Is There a Place for Thyroidectomy in Older Patients with Thyrotoxic Storm and Cardiorespiratory Failure?

Abstract

Early thyroidectomy is the treatment of choice for thyrotoxic storm in patients with thyroid autonomy often induced by iodine. However, older patients who are mostly affected by this condition often have underlying chronic cardiopulmonary diseases, apparently contradicting surgical intervention. The published evidence for suitable treatment strategies in these patients is limited. We report the outcome of a series of older critically ill patients who were treated by thyroidectomy because of thyrotoxic storm. We retrospectively analyzed the outcome of 10 patients (4 males, 6 females; 70 years of age, range, 54-79, Burch-Wartofsky point scale, 61; range, 40-85) with thyrotoxic storm, thyroid autonomy, and severe cardiorespiratory and renal failure with cardiac arrhythmia, coronary artery or chronic obstructive pulmonary disease, or acute inflammation. Thyroidectomy was performed for the following reasons: symptoms of thyrotoxic storm deteriorated or did not improve within 24-48 hours despite intensive medical treatment, or patients developed thionamide-induced agranulocytosis or severe thrombocytopenia. All patients with severe accompanying diseases survived thyroidectomy (early post-operative mortality, 0%). The two oldest patients died 2-3 weeks after thyroidectomy because of myocardial infarction or respiratory failure (late postoperative mortality, 20%). In contrast, in the few previous reports of patients who underwent thyroidectomy for thyrotoxic storm and severe accompanying diseases (n = 7), late postoperative mortality was 43%. The overall mortality for all reported patients including our own, who underwent thyroidectomy for thyrotoxic storm with and without severe accompanying disease (n = 49) was 10%. Our results suggest that early total thyroidectomy should be considered as the method of choice for older, chronically ill patients with thyrotoxic storm complicated by cardiorespiratory and renal failure, especially if high-dose thionamide treatment, iopanoic acid, glucocorticoids, and intensive care fail to improve the patient's conditions within 12-24 hours.

2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (First edition)

“…Postoperative mortality in these patients was reported in 5 of 49 patients (10.2%) [178]. The authors advocated early thyroidectomy to treat thyroid storm, particularly in chronically ill older patients with concurrent cardio-pulmonary and renal failure who fail to respond to the standard intensive multifaceted therapy for thyroid storm [178].…”

Therapeutic Plasmapheresis in Patients with Thyrotoxicosis. Report of Two Cases

“…If the proposed control is not achieved, mortality associated with surgery can be up to 46%. The surgical option should be considered for cases of persistent thyrotoxicosis complicated with heart, ventilatory or renal failure that have not responded to the appropriate treatment; in these cases acceptable results have been achieved with early mortality of 0%, and late mortality (at 3 weeks) being 20% [11].…”

Surgical Management of an Atypical Presentation of a Thyroid Storm

“…Although this is the first line treatment, circumstances may arise that require alternative therapies. In such situations, emergent thyroidectomy has been shown to be a safe method for treating the crisis (8, 11-13). …”