CC BY
34
14. Park C. H., Valore E. V., Waring A. J., Ganz T. Hepcidin, a urinary antimicrobial peptide synthesized in the liver//J. Biol. Chem. - 2001. -Vol. 276, N 11. - P. 7806-7810.
15. Pigeon C., Ilyin G., Courselaud B. et al. A new mouse liver-specific gene, encoding a protein homologous to human antimicrobial peptide hepcidin, is overexpressed during iron overload//J. Biol. Chem. - 2001. - Vol. 276, N 4. - P. 7811-7819.
16. Punnonen K, Irjala K, Rajamaki A. Serum transferrin receptor and its ratio to serum ferritin in the diagnosis of iron deficiency. Blood -1997;89:1052-7.
17. Uchaykin V. F., Cherednichenko T. V., Smirnov A. V. Infectious pathology./Monography, ed. GEOTAR-media, - Moscow. - 2012.-640p. (in Russian).
18. Weiss G., Goodnough L. T. Anemia of chronic disease//N. Engl.J. Med. - 2005. - Vol. 352, N 10. - P. 1011-1023.
19. Weizer-Stern O., Adamsky K., Margalit O. et al. Hepcidin, a key regulator of iron metabolism, is transcriptionally activated by P. 53//br. J. Haemotol. - 2007. - № 2. - P.253-262.
20. WHO/UNISEF/UNU. Iron Deficiency Anemia: Assessment, Prevention, and Control. - Copenhagen, - 2005. - P.114.
DOI: http://dx.doi.org/10.20534/ESR-16-9.10-93-98
Ismailov Said Ibragimovich, Doctor of medical sciences, Professor, Director of the Republic specialized scientific research center of endocrinology (Tashkent, Uzbekistan),
E-mail: endocrin@uzsci.net Alimdzhanov Nusratzhon Amildzhonovich, Candidate of medical sciences, Head of the Department of endocrine surgery of the Republic specialized scientific research center of endocrinology
(Tashkent, Uzbekistan), E-mail: endocrin@uzsci.net Rashitov Murad Mukhammedzhanovich, Candidate of medical sciences, senior research associate at the Department of endocrine surgery of the Republic specialized scientific research center
of endocrinology (Tashkent, Uzbekistan), E-mail: endocrin@uzsci.net Uzbekov Kamil Kashafovich, Candidate of medical sciences, senior research associate at the Department of endocrine surgery of the Republic specialized scientific research center
of endocrinology (Tashkent, Uzbekistan), E-mail: endocrin@uzsci.net. Omilzhonov Murodzhon Nusratdzhonovich, Junior research associate at the Department of endocrine surgery of the Republic specialized scientific research center of endocrinology (Tashkent, Uzbekistan),
E-mail: endocrin@uzsci.net Elov Azizkul Alikulovich,
Junior research associate at the Department of endocrine surgery of the Republic specialized scientific research center of endocrinology (Tashkent, Uzbekistan),
E-mail: eaa81@bk.ru
Correlation of thyroidectomy difficulty scale with the time of an operation and its complications
Abstract: The aim of the research was to evaluate the use of thyroidectomy difficulty scale (TDS) for its concordance, correspondence with operative time and correlation with complications. TDS can serve as a tool of forecast of operation difficulty. Keywords: thyroid gland, thyroidectomy, difficulty of an operation.
Introduction
Last century, thyroidectomywas associated with high mortality and frequent development of post-operative complications. Many medical specialists ofthat time started considering thyroid gland surgery as murderous, which led to the ban on its conduct because ofhigh mortality.
