CC BY
15
I. SURGERY
МРНТИ 76.29.37 UDC 616.441-006.5-052-089
Magomedov M.M.
orcid.org/0000-0002-3335-525x
Osmanov О.М.
orcid.org/0000-0002-6000-2425
MODERN PRINCIPLES OF SURGERY TREATMENT OF PATIENTS WITH NODULAR GOITER
Osmanov O.M.1, Magomedov M.M.2
'State Budgetary Institution of Healthcare "Clinical City Hospital №67", Moscow, Russia 2Federal State Budgetary Educational Institution of Higher Education «Dagestan state medical university», Department of surgery, faculty of advanced training and professional retraining of specialists with the course of endoscopic surgery, Makhachkala, Republic of Dagestan, Russia
Keywords
thyroidectomy, subtotal thyroidectomy, hemithyroidectomy, hypothyroidism, hypoparathy-roidism
Abstract
Purpose of the study. To justify and confirm the differentiated approach to choosing the volume of surgical intervention in benign nodular goiter. Materials and methods. A prospective analysis of 180 patients who underwent thyroid surgery was performed; 11 (6.1%) were men and 169 (93.9%) were women aged 20-65 years. The duration of the patients disease was 8 months to 12 years. All patients with benign non-toxic goiter underwent a thorough evaluation of changes in the level of thyroid hormones in serum, ultrasound of the thyroid gland, and aspiration biopsy of the thyroid gland. Results. In laboratory studies, a high level of malignancy is observed in patients with higher levels of TSH and antibodies, TG and antibodies, TPO. There were no significant differences in the values of T3 and T4. In the ultrasound study, the average and maximum diameter of malignant nodes were significantly smaller than that of benign ones (1.99 ± 1.88 cm; p < 0.001). The difference between surgical procedures described as subtotal, total, and hemi-thyroidectomy was statistically significant. In 128 (71.1%) patients nodes were located in one lobe, 68 (37.8%) patients had multiple nodes, and 52 (28.9%) had solitary nodes in one of the thyroid lobes. In-traoperatively, 68 (37.7%) patients underwent cytomorphological examination of removed thyroid tissue. Hemithyroidectomy was performed in only 57 (31.6%) patients. Subtotal thyroidectomy was performed in 78 (43.3%) patients, and total thyroidectomy was performed in 45 (25%) pa-tients. With the development of hematoma, one patient was re-operated after total thyroidectomy. Hypoparathyroidism was diagnosed in 2 (4.4%) patients after thyroidectomy, and in 1 (1.3%) patient after subtotal thyroidectomy. 3 patients had transient laryngeal paresis after thyroidectomy. Hypothyroidism developed in 14 (24.6%) patients after hemithyroidectomy, in 50 (64.1%) patients after subtotal thyroidectomy and in 45 (100%) after thyroidectomy. Conclusion. The decision of surgical intervention should be differentiated with respect to the choice of surgical intervention tactics.
ТYйiндi зобпен аурытын наукастарды хирургиялык емдеудщ заманауи принцит^
Туйш сездер
тиреоидэктомия, субтоталды тиреоидэктомия, гемитиреоидэктомия, гипотериоз, гипопаратиреоз
Османов О.М.1, Магомедов М.М.2
1МБДСМ №67 Калалык, клиникалык, аурухана, Мэскеу к,., Ресей
2ФМББМ ЖО «Дагестан мемлекетпк медицина университет^, Эндоскопиялык, хирургия курсы бар ККД жэне БАФ хирургия кафедрасы, Махачкала к., Да?ыстан Республикасы, Ресей
Ацдатпа
