1 Division of Endocrine Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine , Miami, Florida.
2 Division of Biostatistics, Department of Public Health Sciences, University of Miami Leonard M. Miller School of Medicine , Miami, Florida.
Thyroid. 2017 Jun;27(6):825-831. doi: 10.1089/thy.2016.0500. Epub 2017 May 22.
Current surgical indications for Graves' disease include intractability to medical and/or radioablative therapy, compressive symptoms, and worsening ophthalmopathy. Total thyroidectomy for Graves' disease may be technically challenging and lead to untoward perioperative outcomes. This study examines outcomes in patients with Graves' disease who underwent total thyroidectomy and assesses its safety for this patient population.
A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample database from 2006 to 2011. Total thyroidectomy performed in patients with Graves' disease, benign multinodular goiter (MNG), and thyroid cancer was identified. Demographic factors, comorbidities, and postoperative complications were evaluated. Chi-square, one-way analysis of variance, and risk-adjusted multivariable logistic regression were performed.
Of 215,068 patients who underwent total thyroidectomy during the study period, 11,205 (5.2%) had Graves' disease, 110,124 (51.2%) MNG, and 93,739 (43.6%) thyroid malignancy. Patients with Graves' disease were younger than MNG and thyroid cancer patients (M = 42.8 years vs. 55.5 and 51.0 years; p < 0.01). The Graves' disease group included a higher proportion of women (p < 0.01) and nonwhites (p < 0.01). Postoperatively, Graves' patients had significantly higher rates of hypocalcemia (12.4% vs. 7.3% and 10.3%; p < 0.01), hematomas requiring reoperation (0.7% vs. 0.4% and 0.4%; p < 0.01), and longer mean hospital stay (2.7 days vs. 2.4 and 2.2 days; p < 0.01) compared to MNG and thyroid cancer patients, respectively. On risk-adjusted multivariate logistic regression, Graves' disease was independently associated with a higher risk of vocal-cord paralysis (odds ratio [OR] = 1.36 [confidence interval (CI) 1.08-1.69]), tracheostomy (OR = 1.35 [CI 1.1-1.67]), postoperative hypocalcemia (OR = 1.65 [CI 1.54-1.77]), and hematoma requiring reoperation (OR = 2.79 [CI 2.16-3.62]) compared to MNG patients. High-volume centers for total thyroidectomy were independently associated with lower risk of postoperative complications, including in patients with Graves' disease.
Despite low overall morbidity following total thyroidectomy, Graves' disease patients are at increased risk of postoperative complications, including bleeding, vocal-cord paralysis, tracheostomy, and hypocalcemia. These risks appear to be lower when performed at high-volume centers, and thus referral to these centers should be considered. Total thyroidectomy may therefore be a safe treatment option for appropriately selected patients with Graves' disease when performed by experienced surgeons.
Graves 病的当前手术指征包括对药物和/或放射性治疗的耐药性、压迫症状和眼病恶化。Graves 病的全甲状腺切除术可能具有技术挑战性，并导致不良的围手术期结果。本研究检查了接受 Graves 病全甲状腺切除术的患者的结果，并评估了其对该患者人群的安全性。
使用 2006 年至 2011 年全国住院患者样本数据库进行回顾性横断面分析。确定了 Graves 病、良性多结节性甲状腺肿（MNG）和甲状腺癌患者中进行的全甲状腺切除术。评估了人口统计学因素、合并症和术后并发症。进行了卡方检验、单因素方差分析和风险调整多变量逻辑回归。
在研究期间接受全甲状腺切除术的 215068 例患者中，11205 例（5.2%）患有 Graves 病，110124 例（51.2%）患有 MNG，93739 例（43.6%）患有甲状腺恶性肿瘤。Graves 病患者比 MNG 和甲状腺癌患者年轻（M=42.8 岁比 55.5 和 51.0 岁；p<0.01）。Graves 病组中女性（p<0.01）和非白人（p<0.01）的比例更高。术后，Graves 病患者的低钙血症发生率明显更高（12.4%比 7.3%和 10.3%；p<0.01），需要再次手术的血肿发生率更高（0.7%比 0.4%和 0.4%；p<0.01），平均住院时间更长（2.7 天比 2.4 天和 2.2 天；p<0.01）与 MNG 和甲状腺癌患者相比。在风险调整后的多变量逻辑回归中，与 MNG 患者相比，Graves 病与声带麻痹（比值比[OR] = 1.36 [95%置信区间[CI] 1.08-1.69]）、气管切开术（OR=1.35 [CI 1.1-1.67]）、术后低钙血症（OR=1.65 [CI 1.54-1.77]）和需要再次手术的血肿（OR=2.79 [CI 2.16-3.62]）的风险增加独立相关。全甲状腺切除术的高容量中心与术后并发症风险降低独立相关，包括 Graves 病患者。
尽管全甲状腺切除术后总体发病率较低，但 Graves 病患者术后并发症的风险增加，包括出血、声带麻痹、气管切开术和低钙血症。当由经验丰富的外科医生进行操作时，这些风险似乎在大容量中心较低，因此应考虑将其转诊至这些中心。对于适当选择的 Graves 病患者，全甲状腺切除术可能是一种安全的治疗选择。
