Abstract
Background
Thyroidectomies are routinely same-day elective procedures. The aim of this study was to investigate outcomes in patients who underwent uncommon urgent thyroidectomy.
Methods
We retrospectively reviewed patients diagnosed with thyrotoxicosis at a quaternary medical center between 2011 to 2023. Included were patients admitted non-electively with thyroidectomies performed during same hospital stay. Patient demographics, comorbidities, hospital course and operative outcomes were analyzed.
Results
Thirty patients met the inclusion criteria. The majority were female (60%) and Black (60%) with a mean age of 41 ± 14 years. At admission, 76.6% had undetectable thyrotropin levels (<0.01 µU/mL), and 26.7% were diagnosed with thyroid storm. Common presenting comorbidities included atrial fibrillation (53.3%), heart failure (40%), and liver failure (16.7%). Graves’ disease was diagnosed in 83.3% of patients, while 13.3% had amiodarone-induced thyrotoxicosis. Median hospital stay before surgery was 8 days (Interquartile range: 4 – 16). Indications for surgery were adverse medication events (30%), inadequate therapeutic effect by medication (30%), and worsening heart failure (26.7%). Postoperatively, 6.7% required reoperation for neck hematoma, 13.3% experienced temporary hypoparathyroidism, and 6.7% had hoarseness. Following surgery, 50% of patients with atrial fibrillation experienced resolution, and 50% with heart failure with reduced ejection fraction showed ultrasonic improvement. Within 30 days, 20% visited the emergency department, none due to thyroidectomy complications, and 13.3% were readmitted for comorbidities. One patient (3.3%) died from liver failure.
Conclusions
Patients who require an urgent thyroidectomy often have life-threatening comorbidities, particularly cardiac disease. Performing thyroidectomy in these patients can potentially create clinical homeostasis for further management of their comorbidities.
Keywords: Hyperthyroidism, Thyroidectomy
Introduction
Thyrotoxicosis is a clinical syndrome caused by excessive thyroid hormone (1). It can either arise from overactive thyroid such as Graves’ disease, or destruction of thyroid glands due to thyroiditis (2, 3). Thyrotoxicosis can be medically treated using antithyroid drug and radioactive iodine, with a failure rate of 52% and 15% respectively (4, 5). For patients with contraindications to the above methods, seeking definitive treatment, or having clear surgical benefits like obstructive goiter or concomitant malignancy, surgery is recommended.
Thyroidectomy is commonly performed as an elective outpatient procedure by experienced surgeons (6). Patients are usually maintained on antithyroid drug (ATD) preoperatively to achieve euthyroid state and reduce risk during anesthesia. While most thyroidectomies occur in preconditioned patients, some require urgent thyroidectomy due to life-threatening thyrotoxicosis and exacerbated comorbidities (7). Thyrotoxicosis, especially thyroid storm, can aggravate multiorgan decompensation with mortality ranging from 1.2 to 10% (8, 9). Life-threatening thyrotoxicosis, a severe manifestation of thyrotoxicosis, can cause significant current or imminent rapid deterioration of the patient’s clinical condition. Therefore, a surgeon’s decision on whether an early thyroidectomy should be performed can make a huge difference in these patients. Despite its significance, there is limited literature on urgent thyroidectomies. Here we aim to evaluate the clinical course and outcome of patients who underwent urgent thyroidectomies for thyrotoxicosis in a quaternary medical center over a decade.
Material and Methods
The study included adult patients who underwent thyroidectomy with a discharge diagnosis of thyrotoxicosis. Patients meeting the inclusion criteria were identified by the following ICD-9 and ICD-10 codes: 242.00 and 242.01 (toxic diffuse goiter with/without thyrotoxic crisis or storm), 242.10 (toxic uninodular goiter without mention of thyrotoxic crisis or storm), 242.20 (toxic multinodular goiter without mention of thyrotoxic crisis or storm), 242.80 (other specified thyrotoxicosis without mention of thyrotoxic crisis or storm), and 242.90 and 242.91 (thyrotoxicosis with/without mention of thyrotoxic crisis or storm, unspecified) and E05.00 and E05.01 (thyrotoxicosis with diffuse goiter with/without thyrotoxic crisis or storm), E05.20 and E05.21 (thyrotoxicosis with toxic single thyroid nodule with/without thyrotoxic crisis or storm), E05.80 (other thyrotoxicosis without thyrotoxic crisis or storm), and E05.90 (thyrotoxicosis, unspecified without thyrotoxic crisis or storm). We defined urgent thyroidectomy cases as patients who were admitted non-electively and whose condition necessitated an urgent thyroidectomy before discharge. This study was approved by the UAB Institutional Review Board.
