rnative to consider, and total thyroidectomy is preferred [ 201, 204]. The preferential use of surgery rather than radioactive iodide in the management of patients with severe Graves’ ophthalmopathy, and the greater, more frequent exacerbation of eye disease after RAI therapy, has been supported in a number of studies including those by Torring et al [204a], Moleti et al [204b], and De Bellis et al [204c]. Marcocci et al, in contrast, report that near-total thyroidectomy had no efffect on the course of ophthalmopathy in a group of patients who had absent or non-severe preexisting ophthalmopathy. The relevance of this to patients with more severe ocular disease is uncertain, since it is logical to expect that in these patients there would be no effect of removing antigens, if they lacked any tendency to develop ophthalmopathy [204d]. Moleti et al recently reported on 55 patients with Graves’ disease and mild to moderate Graves’ ophthalmopathy, who underwent near-total thyroidectomy, and of whom 16 had standard ablative doses of radioactive iodide. They found that the course of ophthalmopathy, both short and long term after treatment, was significantly better in the group of patients who underwent thyroidectomy and 131-I ablation, and suggest that this is a more effective means of inducing and maintaining ophthalmopathy inactive (204e). In a randomized, prospective study, total thyroidectomy, rather than partial thyroidectomy, was followed by a better outcome of GO in patients given iv glucocorticoids. Radioiodine uptake test and thyroglobulin assay showed complete ablation in the majority of total, but not of partial thyroidectomy patients (204g).
The rate of patient rehabilitation is probably quickest with surgery. Although the source of hormone is directly and immediately removed by surgery, the patient usually must undergo one to three months of preparation before operation. The total time from diagnosis through operative convalescence is thus three to four months. Antithyroid drugs, in contrast, provide at best only 30 – 40% permanent control after one year of therapy. Iodine-131 can assuredly induce prompt remission. Low dose protocols, as noted, are plagued by a need for medical management and retreatment over one to three years before all patients are euthyroid. Treatment with higher doses provides more certain remission at the expense of hypothyroidism.
There are several strong contraindications to surgery, including previous thyroid surgery, severe coincident heart or lung disease, the lack of a well-qualified surgeon, and pregnancy in the third trimester, since anesthesia and surgery may induce premature labor. More enthusiastic surgeons have in the past recommended surgery for all children as the initial approach, claiming that there is less interference with normal growth and development than with prolonged antithyroid drug treatment . Therapy for childhood thyrotoxicosis is discussed further below.
Preparation for Surgery
Antithyroid drugs of the thiocarbamide group are employed to induce a euthyroid state before subtotal thyroidectomy when surgery is the desired form of treatment. Two approaches are used. Mmethimazole (or PTU if used) may be administered until the patient becomes euthyroid. After this state has been reached, and while the patient is maintained on full doses of thiocarbamides, Lugol’s solution or a saturated solution of potassium iodide is administered for 7 – 10 days. This therapy induces an involution of the gland and decreases its vascularity, a factor surgeons find helpful in the subsequent thyroidectomy. In one study Lugol solution treatment resulted in a 9.3-fold decreased rate of intraoperative blood loss. Preoperative Lugol solution treatment decreased the rate of blood flow, thyroid vascularity measured by histomorphometry , and intraoperative blood loss during thyroidectomy(191.1).
The iodide should be given only while the patient is under the effect of full doses of the antithyroid drug; otherwise, the iodide may permit an exacerbation of the thyrotoxicosis. Alternatively patients 