, 4% to 7% of the respondents recommended operation. In our clinic we often recommend operation for young adult patients with large goiters who have had recurrent hyperthyroidism after antithyroid drug (ATD) therapy, have allergic reactions to ATD, are not compliant, are ATD failures, or refuse 131I therapy. Thus operation for Graves' disease is recommended more frequently in our clinic than this survey indicates. From 1980 to 1992, 81 patients with Graves' disease (15 men and 66 women; mean age, 30 years) underwent a subtotal thyroidectomy. Patients had been pretreated with antithyroid drugs and saturated solution of potassium iodide, and thyroid conditions were normal at the time of operation. All patients underwent subtotal thyroidectomy by one surgeon and 3 to 5 grams of thyroid were left on each side. There was no permanent recurrent nerve damage or hypoparathyroidism. Hyperthyroidism recurred in one patient (1.2%). Hypothyroidism developed in 59% of our patients, 77% within 1 year after operation, which was easily managed with replacement doses of levothyroxine. Ophthalmopathy had not developed or progressed in any patient, as has recently been suggested to occur after 131I therapy of Graves' disease. Because our patients are almost always hospitalized for no more than 24 to 36 hours, have had no complications except for hypothyroidism, have had their disease abruptly terminated, did not have ophthalmopathy, required far fewer physician visits and laboratory tests compared with patients treated with ATD or 131I, surgery remains a reasonable approach to the management of Graves' disease.