Author response: Role of Lugol solution before total thyroidectomy for Graves’ disease: randomized clinical trial

BJS, https://doi.org/10.1093/bjs/znae196, published 12 August 2024

Dear Editor

We thank Wei-Zhen Tang et al. for their interest in our paper on the role of preoperative Lugol’s Solution (LS) in Graves’ disease¹. They claim the absence in the paper of details about pre-, intra- and postoperative treatments may potentially impact on the interpretation of the results. Considering only a selection of data may be presented and that further details are available on request, we would underline that most of the clinical data are presented in the paper.

Moreover, we would underline that this RCT was designed to evaluate as primary outcomes intra- and postoperative blood loss, that were not significantly decreased after Lugol’s administration. These findings were further assessed by subjective surgeon assessment and the absence of any differences in thyroid vascularity according to the ultrasonographic and immunohistochemical reports. The remaining secondary outcomes (including surgical morbidity) were not significantly different in our study, but we accept a larger RCT is needed to confirm this issue, as acknowledged among the limitations of the study.

All patients in both study groups were prepared for surgery by antithyroid drugs, including methimazole or propylthiouracil, and beta-blockers, whenever necessary, Levothyroxine was never administered preoperatively since it is definitively needed only after surgery. We agree that preoperative treatment is crucial for controlling hyperthyroid symptoms, and ( hopefully) to reduce surgical risks, although rising evidence suggests good results with minimal morbidity may be reached in high volume centres even in hyperthyroid patients.

Concerning the surgical details; as shown in the Results section, no recurrent laryngeal nerve morbidity, or differences in the number of parathyroid glands remaining in situ were found in our study. Although hypoparathyroidism occurred 1.5 times more often in the no-Lugol’s group, the difference was not statistically significant; larger studies are needed to explore the role of Lugol’s on parathyroid morbidity.

Concerning the pathological findings, we are sceptical that the incidental finding of a micropapillary thyroid carcinoma (i.e less than 1 cm in size) may affect the results of the study, especially when considering that no further treatments were needed.