Graves病术前TSH显著升高与手术难度增加相关：单中心队列研究
该回顾性队列纳入2009-2022年单中心接受全甲状腺切除术的1516例Graves病患者，主要分析1407例。术前TSH≥10.0 μIU/mL组（48例，3.4%）较TSH<10.0组术中出血量更多、甲状腺增大比更高、手术时间更长、切除甲状腺更重；校正后TSH≥10.0仍独立关联出血量增加和增大比升高。结论提示术前应避免医源性甲减和TSH显著升高。
要点
- 术前TSH≥10.0 μIU/mL与全甲状腺切除的Graves病患者出血量增加独立相关。
- TSH≥10.0 μIU/mL与甲状腺增大比≥1.1的风险升高独立相关。
- 术前准备中避免TSH显著升高可能改善手术条件。
核心结论
- 术前TSH≥10.0 μIU/mL与Graves病全甲状腺切除术患者术中出血量增加和甲状腺增大比升高独立相关。
- 避免术前医源性甲减和TSH显著升高可能改善手术条件。
研究设计与样本
- 回顾性队列研究，纳入2009-2022年单中心连续接受全甲状腺切除术的Graves病患者（n=1516）。
- 主要分析采用完整病例队列设计（n=1407；TSH≥10.0组48例，TSH<10.0组1359例）。
主要发现
- 术前TSH≥10.0 μIU/mL者占3.4%（48/1407）。
- 未校正分析中，TSH≥10.0组术中出血量中位数52 mL vs 34 mL（p<0.001），增大比1.137 vs 1.029，手术时间129分钟 vs 112分钟，切除甲状腺重量131.8 g vs 97.0 g。
- 校正后TSH≥10.0独立关联出血量增加（β=53.03 mL；p<0.001）和增大比升高（β=0.12；p=0.002）。
- 二分类分析显示TSH≥10.0增加增大比≥1.1的比值比（aOR 2.60；p=0.004）和手术时间≥120分钟的比值比（aOR 2.29；p=0.018）。
- TSH≥10.0组入院前TSH≥10.0的比例更高（20.8% vs 3.2%），提示TSH升高出现较早。
关键数值与推荐
- 术前TSH切点采用≥10.0 μIU/mL。
- 增大比定义为估计术前甲状腺重量/入院前甲状腺重量。
临床怎么用
- Graves病术前准备应监测TSH，避免因强化治疗导致TSH显著升高至≥10.0 μIU/mL。
- 对术前TSH≥10.0 μIU/mL的患者，应预判术中出血量增加和手术难度增大。
局限性
- 单中心回顾性设计。
- TSH≥10.0组样本量较小（n=48）。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
BACKGROUND: Preoperative management of Graves' disease (GD) typically includes antithyroid drugs, β-blockers, and short-term iodine. However, intensified therapy may result in excessive elevation of thyroid-stimulating hormone (TSH). Whether a TSH threshold (≥10.0 μIU/mL) can determine greater operative difficulty in such patients is unclear. Therefore, we assessed this association in patients with GD who underwent total thyroidectomy. METHODS: This retrospective cohort study included consecutive patients with GD who underwent total thyroidectomy at a single center between 2009 and 2022 (n = 1516). The primary analysis comprised a complete case-cohort design (n = 1407; TSH ≥ 10.0 group, n = 48; TSH < 10.0 group, 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's 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 < 10.0 μIU/mL category. RESULTS: Of 1407 patients, 48 (3.4%) had preoperative TSH ≥ 10.0 μIU/mL. Unadjusted analyses indicated that the TSH ≥ 10.0 group had greater blood loss (median, 52 mL vs. 34 mL; p < 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 ≥ 10.0 was independently associated with greater blood loss (β = 53.03 mL; p < 0.001) and higher ERs (β = 0.12; p = 0.002). Dichotomized analyses indicated that TSH ≥ 10.0 increased the odds of ER ≥ 1.1 (adjusted odds ratio [aOR] 2.60; p = 0.004) and operative times ≥ 120 minutes (aOR: 2.29; p = 0.018). Preadmission TSH ≥ 10.0 μIU/mL was more common in the TSH ≥ 10.0 group (20.8% vs. 3.2%), indicating earlier elevation. CONCLUSIONS: Preoperative TSH ≥ 10.0 μIU/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.
引用
- Sasaki T, Kihara M, Fujishima M, et al. Markedly Elevated Preoperative Thyroid-Stimulating Hormone Levels and Greater Operative Difficulty in Graves' Disease: A Single-Center Cohort Study. Thyroid. 2026. PMID: 42126184. doi:10.1177/10507256261449452
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。