With the improvement of notions of physiology and anatomy of thyroid gland, thyroid surgery has become much safer. Theodor Kocher
reduced mortality below 1% and received a Noble prize in 1909 for the promotion of thyroid surgery. Today, thyroidectomy is associated with almost zero mortality and extremely low incidence of disease, when it is performed by experienced surgeons [1]. Nevertheless, the complications of thyroidectomy can affect the quality of life. They include the damages ofrecurrent laryngeal nerve causing hoarseness and dysphagia, damages of parathyroid glands as a result of which, hypocalcemia and
post-operative bleedings develop. The incidence of damages ofrecurrent laryngeal nerve and hypoparathyrosis in the performance of qualified surgeons is less than 2% [2; 3]. The frequency of time complications is much higher and they differ depending on the volume ofthyroidectomy pathology and conduct oflymph node dissection. According to the data ofpublications, the frequency oftransient hypocalcemia fluctuates from 7 to 38% [4; 5]. Surgeons operating on thyroid relate certain thyroid diseases to the more complex resection and high frequency of complications. They include thyroidectomy in Grave's disease, Hashimoto's thyroiditis, large goiters (struma magna) and widely invasive thyroid carcinomas [6; 7; 8; 9; 24]. For instance, the cases of temporary complications fluctuate irom 12 to 38% in patients with AIT [7; 10] and from 11 to 28% [6; 11] in patients with Grave's disease. The frequency of complications, blood loss and duration ofoperation serve as surrogate of difficulty ofthe operation. Difficulty scales were also designed for other procedures, often as educational means [12; 13; 14]. The notion of difficulty ofthyroid surgery in reference literature remains subjective and is limited with separate cases, opinions and operation technique [15; 16]. Traditionally, factors affecting the difficulty of thyroid surgery include: increase of vascularization, inflammation, porousness, fibrosis and big size of the gland [7].
Currently, unlike other kinds of operations, there are no scales measuring thyroidectomy difficulty. This requires more objective evaluation of difficulty and definition offactors of disease related to difficulty based on evidential data. The aim of the research was to evaluate the use of thyroidectomy difficulty scale (TDS) for its concordance, correspondence with operative time and correlation with complications.
Methods
This prospective study was conducted at the Department of endocrine surgery of the Republic specialized scientific research center of endocrinology (Tashkent, Uzbekistan) in 2014-2015. A scale with six elements (points) (vascularization, porousness, mobil-ity/fibrosis, gland size, displacement of trachea, retrosternal position) was used according to earlier designed scheme. 30-point TDS was used for the evaluation of each element on the scale from one to five (Fig. 1). After an operation, which involved two specialized surgeons, each of them filled in TDS privately. Participating surgeons had working experience from 15 to 30 years. Paired gaining of TDS points was compared with the help of Spearman's rank correlation coefficient and concordance was evaluated by Kappa parameter. Co-existing diseases of the patient, disease data and pre-operative laboratory results were obtained from the medical history. The data of operative time was obtained from the operative journal and was calculated as time from the cut to closing of the wound.
Compression symptoms included discomfort in the neck, dysphagia or respiratory symptoms. Complications included hoarseness, hypoparathyrosis and bleedings. Correlation between the operative time and TDS points were analyzed by linear regression. Binary comparisons were made with the use of Student's test, ^2 test or Mann-Whitney test, where it was necessary. Multiple regression was used to evaluate the association of TDS points and other clinical data with the duration of the operation. All analyses were conducted with the use of STATA version 12.1.
Figure 1. - Thyroidectomy difficulty scale (TDS)
Thyroidectomy difficulty scale
Patient's name
Surgeon
Date of operation
Type of operation
Vascularization 1 2 3 4 5
Normal Medium Expressed
Porousness 1 2 3 4 5
Easy to retract Breaks easily, but retraction is possible Impossible to hold with a clamp
Mobility/ fibrosis 1 2 3 4 5
Easily lifted Retraction by force is possible Fixed, retraction is not possible
Gland size 1 2 3 4 5
Normal Higher than average Big size
Displacement and narrowing of the trachea 1 2 3 4 5
Not displaced Displaced insignificantly up to 1cm without narrowing Displaced with narrowing up to 1,5 cm Displaced significantly, over 4 cm or narrowed, less than 1 cm
Retrosternal position 1 2 3 4 5
Not retrosternal Partially in retrosternal position 1/2 of the part of thyroid in retrosternal position 2/3 of the part of thyroid in retrosternal position Entire thyroid in retrosternal position
Total points
Difficulty of operation Easy; Medium; Difficult; Very difficult
Results
Pre-operative data
This study included 146 patients. Mean age of the patients was 39,5±11,8 years; 118 (80,8%) of which were women (Table 1). 11 (7,5%) were the smokers. As for thyroid pathology, nodal forms
were the majority: nodular goiter — 52 (35,6%), multi-nodular goiter — 22 (15%). Toxic forms, including several nosologies (Grave's disease, multi-nodular toxic goiter and mixed toxic goiter) accounted for 45 (30,8%), Hashimoto thyroiditis — 8 (5,4%) and thyroid cancer — 11 (7,5%); although, these groups couldn't not
be mutually exclusive (Table 1). Total 45 patients (37,8%) reported strangulated (compression) symptoms (Table 1).
