Thyroidectomy for hyperthyroidism before the euthyroid state: is it safe?

Guidelines generally recommend achieving a biochemically euthyroid state before thyroidectomy in patients with an indication for surgery to reduce the risk of thyroid storm. However, in real-world settings, this may not always be feasible. This study aimed to compare perioperative outcomes between biochemically controlled (normal fT3 and fT4) and uncontrolled (elevated fT3 and/or fT4) hyperthyroid patients undergoing thyroidectomy.

We retrospectively analyzed patients who underwent thyroidectomy for hyperthyroidism at our institution between September 2020 and 2024. The demographic, perioperative, and postoperative data were collected. Patients with preoperative fT3 and/or fT4 levels above the institutional reference range were classified as uncontrolled, whereas those with both fT3 and fT4 levels within the reference range were considered controlled. The outcomes were compared between the controlled and uncontrolled groups.

A total of 110 patients were included: 92 (83.6%) in the controlled group and 18 (16.4%) in the uncontrolled group. Patients in the uncontrolled group were significantly younger (median age 33.5 vs. 49 years, p = 0.015). Graves' disease was more prevalent among uncontrolled patients (83.3% vs. 45.7%, p = 0.013). The use of Lugol's iodine (27.8% vs. 1.1%, p < 0.001) and steroids (38.9% vs. 6.5%, p < 0.001) was significantly higher in the uncontrolled group than in the control group. Operative times and complication rates-including transient/permanent hypocalcemia, recurrent laryngeal nerve palsy, and neck hematoma-did not significantly differ between the groups.

Despite the presence of biochemical hyperthyroidism, no thyroid storm occurred in our cohort, and complication rates were comparable between groups. These findings suggest that thyroidectomy may be performed in selected patients without full biochemical control, particularly in urgent situations or in high-volume centers with experienced surgical teams. However, biochemical euthyroidism remains the standard of care, and our results should be interpreted cautiously given the small sample size and single-center setting.