Resultados de la tiroidectomía total en el tratamiento del hipertiroidismo / Results of total thyroidectomy in the treatment of hyperthyroidism

INTRODUCCIÓN: En el tratamiento del hipertiroidismo se recurre a la cirugía en casos de bocio grande, fracaso del tratamiento médico o indicación social de tratamiento definitivo. OBJETIVO: Analizar los resultados en cuanto a función tiroidea del tratamiento del hipertiroidismo mediante tiroidectomía total (TT). MATERIAL Y MÉTODO: Estudio retrospectivo de 26 pacientes con hipertiroidismo, intervenidos en el Hospital de la Plana durante 2015-2018, con seguimiento de 36 meses. Tras estudio estadístico descriptivo e inferencial, se analizó la probabilidad de recidiva del hipertiroidismo mediante el método de Kaplan-Meier, y se utilizó el modelo de Cox para ajustar los efectos sobre la recidiva de las diferentes variables. RESULTADOS: El 73,1% tenían normofunción tiroidea; el 19,2%, hiperfunción, y en otro 7,7% existía hipofunción. El tiempo medio de supervivencia (normofunción) fue de 25,87 meses (IC: 17,52-34,21). En el estudio de supervivencia con el log-rank en función de la variable anatomía patológica y complicaciones, no hay diferencias estadísticamente significativas en la supervivencia de ambos grupos. DISCUSIÓN: Coincide con otros trabajos publicados. CONCLUSIÓN: La TT es un método efectivo de tratamiento para el hipertiroidismo, con baja incidencia de complicaciones. Sin embargo, no hemos encontrado ninguna variable que nos permita predecir el resultado.

INTRODUCTION: Surgery is used in the management of hyperthyroidism in cases of large goiter, failure of medical treatment or social indication of definitive treatment. AIM: To analyze the results of the treatment of hyperthyroidism by total thyroidectomy (TT) regarding to thyroid function. MATERIAL AND METHODS: Retrospective study of 26 patients with hyperthyroidism, operated on the Hospital de la Plana during 2015-2018, with a follow-up of 36 months. After a descriptive and inferential statistical study, the probability of recurrence of hyperthyroidism was analyzed using the Kaplan-Meier method, and the Cox model was used to adjust the effects on recurrence of the different variables. RESULTS: 73.1% had thyroid normofunction; in 19.2% there was hyperfunction, and in another 7.7% there was hypofunction. The average survival time (normofunction) was 25,87 months (CI: 17,52-34,21). In the study of survival with the log-rank depending on the pathological results and complications, there are no statistically significant differences in the survival of both groups. DISCUSSION: This coincides with other published works. CONCLUSION: TT is an effective method of treatment for hyperthyroidism, with a low incidence of complications. However, we have not found any variable that allows us to predict the result.

Experiencia en la cirugía del bocio tóxico / Experience in surgery of toxic goiter

Introducción: se hace recuento del hipertiroidismo y sus dos causas principales donde prima la enfermedad de Graves Basedow. Se mencionan su diagnóstico y tratamiento. Objetivo: determinar el comportamiento de la cirugía en el bocio tóxico en un grupo de trabajo del servicio de cirugía del Hospital Universitario Amalia Simoni de Camagüey. Métodos: se realizó un estudio retrospectivo transversal sobre bocio tóxico en 12 años con una muestra conformada por 57 pacientes operados en un grupo de trabajo. Se tuvieron en cuenta, aspectos clínicos, de diagnóstico y terapéuticos. Resultados: predominó el sexo femenino en un rango de edades de 21 a 40 años, así como la positividad de los complementarios realizados. Se expuso la preparación preoperatoria más utilizada, la técnica quirúrgica realizada y las complicaciones en el orden del 29,81 porciento. Conclusiones: la mayoría fueron mujeres, con edad media de 35 años, se subutilizaron algunos medios diagnósticos, la preparación preoperatoria más usada fue propiltiuracilo, propanolol y lugol. El proceder más realizado fue la tiroidectomía subtotal y las complicaciones no fueron ni elevadas ni graves(AU)

