We performed a systematic review of the existing literature in 2012 (Genovese and Noureldine et al. Ann Surg Oncol 2012) and examined 4,546 patients who underwent surgical resection for Graves' disease (3,158 patients had subtotal thyroidectomy and 1,388 had total thyroidectomy).
Of the patients that underwent subtotal thyroidectomy, 330 (10.4%) had persistent or recurrent hyperthyroidism. While only 4 (0.3%) patients who underwent total thyroidectomy had persistent or recurrent hyperthyroidism.
In the studies analyzed, the rate of permanent recurrent laryngeal nerve palsy in patients who underwent subtotal thyroidectomy ranged from 0-1.9%. There were no reports of transient recurrent laryngeal nerve palsy. In patients who underwent total thyroidectomy, the rate of permanent recurrent laryngeal nerve palsy ranged from 1.5-11.1%, and the rate of transient nerve palsy was 1.3-7%.
You can also read the meta-analysis by Palit et al. (palit T et al. J Surg Res, 2000), contrasting total versus subtotal thyroidectomy, as they have showed no significant difference between complication rates of total thyroidectomy and lesser resections. The rate of permanent recurrent laryngeal nerve palsy was 0.9% after total thyroidectomy and 0.7% after subtotal thyroidectomy, for those studies when nerve function was reported. Transient hypocalcemia occurred in 9.6% and 7.4%, respectively. Interstingly, permanent hypoparathyroidism occurred in 0.9% of patients after total thyroidectomy and in 1.0% after subtotal thyroidectomy. Total thyroidectomy was also found to have higher cure rates and negligible recurrence rates.
Initially, subtotal thyroidectomy was advocated as the standard surgical treatment for Graves' disease due to the assumed lower risk of complications, compared to total thyroidectomy, and the possibility of avoiding hormone replacement therapy. However, given that subtotal thyroidectomy provided an unpredictable outcome with regard to ultimate thyroid hormone levels and that the risk of permanent complications was no greater than with total thyroidectomy, there appear little logical reason to continue recommending subtotal thyroidectomy for the surgical management of GD.
Also, you can read Kandil, Noureldine et al. Surgery 2013, Surgery for Graves disease is associated with a higher risk for complications when performed by less experienced surgeons. Graves disease was not a significant predictor of postoperative complications when performed by high volume surgeons. Hospital volume had an inconsistent and marginal protective effect on postoperative outcomes.This finding should prompt recommendations for increasing surgical specialization and referrals to high-volume surgeons in the management of Graves disease.
We have been doing thyroid surgery ,average 10 to 12 cases every month ,we have been doing sub total thyroidectomy for non toxic /simple goitres and now feel comfortable doing total thyroidectomy.for Graves' disease total or near total thyroidectomy is our policy with reasonable results,and we support and recommend the same ,
We have a thyroid volume of around 650-700 per year and we perform total thyroidectomy. There is either nodules on the other side or has microcarcinoma. So we suggest total thyroidectomy.
Total thyroidectomy should be relatively subtotal. Allowing adequate preservation of laryngeal nerve and adequacy of parathyroids.
Dr. Walter Futterweit
Total thyroidectomy of course !
Subtotal thyroidectomy that we used to do in the past don't let enough thyroid for the hormonal secretion and represent a risk of recurrence of the disease.
Hi, Awad
I think, near total thyroidectomy will be enough, as the incidence of hypoparathyroidism increases with total, beside total or subtotal had the same effect Gravies eye changes.
I perform either a near-total or total depending on what the anatomy allows with the aim of protecting the RLN entry and the blood supply to the PIV parathyroid. When l say near total it would be a very tiny remnant. The problem with a total is you may damage the blood supply to the superior gland and often it is difficult to preserve the blood supply to the inferior glands no matter how careful you are. It is accepted in the literature that a sub-total is a outmoded procedure due to a high risk of recurrent thyrotoxicosis
I perform total thyroidectomy , I used to PTH intraoperatore and Ligasure to faciliting dissection and preserve the blood supply to de superior gland and often i preserve the vein thyroidian inferior it's important.
Interesting question. First of all, surgery should be the last therapeutic option in the treatment of Graves disease. The majority of patients are effectively treated with antithyroid agents. In case of surgery, current data seem to support total thyroidectomy. However, total thyroidectomy can result to transient or permanent hypocalcaemia. On the other subtotal thyroidectemy could lead to an euthyroid patient without lefelong thyroid hormone replacement dependence.
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