**3. Treatment choices for Graves' hyperthyroidism**

Patients with overt Graves' hyperthyroidism should be treated with any of the following modalities: RAI therapy, ATDs, or thyroidectomy. Once the diagnosis has been made, the treating physician and patient should discuss each of the treatment options, including the logistics, benefits, expected speed of recovery, drawbacks, potential side effects, and costs. This sets the stage for the physician to make recommendations based on best clinical judgment and allows the final decision to incorporate the personal values and preferences of the patient. The treatment selection should also take into account the local availability and the associated costs. Whenever surgery is selected as treatment one should consider the use of expert high-volume thyroid surgeons with on average lower risk of complications; lack of that expertise should be considered against the known risk of alternative choices. Long-term continuous treatment of hyperthyroidism with ATDs may be considered in selected cases [12]. Despite the use of these three treatments for decades, selection of the optimal therapy for GD still poses a challenge for both the physician and the patient.

#### **3.1 Thyroidectomy**

Thyroidectomy, in particular subtotal thyroidectomy, is the oldest way of treating hyperthyroidism [13]. A Swiss surgeon, Theodor Kocher (1841–1917) won the Nobel Prize for Medicine and Physiology in 1909 after performing the first successful surgeries for GD [14]. Nowadays, thyroidectomy is the least preferable therapeutic selection for GD worldwide [15]. However, in some circumstances it is regarded as the most preferable treatment option. In particular, it is indicated for women who are planning a pregnancy in less than 6 months (provided they are rendered euthyroid with ATD), in patients with large goiters (≥80 g) or with compressive symptoms, in cases of coexisting hyperparathyroidism which will lead to a surgery and when thyroid cancer is suspected. Also, surgery is preferred in patients with moderate to severe active Graves orbitopathy (GO), in cases of large thyroid nodules that are additionally cold (has lower radiopharmaceutical uptake than the surrounding thyroid tissue) on scintigraphy, when TRAb values are very high or radioiodine uptake is low. Thyroidectomy should not be considered in patients with comorbid conditions such as cardiopulmonary disease and end-stage malignancy. Lack of access to a high-volume thyroid surgeon may also, directs against the choice of surgery. During pregnancy it can be considered as an emergency treatment of hyperthyroidism, when rapid control of the latter is crucial and ATD therapy cannot be used, but it is followed by a higher rate of complications such as hypoparathyroidism and recurrent laryngeal nerve (RLN) injury [12].

Thyroidectomy can be associated with postoperative complications, such as hypocalcemia, wound infection, hematoma, recurrent laryngeal nerve (RLN) injury, and Horner's syndrome. Those complications are dependent on surgeon's experience and skills as well as on removal approaches and the type and extent of the disease, having a great impact on patient's quality of life. Studies have shown that surgeons experience and post surgery complications are inversely proportional. In rare cases, after subtotal thyroidectomy recurrence of GD may be present [16].
