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World Journal of Surgery

, Volume 32, Issue 7, pp 1269–1277 | Cite as

Surgical Treatment of Graves’ Disease: Evidence-Based Approach

  • Peter StålbergEmail author
  • Anna Svensson
  • Ola Hessman
  • Göran Åkerström
  • Per Hellman
Article

Abstract

Background

The optimal treatment of Graves´ disease (GD) is still controversial. Surgery is one treatment option along with radioactive iodine (RAI) and antithyroid medication. In this evidence-based review, we examine four issues: (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

We conducted a systematic review of the literature using evidence-based criteria regarding these four issues.

Results

(1) There are no recommendations reaching any grade of evidence for which treatment to choose for adults with GD. (2) Total thyroidectomy has complication rates equal to those seen with lesser resections but it has higher cure rates and negligible recurrence rates (Level I–IV data leading to a grade A recommendation). (3) Data support surgery when severe GO is present, but RAI combined with glucocorticoids may be equally safe (Level II–IV data, grade B recommendation). The extent of thyroid resection does not influence the outcome of GO (Level II data, grade B recommendation). (4) Based on the available data, definitive treatment can be advocated for children (Level IV data, grade C recommendation) using either RAI or surgery. No recommendation can be given as to whether RAI or surgery is preferred owing to the lack of studies addressing this issue. Increased cancer risk with RAI in children below the age of 5 years supports surgery in this setting (Level I data, grade A recommendation).

Conclusion

If surgery is considered for definitive management, evidence-based criteria support total thyroidectomy as the surgical technique of choice for GD. Available evidence also supports surgery in the presence of severe endocrine GO. Children with GD should be treated with an ablative strategy. Whether this is achieved by total thyroidectomy or RAI may still be 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.

