BACKGROUND
Hyperthyroidism, or overactive thyroid, is a condition where the thyroid is producing too much thyroid hormone. The most common cause of hyperthyroidism in the United States is Graves’ disease followed by toxic, or overactive, thyroid nodules. Symptoms of hyperthyroidism can range from relatively minor with a mild tremor, insomnia and anxiety, to moderate with severe palpitations and irregular heart rhythms and significant weight loss to the most extreme cases with thyroid storm, which can be fatal. Treatment options include antithyroid medications, radioactive iodine therapy and surgery. Surgery with removal of the entire thyroid (thyroidectomy) is usually pursued when patients have large goiters with compressive symptoms or have a contraindication to medical therapy or radioactive iodine treatment. American Thyroid Association guidelines suggest that patients should have their thyroid levels in the normal range with antithyroid medications prior to surgery to prevent thyroid storm. However, despite strong recommendations, there is very little clear evidence for this. This study aimed to assess safety and efficacy of thyroidectomy in patients while still in the hyperthyroid state.

THE FULL ARTICLE TITLE
Fazendin J et al 2023 Surgical treatment of hyperthyroidism can be performed safely before a euthyroid state is achieved. Thyroid 33:691–696. PMID: 37253173.

SUMMARY OF THE STUDY
This was a study of adult patients with hyperthyroidism who underwent thyroidectomy from December 2015 to November 2022 at an academic medical center in the United States. These patients were divided into two groups: those with controlled and those with uncontrolled hyperthyroidism (defined as serum triiodothyronine [T3] or thyroxine [T4] higher than the assay’s upper limit of normal immediately before surgery). Four high-volume endocrine surgeons performed the surgeries.

Outcomes included temporary and permanent hypocalcemia, defined as serum calcium <8.4 mg/dl, temporary and permanent hoarseness, the need for urgent re-operation due to bleeding, and thyroid storm.

The study included 275 subjects; 67.9% of the subjects had hyperthyroidism due to Graves’ disease and 32.1% had a toxic nodule. The majority of patients underwent surgery for persistent symptoms (91.8% and 77.3% in the controlled and uncontrolled groups, respectively), while smaller proportions were referred for surgery owing to a reaction to medication (6% and 12.1%), thyroid storm (6.4% and 1.5%), or allergy to medication (4.3% and 0.7%). Out of 275 patients, about half (51.3%) had uncontrolled hyperthyroidism at the time of surgery.

Patients with uncontrolled hyperthyroidism were more likely to have Graves’ disease (85.1% vs. 67.9%) and to have taken antithyroid medications prior to surgery (2.3% vs. 1.4%) than patients with normal thyroid function. Most notably, none of the patients in either of the groups progressed to thyroid storm during the perioperative period. Notably though, 6.4% of the patients in the uncontrolled group had thyroid storm prior to surgery. As compared to those with uncontrolled hyperthyroidism, controlled patients had shorter operative times, decreased estimated blood loss and less temporary hypocalcemia. Clinical outcomes, including incidence of permanent hypocalcemia, temporary hoarseness, and permanent hoarseness, were similar in the two groups.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
In this study performed at a high-surgical-volume academic center, thyroidectomy during the hyperthyroid state did not precipitate thyroid storm or worsen clinical outcomes. This study shows that thyroid surgery while a patient is still hyperthyroid can be done safely. The main caveat is that the surgery in this study was performed by an experienced, high-volume thyroid surgeon. Overall, it is preferable for a patient to have normal thyroid levels prior to surgery, but this may be not possible for a variety of reasons. This study shows that such surgery can be safely.

— Alan P. Farwell, MD

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