CC BY
11
Received: 24 January 2021 / / Accepted: 14 March 2021 / Published online: 30 April 2021
DOI 10.34689/SH.2021.23.2.010 UDC 616.441-08(075.8)
RESULTS THE USE OF VARIOUS SURGICAL METHODS FOR THE TREATMENT OF PATIENTS WITH DIFFUSE TOXIC GOITER
Tolegen A Toleutaev1, Nazarbek B. Omarov1, Meirbek Zh. Aimagambetov1, Tolkyn A. Bulegenov1,
Tolegen L. Akparov1, Dinara O. Akhmetzhanova1, Kuanysh T. Karibayev1,
1 NСJSC «Semey Medical University», Semey, Republic of Kazakhstan
Abstract
This article discusses the problems of surgical tactics in diffuse - toxic goiter and its complications, both in the early postoperative period and in the long term. The above complications require surgeons to search for the most optimal method of surgical treatment.
Aim: Evaluation of immediate, long-term results and hormonal status with various methods of surgical treatment of diffuse-toxic goiter.
Materials and research Methods. The article presents the experience of treating 149 patients. The analysis of immediate and long-term results of surgical interventions in relation to thyroid status is given. In 90 patients, subtotal resection of the thyroid gland was performed, in 31 - thyroidectomy, in 28 cases - embolization of the thyroid artery. Thyroid status was analyzed 1, 6, 12, 24 months after surgery. The patients were divided into subgroups depending on the initial volume of the thyroid gland (less than 45 cm3 and more than 45 cm3). Statistical analysis of numerical series was carried out using the Mann-Whitney method, relative values - using Fisher's two-sided exact test.
Research results. A moderate number of postoperative complications was revealed, with a predominance of extirpation of the gland in the group and no extirpation in patients undergoing arterial embolization.
On the contrary, a higher incidence of recurrence of the hyperthyroid state was characteristic for the latter group, where it was 28.6% over a follow-up period of 24 months. With subtotal resection, the corresponding indicator was 14.4%; after extirpation, no cases of relapse were observed. Extirpation led to the development of total hypothyroidism in all patients, in other groups this condition was observed in about half of the cases.
An excess of the initial gland volume of 45 cm3 was characterized by a sharp increase in the incidence of postoperative hypothyroidism.
Conclusions: The use of different approaches to the surgical treatment of diffuse-toxic goiter gives differences in the frequency of perioperative complications (excess during extirpation of the thyroid gland) and late complications. Among the late complications, hypothyroidism dominates, which is subject to compensation with the help of substitution therapy.
The frequency of recurrence of thyrotoxicosis has a double dependence on the approach to treatment and the initial volume of the thyroid gland. In order to prevent relapse for surgical treatment of DTG with a gland volume of more than 45 cm3, the most rational is extirpation.
Key words: Diffuse toxic goiter; thyroidectomy; resection of the thyroid gland; embolization; relapse.
Резюме
РЕЗУЛЬТАТЫ ПРИМЕНЕНИЯ РАЗЛИЧНЫХ ХИРУРГИЧЕСКИХ МЕТОДОВ ЛЕЧЕНИЯ БОЛЬНЫХ С ДИФФУЗНО-ТОКСИЧЕСКИМ ЗОБОМ
Толеген А. Толеутаев1, Назарбек Б. Омаров1,
Мейрбек Ж. Аймагамбетов1, Толкын А. Булегенов1,
Толеген Л. Акпаров1, Динара О. Ахметжанова1, Куаныш Т. Карибаев1
1 НАО «Медицинский университет Семей», г. Семей, Республика Казахстан
В данной статье рассматривается проблемы хирургической тактики при диффузно - токсическом зобе и ее осложнениях, как в раннем послеоперационном периоде, так и в отдаленном периоде. Вышеуказанные осложнения требуют от хирургов поиска наиболее оптимального метода хирургического лечения.
Цель работы: Оценка непосредственных, отдаленных результатов и гормонального статуса при различных методах хирургического лечения диффузно-токсического зоба.
Материалы и методы исследования: В статье представлен опыт лечения 149 пациентов. Дан анализ непосредственных и отдаленных результатов хирургических вмешательств в отношении тиреоидного статуса. У 90 больных проведена субтотальная резекция щитовидной железы, у 31 - тироидэктомия, в 28 случаях - эмболизация артерии щитовидной железы. Тиреоидный статус анализировался через 1, 6, 12, 24 месяца после операции.
Пациенты были распределены на подгруппы в зависимости от исходного объема щитовидной железы (менее 45 см3 и более 45 см3). Статистический анализ числовых рядов проведен по методу Манна-Уитни, относительных значений - с применением двустороннего точного критерия Фишера.
Результаты исследования. Выявлено умеренное число послеоперационных осложнений с преобладанием в группе экстирпации железы и отсутствием у пациентов, подвергавшихся эмболизации артерии.