Introduction: a recount of hyperthyroidism and its two principal causes in which Graves-Basedow disease takes priority is made. Its diagnosis and treatment are also mentioned. Objective: to determine the surgical behavior of toxic goiter in a work group of the Surgery Service at Amalia Simony University Hospital in Camaguey. Methods: a transversal retrospective study about toxic goiter was conducted during 12 years. The sample was composed of 57 patients who were operated on by a work group. Clinical, diagnostic and therapeutic aspects were considered. Results: the female sex predominated between the ages of 21 and 40 years, as well as the positive results of the complementary tests performed. The most used preoperative preparation, the surgical technique applied and the complications were shown in the order of 29.81 percent. Conclusions: most of the patients were women, with a mean age of 35 years; some diagnostic methods were sub-utilized; the most used preoperative preparations were propylthiouracil, propranolol and lugol. The most preformed procedure was the subtotal thyroidectomy and the complications were neither high nor serious(AU)

Severe congenital non-autoimmune hyperthyroidism associated to a mutation in the extracellular domain of thyrotropin receptor gene / Hipertireoidismo congênito não autoimune grave associado com uma mutação no domínio extracelular do gene receptor da tirotrofina

Activating mutations in the TSH Receptor (TSHR) gene have been identified as the molecular basis for congenital non-autoimmune hyperthyroidism. We describe the clinical findings and molecular characterization in a girl who presented severe non-autoimmune hyperthyroidism since birth, born to a mother with autoimmune thyroid disease. She was treated with methylmercaptoimidazol and β-blockers, but remained hyperthyroid and required total thyroidectomy. To characterize the presence of an activating mutation, the whole coding sequence and intron-exon boundaries of TSHR gene were analyzed. The patient was heterozygous for p.Ser281Asn mutation and p.Asp727Glu polymorphism. This recurrent mutation, p.Ser281Asn, characterized in vitro by increased basal production of cAMP, is the unique germline activating gene variant described so far in the extracellular domain of TSH receptor. Interestingly, the patient's mother presented hyperthyroidism but without any TSHR gene activating mutation. Although congenital non-autoimmune hyperthyroidism is a rare condition, it should be investigated when severe disease persists, even in a newborn from an autoimmune hyperthyroid mother, in order to differentiate it from the more common congenital autoimmune disease. Arq Bras Endocrinol Metab. 2012;56(8):513-8.

Mutações ativadoras no gene receptor de TSH (TSHR) foram identificadas como a base molecular do hipertireoidismo congênito não autoimune. Descrevemos os achados clínicos e a caracterização molecular de uma menina que apresentou hipertireoidismo autoimune grave desde o nascimento, nascida de uma mãe com desordem tiroidiana autoimune. Tratada com metilmercaptoimidazol e β-bloqueadores, ela permaneceu com hipertiroidismo e necessitou de tiroidectomia total. A fim de caracterizar a presença da mutação ativadora, foram analisados toda a sequência codificadora assim como os extremos dos íntrons e éxons do gene TSHR. A paciente era heterozigota para a mutação p.Ser281Asn e para o polimorfismo p.Asp727Glu. Essa mutação recorrente, p.Ser281Asn, caracterizada in vitro pelo aumento da produção basal de cAMP, é a única variante genética ativadora da linhagem germinativa descrita até hoje no domínio extracelular do receptor de TSH. Interessantemente, a mãe da paciente apresentou hipertireoidismo sem qualquer mutação ativadora do gene TSHR. Embora o hipertireoidismo congênito não autoimune seja uma condição rara, ele deve ser investigado quando há persistência da doença grave, mesmo em um recém-nascido de uma mãe com hipertireoidismo autoimune, a fim de se diferenciar o caso da forma mais comum da doença autoimune congênita. Arq Bras Endocrinol Metab. 2012;56(8):513-8.

