Surgery hyperthyroid patients

Preparation of hyperthyroid patients for surgery can be satisfactorily achieved by making them euthyroid with one of the above drugs plus a P-adrenoceptor blocker for comfort (see below) and safety, and adding iodide for 7-10 days before operation (not sooner) to reduce the surgically inconvenient vascularity of the gland. 

Hyperthyroidism (excessive production of thyroid hormones) asually requires surgery, but before. surgery the patient mu.st be prepared by preliminary abolition of the hyper-thyroidi.sm through the use of antithyroid drugs. Thiourea and related eompounds. show an antithyroid activity, but they arc too toxic for clinical use. The more useful drugs are 2-thiouracil derivatives and a closely related 2-thioimidazolc derivative. All of these appear to have a similar mechanism of action (i.c.. prevention of the iodination of the precursors of thyroxine and triiodothyronine). The main difference in the compounds lies in their relative toxieities. 

Three common treatment modalities are used in the management of hyperthyroidism surgery, antithyroid medications, and radioactive iodine (RAI) (Table 73-5). The overall therapeutic objectives are to eliminate the excess thyroid hormone and minimize the symptoms and long-term consequences of hyperthyroidism. Therapy must be individuahzed based on the type and severity of hyperthyroidism, patient age and gender, existence of nonthyroidal con-... 

To prepare hyperthyroid patients for thyroid surgery, thyrotoxic crisis, thyroid blocking in radiation therapy... 

Polythiouracil is used in the preparation of the hyperthyroid patient for surgery. It is also employed in the complete management and treatment of hyperthyroidism spread over a period ranging from 6 months to 3 years. 

Propranolol (Inderal) P adrenergic receptor antagonist. Suppresses tachycardia and other catecholamine effects. Emergent preparation of hyperthyroid patients for surgery. Thyrotoxicosis in pregnancy. Thyroid storm. CNS sedation and depression. Suppression of failing heart. 

Overtly hyperthyroid patients need to be pretreated with antithyroid drugs, as described above, before undergoing surgery in order to reduce perioperative mortality and morbidity. The exception is cases of thyroid storm, where emergency operation is scheduled within 48 h, because a delay would worsen the prognosis of the patient. 

After therapy (thionamides, RAI, or surgery) for hyperthyroidism has been initiated, patients should be evaluated on a monthly basis until they reach a euthyroid condition. 

Leukemia does not occur more often in patients treated with 131I for hyperthyroidism than in similar patients treated by surgery. After use of the high doses used in the treatment of thyroid cancer there was a definite increase in the incidence of leukemia (18). 

There is an increased incidence of late hypothyroidism in patients with autoimmune hyperthyroidism, but the risk increases markedly after extensive thyroid surgery and especially after I treatment. Analysis of the cumulative incidence of hjrpothjroidism shows two phases an early phase of radiation death of thyroid cells, depending on the I dosage and occurring during the first 1-2 years after treatment a second period of a lower (0.5-3.5% per year) but hfe-long risk of developing hypothyroidism for a variety of reasons (natural history of the disease, autoimmune processes) (see Table 1) (12-14). 

The thioamides are often used as primary therapy for hyperthyroidism. They are also used as adjunctive therapy to achieve euthyroidism in patients prior to surgery or radioactive iodine therapy. The thioamides primarily inhibit... 

Acute symptomatic hypocalcemia may be seen in hospitalized patients for various reasons. Rapid remineralization of bone after surgery for primary hyperparathyroidism (hungry bone syndrome), treatment for hyperthyroidism, or treatment for hematological malignancy may result in hypocalcemia. Acute hemorrhagic or edematous pancreatitis is frequently complicated by hypocalcemia. Vitamin D deficiency may also be associated with hypocalcemia because of impaired intestinal absorption of calcium and skeletal resistance to PTH. Osteomalacia and rickets are discussed in a later section of this chapter. 

The overall morbidity rate with surgery is 2.7%. Hyperthyroidism persists or recurs in 0.6% to 17.9% of patients after thyroidectomy for Graves disease and is more common in children. The most common complications of surgery include hypothyroidism (up to about 49%), hypoparathyroidism (up to 3.9%), and vocal cord ab-normahties (up to 5.4%). The frequent occurrence of hypothyroidism following surgery requires periodic follow-up for identification and treatment of these patients. ... 

Saenger et al. (1968) studied 36 (XX) patients with hyperthyroidism (a cancer causing the thyroid to grow), of which 22 (X)0 were treated with (only / , no 7 local doses of several hundred Sv) while the rest underwent surgery or chemical therapy. Although the 1 patients received bone marrow doses of about 100 mSv, no difference was observed in relation to the non-irradiated group with respect to incidence of leukemia. 

In the morbid state produced by excessive secretion of the thyroid gland i.e., hyperthyroidism, the only remedial measure is surgery. However, for pre-surgery treatment the patient must be administered with antithyroid drugs to abolish hyperthyroidism to a considerable extent. 

Patients were registered as hyperthyroid if they had been treated for hyperthyroidism by surgery RAI or medication, or if they had a history of hyperthyroidism on the thyroid register. Patients on long-term thyroid replacement therapy according to the MEMO database were registered as hypothyroid. A validation of the database system was performed in 450 patients from general practice. A positive predictive value of 0.98 and 0.96 was found for treated hyperthyroidism and hypothyroidism, respectively. 

To ensure a definitive cure of hyperthyroidism, radioiodine treatment or surgery is available. Long-term use of thionamide drugs may be advisable only in severely ill and multimorbid patients, who are unable to undergo one of these two treatments. 

The direct and immediate treatment result, as opposed to the delayed effect of radioiodine, is another advantage of surgery. The latter may be particularly relevant to patients who require rapid correction of thyrotoxicosis in case of thyroid storm or severe iodine-induced hyperthyroidism. 

The choice of treatment is discussed by the specialist and the patient. In the absence of one of the indications for surgery, we would suggest radioiodine treatment as the first choice. In case of overt hyperthyroidism, pretreatment with antithyroid drugs may be necessary. Optimum treatment modalities including the presence of a suppressed TSH in toxic adenoma or multinodular goiter should be established. On the one hand, patient s fears regarding radiation exposure and, on the other hand, possible surgical complication often infiuence the decision and have to be addressed. 

Uses Treatment with the thionamides thia-mazole (carbimazole), its active metabolite methimazole, or propylthiouracil remains one of the main therapeutic methods in hyperthyroidism. Unlike treatment with or surgery, thionamides are not ablative and permanent remission rates are low, even after prolonged administration. Suppression of serum thyrotropin (TSH) when antithyroid drugs are discontinued is a poor prognostic indicator of cure [13 ]. In a retrospective study there were higher remission rates at 6,12, and 24 months after withdrawal of antithyroid drugs in 40 subjects who had mild hypothyroidism (serum TSH over 10 pIU/l) compared with 37 sex- and age-matched patients who remained euthyroid during treatment with... 

The administration of SSKI a few days after for the treatment of hyperthyroid Graves disease and continued for weeks later has been reported to more rapidly ameliorate the symptoms of thyrotoxicosis and to reduce the dose of l necessary to effectively treat the hyperthyroidism (10). However, hypothyroidism not infrequently occurred during iodide therapy and disappeared when iodides were discontinued. Years ago, we reported that the administration of 5 drops SSKI to euthyroid patients treated years earlier with 1 or surgery for Graves disease almost always induced hypothyroidism within weeks (11). The euthyroid state rapidly returned when the iodine was withdrawn. It is likely that these... 

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