**8. Geographic variability in preferred treatment options**

There are wide variations in the preferred first line treatment for GD. The choice is culmination of patient and physician preference along with disease status. In the US, RAI is likely to be the primary therapy though its popularity is decreasing. ATD are preferred in Latin America, Europe and Japan [30, 31]. Popularity of ATD has also surpassed RAI in New Zealand [32]. Once again ATD are the favored first line treatment in middle east and north African regions. Also, the physician practices were found to be that between European and American preferences, probably attributed to their training and affiliations [33].

#### **9. Peri operative management**

Imaging of thyroid is essential, and ultrasonography is useful. It aids in surgical planning and presence of nodule(s) mandates a fine needle aspiration cytology before surgery. Contrast enhanced CT scan (CECT) may be required for large goiters. Euthyroid state should be achieved in all patients before surgery [30]. This is achieved by ATD which is continued till the morning of surgery. Tachycardia if present is controlled by institution on beta blockers. The role of pre-operative Iodine solution remains controversial but the authors favor same [34]. Lugols Iodine/ collosal Iodine/SSKI is given thrice a day for 7–12 days prior to surgery. Iodine has been shown to decrease the vascularity the thyroid and makes the gland firmer. These changes aid the surgeon [35]. Guidelines suggested by various professional bodies aid in management and peri operative preparation of hyperthyroid patients of which American Thyroid Association (ATA) seems to be most commonly followed. However, a study by Siddique Akram et al. found that adherence to ATA guidelines did not impact the outcome significantly but for increased intra operative tachycardia in patient not following ATA guidelines [36]. In fact, almost 28% of the cohort remained hyperthyroid at the time of surgery but no adverse impact was noted. Pre-operative vit D deficiency may result in higher incidence of post thyroidectomy hypocalcemia [37]. Vit D and calcium may be supplemented in pre-operative period to reduce the incidence of post-surgery hypocalcemia [38, 39]. However unpublished data from authors have not shown any advantage of supplementation in reducing post TT hypocalcemia.

#### *Surgery for Graves' Disease DOI: http://dx.doi.org/10.5772/intechopen.96958*

Surgery is best performed by a high-volume surgeon in a specialized unit for best outcome [40]. Surgical adjuncts may be utilized as per need, availability, cost constraints and surgeon preference. Meticulous surgery parathyroid vascularity is of prime importance in bettering outcomes. Parathyroid auto transplantation after inadvertent injury or excision results in increased occurrence of temporary hypocalcemia but not permanent hypocalcemia [41].

Post thyroidectomy, patients are kept under observation for development of hypocalcemia or risk of bleed. These were traditionally said to occur at a higher incidence after surgery performed for GD [41]. Hungry bone syndrome, Vitamin D deficiency, female sex are factors that have been associated with apparent higher incidence of post TT hypocalcemia in GD. However, recent studies have concluded that hypocalcemia and post thyroidectomy bleed do not occur at a significantly higher rate in GD [42]. Post TT PTH may be evaluated as per institutional protocols to predict hypocalcemia and plan early discharge. PTH gradient is said to better predict hypocalcemia than any single value. Same day safe discharge of patients is feasible for GD after surgery with no adverse outcomes [43]. ATD are discontinued and Beta blockers if prescribed are tapered gradually in the post-operative period. Thyroxine supplement is started between POD1–7 at a dose if 1.6–2.1 microgram/Kg.
