Evaluating an Outpatient Rapid Preoperative Optimization Protocol for Poorly Controlled Graves’ Disease: A Retrospective Cohort Study

This is the authors' abstract. We don't add key points for this paper.

Background: Thyroidectomy is indicated in relapsed or poorly controlled Graves' disease, thyroid eye disease, pregnancy, suspected malignancy, and large goiter.Guidelines recommend rendering patients biochemically euthyroid and adequately beta-blocked before surgery to reduce the risk of perioperative thyroid storm, but thionamide therapy commonly requires four to eight weeks to achieve this.Rapid multimodal preparation, used where antithyroid drugs fail or are not tolerated, and surgery cannot wait, has conventionally required a 10-to 14-day admission, with no standardized outpatient alternative described.The Sheffield Perioperative Rapid Optimization in Graves' Disease (SPROG) protocol was developed locally to achieve rapid biochemical control and was adapted for entirely outpatient delivery during the COVID-19 pandemic in response to hospital bed pressures.This study evaluated its safety and effectiveness as an outpatient regimen.Materials and methods: A single-center retrospective observational study was conducted at a tertiary endocrine surgery unit.Patients with poorly controlled Graves' disease who underwent thyroidectomy after outpatient optimization between December 2020 and December 2025 were included.Eligibility required free thyroxine above 30 pmol/L or free triiodothyronine above 10 pmol/L at baseline.The protocol escalates therapy stepwise over approximately 14 days, beginning with propranolol and Lugol's iodine and adding cholestyramine, propranolol titration, and dexamethasone as required, with thyroid function measured on alternate weekdays.The primary efficacy outcome was achievement of either predefined targets, free thyroxine below 30 pmol/L or free triiodothyronine below 10 pmol/L, at the final preoperative assessment; the primary safety outcome was perioperative thyroid storm.Results: Twenty-three patients were included, 20 (87%) female, with a median age of 41 years (interquartile range 31-47 years).All underwent total thyroidectomy, and none required preoperative admission.Both targets were achieved at the final preoperative assessment in 23 of 23 patients (100%).Median free thyroxine decreased from 78.6 pmol/L at baseline to 24.1 pmol/L (interquartile range 18.25-35.05pmol/L), and median free triiodothyronine from 38.5 pmol/L to 6.5 pmol/L (interquartile range 5.32-7.58pmol/L).No perioperative thyroid storm occurred (0 of 23; 95% confidence interval 0 to 14.8%).Off-protocol rescue therapy was required in one patient (4.3%).Hypocalcemia occurred in nine patients (39.1%), was transient in seven (30.4%), and persisted beyond six months in two (8.7%).Voice change occurred in two patients (8.7%) and was long-term in one (4.3%).There were no cases of bleeding, infection, reoperation, readmission, or death.Median postoperative stay was one day.Incidental papillary microcarcinoma was found in five patients (21.7%).Conclusions: Structured rapid preoperative optimization was delivered entirely on an outpatient basis, with predefined biochemical targets achieved in most patients and no perioperative thyroid storm observed.The retrospective, uncontrolled design and small cohort mean this study cannot establish the safety of the approach with confidence or demonstrate equivalence to inpatient optimization.Prospective comparative evaluation is required before wider adoption.