Know Your Options: Thyroidectomy for Graves Disease

This transcript has been edited for clarity.

Kaniksha Desai, MD: Welcome to today's video commentary on thyroidectomy for the treatment of Graves disease. I'm Kaniksha Desai, an endocrinologist from Stanford University School of Medicine and your moderator. Joining me today are two esteemed thyroidologists, Dr Tracy Tylee and Dr Quan-Yang Duh.

Dr Tylee is associate professor of medicine at the University of Washington in Seattle and serves as a program director in the Division of Endocrinology for their fellowship. Dr Duh is joining us from the University of California, San Francisco where he is the chief of endocrine surgery. Both are experts in managing Graves disease along with the use of thyroidectomy for the treatment of Graves disease.

As some of you may know, thyroidectomy is the least-used treatment option of Graves disease. In today's session, we will explore the indications, techniques, and outcomes of thyroidectomy in the management of Graves disease and why you should consider it as a primary form of treatment for some of our patients with Graves disease.

I wanted to start off with our endocrinologist, Dr Tylee. Can you briefly review Graves disease in a sentence or two and then focus on the common treatment options for Graves disease, specifically for surgery as a treatment option?

Tracy S. Tylee, MD: Graves disease is one of the most common causes of hyperthyroidism in the United States due to antibodies targeted against the thyroid-stimulating hormone receptor. These antibodies essentially turn on the thyroid and lead to uncontrolled thyroid hormone production.

The treatment options we have for Graves disease are targeted primarily at the level of the thyroid in preventing excess thyroid hormone. We don't currently have treatments targeting the underlying pathophysiology of Graves disease, which would be targeting the antibodies.

To control the hyperthyroidism associated with Graves disease, we can treat patients with a medication. Methimazole is the most commonly used in the United States, which interferes with thyroid hormone production and decreases the amount of thyroid hormone that the thyroid can produce.

Alternatively, we can target the thyroid itself, destroying it through radioactive iodine or removing the thyroid through surgery. These all are valid options for controlling the hyperthyroidism associated with Graves disease, but they each have different risks and benefits, which is what we often have to consider when making recommendations to patients.

Desai: How common is a thyroidectomy? In what circumstances would you recommend a thyroidectomy for primary treatment of Graves disease?

Tylee: As you mentioned earlier, it's uncommonly used for treating Graves disease. Historically, in the United States, radioactive iodine was most commonly used. Over the past 10 years, that shift has really moved toward the antithyroid medications, and that typically is our first-line therapy.

The main reason for that is there's a small chance that patients with Graves disease could go into remission, and there's a chance that they would be able to go off all medication over time. Unfortunately, if they're treated with radioactive iodine or surgery, they're going to be hypothyroid lifelong and require medication. Using one of those two options as our primary treatment is not very common.

However, there are some patients where methimazole or the antithyroid medications just aren't effective. Either they have adverse reactions to the medications, they are not able to tolerate the medications, or they're planning pregnancy, in which the medications are not an ideal choice.

Most of the cases where I've referred patients to surgery were where we just have a very hard time controlling their thyroid hormone levels, despite adequate doses of medication. They feel miserable. They've been hyperthyroid for months. We can't get things under control, and they just want to be done with it. Surgery is a great option because it's going to be the quickest way to control their hyperthyroidism. Then, even though they'll be hypothyroid, we can work to get them on a stable dose of levothyroxine post-op.

Desai: Dr Duh, I know you just get the referrals for surgery, but is there an ideal patient that you get for surgery?

Quan-Yang Duh, MD: The ideal patient usually doesn't need a thyroidectomy, and that's a problem. The usual patients that I see who need a thyroidectomy have issues that are specifically related to things that are better treated surgically. The most common one is eye disease. I think patients with eye disease, in general, do better with less disease progression in the eye disease with surgery because you remove the gland and you remove all the antigens. I think there's enough support that for patients who have bad enough ophthalmopathy, that's what the best treatment is.

I don't know about how the newer medications would affect the need for surgery. That's probably one of the most common things. The other ones are, as Dr Tylee just mentioned, issues with the medication. I have seen patients develop agranulocytosis, for example. Those things are pretty rare. There may be liver function abnormality that they're worrying about or they just don't like to take the medicine.

