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UDC 616.43-089(083.132)
EXPERIENCE OF DIAGNOSTICS AND SURGICAL TREATMENT OF ENDOCRINE ORGAN DISEASES
1 Altai State Medical University, Barnaul
2 Multiprofile hospital of JSC Russian Railways at the Barnaul station, Barnaul
Ya.N. Shoikhet1, A.A. Bazhenov1, A.A. Pantyushin2, A.A. Andrusov2, E.A. Akatova2, M.V. Varvarin2, E.V. Kotlyar2, A.A. Guryanov12, A.G. Klimov 2
The work presents the details of the experience of diagnosis and surgical treatment of lesions of endocrine organs in 20,674 patients in the period from 1958 to 2017 in the Faculty Surgery Clinic of the Altai State Medical University on the basis of the surgical department of Clinical Hospital at the station Barnaul Russian Railways. The largest group is represented by lesions of the thyroid gland - 20232 patients. Diseases of the adrenal glands there were operated 361 patients, with lesions of the parathyroid glands - 81 patients.
There are highlighted the key stages in the development of endocrine surgery at the clinic, improved methods of instrumental diagnostics endocrinopathies, rational treatment strategies and methods of operations. The advantages of endovideosurgery methods by operations on the adrenal glands are shown. The experience of the clinic is modern and comparable with the leading centers of endocrine surgery. Key words: thyroid gland, endocrine surgery, endocrinopathy, endovideo surgery.
Surgery of endocrine organs in Altai Krai, as well as many independent, scientifically substantiated sections of clinical medicine, began to be formed 60 years ago on the basis of the Clinical Department of Faculty Surgery under the guidance of prof. I.I. Neimark opened in 1957 in the Hospital of Russian Railways at the Barnaul station.
The urgency and need for a systemic formation of diagnostics and treatment of endocrine organs and, first of all, of the thyroid gland (TG) was obvious, as mountain and foothill Altai were the regions of goiter endemia, and the plains of Altai Krai are also characterized by widespread goiter and tumoral disorders.
Professor I.I. Neimark and his team developed a scientifically grounded strategy for the development of complex specialized care for thyroid lesions. Together with the departments of hygiene, normal and pathological anatomy, therapy, epidemiology of thyroid lesions, etiology, macro-and micromorphology of various forms of diseases have been studied. Clear indications for surgical and conservative treatment have been developed. The principles of preoperative preparation, volumes and methods of surgical interventions, prevention and treatment of possible complications in various types of pathology were defined.
The department and the clinic quickly acquired the deserved status of the scientific and practical school for thyroid surgery. The results of the activity were summarized in a number of monographs, dissertations, conference materials, methodological developments, etc. and have not lost their significance and relevance for many years [1-5].
The introduction of radionuclide diagnostics and treatment of thyroid lesions (1963), regional infusion of chemotherapy drugs in thyroid tu-
mors (1965), preoperative cytological diagnostics (1968), intracerebral blockade with glucocorticoids in immune thyroiditis facilitated the improvement of approaches to diagnosis and treatment of thyroid lesions (1978), discrete therapeutic plasma-pheresis (1982), determination of the concentration of thyroid hormones by radioimmune method (1984), cardio- and hemodynamics research and its correction in surgical treatment of thyroid diseases (1975-88 gg.) and others.
Employees of the department and clinic successfully defended 13 candidate theses on various issues of thyroid pathology and surgery.
Since the beginning of the 1990s, all Altai medicine has entered a qualitatively new stage of development, associated primarily with the widespread introduction of modern methods of diagnosing a variety of diseases in the early stages and progressive technologies for their treatment. Huge possibilities of ultrasonic and radiation diagnostics (CT, MRI), immunoenzymatic analysis allowed to identify pre-clinical stages, including diseases of endocrine organs (thyroid gland, adrenal glands, pituitary gland, pancreas, etc.), especially tumors. Successes in the practical implementation of these areas became possible on the basis of a comprehensive program to eliminate the consequences of nuclear tests at Semipalatinsk test site. The issues of epidemiology, etiology of various diseases and especially oncology were studied in detail in the context of the influence of ionizing radiation on their development. This is especially true for the thyroid pathology - the target organ for iodine isotopes as a product of nuclear decay. Employees of the clinic were actively engaged in the implementation of progressive methods of diagnosis and treatment of thyroid and adrenal glands disorders.
