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12
DOI: 10.12737/article_5a0a90007b9072.55673561
Ilyicheva E.A. 1 2, Zharkaya A.V. 1 2, Bulgatov D.A. 2, Makhutov V.N. 2, Borichevskiy V.I. 2, Karasev V.P. 2, Aldaranov G.Yu. 2, Ovakimyan G.A. 2
EXPERIENCE OF SURGICAL TREATMENT OF THYROID AND PARATHYROID DISEASES
11rkutsk Scientific Centre of Surgery and Traumatology (ul. Bortsov Revolyutsii 1, Irkutsk 664003, Russian Federation)
2 Irkutsk Regional Clinical Hospital (Yubileyniy 100, Irkutsk 664079, Russian Federation) 3 Irkutsk State Medical University (ul. Krasnogo Vosstaniya 1, Irkutsk 664003, Russian Federation)
Background. In our country some aspects of thyroid and parathyroid surgery are still discussed. Aim. To present our experience in surgical treatment of benign diseases of the thyroid and parathyroid glands. Materials and methods. A retrospective analysis of the results of surgical treatment of 1511 patients with thyroid and parathyroid disease was performed.
Results. Thyroidectomy was performed in 73.6 % of cases with thyroid diseases. The frequency of postoperative complications: laryngeal paresis -1.37 %, hypoparathyroidism - 0.84 %, hemorrhagic complications -1.2 %. Selective parathyroidectomy was performed in 99 % of cases with primary hyperparathyroidism. Persistent hypoparathyroidism and laryngeal paresis have not been identified. Total parathyroidectomy with central neck dissection, upper mediastinum and upper horn of the thymus gland was performed in 66.3 % of cases with secondary hyperparathyroidism. Persistent laryngeal paresis was established in 3.3 % of cases, hemorrhagic complications - in 3.3 %.
Conclusions. Constant analysis of our own results gives us reasons for our own attitude to the controversial issues of thyroid and parathyroid surgery. Presently, we prefer thyroidectomy in the treatment of diffuse toxic goiter and multinodular goiter, hemithyroidectomy - for the single-node goiter. In the surgical treatment of primary and uremic hyperparathyroidism, we consider mandatory the use ofintraoperative monitoring of intact parathyroid hormone. When performing total parathyroidectomy, we perform the autotransplantation of the fragment of the parathyroid gland. Key words: thyroidectomy, parathyroidectomy
ОПЫТ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ДОБРОКАЧЕСТВЕННЫХ ЗАБОЛЕВАНИЙ ЩИТОВИДНОЙ ЖЕЛЕЗЫ И ОКОЛОЩИТОВИДНЫХ ЖЕЛЕЗ
Ильичева Е.А. 2, Жаркая А.В. 2, Булгатов Д.А. 3, Махутов В.Н. 2, Боричевский В.И. 2, Карасев В.П. 2, Алдаранов Г.Ю. 2, Овакимян Г.А. 2
1ФГБНУ «Иркутский научный центр хирургии и травматологии» (664003, г. Иркутск, ул. Борцов Революции, 1, Россия) 2 ГБУЗ «Иркутская ордена «Знак почёта» областная клиническая больница»
(664079, г. Иркутск, Юбилейный, 100, Россия) 3 ФГБОУ ВО «Иркутский государственный медицинский университет» Минздрава России
(664003, г. Иркутск, ул. Красного Восстания, 1, Россия)
Обоснование. На сегодняшний день некоторые хирургические аспекты лечения доброкачественных заболеваний щитовидной и около щитовидных желёз остаются широко обсуждаемыми. Цель исследования: представить опыт коллектива в хирургическом лечении доброкачественных заболеваний щитовидной железы и околощитовидных желёз.
