Surgery in Graves’ Disease

Abstract

Graves’ disease (GD) is an autoimmune disorder associated with hyperthyroidism, diffuse goiter, ophthalmopathy, dermopathy, and thyroid acropachy. Hyperthyroidism in GD is caused by stimulatory autoantibodies to TSH-receptor antibody. Typical signs and symptoms of thyrotoxicosis, ophthalmopathy, elevated thyroid hormone levels, and decreased serum TSH levels with or without the presence of serum thyroid antibodies confirm the diagnosis of GD. Thyroid ultrasound also provides useful prognostic information in terms of thyroid volume and vascularity. Radionuclide imaging is helpful in situations where thyroiditis cannot be distinguished from Graves’ hyperthyroidism.

Treatment options for GD are medication, radioactive iodine treatment (RAT), or thyroidectomy. Antithyroid drugs (ATD) are often chosen as a primary treatment, and they are also used as pretreatment in selected patients prior to definitive treatment. For the management of resistant thyrotoxicosis, surgery or RAT is the treatment option. RAT is indicated in women planning a pregnancy in later than 4–6 months and patients with contraindication to ATD use or failure to medical therapy with ATDs. Surgery is usually considered for patients who have a large goiter, compressive symptoms, and a risk for malignancy and for women desiring pregnancy within 4–6 months or having significant ophthalmopathy. Total and near-total thyroidectomy is the recommended operation for patients undergoing surgery for GD. Nodular lesions are also detected in GD and would be managed in a similar manner as that in patients without this disorder. Papillary thyroid cancer might also coexist with GD. We present a case that highlights management options in patients with resistant thyrotoxicosis. Radioactive iodine and surgery are definitive modes of treatment, while beta-blockers, glucocorticoids, Lugol’s solution, and cholestyramine can be used for rapid preoperative preparation in patients with resistant GD and to achieve euthyroidism.