Thyroid surgery The greatest number of patients with thyroid
During 1958-2017, in the clinic there were op- gland diseases was operated in 1991-2017 - 69.4%,
erated 20 232 patients with thyroid gland diseases which is more than 2.2 times higher than the level
(Table 1). of the previous 33 years.
Table 1
Number of operated patients with thyroid disease
Patients total Average number Including with thyroid cancer
Period (years) absolute number (n) % of patients per year(n) absolute number (n) %
1958-1970 2172 10,7 167 200 9,2
1971-1980 1600 7,9 160 150 9,4
1981-1990 2400 11,9 240 162 6,8
1991-2000 6440 31,8 644 561 8,7
2001-2017 7620 37,6 448 1219 16,0
Total (1958-2017) 20232 100,0 337 2292 11,3
The maximum of surgical activity was achieved in the period of 1998-2003, which is explained by optimization of diagnostic technologies - widespread introduction of ultrasound, targeted puncture biopsy (PB), assessment of the hormonal and immune status of patients. This also led to an in-depth understanding of the nosological nature of thyroid pathology, the objectification of its diagnosis, and contributed to the development of a rational strategy and tactics for managing patients. Ultrasonography (ultrasound) of the TG has made it possible to identify and structure a significant number of people with obvious and especially subclinical lesions in the form of impalpable nodes (less than 10 mm in diameter), which often turned out to be suspicious for thyroid tumors - more often adenomas, less often thyroid carcinomas (TGC).
The ubiquitous avalanche-like growth of thyroid pathology, especially subclinical - small volumes, required from surgeons a deeply thought-out therapeutic-tactical approach, primarily to determine weighted indications for the surgical treatment of structural and extensive lesions of the thyroid gland. It was necessary to avoid extreme positions - from the "surgical epidemic" -by unconditional, total removal of all possible sites and, on the contrary, not to allow excessive conservatism in attempts of observation and poorly based medical treatment of a number of thyroid diseases, especially nodal forms.
Scientific analysis of diagnostic features, especially ultra-sonographic (ultrasound) and cytomorphological, suspicious for thyroid cancer, based on the relative risk criteria was conducted by the surgeon Bazhenova (Akatova) E.A. in the dissertation of Ph.D. in 2004 [6]. This work has allowed to quantitatively objectify ultrasound
and thyroid cytomorphology punctates of TG results and served as a base, the proof-term position of the lesions and the structuring of balance indications for surgery for nodular pathology from the point of cancer risk. The author had analyzed a large amount of material about 3065 examined and operated patients, including 290with thyroid cancer [6].
As a result of the systemic work on optimization of diagnosis and treatment of thyroid lesions, the indications for surgery have already been standardized on the stages of consultative techniques of endocrine surgeons of the clinic. Significantly reduced the indications for operations with verifiable follicular-colloid goiters of small volumes, and, on the contrary, the need for surgical treatment was expanded in the first place in diagnosed tumors of the thyroid gland - adenomas and cancers, including with suspicious ones only. Also, indications for surgery were justified with intensive proliferation of the epithelium of the nodes - goiter and thyroiditis. At the same time, a restrained position was developed from the prevailing thesis for a long time - that the colloidal thyroid gland can be cancer, therefore it requires exceptionally removal. It is only an objective, evidence-based diagnostic search for cancer risk in the nodal thyroid pathology that has made it possible to implement a rational tactical approach in solving the problems of nodular thyroid lesions.
Results of surgical treatment of patients with various thyroid lesions over the period 2001-2017 are presented in Table 2.
Analysis of the nosological structure of the operated patients testifies to the prevalence of nodal forms of nontoxic goiter - 44.0%. In the second place, slightly inferior in frequency, there are
Table 2
Structure of operated patients with thyroid diseases in 2001-2017.