Методы. Проведён ретроспективный анализ результатов хирургического лечения 1511 пациента, оперированного по поводу доброкачественных заболеваний щитовидной железы и околощитовидных желёз за период с 2005 г. по апрель 2017 г. в торакальном хирургическом отделении ГБУЗ ИОКБ. Результаты. При заболеваниях щитовидной железы в 73,6 % случаев выполнялась тиреоидэктомия. Частота послеоперационных осложнений: парез гортани -1,37 % случаев, гипопаратиреоз - 0,84 %, геморрагические осложнения - 1,2 %. При первичном гиперпаратиреозе в 99 % случаев выполнена селективная паратирео-идэктомия. Стойкого гипопаратиреоза и пареза гортани не выявлено. При вторичном гиперпаратиреозе в 66,3 % случаев выполнена тотальная паратиреоидэктомия с диссекцией центральной клетчатки шеи, верхнего средостения и верхних рогов вилочковой железы. Стойкий парез гортани был установлен в 3,3 % случаев, геморрагические осложнения - в 3,3 %.
Заключение. Постоянный этапный анализ собственных данных позволяет аргументировать отношение авторов к спорным вопросам хирургии доброкачественных заболеваний щитовидной и околощитовидных желёз. Аргументация связана с низким риском персистенции и рецидива заболеваний, приемлемой частотой послеоперационных осложнений и отсутствием летальности. Ключевые слова: тиреоидэктомия, паратиреоидэктомия
To date, the pathology of the thyroid and parathyroid glands occupy the second and third place in terms of prevalence among diseases of the endocrine system after diabetes mellitus [4]. Surgery of diseases of the thyroid and parathyroid glands is the continuously developing direction of general surgery with changing views on indica-
tions for surgical treatment and tactical aspects. The most topical issues are the questions of differential diagnosis of primary and secondary hyperparathyroidism, the use of intraoperative monitoring in the surgical treatment of primary and uremic hyperparathyroidism, and the choice of the scope of surgical intervention in secondary
hyperparathyroidism. Discussion remains in the choice of the volume of surgical intervention for diffuse toxic and multi-node goiter.
In 2004, the authors called oncological alertness as the main cause of operative activity in cases of nodular goiter. Hypothyroidism was regarded as a complication of surgical treatment, and surgeons kept to organ-preserving resections of the thyroid gland [1]. The Clinical recommendations of the Russian Association of Endocrinologists for the diagnosis and treatment of nodular goiter (2004) identified two groups of indications for surgical treatment: a nodal (multinodular) goiter with signs of compression of surrounding organs and/or cosmetic defect and nodal (multinodular) goiter in the presence of decompensated functional autonomy thyroid gland (toxic goiter) or at a high risk of its decompensation [5].
For 2008, the most common volume of surgical intervention for Graves disease in Russia was subtotal resection of the thyroid gland. This volume of surgery was considered necessary to maintain the patient s euthyroid status in the postoperative period [12]. Other domestic authors showed that thyroidectomy can significantly reduce the risk of relapse of thyrotoxicosis in comparison with subtotal resections of the thyroid gland, in the absence of an increase in the incidence of complications and deterioration in the quality of life [11]. In the Clinical Recommendations of the Russian Endocrinology Association in 2007, the goal of surgical treatment was to remove the greater part of the thyroid gland ensuring the development of postoperative hypothyroidism (which is not currently considered a complication of surgical treatment of Graves disease but is considered its goal), excluding any possibility of relapse of thyrotoxicosis [3].
This discussion is still ongoing. The authors indicate (2015) that the volume and method of surgical intervention for diffuse toxic goiter should be selected individually, taking into account the severity of the disease, the presence or absence of endocrine ophthalmopathy, the titer of antibodies to thyroid-stimulating hormone receptors, the age and duration of antithyroid therapy [10]. In the Clinical recommendations of the Russian Endocrinology Association in 2014, the total thyroidectomy is indicated as operative treatment of choice for diffuse toxic goiter [10].
To this day surgical tactics regarding secondary (uremic) hyperparathyroidism remains the subject of discussions. There is no generally accepted recommended volume of surgical treatment [2]. The main problem of choosing surgical tactics in the treatment of patients with chronic kidney disease at the dialysis stage, suffering from severe secondary hypoparathyroidism, is the lack of consensus on the purpose of the operation - achieving target levels of parathyroid hormone or hypoparathyroidism and the absence of a risk of persistence and relapse of the disease.
As we have accumulated experience in the treatment of benign thyroid and parathyroid pathologies, we find this report to be very important.
AIM OF THE STUDY
To present the team's experience in the surgical treatment of benign diseases of the thyroid gland and parathyroid glands.
