Reoperation as treatment of relapse after subtotal thyroidectomy in Graves' disease

Background and methods. In Graves' disease radioiodine is the recommended t reatment for relapses after subtotal thyroidectomy. If patients reject radi oiodine, hyperthyroidism is managed with antithyroid drugs; surgery is gene rally not considered as an alternative. Here we retrospectively analyzed 30 consecutive patients with Graves' disease who had recurrent hyperthyroidis m after subtotal thyroidectomy. Results. On relapse after the first operation, the patients were initially treated by medication; 25 opted for definitive treatment (19 for reoperatio n and 6 for radioiodine). Operations consisted of 10 unilateral and 8 bilat eral resections (total or near-total with capsular remnants of <1 g) and 1 transsternal approach (because of dystopic intrathoracic thyroid tissue). T he decision between a unilateral and a bilateral reintervention was based o n the ultrasonographic determination of remnant volumes. These size estimat es were valid because they were significantly correlated to the weight of t he resected remnants (r = 0.92, slope = 0.95). Eighteen of the 19 patients were adequately treated by this approach. Unilateral resection was performe d in 1 patient with a remaining contralateral remnant of 5.4 mL; this patie nt had a second relapse. The complication rate was low (2 cases of transien t recurrent nerve injury and 1 of transient hypocalcemia). Conclusion. Provided that no contraindication is present, reoperation is sa fe, effective, and expeditious in recurrent hyperthyroidism. Because the li kelihood of a recurrence depends on the total remnant size, the goal is to keep it below 2 g. Preoperative ultrasonography can effectively guide the d ecision between a unilateral and a bilateral resection.