Graves’ Disease with Moderate-Severe Endocrine Ophthalmopathy
Long Terms Results of a Prospective, Randomized Study of Total or Subtotal Thyroid Resection
Introduction: In patients who have Graves’ disease and Graves’ ophthalmopathy (GO), deciding which thyroid surgery to perform is a subject of debate in the medical community. Thyroid resection has its place, but the extent of the resection needed is not clearly established. Therefore, total thyroidectomy has been used, and some trials show favorable results with that.
The current study was undertaken to compare the outcomes of subtotal thyroidectomy vs. total thyroidectomy in patients with moderate-severe GO.
Methods: In this prospective, randomized trial of treatment, there were 43 patients. They were randomly assigned to either subtotal thyroidectomy (leaving a thyroid remnant of approximately 2 g) or total thyroidectomy.
Prior to being enrolled in the study, all patients had been treated with antithyroid drugs; 12 had also used corticosteroids.
Following surgery—subtotal or total—patients received thyroxine supplementation. They were followed up for 3 years.
Results: For all patients, GO improved following surgery. The 2 groups did not have significant differences in subjective and objective eye symptoms or lab results.
Motility disturbances were present in 8 of the subtotal thyroidectomy patients at the beginning of the study; proptosis was present in 16. After the 3 years of the study, there were 3 cases with motility disturbances and 16 cases with proptosis.
In the total thyroidectomy group, there were motility disturbances in 11 cases pre-operatively; following treatment, it was present in 6 cases. In regards to proptosis, the pre-operative count was 17, and the post-operative count was 15.
In 21 patients, thyrotropin-receptor antibody levels gradually fell and eventually became undetectable.
In the total thyroidectomy group, the surgical complication rate was significantly higher. Surgical complications were permanent recurrent laryngeal paresis and permanent hypoparathyroidism.
Conclusions: This study shows that, in comparison to total thyroidectomy, subtotal thyroidectomy will reduce surgical risks for patients with Graves’ disease and moderate-severe GO—without reducing the benefits of surgery.
This is probably one of the best available prospective trials of the effect of thyroid resection on GO activity. Whereas there was clear decline in thyrotropin-receptor antibody levels in nearly half the cases, the effect on GO activity is difficult to interpret from the available data.
Over 3 years, GO may spontaneously improve, so not having a control group makes the assessment of the therapy a little difficult. It would have been helpful to compare the surgical groups to 2 other groups, one including patients who continued on antithyroid medications and another including patients treated with radioactive iodine.