Open Total Thyroidectomy for Graves’ Disease

Abstract

Graves’ disease is an autoimmune condition that causes hyperthyroidism. There are several options for management which include medications, radioactive iodine ablation, and surgery. Over time, total or near-total thyroidectomy has become the gold standard in surgical management of this disease. Although there is a slightly higher risk of complications following total thyroidectomy in patients with Graves’ disease as compared to their non-Graves' counterparts undergoing thyroidectomy, the absolute risk remains low, especially for high-volume endocrine surgeons.

Keywords

Graves’ disease; graves; total thyroidectomy; thyroidectomy; hyperthyroidism

Case Overview

Background

Graves’ disease is the most common etiology of hyperthyroidism.^1,2 The disease has an annual incidence of 20 to 50 cases per 100,000 persons, affecting women 5- to 10-fold more commonly than men.¹ Graves is an autoimmune disorder characterized by the production of thyrotropin receptor autoantibodies which stimulate thyroid-stimulating hormone receptors (TSHR), leading to hyperthyroidism. While there is a strong hereditary component, with many patients reporting a family history of autoimmune thyroid disease, the disorder is thought to arise from an interplay of genetic, endogenous, and environmental factors.²

Due to the widespread effects of thyroid hormone, symptoms of Graves’ disease are broad. Most commonly, patients present with palpitations, tremor, fatigue, heat intolerance, and weight loss. Patients older than 60 are more likely to present with cardiac manifestations such as atrial fibrillation.¹ Other symptoms include dyspnea, anxiety, pruritus, irregular menses, erectile dysfunction, eye swelling, and visual disturbances.¹ Graves orbitopathy is characterized by proptosis, eyelid retraction, and periorbital edema and occurs in 25% to 30% of patients.³ 

Diagnosis relies on clinical history and physical exam as well as laboratory studies which show suppressed thyroid stimulating hormone (TSH), increased free thyroxine (T4) and free triiodothyronine (T3), and the presence of thyroid receptor antibodies (TRAb). 

Focused History of Patient

The patient is a 55-year-old woman with a prior history of subclinical hypothyroidism who presented one year prior with biochemical evidence of hyperthyroidism. She was found to have a positive thyroid stimulating immunoglobulin (TSI) test and was diagnosed with Graves’ disease. She was started on antithyroid drugs (ATDs) and quickly became biochemically euthyroid; however, she continued to endorse symptoms of palpitations, anxiety, and fatigue. One year after diagnosis, she was found to have mild thyroid eye disease despite adherence to ATDs and therefore she was referred for surgical evaluation.

Physical Exam

Patients presenting with symptoms of hyperthyroidism should undergo a complete physical exam. In patients with hyperthyroidism, vital signs may reveal tachycardia and elevated systolic blood pressure. Eye exam may reveal exophthalmos and lid retraction. Examination of the thyroid will likely demonstrate a diffusely enlarged goiter, with or without concomitant nodules. The remainder of the exam may be notable for fine tremor, hyperreflexia, acropachy and pretibial myxedema.^1,3

For our patient, her initial exam was notable for normal vital signs and a mildly enlarged, palpable thyroid. One year later, her exam became notable for mild periorbital edema. 

Imaging

While the cornerstone of diagnosis for Graves’ disease is clinical history, exam, and laboratory testing, imaging can have utility in instances of diagnostic uncertainty. Nuclear scintigraphy can differentiate between Graves’ disease and multinodular goiter by demonstrating diffuse uptake in the case of the former. Ultrasonography with doppler flow may show a diffusely hypervascular gland, indicating thyroid hyperactivity. This study can be particularly useful in patients with a contraindication to nuclear scans, such as pregnant or breastfeeding women.4 In patients with orbitopathy of unclear etiology, cross sectional imaging with computed tomography or magnetic resonance imaging of the head may be useful.

Our patient underwent thyroid ultrasound as part of her initial workup. This ultrasound demonstrated a diffusely heterogenous thyroid gland without hypervascularity on doppler. Her right lobe measured 2.9 cm and her left lobe measured 3.6 cm. There were no nodules or adenopathy identified. As the patient was diagnosed based on clinical presentation and laboratory results, no further imaging was pursued. 

Natural History

While there are case reports of spontaneous remission from Graves’ disease,⁴ the vast majority of patients require treatment, and initiation of ATDs at the time of diagnosis is the standard of care. In the short term, untreated thyrotoxicosis can lead to thyroid storm, which can be life-threatening and require intensive care and multimodal treatments. If left untreated long-term, which is unusual in the present day, the disorder can lead to severe complications such as heart failure and pulmonary hypertension.⁵ Untreated ophthalmopathy can cause vision loss due to corneal abrasions or optic nerve compression.³ 

Options for Treatment

There are three treatment options for Graves’ disease: ATDs, radioactive iodine (RAI) ablation and surgery. Worldwide, ATDs, which include methimazole and propylthiouracil (PTU), are the most common first-line therapy and aim at achieving a euthyroid state by blocking extrathyroidal conversion of T4 to T3. Remission occurs in 35–50% of patients with a 12–18 month treatment course,^1,6 with higher success rates occurring in non-smokers and patients with mild disease.^6,7 ATDs have potential for significant adverse reactions including agranulocytosis, hepatotoxicity, and teratogenic effects. Patients who do not achieve remission after a long course of treatment have disease relapse after initial remission or cannot tolerate ATDs require definitive therapy with RAI or surgery. In the United States, RAI ablation is favored as the initial treatment for Graves’ disease.^3,6 Success rates of RAI therapy vary widely in the literature, ranging from 69–90%.^1,8 Contraindications to RAI include pregnancy, breastfeeding, moderate-to-severe ophthalmopathy, and suspicion of or confirmed thyroid cancer.^6,9

