An analysis of clinical, subclinical features of Graves’ patients before endoscopic thyroid surgery

Journal of military pharmaco-medicine no8-2018

AN ANALYSIS OF CLINICAL, SUBCLINICAL FEATURES OF
GRAVES’ PATIENTS BEFORE ENDOSCOPIC THYROID SURGERY
Tran Doan Ket1; Tran Ngoc Luong1; Kieu Trung Thanh2
SUMMARY
Objectives: To analyse clinical, subclinical features of Graves’ patients indicated endoscopic
surgery. Subjects and methods: A prospective study based on data of patients undergoing
endoscopic thyroid surgery in National Hospital of Endocrinology from 1 - 2005 to 5 - 2017.
Results: Rate of goiter’s size in grade II was 88.2%. Mean volume of thyroid gland was 30.48 ± 1.15.
Mean number of vessel spots was 3.42 ± 0.87. Subclinical: Serum T3 level: 1.55 ± 0.39 nmol/L,
serum FT4: 17.25 ± 2.73 pmol/L, serum TSH 1.13 ± 0.92 µIU/mL. Serum TRAb: 10.48 ± 3.85
U/L. Conclusion: Clinical and subclinical examinations prior to endoscopic surgery for Graves’
patient are essential for prognosis, aiming to evaluate surgery, ensuring surgical safety.
* Keywords: Grave disease; Endoscopic thyroid surgery; Subclinical and clinical features.

INTRODUCTION
Graves’ disease was a common
autoimmune disorder in our country and all
the world. In Europe, the annual incidence
was 20 cases per 100,000 people. In America,
this figure was 40 cases per 100.000 people.
This disease was predominant in females,
the incidence in female was 4 - 6 times
higher than in males. The common age
was from 20 to 50 [5].
In Vietnam, there have been no a
national statistics on Graves’ disease.
According to Le Huy Lieu, Graves disease
accounted for 45.8% of patients with
endocrine disease and 2.6% of internal

diseases in Bachmai Hospital.
Currently, there were 3 treatment options
for Graves’ patient: internal treatment,

radioactive iodine therapy and surgery.
Each method had its own strengths and
weaknesses, which needs appropriate
indication.
Open surgery for Graves’ disease has
been strongly developed since the 1990s
and has achieved extremely high results:
95 - 97% curable, the low incidence of
accidents and complications [1].
However, open surgery also revealed
some disadvantages such as pain, paresthesia
in the neck, ugly scars even keloids.
Thyroid and parathyroid endoscopic
surgery was initiated in 1997 by Gagnet
and today, from the basic foundation of
open surgery, open endoscopic thyroid
surgery has been completed and widely
used [6].

1. National Hospital of Endocrinology
2. 103 Military Hospital
Corresponding author: Tran Doan Ket ()
Date received: 15/08/2018
Date accepted: 02/10/2018

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Journal of military pharmaco-medicine no8-2018
In Vietnam, endoscopic thyroid surgery
was first applied at National Hospital
of Endocrinology in 2003 and later
developed in many major hospitals in the
country such as 103 Military Hospital,
Binh Dan Hospital, Nhan Dan Hospital
Gia Dinh, Cho Ray Hospital, 175 Military
Hospital... and thyroid endoscopic surgery
have confirmed the advantages such as:
hidden scar, avoiding the risk of scarring
and postoperative paresthesia in the neck,
significantly improving aesthetics.
Thyroid endoscopy was more significantly
complex than conventional surgery, but
so far, no studies have been adequately
evaluated and systematized. Clinical,
subclinical examinations can support and
help surgeon set up the best endoscopic
surgery plan for Graves’ patients and help
them to stay stable soon with normal
thyroid function.
Therefore, we conducted a study with
the aim: To analyze clinical and subclinical
features of Graves’ patients before thyroid
endoscopic surgery at National Hospital
of Endocrinology (2005 - 2017).
SUBJECTS AND METHOD