Resistencia a hormonas tiroideas no asociada a mutación de la isoforma beta del receptor de hormonas tiroideas: caso clínico / Thyroid hormone resistance not associated to mutation on the beta isoform of the thyroid hormone receptor: report of one case

Thyroid hormone resistance (RTH) is inherited as an autosomal dominant trait, with variable clinical presentations. The hallmark of the syndrome is a variable degree of resistance to thyroid hormones, with high levels of circulating thyroid hormones, inappropriately normal or elevated TSH values and a clinical pattern of mixed hypothyroidism and hyperthyroidism. RTH is related in more than 85 percent of cases to thyroid hormone beta receptor mutations. We report a 11 years female with a history of treatment with propylthiouracil (PTU) for hyperthyroidism, presenting with a progressive goiter. Thyroidectomy was performed, removing 233 grams of thyroid tissue showing follicular hyperplasia. After surgery, a fast growth of the remnant thyroid gland was observed along with tachycardia. Laboratory showed a TSH of 38 mU/mL a triiodothyronine level of 300 ng/dL a thyroxin level of 14.8 ug/dL and a free thyroxin of 3.19 ng/dL, suggesting the diagnosis of RTH. The molecular study was negative for mutation of the beta isoform of thyroid hormone receptor. The possible theories that can explain these findings are discussed.

Anesthetic management of patient with myasthenia gravis and uncontrolled hyperthyroidism for thymectomy.

The relationship between myasthenia gravis (MG) and other autoimmune disorders like hyperthyroidism is well known. It may manifest earlier, concurrently orafter the appearance of MG. The effect of treatment of hyperthyroidism on the control of MG is variable. There may be resolution or conversely, deterioration of the symptoms also. We present a patient who was diagnosed to be hyperthyroid two and half years before the appearance of myasthenic symptoms. Pharmacotherapy for three months neither improved the myasthenic symptoms nor the thyroid function tests. Thymectomy resulted in control of MG as well as hyperthyroidism. In conclusion, effective control of hyperthyroidism in the presence of MG may be difficult. The authors opine that careful peri-operative management of thymectomy is possible in a hyperthyroid state.

Parathyroid surgery without instant PTH or radioguided Sestamibi scan

BACKGROUND: Radioguided Sestamibi scan and instant PTH (iPTH) are being used in minimally invasive parathyroid surgery (MIP). Experienced surgeons cure over 90-95% of the patients with primary hyperparathyroidism. PURPOSE/METHOD: To study the surgical results in treating hyperparathyroidism in a for profit community hospital lacking both iPTH and radioguided Sestamibi scan, we reviewed the patients operated from November 1, 2005 to October 31, 2006. RESULTS: The study comprised 56 patients: 52 with primary hyper-parathyroidism, three with secondary hyperparathyroidism and one with tertiary hyperparathyroidism. The only localizing test utilized pre-operatively was the Sestamibi Scan. PTH was measured immediately before and after surgery but the results was received seven to ten days later. The affected glands were removed in all patients. Fifty of 52 (96%) of the patients with primary hyperparathyroidism, the three patients with secondary hyper-parathyroidism and the patient with tertiary hyperparathyroidism are normocalcemic with normal PTH levels. Two patients have persistent mild hypercalcemia. Associated conditions were three papillary carcinoma of the thyroid, three multinodular goiter, four had a single thyroid nodule, one had an adrenal tumor and three were reoperations. CONCLUSION: Parathyroid surgery can be done safely and effectively in community hospitals without the utilization of radioguided Sestamibi scan and iPTH measurement.

Hipertiroidismo y su tratamiento / Hyperthyroidism and its treatment

El hipertiroidismo afecta el 0,5 a 1,0 por ciento de la población general, siendo 10 veces más frecuente en la mujer que en el hombre. El 85 por ciento de los casos corresponde a enfermedad de Basedow-Graves de naturaleza autoinmune. El 15 por ciento restante se debe a bocio multinodular y adenoma tóxico, tiroiditis de Quervain, etc. Hay casos iatrogénicos tales como los debido a administración de amiodarona. El cuadro clínico es una combinación de manifestaciones de tirotoxicosis, bocio y oculopatía y de compromiso muscular y cardíaco. El tratamiento consiste en administración de drogas antitiroídeas (propiltiouracilo); yodo radioactivo y/o resección quirúrgica según los casos