Characteristics of TG diseases abs. number (n) %
Non-toxic nodal goiter 1073 14,1
Non-toxic multinodular goiter 2280 29,9
Diffuse toxic goiter 425 5,6
Nodal toxic goiter 284 3,7
Subacute thyroiditis 17 0,2
Autoimmune thyroiditis 384 5,0
Thyroid adenoma 1938 25,4
Thyroid cancer (TGC) 1219 16,0
Total patients 7620 100,0
neoplasms of the thyroid gland - 41.4% (adenomas - 25.4%, thyroid cancer - 16.0%). This indicates a high oncological potential of thyroid diseases and dictates the need for further optimization of early preoperative diagnosis of adenomas and thyroid cancer in the total mass of various nodal lesions.
Thyrotoxic forms of goiter are relatively few - 9.3%, prevalent were diffuse toxic cysts (Graves-Basedov disease) - 5.6%. Autoimmune thyroiditis Hashimoto (without combined pathology) was registered in 5.0% of operated patients with lesions of the thyroid. At the same time, in recent years, there was registered an absolute growth of patients with toxic goiter treated with surgical treatment by more than two times, and with autoimmune thyroiditis - by more than four times as compared to the period 1971-80.
Particular importance in the growth of thyroid pathology takes measures to improve the prevention and conservative treatment of thyroid diseases and in parallel - to optimize surgical tactics and indications for surgery for various lesions of the thyroid. This will allow timely and radically operate neoplasms (adenomas and cancer of the thyroid gland), as well as prevent the development of irreversible gross transformation of the gland by goiter, leading to the need for almost total removal of the organ.
A thorough analysis of diagnostic information on the basis of presentations of echo- and cyto-morphologic semiotics of various thyroid diseases allowed to reasonably refrain from surgical treatment in almost 40% of patients who had small - up to 1.0-1.5 cm - goiter, small cysts, foci of autoimmune thyroiditis, and continue their dynamic observation and treatment.
When deciding on tactics for nodular thyroid lesions with cancer risk, we distinguish two main groups of indications for the operation - the actual cancer risk and the volume of thyroid nodal lesions. From the standpoint of the classical methodology, any thyroid node can turn out to be cancer. How-
ever, modern methods of instrumental diagnosis with a high degree of probability - up to 80-90% -can provide information about the nature of the disease, its morphological structure At the same time, incorrect diagnostic material and its simplified assessment can drastically reduce the prospects for correct diagnosis. Particularly dangerous are false-negative conclusions for thyroid tumors of small volume, when the diagnosis of small-nodular goiter is mistaken, and the patient is been observed and treated conservatively unreasonably long for many months.
Therefore, the detection of hypoechogenic nodes with fuzzy contours, microcalcinates and increased vascularization by ultrasound of the thyroid gland are suspicious for thyroid cancer and, regardless of the size of the node, require a puncture biopsy for morphological verification of the lesion. The detection of cytomorphological signs suspicious for thyroid cancer, atypia, polymorphism of thyroid cells, the presence of papillary-like structures are an absolute indication for surgical treatment in connection with the high risk of a malignant node. Identification of a node with cyto-morphological signs of intensely proliferating epithelium, layers and cell complexes is a persistent indication for surgical treatment in connection with the risk of transformation of the node. The absence of cytomorphological symptomes suspicious for malignancy in the detection of alarming echo signs also does not exclude the risk of degeneration of the nodes and requires discussion of the expediency of the operation [7].
Only in the absence of these cytomorpholog-ical signs, which are suspicious for thyroid cancer and adenoma, can the deviation of the need to remove a small-sized node (up to 1.0-1.5 cm) with compulsory dynamical observation be rejected. The formation of a node of a larger diameter (more than 1.5 cm) should be operated for relative, and more than 3 cm - for persistent indications.
To a greater extent, surgical treatment for voluminous indications should be recommend-
ed in those cases when the whole thyroid gland or one of the lobes is completely replaced by multiple large sites, especially if their localization is partially or completely overloaded.
The above mentioned approaches to surgical treatment of nodular lesions of the thyroid gland, worked out in the clinic, have shown high efficiency in the timely early and radical treatment of thyroid cancer, adenomas and proliferating follicular goiter. This is illustrated by a high level of operated small thyroid cancer (50-60% of all thyroid cancer), and a rather high specific gravity of thyroid adenomas - 25% of all operated patients with nodular formations. The majority of patients with follicu-lar-colloid nodal lesions were timely and radically operated, which provided a favorable functional-morphological result and prevention of progression and relapse of goiter.
