Thyroidectomy by High Volume Surgeon Offers Best Outcomes for Grave's Disease

Total thyroidectomy is underutilized but promises the best outcomes for Grave's disease, but the risk of serious complications is high, necessitating referral to a highly trained surgeon.

Written by Wendy Lyons Sunshine

With Gustavo A. Rubio, MD, and J. Woody Sistrunk, MD

Researchers examined 5 years of national data to see how patients fared after total thyroidectomy for Graves’ disease, and the findings of this retrospective, cross-sectional analysis were published in Thyroid.1

Total thyroidectomy is a technically challenging surgical procedure, performed most often in patients with benign multinodular goiter (MNG) and thyroid malignancy. Of the total 215,068 patients across the country who underwent thyroidectomy during the study period, just 5.2% were treated for Graves’ disease.1

“We suspected that total thyroidectomy was underutilized for the treatment of Grave's’ disease in the United States, despite promising outcomes in high-volume settings,” lead author, Gustavo A. Rubio, MD, told EndocrineWeb.

“Total thyroidectomy is, after all, a definitive treatment and it takes care of the problem once and for all,” said Dr. Rubio,  an endocrine surgeon at the University of Miami Miller School of Medicine in Miami, Florida.“The reason why we did this study using the Nationwide Inpatient Sample databases is that it not only includes big academic teaching hospitals with high volume but also includes non-academic hospitals and those situated in rural areas and from different geographic regions.”

“We wanted to get a sense of the complication rates and the outcomes in [a wide range of] patients,” he said. “We defined high volume as being the top 20-25%, of total thyroidectomy.”

Postoperatively, patients with Graves’ disease faced higher rates of complications. Compared to MNG and thyroid cancer patients, these patients had significantly higher rates of hypocalcemia (12.4%), hematomas requiring reoperation (0.7%), and longer mean hospital stays (2.7 days). In addition, they also had a higher risk of vocal cord paralysis and tracheostomy.1

The best outcomes for all three groups of patients, with the lowest risk for postoperative complications, were at surgery centers that performed a high volume of this difficult procedure. Low-volume hospitals, for example, had about twice as many hematomas and hypocalcemia, and nearly triple the rate of major medical complications.1

Dr. Gustavo recommended as a good resource for finding a high volume surgeon in underserved rural areas to refer patients to members of the American Association of Endocrine Surgeons (AAES). Providers can identify dedicated endocrine surgeons that are more likely to do the most surgeries in their area, he said.

“While most people use radioactive iodine therapy or anti-thyroid drugs for first line therapy, treatment choices are not cut and dry,” J. Woody Sistrunk, MD, FACE, ECNU, of Jackson Thyroid & Endocrine Clinic in Jackson, Mississippi, told EndocrineWeb. For example, surgery could be better for a smoker with Grave's disease because of concern about radioactive iodine worsening the related eye disease.

“Unfortunately, when Grave's disease is being managed by a primary care provider, they are less likely to have the experience to be able to anticipate the bad outcomes that may occur,” Dr. Sistrunk said.

“If you're doing a study based solely on ICD-10 codes, which it looks like they were, there was probably a lot of transient hypoparathyroidism that was not reported. The complications are probably higher than what is reported in that study,” he said.

“You would hope that their primary care physician is smart enough to get them into the hands of the right person to take care of them,” he said. “We have surgeons ready to operate everywhere, but in most underserved areas, there are very few if any endocrinologists that are available to see a patient in consultation.” He believes the patient is best served to travel to the closest high volume surgical facility.

Learning a provider’s surgery outcomes are not easy for the general public or even other clinicians, Dr. Sistrunk said.

“This is not a number that gets put on websites from surgeons saying I do this many a year,” Dr. Sistrunk said, and he emphasized “the endocrinologist is probably the most important person in deciding, whether surgery is necessary, and, if so, who is the best surgeon to do the job. The endocrinologist's responsibility is to make sense of the story and carry it forward with whatever treatment modality would be best for that patient taking into account the totality of their circumstances.”


  1. Rubio GA, Koru-Sengul T, Vaghaiwalla TM, Parikh PP, Farra JC, Lew JI. Postoperative outcomes in Grave's disease patients: results from the Nationwide Inpatient Sample Database. Thyroid. 2017;27(6):825-831.

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