MATERIALS AND METHODS
We have conducted a retrospective analysis of the results of surgical treatment of patients operated for benign thyroid and parathyroid gland diseases in the thoracic surgical department of the Irkutsk Regional Clinical Hospital for the period from 2005 to April 2017. The criterion for inclusion in the study was a surgical intervention for benign diseases of the thyroid gland and parathyroid glands. The criterion for exclusion from the study was the lack of consent to the processing of personal data. The inclusion criteria totaled 1511 cases, all observations included in the study.
Table 1 presents the distribution of surgeries by year.
Table 1
Dynamics of surgical activity for diseases of thyroid and parathyroid glands
Year Number of surgeries for diseases of thyroid gland Number of surgeries for primary hyperparathyroidism Number of surgeries for secondary hyperparathyroidism
2005 0 0 1
2006 119 0 1
2007 144 5 1
2008 31 0 0
2009 121 9 1
2010 110 3 5
2011 108 1 5
2012 91 5 5
2013 111 10 6
2014 90 15 11
2015 162 23 21
2016 170 32 22
before April 2017 52 10 10
Total: 1309 113 89
Mean age - 51 (40; 59) y.o., most patients were women (88.7 %).
In the structure of the underlying disease, multi-nodular or nodal goiter and diffuse toxic goiter prevailed (Figure 1). A high percentage of operations for diffuse toxic goiter, in our opinion, is associated with the continued low availability of radioiodine therapy in our country, in particular in the Irkutsk region.
Indications for surgical treatment for thyroid diseases were: nodal or multinodular goiter with signs of compression of the neck (trachea, esophagus), nodular or multinodular goiter with decompensation of functional autonomy, relapse of thyrotoxicosis in diffuse toxic goiter, intolerance to thyrostatics, diffuse toxic goiter with compression of the organs of the neck.
Indications for surgical treatment for primary hyperparathyroidism were as follows: manifest form of primary hyperparathyroidism, daily excretion of calcium with urine more than 10 mmol/L per day, decrease in glomerular filtration rate of kidneys less than 60 ml/ min/1.73 m2, progressive decrease in bone mineral density on the background of conservative therapy, age younger than 50 years.
432; 29%
89; 6% 113; 7%
/ -----458; 30%
2; 0%^46;' 3%
□ Graves' disease
□toxic nodular/multinodular goiter
□ nodular/multinodular goiter
Hautoimmune thyroiditis
□ aberrant thyroid gland
□ primary hyperparathyroidism
Bsecondary hyperparathyroidism
Fig. 1. Disease structure in patients operated for benign thyroid and parathyroid gland pathologies.
Indications for surgical treatment for secondary hyperparathyroidism were: increased PTH levels of more than 800 pg/mL in combination with hyperphosphatemia resistant to conservative therapy, the presence of extraskeletal calcification, hypercalcemia, or progressive skeletal lesion.
The statistical processing of the results was performed with the use of Statistica 10 for Windows software package (license No. AXAR402G263414FA-V). The normal distribution of the feature was analyzed using the Kolmog-orov-Smirnov test. The quantitative data were presented as a median with interquartile range (Me (Q25; Q75)).
When performing surgeries on the thyroid and parathyroid glands, we use microsurgical technique (with amplification), with visualization of recurrent laryngeal nerves and parathyroid glands. The structure of the performed surgical interventions is presented in Table 2.
Table 2
Surgeries performed for diseases of thyroid and parathyroid glands
Volume of the surgery Number
abs. %
Subtotal resection of the thyroid gland 8 0,53
Maximally subtotal resection of the thyroid gland 137 9,07
Thyroidectomy (including extirpation of the thyroid stump) 964 63,80
Hemithyroidectomy 198 13,10
Pa rathyroidecomy 112 7,41
Total parathyroidecomy 13 0,86
Subtotal parathyroidecomy 17 1,13
Total parathyroidectomy with dissection of the central cellular tissue of the neck and mediastinum 59 3,90
Removal of the aberrant ectopic lobe of the thyroid gland 2 0,13
Removal of ectopic parathyroid adenoma 1 0,07
Total: 1511 100
RESULTS AND DISCUSSION
When analyzing the structure of surgeries for the pathology of the thyroid gland (Table 2), it was found that in the vast majority of cases, thyroidectomy was performed (73.6%), which is related to predomination of multinodular goiter and diffuse toxic goiter in the structure of diseases. From our point of view, the performance of thyroidectomy is pathogenetically justified method of treating this pathology. With a unilateral pathological process, the minimum volume of surgery performed in our clinic is hemithyroidectomy with removal of the thyroid isthmus.