It is important to note the high efficiency of removal of thyroid nodules with complex perioperative morphological verification of tumor and non-tumor lesions. The effectiveness of accurate diagnosis of thyroid cancer during surgery reached 95%.
A special approach is required when determining the tactics of treatment of autoimmune thyroid-itis and thyrotoxic goiter. Autoimmune Hashimoto thyroiditis (AITH) is a hypertrophic, "goiter" form of autoimmune thyroiditis, characterized more often by diffuse enlargement of the thyroid gland, which has a volume of more than 40 ml in 1/3 patients. Up to 25-30% of patients usually have nodal formations: true - adenomas, proliferating follicular nodular goiter, less often thyroid cancers and so-called pseudo nodes, associated with heterogeneity and uneven pathomorphological changes in thyroid tissue of lobate, nodular-like nature.
The clinic has experience in treating more than 1650 patients with AITH, from which 1240 patients were operated. Over the past 40 years, there has been a significant evolution of ideas about the nature of AITH, perfected methods of pre-op-erative diagnosis based on modern laboratory-instrumental methods, which naturally influenced the formation of therapeutic-tactical approaches and directions. Of particular relevance to the problem of AITH is the multiple widespread growth, both absolute and relative, in the structure of thyroid pathology. The number of operated patients with AITH since the early 1990s to the present is 20-40 people, which exceeds the level of the period 1981-1990 by two times and by four times -the period of 1971-1980.
Tactics of treatment of patients with AITH, according to the literature, is ambiguous and often polar - from persistent attempts of conservative cure based on immunomodulating therapy to the maximum expansion of indications for surgical treatment, given the insufficient effectiveness
of existing methods of conservative treatment and real cancer risk [8, 9]. The analysis of the problem as a whole and long-term own experience made it possible to formulate a program of a differentiated approach to the treatment of patients with AITH.
Surgical treatment of AITH is prescribed
- by a persistent significant growth of thyroid gland - a volume of more than 40 cm3;
- in the presence of nodes or dubious foci, suspicion of cancer - regardless of the volume of the thyroid;
- by severe compression of the neck;
- by a significant morphofunctional incidence of thyroid disease (by the severity of apoptosis of the thyroid parenchyma, cicatrization of the stro-ma and lymphoid infiltration of tissue - the 3rd-4th degree of AITH according to A.P. Kalinin) [10].
In all situations, except for the suspicion of the transformation of the nodes, it is necessary to start treatment of AITH with a set of conservative measures.
Most patients with AITH were operated in the presence of nodes suspicious for adenoma and cancer, and by thyroiditis with a large volume of thyroid cancer.
The method of choice by AITH was subcap-sular subtotal thyroidectomy. Hemithyroidecto-my was performed by unilateral nodular forms of AITH, with a full contralateral thyroid lobe. With the pronounced replacement of the parenchyma of the thyroid gland by AITX (grade 3-4 according to A.P. Kalinin) [10], the operation volume was expanded to total-subtotal thyroidectomy due to the irreversible significant morphofunctional insufficiency of the thyroid gland and the high probability of recurrence of AITH. After the operation, all patients were prescribed therapy with thyrox-ine before achieving stable euthyroidism. The true recurrence of AITH, requiring repeated interventions, is rare - up to 2%.
Diffuse toxic goiter (Bazedov-Graves disease) is a common disease, characterized by a sharp increase in the rate of synthesis and secretion of thyroid hormones of hyperplastic parenchyma TG and the development of thyrotoxicosis.
In the period 2001-2017, operative treatment of DTG as a method of choice was performed in 425 patients.
Indications for the operation were:
- moderate and severe thyrotoxicosis and unstable remissions from conservative treatment, regardless of the degree of enlargement of the thyroid gland;
- large size of goiter (more than 40 cm3), regardless of the severity of thyrotoxicosis;
- persistent expressed autoimmunity, determined by the titer of autoantibodies, the degree of lymphoid infiltration in the thyroid cytograms, the characteristic changes in immunograms,
and the severity of endocrine ophthalmopathy. Particular importance was attached to the presence of increased content in the blood of stimulating autoantibodies to TSH receptors of thyreocytes.