While surgery is most frequently considered as a second-line therapy in patients who have failed other therapies, it is considered as a first-line therapy in several patient groups: those who are pregnant, breastfeeding, or planning a pregnancy within 6 months of treatment; those with other contraindications to ATDs and RAI; those who have a large goiter with compressive symptoms; or those with a concomitant thyroid cancer, large nodule, or hyperparathyroidism.^3,9 Patients should be euthyroid at the time of surgery and therefore are typically treated with ATDs as well as beta blockade prior to the operation. Some patients receive potassium iodide as SSKI for 7 to 10 days prior to surgery which reduces thyroid vascularity with unclear effect on complication rates.^10,11 While Graves’ disease increases the risk of thyroidectomy-specific surgical complications, the risks remain low.³

Rationale for Treatment

Our patient was treated with ATDs for a year and despite achieving a euthyroid status, she remained symptomatic and developed mild orbitopathy. Her thyroid function tests did not allow further dose-increase of her methimazole, and therefore she was referred for definitive treatment. The patient preferred to proceed with surgery rather than RAI ablation and was a fit surgical candidate. 

Discussion

Previously, subtotal thyroidectomy was the preferred surgical approach for Graves’ disease, with the aim of rendering the patient euthyroid without need for lifelong thyroxine supplementation. Unfortunately, after this procedure, only a small percentage of patients became euthyroid and the rate of recurrent disease was up to 30%.^12,13 Therefore, over time, total or near-total thyroidectomy has become the gold standard in the surgical treatment of Graves.^12,14,15 This procedure, in which the entire or nearly the entire thyroid gland is removed, confers close to 100% cure rate with extremely low risk of recurrent disease.^9,12 While total thyroidectomy confers a higher risk of permanent hypoparathyroidism and permanent recurrent laryngeal nerve palsy as compared to subtotal thyroidectomy, the absolute risk of these complications is quite low.¹⁵

In general, Graves’ disease is thought to be a predictor of higher surgical complication rates as compared to other indications for total thyroidectomy. In particular, there appears to be a higher rate of readmission, reoperation for hematoma, and wound complications.¹⁶ While there is a higher rate of intraoperative parathyroid auto-transplantation, there is not a significantly higher rate of permanent hypocalcemia or permanent recurrent laryngeal nerve damage as compared to non-Graves controls.¹⁷ A randomized controlled trial further showed very similar complication rates between near-total thyroidectomy and total thyroidectomy for Graves’ patients.¹⁸ Patient-reported outcomes studies have demonstrated improvement in quality of life and thyroid-specific symptoms following surgery in these patients both in the short and long term.¹⁹ 

Nonetheless, as the thyroid is often large and hypervascular in these patients, it is recommended that patients with Graves’ disease undergo surgery with a high-volume endocrine surgeon.⁹ As demonstrated in this video, successful surgery requires careful dissection of the gland to identify the parathyroid glands as well as recurrent laryngeal nerves bilaterally. A useful technique that was demonstrated is leaving a small amount of thyroid tissue in situ at the insertion of the recurrent laryngeal nerve to avoid a traction or transection injury. Ensuring adequate hemostasis after removal of the gland, often with the assistance of a Valsalva maneuver, is of the utmost importance to avoid reoperation for hematoma. We favor the usage of hemostatic agents in the operative bed bilaterally for these cases. 

Our patient was observed in the postoperative care unit for several hours and then discharged home the same day as surgery. Her pathology revealed a specimen weighing 11 grams with diffuse nodular follicular hyperplasia consistent with Graves’ disease. She recovered well postoperatively with improvement in her preoperative symptoms.

Minimally invasive approaches to thyroidectomy have evolved significantly, offering alternatives to conventional open surgery with benefits such as improved cosmetic outcomes, reduced postoperative pain, and faster recovery. Endoscopic thyroidectomy via the transoral vestibular approach (ETOVA) and the areola approach (ETAA) are two techniques that avoid visible neck scars while maintaining oncologic safety. A meta-analysis comparing these approaches demonstrated that ETOVA is associated with reduced blood loss and higher cosmetic satisfaction scores, though both techniques showed comparable complication rates.²⁰ Another emerging technique, the bilateral axillo-breast approach (BABA) robotic thyroidectomy, provides a three-dimensional symmetric view of the thyroid lobes, minimizing the risk of nerve injury and optimizing anatomical landmark visualization. While BABA RT offers superior cosmetic results, it may lead to temporary anterior chest paresthesia, which typically resolves within three months.²¹

Despite these advancements, traditional open thyroidectomy remains the gold standard for complex cases, including Graves’ disease, where gland hypervascularity and size necessitate meticulous dissection. However, as surgical expertise and technology advance, minimally invasive approaches may continue to gain prominence in carefully selected patients. 

Equipment

• Nerveana nerve monitor.
• Stryker Ethicon Harmonic scalpel. 

Disclosures

The authors have no disclosures to report. 

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.