Зерттеу мацсаты. Кдтераз туШнд жемсау кезндеп отанын келемн аныктауды тандаудагы дифференциал-ды тэслдемен непздеу жэне бек'гту. Материалдар мен адстер. Калканша безне ота жасаткан 180 наукаска проспективтталдаужурпз^. ОнынЫнде - 20-65жасаралыгындары 11 (6,1%) ерадамдаржэне 169(93,9%) эйелдер. Наукастардын ауру узактыты - 8 айдан 12 жыл€а деШн. Кдтераз токсикалык емес жемсауы бар наукастарлын барлы^ы кан сарысуындары К,Б гормондары денгеШнп езгерстерн мукият багалаудан, калканша безЩ УдЗ-сынан, калканша безЩ аспирациялык биопсиясынан етп. Нэтижелер: Зертханалык зерттеу кезнде кдтерлшЫц жо€ары денгей ТТГ жэне АТ, ТГ жэне АТ, ТПО жшры денгей бар наукастарда байкалды. Т3 жэне Т4 мэндернде накты айырмашылык аныкташн жоц. УДЗ зерттеу кезнде катераз тушндерге к&ратанда, катерлi туШндердщ орташа жэне макси-малды диаметрi едэ^р аз болды (1, 99± 1,88 см; р<0,001). Субтоталды, тоталдыжэне гемитиреоидэктомияретнде сипатталран хирургиялык шаралар арасындаFы айырмашылык статистикалык манызды болды. Наукдстардын 128-нде (71,1%) туШндер бiр бепкте, наукастардын 68-нде (37,8%) кептеген туШндер болтан, ал 52 (28,9%) наукаста калканша безЩ ф белюнде жеке туШндер болды. Интраоперациялык кезенде 68 (37,7%) наукастын калканша бездерЩ жойылран тщерне цитоморфологиялык зерттеу журпз57 (31,6%) наукаска гемитиреоидэктомия жасалды. 78 (43,3%) наукаска субтоталды тиреоидэктомия, ал 45 (25%) наукаска тоталды тиреоидэктомия орындалды. Гематоманын даму-ына байланысты тоталды тиреоидэктомиядан кейн бiр наукаска, гипопаратиреоз тиреоидэктомиядан кеШн 2 (4,4%) наукаска, субтоталды тиреоидэктомиядан кейн 1 (1,3%) наукаска кайтадан операция жасалды. 3 наукаста тиреоидэктомиядан кеШн кемейдн транзиторлыкжарасы пайда болды. Гемитиреоидэктомиядан кеШн 14 (24,6%), субтоталды тиреоидэктомиядан кеШн 50 (64,1%) жэне тиреоидэктомиядан кеШн 45 (100%) наукаста гипотиреоз дамыды. Цорытынды. Оталык араласудын шешiмi отанын тактикасын тандауеа катысты саралануы тис.
Современные принципы хирургического лечения больных с узловым зобом
Османов О.М.1, Магомедов М.М.2
1ГБУЗ Городская клиническая больница №67, г. Москва, Россия
2ФГБОУ ВО «Дагестанский государственный медицинский университет», кафедра хирургии ФПК и ППС с курсом эндоскопической хирургии, г. Махачкала, Республика Дагестан, Россия
Аннотация
Цель исследования. Обосновать и подтвердить дифференцированный подход к выбору объема оперативного вмешательства при доброкачественном узловом зобе. Материалы и методы. Проведен проспективный анализ 180 пациентов, перенесших операцию на щитовидной железе. Из них - 11 (6,1%) мужчин и 169 (93,9%), женщин в возрасте от 20 до 65 лет. Продолжительность заболевания пациентов от 8 месяцев до 12 лет. Все пациен-ты с доброкачественным нетоксическим зобом прошли тщательную оценку с изменением уровня гормонов ЩЖ, в сыворотке крови, УЗИ щитовидной железы, аспирационная биопсия щитовидной железы. Результаты. При лабораторном исследовании высокий уровень злокачественности наблюдается у пациентов с более высоким уровнем ТТГ и АТ, ТГ и АТ, ТПО. Достоверных различий в значениях Т3 и Т4 не было выявлено. УЗИ исследовании средний и максимальный диаметр злокачественных узлов было достоверно меньше, чем у доброкачественных (1,99±1,88 см; р<0,001). Разница между хирургическими процедурами, описанными как субтотальная, тотальная и гемитиреоидэктомия, была статистически значимой. У 128 (71,1%) пациентов узлы располагались в одной доле, у 68 (37,8%) пациентов узлы были множественные, а 52 (28,9%) - солитарные узлы в одной из долей щитовидной железы. Интраоперационно у 68 (37,7%) проводилась цитоморфологическое исследование удаленной ткани щитовидной железы. Гемитиреои-дэктомия была выполнена всего 57 (31,6%) пациентам. Субтотальная тиреоидэктомия выполнена 78 (43,3%) пациентам, а тотальная тиреоидэктомия была выполнена у 45 (25%) пациентов. С развитием гематомы повторно была оперирована одна больная после тотальной тиреоидэктомии, у пациентов после тиреоидэктомии гипопаратиреоз у 2 (4,4%), а после субтотальной тиреоидэктомии 1 (1,3%). У 3 пациентов после тиреоидэктомии транзиторный парез гортани. Гипотиреоз развился после гемитиреоидэктомии у 14 (24,6%), субтотальной тиреоидэктомии 50 (64,1%) и тиреоидэктомии 45 (100%). Заключение. Решение оперативного вмешательства должно быть дифференцированным относительно выбора тактики оперативного вмешательства.