Descriptive analysis was conducted on patient demographics, symptoms, and laboratory values. The normal reference ranges were: thyroid-stimulating hormone (TSH) 0.45 – 5.33 µU/mL, free T4 0.58 – 1.64 ng/dL, free T3 2.8 – 4.4 pg/mL, white blood cell count 4000 – 11000 cmm, hemoglobin 11.3 – 15.2 mg/dL (women), 13.5 – 17 mg/dL (men). The volume of the thyroid was calculated by multiplying the three dimensions of each thyroid lobe measured on neck ultrasound by a correction factor of 0.479, and then adding the results together (10). A patient’s overall health before surgery was assessed using American Society of Anesthesiologists (ASA) score.
The diagnosis of thyroid storm was established when the Burch-Wartofsky score on the initial endocrinology note following admission was greater than or equal to 45. Heart failure was defined as left ventricular ejection fraction ⩽40% (normal ⩾ 55%) or B-type natriuretic peptide (BNP) >400 pg/mL (normal < 100 pg/mL). Liver failure was diagnosed based on the presence of jaundice with hepatic encephalopathy within 4 weeks and laboratory evidence of increased international normalized ratio >1.5. Kidney failure was defined as the status of long-term dialysis or a confirmed estimated glomerular filtration rate (eGFR) <15 ml/min per 1.73 m2. Hypoparathyroidism was defined as parathyroid hormone less than 12 pg/mL accompanied by symptoms and/or signs of hypocalcemia. The need for urgent surgery was ascertained from the most recent notes prior to surgery. ATDs mentioned in this study specifically indicate methimazole and propylthiouracil. Adverse events and the adequacy of therapeutic effects of ATDs were determined based on the last endocrinology consult note before surgery. Improvement in atrial fibrillation and heart failure was determined using discharge summaries, subsequent clinic visits, or cardiac ultrasounds. Rates of emergency department (ED) visits, readmissions, and mortality were computed for all causes within 30 days post-surgery.
For statistics, the mean was reported with standard deviation (SD), and the median was reported with interquartile range (IQR). Comparison of continuous variables with a non-parametric distribution was performed with the Wilcoxon test. The analysis was performed using R (version 4.3.1) and RStudio (version 2023.06.1+524). A p-value of < 0.05 was considered statistically significant.
Results
Thirty patients met the inclusion criteria for this study, with an average age of 41 ± 14 years (Table 1). The cohort consisted of 18 (60%) women and 12 (40%) men. The racial composition was 60% Black and 40% White. The mean body mass index (BMI) was 26.6 ± 5.3 kg/m2. At admission, the most common chief complaints were shortness of breath (50%), palpitations (30%), and chest pain (6.7%). One patient (3.3%) had a fever over 100.4°F, nine (30%) were hypertensive (blood pressure > 140/90 mmHg), and 18 (60%) were tachycardic (heart rate > 100 beats per minute (bpm)). Leukocytosis was present in 14 patients (46.7%), anemia in 20 (66.7%), and elevated liver enzymes in 8 (26.7%). At admission, TSH levels were undetectable (<0.01 µU/mL) in 23 patients (76.7%) and low in 7 patients (23.3%). The median free T4 was 4.9 [3.5, 5.6] ng/dL, and the median T3 was 16.9 [7.1, 20.0] pg/mL.
Table 1.
