1. Surgical treatment for Graves’ disease Subtotal or Total Thyroidectomy?
Dr. Chun-Fan KU
Department of Surgery
Pamela Youde Nethersole Eastern Hospital

2. Treatment of Graves’ disease
Antithyroid medication
I131 ablation
Surgery

3. Surveys of the European and American Thyroid Associations 1987,1990

4. Antithyroid medication
Requires long treatment duration
Low permanent remission rates
Side effects

5. I131 ablation Pregnancy or lactation Children ?severe ophthalmopathy
?large goitre
May requires >1 dose of I131
Eventually developed hypothyroidism

6. Surgical indications --Suspect malignancy --Desiring pregnancy
--Local compression
--Fear of irridation
--Children
--Poorly compliant patients
--Cosmetic
--Severe Graves’ ophthalmopathy
--Need of rapid symptom control
--Roe SM J Am Coll Surg 2001

8. Subtotal vs Total Thyroidectomy
Simpler operation with lower complication rates
--recurrent laryngeal nerve injury
--parathyroid injury
Achieves a low recurrence rate
while maintaining euthyroidism

9. Subtotal vs Total Thyroidectomy
Complication rates
Subtotal
n=6703
Total
n=538
p value
Temporary RLN palsy
2.8%
7.7%
>0.05
Permanent RLN palsy
0.7%
0.9%
Temporary hypoparathyroidism
7.4%
9.6%
Permanent
Hypoparathyroidism
1.0%
--Palit TK. J. Surg. Res. 2000

10. Thyroid function after Subtotal Thyroidectomy
Hypothyroidism%
Recurrence%
Farnell
100 75 1
Dominello
184 69 3
Menegaux
215 49 4
Sugino
728 46 15
Chou
205 44 7
Kasuga
134 42 17
Noguchi
325 8
Noh 14

11. Instability of thyroid function after Subtotal Thyroidectomy
79% of patients change thyroid status during follow up period of 8-12yrs
--Kuma K. Am J Med Sci 1991

12. --Dominello A. Asian J of Surg. 2000

13. Predictability thyroid function after Subtotal Thyroidectomy
TSH receptor antibody
Lymphoid infiltration
Antimicrosomal and other antithyroid antibodies

14. wt of residual thyroid (g)
Remnant size
8.9% decline in the rate of hypothyroidism for each gram of thyroid remnant
--Palit TK. J. Surg. Res. 2000
wt of residual thyroid (g)
Recurrence rate (%)
6-8
23.8 4
9.4
<2
--Hermann M. Surgery. 1998

15. Graves’ ophthalmopathy
Theoretical advantage of downregulating the autoimmune response of ophthalmopathy by removal of persistent antigenic stimulation after total thyroidectomy
Protosis improvement of –0.9mm vs +0.5mm
--Kurihara H. Thyroid.2002

16. Total Thyroidectomy Comparable permanent complication rates
Predictable outcome in terms of thyroid function
No risk of recurrence
(need for life long thyroxine replacement)

17. Conclusion Surgeon’s preference
Patient’s choice between chance of recurrence and life long thyroxine replacement