Patients should be rendered euthyroid, that is the TSH level should be in the normal range, and there should not be overactive thyroid function. This is typically achieved with antithyroid medications prior to surgery. It is a bad idea to operate on a patient while they are actively hyperthyroid. This dangerous situation increases the risk of thyroid storm -which can be a life-threatening situation. Thyroid storm can develop when the overactive thyroid gland is surgically manipulated, releasing sudden increased amounts of thyroid hormone. This can send the blood pressure and the heart rate skyrocketing. This is an extremely dangerous situation and can even result in intraoperative death.
Preparation for Safe Surgery
Prior to surgery, calcium should be restored to normal levels and evaluation for overactive parathyroid glands (or hypercalcemia) should also be done. In Graves’ disease, a total thyroidectomy is the recommended operation. If a thyroid is removed completely, there is 0% risk of recurrence of the Graves’ disease. Sometimes a subtotal thyroidectomy is done by less experienced surgeons. This presents approximately an 8% risk of persistence of Graves’ disease or recurrence within the first five years following surgery. Therefore, subtotal thyroidectomy is not recommended.
Choose Your Thyroid Surgeon With Care!
The American Thyroid Association recommends that if surgery is chosen as a primary therapy for Graves’ disease, the patient should be referred to a high-volume thyroid surgeon. This is a strong recommendation by the ATA and is good advice. Specifically, average complication rates, lengths of hospital stay, and costs are reduced when the operation is performed by a surgeon who conducts many thyroidectomies. Complication rates in Graves’ disease are higher than in normal thyroidectomies, increasing the need for a high-volume, experienced surgeon. The American Thyroid Association sites a 51% higher complication rate in thyroidectomy done by low-volume surgeons in the setting of Graves’ disease. Following thyroidectomy for Graves’ disease in the hands of a high-volume thyroid surgeon, the rate of permanent hypoparathyroidism should be less than 2% and a permanent recurrent laryngeal nerve injury should occur in less than 1% of these operations. Higher complication rates are seen with less experienced surgeons. So, the advice to choose your surgeon wisely, is even more important in Grave’s disease.