Baseline characteristics of patients undergoing urgent thyroidectomy
| Clinical variables | |
|---|---|
| Age, years | 41 (14) |
| Female | 18 (60.0%) |
| Race | |
| Black | 18 (60.0%) |
| White | 12 (40.0%) |
| BMI, kg/m2 | 26.6 (5.3) |
| Chief complaints | |
| Shortness of breath | 15 (50.0%) |
| Palpitation | 9 (30.0%) |
| Chest pain | 2 (6.7%) |
| Fever | 1 (3.3%) |
| Hypertension | 9 (30.0%) |
| Tachycardia | 18 (60.0%) |
| Leukocytosis | 14 (46.7%) |
| Anemia | 20 (66.7%) |
| Elevated transaminase | 8 (26.7%) |
| TSH level | |
| Undetectable | 23 (76.7%) |
| Low | 7 (23.3%) |
| Free T4 at admission, ng/dL | 4.9 [3.5, 5.6] |
| Free T3 at admission, pg/mL | 16.9 [7.1, 20.0] |
BMI, Body mass index; TSH, thyroid stimulating hormone. Categorical variables are presented as number (percentage), while numerical variables are shown as mean (standard deviation) or median [Q1, Q3] based on their distribution.
Of the cohort, 22 patients (73.3%) had a prior diagnosis of hyperthyroidism, while 8 (26.7%) were newly diagnosed (Table 2). Seven patients (23.3%) were on antithyroid drugs (ATD) at admission, with a median treatment duration of 33 [14, 168] days from prescription to admission. Thyroid storm was diagnosed in 8 patients (26.7%), with a mean Burch-Wartofsky score of 50 ± 4. Atrial fibrillation was noted in 16 patients (53.3%) with a mean heart rate of 114 ± 26 bpm. Heart failure was present in 12 patients (40%) with a median BNP of 620 [541, 1630] pg/mL. Liver failure occurred in 5 patients (16.7%) with a median MELD score of 23 [19, 34]. One patient (3.3%) had kidney failure with an eGFR of 12 ml/min per 1.73 m2. Two patients (6.7%) had experienced cardiac arrest within the seven days before admission.
Table 2.
Presenting problems of patients undergoing urgent thyroidectomy
| Clinical variables | |
|---|---|
| Previous diagnosis of thyrotoxicosis | 22 (73.3%) |
| New diagnosis of thyrotoxicosis | 8 (26.7%) |
| Taking ATD before admission | 7 (23.3%) |
| Duration of ATD use before admission, days | 33 [14, 168] |
| Thyroid storm | 8 (26.7%) |
| BWPS score | 50 (4) |
| Atrial fibrillation | 16 (53.3%) |
| Heart rate at admission, bpm | 114 (26) |
| Heart failure | 12 (40.0%) |
| BNP, pg/mL | 620 [541, 1630] |
| Liver failure | 5 (16.7%) |
| MELD score | 23 [19, 34] |
| Kidney failure | 1 (3.3%) |
| Cardiac arrest | 2 (6.7%) |
ATD, antithyroid drug; BWPS: Burch-Wartofsky Point Scale; bpm, beats per minute bpm; BNP, brain natriuretic peptide; MELD, model for end-stage liver disease. Categorical variables are presented as number (percentage), while numerical variables are shown as mean (standard deviation) or median [Q1, Q3] based on their distribution.
The median time from admission to surgery was 8 [4, 16] days (Table 3). Graves’ disease was the cause of thyrotoxicosis in 83.3% of patients, followed by amiodarone-induced thyrotoxicosis in 13.3%, and ipilimumab-induced thyrotoxicosis in 3.3%. Defibrillation was required in 3 patients (10%), and intubation was necessary for 3 patients (10%) due to altered mental status (n = 2) and respiratory failure (n = 1). An ICU stay was necessary for 16 patients (53.3%), with the primary reasons being cardiac monitoring (68.8%), multiorgan failure (18.8%), and respiratory failure (12.5%). Surgery was decided upon jointly by surgeons, endocrinologists, and other relevant specialists. The major indications for surgery included adverse events due to ATD (30%), inadequate therapeutic effects of ATD (30%), worsening heart failure (26.7%), airway compression (6.7%), and worsening multiple organ dysfunction syndrome (6.7%). Preoperatively, only one patient achieved a normal TSH level, while the others either had unavailable or still low levels. The median preoperative free T4 was 3.6 [1.8, 5.2] ng/dL, and the median T3 was 5.4 [4.2, 11.1] pg/mL.
Table 3.