1. Subjects.
Graves’ patient had received treatment
at the National Hospital of Endocrinology
from January 2005 to May 2017.
* Selection criteria: Patients received
internal treatment for 3 - 6 months with
normal function of clinical and subclinical
thyroid. Age ranged from 14 to 50. Goiter
grading was grade Ib, grade II (WHO
classification 1995). Patients desired for
endoscopic surgery and agreed to participate
in research.
200

2. Method.
This is a prospective study.
* Size: Convenient size from January
2005 to May 2017 was 76 patients meeting
the research standards.
* Variable, index:
- Physical examination:
+ History: Age, gender, duration of illness.
+ Thyroid examination: Evaluation of
thyroid: size, density, mobility, thyroid
classification by WHO (1995).
- Subclinical examination:
+ Thyroid volume: Based on thyroid
ultrasound, using two-dimensional black
and white ultrasound, flat probe with
frequency from 5 - 10 MHz to measure

thyroid volume.
+ Number of vessel spots: Based on
thyroid color Doppler ultrasound. Number
of vessel spots per centimeter increased
when it is higher than 2.5 spot (normal ≤ 2).
+ Heart rate: Measured by electrocardiogram.
+ Blood test: Thyroid hormone (T3,
FT4) and TSH - pituitary hormone were
measured by the spectrophotometric method.
+ TrAb: Measured TrAb by receptor
radioimmunoassay (RRA). Normal value
of labo: TRAb < 1.5 U/L.
The thyroid hormone test was performed
by the Ci 8,200 machine provided by
ABBOTT, according to the spectrophotometric
method.
Normal: T3 from 1 to 3 nmol/L.
FT4 from 9 to 25 pmol/L.
TSH from 0.3 to 5.5 miU/mL.
The thyroid hormone test and TRAb
test were performed at Department of


Journal of military pharmaco-medicine no8-2018
Biochemistry and Immunology Labo of
National Hospital of Endocrinology.
* Analyzing data:
The results were recorded on the
sample form. The data were collected and
analyzed by using SPSS 16.0 statistical

software.
* Research ethics:
The study was agreed by the selected
patients and approved by Hospital
Science Council and by National Hospital
of Endocrinology. All information of the
patients were kept confidential.
RESULT AND DISSCUSSION
1. Features of patients.
* Age distribution of 76 patients:
≤ 20 years old: 12 patients (15.8%);
21 - 30 years old: 47 patients (61.8%);
31 - 40 years old: 16 patients (21.1%);
41 - 50 years old: 1 patient (1.3%);
average age: 26.38 ± 6.02.
Group of patient from 21 to 30 occupied
the highest proportion (61.8%). The majority
was in the youth age, being the staffs who
have high demand of aesthetics. In the
study, one patient aged 46 who had a
social place, frequent communication.
Together with the development of the
society, the application of endoscopic
techniques is also of great necessity.
* Duration of illness (n = 76):
According to Nguyen Ngoc Trung,
average internal treatment time was
17.0 ± 3.1 months; Nguyen Huu Binh:
20.3 ± 3.5 months. The shortest duration
of illness in our study was 4 months,

the longest one was 132 months, mean
time 50.85 ± 37.06 [3, 4].

2. Clinical and subclinical features.
* Clinical features:
- Classification of goiter grading
according to WHO (1995) (n = 76):
Grade Ia: 0 patient; grade Ib: 9 patients
(11.8%); grade II: 67 patients (88.2%);
grade III: 0 patient.
- Grades of goiter: According to
Do Trung Quan, goiter in Graves’ disease
was a diffuse goiter, grade II occupied
70.62%, grade III occupied 13.03% [2].
Clinical examination of the thyroid’s size
and ultrasonography evaluated thyroid
volume as one of the factors determining
the surgical decision. Authors often indicated
open surgical treatment for Graves’ disease
with goiter in grade II and grade III.
However, the endoscopic surgery was
performed in patients with too large goiter
would be more difficult because of many
limitations, so we chose goiters in grade Ib
and grade II.
* Subclinical features:
- Volume of thyroid gland on ultrasound
(n = 76):
Thyroid volume was determined by
conventional thyroid ultrasound, ultrasound

