Skip to main content

Advertisement

SpringerLink
Log in

Prevention and management of hypothyroidism after thyroidectomy for thyrotoxicosis

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Postoperative hypothyroidism is the most common complication of thyroidectomy for thyrotoxicosis. Its incidence is inversely related to remnant size. Destructive autoimmunity, as measured by the presence of antithyroid antibodies in the serum, may be another of the factors predisposing to postoperative hypothyroidism, but the extent to which such considerations should influence remnant size is a matter for debate. Experience in Iceland suggests that high iodine ingestion is associated with a low incidence of hypothyroidism and a high rate of recurrent thyrotoxicosis; consequently, smaller remnants are obligatory in Iceland. Therefore, it would seem that environmental factors also play a part, and that a remnant “norm” for each locality should be determined empirically to achieve optimum balance between hypothyroidism and recurrent thyrotoxicosis. With the establishment of a “norm,” prediction of hypothyroidism for a group of patients is reasonably accurate. For the individual patient, postoperative status cannot be predicted and it is not possible to select for alternative methods of treatment patients who might be at risk of postoperative hypothyroidism.

Irrespective of large remnant size, approximately 15% of patients will develop postoperative hypothyroidism. These may be the patients described at the turn of the century, before effective treatment became available, in whom the natural course of the disease progressed through euthyroidism to hypothyroidism. It would appear, for some patients at least, that surgery merely accelerates the natural course of the disease and compresses into a matter of weeks events which normally take several months and even years. Fortunately, postoperative hypothyroidism declares itself within 12–15 months and, if clinical scrutiny is sufficiently acute, late onset hypothyroidism is rare. The ethical responsibility remains for a prolonged follow-up of all postthyroidectomy patients.

Résumé

L'hypothyroïdie est la complication postopératoire la plus fréquente de la thyroïdectomie pour hyperthyroïdie. Sa fréquence est inversement proportionnelle à la masse de tissu thyroïdien laissée en place. Les réactions auto-immunitaires destructrices, dont l'importance peut être mesurée par les anticorps antithyroïdiens circulants, sont peut-être un autre facteur prédisposant à l'hypothyroïdie postopératoire; on ne sait pas encore dans quelle mesure il faut en tenir compte pour déterminer le volume de tissu thyroïdien restant. L'expérience acquise en Islande suggère qu'un apport alimentaire riche en iode réduit la fréquence de l'hypothyroïdie et accroît le risque de récidive d'hyperthyroïdie. En Islande, il faut donc laisser relativement peu de tissu thyroïdien. Il apparait donc que des facteurs d'environnement jouent un rôle et qu'il faut, selon les pays, fixer empiriquement la taille “normale” du tissu thyroïdien restant pour obtenir un équilibre optimum entre hypothyroïdie et récidive d'hyperthyroïdie. Une fois la “norme” établie, on peut raisonnablement prédire la fréquence des hypothyroïdies postopératoires. Mais la prédiction individuelle est impossible et il est également impossible de choisir, en fonction du risque d'hypothyroïdie, le traitement de chaque malade.

Même si on laisse beaucoup de tissu thyroïdien, quelques 15% des opérés deviendront hypothyroïdiens. Il s'agit peut-être de ce type de malades, décrits au début du siècle avant les thérapeutiques efficaces, chez qui l'histoire naturelle de la maladie évoluait vers l'eu- puis l'hypothyroïdie. Il semble que, chez certains malades, la chirurgie ne fait qu'accélérer le cours naturel de la maladie, ramassant en quelques semaines une évolution qui normalement se fait en mois ou même en années. Heureusement, l'hypothyroïdie postopératoire apparait en quelques 12–15 mois: si l'observation clinique est attentive, l'hypothyroïdie tardive est rare. La responsabilité médicale exige néanmoins un follow-up de longue durée pour tous les malades thyroïdectomisés.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Pemberton, J. de J.: Recurring exophthalmic goiter: its relation to the amount of tissue preserved in thyroid gland. J.A.M.A.94:465, 1930