Напротив, более высокая частота развития рецидива гипертиреоидного состояния была характерна для последней группы, где она составила 28,6% за период наблюдения 24 месяца. При субтотальной резекции соответствующий показатель составил 14,4%, после экстирпации случаев рецидива не наблюдалось. Экстирпация привела к развитию тотального гипотиреоза у всех пациентов, в остальных группах это состояние наблюдалось примерно в половине случаев.
Превышение исходного объема железы 45 см3 характеризовалось резким ростом частоты развития послеоперационного гипотиреоза.
Выводы: Применение различных подходов к оперативному лечению диффузно-токсического зоба дает отличия в частоте периоперационных осложнений (превышение при экстирпации щитовидной железы) и поздних осложнений. Среди поздних осложнений доминирует гипотиреоз, подлежащий компенсации с помощью заместительной терапии.
Частота рецидивов тиреотоксикоза имеет двойную зависимость от подхода к лечению и исходного объема щитовидной железы. С целью предотвращения рецидива для оперативного лечения ДТЗ при объеме железы более 45 см3 наиболее рациональной является экстирпация.
Ключевые слова: Диффузно-токсический зоб; тиреоидэктомия; резекция щитовидной железы; эмболизация; рецидив.
Туйшдеме
ДИФФУЗДЫ-УТОКСИКАЛЫК ЖЕМСАУЫ БАР НАУКАСТАРДЫН ЭРТУРЛ1 ХИРУРГИЯЛЫК ЕМДЕУДЩ 9Д1СТЕРШ КОЛДАНУ НЭТИЖЕЛЕР1
Телеген А. Телеутаев1, Назарбек Б. Омаров1,
Меiрбек Ж. Аймагамбетов1, Толкын А. Булегенов1,
Телеген Л. Акпаров1, Динара О. Ахметжанова1, Куаныш Т. Кэрiбаев1
1 КеАК «Семей Медицина университет», г. Семей, Республика Казахстан.
Бул макалада диффузды - токсикалык зоб кезшдеп хирургиялык тактиканыч м8селелерi жэне оныч операциядан кейЫп ерте кезечдеп ж8не узак мерзiмдi аскынулары туралы айтылады. Жогарыда аталган аскынулар хирургтардан хирургиялык емдеудщ очтайлы 8дiсiн iздеудi талап етедк
Жумыстыц максаты: Диффузиялык-токсикалык зобты хирургиялык емдеудiч 8ртYрлi 8дiстерiмен жедел, узак мерзiмдi н8тижелердi ж8не гормоналды статусты багалау.
Зерттеу материалдар жэне эд1стер1. Макалада 149 наукасты емдеу т8жiрибесi кврсетiлген. ^алканша безiнiи статусына байланысты хирургиялык араласудыч жедел ж8не узак мерзiмдi н8тижелерiн талдау берiлген. 90 наукаска калканша безiнiи субтотальды резекциясы, 31-де - тиреоидэктомия, 28 жавдайда - калканша артерия эмболизациясы жасалды. ^алканша безiнiи гормоны операциядан 1, 6, 12, 24 ай вткен соч талданды. ^алканша безiнiи бастапкы квлемiне байланысты наукастар кiшi топтарга бвлiндi (45 см3 аз ж8не 45 см3 артык). Сандык катарлардыч статистикалык талдауы Манн-Уитни 8дiсi бойынша, салыстырмалы м8ндер - Фишердiч ею жакты д8л тестi аркылы жYргiзiлдi.
Зерттеу нэтижелер1. Операциядан кейiнгi аскынулардыч орташа саны аныкталды, топта без экстирпациясы басым болды ж8не артерия эмболизациясына ушыраган наукастарда экстирпация болмайды.
Керiсiнше, гипертиреоидтык жавдайдыч кайталануыныч житт сочгы топка т8н болды, мунда ол 24 айлык бакылау кезечЫде 28,6% курады. Субтотальды резекция кезЫде тиiстi кврсеткiш 14,4% курады, экстирпациядан кейЫ рецидив жавдайлары байкалмады. Экстирпация барлык наукастарда жалпы гипотиреоздыч дамуына 8келдi, баска топтарда бул жавдай жагдайлардыч жартысында байкалды.
Бездiч бастапкы квлемУч 45 см3 артык болуы операциядан кейiнгi гипотиреоз ауруыныч кYрт всуiмен сипатталды.
Корытынды: Диффузиялык-токсикалык зобты хирургиялык емдеудiч 8ртYрлi т8стдерЫ колдану периоперациялык аскынулардыч (калканша безУч экстирпациясы кезiндегi артык) ж8не кеш аскынулардыч айырмашылыктарын бередi. Кеш аскынулардыч шнде гипотиреоз басым, ол ауыстыру терапиясымен втелуге жатады.