For those who are very impatient, surgery, obviously, is the fastest thing to do. Another group that used to be more common was Graves disease patients with nodules. I think we're better now in evaluating the nodules. In the old days, somebody with Graves disease with a nodule would say, "Let's just take it out." It was much easier.

Nowadays, we're able to evaluate the nodules and obviously, these are usually by definition called nodules. Now, if there's some concern, you can use biopsy to alleviate those concerns. I think that is not as common anymore. The people who want to get pregnant and they want to get pregnant soon, they don't want to wait for remission. We see young patients that are already thinking about doing in vitro fertilization and all that kind of stuff, so it's just easier for them.

Desai: We talked about some patients who would really benefit from the surgery, including patients with complications of methimazole, pregnant patients, and patients with thyroid eye disease.

Dr Tylee, can you talk about some of the risks and benefits of doing a total thyroidectomy, specifically for those groups and just in general compared to radioactive iodine and antithyroid medications?

Tylee: I think that's the discussion that we have with patients. Because all these treatment options work, the discussion of the risks and benefits and which ones of those are most acceptable to our patients is really the big part of the discussion. The main risk, other than the surgical risks with surgery, is that the patients are 100% of the time going to be hypothyroid after the surgery. They're essentially going to be trading their methimazole for levothyroxine.

Levothyroxine is a very safe medication. We can use it during pregnancy. We are not going to see the side effects of agranulocytosis or liver function abnormalities, so it's considered a very safe medication to take. Patients are going to need to be on a medication lifelong, and that's something that they need to be okay with.

There's a large amount of information about thyroid disease out there. Many patients are worried about gaining weight or being tired, and they don't want to have to deal with these issues. That's an important consideration as well, although in all honesty, most patients with Graves disease who then are subsequently treated are going to gain some amount of weight because of the shift in their metabolism.

When we compare it to the other treatment options, with methimazole and the antithyroid medications, there is that possibility of remission and the possibility of being without medication. There's only about a 30% chance of that. Whereas the risks with the medication, again, are that you're on a lifelong medication. There are the negative side effects of that, with the liver function abnormalities and the agranulocytosis.

With the radioactive iodine, those patients are also most likely going to be hypothyroid. That's the same for both of those. It also can take up to 6 months for your thyroid hormone levels to normalize, whereas with surgery, you're going to be euthyroid when you come out of the operating room, and you're started on your thyroid hormone replacement. Surgery is a quicker resolution.

The medication you're going to be on is going to have fewer side effects than the methimazole, but it does carry the risk for surgical complications that we would see that you're not going to have with the other options. For someone who's a poor surgical risk, it's obviously not going to be a good option for them because we have two other options that are equally good at carrying the hyperthyroidism and probably safer for those patients. I would argue that for many patients, surgery is a very good and valid option.

Desai: Speaking of those complications, Dr Duh, can you talk a little bit about some of those complications that you see in your surgical patients? Is it different for Graves disease vs cancer patients vs goiter patients?

Duh: The usual three complications we talk about related to thyroid operations are injury to the recurrent laryngeal nerves and other nerves, injury to parathyroid glands causing hypoparathyroidism, and then bleeding after the operation that require reoperation for neck hematoma.

If we take it one at a time, for recurrent laryngeal nerve injury, the usual rate we quote to patients is about a 5% chance of at least temporary injury. In the best centers, there would be about a 1% chance of permanent rate. Now, keep in mind that if you're trying to do a total thyroidectomy and you injure the nerve on the first side, you will probably end up with a lobectomy or at best a subtotal thyroidectomy.

The hypoparathyroidism rate is usually also quoted at 5% temporary and 1% permanent, but the real rate is at least double that. We know the risk for parathyroid problems, with the Graves disease gland the way it is, tends to be higher. Actually, between the two, hypoparathyroidism probably is a worse problem, which is underappreciated.

If you end up with a unilateral vocal cord paralysis, that's permanent, and if the voice is bad, you can get a vocal cord injection augmentation/medialization at one shot and your voice is, if not 100%, back to 90%.