was a necessary test and increasingly
applied in clinical specialties, especially in
diagnosis of thyroid disease. Ultrasound
could measure volume and thyroid
morphology and help surgeons indicate
an endoscopic or open surgery. In our
study of 76 patients, the patient had a
minimum volume of 12.5 cm3 and a
maximum of 65 cm3, with an average of
30.48 ± 1.15 cm3. If the volume was too
large, the operation time would be longer.
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Journal of military pharmaco-medicine no8-2018
Table 1: Number of vessels before and
after lugol treatment (n = 76).
Vessel

Min

Max

Mean

1

5

3.42 ± 0.87

0.5

3.5

1.89 ± 0.74

Before
After

Number of vessel spots was determined
by thyroid Doppler ultrasonography. We
performed thyroid Doppler ultrasound to
evaluate vessel spots and thyroid blood
flow. The smallest number of spots in our
study was 1.0 and the largest was 5 spots.
After a 7-day treatment with lugol, the
smallest number of spots was 0.5 and the
largest was 3.5. We found that the higher
number of vessel spots, the more the
thyroid blood flow and the more difficult the
surgery was , the more bleeding was.
Table 2: Thyroid and pituitary hormone
test before surgery (n = 76).
Hormone

Min

Max

Mean

Normal

T3 (nmol/L)

0.86

2.9

1.55 ± 0.39

1.0 - 3.0

FT4 (pmol/L) 10.22

21.72

17.25 ± 2.73 9.0 - 25.0

TSH (µIU/mL)

0.03

3.5

1.13 ± 0.92

0.3 - 5.5

TRAb (U/L)

1.0

21.0

10.48 ± 3.85

1 - 1.58

This could be explained by the thyroid
hormone TSH secreted by the anterior
pituitary gland, which regulates T3 and
FT4 production in the thyroid without
directly causing clinical manifestations of
thyroid gland function. Hence, the TSH
level was always fluctuated to remain
production of thyroid hormones flat. Thus,
all patients in our study were clinically normal.
- TrAb antibody test: Cappelli. C showed
that Graves’ disease was an autoimmune
disorder, characterized by the presence of
autoantibody TrAb that stimulates the
thyroid gland. TRAb played a role in the
diagnosis and follow-up of treatment
based on disease. It helped identify the
patients who are likely to be cured for
short-term treatment, who should continue
to maintain antithyroid drugs longer and
who need optimal interventions such as

surgery or radioiodine [7].
TRAb was an antibody against TSH
receptor of thyroid cells, which had a
diagnostic value as it is elevated and had
a prognostic value in the treatment of
disease, recurrence, and surgical indication
in the Graves’ disease.
CONCLUSION

Thyroid and pituitary hormone: All 76
patients in the study group were tested for
serum T3, FT4 and TSH levels before
surgery. All patients had T3 levels, FT4
was within normal limits. 02 cases had
higher TSH than normal and 3 cases
were lower than normal but T3 and FT4
were within the normal range, accompanied
by clinical symptoms without manifestations
of hyperthyroidism or hypothyroidism.
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The average duration of internal
treatment was 50.85 ± 37.06 months.
Patients with grade II goiter had a major
proportion (88.2%). Mean volume of
thyroid gland was 30.48 ± 1.15. Mean
number of vessel spots was 3.42 ± 0.87.
Subclinical: serum T3 level: 1.55 ± 0.39
nmol/L, serum FT4: 17.25 ± 2.73 pmol/L,
serum TSH 1.13 ± 0.92 µIU/mL. Serum

TRAb: 10.48 ± 3.85 U/L.


Journal of military pharmaco-medicine no8-2018
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