- poor tolerance of conservative treatment, development of leukopenia, drug allergy, drug hepatitis, agranulocytosis against antithyroid therapy. For preparation, there was performed therapeutic plasmapheresis.
The method of choice in the past decade has been extremely-subtotal thyroidectomy as a guarantee of radicalization, prevention of recurrence and as a standard technique [9, 10].
Nodal thyrotoxic goiter (including toxic adenomas of Plummer) was present in 284 patients -after correction of hormonal disorders, there were successfully performed operations in the volume of hemithyroidectomy.
Due to careful complex preoperative preparation, well-developed technique of surgical intervention, adequate anesthesia with artificial ventilation, controlled management of the postoperative period, all patients managed to avoid thyrotoxic crises and other persistent specific complications.
Thus, at present there is a continuous increase in the number of patients with various thyroid lesions, including those who need timely early and radical surgical treatment. This is especially true for thyroid tumors, primarily the thyroid cancer. Only a thorough rational pre-clinical diagnosis of a possible cancer risk of nodal lesions can make an optimistic decision on this problem, and a weighted surgical tactic ensures timely adequate surgical interventions.
The final analysis testifies to the continuous and distinct tendency of the growth of thyroid pathology, which has been subject to surgical treatment since the beginning of the 1990s in a total of 2.2 times, and the thyroid cancer is almost 3.5 times relative to the period of 1960-80s. Thus, the conclusion follows that the thyroid gland pathology in Altai Krai remains a serious problem. There is a high potential for the development and growth of various hyperplastic processes, especially goiter and tumor, as well as autoimmune and functional disorders. This leads to a serious tendency to irreversibility of these pathological processes and the formation of decompensated forms of diseases. The flow of patients with thyroid disorders that need surgical treatment is continuously increasing, as a forced and often extreme, but only radical measure, especially in thyroid tumors.
Surgery of the parathyroid glands
Surgery of parathyroid glands (PTG) as an independent direction began to develop in the clinic from the 1990s, when real methods of instrumental diagnostics of volumetric lesions of PTG - ultrasound, MRI, direct evaluation of their function in terms of parathyroid hormone (PTH) and me-
diated - for violations of the balance of calcium and phosphorus and bone densitometry. The pathology was relatively infrequent.
Over the period from 1996 to 2017, 81 patients with lesions of the parathyroid glands were operated in the clinic.
Among them there were 67 patients with adenoma of TG, in 12 patients, hyperplasia of all parathyroid glands was revealed, in 2 - with cyst. The age of the patients varied from 26 to 70 years. There were 72 women, 9 men.
The majority of patients (68) were hospitalized with a confirmed diagnosis of extensive lesion of PTG. Only in 4 patients, adenomas of the PTG were detected "as a finding" in the course of operations on the thyroid gland.
Out of 68 patients with pre-operative diagnosis of adenomas, only 2 had no clinical signs of thyroid dysfunction without changes in the levels of PTH, calcium and phosphorus. In 66 patients with adenomas, hyperparathyroidism was diagnosed, in 56 patients, hyperparathyroidism was primary, in 10 patients - tertiary. The diagnostic algorithm was based on modern, generally accepted methods [8, 9, 10]. The degree of severity of hyperparathyroid-ism and adenomas was different and depended on the form of the lesion.
In patients with primary hyperparathyroidism, there were single adenomas of PTG, more often inferior, with a size of 8 mm to 34 mm in length. They were revealed by ultrasound of the thyroid-cervical complex in the form of ovoid hypo-echogenic nodes with a clear contour in the posterior capsule of the thyroid gland. Palpable adenomas were only in 10 patients in the form of small formations in the lower third of the neck.
