Refractory diffuse toxic giant goiter with severe hyperthyroidism Thyroid surgery is one of the basic general surgery procedures, but some unconventional, complex and difficult thyroid surgeries are extremely challenging for the surgeon’s surgical skills because of the numerous blood vessels and nerves involved in neck surgery. Here we will share the treatment of a rare patient with a refractory diffuse toxic giant goiter with severe hyperthyroidism. The patient, a 19-year-old female with a ten-year history of hyperthyroidism and a ten-year history of progressive bilateral enlargement of the anterior cervical region, was diagnosed with diffuse toxic giant goiter with severe hyperthyroidism. The patient had been treated with medication in the endocrinology department, but although the antihyperthyroid drugs had reached the clinical dose limit and drug-related liver damage had occurred, the hyperthyroidism was still not completely controlled, and the disease continued to progress, with gradual thickening of the neck and protrusion of the eyes becoming increasingly severe. By the time of consultation, the bilateral anterior neck area had become significantly enlarged, and the neck even exceeded the diameter of the head. The patient sought treatment at Ruijin Hospital, and the examination revealed that the bilateral thyroid glands were obviously enlarged, with the upper part reaching the lower jaw and the lower part fusing with the clavicle, the anterior cervical muscles could not be retrieved, the neck movement was limited, all the bony signs of the neck disappeared, and a significant vascular murmur could be detected on auscultation. Because of the complexity of the patient’s condition, the endocrinology department organized a hospital-wide consultation of MDT (multidisciplinary treatment) including endocrinology, nuclear medicine, radiology and general surgery. After discussion, the endocrinologists concluded that the patient had a 10-year history of hyperthyroidism and the antihyperthyroid drugs had reached the limit of clinical dosage, but still could not control the hyperthyroidism, and the patient had developed serious drug-related liver function damage due to the long-term consumption of large amounts of drugs for the treatment of hyperthyroidism, so it was necessary to seek other effective treatments besides drug therapy. The nuclear medicine specialist opined that because the patient’s thyroid gland was too large, 131 iodine treatment would require repeated use of large amounts of iodine, which would be too risky, and the efficacy could not be determined, and crucially, life-threatening thyroid crisis could occur during treatment, so iodine treatment was not recommended. The radiologists concluded that the patient’s bilateral thyroid glands were huge, pushing the arteries, veins and nerves in the neck, lacking normal anatomical landmarks in the neck, and the trachea was obviously compressed from round to narrow and elongated, while the entire thyroid gland was surrounded by a large number of varicose blood vessels due to hyperthyroidism and the huge glands, making the surgery a huge risk. After a hospital-wide consultation with experts from Ruijin Hospital, it was agreed that surgical treatment was the only effective means for this patient. The patient was a complex and difficult thyroid surgery with huge surgical risks. The patient’s surgical risks were mainly as follows: 1. The patient’s thyroid gland was significantly enlarged bilaterally, and the unilateral thyroid gland was 15-20 cm in diameter, and the imaging examination suggested that the thyroid gland was surrounded by a large number of varicose blood vessels, which could lead to serious consequences if the operation was not done carefully. The patient had a 10-year history of hyperthyroidism, and after repeated hyperthyroidism medication, the thyroid gland was severely adherent to the surrounding tissues, with unclear demarcation, and the huge thyroid gland was wrapped around and pressed against normal tissues, especially the internal jugular vein, common carotid artery, vagus nerve, phrenic nerve, and recurrent laryngeal nerve were pressed and pushed by the huge gland. The wall of the internal jugular vein itself was only the thickness of a piece of paper, which made the surgical operation extremely difficult. 3. The patient’s trachea was obviously compressed, and the trachea was compressed by the huge thyroid gland into a “line of sight” as observed from the CT. Excision. 4. Due to long-term hyperthyroidism that cannot be completely controlled, the patient’s preoperative TSH is 0.0017umol/ml, which is much lower than the normal value of 0.35-4.94umol/ml, and any carelessness in intraoperative and perioperative management may lead to severe thyroid crisis and even life-threatening. 5. The drug-related liver damage is serious, with preoperative ALT 217U/L and AST 105U/L. The stimulation of the thyroid gland by surgery may easily lead to liver failure. Although surgery is a huge risk, it is the only effective means for refractory diffuse toxic giant goiter with severe hyperthyroidism that has failed to respond to medication. After several communications with the family about the condition, Dr. Qiu decided to challenge the risk and perform a total bilateral giant thyroidectomy with the technical support of specialists from the Department of Anesthesiology, Critical Care Medicine and Endocrinology. In July 2013, a total bilateral giant thyroidectomy was performed at the hospital’s General Hospital. On intraoperative investigation, the thyroid glands were abnormally enlarged bilaterally, with the left thyroid about 18x8x7cm and the right thyroid about 17x7x6cm, with soft thyroid gland texture and obvious varicose veins around the gland up to 1cm in diameter. The thyroid gland was compressed by bilateral recurrent laryngeal nerves, common carotid artery, internal carotid vein and vagus nerve, and the trachea was significantly compressed. After a 3-hour operation, the patient was successfully protected from all the blood vessels and nerves in the neck by complete removal of both thyroid glands. After the operation, the patient recovered quickly after careful care by all the medical staff and was discharged from the hospital three days after the operation without any complications related to hoarseness and hypocalcemia of the hands and feet. After the postoperative outpatient review, the hyperthyroidism symptoms improved significantly, the neck pressure was released, and the patient recovered well. The thyroid gland is located in the “throat” of the human body and has important endocrine functions. It requires precise excision of thyroid tissue, complete preservation of the recurrent laryngeal nerve, superior laryngeal nerve and parathyroid glands, and complete protection of the regional lymph node dissection when necessary. It also requires complete protection of the common carotid artery, internal jugular vein, vagus nerve, paramedian nerve, phrenic nerve and other important anatomical structures when regional lymph node dissection is necessary. The difficulty of this case was the combination of such a large thyroid gland with uncontrollable hyperthyroidism and drug-induced liver damage.