If you are permanently hypoparathyroid, that's a problem. That's a worst problem to take care of than anything else. Actually, usually the surgeons give those patients to the endocrinologists to take care of. In fact, I emphasize that issue with my patients more than anything else because there is no good treatment for it.

The bleeding issue is also more common in Graves disease. My usual quote to the patient is about 1 in 100 to 1 in 200 patients may require reoperation because they bleed into the neck. Graves disease glands tend to be quite vascular. Usually, blood loss in a Graves disease patient's operation tend to be higher. Those are the usual three things we tell our patients.

Another thing that's very obvious, but it seems to be an issue for many patients nowadays, is scarring in the neck. Now, surgeons tend to downplay that by saying, "Well, you had an operation so you have a scar." A scar in the neck vs a scar someplace else is a different issue.

That's why, especially in places like Asia, a good number of these operations are being done through remote access, making incisions outside of the neck — transaxillary, transbreast, and even transoral, can take it out through the mouth — using robots and doing all kinds of things. There's a large amount of effort to try to avoid a scar in the neck. For some people, that's actually a very important issue and that would be taken into the consideration of whether or not somebody wants an operation.

Desai: Speaking of some of those complications, would there be any benefit of making sure the patient is euthyroid before surgery or adding any sort of potassium iodine from your perspective?

Duh: A couple of things. I usually tell my patients that even though we're going to treat the hyperthyroidism permanently with surgery, we still would prefer them to be euthyroid. The anesthesia will be safer, and at least theoretically, the risk for thyroid storm would be lower. I do have to tell you, even though we talked about it all the time, I actually have not seen a single case of a thyroid storm perioperatively, but we always prepare for it.

We would definitely like to have the patient well prepared. In a pinch, if somebody just cannot be controlled well or is allergic to the medical treatment, and we just have to get it done, beta-blockers actually can be used for it.

The use of iodine as a preoperative preparation has a very interesting history. Traditionally, people use Lugol's solution, which is a little bit less strong than potassium iodine, but they're basically used the same way. The idea is you load the patient up with iodine, and through the Wolff-Chaikoff effect, it will make them less hyperthyroid.

More importantly, the interesting thing is that iodine seems to shrink the thyroid. It's well known that it makes things less vascular. Many good studies have shown less blood loss in the range of 20 or 30 cc. There is not a difference in terms of transfusion or anything like that, but it does make things less bloody.

Interestingly enough, if you ask the audience in a national meeting of surgeons, probably half of the people would raise their hand and say they use it, and the other half don't use it. The reason is that some surgeons would rather have a soft gland, even though it may be friable and bloodier, which is easier to manipulate than a very hard, firm, but less bloody thyroid.

It's almost a personal choice. I don't make a big deal. I usually use it, and I usually order it. Historically, you tell the patient to take it for 10 days before, but I usually do it at 7 days. The reason is that, in the old days, when scheduling could be an issue, if something happened at 7 days, you had 1 more week to get the patient back on the schedule to get it done. After that, it's no good.

I do it for 7 days. If my patient forgets to take it or whatever, I don't make a big deal out of it. It's just a little bit of a different operation. It's got a good story behind it. Actually, it's difficult to get Lugol's solution nowadays. Many pharmacies don't have it.

Desai: Dr Tylee, from your perspective, ideally you would use methimazole to get the patient euthyroid. Do you use iodine frequently?

Tylee: Often in referring patients to surgeons, I defer or at least have conversations with the surgeon to prepare the patient for it because honestly, you don't want to start the iodine until you know the patient is going to surgery. They will have already had their consultation with the surgeon.

I have several surgeons that I work very closely with. An important part is you want to make sure you're both on the same page. They'll let me know if they need me to prescribe the iodine, which I'm happy to do, although as you mentioned, it's sometimes a little hard to track down, in which case, we just use methimazole to get them euthyroid.

If the patient is euthyroid, the surgeon is usually happy to go ahead with it. I have one surgeon who really likes iodine, another one who doesn't care as much. It's very much what Dr Duh said; it seems to be independent. I do always start all my patients on methimazole if there are no contraindications.