Forms of primary hyperparathyroidism in adenomas of PTG:
a) subclinical (asymptomatic), when there was a moderate increase in the level of PTH from 80 to 150 pg/ml, usually with minor hypercalcaemia -up to 2.75 mmol/l. It was diagnosed in 22 patients.
b) symptomatic - clinically obvious hyper-parathyroidism - in 34 patients. It was characterized by a bone form - 20 patients; gastrointestinal (gastritis, ulcer) - 3 patients; mixed - 11 patients. In 3 patients with a bone form, there were pathological fractures of the thoracic and lumbar vertebrae and pronounced osteoporosis. In 14 patients, the symptoms were less pronounced - there were minor pains in the bones, a decrease in their density by densitometry. The level of parathyroid hormone was significantly increased to 140-260 pg/ml, and hypercalcemia reached 3.0-3.25 mmol/l.
In 8 patients with a mixed form of hyperpara-thyroidism, there was a combination of osteoporosis with arterial hypertension (in 5 patients), with moderate nephrocalcinosis (in 1 patient), with uro-lithiasis (in 2 patients).
Indication for surgical treatment in all patients with adenomas of TG and primary hyperparathy-roidism was precisely the combination of extensive pathomorphological changes in PTG with their increased function. Depending on the degree of PTG growth and its hyperfunction, the patients were operated either according to absolute indications - with severe clinical symptoms (pathological fractures, risk of hypercalcemic crises, cardiac, kidney and other organ disorders), or persistent indications for mild symptomatology.
The operation - removal of the adenoma of PTG was performed under intubation anesthesia from the Kocher's incision on the neck. After a thorough revision of the entire thyroid-cervical complex for the verification of pathology, the presence, as a rule, of a single (solitary) adenoma of PTG cancer was confirmed. It was removed according to the standard procedure in full. In 7 patients of this group, there was also a pathology of thyroid gland: mono- and polynodous goiters, which required their parallel removal - by resection of the thyroid gland. The postoperative period in patients proceeded well, pleasantly, without complications and persistent dysfunctions.
Since 2013, together with the doctors-nephrol-ogists of Altai Krai, has began a study of patients who are on program hemodialysis for CKD of terminal stage, for the possibility of tertiary hyper-parathyroidism. As a screening, the determination of the level of total and ionized calcium of blood, phosphorus and parathormone was used. When hyperparathyroidism was detected, instrumental diagnostics was performed - ultrasound of the thyroid-cervical complex. The indication for the operation was a marked increase in the level of parathyroid hormone, which was from 884 pg/ml to 4,700 pg/ml (norm 10-77 pg/ml) and revealed volumetric formations in the projection of the parathyroid glands during ultrasound examination. During this period, operative treatment was performed in 17 patients with tertiary hyperparathyroidism, among them 6 men and 11 women.
The age of the patients ranged from 26 to 56 years. The time spent on hemodialysis at the time of surgery ranged from 6 years to 21 years. All patients underwent program bicarbonate hemodialy-sis, every other day. Hypercalcemia was detected in only 5 patients. Operative treatment was carried out the day after hemodialysis, then, for the next 2 days, observation, bandaging, control of total calcium of blood was carried out. Operative intervention was performed under intravenous anesthesia with mechanical ventilation. Access - Kocher section. The average duration of the operation was 30 minutes. During the operation, despite the results of ultrasound examination, a revision of all typically located parathyroid glands was mandatory. In 5 cases, single adenomas of the near-thyroid glands were identified, in 12 cases - increased, dense,
volumetric formations by the type of hyperplasia of the three parathyroid glands. The size of the removed parathyroid glands was from 10 mm to 25 mm. All patients underwent a histological study of preparations, which confirmed benign tumors and hyperplasia of the parathyroid glands. All patients were discharged with recovery, without postoperative complications.
The accumulated experience allows to conclude about the advisability and comparative safety of surgical treatment of patients with PTG lesions, especially in the presence of obvious primary or tertiary hyperparathyroidism, which are dangerous for their severe consequences.
Surgery of adrenal glands
Until the early 1990s, operations on the adrenal glands were few in number, which was due to the lack of reliable methods for verifying adrenal lesions. The only objectivizing method of visualization - retropneumoperitoneography - had limited diagnostic capabilities. There were no direct ways to evaluate the hormonal function of the adrenal glands, and open operative accesses were traumatic. Only a clear clinic with obvious symptomatic arterial hypertension and metabolic disturbances made it possible to propose hormone-active tumors of the adrenal glands, primarily pheochromocyto-mas. In 10 such patients, indications for surgery were established and successful adrenalectomy was performed.