Тиреотоксикоздыч кайталану жиiлiгi емдеу т8сiлiне ж8не ^алканша безiнiч бастапкы квлемiне екi есе т8уелдi болады. ДТЖ безiнiч квлемi 45 см3-ден жогары хирургиялык емдеу кезЫде рецидивтiч алдын алу Yшiн еч утымдысы - экстирпация.
ТYйiндi свздер: Диффузды-токсикалык зоб; тиреоидэктомия; калканша без1н1ц резекциясы; эмболизация; рецидив.
Bibliographic citation:
Toleutaev T. A., Omarov N. B., Aimagambetov M. Zh., Bulegenov T.A., Akparov T. L., Akhmetzhanova D. O., Karibayev K.T. Results the use of various surgical methods for the treatment of patients with diffuse toxic goiter // Nauka i Zdravookhranenie [Science & Healthcare]. 2021, (Vol.23) 2, pp. 103-110. doi 10.34689/SH.2021.23.2.010
Толеутаев Т.А., Омаров Н.Б., Аймагамбетов М.Ж., Булегенов Т.А., Акпаров Т.Л., Ахметжанова Д.О., Карибаев К.Т. Результаты применение различных хирургических методов лечения больных с диффузно-токсическим зобом // Наука и Здравоохранение. 2021. 2(Т.23). С. 103-110. doi 10.34689/SH.2021.23.2.010
Твлеутаев Т.А., Омаров Н.Б., Аймагамбетов М.Ж., Булегенов Т.А., Акпаров Т.Л., Ахметжанова Д.О., Kepi6aee К.Т. Диффузды-утоксикалык жемсауы бар наукастардыщ 8ртYрлi хирургиялык емдеудщ эдютерЫ колдану н8тижелерi // Гылым ж8не Денсаулык сактау. 2021. 2 (Т.23). Б. 103-110. doi 10.34689/SH.2021.23.2.010
Introduction
Diffuse toxic goiter (DTG) is one of the most common diseases of the endocrine system. The frequency of new cases of DTG varies from 30 (0.03%) to 200 (0.2%) per 100 thousand population per year. In regions with normal iodine supply, DTG is the most common cause of persistent thyrotoxic conditions, and in iodine-deficient regions in the etiological structure of toxic goiter, DTG competes with the functional autonomy of the thyroid gland (TG). DTG, the most common cause of hyperthyroidism [1,3], is an autoimmune disease in which autoantibodies targeting thyroid stimulating hormone (TSH) receptors stimulate receptors, resulting in an excessive increase in thyroid hormone [2].
The disease is characterized by hyperthyroidism and, in some cases, ophthalmopathy. There are currently three established treatments for this disease: surgery, radioactive iodine, and antithyroid drugs. However, all three of these treatments have some limitations and disadvantages. Medicines consisting of antithyroid drugs for 12-18 months have a serious drawback in the high relapse rate from 20% to 75% [4,5]. The use of radioactive iodine is associated with a delayed onset and a high cumulative incidence of hypothyroidism over 10 years, exceeding 70% [6]. Although surgery offers the advantage of rapid control of hyperthyroidism and has an extremely low morbidity in experienced hands, it can be complicated by re-injury of the laryngeal nerve or persistent hypoparathyroidism after nearly total thyroidectomy [7-9]. Most surgeons adhere to the tactics of performing a subtotal resection of the thyroid gland. Abroad, on the contrary, most authors advocate thyroidectomy [10]. Currently, this issue remains relevant and debatable. Postoperative hypothyroidism is observed in 10-80% of cases, which is regarded as a natural outcome of surgical treatment. Recurrence of thyrotoxicosis occurs in 10-15%.
According to most researchers, the thyroid status of operated patients depends on the functional activity of the thyroid gland, the autoimmune process and the volume of the thyroid residue after resection [11,12]. Insufficient attention has been paid to the study of the relationship between morphological changes occurring in the thyroid tissue in patients with DTG, the duration of thyrostatic therapy, the age of the patients, and the volume of the thyroid residue.
According to S.N. Styazhkina, A.V. Ledneva, E.L. Poryvaev in 2019, a retrospective analysis of 70 case histories of operated patients with diffuse toxic goiter for the
period from 2008 to 2014 was carried out. The percentage of patients with postoperative hypothyroidism: varying degrees of severity ranged from 5% to 66%. relapses of DTG are not noted. The authors note that their patients presented the following complaints: weight gain, chilliness of the limbs, interruptions in the work of the heart, edema, drowsiness, lethargy, impaired appetite, pallor of the skin, brittle nails, hair loss, joint pain. As a result of the thyroidectomy, all patients developed hypothyroidism, which required constant hormone replacement therapy with L-thyroxine preparations. In the case of constant intake of drugs, individually selected dosage, the quality of life did not suffer.
