Short-Term Outcomes of Surgery for Graves’ Disease in Germany

Abstract

Background: Surgical treatment of Graves’ disease (GD) has a potentially increased incidence of postoperative hypoparathyroidism, recurrent laryngeal nerve palsy (RLNP) and bleeding. The aim of this study was to evaluate the current extent of surgery for the treatment of GD and its safety as a short-term outcome. Methods: Patients who underwent thyroid resection for GD were identified from the prospective StuDoQ/Thyroid registry. Patient data were retrospectively analyzed regarding demographics, surgical procedures and perioperative outcomes. Statistics were performed with Student’s t-test or Fisher’s exact test and multivariate Cox regression analysis. The level of statistical significance was set at p < 0.05. Results: A total of 1808 patients with GD with a median age of 44 (range 14–85) years were enrolled in a 25-month period by 78 departments, of which 35.7% (n = 645) had an endocrine orbitopathy and 0.1% (n = 6) had thyrotoxic crisis. Conventional open surgery was used in 98.6% of cases and minimally invasive or remote-access approaches were used in 1.4%. Total thyroidectomy was performed in 93.4% of cases (n = 1688). Intraoperative neuromonitoring (IONM) was used in 98.9% (n = 1789) of procedures. In 98.3% (n = 1777) at least one parathyroid gland was visualized and in 20.7% (n = 375) parathyroids were autografted. The rates of unilateral and bilateral transient RLNP were 3.9% (n = 134/3429 nerves at risk) and 0.1% (n = 4/3429 NAR). The rates of transient RLNP tended to be higher when intermittent IONM was used compared to continuous IONM (4.1% vs. 3.4%, p < 0.059). The rate of transient postoperative hypoparathyroidism was overall 29% (n = 525/1808). Multivariate analysis revealed fewer than 300 thyroid resections and fewer than 15 thyroid resections for GD per year, male sex, BMI > 30, autotransplantation of parathyroid glands and previous bilateral thyroid surgery as independent risk factors for postoperative temporary hypoparathyroidism. Reoperations for bleeding (1.3%) were rare. Conclusion: Total thyroidectomy with IONM is safe and currently the most common surgical therapy for GD in Germany. Postoperative hypoparathyroidism is the major complication which should be focused on.

Revisiting the role of surgery in the treatment of Graves’ disease

“…Intraoperative nerve monitoring (IONM) was used in 98.9% of the cases. The rate of unilateral transient RLN injury was 3.9%, 57 compared with a 2.74% rate found on a meta‐analysis for IONM in thyroid surgeries 66 . This comparable rate may stress the importance of IONM in GD patients.…”

“…Numerous studies, from both Europe and the United States, have found that high‐volume thyroid centres have a lower complication rate, yet the cutoff for high‐volume ranged from 25 to 50 surgeries per year 57,67 . The authors agree that GD patients should only be treated in dedicated centres that have a high‐volume endocrine practice.…”

“…To keep in line with complications related to RAI and ATDs, three major complications should be addressed: RLN injury, hypoparathyroidism and haematoma (which can result in reoperation). The latter prevalence is 1%–1.5% and is excluded from this section, 14,57 though a recent meta‐analysis found an odds ratio of 1.58 (1.09–2.31) for GD surgery 58 …”

“…RLN injury, hypoparathyroidism and haematoma (which can result in reoperation). The latter prevalence is 1%-1.5% and is excluded from this section, 14,57 though a recent meta-analysis found an odds ratio of 1.58 (1.09-2.31) for GD surgery. 58 There is a lack of uniformity in the definition of reported complications: RLN injury varies in the definition for transient versus permanent and methods of diagnosis (mandatory observation of the vocal cords vs. clinical complaints) between studies 57,59,60 ; hypocalcemia was shown to have a significant variation in both definition (minimum level of calcium) and duration of symptoms which correlates with its subsequent incidence.…”

“…The latter prevalence is 1%-1.5% and is excluded from this section, 14,57 though a recent meta-analysis found an odds ratio of 1.58 (1.09-2.31) for GD surgery. 58 There is a lack of uniformity in the definition of reported complications: RLN injury varies in the definition for transient versus permanent and methods of diagnosis (mandatory observation of the vocal cords vs. clinical complaints) between studies 57,59,60 ; hypocalcemia was shown to have a significant variation in both definition (minimum level of calcium) and duration of symptoms which correlates with its subsequent incidence. 61 This, in turn, undermines the reliability of systematic reviews analysing these complications.…”