For many of them, they want to do that for a short course anyway — a short course being a year — to see if they can go into remission before making a final decision. The iodine is done in conjunction with the surgeon.

Duh: Let me add one thing. Some surgeons, and recently, I have begun to do that, is to start the patient on some oral calcium. I don't use calcitriol. The reason is that because these patients are at higher risk for postoperative hypocalcemia.

For most of my standard thyroid operations, I start some oral calcium afterward and then stop them. For Graves patients, I tend to get them going a little bit earlier so they are used to taking some calcium because many of them will need it. It's good that they know where they put their bottles of Tums and where the prescription is.

Desai: There is one other surgical question I wanted to ask for you, Dr Duh, because I get this question frequently from my patients. Can you do a subtotal so that you make the patient euthyroid without making them hypothyroid?

Duh: It's a great question. I can spend the next 2 hours talking about this. I have great stories. Historically, when Kocher first did a thyroid operation, he did total thyroidectomy, and of course, he found out that the patient became hypothyroid. That was one of the reasons he got his Nobel Prize.

He switched to subtotal resections for all his patients, not just Graves patients, because we didn't have enough knowledge about thyroid hormone supplementation. For the longest time, historically, the treatment was a subtotal thyroidectomy. The way most people have done it before is to do a bilateral subtotal, leaving a small amount, anywhere from 2 to 4 g, on each side.

Subsequent to that, a very famous surgeon, Dr Dunhill, came out with the Dunhill procedure, which is one side a total lobectomy and the other side a subtotal. Usually, the surgeon would be in the operating room and say, "I'm leaving the size of my thumb there," and that's somewhere around 4-6 g. I've done that. I grew up in the days when that was a standard operation.

Now, the bad thing is that a surgeon never can get it exactly right. You either get it too little so you still have some hyperthyroidism, or you get it too much and they still need to take some thyroid medication. The complication rate turns out to be about the same. Even though you think you leave something behind so you can prevent more complications, the complication rate isn't that different. That's the reason why we came to the conclusion that everybody should just get a total.

Knowing that historical perspective tells you several things. One is when the surgeon is doing a thyroid operation for Graves disease, he or she does not have to be as aggressive about making sure every last bit of thyroid comes out because whatever you leave behind is not going to be enough to cause patient hyperthyroidism.

I make a little bit more effort when I'm doing somebody with eye disease because then, your idea is to leave as little antigen as possible behind. If I'm doing it for hyperthyroidism, most surgeons doing even the so-called near-total thyroidectomy are not going to leave that much anyway. Hopefully, if you do the Dunhill procedure, you have a better chance of protecting some of the parathyroid. That's one of the reasons to do it.

If the patient is interested in it and understands the whole story of this, historically, when I used to do it, I would say 80% of the time we can actually hit it within a reasonable range. The trouble is that the other 20% end up still not quite, but one can argue that that may be okay.

For people who work and are doing operations in resource-constrained areas, where patients may actually have trouble getting thyroid hormone consistently, subtotal thyroidectomy is still being used. That's what you do in some countries that don't get thyroid hormone, but you do take some of these risks in terms of either incomplete operation — in that case, you may still have to take some medication, but maybe not as much, Or in fact, you do enough that you still have to take some thyroid hormone.

Desai: I wanted to transition over to the postoperative management. Dr Tylee, I know Dr Duh said he recommended patients to take calcium. Do you recommend them to take calcium? How do you dose their thyroid hormone postoperatively?

Tylee: Usually, when they come to me post-op, the surgeon has had them on calcium. By the time they're seeing me, we're deciding whether or not they can stop it. All my patients are started on calcium post-op. I hadn't been starting patients preoperatively on calcium, but now, I may be doing that. If I'm sending someone for surgery for their Graves disease, we may discuss making sure they're on enough calcium.

Coming from post-op, they're usually started on levothyroxine as well. Again, working with our thyroid surgeons, we're pretty similar on the dosing. It's weight-based, usually about 1.6 µg/kg/d, give or take. If it's a really high dose, that makes me a little nervous. For an elderly patient or someone who's at really high risk for complications for hyperthyroidism, we may purposely underdose.