Hospital course of patients undergoing urgent thyroidectomy
| Clinical variables | |
|---|---|
| Hospital stay before surgery, days | 8 [4, 16] |
| Diagnosis | |
| Graves’ disease | 25 (83.3%) |
| Amiodarone induced thyrotoxicosis | 4 (13.3%) |
| Ipilimumab induced thyrotoxicosis | 1 (3.3%) |
| Defibrillation | 3 (10.0%) |
| Intubation | 3 (10.0%) |
| Indication for intubation | |
| Altered mental status | 2/3 (66.7%) |
| Respiratory failure | 1/3 (33.3%) |
| ICU stay | 16 (53.3%) |
| Indication for ICU | |
| Cardiac monitoring | 11/16 (68.8%) |
| Multiorgan failure | 3/16 (18.8%) |
| Respiratory failure | 2/16 (12.5%) |
| Indication for surgery | |
| Adverse event due to ATD | 9 (30.0%) |
| Inadequate therapeutic effect of ATD | 9 (30.0%) |
| Worsening of heart failure | 8 (26.7%) |
| Airway compression | 2 (6.7%) |
| Worsening of MODS | 2 (6.7%) |
| Preoperative TSH | |
| Undetectable | 10 (33.3%) |
| Low | 3 (10.0%) |
| Normal | 1 (3.3%) |
| Not available | 16 (53.3%) |
| Free T4 before surgery, ng/dL | 3.6 [1.8, 5.2] |
| Free T3 before surgery, pg/mL | 5.4 [4.2, 11.1] |
ICU, intensive care unit; ATD, antithyroid drug; MODS, multiple organ dysfunction syndrome; TSH, thyroid stimulating hormone. Categorical variables are presented as number (percentage), while numerical variables are shown as mean (standard deviation) or median [Q1, Q3] based on their distribution.
All patients underwent a total thyroidectomy. 17 patients (56.7%) were classified with an ASA score of 3, while 11 (36.7%) had an ASA score of 4 (Table 4). The median operative time was 140 [103, 184] minutes. The estimated blood loss was 33 [20, 119] mL, and the median thyroid volume was 62.5 [47.8, 101] mL. Two patients (6.7%) required reoperation due to postoperative hematoma. Temporary hypoparathyroidism and hoarseness were noted in 4 patients (13.3%) and 2 patients (6.7%), respectively, with no cases of permanent hypoparathyroidism or hoarseness. The median hospital stay post-surgery was 6 [3, 10] days. Six patients (20%) visited the emergency department within 30 days, mainly for comorbidity-related issues, except for one case of wound swelling. The 30-day readmission rate was 13.3%, with three patients readmitted for heart issues and one for gastrointestinal bleeding. One patient (3.3%) died within 30 days post-surgery due to fulminant liver failure. On follow-up, 8 (50%) of the 16 patients with pre-existing atrial fibrillation had symptom resolution post-thyroidectomy. Of the 6 patients monitored with echocardiography for heart failure, 3 (50%) showed improved left ventricular ejection fraction (LVEF).
Table 4.
Outcome and follow ups of patients undergoing urgent thyroidectomy
| Clinical variables | |
|---|---|
| ASA score | |
| II | 2 (6.7%) |
| III | 17 (56.7%) |
| IV | 11 (36.7%) |
| Operative time, minutes | 140 [103, 184] |
| Estimated blood loss, mL | 33 [20, 119] |
| Volume of thyroid, mL | 62.5 [47.8, 101] |
| Reoperation | 2 (6.7%) |
| Hematoma | 2 (6.7%) |
| Temporary hypoparathyroidism | 4 (13.3%) |
| Permanent hypoparathyroidism | 0 (0) |
| Temporary hoarseness | 2 (6.7%) |
| Permanent hoarseness | 0 (0) |
| Hospital stay after surgery, days | 6 [3, 10] |
| ED visit within 30 days of discharge | 6 (20.0%) |
| Readmission within 30 days of discharge | 4 (13.3%) |
| Death within 30 days of discharge | 1 (3.3%) |
| Improvement in atrial fibrillation | 8/16 (50.0%) |
| Change in LVEF | |
| Improved | 3/6 (50.0%) |
| Same | 3/6 (50.0%) |
ASA, American Society of Anesthesiologists; ED, emergency department; LVEF, left ventricular ejection fraction. Categorical variables are presented as number (percentage), while numerical variables are shown as mean (standard deviation) or median [Q1, Q3] based on their distribution.