There was no postoperative lethality. Postoperative resistant hypoparathyroidism was established in 11 cases (0.84 %), which does not exceed the data known in the literature [15]. Hemorrhagic complications in the early postoperative period developed in 16 cases (1.2 %), laryngeal transit paresis - in 182 cases (13.9 %), persistent laryngeal paresis - in 18 cases (1.37 %), which also fits within known limits of frequency of these complications [13]. In 2 cases (0.15 %) tracheal perforation was established: in 1 observation, the lesion was established intraoperatively with a thyroid volume exceeding 300 cm3, in 1 case the perforation was established in the early postoperative period and was associated with the use of electrocoagulation. In both cases, after the suturing of the defect of the tracheal wall, recovery occurred.
Pathomorphological study of surgical material in the nodal and multinodular goiter detected 58 cases of highly differentiated thyroid cancer (3.84 %).
When analyzing the structure of surgeries for primary hyperparathyroidism, we have found that in the vast majority of cases parathyroidectomy (99.1%) was performed with removal of one or several pathologically altered parathyroids, and there was 1 (0.9 %) case of subtotal parathyroidectomy with multiple parathyroid lesions. Repeated surgeries in the early postoperative period in connection with the persistence of the disease were performed in 2 cases (1.8 %), in the long-term period -in 1 patient (0.9 %). 59 surgical interventions (52.2 %) were accompanied by intraoperative monitoring of the level of intact parathyroid blood hormone. The use of an intraoperative test of the degree of reduction in the level of intact parathyroid hormone after parathyroidectomy (according to the Miami criterion), in our opinion, allows to reduce the amount of persistence of the disease, but requires the specification of the surgeon's tactics in case of negative sample result [8].
Multiple lesion of the parathyroid by the results of our study made 11 %, which fits into the known data.
Surgical activity in relation to primary hyperparathyroidism has been increasing during the last 3-4 years (Table 1), which, in our opinion, is a consequence of improving the quality of diagnosis of this disease. There were no postoperative lethality, wound septic complications or bleedings. The laryngeal paresis developed in 10 cases (8.9 %) and was transient in all cases.
In secondary (uremic) hyperparathyroidism, total parathyroidectomy with a dissection of the central cellular tissue of the neck, the superior mediastinum and the upper horns of the thymus gland was performed in 59 cases (66.3 %). The choice of this volume of surgical
371; 25%
treatment was based on the analysis of our own data [6, 7]. Absence of synchronicity of pathological changes in the parathyroid glands at uremic hyperparathyroidism and their unavoidable progression due to chronic kidney disease leads to persistence and relapse of the disease, which is an unfavorable outcome, increasing the risk of developing cardiovascular complications. Total parathyroidectomy with the removal of the parathyroid glands of all possible localizations accessible from the cervical approach (including the thyroid gland with established ectopia, the central cellular tissue of the neck and upper mediastinum, the upper horn of the thymus gland) is the only surgical intervention that allows removing parathyroid glands in whole, including parts not detectable with intraoperative revision. This volume of surgery does not increase the risk of postoperative complications in comparison with subtotal parathyroidectomy and standard total parathyroidectomy.
Postoperative paresis of the larynx developed in 5 cases (5.6 %), in three of them (3.3 %) it was of transient nature. In three cases (3.3 %), the larynx paresis was observed after repeated surgery on the neck, including one case (1.1 %) after necessary resection of the recurrent laryngeal nerve against the background of advanced parathyroidism.
Hemorrhagic complications were revealed in three cases (3.3 %). In two cases, complications were presented by subcutaneous hematoma and bleeding from the drainage canal, which did not require recer-viticotomy. These complications can be associated with the four-hour programmed hemodialysis with the use of heparin in the early postoperative period. In 1 case (1.1 %), a tense mediastinal hematoma developed after sternotomy when an adenoma grown into the aortopul-monary window was removed, the complication was eliminated using a video-assisted mini-thoracotomy. The frequency of hemorrhagic complications in our study did not exceed the values reported by other authors - from 2 % to 4.3 % (bleeding, neck necrosis, requiring surgical drainage) [14, 16].