TDS points
Mean average TDS point was 14,4 (range 6-30) (Table 2). Considering the point profiles of the patients with different thyroid pathologies, patients with hyperthyroidism, as a rule, gained higher points in vascularization (3,0±1,1). The highest total points (16±1,9) were gained by patients with multi-nodular goiters at the expense of high points of retrosternal position and displacement of trachea (2,6±1,3) (Table 2). In Hashimoto thyroiditis, as a rule, patients gained higher points in the category of fibrosis (2,6±1,1) (Table 2). Patients with hyperthyroidism had a higher median of points than patients with euthyroidism (14,1 against 10,1 p = 0,04).
Table 1. - Patients' data (n-119)
Age (years) 39,5±11,8
Sex (females) 118 (80,8%)
BMI 31,5±6,6
Smoking 11 (7,5%)
Co-existing pathology 42 (28,7%)
Cancer 11 (7,5%)
Recession 8 (5,4%)
Hashimoto thyroiditis 8 (5,4%)
Multi-nodular goiter 22 (15%)
Nodular goiter 52 (35,6%)
Grave's disease 17 (11,6%)
Multi-nodular toxic goiter 13 (8,9%)
Mixed toxic goiter 15 (10,2%)
Strangulated syndrome 45 (37,8%)
Table 2. - TDS points table
TDS indicator Mean SD
Hashimoto thyroiditis
Vascularization 2,3 1,1
Porousness 1,7 0,8
Mobility/fibrosis 2,6 1,1
Thyroid size 2,1 0,9
Displacement, narrowing of trachea 1,2 0,6
Retrosternal position 1,8 0,9
Total 11,5
Grave's disease
Vascularization 3,0 1,1
Porousness 2,5 1,0
Mobility/fibrosis 2,2 1,0
Thyroid size 2,5 0,9
Displacement, narrowing of trachea 1,9 0,9
Retrosternal position 2,1 1,0
Total 14,1
Multi-nodular goiter (including thyrotaxi-cosis)
Vascularization 2,8 1,4
Porousness 2,4 1,2
Mobility/fibrosis 1,8 1,0
Thyroid size 3,0 1,4
Displacement, narrowing of trachea 2,6 1,2
Retrosternal position 2,6 1,3
Total 15,0
Surgeon №2
Figure 2. - Correlation between two surgeons according to total points
It is important to note that a concurrence is significantly better for
Concordance
For separate elements of TDS, exact concurrence between surgeons fluctuated from 62,2 to 73%. Concordance according to the Cohen's kappa (k) fluctuated from 0:44 to 0:59, and showed moderate and good concurrence between the surgeons (Table 3).
every separate element of TDS (Table 3).
The points of two surgeons correlated well, even if they were not identical. Total points of both surgeons showed high degree of correlation (Spearman's rho= 0,82. P<0,001) (Fig. 2).
Correlation with operative time
TDS points demonstrated linear dependence with operative time (R2 = 0:79, p <0,01) (Fig. 3). Cases with the point > 13 are 46,0% more compared with cases with the point <13 (p <0,01).
In case of a multiple regression analysis, TDS points are independently related to operative time considering other clinical and laboratory factors of the patients (p<0,01).