Discussion
More than 100,000 thyroidectomies are performed in the US annually (11–13). Of these, the majority are elective operations, with only 11.7% classified as urgent (14). The preference for elective thyroidectomy is based on two factors: First, thyroid surgery candidates typically present with less complicated comorbidities, diminishing the immediate need for surgical attention (14). Secondly, medical management often successfully controls thyrotoxicosis, allowing patients to reach euthyroid state before surgery (1). However, when these conditions are not satisfied, the morbidity and mortality risks associated with thyroidectomy can increase significantly, presenting surgeons with the challenging decision of whether and when to operate (15, 16).
The published evidence for appropriate surgical strategies in patients with severe thyrotoxicosis is limited. In a study by Scholz et al.(17), ten patients, all above 60 and presenting with concurrent cardiopulmonary failure, were diagnosed with thyroid storm. When 48 hours of intensive medical treatment proved ineffective, they underwent urgent thyroidectomy. Within the perioperative period, only one patient (10%) succumbed, while the majority exhibited improved symptoms of heart failure and tachycardia. In another study involving sixteen patients with obstructive multinodular goiters who underwent emergent thyroidectomies (18), a perioperative mortality rate of 6.3% (one patient) was reported, with the remaining patients recovering well post-surgery. These findings are consistent with our observation that timely surgical interventions for patients with critical thyrotoxicosis and comorbidities are associated with relatively low mortality.
As more than 2500 thyroidectomies have been performed for thyrotoxicosis at our center over the 12-year study period, urgent thyroidectomies are rarely performed, and the 30 patients described in our current study represent a very specific subgroup. In 2023, our group published a study on postoperative outcomes in 134 patients with hyperthyroidism who had normalized free T4 and T3 levels before surgery (15). The study reported a median operative time of 1–2 hours, a median estimated blood loss of 15 mL, a 4.7% incidence of temporary hypocalcemia, a 0.7% incidence of hematoma, and a 6.6% incidence of temporary hoarseness. By comparing our results with patients who underwent elective surgery for hyperthyroidism, it is evident that although urgent thyroidectomies are generally safe, perioperative complications and mortality rates are still significantly higher in those requiring urgent thyroidectomies. Despite these challenges, most issues are typically surmountable from a technical perspective, and surgery can be justified by the potential long-term clinical benefits for patients.
In our study, we found a major indication for urgent thyroidectomy was to prevent worsening of life-threatening comorbidities, especially cardiac issues. In our cohort, we noted a pronounced prevalence of atrial fibrillation and heart failure. This observation is consistent with other studies, which showed that 19.4% of thyrotoxicosis patients with storm had heart failure, compared to 10.3% without storm, highlighting a potential association between heart failure and the severity of thyrotoxicosis (9). A considerable portion of our patients had a prior hyperthyroidism diagnosis but displayed poor medication adherence (19). In the setting of prolonged untreated hyperthyroidism, persistent tachycardia and high cardiac output state can contribute to chronic heart failure seen in our patients (20). While comorbidities increase the risk of surgery, our results showed that almost all patients were safely discharged postoperatively, with many experiencing complete resolution of atrial fibrillation or improvement of echocardiographic measurements. These findings suggest urgent thyroidectomy can mitigate, if not reverse, severe comorbidity progression and should be considered for patients with severe thyrotoxicosis.
Another major indication for urgent thyroidectomy was toxicity or failure with antithyroid drugs, which was present in over half of our patients. Two reasons may account for the reduced efficacy of antithyroid drugs in our cohort compared to the general hyperthyroidism population (21). First, 26.7% of our patients had elevated liver enzymes upon admission, with 16.7% manifesting liver failure. Such compromised liver function increases susceptibility to medication side effects. Second, our patients presented very high thyroid hormone levels, necessitating larger initial doses and extended treatment durations with antithyroid drugs (22). Our results indicate that, even after a week of conservative antithyroid drug management prior to surgery, most patients remained hyperthyroid. Therefore, surgery is the more definitive and faster solution to achieve euthyroid state and prevent worsening of comorbidities (23, 24).