Qualitatively, a new stage in the development, especially of adrenal gland disorders, began in 1993, when modern diagnostic methods (CT, MRI) and a wide range of hormones (cortisol, aldo-sterone, adrenaline, appeared in the Altai Regional Diagnostic Center), ACTH, estrogens, etc.). This allowed to identify the structural and functional lesions of the adrenal glands at the early, preclinical stages and, what is especially important, by small sizes of nodular tumor lesions.
The close cooperation of the clinic with the Altai Regional Diagnostic Center made it possible to standardize diagnostic and tactical approaches to managing patients and selecting them for surgical treatment. First of all, they were patients with hormonal-active ovules, measuring more than 3 cm in diameter and with suspicion of adrenal cancer.
As a result, in the clinic of faculty surgery on the basis of the Multiprofile hospital of JSC Russian Railways at the Barnaul station 361 patients with various diseases of the adrenal glands aged 18 to 78 years were operated.
Until 2003, 55 patients were operated with traditional open thoracophrenolumotomy access. They were dominated by hormonal-non-active tumors - aldosteroma, pheochromocytoma (Table 3).
Qualitatively new stage in perfection of adrenal surgery proper was the introduction of endovideo-surgical methods of adrenalectomy, which signifi-
cantly reduced the traumatic nature of the operation and the frequency of complications compared with open adrenalectomies [11].
Based on the experience of open adrenalecto-mies, video-laparoscopic operations on the abdominal organs, we optimized retroperitoneovideo-scopic adrenalectomy from the lateral abdomen. Its advantages were relatively low-traumatic extra-abdominal access to the adrenal gland and the optimization of its direct mobilization and removal.
The first retroperitoneovideoscopic adrenalec-tomy (RPVEA) from the side abdomen in our clinic was performed in 2003. For the period of 2003-2017, by extensive formations of suprarenals, 306 operations were performed. The age of the patients varied from 20 to 78 years. There were 83 patients with
aldosterone-producing formations, 33 with pheo-chromocytoma, 175 supra-capillary hormone-inactive tumors (more than 3cm in length), with Cush-ing syndrome and disease. Consequently, the main indications for adrenalectomy were the hormonal activity of the adrenal glands or their size more than 3 cm in the longitudinal axis. The duration of surgical intervention in operated patients was 50.3 ± 15.0 minutes.
After the operation, the patients independently got up within a few hours of the end of the intervention, did not need narcotic analgesics. Drainages were removed 24-48 hours after the operation.
In 8 (2.6%) patients there were complications by retroperitoneovideoscopic adrenalectomy from lateral access (Table 4).
Table 3
Characteristics of adrenal neoplasms
Neoplasm type RPVEA main group Open adrenalectomy comparison group
abs. number % abs. number %
Aldosteroma 83 27,1 31 56,4
Hormonal-inactive 175 57,2 11 20
Pheochromocytoma 33 10,8 7 12,7
Cortisol - producing 15 4,9 3 5,5
Cancer - - 3 5,5
Total 306 100 55 100
Table 4 Comparative assessment of the incidence of complications by adrenalectomy from thoracophrenolumbomatologic access through the X intercostal space and retroperitoneovideoscopic access from the lateral abdomen
Complication type RPVEA main group n-232 Open adrenalectomy comparison group n-55 P
abs. number % abs. number %
Bleeding from the abdominal wall - - 3 5,5
Opening of the pleural cavity 3 1,3 41 75 < 0,001
Abdominal opening - - 3 5,5
Wound abscess 1 1,2 5 9,1 <0,02
Retroperitoneal hematoma 3 1,3 2 3,6 >0,05
Subhepatic abscess - - 1 1,8
Acute cardiovascular inefficiency 1 0,33 1 1,8
Myocardial infarction - - 2 3,6
Total 7 3,0 58 105,5 <0,001
The results showed that retroperitoneovideo- and accompanied by a minimal number of compli-
scopic adrenalectomy is a low-traumatic surgical cations.
intervention providing direct access to the adrenal However, endovideosurgical interventions are
gland, characterized by good functional results in no way opposed to open methods of surgery,
which are suitable for large tumor sizes, signs
of malignancy and the development of intraoperative complications.
