Surgery for Graves' disease: total versus subtotal thyroidectomy-results of a prospective randomized trial

The effect of surgery on Graves' orbitopathy (GO) is still controversial. Retrospective analyses of many authors (including our own group) demonstrated GO improvement after subtotal thyroid resection in up to 70% of operated patients, so the question arose whether total thyroidectomy could add anything to this pronounced positive effect on GO. We therefore performed a prospective randomized trial on 150 patients with Graves' disease (125 women, 25 men; mean thyroid volume 80.5 ml) comparing three surgical procedures (bilateral subtotal thyroid resection-total remnant < 4 ml; unilateral hemithyroidectomy with contralateral subtotal thyroid resection-remnant < 4 ml; total thyroidectomy) and their effect on postoperative GO changes, postoperative thyroid-stimulating hormone receptor (TSH-R) antibody titers, and postoperative complication rates. After a period of at least 6 months (6-36 months) GO had improved in 71% to 74% of all patients regardless of whether total or subtotal thyroidectomy was performed. TSH-R antibody titers showed no differences for the three surgical groups. Postoperative recurrent hyperthyroidism occurred in two patients with subtotal resections, and early postoperative hypoparathyroidism was more frequently detected in patients with total thyroidectomy than in those with subtotal thyroid resection (28% vs. 12%; p < 0.002). In respect to possible postoperative hypoparathyroidism and a lack of difference in postoperative GO changes, we do not advocate total thyroidectomy for patients with Graves' disease and Graves' orbitopathy but prefer radical subtotal thyroid resection with a remnant of less than 4 ml.