    Google Scholar 

  2. Riddell, V.: Thyrotoxicosis and the surgeon. Br. J. Surg.49:465, 1962

    PubMed  Google Scholar 

  3. Hedley, A.J., Fleming, C.J., Chester, M.I., Michie, W., Crooks, J.: Surgical treatment of thyrotoxicosis. Br. Med. J.1:519, 1970

    PubMed  Google Scholar 

  4. Beahrs, O.H., Sakulsky, S.B.: Surgical thyroidectomy in the management of thyrotoxicosis. Arch. Surg.96:512, 1968

    PubMed  Google Scholar 

  5. Crile, G., McCullagh, E.P.: Treatment of hyperthyroidism: evaluation of thyroidectomy, of prolonged administration of propyl thiouracil and of radioactive iodine. Ann. Surg.134:18, 1951

    PubMed  Google Scholar 

  6. Wilson, G.M.: Symposium on Thyroid Disease and Calcium Metabolism. Royal College of Physicians of Edinburgh, Edinburgh, T & A Constable, 1967, pp. 51–76

  7. Thjodleifsson, B.: A study of Graves' disease in Iceland. Acta Med. Scand.198:309, 1975

    PubMed  Google Scholar 

  8. Michie, W., Pegg, C.A.S., Bewsher, P.D.: Prediction of hypothyroidism after partial thyroidectomy for thyrotoxicosis. Br. Med. J.1:13, 1972

    PubMed  Google Scholar 

  9. Goudie, R.B., Anderson, J.R., Gray, K.G.: Complement-fixing antithyroid antibodies in hospital patients with asymptomatic thyroid lesions. J. Pathol. Bact.77:389, 1959

    Google Scholar 

  10. Williams, E.D., Doniach, I.: The postmortem incidence of thyroiditis. J. Pathol. Bact.83:255, 1962

    Google Scholar 

  11. Buchanan, W.W., Koutras, D.A., Crooks, J., Alexander, W.D., Brass, W., Anderson, J.R., Goudie, R.B., Gray, K.G.: The clinical significance of the complement fixation test in thyrotoxicosis. J. Endocrinol.24:115, 1962

    PubMed  Google Scholar 

  12. Whitesell, F.B., Black, B.M.: Statistical study of clinical significance of lymphocytic and fibrocytic replacements in hyperplastic thyroid gland. J. Clin. Endocrinol.9:1202, 1949

    Google Scholar 

  13. Williamson, R.T.: Remarks on prognosis in exophthalmic goitre. Br. Med. J.2:1373, 1896

    Google Scholar 

  14. Mackenzie, H.: Graves' disease. Br. Med. J.2:1077, 1905

    Google Scholar 

  15. Sattler, H.: Basedow's Disease (transl, by G.W. Marchand, J.F. Marchand) New York, Grune and Stratton, 1952, p. 284

    Google Scholar 

  16. Campbell, J.H.M.: Some aspects of exophthalmic goitre. Q. Med. J.15:55, 1921

    Google Scholar 

  17. Baldwin, W.W.: Graves' disease succeeded by atrophy. Lancet1:145, 1895

    Google Scholar 

  18. Campbell-Gowan, B.: Myxoedema and its relation to Graves' disease. Lancet1:478, 1895

    Google Scholar 

  19. Crooks, J., Murray, I.P.C., Wayne, E.J.: Statistical method applied to the clinical diagnosis of thyrotoxicosis. Q. Med. J.28:211, 1959

    Google Scholar 

  20. Hobbs, J.R., Bayliss, R.I.S., MacLagan, N.F.: The routine use of132I in the diagnosis of thyroid disease. Lancet1:8, 1963

