{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T03:12:44Z","timestamp":1788405164599,"version":"build-2803163510"},"reference-count":30,"publisher":"SAGE Publications","issue":"6","license":[{"start":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T00:00:00Z","timestamp":1778630400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T00:00:00Z","timestamp":1778630400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Thyroid\u00ae"],"published-print":{"date-parts":[[2026,6,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Preoperative management of Graves\u2019 disease (GD) typically includes antithyroid drugs, \u03b2-blockers, and short-term iodine. However, intensified therapy may result in excessive elevation of thyroid-stimulating hormone (TSH). Whether a TSH threshold (\u226510.0 \u03bcIU\/mL) can determine greater operative difficulty in such patients is unclear. Therefore, we assessed this association in patients with GD who underwent total thyroidectomy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>\n                      This retrospective cohort study included consecutive patients with GD who underwent total thyroidectomy at a single center between 2009 and 2022 (\n                      <jats:italic toggle=\"yes\">n<\/jats:italic>\n                      = 1516). The primary analysis comprised a complete case-cohort design (\n                      <jats:italic toggle=\"yes\">n<\/jats:italic>\n                      = 1407; TSH \u2265 10.0 group,\n                      <jats:italic toggle=\"yes\">n<\/jats:italic>\n                      = 48; TSH &lt; 10.0 group,\n                      <jats:italic toggle=\"yes\">n<\/jats:italic>\n                      = 1359). Primary outcomes included intraoperative blood loss, enlargement ratio (ER; estimated preoperative thyroid weight\/preadmission thyroid weight), and operative time. Secondary outcomes were perioperative complications and resected thyroid weight. Multivariable linear or logistic regression included prespecified covariates. Rare events were modeled using Firth\u2019s penalized logistic regression. For temporal context, we compared preadmission and preoperative TSH levels. Preoperative TSH was modeled as four clinically defined categories based on the institutional reference range to address heterogeneity within the TSH &lt; 10.0 \u03bcIU\/mL category.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>\n                      Of 1407 patients, 48 (3.4%) had preoperative TSH \u2265 10.0 \u03bcIU\/mL. Unadjusted analyses indicated that the TSH \u2265 10.0 group had greater blood loss (median, 52 mL vs. 34 mL;\n                      <jats:italic toggle=\"yes\">p<\/jats:italic>\n                      &lt; 0.001), higher ERs (1.137 vs. 1.029), longer operative times (129 minutes vs. 112 minutes), and heavier resected thyroids (131.8 g vs. 97.0 g). Adjusted models indicated that TSH \u2265 10.0 was independently associated with greater blood loss (\u03b2 = 53.03 mL;\n                      <jats:italic toggle=\"yes\">p<\/jats:italic>\n                      &lt; 0.001) and higher ERs (\u03b2 = 0.12;\n                      <jats:italic toggle=\"yes\">p =<\/jats:italic>\n                      0.002). Dichotomized analyses indicated that TSH \u2265 10.0 increased the odds of ER \u2265 1.1 (adjusted odds ratio [aOR] 2.60;\n                      <jats:italic toggle=\"yes\">p<\/jats:italic>\n                      = 0.004) and operative times \u2265 120 minutes (aOR: 2.29;\n                      <jats:italic toggle=\"yes\">p<\/jats:italic>\n                      = 0.018). Preadmission TSH \u2265 10.0 \u03bcIU\/mL was more common in the TSH \u2265 10.0 group (20.8% vs. 3.2%), indicating earlier elevation.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>Preoperative TSH \u2265 10.0 \u03bcIU\/mL was independently associated with greater blood loss and higher ERs in patients with GD who underwent total thyroidectomy. Avoiding iatrogenic hypothyroidism and marked TSH elevation during preoperative preparation may improve operative conditions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/10507256261449452","type":"journal-article","created":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T12:36:10Z","timestamp":1778675770000},"page":"630-640","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Markedly Elevated Preoperative Thyroid-Stimulating Hormone Levels and Greater Operative Difficulty in Graves\u2019 Disease: A Single-Center Cohort Study"],"prefix":"10.1177","volume":"36","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9513-5036","authenticated-orcid":false,"given":"Takahiro","family":"Sasaki","sequence":"first","affiliation":[{"name":"Department of Head and Neck Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Minoru","family":"Kihara","sequence":"additional","affiliation":[{"name":"Department of Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Makoto","family":"Fujishima","sequence":"additional","affiliation":[{"name":"Department of Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiroo","family":"Masuoka","sequence":"additional","affiliation":[{"name":"Department of Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takuya","family":"Higashiyama","sequence":"additional","affiliation":[{"name":"Department of Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasuhiro","family":"Ito","sequence":"additional","affiliation":[{"name":"Department of Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akihiro","family":"Miya","sequence":"additional","affiliation":[{"name":"Department of Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akira","family":"Miyauchi","sequence":"additional","affiliation":[{"name":"Department of Surgery, Kuma Hospital, Kobe, Japan."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Takashi","family":"Akamizu","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Kuma Hospital, Kobe, 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NICE guideline NG145","author":"National Institute for Health and Care Excellence (NICE)","year":"2019","unstructured":"30.National Institute for Health and Care Excellence (NICE). Thyroid disease: assessment and management. NICE guideline NG145. NICE: London; 2019. 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