 sole therapy only when complications with antithyroid drugs preclude their use and surgery is strongly preferred to treatment with 131-I.
Amiodarone induced hyperthyroidism is typically difficult to manage, as described in Chapter 13. Administration of iopanoic acid, 1 gm daily for 13 days, has been shown to provide successful pre-operative therapy, reducing T3 levels to normal (195a). Propranolol is the usual drug used for preparation of patients with amiodarone induced hyperthyroidism going to surgery.
Surgical Techniques and Complications
The standard operation is a one-stage subtotal thyroidectomy. General anesthesia is standard, but cervical plexus block and out-patient surgery is employed by some surgeons [192.1, 192.2]. The amount of tissue left behind is about 4-10 grams, but this amount is variable. Taylor and Painter  found that the average volume of this remnant in 43 patients achieving a remission was about 8 ml, and Sugino et al recommended leaving 6 grams of tissue [196a]. The toxic state recurred in only two patients in their series, and in these twice the amount of tissue mentioned above was left. Ozaki also noted the importance of the amount of thyroid remaining as the principal predictor of eu- or hypo-thyroidism [196.1].There seems however to be no relation between the original size of the thyroid and the size of the remnant necessary to maintain normal metabolism.
Motivated in part by economic considerations, there has been in recent years a reevaluation of thyroidectomy done under local anesthesia as a day-surgery proceedure. Pros and cons have recently been discussed [196.2]. In proper hands local anesthesia and prompt discharge seem acceptable, but most surgeons opt for the standard in hospital approach since it offers a more controlled operative setting and an element of safety the night after surgery.
Some clinicians argue for total-thyroidectomy in an effort to reduce recurrence rates (196.3), and point out that this operation seems to reduce anti-thyroid autoimmunity and reduces the chance of exacerbation of ophthalmopathy. Permanent cure of the hyperthyroidism is produced in 90 – 98% of patients treated this way. Although surgery of the thyroid has reached a high degree of perfection, it is not without problems even in excellent hands. The complication rates at present are low . Among 254 patients operated on at three Nashville hospitals in the decade before 1970, there was no mortality, only minor wound problems, a 1.9% incidence of permanent hypoparathyroidism, and a 4.2% recurrence rate . Hypo-parathyroidism is the major undesirable chronic complication.
Surgical therapy at the Mayo Clinic has in recent years  been associated with a 75% rate of hypothyroidism but only a 1% recurrence rate, as an effort was made to remove more tissue and prevent recurrences. There is typically an inverse relationship between these two results of surgery. In the recent experience of the University of Chicago Clinics, the euthyroid state has been achieved by surgery in 82%; 6% became hypothyroid, and the recurrence rate was 12% . Palit et al. recently published a meta analysis of collected series of patients treated for Graves’ disease, either by total thyroidectomy or subtotal thyroidectomy. Overall, the surgery controlled hyperthyroidism in 92% of patients. There was no difference in complication rates between the two kinds of operations, with permanent laryngeal nerve injury occurring in 0.7 – 0.9% of patients, and permanent hypoparathyroidism in 1 – 1.6% of patients. Since many surgeons have become more familiar and capable with total thyroidectomy, and this avoids the possible recurrence of disease, although possibly slightly increasing the risk of nerve or parathyroid damage, total thyroidectomy has become a common or even preferred alternative to subtotal thyroidectomy for managing hyperthyroidism [200a].
Recurrence rates are higher in patients with progressive exophthalmos or positive assays for TRAb, suggesting that total thyroidectomy may be preferred in these cases . Geographic differences in iodin