According to N.A. Maistrenko, P.N. Romashchenko, D.S. Krivolapov, A.P. Prishvin, G.V. Mikhalchenko in thyroid gland (TG) surgery, minimally invasive interventions using endoscopic and robotic technologies are widely used. The prerequisites for their use are due to an increase in the number of patients with surgical pathology of the thyroid gland, improvement of diagnostic capabilities and early detection of malignant neoplasms, the development of endovideosurgical technologies and the development of criteria for choosing minimally invasive interventions, the desire to improve the quality of life of patients, and to accelerate their labor and social rehabilitation. They operated on 155 patients with surgical thyroid diseases using various minimally invasive techniques. The examination of patients was carried out in accordance with the clinical guidelines concerning not only the list of laboratory and instrumental examination, but also the interpretation of the results obtained according to the generally accepted classifications - TIRADS and Bethesda (Horvath E. et al., 2009; Kwak JY et al., 2011; Cibas ES et al., 2009). The selection criteria for patients corresponded to generally accepted ones and took into account the main factors: the size of the nodules, the volume of the thyroid gland. This technique of surgical treatment of DTG was used in 36 patients. The results of the study will allow a reasonable and differentiated approach to the selection of patients with surgical thyroid diseases for minimally invasive surgical interventions. Ensuring the methodical and safe performance of techniques with the obligatory use of intraoperative neuromonitoring and visualization of the parathyroid glands will help to reduce the incidence of specific complications, minimize surgical trauma and the length of stay of those operated on in the hospital, improve cosmetic results and the quality of life of patients. A detailed study of the condition of patients after subtotal resection of
the thyroid gland, performed for thyroid gland disease, will allow developing the optimal tactics of surgical treatment, correcting postoperative complications, and developing a set of measures for the prevention and treatment of dysfunctions of the thyroid residue. Due to the significant progress achieved in endovascular technologies in recent years, the therapy of diffuse-toxic goiter through embolization of the arteries of the thyroid gland has appeared [6].
The East Kazakhstan region is endemic in terms of iodine deficiency and thyroid gland diseases. Despite the measures taken to prevent it, the frequency of pathology of this organ remains higher than the national average. [7].
X-ray endovascular embolization of the thyroid arteries reduces the incidence of intraoperative complications by eliminating the flow of arterial blood to the thyroid gland with a subsequent decrease in its volume, which leads to a decrease in the trauma of the operation and intraoperative blood loss. This technique is especially relevant for large volumes of the gland, as well as for the retrosternal location of the goiter, in which there is a high likelihood of trauma to the lower thyroid artery. In addition, this approach is also used as an independent method of treatment, because allows you to reduce the production of thyroid hormones without surgery. [8,13,14].
Aim: Evaluation of immediate, long-term results and hormonal status with various methods of surgical treatment of diffuse-toxic goiter.
Materials and research methods
This study was designed as a prospective, controlled clinical study. The sample size was calculated using the PASS 2000 program, version 12.0.4.
General characteristics of the examined patients
In the surgical department of the University Hospital Non-profit Joint Stock Company «SMU» from 2013 to September 2020, 149 patients with diffuse toxic goiter were operated on, of which 19 were men and 130 women (ratio -1: 7) aged 17 to 74 years (average age - 41.5 ± 2.6 years), the largest number of patients 86 (57.7%) fell on the age group 30-49 years.
Study inclusion criteria:
1. Patients with DTG from 18 to 60 years old.
2. Surgical treatment.
3. Patients who signed an informed consent for surgical treatment with the proposed method and the use of the obtained data in a scientific study.
Criteria for exclusion from the study:
1. Patients with DTG under 18 and over 60 years of
age.
2. The presence of an acute condition (ACA, ACS), stage IV cancer patients, recurrence of chronic diseases.
3. Patients who refused the proposed method of treatment and participation in the study.
All patients were admitted for surgical intervention for DTG initially.
Patients, depending on the volume of the thyroid gland and the level of thyroid hormones, underwent the following surgical interventions: subtotal subfascial resection of the thyroid gland according to O.N. Nikolaev (n = 90), total thyroidectomy (n = 31), embolization of the thyroid artery (n = 28). In the long-term period, all patients included in the study were registered with an endocrinologist at the family
dispensary at their place of residence. Control studies of the content of thyroid hormones in the blood were carried out after 1, 6, 12, 24 months.
The diagnosis of DTG was made taking into account the history, the presence of a characteristic clinical picture and was confirmed by the data of hormonal blood tests. The patients had moderate thyrotoxicosis - 106 (71.1%) or severe - 43 (28.9%) degree. Goiter III degree according to the classification of O.V. Nikolaev was observed in 89 patients (59.7%), IV - in 51 (34.3%), V - in 9 (6.0%). Eye symptoms (Grefe, Kocher, Moebius, Rosenbach, Stelvag) were observed in 109 patients (73.2%); endocrine ophthalmopathy of varying severity was diagnosed in 72 patients (48.3%).