By the time I see them in follow-up, it's usually about 4-6 weeks after surgery. We get their repeat labs and then adjust the dose from there. It usually takes 3-6 months to get them on a stable dose.

For Graves disease, once they're on a stable dose of levothyroxine, I can send them back to their primary care for long-term follow-up because unlike thyroid cancer patients, there's not a lot of ongoing surveillance as long as they remain euthyroid. They are always welcome to come back and see me if they develop symptoms of Graves disease again because it's always possible, although unlikely.

Desai: What are the questions with that? Do either of you check parathyroid levels postoperatively? Do you base any sort of calcitriol regimen on the parathyroid? I know some surgeons do.

Duh: That's a good question. I think many of us now get a parathyroid level. The end of the case may be as short as 10 minutes and as long as being in the recovery room, so that would be a few hours after the operation, and looking at the parathyroid level to predict how likely somebody may be severely hypoparathyroid.

The usual generalization to think about it is that if somebody has a parathyroid level of above 20, and there's enough half-life, and you know that's almost a steady state, those patients in general will be fine. If they need calcium at all, they won't need it for long.

Anything above 10, they're going to be unlikely to need some real serious treatment. When they're below 10, in some institutions, they're automatically started on calcitriol. That's the way people distinguish these things. I can't get them in the recovery room, so I get it at the end of the operation, and I gauge my aggressiveness of calcium treatment on that.

My usual thing is I just give them calcium carbonate, Tums. About 1 g twice a day will be the usual. Some people give them 2 g twice a day. For people who have gastric operations or some other trouble and are on antacids, we may use calcium citrate.

The reason we use calcium carbonate perioperatively is that it works faster. We give patients the Tums and say, "You take this twice a day. If you get tingling and numbness, take extra. You take as much extra as you want because it won't hurt you. If you're taking much more, you should call me so we can send you to the lab."

That way, you can prevent many phone calls. You can prevent some emergency room visits. The worst case for these patients is that they go to the emergency room. Frequently, the people in the emergency department don't understand these things and then get everybody all upset; they hyperventilate and make things worse. The next thing you know, it's intravenous calcium and all that stuff.

They have to take extra Tums. I tell people to take as much as they can because it won't hurt them, but they obviously should have it checked if they're taking a large amount of calcium.

Desai: Do you ever have patients who get hypercalcemic? Dr Tylee, have you ever seen the opposite?

Tylee: I've never seen anyone get hypercalcemic after thyroid surgery.

Duh: Not on oral calcium.

Tylee: They get tired of taking that stuff. By the time they come to see me, they've usually stopped it because they can't remember to take four Tums a day. If they have a low parathyroid post-op, I will check it when I see them on follow-up because very often, it's temporary. By the time I see them, it's back to normal, and we can get them off of it. If they had normal parathyroid calcium after the operating room, I don't repeat it when I see them.

Duh: Actually, I tell my patients that after 4 or 5 days, they are allowed to either drop lower or just stop the calcium because the nadir for calcium occurs between 2 and 3 days. If it has been 4 or 5 days, they don't have any symptoms, and they're not taking any extra calcium, chances are they're not going to be the people that really need it. If taking calcium is a problem, they should just stop. It's perfectly fine.

Desai: We talked about the short-term complications. What about long term? What is quality of life in these patients? I'll start with you, Dr Tylee.

Tylee: I think that for my patients who have had surgery for their Graves disease, usually the quality of life before surgery is not good. That's a big reason why we're thinking about surgery. I have mostly two or three categories of patients. One is the eye disease, so the patients who have eye disease, cannot get radioactive iodine, and are not happy with methimazole. For those patients, the eye disease is very often the main driver of their quality of life.

For the other patients — the ones who are planning pregnancy, surgery — getting started on levothyroxine often takes much of the anxiety of the medications, taking methimazole during pregnancy, worrying about hyperthyroidism recurring during pregnancy, all of that, makes it easier to manage. People are happy on the levothyroxine for the most part.