Ключевые слова
тиреоидэктомия, субтотальная тиреоидэктомия, гемитиреоидэктомия, гипотериоз, гипопаратиреоз
Introduction
In recent years, there has been an increase in thyroid diseases, including nodular goiter. Dagestan is an endemic region where nodules are detected in most patients with thyroid pathology. The frequency of nodular non-toxic goiter among other thyroid diseases ranges from 25 to 62% [1, 2, 3, 4]. Recently, surgery for a benign goiter has been recognized as an acceptable and safe treatment method that has a low surgical risk and mortality. Despite improvements in the diagnosis and treatment of thyroid diseases over the past two decades, the literature remains controversial as to which method is best for a benign disease [2]. Previously, subtotal thyroidectomy for multiple goiter was considered a gold standard treatment, which was due to a decrease in complications related to the laryngeal nerve and parathyroid gland and a decrease in the need for lifelong hormone replacement therapy [3, 4, 5]. However, it is widely known that with long-term follow-up after subtotal thyroidectomy in multi-nodular goiter an increase in the frequency of relapses to 78% should be expected [5, 7]. Meanwhile, it is well known that repeated surgery for a receding nodular goiter results in increased damage to the laryngeal nerve and parathyroid gland compared to the original approach to the surgery. Although many clinics have changed their surgical strategy in favor of thyroidectomy, sub-
total thyroidectomy still appears to be the preferred option in every-day practice [6].
At the same time, the issue of choosing the volume of surgical intervention in patients with non-toxic goiter has not been completely resolved and requires further study [6, 7, 8, 9,10].
Purpose of the study
To justify and confirm the differentiated approach to choosing the volume of surgical intervention in benign nodular goiter.
Material and methods
A prospective analysis of 180 patients who underwent thyroid surgery for nodular and multi-nodal non-toxic goiter at the Republican Clinical Hospital and Clinical City Hospital № 67 in Moscow was performed.
11 (6.1%) were men and 169 (93.9%) were women aged 20-65 years. The duration of the patients' disease was 8 months to 12 years.
All clinical and pathological data were prospec-tively entered into a computer database from medical records. We extracted data on gender, age, the composition of thyroid disease and the frequen-cy of postoperative complications. The ethics Committee of Dagestan State Medical University approved this study, and all patients signed an informed consent.
Table 1.
Volume and composition of surgical intervention in nodular goiter of benign origin
Criteria for exclusion from the study:
1. a case of a malignant disease diagnosed before surgery;
2. the suspicion of malignancy before surgery;
3. those who have previously had thyroid surgery;
4. patients receiving treatment.
A reasonable criterion for including patients for surgery was ultrasound and fine needle aspiration biopsy with the exception of malignancy. After excluding 8 patients from the study, the main group was formed.
The reason for surgical intervention was tracheal compression syndrome and dysphagia in 108 patients (57.4%). Of these patients, 29 (26.8%) had a cervical and retrosternal arrangement of nodes. Fine needle aspiration biopsy (TAB) is an effective method that should be preferred as first-line diagnostic procedure as it gives the most accurate results for suspicious thyroid nodes detected by ultrasound. In our study, when evaluating thyroid nodes, it showed sensitivity of 65- 88%, speci-ficity of 86% and 5% of false negative results.
Cytological evaluation of patients who underwent a fine needle aspiration biopsy revealed benign cytology in 98 patients, suspicious cytology of thyroid carcinoma in 8 patients, follicular adenoma in 32 patients, and insufficient cytology for diagnosis in 31 patients. 8 patients were excluded from the study as a malignant disease.
In 128 (71.1%) patients, nodes were located in one lobe of the thyroid gland. 68 (37.8%) patients had multiple nodes, and 52 (28.9%) had solitary nodes in one of the thyroid lobes. During the surgical intervention, a cytomorphological assessment was performed in 68 (37.7%) samples of the thyroid tissue. The study of surgery outcome lasted 6 months to 5 years and was conducted on the basis of examination of patients, study of thyroid status by ELISA, thyroid ultrasound was per-formed using the ultrasound scanner "AlocaSSD-3000" with a linear phased antenna transducer with frequency of 7.5 MHz. Serum (TSH), free triiodothyronine (T3), and free thyroxine (T4) were analyzed in the laboratory and determined using a chemilumi-nescent analyzer RocheCodasE601 (Switzerland) and a matched set.