Tratamento cirúrgico no hipertireoidismo: análise prospectiva de 20 pacientes / Surgical treatment of hiperthyroidism: a prospective analysis of 20 patients

Os autores analisam prospectivamente 100 pacientes submetidos à tireoidectomia no período de out. 1994 a maio de 1997. A indicação cirúrgica em 20 pacientes foi por hipotireoidismo, sendo 10 com bócio tóxico multinodular, 5 com nnódulo tóxico solitário e 5 com Doença de Graves. Dos 20 pacientes deste grupo, 14 sofreram tireoidectomia subtotal e 6, tireoidectomia total. Todos retornaram ao ambulatório periódicamente para acompanhamento pós-operatório com controle hormonal. Foram encontrados 6 pacientes no estado eutireoideo, 8 em hipotireoidismo sub-clínico e 6 em hipotireoidismo. Um paciente evoluiu para hipoparatireoídismo e não houve nenhuma lesão de nervo laríngeo recorrente. Os autores concluem que a cirurgia constitui um método eficaz e seguro no tratamento de hipertireoidísmo

Modalidades terapêuticas na doença de Basedow-Graves / Therapeutical approaches in Basedow-Graves disease

Neste artigo säo analisadas as três grandes modalidades terapêuticas do hipertireoidismo - o tratamento clínico, o radioiodo e a cirurgia -, discutindo-se detalhadamente cada uma delas, enfocando seus mecanismos de açäo, vantagens e desvantagens, principais indicaçöes e contra indicaçöes. A abordagem terapêutica também será analisada em grupos especiais como neonatos, crianças e adolescentes, gestantes e idosos

Análisis comparativo entre la TSH de tercera generación y la prueba de estimulación con THR en pacientes con hipertiroidismo, hipotiroidismo y sujetos normales

El análisis de la hormona tiroestimulante (TSH) de tercera generación permite la diferenciación de pacientes con hipertiroidismo real y pacientes con niveles suprimidos de TSH asociados con otras patologías, lo cual era imposible determinar con los análisis de primera y segunda generación

Post-thyroidectomy haemorrhage: an analysis of critical factors in successful management.

Haemorrhage following thyroidectomy is a well known complication and early intervention is advocated to avoid fatality. Traditionally more emphasis has been given to the amount of drainage, increasing size of the swelling and obvious signs of respiratory obstruction as indications of re-exploration leading to delay, and subtle features of hypoxia like tachycardia, sweating, irritability and confusion resulting from upper airway oedema are usually ignored. The authors described their experience of post-thyroidectomy haemorrhage in 396 thyroidectomies performed during a 6-year period (1989-1995) for various thyroid disorders. All these patients were detected early in the postoperative course based on subtle signs of hypoxia and re-explored. There were 10 cases of post-thyroidectomy haemorrhage and they were successfully managed early in the postoperative period with excellent outcome. Close postoperative monitoring for features of hypoxia rather than external evidence of haemorrhage is the key factor in early detection and successful management of such a fatal complication.

Tratamiento quirúrgico de los bocios difusos hipertiroideos: experiencia del hospital de Valdivia / Surgical treatment of diffuse hyperthyroid goiter: experience at Valdivia hospital

The charts of 64 patients, 54 female, aged between 15 and 57 years old, operated between 1985 and 1995 were analyzed. The indication for surgical treatment was failure of medical treatment in 59 patients and a big goiter causing mechanical compression in 3 patients. A subtotal thyroidectomy was done after an abbreviated surgical preparation. The mean weight of the resected glands was 65.9 g. Four patients had transient hypocalcemia and 4 had surgical wound seromas. After a mean follow up of 31 months, 77 percent of patients remain euthyroid, hyperthyroidism relapsed in 13.1 percent and 10 percent became hypothyroid. Surgical treatment of hyperthyroid goiter is safe but the percentage of hyperfunction relapse is high

Bases para realizar tiroidectomía en la enfermedad de Graves-Basedow / Basis to realize thyroidectomy in Graves-Basedow disease