There were several limitations to this study. Firstly, our analysis only encompassed patients who underwent surgery, potentially introducing selection bias. However, it’s worth noting that over 90% of our cohort were classified with an ASA score of either three or four, indicating that suggesting that this study wasn’t limited to only the most surgically fit patients. Secondly, none of our patients underwent plasmapheresis due to its accessibility, preventing us from assessing it as a potential alternative treatment for severe thyrotoxicosis. Thirdly, ICD codes are subject to omissions or delays in data entry, which may result in the under identification of the patient cohort.
In conclusion, our study indicates that when patients with severe thyrotoxicosis do not respond to antithyroid medications and face deteriorating life-threatening comorbidities, urgent thyroidectomy provides a swift and safe transition to a euthyroid state and clinical stability, suggesting a potential benefit to patient outcomes.
Grant support
This research did not receive any specific funding from any agencies in the public, commercial, or not-for-profit areas.
Footnotes
Disclosure
Zhixing Song: No conflict of interest.
Ramsha Akhund: No conflict of interest.
Christopher Wu: No conflict of interest.
Rongzhi Wang: No conflict of interest.
Brenessa Lindeman: No conflict of interest.
Jessica Fazendin: No conflict of interest.
Andrea Gillis: No conflict of interest.
Herbert Chen: No conflict of interest.
Informed consent
This study involved the analysis of a large dataset of de-identified patient information from electronic medical records (EMR). The University of Alabama at Birmingham’s Institutional Review Board (IRB) approved the use of these data and granted a waiver of informed consent due to the retrospective nature of the study, the impracticability of obtaining consent from all individuals included in the dataset, and the minimal risk posed to participants. All data were accessed in compliance with applicable privacy laws and regulations to ensure the confidentiality and rights of the patients were maintained.
Statement of human rights
The study was approved by the University of Alabama at Birmingham’s institutional review board (IRB).
References
- 1.Ross D, Burch H, Cooper D, Greenlee MC, Laurberg P, Maia A, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid : official journal of the American Thyroid Association. 2016. [DOI] [PubMed] [Google Scholar]
- 2.Wang R, Disharoon M, Song Z, Gillis A, Fazendin J, Lindeman B, et al. Incidental but Not Insignificant: Thyroid Cancer in Patients with Graves Disease. J Am Coll Surg 2024;238(4):751–8. [DOI] [PubMed] [Google Scholar]
- 3.Wu C, Zmijewski P, Akhund R, Song Z, Allahwasaya A, Murcy MA, et al. Graves’ disease: Unveiling a novel etiology of secondary hyperparathyroidism. Am J Surg 2024;229:182–3. [DOI] [PubMed] [Google Scholar]
- 4.Wang J-q, Qin L Radioiodine therapy versus antithyroid drugs in Graves’ disease: a meta-analysis of randomized controlled trials. The British journal of radiology. 2016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Shalaby M, Hadedeya D, Toraih EA, Razavi MA, Lee GS, Hussein MH, et al. Predictive factors of radioiodine therapy failure in Graves’ Disease: A meta-analysis. Am J Surg 2022;223(2):287–96. [DOI] [PubMed] [Google Scholar]
- 6.Mallick R, Asban A, Chung S, Hur J, Lindeman B, Chen H. To admit or not to admit? Experience with outpatient thyroidectomy for Graves’ disease in a high-volume tertiary care center. Am J Surg 2018;216(5):985–9. [DOI] [PubMed] [Google Scholar]
- 7.Alfadhli EM, Gianoukakis AG. Management of Severe Thyrotoxicosis When the Gastrointestinal Tract Is Compromised. Thyroid. 2011. [DOI] [PubMed] [Google Scholar]