The collected data was analyzed using the SPSS software (version 20; SPSS Inc.). Quantitative data were expressed as an average SD± standard devia-
tion and qualitative data were reported by frequency (%). For interference analysis, we used the exact Fischer test and Chi-square to compare qualitative data in the frequency distribution. Based on the results of the Kol-mogorov-Smirnov test, which shows the normality of the data distribution, independent t-test samples were used to compare quantitative data for each gender. Logistic regression was used to assess the association of factors such as gender, age, body mass index (BMI), medical history, type of surgery, indications for surgery, the experience of the surgeon, and the frequency of post-operative early and late complications. Thus, the values for the 95% confidence interval and the odds ratio were obtained. The significance level (p<0.05) was taken into account for all analyses.
Results
Surgical intervention was performed depending on the composition and spread of the pathological process, the results of preoperative (fine needle aspiration biopsy) performed under the control of ultrasound. During the operation thyroid tissue was removed using intraopera-tive cyto-photometry.
At the nodal lesion of one lobe, hemithyroidec-tomy was carried out with removal of isthmus. He-mithyroidectomy was performed with visual control of the recurrent laryngeal nerve and extracap-sular ligation of the thyroid artery tributaries. The thyroid artery was not ligated to preserve blood flow to the parathyroid gland. Only 57 (31.6%) patients underwent such operations. If there were small nodes in the other lobe, the subtotal removal of that lobe was performed. Thyroidectomy was performed for multi-nodal goiter and adenoma of both lobes.
Subtotal thyroidectomy was performed according to the method of O. V. Nikolaev in 78 (43.3%) patients with the colloid goiter with the preservation of a clinically significant volume of tissue of the thyroid residue (more than 3 cm3), in the absence of clinical and morphological data indicating the presence of thyroid cancer. Thyroidectomy was performed in 45 (25%) patients.
There was a significant difference between the groups of surgical patients (p < 0.05).
The composition and volume of surgical intervention for benign thyroid diseases are presented in table 1.
№ Volume of surgical intervention n= 180
Quant. %
1. Hemithyroidectomy 57 32,0
2. Subtotal thyroidectomy 78 43,3
3. Total thyroidectomy 45 25
Total 180 100
Complications of various thyroid operations and the frequency of postoperative complications were compared between patients with different approaches. There was no lethality in the postoperative period. A serious complication requiring re-opening of the operative wound occurred only in a 57 year-old patient who underwent a thyroidectomy with a modified neck dissection with the development of a hematoma. In patients who underwent radical treatment (thyroidectomy) hypocalcemia (levels less than 2.1 mmol/l) was observed in 2 (4.4%), and in 1 (1.2%) after subtotal thyroidectomy.
In 3 patients, the operating period after thyroidectomy was complicated by transient laryngeal paresis with respiratory preservation. Surgical intervention performed for a benign nodular formation of the thyroid gland was confirmed by the results of histological examination of the surgical material. In a laboratory study, as shown in table 2, there were no significant differences in the values of T3 and T4 between the two groups. The prevalence of malignant diseases was 1.6% at a TSH level of less than 0.36 Mme/l, compared to 8.5% at a TSH level of 4.9 Mme/l or more (p = 0.14). A relatively high level of malignancy was observed in patients with higher levels of TSH.
Continuous variables are compared using the Mann-Whitney U-criteria, and categorical variables are compared using x2-x tests (p < 0.05).
Abbreviations: Ab-TG - antibody against thyro-globulin, Ab-TPO - antibody against thyroid peroxidase.
Patients with malignant nodes had positive results of Ab-TG and Ab-TPO testing more often than patients with benign nodes, as can be seen from the table 2. In an ultrasound study, the average maximum diameter of malignant nodes was significantly smaller than that of benign ones (1.99±1.88 cm vs. 2.88±1.91 cm, p<0.001). The distribution of solitary nodes in malignant cases did not differ from that in benign ones (29.1% vs. 25.4%, p = 0.108).
There were no differences in eggshell calcification between the benign and malignant groups (p > 0.05).