    PubMed  Google Scholar 

  21. Fulthorpe, A.J., Roitt, I.M., Doniach, D., Couchmann, K.: A stable sheep cell preparation for detecting thyroglobulin autoantibodies and its clinical applications. J. Clin. Pathol.14:654, 1961

    PubMed  Google Scholar 

  22. Beck, J.S.: Immunofluorescence techniques in immunopathology and histopathology. Association of Clinical Pathologists' Broadsheet 69, London, 1971

    Google Scholar 

  23. Billewicz, W.Z., Chapman, R.S., Crooks, J., Dey, M.E., Gossage, J., Wayne, E.J., Young, A.J.: Statistical methods applied to the diagnosis of hypothyroidism. Q. Med. J.38:255, 1969

    Google Scholar 

  24. Bowley, A.R., Digwood, J., Hedley, A.J., Young, A.C.: A new simple detector for Achilles reflex measurement. Med. Biol. Eng.9:351, 1971

    PubMed  Google Scholar 

  25. Hedley, A.J., Hall, R., Amos, J., Michie, W., Crooks, J.: Serum-thyrotropin levels after subtotal thyroidectomy for Graves' disease. Lancet1:455, 1971

    PubMed  Google Scholar 

  26. Werner, S.C., Spooner, M.: A new and simple test for hyperthyroidism employing I-triiodothyronine and the 24-hour132I uptake method. Bull. N.Y. Acad. Med.31:137, 1955

    PubMed  Google Scholar 

  27. Irvine, W.J., MacGregor, A.G., Stewart, A.E.: The prognostic significance of thyroid antibodies in the management of thyrotoxicosis. Lancet1:843, 1962

    Google Scholar 

  28. Van Welsum, M., Feltcamp, T.E.W., de Vries, M.J., Doctor, R., Van Zijl, J., Hennemann, G.: Hypothyroidism after thyroidectomy for Graves' disease: a search for an explanation. Br. Med. J.4:755, 1975

    Google Scholar 

  29. Hedley, A.J., Michie, W., Duncan, T., Hems, G., Crooks, J.: The effect of remnant size on the outcome of subtotal thyroidectomy for thyrotoxicosis. Br. J. Surg.59:559, 1972

    PubMed  Google Scholar 

  30. Hedley, A.J., Scott, A.M., Weir, R.D., Crooks, J.: Computer-assisted follow-up register for the north-east of Scotland. Br. Med. J.1:556, 1970

    Google Scholar 

  31. Young, R.J., Beck, J.S., Michie, W.: The predictive value of histometry of thyroid tissue in anticipating hypothyroidism after subtotal thyroidectomy for primary thyrotoxicosis. J. Clin. Pathol.28:94, 1975

    PubMed  Google Scholar 

  32. Simpson, J.G., Gray, E.S., Michie, W., Beck, J.S.: The influence of preoperative drug treatment on the extent of hyperplasia of the thymus in primary thyrotoxicosis. Clin. Exp. Immunol.22:249, 1975

    PubMed  Google Scholar 

  33. Green, W.L.: Mechanism of action of antithyroid compounds. In The Thyroid, S.C. Warner, S.H. Ingbar, editors. New York, Harper and Row, 1971, pp. 41–52

    Google Scholar 

  34. Ingbar, S.H., Woeber, K.A.: The thyroid gland. In Textbook of Endocrinology, 5th ed., B.H. Williams, editor. Philadelphia, Saunders, 1974, p. 121

    Google Scholar 

  35. Wilkin, T.J., Beck, J.S., Michie, W.: Does preoperative iodine treatment for thyrotoxicosis bring about involution? J. Clin. Pathol. (in press)

  36. Sigurjonson, J.: Structure and iodine content of thyrotoxic goiters in Iceland. Am. J. Pathol.26:1103, 1950

    PubMed  Google Scholar 

  37. Williams, E.D., Doniach, I., Bjarneson, O., Michie, W.: Thyroid cancer in an iodine-rich area: a histopathological study. Cancer (in press)