Keywords

Thyroid Cancer Goiter Total Thyroidectomy Radioactive Iodine Prospective Randomized Control Trial 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Prabhakar BS, Bahn RS, Smith TJ (2003) Current perspective on the pathogenesis of Graves’ disease and ophthalmopathy. Endocr Rev 24:802–835PubMedCrossRefGoogle Scholar
  2. 2.
    Patwardhan NA, Moront M, Rao S et al (1993) Surgery still has a role in Graves’ hyperthyroidism. Surgery 114:1108–1112; discussion 1112–1113PubMedGoogle Scholar
  3. 3.
    Glinoer D, Hesch D, Lagasse R et al (1987) The management of hyperthyroidism due to Graves’ disease in Europe in 1986. Results of an international survey. Acta Endocrinol Suppl (Copenh) 285:3–23Google Scholar
  4. 4.
    Solomon B, Glinoer D, Lagasse R et al (1990) Current trends in the management of Graves’ disease. J Clin Endocrinol Metab 70:1518–1524PubMedGoogle Scholar
  5. 5.
    Wartofsky L, Glinoer D, Solomon B et al (1991) Differences and similarities in the treatment of diffuse goiter in Europe and the United States. Exp Clin Endocrinol 97:243–251PubMedGoogle Scholar
  6. 6.
    Weetman AP (2000) Graves’ disease. N Engl J Med 343:1236–1248PubMedCrossRefGoogle Scholar
  7. 7.
    Cooper DS (1998) Antithyroid drugs for the treatment of hyperthyroidism caused by Graves’ disease. Endocrinol Metab Clin North Am 27:225–247PubMedCrossRefGoogle Scholar
  8. 8.
    Cooper DS (2003) Antithyroid drugs in the management of patients with Graves’ disease: an evidence-based approach to therapeutic controversies. J Clin Endocrinol Metab 88:3474–3481PubMedCrossRefGoogle Scholar
  9. 9.
    Leech NJ, Dayan CM (1998) Controversies in the management of Graves’ disease. Clin Endocrinol (Oxf) 49:273–280CrossRefGoogle Scholar
  10. 10.
    Weetman AP (2000) Controversy in thyroid disease. J R Coll Physicians Lond 34:374–380PubMedGoogle Scholar
  11. 11.
    Schott M, Eckstein A, Willenberg HS et al (2007) Improved prediction of relapse of Graves’ thyrotoxicosis by combined determination of TSH receptor and thyroperoxidase antibodies. Horm Metab Res 39:56–61PubMedCrossRefGoogle Scholar
  12. 12.
    Schussler-Fiorenza CM, Bruns CM, Chen H (2006) The surgical management of Graves’ disease. J Surg Res 133:207–214PubMedCrossRefGoogle Scholar
  13. 13.
    Kaplan MM, Meier DA, Dworkin HJ (1998) Treatment of hyperthyroidism with radioactive iodine. Endocrinol Metab Clin North Am 27:205–223PubMedCrossRefGoogle Scholar
  14. 14.
    Alsanea O, Clark OH (2000) Treatment of Graves’ disease: the advantages of surgery. Endocrinol Metab Clin North Am 29:321–337PubMedCrossRefGoogle Scholar
  15. 15.
    Watson AB, Brownlie BE, Frampton CM et al (1988) Outcome following standardized 185 MBq dose 131I therapy for Graves’ disease. Clin Endocrinol (Oxf) 28:487–496CrossRefGoogle Scholar
  16. 16.
    Rivkees SA, Sklar C, Freemark M (1998) Clinical review 99: The management of Graves’ disease in children, with special emphasis on radioiodine treatment. J Clin Endocrinol Metab 83:3767-–3776PubMedCrossRefGoogle Scholar
  17. 17.
    Ron E, Doody MM, Becker DV et al (1998) Cancer mortality following treatment for adult hyperthyroidism. Cooperative Thyrotoxicosis Therapy Follow-up Study Group. JAMA 280:347–355PubMedCrossRefGoogle Scholar
  18. 18.
    Franklyn JA, Maisonneuve P, Sheppard MC et al (1998) Mortality after the treatment of hyperthyroidism with radioactive iodine. N Engl J Med 338:712–718PubMedCrossRefGoogle Scholar
  19. 19.
    Franklyn JA, Maisonneuve P, Sheppard M et al (1999) Cancer incidence and mortality after radioiodine treatment for hyperthyroidism: a population-based cohort study. Lancet 353:2111–2115PubMedCrossRefGoogle Scholar
  20. 20.
    Vellar ID (1999) Thomas Peel Dunhill: pioneer thyroid surgeon. Aust N Z J Surg 69:375–387PubMedCrossRefGoogle Scholar
  21. 21.
    Dobyns BM, Sheline GE, Workman JB et al (1974) Malignant and benign neoplasms of the thyroid in patients treated for hyperthyroidism: a report of the cooperative thyrotoxicosis therapy follow-up study. J Clin Endocrinol Metab 38:976–998PubMedGoogle Scholar
  22. 22.
    Yano Y, Shibuya H, Kitagawa W et al (2007) Recent outcome of Graves’ disease patients with papillary thyroid cancer. Eur J Endocrinol 157:325–329PubMedCrossRefGoogle Scholar
  23. 23.
    Belfiore A, Garofalo MR, Giuffrida D et al (1990) Increased aggressiveness of thyroid cancer in patients with Graves’ disease. J Clin Endocrinol Metab 70:830–835PubMedCrossRefGoogle Scholar
  24. 24.
    Sackett DL (1989) Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 95(Suppl):2S–4SPubMedCrossRefGoogle Scholar
  25. 25.
    Heinrich S, Schafer M, Rousson V et al (2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243:154–168PubMedCrossRefGoogle Scholar
  26. 26.
    Torring O, Tallstedt L, Wallin G et al (1996) Graves’ hyperthyroidism: treatment with antithyroid drugs, surgery, or radioiodine–a prospective, randomized study. Thyroid Study Group. J Clin Endocrinol Metab 81:2986–2993PubMedCrossRefGoogle Scholar
  27. 27.
    Andaker L, Johansson K, Smeds S et al (1992) Surgery for hyperthyroidism: hemithyroidectomy plus contralateral resection or bilateral resection? A prospective randomized study of postoperative complications and long-term results. World J Surg 16:765–769PubMedCrossRefGoogle Scholar
  28. 28.
