title: Safety and efficacy of surgical management of hyperthyroidism: 15-year experience from a tertiary care center in a developing country.
abstract: BACKGROUND
  Ideal management of toxic goiter still remains elusive. Though surgical management of toxic multinodular goiter (MNG) is well accepted, surgical treatment of Graves' disease (GD) is still controversial in view of the presumed increased incidence of complications. In this paper, we discuss the experience of the surgical management of hyperthyroidism at a specialized tertiary care endocrine center in a developing country, highlighting the minimal morbidity and satisfactory outcome in experienced hands.
  
  
  METHODS
  We retrospectively reviewed 325 consecutive patients with hyperthyroidism managed surgically from 1990 to 2005. The etiologic diagnoses were Graves' disease (185), toxic MNG (105), and autonomously functioning thyroid nodules (AFTN) (n = 35). The indications for surgery in Graves' patients were large goiter, relapse after antithyroid drug therapy (ATD), Graves' ophthalmopathy, and presence of nodule. The indications for surgery in toxic MNG were retrosternal extension (n = 15), compressive symptoms (n = 20), and large size (grade II). Among the AFTN nodule size, those greater than 4 cm (85%) formed the major indication for surgery. Subjects with GD and toxic MNG were subjected to subtotal thyroidectomy (n = 93 prior to 1995) or total thyroidectomy (n = 205 post-1995). Hemithyroidectomy was the procedure of choice in patients with AFTN.
  
  
  RESULTS
  Patients with Graves' disease were younger in age, with shorter mean duration of goiter when compared with the other 2 groups. Eight percent of patients with Graves' disease without a clinically palpable nodule and 25% of those with nodules had associated differentiated carcinoma, including papillary, follicular, and medullary thyroid cancer. Four percent of patients with toxic MNG had malignancy. Complications included temporary hypocalcemia (24%), permanent hypocalcemia (3%), and permanent vocal-cord palsy (1%).
  
  
  CONCLUSIONS
  Surgery for hyperthyroidism has negligible mortality and acceptable morbidity in experienced hands. It is a definite option in selected cases. Immediate and permanent cure of hyperthyroidism is achieved, with no recurrences, after total thyroidectomy. The cosmetic outcome is good, with excellent patient satisfaction and acceptance.
authors.affiliation: Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae-Bareillei Road, Lucknow, Uttar Pradesh, 226014, India.
authors.forename: P V
authors.initials: PV
authors.lastname: Pradeep
authors.forename: Amit
authors.initials: A
authors.lastname: Agarwal
authors.forename: Mukta
authors.initials: M
authors.lastname: Baxi
authors.forename: Gaurav
authors.initials: G
authors.lastname: Agarwal
authors.forename: Sushil Kumar
authors.initials: SK
authors.lastname: Gupta
authors.forename: S K
authors.initials: SK
authors.lastname: Mishra
mesh_terms: D000328:Adult; D003906:Developing Countries; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006980:Hyperthyroidism / Q000209:etiology / Q000601:surgery*; D007194:India; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D012189:Retrospective Studies; D013965:Thyroidectomy / Q000009:adverse effects* / Q000401:mortality; D016896:Treatment Outcome