Should we use this on all Graves' thyroidectomies?

Thyroidectomy has a low rate of complications. Bleeding is rare but can be life-threatening, needing an emergent reoperation. There are several risk factors for bleeding following a thyroidectomy, namely:

• extent of ressection

• anticoagulant usage

• age

• Graves' disease

The thyroid gland in a patient with Graves' disease has increased vascularization because there are more blood vessels. This is the reason why the risk of bleeding is increased in these patients. Additionally, Lugol solution was usually used in the past, aiming at decreasing the gland's vascularization before performing a thyroidectomy in a patient with Graves' disease. This is no longer recommended because the bleeding risk has not been reduced.

The most important factor known to reduce the risk of postoperative bleeding is good surgical technique with meticulous hemostasis. Although good hemostasis has been performed, the bleeding risk following a thyroidectomy for Graves' disease is still increased compared to other diagnoses. In that setting, Dr. E.J. Thomas et al. from the UK published an abstract in BJS analysing the effect of a single dose of preoperative tranexamic acid on reducing the bleeding after Graves' thyroidectomy. They retrospectively studied 1847 patients submitted to thyroidectomy for Graves' disease, cancer, and multinodular goiter, before and after introducing the single dose of IV tranexamic acid (TXA) at the beginning of surgery. Additionally, VTE events were also analysed to draw some conclusions on safety. Results are important, I think.

In Graves' thyroidectomy, there was a reduction in postoperative bleeding from 4.4% to 1%, and a decrease from 3.6% to 0% of bleeding needing a reoperation. These results have statistical significance (p<0.0001). Do you think this was also true in thyroidectomy for cancer or multinodular goiter? No, it was not. About VTE events within 6 months of surgery with or without tranexamic acid, there was no difference at all. Dr. Thomas et al. conclude that "a single dose of tranexamic acid significantly reduces bleeding in Graves' thyroidectomy without increasing VTE risk". So, it is effective and looks safe. However, from the abstract, we have no information on the patient's comorbidities. Will the risk be the same in patients with a past medical history of VTE or cardiovascular events?

This work may be important in changing our daily practice when treating Graves' disease. If a single dose of TXA can prevent a life-threatening complication and a reoperation, it is worth doing. Although prospective and randomized trials must be conducted to draw solid conclusions, these results will probably have an impact on my practice, at least in patients with a low risk of VTE or ischemic events. Will you also consider using tranexamic acid as bleeding prophylaxis in a future Graves' thyroidectomy?

Link to abstract:

E.J. Thomas, H.L. Rossiter, A. Poacher, et al. A single dose of IV tranexamic acid reduces bleeding in Graves' thyroidectomy and is safe. BJS 2025; 112 (issue supplement 9).

Dr. Carlos Eduardo Costa Almeida

General Surgeon

#thyroidectomy #bleeding #complications #Graves #toxic #goiter #tranexamic_acid #thyroid #cancer #thyroid_cancer