Hermann M, Roka R, Richter B, Freissmuth M
Department of Surgery, University of Vienna, Austria.
Surgery. 1998 Nov;124(5):894-900.
The relative merit of operation in the treatment of Graves' disease has been questioned, and the extent of surgical resection is still a matter of debate.
We have analyzed retrospectively the incidence of recurrent hyperthyroidism (frequency and time point) in 215 consecutive patients subjected sequentially to subtotal thyroidectomy (n = 63; remnant mass 6 to 8 g, based on surgeons' estimates and dimensions measured during operation), extensive subtotal thyroidectomy (n = 106; remnant mass approximately 4 g), and near-total (n = 27; unilateral capsular remnant of < 2 g) or total thyroidectomy (n = 19). In addition, we have evaluated the postoperative kinetics of thyroid hormone elimination (free triiodothyronine and free thyroxine) in 14 selected patients with hyperthyroidism who underwent operation under beta-adrenergic blockade but without any thyrostatic pretreatment.
The size of the remnant significantly (P < .05) affected the relapse rate (23.8%, 9.4%, and 0% in subtotal, extensive subtotal, and near-total/total thyroidectomy, respectively). However, the time point at which the relapse occurred did not differ in subtotal and extensive subtotal thyroidectomy. All relapses occurred within the first 70 weeks. The incidence of complications (permanent recurrent nerve paresis and persistent hypocalcemia) was comparable in all groups. The elimination of fT3 was biphasic and rapid such that the levels were within the normal range on the second day. In contrast, 15 days were required until the fT4 level had declined below the upper limit in all patients.
We propose that the therapeutic goal in thyroid operations is to avoid recurrent hyperthyroidism. This is not reliably achieved by subtotal thyroidectomy; in contrast, near-total and total thyroidectomy are effective and safe. On the basis of the postoperative elimination kinetics, hormone replacement is to be instituted within 2 weeks after operation.
手术治疗格雷夫斯病的相对优点一直受到质疑，手术切除范围仍是一个有争议的问题。
我们回顾性分析了215例连续接受次全甲状腺切除术（n = 63；残留甲状腺组织6至8 g，根据外科医生的估计及手术中测量的尺寸）、广泛次全甲状腺切除术（n = 106；残留甲状腺组织约4 g）、近全切除术（n = 27；单侧甲状腺包膜残留小于2 g）或全甲状腺切除术（n = 19）患者的复发甲亢发生率（频率和时间点）。此外，我们评估了14例接受手术的甲亢患者在β-肾上腺素能阻滞剂作用下但未进行任何甲状腺抑制预处理时术后甲状腺激素消除（游离三碘甲状腺原氨酸和游离甲状腺素）的动力学变化。
残留甲状腺组织的大小对复发率有显著影响（P < 0.05）（次全甲状腺切除术、广泛次全甲状腺切除术、近全切除术/全甲状腺切除术的复发率分别为23.8%、9.4%和0%）。然而，次全甲状腺切除术和广泛次全甲状腺切除术复发的时间点没有差异。所有复发均发生在最初70周内。所有组的并发症发生率（永久性喉返神经麻痹和持续性低钙血症）相当。fT3的消除呈双相且迅速，以至于第二天其水平就处于正常范围内。相比之下，所有患者的fT4水平降至上限以下需要15天。
我们认为甲状腺手术的治疗目标是避免复发甲亢。次全甲状腺切除术不能可靠地实现这一目标；相比之下，近全切除术和全甲状腺切除术有效且安全。根据术后消除动力学，应在术后2周内开始激素替代治疗。