Simultaneous operations were performed in 47 cases (3.1 %): parathyroidectomy with concomitant hyperparathyroidism in thyroid pathology - 21 cases (44.7 %); hemithyroidectomy and thyroidectomy with concomitant thyroid gland pathology during surgery for secondary hyperparathyroidism - 8 cases (17 %); resection of the internal carotid artery in pathological tortuosity - 9 cases (19.2 %); lobectomy for lung tuberculosis - 1 case (2.1 %); cholecystectomy for chronic calculous cholecystitis - 1 case (2.1 %); inguinal hernia repair - 1 case (2.1 %); stabilization of vertebral bodies with metal cages - 1 case (2.1 %); removal of peritoneal catheter - 1 case (2.1 %); removal of the trachea diverticulum - 1 case (2.1 %); removal of the esophageal diverticulum - 1 case (2.1 %); herniolaparotomy with plastic mesh prosthesis - 1 case (2.1 %); herniolaparotomy with local flaps grafting - 1 case (2.1 % ).
CONCLUSION
In the surgical treatment of benign diseases of the thyroid and parathyroid glands there remains a considerable number of controversial points. At the same time,
a detailed analysis of immediate and remote results of surgeries performed in our clinic gives us reason for our own attitude to some contentious issues. Currently, we prefer thyroidectomy in the treatment of diffuse toxic goiter and multinodal goiter, and hemithyroidectomy for a single-node goiter. In the surgical treatment of primary and uremic hyperparathyroidism, we consider it mandatory to use intraoperative monitoring of intact parathyroid hormone. When performing total parathyroidectomy, we perform autotransplantation of the parathyroid gland fragment.
The authors declare that there is no conflict of interest regarding the publication of this article.
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Information about the authors
Ilyicheva Elena Alekseyevna - Doctor of Medical Sciences, Professor, Head of the Scientific Department of Clinical Surgery, Irkutsk Scientific Centre of Surgery and Traumatology; Thoracic Surgeon at the Thoracic Surgical Department, Irkutsk Regional Clinical Hospital (664003, Irkutsk, ul. Bortsov Revolyutsii, 1; tel. (3952) 40-78-28; e-mail: [email protected]) © ORCID orcid.org/0000-0002-2081-8665
ZharkayaAnastasiya Valeryevna - Candidate of Medical Sciences, Junior Research Officer at the Scientific Department of Clinical Surgery, Irkutsk Scientific Centre of Surgery and Traumatology; Surgeon at the Endocrinology Center, Irkutsk Regional Clinical Hospital (e-mail: [email protected]) © ORCID orcid.org/0000-0002-9337-2369
BulgatovDmitriyAleksandrovich - Postgraduate at the Department of Advanced Level Surgery, Irkutsk State Medical University (664003, Irkutsk, ul. Krasnogo Vosstaniya, 1; e-mail: [email protected]) © ORCID orcid.org/0000-0002-2440-0813
Makhutov Valeriy Nikolaevich - Candidate of Medical Sciences, Head of the Thoracic Surgical Department, Irkutsk Regional Clinical Hospital (664079, Irkutsk, Yubileyniy, 100) © ORCID orcid.org/0000-0001-7318-7193
Borichevskiy Vitaliy Ivanovich - Thoracic Surgeon at the Thoracic Surgical Department, Irkutsk Regional Clinical Hospital © ORCID orcid.org/0000-0003-0203-0724
Karasev Valeriy Petrovich - Surgeon at the Thoracic Surgical Department, Irkutsk Regional Clinical Hospital © ORCID orcid. org/0000-0002-8513-3915
Aldaranov Gennadiy Yuryevich - Surgeon at the Thoracic Surgical Department, Irkutsk Regional Clinical Hospital © ORCID orcid. org/0000-0003-3123-1939
Ovakimyan Gor Alesanovich - Surgeon at the Thoracic Surgical Department, Irkutsk Regional Clinical Hospital © ORCID orcid. org/0000-0003-0657-3945