El objetivo de este estudio fue analizar los datos más relevantes de 161 pacientes con enfermedad de Graves-Basedow, entre 713 casos de pacientes sometidos a cirugía de tiroides en la Unidad 307 de Cirugía General del Hospital General de México de la Secretaría de Salud. Estos datos nos revelan los problemas y retos fundamentales en el manejo de la enfermedad de Graves-Basedow. Se explican las bases para someter a los pacientes a cirugía y se compara ésta con otros métodos de tratamiento. Las conclusiones son que la cirugía en manos experimentadas presenta una morbilidad baja y sigue teniendo un papel preponderante en el tratamiento de este padecimiento, y finalmente que las complicaciones, la mayoría de las veces esperadas (como es la hipocalcemia), son leves y transitorias

Hemiagenesia da glândula tireóide associada a hipertireoidismo: revisäo da literatura e apresentaçäo de dois casos / Hemiagenesis of the thyroid gland associated to hyperthyroidism: review of the literature and report of 2 cases

A hemiagenesia da glândula tireóide é bastante rara. Apresentamos dois casos de pacientes com quadro de hipertireoidismo, tratados inicialmente com metimazol e posteriormente com cirurgia, durante a qual foi realizado o diagnóstico, sendo que em um deles, ocorreu associaçao com carcinoma folicular. Discutimos estes casos revisando a literatura quanto aos estudos cirúrgicos, cintilográficos e necroscópicos.

Tratamiento quirúrgico de la enfermedad de graves / Surgical treatment of graves disease

Se presenta una serie de sesenta pacientes portadores de enfermedad de Graves y operados entre enero de 1980 y diciembre de 1991. Representan el 7,2// de las tiroidectomías durante este período. El promedio de edad fue de 28 años y 43 (72//) fueron mujeres. Todos ellos tuvieron hipertiroidismo clínico y biológico, y fueron inicialmente con drogas antitiroideas, propanolol o una combinación de ambas. A 46 pacientes se le realizó una tiroidectomía subtotal bilateral, a 11 una lobectomía total de un lado y parcial contralateral, y a 3 unilateral, otros dos mostraron infección de la herida, y hubo un caso de hematoma sofocante. Dos pacientes tuvieron hipocalcemia transitoria. El estudio patológico reveló un carcinoma papilar coincidente en una oportunidad (1,6//). El tratamiento quirúrgico de la enfermedad de Graves tiene un bajo índice de complicaciones y permite un rápido control de la tirotoxicosis

Tratamento da doença de Graves: experiência de um hospital universitário / Treatment of Graves' disease: an university hospital experience

Com o objetivo de levantar as principais caracteísticas dos pacientes com doença de Graves, assim como analisar as diversas estratégias utilizadas no manejo desta doença em um hospital universitário, os autores revisaram os dados de 238 pacientes com doença de Graves atendidos no Hospital de Clínicas da UFPR, de janeiro de 1990 a junho de 1991. Observou-se uma preferência por drogas antitireoideanas como opçäo inicial de tratamento (74 por cento ), seguida de cirurgia (17 por cento ) e iodo radioativo (9 por cento ). A remissäo com antitireoideanos foi pequena, ocorrendo em 32,4 por cento dos pacientes. A maior indicaçäo de cirurgia em relaçäo ao iodo radioativo como primeira opçäo, revela características próprias do nosso hospital. Por último, os autores comentam as dificuldades em se predizer o curso clínico dos pacientes com doença de Graves, após a interrupçäo das drogas antitireoideanas

Cirugia del graves-basedow sin lugol / Graves-basedow surgery without lugol

Presentamos diez casos de enfermead de Graves-Basedow, diagnosticados y tratados quirúrgicamente en el Servicio de Cirugía General del Hosoital Rísquez de Caracas, sin la administración de lugol en el preoperativo, obteniendo excelentes resultados. No se presentaron complicaciones per-operatorias, un solo caso presentó hematomas, y otro caso ameritó traqueostomia de emergencia en el pos-operatorio