Thus, the clinic continues to develop the experience of diagnosis and surgical treatment of various lesions of the adrenal glands, thyroid and parathyroid glands.
Modern methods of diagnosing various endocrine diseases are effectively used, the evidence for operations is substantiated and differentiated, their technique and perioperative management of patients are improved. This contributed to improving the outcomes of surgical treatment, minimizing complications and achieving optimal results.
References
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2. Neimark I.I. Clinic and treatment of diseases of the thyroid gland. Barnaul; 1967.
3. Neimark I.I. Diseases of the thyroid gland in the Altai Territory. Barnaul; 1984.
4. Neimark A.I., Neimark I.I., Kalinin A.P. Efferent therapy for surgical diseases. Krasnoyarsk; 1991.
5. Shoikhet Ya.N., Lazarev A.F., Petrova V.D., Pisareva L.F. Thyroid cancer in the Altai Territory. Barnaul: ASU; 2003.
6. Bazhenova E.A. Optimization of diagnosis of thyroid cancers within the limits of 10 mm in the largest dimension. [abstract of the thesis of the candidate of medical sciences] Barnaul; 2004.
7. Shoikhet Ya.N., Bazhenova E.A., Bazhenov A.A. Diagnosis of the microcarcinoma of the thyroid gland. Problems of clinical medicine. 2005; 2: 126132.
8. Valdina E.A. Thyroid disease: Guidance. 3rd ed. St. Petersburg: Pbter; 2006.
9. Romanchishen A.F. Surgery of the thyroid and parathyroid glands. St. Petersburg:Vesti; 2009.
10. Dedov I.I., Kuznetsova N.S., Melnichenko G.A., ed. Endocrine surgery. Moscow: Litterra; 2014.
11. Kalinin A.P., Maistrenko N.A. Surgery of the adrenal glands. Moscow: Meditsina; 2000.
Contacts
Corresponding author: Shoikhet Yakov Na-khmanovich, corresponding member of RAS, Doctor of Medical Sciences, Professor of the Department of Faculty Surgery named after Professor I.I. Neimark, hospital surgery with the course of FVE of the Altai State Medical University, Barnaul. 656045, Barnaul, Zmeinogorsky Trakt, 75. Tel.: (3852) 268233. Email: [email protected]
Bazhenov Alexey Alexandrovich, Candidate of Medical Sciences, Assistant of the Department of Faculty Surgery named after Professor I.I. Nei-mark, hospital surgery with the course of FVE, Al-
tai State Medical University, Barnaul. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
Pantyushin Aleksandr Aleksandrovich, Candidate of Medical Sciences, Head of General Surgery Department of the Multiprofile hospital of JSC Russian Railways at the Barnaul station. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. E-mail: [email protected].
Andrusov Anton Anatolievich, resident physician of General Surgery Department of the Multiprofile hospital of JSC Russian Railways at the Barnaul station.
656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256.Email: [email protected]
Akatova Elena Alekseyevna, Candidate of Medical Sciences, surgeon of General Surgery Department of the Multiprofile hospital of JSC Russian Railways at the Barnaul station. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
Varvarin Mikhail Vladimirovich, resident physician of General Surgery Department of the Multiprofile hospital of JSC Russian Railways at the Barnaul station.
656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
Kotlyar Evgeny Vladimirovich, Candidate of Medical Sciences, resident physician of General Surgery Department of the Multiprofile hospital of JSC Russian Railways at the Barnaul station. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
Guryanov Andrey Aleksandrovich, Doctor of Medical Sciences, surgeon of General Surgery Department of the Multiprofile hospital of JSC Russian Railways at the Barnaul station. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
Klimov Alexey Gennadievich, Candidate of Medical Sciences, surgeon of General Surgery Department of the Multiprofile hospital of JSC Russian Railways at the Barnaul station. 656038, Barnaul, ul. Molodezhnaya, 20. Tel.: (3852) 201256. Email: [email protected]