Table 3. -
Complications
19 cases of complication were observed (19.3%). 6 (31,5%) patients showed transient hoarseness; 12 (63,1%) had transient hypocalcemia and 1 patient (5,2%) showed post-operative bleeding. Neither ofthese patients had constant complication. Patients, who experienced complications, had higher TDS points than the patients without complications (15 against 4, p < 0,01). Step-by-step increase of the percentage of complications was observed at the increase of TDS points (Fig. 4). 88% ofpatients with complications had the level ofpoints over >15.
Concordance
TDS indicators Concurrence (%) Possible concurrence (%) Concordance (k) Р
Vascularization 62.2 26.7 0.48 <0.01
Porousness 62.2 32.5 0.44 <0.01
Mobility 63.1 30.2 0.46 <0.01
Thyroid size 68.9 24.1 0.59 <0.01
Retrosternal position 73.1 23.2 0.64 <0.01
Displacement of trachea 68.9 24.1 0.59 <0.01
Discussion
TDS showed good concordance in different thyroid diseases. It should be noted that TDS points correlate with operative time and number of complications. Consequently, TDS can serve as a useful instrument for the identification of a patient and peculiarities of a disease related to the difficulty of thyroidectomy. This will allow further study of the factors contributing to the difficulty of operations. TDS is unique. There are several scales of difficulty of operations: laparoscopy, cataract removal operations, or aneurysms [12; 13; 17]. Reference literature has quite poor data on the difficulty of thyroid operations. Nevertheless, it includes multiple examples of every separate point that forms TDS with a single conducted research, where several components were studied together [20]. Thus, the use of potassium iodide (Lugol's solution) to reduce blood supply and porousness of thyroid in patients with Grave's disease is still discussed [18; 19]. Fibrosis, another TDS component observed in Hashimoto thyroiditis, contributes to the increase of frequency of complications, particularly, vocal cord paresis [7]. At last, a big size of thyroid contributes to the increase of frequency of complications, particularly, vocal cord paresis and transient hypocalcemia [10; 16]. Schneider et. al. included four components in his research: vascularization, porousness, thyroid size and fibrosis. In our research, we included two additional components (retrosternal position, displacement of trachea), which play important role in the difficulty of operation. The evaluation of difficulty is important. The difficulty may be evaluated intra-operationally or during post-operative period; a surgeon cannot use TDS as pre-operative tool of forecast as indicated by Schneider et. al earlier [20]. Pre-operative analysis of all these factors contributing to the difficulty of thyroidectomy will allow performing a more careful pre-operative preparation of patients with the analysis of risk of development of complications during intra-operative and post-operative period. To do this, we first need to perform an objective evaluation of difficulty during pre-operative period with all available means (physical method, instrumental method). This study supports the use of TDS as proved difficulty scale. The next step in this research will be to define preoperative laboratory indicators, drugs, co-existing diseases and/or demography of patients to forecast difficult operations (high TDS points), consequently, with high risk of complications. Further study of the factors contributing to the difficulty of operations with the use of TDS may allow performing a more personalized evaluation of post-operative risks.
TDS factors in this research also correlated with operative time. If TDS can improve the understanding of certain factors contributing to the difficulty of operation, it can be used to forecast operative-time. Further use of TDS can help reveal the cases, where more operative time and provision of this time is required. Since the degrees of difficulty of TDS and its points correlate with operative time and complications, further studies may use TDS points to identify patients and factors of the disease related to high difficulty (and, consequently, high risk).
Although, most reference literature on thyroid surgery uses operative time, blood loss and complications as difficulty substitutes [8; 18; 21; 22], these items alone cannot cover the entire notion of difficulty. For instance, Consorti et. al [23] considered the factors affecting operative time in total thyroidectomy. They discovered that such factors as thyroid volume or neck circumference tell about a very small difference in operative time. The increase of the size of thyroid is traditionally considered as factor contributing to the difficulty of operation. Although our TDS correlated with operative time, we tested TDS on different thyroid pathologies and correlation is better in more homogeneous group.
This study was conducted at a large specialized center. We acknowledge that certain levels in every category remain slightly subjective despite recommendations and examples for every level of points (Fig. 1). Since this cohort included cases where only two surgeons had at least 15 years of experience, this fact may provide preconceived evaluation in respect of more severe cases. TDS will be accepted in other institutions, if it is used for wide number of cases. The range of pathological processes and points presupposes that this group included a whole range of diseases and different levels of difficulty.