The duration of the disease before surgery varied from 3 months to 15 years (average 7.2 ± 0.6 years). In half of the patients, DTG was diagnosed more than 2 years before inclusion in the study. The duration of thyrostatic therapy ranged from several months to 10 years (on average 2.1 ± 0.4 years) and did not always coincide with the duration of the disease due to late initiation of treatment or interruptions between courses of conservative therapy. It should be noted that 42 patients (30.7%) took thyreostatics for more than 2 years.
The indication for surgical treatment in 101 patients (73.7%) was the ineffectiveness of conservative therapy. In 12 patients (8.8%) with grade IV-V goiter and in one patient with retrosternal goiter, surgical intervention was performed due to the development of compression of the neck organs. In 4 patients (2.9%), the ineffectiveness of thyreostatic therapy was combined with the presence of a large goiter, in 9 (6.6%) - with a relapse of the disease after surgical treatment. In 5 cases (3.6%) the indication for surgery was the need to quickly eliminate severe thyrotoxicosis, in 4 (2.9%) cases - contraindications to the use of thyrostatics, in 1 (0.7%) - the patient's categorical refusal from long-term conservative therapy.
A prerequisite for performing surgery to prevent the development of a thyrotoxic crisis was the achievement of the euthyroid state.
Subtotal resection of the thyroid gland (SRTG) was performed in 90 patients (60.4%), thyroidectomy for various indications was performed in 31 patients (20.8%), embolization of the thyroid artery in 28 patients (18.8%).
Biochemical and hormonal studies.
The hormonal status was determined in all patients, thyroid hormones were examined before admission, after surgery and after 1,3,6 months. For the reference value were taken: TSH - 0.4-4.0 mIU / ml; free T4 - 9-19.1 pmol / l; free T3 - 2.63-5.7 pmol / l; Antibodies to rTTG - 0-1.75 IU / L; Antibodies to TPO - 0-35 U / ml.
Instrumental research methods
Assessment of the size and echographic characteristics of the thyroid gland in patients before the operation and in the postoperative period was carried out in the department of functional diagnostics of the University Hospital Nonprofit Joint Stock Company «SMU» on the "LOGIQ 3 expert" apparatus with a linear transducer with a frequency of 8-10 MHz. Based on the ultrasound data, the volume of the thyroid gland was calculated, blood flow and the presence of nodules were assessed. The total thyroid volume was calculated by multiplying the length, thickness,
width of each lobe, the result was multiplied by a factor of 0.479 (WHO recommendations, 1994). The normal values were taken for the thyroid volume in women up to 18 cm3, and in men - up to 25 cm3.
Statistical analysis
Intergroup comparison of quantitative trait values was performed using the Mann-Whitney U-test. Comparison of frequency indicators in independent samples was carried out using Fisher's exact test [15]. Differences were considered statistically significant at p <0.05.
Results
The initial parameters of the thyroid gland were analyzed taking into account the previous operations: subtotal subfascial resection of the thyroid gland according to O.N. Nikolaev (n = 90), total thyroidectomy (n = 31), embolization of the thyroid artery (n = 28), which are shown in Table 1.
Table 1 summarizes the data on the baseline indicators of the morphofunctional state of the thyroid gland.
Table 1.
Baseline clinical, instrumental and biochemical indicators depending on the type of surgery.
Indicator Subtotal resection of the thyroid gland (n = 90) Extirpation of the thyroid gland (n = 31) Thyroid artery embolization (n = 28) р
Average age at the time of surgery, years 46,9±1,33 50,2±1,9 42,3±1,9 0,152
Duration of the disease, months 69,7±7,2 66,1±10,0 62,7±4,2 0,б87
Initial mean volume of the thyroid gland, ml3 43,4±3,2 48,6±7,1 47,5±3,1 0,579
TSH mIU 1,99±0,63 1,18±0,27 1,54±0,23 0,83б
free.T4, pmol / l 34,46±1,63 40,18±3,50 37,81 ±5,40 0,224
free.T3, pmol / l 5,32±0,51 6,17±1,94 6,43±0,48 0,111
Antibodies to TPO 468,2 207,3 356,7 0,107
Antibodies to rTTG 38,18 16,79 17,25 0,037
Ophthalmopathy,% 29,7 48,6 32,4% 0,042
Table 1 shows that significant differences were revealed only in the values of one indicator, namely, in the content of antibodies to rTTG in the group of patients who underwent subtotal resection of the thyroid gland over the other groups. In clinical terms, these differences could be of interest in relation to the continuation of conservative
treatment, but did not have a significant value in the case of surgery.
Depending on the surgical treatment performed in patients with DTG in the early postoperative period, the following complications developed, which are presented in Table 2.