- 8.Angell T, Lechner M, Nguyen C, Salvato VL, Nicoloff J, Lopresti J. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. The Journal of clinical endocrinology and metabolism. 2015. [DOI] [PubMed] [Google Scholar]
- 9.Galindo RJ, Hurtado C, Pasquel FJ, Tome RG, Peng L, Umpierrez GE. National Trends in Incidence, Mortality, and Clinical Outcomes of Patients Hospitalized for Thyrotoxicosis With and Without Thyroid Storm in the United States, 2004–2013. Thyroid. 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Brunn J, Block U, Ruf G, Bos I, Kunze WP, Scriba PC. [Volumetric analysis of thyroid lobes by real-time ultrasound (author’s transl)]. Dtsch Med Wochenschr 1981;106(41):1338–40. [DOI] [PubMed] [Google Scholar]
- 11.Sun GH, Demonner S, Davis MM. Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996–2006. Thyroid : official journal of the American Thyroid Association. 2013. [DOI] [PubMed] [Google Scholar]
- 12.Beninato T, Laird AM, Graves CE, Drake FT, Alhefdhi A, Lee JA, et al. Impact of the COVID-19 pandemic on the practice of endocrine surgery. Am J Surg 2022;223(4):670–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Manzella A, Kravchenko T, Kheng M, Chao J, Laird AM, Pitt HA, et al. Effects of the COVID-19 pandemic on endocrine operations in the United States. Am J Surg 2023. [DOI] [PubMed] [Google Scholar]
- 14.Moridzadeh RS, Sanaiha Y, Madrigal J, Antonios JW, Benharash P, Baril DT. Nationwide comparison of the medical complexity of patients by surgical specialty. Journal of Vascular Surgery. 2021. [DOI] [PubMed] [Google Scholar]
- 15.Fazendin J, Zmijewski P, Allahwasaya A, McLeod C, Akhund R, Gillis A, et al. Surgical Treatment of Hyperthyroidism Can Be Performed Safely Before a Euthyroid State is Achieved. Thyroid. 2023;33(6):691–6. [DOI] [PubMed] [Google Scholar]
- 16.Fazendin JM, Smithson M, Asban A, Chen H, Lindeman B. The euthyroid state: An often difficult-to-achieve (and unnecessary?) goal at the time of surgery. Am J Surg 2021;222(3):499–500. [DOI] [PubMed] [Google Scholar]
- 17.Scholz GH, Hagemann E, Arkenau C, Engelmann L, Lamesch P, Schreiter D, et al. Is there a place for thyroidectomy in older patients with thyrotoxic storm and cardiorespiratory failure? Thyroid : official journal of the American Thyroid Association. 2003. [DOI] [PubMed] [Google Scholar]
- 18.Rohana A, Hisham AN. Emergency Thyroid Surgery: A Surgical Challenge. Asian Journal of Surgery. 2009. [DOI] [PubMed] [Google Scholar]
- 19.Asban A, Chung SK, Tresler MA, Huilgol P, Xie R, Kirklin JK, et al. Hyperthyroidism is Underdiagnosed and Undertreated in 3336 Patients: An Opportunity for Improvement and Intervention. Ann Surg 2018;268(3):506–12. [DOI] [PubMed] [Google Scholar]
- 20.Osuna PM, Udovcic M, Sharma MD. Hyperthyroidism and the Heart. Methodist DeBakey cardiovascular journal. 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Bobanga I, Jin J, Wilhelm S, Sarode A, Alvarado CE, ElSherif A, et al. Primary hyperparathyroidism after radioactive iodine therapy: Is it a distinct clinical entity? Am J Surg 2023;225(1):180–3. [DOI] [PubMed] [Google Scholar]
- 22.Liu J, Fu J, Xu Y, Wang G. Antithyroid Drug Therapy for Graves’ Disease and Implications for Recurrence. International Journal of Endocrinology. 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Romero-Velez G, Burneikis T, Zolin SJ, Noureldine SI, Jin J, Berber E, et al. Quantifying disease-specific symptom improvement after parathyroid and thyroid surgery using patient-reported outcome measures. Am J Surg 2022;224(3):923–7. [DOI] [PubMed] [Google Scholar]
- 24.Gillis A, Obiarinze R, McLeod MC, Zmijewski P, Chen H, Fazendin J, et al. Time to Symptom Resolution After Total Thyroidectomy for Graves’ Disease. J Surg Res 2023;281:185–91. [DOI] [PMC free article] [PubMed] [Google Scholar]