The ones who really struggle with methimazole, who have side effects, who can't get their levels controlled, who have to go up to 20 and then they become hypothyroid so we have to drop to 5, they become hyperthyroid again, and we're doing this up and down, they really feel awful. They're frustrated and they just want to be done with it. Very often, after surgery, they feel great because things are stable. The levothyroxine is easier to manage than the methimazole was.

It's obviously not going to be for everyone. Not everyone is going to feel perfect after having thyroidectomy. They may struggle with their levothyroxine replacement, but I haven't had anyone whose quality of life is worse after surgery. So far, everyone has felt better, like I said, often because they're not doing well going into it.

Desai: I guess you agree, Dr Duh?

Duh: I agree. I do want to put in a caveat. If the patient is planning for pregnancy and that is a reason why they have a thyroidectomy, one of the worst complications you can have is actually hypoparathyroidism. Now, that pregnancy becomes complicated for a different reason. It's not the Graves, but now you've got to manage the calcium and hypoparathyroidism during pregnancy. That can be a bit of a chore. In terms of making people's life better or worse, you can definitely make things worse. But the rest? They are happier.

Tylee: With the pregnancy, if they have very mild Graves disease, oftentimes we'll just let them go and see if we can get them off medication altogether. Overall, the goal is to do as little as possible to disrupt a patient's life. If they can become euthyroid without medication, great. If we can put them on levothyroxine and keep them stable, that's great.

For pregnancy, that is definitely a consideration. We don't want to make things worse. In some cases, we just let them be and see how they do before we make any decisions.

Desai: I know you talked about coordinating care. Can each of you briefly talk about how your practice works in conjunction with the other?

Tylee: When I have a patient who wants surgery for their Graves disease, I usually send a message directly to whichever surgeon I'm referring to within our system. It's easy for us because we're all in the same system, so I can just send a message in our EMR. We're lucky in that we have a number of very good thyroid surgeons within our institution.

I let them know what we're thinking and why we're discussing surgery. I know my surgeons won't do surgery if it's not appropriate, which I very much appreciate.

I always tell that to the patient, emphasizing that this is not you signing up for surgery. This is you having a discussion with the surgeon about what surgery might look like. It may not be the right choice for you, but I really think it's in their best interest to hear about surgery from a surgeon rather than to hear about surgery from me.

That's another thing I really appreciate about the surgeons that I work with is they're happy to see these patients, even if they ultimately end up not doing surgery, which is why I trust them — because they're going to say no in the appropriate situations.

Duh: I would agree with that. In fact frequently, when the patients show up, I explain to them that the good endocrinologists are very liberal in sending patients to surgeons. A good surgeon in general is very conservative in recommending surgery for the patient. That is a good combination.

A bad combination would be an endocrinologist who is afraid to send patients to the surgeons, and surgeons who operate on everything that walks in. That would be the bad thing. Sometimes, my patients say, "Well, why did my doctor send me to you if I don't need an operation?" It's actually important that they know that.

The other thing is when you work with people you know, you also get a sense of how liberal somebody is. I have people that refer patients to me within a month of diagnosis of Graves disease because their sense is that this patient has a high probability that they will need surgery as an option.

Some of these patients I'll see and say, "Okay, go back and do your thing, and then see me 6 months later." Once in a while, we have some people with terrible eye disease, and everybody knows that they just have to get it done.

Desai: For my practice, I have multiple surgeons as well. We use both endocrine surgery and head and neck surgery here at Stanford. We have great relationships with our surgeons. I agree we're in the side of send more and do less surgery than send less and do more surgery. I totally agree with that.

For the future, what do both of you see as an area of research or new development? I know we have some stuff coming out for eye disease. Is there any room for growth in this area?

Tylee: I think there's always room for growth. We don't yet have treatments targeting the actual underlying cause of Graves disease. Right now, we're either treating the eye disease or we're treating the thyroid disease. There are not many treatments for both, but we can target the underlying mechanism with the antibodies or the antibody signaling.

Immunotherapy, I think, would be an interesting future. It's always hard to know where that's going to fit into our treatment regimen given how cheap methimazole is and how expensive these medications are likely to be. Patients are definitely interested in treating the disease rather than destroying their thyroid.

