Preoperative Preparation in Hyperthyroidism and Surgery in the Hyperthyroid State

Hyperthyroidism is a clinical condition that develops due to the excessive production and secretion of thyroid hormones by the thyroid gland, leading to an elevated concentration of thyroid hormones in tissues. Hyperthyroidism is characterized by low TSH and elevated T3 and/or T4, with the most common causes being Graves' disease, toxic multinodular goiter, and solitary toxic adenoma. T3 is the peripherally active form of thyroid hormone, affecting nearly each tissue and system. The most prominent aspects of hyperthyroidism are related to the cardiovascular system. The treatment of hyperthyroidism includes three options: antithyroid drugs (ATDs), radioactive iodine therapy (RAI), and surgery. Among these treatment modalities, surgery is considered as the most effective one. For patients who are candidates for surgery, preoperative preparation is required to ensure that the thyroidectomy can be performed under optimal conditions. Preoperative preparation should be a combination therapy aimed at preventing the synthesis, secretion, and peripheral effects of thyroid hormones from the thyroid gland. Medications that can be used in this treatment include thionamides, beta-blockers, iodine, corticosteroids, cholestyramine, perchlorate, lithium, and therapeutic plasma exchange. These treatment options can be combined based on the patient's condition. While it is recommended that patients be made euthyroid through preoperative antithyroid treatment to prevent the feared complication, which is the thyroid storm, the supporting evidence is limited. Preoperative treatment does not prevent against thyroid storm whether the patient is euthyroid or hyperthyroid during surgery. Whether surgery should be delayed until biochemical euthyroidism is achieved in hyperthyroid patients remains a topic of debate. Recent studies suggest that thyroidectomy can be safely performed during the hyperthyroid phase by experienced anesthesiologists and surgeons without precipitating thyroid storm or increasing intraoperative and postoperative complications. Although achieving the euthyroid state before surgery is ideal in hyperthyroid patients, it is not always possible. Factors such as allergies to medications, drug side effects, treatment-resistant disease, patient noncompliance, and the urgency of definitive treatment are critical in determining whether hyperthyroidism can be controlled preoperatively. When surgery is necessary in hyperthyroid patients without achieving euthyroidism, the patient's overall condition and comorbidities should be evaluated together by the anesthesiologist, surgeon and endocrinologist, with particular attention to stabilizing the cardiovascular system. We believe that in hyperthyroid patients who are cardiovascularly stable during the hyperthyroid phase, thyroid surgery may not need to be delayed and can be performed safely.

Hipertiroidide Preoperatif Hazýrlýk ve Hipertiroidik Durumda (Evrede) Cerrahi

Hipertiroidizm tiroid bezi tarafýndan fazla tiroid hormonu üretimi ve sekresyonu ile dokularda fazla tiroid hormonu konsantrasyonuna baðlý geliþen klinik durumdur. Hipertiroidizm düþük TSH ve yüksek T3 ve/veya T4 ile karakterizedir ve en sýk sebepleri Graves hastalýðý, toksik multinodüler guatr ve soliter toksik adenomdur. T3 tiroid hormonunun periferik etkili aktif formu olup hemen her doku ve sistemi etkilemektedir. Hipertiroidizmle ilgili en belirgin özellikler kardiyovasküler sistemle ilgili olanlardýr. Hipertiroidizmin tedavisinin 3 tedavi opsiyonu antitiroid ilaçlar (ATDs), radyoaktif iyot tedavisi (RAI) ve cerrahi olup, bunlar arasýnda en etkili tedavi cerrahidir. Cerrahi endikasyon koyulan hastalarda tiroidektominin optimal þartlarda uygulanabilmesi için hastalarýn preoperatif hazýrlýk tedavisinin yapýlmasý gerekmektedir. Preoperatif hazýrlýk tedavisi, tiroid bezinden tiroid hormonlarýnýn sentezini, salgýlanmasýný ve periferik etkilerini önlemeyi hedefleyen bir kombinasyon tedavisi olmalýdýr. Bu tedavide kullanýlabilen ilaçlar tiyonamidler, beta blokerler, iyod, kortikosteroidler, kolestiramin, perklorat, lityum, terapötik plazma deðiþimi olarak sayýlabilir. Hastanýn durumuna göre bu tedavi seçenekleri kombine edilebilir. Hipertiroidide cerrahi tercih edilecekse, hipertiroidinin korkulan komplikasyonu olan tiroid fýrtýnasýný önlemek için hastalarýn preoperatif antitiroid tedavi ile ötiroid hale getirilmesi önerilmekle birlikte kanýt düzeyi düþüktür. Ameliyat öncesi tedavi, ameliyat sýrasýndan hastanýn ötiroidi veya hipertiroidi olmasý tiroid fýrtýnasýndan korumaz. Hipertiroidik hastalarda biyokimyasal ötiroidi saðlanana kadar cerrahinin ertelenmesinin gerekip gerekmediði halen tartýþma konusudur. Son yýllarda yayýnlanan çalýþmalarda deneyimli anestezist ve cerrahlar tarafýndan hipertiroidik safhada tiroidektomi uygulanmasýnýn tiroid fýrtýnasýný presipite etmeden, intraoperatif ve postoperatif komplikasyon geliþimini arttýrmadan güvenli bir þekilde uygulanabileceði bildirilmektedir. Hipertiroidik hastalarda cerrahi öncesi ötiroid durumuna ulaþmak ideal olsa da, her zaman mümkün deðildir. Ötiroid ilaçlara karþý alerji, ilaç yan etkileri, tedaviye dirençli hastalýk, hastanýn tedaviye uyumsuzluðu ve kesin tedavinin ne kadar acil olmasý gerektiði gibi faktörler, hipertiroidizmin ameliyat öncesi kontrol edilip edilemeyeceðini belirlemede kritik öneme sahiptir. Hipertiroidik hastalarda ötiroid hale gelmeden cerrahi gerektiðinde hastanýn genel durumu, komorbiditeleri anestezist, cerrah ve endokrinolog tarafýndan birlikte deðerlendirilmeli, özellikle kardiyovasküler sistem stabilize edilmelidir. Hipertiroidik safhada ve kardiyovasküler açýdan stabil olan hastalarda tiroid cerrahisinin ertelenmeyebileceði ve güvenli bir þekilde uygulanabileceði düþüncesindeyiz. (SETB-2024-09-148)