This questionnaire can be used in the forecast of difficulty and risk of development of complications during pre-operative period. For this case, all factors of the questionnaire should be studied more thoroughly with the use of additional laboratory-instrumental methods of diagnostics (for instance: MRT examination of the neck in the presence of such factors as retrosternal position of the thyroid or narrowing or displacement of trachea). During physical examination of thyroid, work experience of a person conducting the evaluation (endocrinologist, surgeon) plays important role in objective evaluation of such factors as porousness, mobility/fibrosis, gland size, displacement of trachea.
Figure 3. Correlation of TDS points with operative time. The dark line shows linear regression between TDS points and operative time
10
6-9 points
10-14 points
15-19 points
i
>20 points
Figure 4. Correlation of separate groups of levels of TDS points with the number of complications
Conclusions
TDS is a new tool with high degree of concordance for the evaluation of difficulty of thyroid operations. Correlation between the duration of an operation and point of difficulty of thyroidectomy was r=0,79 (p<0,002). Thus, TDS points correlated with operative time and complications (r=0,83). 88% of patients with
complications showed the level of points over >15. Concordance between two surgeons was 68% (k-0,59). TDS can be used during pre-operative period to forecast the difficulty of operation, which requires further wider study of TDS factors with the use of laboratory-instrumental methods of diagnostics.
References:
1.
Sosa JA, Bowman HM, Tielsch JM et al (1998) The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Sure - 228:320-330.
Mazeh H, Chen H. Advances in surgical therapy for thyroid cancer. NatRevEndocrinol. - 2011; 7:581-588. Yip L, Stang MT, Carty SE. Thyroid carcinoma: the surgeon's perspective. RadiolClin North Am. - 2011; 49:463-471. Thomusch O, Machens A, Sekulla C (2003) The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of5846 consecutive patients. Surgery - 133:180-185.
Steinmuller T1, Klupp J, Wenking S, Neuhaus P. Complications associated with different surgical approaches to differentiated thyroid carcinoma. Langenbecks Arch Surg. - 1999 Feb; 384 (1):50-3.
Wilhelm SM, McHenry CR (2010) Total thyroidectomy is superior to subtotal thyroidectomy for management of Graves' disease in the United States. World J Surg - 34:1261-1264.
McManus C, Luo J, Sippel R et al (2012) Is thyroidectomy in patients with Hashimoto thyroiditis more risk? J Sure Res - 178:529-532. McHenry CR, Piotrovski JJ (1994) Thyroidectomy in patients with marked thyroid enlargement: airway management, morbidity. and outcome. Am Surg - 60:586-591.
Wagner HE, Seiler C (1994) Recurrent laryngeal nerve palsy after thyroid gland surgery. Br J Surg - 81:226-228. 10. Wormer BA, McHenry CR (2011) Hashintoto's thyroiditis: out-come of surgical resection for patients with thyromegaly and compressive symptoms. Am J Surg 201:416-419 discussion 419.
9.
8
6
4
2
0
11. Liu J, Bargren A, Schaefer S, Chen H et al (2011) Total thyroidectomy: a safe and effective treatment for Graves' disease..J Surg Res -168:1-4.
12. Jamali FR, Sovveid AM, Dimassi H el al (2008) Evaluating the degree of difficulty of laparoscopic colorectal surgery. Arch Surg -143:762-767 discussion 768.
13. Dooley IJ, O'Brien PD (2006) Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg - 32:604-608.
14. Van OldenrijkJ, Schafroth MU, Rijk E et al (2013) Learning curve analysis of the collumfemorispreserving total hip surgical technique. Hip lnt - 23:154-161.
15. Upile T, Jerjes W, Mahil J et al (2011 How to do it: the difficult thyroid. Head Neck Oncol - 3:54.
16. Agarwal A, Agarwal S, Tewari P et al (2012) Clinicopathological profile, airway management, and outcome in huge multinodular goiters: an institutional experience from an endemic goiter region. World J Surg - 36:755-760.
