Comment on: 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

After analysis of the research findings by Schiavone et al.¹, we acknowledge the efficacy of Lugol’s solution in reducing FT3 and FT4 levels. However, the study also indicates that the preoperative use of Lugol’s solution did not significantly reduce intraoperative bleeding, the duration of surgery, or postoperative complications in patients with Graves’ disease undergoing total thyroidectomy. The study concludes that preoperative Lugol’s solution should not be considered mandatory for these patients. Nevertheless, we believe that there are several issues within the study that could impact on the accuracy of the results.

First, the study failed to record the preoperative treatments, including the use of antithyroid drugs, beta-blockers, corticosteroids, and levothyroxine, as well as postoperative calcium and vitamin D supplementation. Preoperative treatment is crucial for controlling hyperthyroid symptoms and reducing surgical risks. Whether these treatments were used directly affects the risk of postoperative complications and patient recovery. The documentation and analysis of these treatment protocols are an important part of the evaluation of the study’s conclusions.

Second, the study did not provide detailed records of surgical data, such as the number of parathyroid glands identified, parathyroid autotransplantation, and intraoperative recurrent laryngeal nerve injury. These too could have affected the outcome. Additionally, incidental findings of six cases of micropapillary carcinoma on postoperative histopathological examination were reported. The presence of cancer could alter the assessment of treatment effects, especially if the discovery of cancer influenced the postoperative management and follow-up. It is not known whether cancer might alter Lugol’s solution’s effectiveness, thereby influencing the interpretation of surgical outcomes and postoperative complications.