91 (50.5%) patients had follicular adenomas, 5 (2.7%) patients had papillary thyroid cancer, and 3 (1.6%) patients had follicular cancer. Ultrasound examination revealed 8 cases of thyroid cancer, but surgical treatment was not included.
The analysis of postoperative intervention found that characteristic preoperative syndromes disappeared in 45% of patients. Clinical manifestations of laryngeal paresis in 3 patients resolved with conservative treatment within a year.
The results of surgical intervention and their functional results are shown in table 3.
The results of surgery for hemithyroidec-tomy with the manifestation of hypothyroidism were observed in 14 (24.6%) patients. Statistically significant differences in the frequency of postoperative hypothyroidism after thyroidec-tomy and subtotal thyroidectomy were found (p < 0.05).
In all patients with hypothyroidism, drug-induced euthyroidism was achieved by prescribing l-thyroxine 75 mcg per day. In patients with subtotal removal of the thyroid gland, the need for L-thyrox-ine was 150 mcg per day.
However, the frequency of relapse largely depended on the duration of the postoperative period. On ultrasound examination, in 8 (14%) patients after hemithyroidectomy nodules with a volume of from 0.6 to 0.9 cm3 were identified. The detection period for these nodes is up to 4 years.
In euthyroid patients after subtotal thyroidec-tomy, in the tissue of the thyroid residue the nodes in the volume from 0.7 to 2.5 cm3 were detected up to 5 years after surgery. In patients who initially underwent less radical hemithyroidectomy, 6 (3.3%) patients relapsed after 8 years and had to un-dergo a second operation to remove the remaining thyroid tissue.
Values Benign tumor Malignant tumor P-value
Free T3, pmol/l 4,11 (3,93 - 5,08) 4,45 (3,98 - 5,01) 0,808
Free T4, pmol/l 14,98 (12,81-16,99) 15,51 (13,7 - 18,08) 0,064
TSH, Miu/l 1,19 (0,59-2,21) 1,65 (0,80-2,70) < 0,001
Ab-TG 15 231,3 < 0,001
Ab-TPO 18,1 126,8 0,028
Table 2.
Laboratory values in patients with nodular formation thyroid
№ Volume of surgical intervention Functional state Total, %
Euthyroidism, % Hypothyroidism, %
1. Hemithyroidectomy 47 (32,8) 14(24,6) 57
2. Subtotal thyroidectomy 28 (35,9) 50 (64,1) 78
3. Total thyroidectomy - 45(100) 45
Total 75 (41,7%) 109 (60,5) 180
Table 3.
The results of surgical intervention
Discussion
There are several types of surgical interventions used in the treatment of benign thyroid diseases. However, in recent years there has been an increase in the use of radical operations, such as total thyroidectomy, and a decrease in the number of less radical operations like subtotal thyroidectomy and hemithyroidectomy. In our study, the percentage of radical thyroidectomy operations increased from 12% in 2001 to 25% in 2018. Some authors have recommended a more radical operation for a non-toxic multi-node goiter [5]. They emphasized that since the entire thyroid gland is affected, leaving behind even a small amount of tissue, the risk of pathological changes, such as a relapse that requires repeated surgery, increases. Other authors consider a high risk of relapse and a significantly higher risk of postoperative complications a similar disadvantage of non-radical treatment [16, 17].
Some studies have found that the frequency of relapses after non-radical surgery of a multi-node non-toxic goiter is very high, up to 20% [7]. However, the frequency of relapses described by various authors largely depended on the duration of the postoperative period. According to these authors, the problem of recovery after surgery is more complex. Relapse is not a problem in itself. The problem occurs when a second operation is required. Repeated operation on the thyroid gland is technically much more difficult and is associated with a higher risk of complications than the previous operation. According to the literature, repeated surgery is associated with a greater risk of damage to the laryngeal nerve and hypoparathyroidism [8]. Hormonal treatment is often discussed by opponents of radical surgery [4]. Subtotal thyroidectomy does not require hormonal treatment. Opponents of a less radical operation quickly disproved this claim [6]. They proved that the left-over thyroid tissue does not protect against hypothyroidism.
According to their research, 100% of patients after subtotal thyroidectomy require high doses of levothy-roxine, up to 150 mcg per day. In our study, all patients after subtotal thyroidectomy re-ceived hormonal support in daily doses from 75 mcg to 100 mcg.
The main goal of surgical treatment of thyroid diseases should always be the most effective performance with minimal complications and frequency of relapses. The authors of less radical thyroid
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