Table 2.
Frequency and structure of complications of the perioperative period in patients with DTG.
Complication
Group
STR TG, n=90
аbs.
%
extirpation of the TG, n=31
abs.
%
Thyroid artery embolization, n=28
аbs.
%
Intraoperative bleeding
б7
74,4
25
80,б
Postoperative bleeding
б,7
б,5
Vocal cord paresis
2,2
б,5
Thyrotoxic crisis
3,3
0,0
During the operation, patients who underwent subtotal, subfascial resection of the thyroid gland and thyroidectomy in 92 cases (76.0%) were accompanied by bleeding during the operation.
In the early postoperative period, the following complications were revealed in patients undergoing subfascial, subtotal resection of the thyroid gland or thyroidectomy: paresis of the vocal cords in 4 (3.3%) patients, bleeding in 8 (6.6%) patients, thyrotoxic crisis in 3 (2.5%).
Together with an endocrinologist, an anesthesiologist-resuscitator, an ENT doctor, these complications were arrested. There were no lethal outcomes.
In the long-term period, all patients included in the study were registered with an endocrinologist at the family dispensary at their place of residence. Control studies of the content of thyroid hormones in the blood were carried out after 1, 6, 12, 24 months. The frequency of detecting thyroid status disorders at the indicated time, depending on the group of examined patients, is presented in table 3.
б
2
2
2
3
0
Table 3.
Distribution of patients depending on the thyroid status in the dynamics of prospective follow-up._
Examination period
Group Thyroid status 1 month 6 month 12 month 24 month
number of patients % number of patients % number of patients % number of patients %
Subtotal resection hypothyroidism 34 37,8 46 51,1 36 40,0 37 41,1
of the thyroid euthyroidism 56 62,2 42 46,7 49 54,4 45 50,0
gland, n=90 hyperthyroidism 0 0,0 2 2,2 5 5,6 8 8,9
Extirpation of the hypothyroidism 24 77,4 31 100 30 96,8 30 96,8
thyroid gland euthyroidism 7 22,6 0 0,0 1 3,2 1 3,2
hyperthyroidism 0 0,0 0 0,0 0 0,0 0 0,0
Thyroid artery hypothyroidism 8 28,6 10 35,7 10 35,7 12 42,9
embolization, euthyroidism 18 64,3 14 50,0 15 53,6 11 39,3
n=28 hyperthyroidism 2 7,1 4 14,3 3 10,7 5 17,9
Note - over the period of 6-24 months, 7 repeated surgical interventions were performed for recurrent thyrotoxicosis, thus, the total number of relapse cases reached 21
The incidence of thyroid disorders in the examined patients depended on the type of surgery performed and the follow-up period, and it increased moderately and insignificantly in the relatively long term.
Discussion
The main approach used in clinical practice - subtotal resection of the gland - in the early and more distant follow-up periods was more associated with the development of hypothyroidism, the frequency of which increased from 37.8% 1 month after the intervention to 41.1% - 2 years later. ... In addition, by the end of the prospective observation period, 13 cases of recurrence of thyrotoxicosis (14.4%) associated with repeated hyperplasia of preserved glandular tissue or with recurrence of the disease in the retrosternal localization (1 case) were detected. Of these, during the follow-up period, repeated surgery, which led to the suppression of hyperproduction of thyroid hormones, was performed in 5 cases.
Extirpation of the thyroid gland was not associated with the presence of recurrence in any case. But almost all
patients had total hypothyroidism, compensated by the intake of thyroid hormones.
A high recurrence rate was observed during gland artery embolization. In total, 8 out of 28 (28.6%) were identified during the observation period. Three patients were reoperated within 24 months from the initial intervention. The incidence of hypothyroidism in this group at different periods of observation was minimal among the compared approaches.
In general, the number of relapses reached 21 (14.1%). We analyzed the influence of the preoperative status and the type of surgical intervention on the development of this complication.
When assessing the volume of the thyroid gland, we identified patients in whom this indicator before surgery was 45 cm3 or less and patients with a thyroid volume of more than 45 cm3. The volume of 45 cm3 was chosen as a dividing one, based on the fact that it turned out to be a whole value closest to the average indicator (44.8 cm3) for all examined patients (Table 4).
Table 4.
Influence of preoperative thyroid volume on the outcomes of subtotal resection.
Volume of the thyroid Volume of the thyroid
Functional outcome of the intervention gland<45cM3, n=48 gland>45 cm3, n=42
abs. % abs. %
Hypothyroidism, n=37 22 45,8 15 35,7
Euthyroidism, n=40 23 47,9 17 40,5
Recurrence of thyrotoxicosis, n = 13 3 6,3 10 23,8*
Note: * - differences are of statistical significance
The analysis revealed that among patients with remaining 23.1% the volume of the gland did not exceed 45 recurrent thyrotoxicosis in this group (n = 13) 76.9% of cm3 (p = 0.020). Table 5 shows the results of a similar patients had a gland volume of more than 45 cm3, in the analysis for thyroid artery embolization.