That is something I hear very frequently from patients. They say, "My thyroid isn't the problem, it's the antibodies that are the problem. Why do you want to destroy my thyroid?" I think it's a reasonable approach. It'll be interesting to see, for these immunotherapies, how they develop and where they fit in.

Desai: Dr Duh, from a surgical perspective, do you see any changes?

Duh: Going back to thinking about Graves disease, it's weird from a surgeon's standpoint. We take out malignant tumors. We take out benign tumors that oversecrete. This is the only one that we're not really treating the basis or the source of the disease process. We're taking out the end organ because we can't control it otherwise. I'm looking forward to the days we don't have to operate on Graves disease patients.

I think the advances in surgery are in two fronts. One is things that are related to minimizing the external appearance and trauma that people feel of having incisions. All these new remote access operations that you see people do, although we don't seem to do it as much in the US, are very common, especially in Asia and some European countries.

Things like some of the percutaneous treatments are probably not going to go anywhere. Radiofrequency is definitely not something that you would use for something like this. In the operating room, there are things that you can do to prevent complications. We do them, and many people do these things.

For example, nowadays in the US and in Europe, neuromonitoring is a routine where you use these neuromonitoring devices to protect the nerve, number one, and also to predict whether the nerve is going to work. You avoid the major complication of having bilateral nerve injury. In fact, in addition, there are other nerves that some people don't usually think about, but with Graves disease being a bigger gland, usually, the chances of hurting the opera singer's nerve, the superior laryngeal nerve, are actually higher. It's important we use all these technologies to help us not hurt the nerve.

For the parathyroid, the newest thing is these autofluorescent devices. The parathyroid fluoresces at a particular wavelength about seven or eight times higher than the background of thyroid. There have been plenty of studies that show that you can lower the risk for inadvertent parathyroid removal and at least lower the risk for temporary hypoparathyroidism. It's a little bit hard to prove a long, permanent hypoparathyroidism because the rate, fortunately, is low enough that you can prove it statistically. I think many of these things are becoming more commonly used and can protect the parathyroid well.

Desai: Could both of you provide one or two summary points for our listeners on what you would recommend if you were considering thyroidectomy for your Graves patient?

Tylee: From my perspective, I think the most important thing is to offer it to patients. As endocrinologists, sometimes we're hesitant to recommend surgical treatment for conditions we know we could treat with medication or radioactive iodine, which we're actually more comfortable with ordering than with surgery. We need to recognize that, from a patient perspective, surgery actually may be a very reasonable option.

Many patients are concerned about radioactive iodine. I think we downplay their concerns and we downplay the possible long-term risks. I think it's a great option for people who are comfortable with that. We know it works really well.

We need to give patients the option of surgery, just making sure that they know it's there. Be realistic about the complications and the risks of the surgery, like we are with every other treatment option that we have for Graves disease. I think it's our responsibility to make sure patients understand they have three options for treating their Graves disease.

Duh: I would agree with that. I tell patients that for the majority of patients with Graves disease, surgery would not be the only or absolutely the best option. Most of the time, there are other options. My job is to make sure that they understand, at least for the surgical part of it, what's involved and what the risks are.

In general, the advantage is that it's very quick. You get it done, and it's done with, but it comes with noticeable complications that one has to deal with. I'm sure you have patients ask you that too. "If you were me, what would you have done?" Many times what I tell the patient is, "Well, I'm not you because we all have very different values."

I don't care if I have a scar on my neck. I mean, I already had my C-spine op, so another scar, like, what's the big deal? For some people, that may be the most important thing. If I have a temporary nerve injury, that would be bad. On the other hand, that would not be the end of the day. If I were a broadcaster or an actor, that could ruin my career.

Some people may think that taking thyroid hormone is the worst thing ever. I'm sure you hear some patients say, "Oh, it's just a pill." The kind of values that the patient has, I think, is very important. I think treatment for thyroid disease and treatment for Graves disease is probably the epitome of when we talk about patient centered and how you engage with the patients to make decisions about what is best for them.

Desai: Thank you both for joining me today on this video commentary to talk about thyroidectomy for Graves patients.

Tylee: Thank you.

Duh: Thank you.