  38. Thjodleifsson, B., Hedley, A.J., Donald, D., Beck, J.S., Crooks, J., Michie, W., Chesters, M.I., Hall, R.: Outcome of subtotal thyroidectomy for thyrotoxicosis in Iceland and north-east Scotland (in press)

  39. Furth, E.D., Rives, K., Beckers, D.V.: Nonthyroidal action of propyl thiouracil in hypothyroid, euthyroid and hyperthyroid man. Clin. Endocrinol.26:239, 1966

    Google Scholar 

  40. Alexander, W.D., Harden, R.M., Shimmins, J.: Thyroidal suppression by triiodothyronine as a guide to the duration of treatment of thyrotoxicosis with antithyroid drugs. Lancet2:1041, 1966

    PubMed  Google Scholar 

  41. Lowry, R.C., Lowe, D., Hadden, R.D., Montgomery, D.A.D., Weaver, J.A.: Thyroid suppressability: follow-up for two years after antithyroid drug treatment. Br. Med. J.2:19, 1971

    PubMed  Google Scholar 

  42. Levitt, T.: Evolution of the toxic thyroid gland: a clinical and pathological study based on 2114 thyroidectomies. Lancet2:957, 1951

    Google Scholar 

  43. Greene, R.: Lymphadenoid change in the thyroid gland and its relation to postoperative hypothyroidism. Mem. Soc. Endocrinol.1:16, 1953

    Google Scholar 

  44. Beck, J.S., Young, R.J., Simpson, J.G., Gray, E.S., Nicol, A.G., Pegg, C.A.S., Michie, W.: Lymphoid tissue in the thyroid and thymus of patients with primary thyrotoxicosis. Br. J. Surg.60:769, 1973

    PubMed  Google Scholar 

  45. Hedley, A.J., Ross, I.P., Beck, J.S., Donald, D., Albert-Recht, F., Michie, W., Crooks, J.: Recurrent thyrotoxicosis and subtotal thyroidectomy. Br. Med. J.4:258, 1971

    PubMed  Google Scholar 

  46. Reinhoff, W.F.: The histological changes brought about in cases of exophthalmic goiter by the administration of iodine. Bull. Johns Hopkins Hosp.37:285, 1925

    Google Scholar 

  47. Olsen, W.R., Nishiyarik, R.H., Graber, L.W.: Thyroidectomy and hypothyroidism. Arch. Surg.101:175, 1970

    PubMed  Google Scholar 

  48. Caswell, H.T., Maier, W.P.: Results of surgical treatment for hyperthyroidism, Surg. Gynecol. Obstet.134:218, 1972

    PubMed  Google Scholar 

  49. Nofal, M.M., Beierwaltes, W.H., Patno, M.E.: Treatment of hyperthyroidism with sodium iodide. J.A.M.A.197:605, 1966

    PubMed  Google Scholar 

  50. Gouch, A.L., Neill, R.W.: Partial thyroidectomy for thyrotoxicosis. Br. J. Surg.61:939, 1974

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Thyroid Clinic, Royal Infirmary, Aberdeen, and the Department of Pathology, University of Dundee, Scotland

    W. Michie M.B.E., F.R.C.S.Ed., J. Swanson Beck B.Sc, M.D., F.R.C.P, F.R.C.Path. & J. E. Pollet M.B., B.Med. Biol., F.R.C.S.Ed.

Authors
  1. W. Michie M.B.E., F.R.C.S.Ed.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Swanson Beck B.Sc, M.D., F.R.C.P, F.R.C.Path.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J. E. Pollet M.B., B.Med. Biol., F.R.C.S.Ed.
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Michie, W., Beck, J.S. & Pollet, J.E. Prevention and management of hypothyroidism after thyroidectomy for thyrotoxicosis. World J. Surg. 2, 307–314 (1978). https://doi.org/10.1007/BF01561500

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01561500

Keywords

Search

Navigation