Table 5.
Influence of preoperative thyroid volume on the outcomes of subtotal resection.
Functional outcome of the intervention Volume of the thyroid Volume of the thyroid
gland <45cm3, n=16 gland >45 cm3, n=12
abs. % abs. %
Hypothyroidism, n=10 7 41,7 3 25,0
Euthyroidism, n=10 7 41,7 3 25,0
Recurrence of thyrotoxicosis, n=8 2 12,5 6 50,0*
Note: * - differences are of statistical significance
The preoperative volume of the thyroid gland also influenced the frequency of recurrence of thyrotoxicosis during embolization of the thyroid artery. With a large volume, the relative recurrence rate exceeded the compared group by 4 times (p = 0.040).
120
Therefore, we carried out a comparative assessment of the risks of long-term complications depending on the initial gland volume and intervention options (Figure 1).
<45 >45 <45 >45 <45 >45
Subtotal resection extirpation Artery embolization,
Figure 1. Risks of long-term complications during various methods of surgical treatment of diffusely toxic goiter.
During extirpation of the gland, the only risk associated with the functional activity of the organ is the development of total hypothyroidism, and it turns out to be almost absolute. In the other two groups, there is a significant excess of the risk of recurrence of thyrotoxicosis with an initially larger volume of the gland. Moreover, for artery embolization, it exceeds the index of the subtotal resection group by more than two times.
Achieving the best functional results in the surgical treatment of any disease is one of the main tasks.
Surgical treatment of patients with diffuse-toxic goiter is the main direction in this pathology. At the present stage, adequate methods of preoperative diagnostics and surgical interventions have been developed, which make it possible to visualize all thyroid tissues and ensure high safety of the intervention. However, there are literature data on the significant frequency of early and late complications in the surgical treatment of DTG [16]. One of the reasons may be the wrong choice of approach to cytoreduction, which does not sufficiently take into account the characteristics of the organ and its pathology [17].
There are also different approaches to assessing the results of treatment. A number of authors believe that a chronic hypothyroid state is quite adequate, since it determines at least a sufficient level of cytoreduction and is easily compensated for through replacement therapy [18, 19]. However, in other works, this condition is considered as the most frequent complication [20].
On the contrary, the attitude towards the development of hyperthyroidism in the period after the intervention is unequivocal. This is a complication that often requires repeated surgery [21].
Our work is devoted to a comparative assessment of the effectiveness of surgical treatment of diffuse toxic goiter using three options of intervention - subtotal resection of the gland, extirpation or embolization of the artery.
Each of these methods has its own supporters, for each it is indicated the presence of advantages and
disadvantages. Artery embolization is characterized by minimal invasiveness, however, due to the peculiarities of the arterial bed and the presence of collateral circulation, it may not be as effective as direct cytoreduction [22,23].
Subtotal resection is associated with a lower operational risk and presupposes the preservation of part of the gland tissue, having hormone-producing activity. There is an opinion that this approach is more adequate in terms of maintaining an adequate biological status of the gland, which cannot be fully compensated by the intake of thyroid hormones inside [24].
Extirpation of the thyroid gland is the most radical operation, but it also poses the greatest risk of intraoperative complications and requires lifelong thyroid hormone replacement therapy.
The study identified the features of the results and risks depending on the initial volume of the gland. A sharp increase in the frequency of the main long-term complication - hyperthyroidism - in artery embolization was revealed, but the degree of its dependence on the initial volume of the gland was also the highest.
Conclusion
The use of various approaches to the surgical treatment of diffuse-toxic goiter gives differences in the frequency of perioperative complications (excess during extirpation of the thyroid gland) and late complications. Among late complications, hypothyroidism dominates, subject to compensation with using substitution therapy in our case.
The frequency of recurrence of thyrotoxicosis has a double dependence on the approach to treatment and the initial volume of the thyroid gland. In order to prevent relapse, extirpation is the most rational for the surgical treatment of DTG when the volume of the gland is more than 45 cm3
Authors' Contributions: All authors were equally involved in the research and writing of this article.
Conflict of Interest: The authors declare that they have no conflict of interest.
Funding: There is no financial support and sponsorship.
Publication Information: The results of this study have not been previously published in other journals and are not pending review by other publishers.
References:
1. AimagambetovM.Zh., OmarovN.B., MasalimovE.O., Auzhanov D.B. et al. Our experience in the treatment of diffuse-toxic and nodular goiter Science of Russia: aims and objectives. 2020 year.
2. Affleck B.D., Swartz K., Brennan J. Surgical considerations and controversies in thyroid and parathyroid surgery. Otolaryng Clin N Am 2004; 36: 159-88.