    Muller PE, Bein B, Robens E et al (2001) Thyroid surgery according to Enderlen-Hotz or Dunhill: a comparison of two surgical methods for the treatment of Graves’ disease. Int Surg 86:112–116PubMedGoogle Scholar
  29. 29.
    Palit TK, Miller CC 3rd, Miltenburg DM (2000) The efficacy of thyroidectomy for Graves’ disease: A meta-analysis. J Surg Res 90:161–165PubMedCrossRefGoogle Scholar
  30. 30.
    Witte J, Goretzki PE, Dotzenrath C et al (2000) Surgery for Graves’ disease: total versus subtotal thyroidectomy-results of a prospective randomized trial. World J Surg 24:1303–1311PubMedCrossRefGoogle Scholar
  31. 31.
    Barakate MS, Agarwal G, Reeve TS et al (2002) Total thyroidectomy is now the preferred option for the surgical management of Graves’ disease. ANZ J Surg 72:321–324PubMedCrossRefGoogle Scholar
  32. 32.
    Ku CF, Lo CY, Chan WF et al (2005) Total thyroidectomy replaces subtotal thyroidectomy as the preferred surgical treatment for Graves’ disease. ANZ J Surg 75:528–531PubMedCrossRefGoogle Scholar
  33. 33.
    Michie W (1975) Whither thyrotoxicosis? Br J Surg 62:673–682PubMedCrossRefGoogle Scholar
  34. 34.
    Tallstedt L, Lundell G, Torring O et al (1992) Occurrence of ophthalmopathy after treatment for Graves’ hyperthyroidism. The Thyroid Study Group. N Engl J Med 326:1733–1738PubMedCrossRefGoogle Scholar
  35. 35.
    Bartalena L, Marcocci C, Bogazzi F et al (1998) Relation between therapy for hyperthyroidism and the course of Graves’ ophthalmopathy. N Engl J Med 338:73–78PubMedCrossRefGoogle Scholar
  36. 36.
    Menconi F, Marino M, Pinchera A et al (2007) Effects of total thyroid ablation versus near-total thyroidectomy alone on mild to moderate Graves’ orbitopathy treated with intravenous glucocorticoids. J Clin Endocrinol Metab 92:1653–1658PubMedCrossRefGoogle Scholar
  37. 37.
    Abe Y, Sato H, Noguchi M et al (1998) Effect of subtotal thyroidectomy on natural history of ophthalmopathy in Graves’ disease. World J Surg 22:714–717PubMedCrossRefGoogle Scholar
  38. 38.
    Jarhult J, Rudberg C, Larsson E et al (2005) Graves’ disease with moderate-severe endocrine ophthalmopathy-long term results of a prospective, randomized study of total or subtotal thyroid resection. Thyroid 15:1157–1164PubMedCrossRefGoogle Scholar
  39. 39.
    Glaser NS, Styne DM (1997) Predictors of early remission of hyperthyroidism in children. J Clin Endocrinol Metab 82:1719–1726PubMedCrossRefGoogle Scholar
  40. 40.
    Karlsson FA, Tuvemo T, Akerstrom G (1998) Childhood Graves’ disease–remission rate and risk factors. J Clin Endocrinol Metab 83:1398–1399PubMedCrossRefGoogle Scholar
  41. 41.
    Ron E, Lubin JH, Shore RE et al (1995) Thyroid cancer after exposure to external radiation: a pooled analysis of seven studies. Radiat Res 141:259–277PubMedCrossRefGoogle Scholar
  42. 42.
    Schlumberger M, Pacini F (2003) Thyroid tumors after external irradiation to the neck. In Schlumberger, Pacini, eds. Thyroid Tumors. Paris: Nucleon, pp 243–255Google Scholar
  43. 43.
    Winsa B, Rastad J, Akerstrom G et al (1995) Retrospective evaluation of subtotal and total thyroidectomy in Graves’ disease with and without endocrine ophthalmopathy. Eur J Endocrinol 132:406–412PubMedGoogle Scholar
  44. 44.
    Miccoli P, Vitti P, Rago T et al (1996) Surgical treatment of Graves’ disease: subtotal or total thyroidectomy? Surgery 120:1020–1024; discussion 1024–1025PubMedCrossRefGoogle Scholar
  45. 45.
    Gaujoux S, Leenhardt L, Tresallet C et al (2006) Extensive thyroidectomy in Graves’ disease. J Am Coll Surg 202:868–873PubMedCrossRefGoogle Scholar
  46. 46.
    Marcocci C, Bruno-Bossio G, Manetti L et al (1999) The course of Graves’ ophthalmopathy is not influenced by near total thyroidectomy: a case-control study. Clin Endocrinol (Oxf) 51:503–508CrossRefGoogle Scholar
  47. 47.
    Levitt MD, Edis AJ, Agnello R et al (1988) The effect of subtotal thyroidectomy on Graves’ ophthalmopathy. World J Surg 12:593–597PubMedCrossRefGoogle Scholar
  48. 48.
    Agarwal A, Mishra SK (2001) Role of surgery in the management of Graves’ disease. J Indian Med Assoc 99:252, 254–256PubMedGoogle Scholar
  49. 49.
    Rudberg C, Johansson H, Akerstrom G et al (1996) Graves’ disease in children and adolescents. Late results of surgical treatment. Eur J Endocrinol 134:710–715PubMedCrossRefGoogle Scholar
  50. 50.
    Krassas GE (2004) Treatment of juvenile Graves’ disease and its ophthalmic complication: the ‘European way’. Eur J Endocrinol 150:407–414PubMedCrossRefGoogle Scholar
  51. 51.
    Sugino K, Ito K, Mimura T et al (2004) Surgical treatment of Graves’ disease in children. Thyroid 14:447–452PubMedCrossRefGoogle Scholar
  52. 52.
    Barrio R, Lopez-Capape M, Martinez-Badas I et al (2005) Graves’ disease in children and adolescents: response to long-term treatment. Acta Paediatr 94:1583–1589PubMedCrossRefGoogle Scholar
  53. 53.
    Sherman J, Thompson GB, Lteif A et al (2006) Surgical management of Graves disease in childhood and adolescence: an institutional experience. Surgery 140:1056–1061; discussion 1061–1062PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Peter Stålberg
    • 1
    Email author
  • Anna Svensson
    • 1
  • Ola Hessman
    • 1
  • Göran Åkerström
    • 1
  • Per Hellman
    • 1
  1. 1.Endocrine Surgical Unit, Department of SurgeryUniversity HospitalUppsalaSweden

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