17. Ahanchi SS, Carroll M, Almaroof В et al (2011) Anatomic severity grading score predicts technical difficulty, early outcomes, and hospital resource utilization of endovascular aortic aneurysm repair. J Vase Surg - 54:1266-1272.
18. Shinall MC Jr, Broome JT, Baker A et al (2013) Is potassium iodide solution necessary before total thyroidectomy for Graves disease? Ann SurgOncol - 20:2964-2967.
19. Ansaldo GL, Pretolesi F, Varaldo E et al (2000) Doppl er evaluation of intrathyroid arterial resistances during preoperative treatment with Lueol's iodide solution in patients with diffuse toxic goiter. J Am CollSurg - 191:607-612.
20. Schneider DF, Mazeh H, Oltmann SC. (2014). Novel thyroidectomy difficulty scale correlates with operative times. World Journal of Surgery, - 38 (8), - 1984-1989.
21. Pollei TR, Barrs DM, Hinni ML et al (2013) Operative time and cost of resident surgical experience: effect of instituting an otolaryngology residency program. Otolaryngol Head Neck Surg - 148:912-918.
22. McManus C, Luo J, Sippel R et al (2011) Should patients with symptomatic Hashimoto's thyroiditis pursue surgery? J Surg Res -170:52-55.
23. Consorti F, Milazzo F, Notarangelo M et al (2012) Factors influencing the length of the incision and the operating time for total thyroidectomy. BMC Surg - 12:15.
24. Исмаилов С. И., Алимджанов Н. А., и др. Хирургическое лечение диффузного токсического зоба (методические рекомендации) г. Ташкент. - 2007. - С. 32.
DOI: http://dx.doi.org/10.20534/ESR-16-9.10-98-100
Karabayeva Indira, independent reseacher Republican specialized scientific practical center of dermatology and venereology, Uzbekistan E-mail: Ikarabaeva.73@mail.ru
Clinical aspects of zooanthroponous microsporia in present — day conditions
Abstract: clinical features of microsporia in children were studied in up- to- date conditions.Typical clinical picture of microsporia of hairy part of the head and smooth skin was revealed in 185 (84%) patients. Atypical forms of microsporia made up 35 (16%) patients. Atypical forms of microsporia are divided into trichophytoid, infiltrative-suppurative, psoriasis form and seborrhek forms.
Keywords: microsporia, atypical forms, children.
Microsporia or ringworm are the most common diseases with mycotic etiology in pediatric practice [2; 8]. Microsporia- a fungus disease from the group of dermatophyte, which is common in man and in animals. It affects the skin and hair, eyebrows, eyelash and lanugo of smooth skin [2; 3]. Analysis of registration of morbidity by the Republic for the last 5 years showed, that the growth of intensive index from 1,3 (in 2009) to 2,6 (in 2013) to 100 thousand population [1]was noted.Alarm condition is still among children contingent by the morbidity with microsporia.So from general number of patients with microsporia children under 18 made up in 2009 -61,5%, in 2010 -63,7%, in 2011-61,5%, in 2012 -59,8%, in 2013-58,9% [1; 5]. 20-fold growth of microsp oria in newborns was marked by the data of literature for the last 20 years. Mycosis has a high contagiosity and in children it may proceed as epidemic outbreak [4; 8].The main source of infection is cats, mainly stray ones.
Infection occurs in the contact with sick animals or through subjects infected by their hair [3]. One of the reasons of the growth of morbidity with mycosis is impertinence of diagnostics of microsporia as a result of changes of epidemiology and clinics of infection in recent years [8]. In current conditions the clinical course of mycosis is different by significant polymorphism, increase the number of obliterated, subclinical and recurrent forms.Usual clinical forms of difficulties in diagnostics do not cause, but atypical manifestations of the disease may serve as a reason of diagnostic pitfall, irrational treatment, irregular conducting of antiepidemic measures [6; 7].
The purpose of the work- to study the clinical features of microsporia in children in current conditions.
Materials and methods
220 children at the age from 2months to 14 with microsporia hospitalized to the department of mycology of the RSSPMC of der-