3. Bartalena L., Marcocci C., Bozaggi F., Panicucci M., Lepri A., Pinchera A. et al. Relation between therapy for hyperthyroidism and the course of Graves' ophthalmopathy // N Engl J Med 1998; 338: 73-8.
4. Bobanga I.D., McHenry C.R. Treatment of patients with Graves' disease and the appropriate extent of thyroidectomy // Best Pract Res Clin Endocrinol Metab. 2019 Aug; 33 (4): 101319. doi: 10.1016 / j.beem.2019.101319.
5. Boger M.S., Perrier N.D. Advantages and disadvantages of surgical therapy and optimal extent of thyroidectomy for the treatment of hyperthyroidism // Surg Clin N Am 2004; 84: 849-74.
6. Chen C.R., Pichurin P., Nagayama Y., Latrofa F., Rapoport B., Mclachlam S.M. The thyrotropin receptor autoantigen in Graves' disease is the culprit as well as the victim // J Clin Invest 2003; 111: 1897-904.
7. Cheng Y., Sun Z., Zhong D., Ren L., Yang H. Cross-sectional investigation of serum creatine kinase concentration in Graves disease patients treated with oral antithyroid drugs // Medicine (Baltimore). 2020 Oct 23; 99 (43): e22898. doi: 10.1097 / MD.0000000000022898.
8. De Leo S., Lee S.Y., Braverman L.E. Hyperthyroidism // Lancet. 2016 Aug 27; 388 (10047): 906918. doi: 10.1016 / S0140-6736 (16) 00278-6.
9. Esbergenova M.Zh., Zamanbekova Zh.K., Uvataeva Zh.S. et al. The state of the thyroid gland in the population of the areas adjacent to the former Semipalatinsk nuclear test site // Science &Healthcare. 2014. №5, pp.75-78.
10. Galkin E.V., Grakov B.S., Protopopov A.V. First clinical experience of radioendo-vascular functional thyroidectomy in the treatment of diffuse toxic goiter // Vestn Rentgenol Radiol. 1994; 3: 29-35.
11. Glantz S.A. Primer of biostatistics. 7th edition. NY: McGRAW-HILL / - 2006. - 768 p
12. Gilbert J. Thyrotoxicosis - investigation and management // Clin Med (Lond). 2017 Jun; 17 (3): 274-277. doi: 10.7861 / clinmedicine.17-3-274.
13. Hermann M., Gschwandtner E., Schneider M., Handgriff L., Prommegger R. Modern thyroid surgery - the surgeon's endocrine-surgical understanding and his responsibility for the extent of surgery and complication rate // Wien Med Wochenschr. 2020 Nov; 170 (15-16): 379-391. doi: 10.1007 / s10354-020-00750-5.
14. Kaminski G., Jaroszuk A., Zybek A., Brzozowski K., Piasecki P., Ziecina P., Ruchala M. The calcium-phosphate balance, modulation of thyroid autoimmune processes and other adverse effects connected with thyroid arterial embolization // Endocrine. 2014 Jun; 46 (2): 292-9. doi: 10.1007 / s12020-013-0072-2.
15. Lin YS, Lin JD, Hsu CC, Yu MC The long-term outcomes of thyroid function after subtotal thyroidectomy for Graves' hyperthyroidism // J Surg Res. 2017 Dec; 220: 112118. doi: 10.1016 / j.jss.2017.06.091.
16. Liu Z.W., Masterson L., Fish B., Jani P., Chatterjee K. Thyroid surgery for Graves 'disease and Graves' ophthalmopathy // Cochrane Database Syst Rev. 2015 Nov 25; (11): CD010576. doi: 10.1002 / 14651858.CD010576
17. Meyer C., Anderson D., Dong Z., Riddick J.B., Elrod M., Ayala M. Prediction of Thyroid Hormone Replacement Following Thyroid Lobectomy: A Long-term Retrospective Study // OTO Open. 2021 Feb 16; 5 (1): 2473974X21992001. doi: 10.1177 / 2473974X21992001.
18. Mu L., Ren C., Xu J., Guo C., Huang J., Ding K. Total versus near-total thyroidectomy in Graves' disease: a systematic review and meta-analysis of comparative studies // Gland Surg. 2021 Feb; 10 (2): 729-738. doi: 10.21037 / gs-20-757.
19. Napier C. Managing thyrotoxicosis in the acute medical setting // Acute Med. 2018; 17 (1): 44-48.
20. Oriazzi J. Management of Graves' hyperthyroidism. Endocrin Metab Clin N Am 1987; 16: 365.
21. Savoca E., Torabi S.J., Kasle D., Mets E., Hajek M., Waldman E.H. Pediatric thyroidectomies: A surgical subspecialty comparison // Int J Pediatr Otorhinolaryngol. 2020 May; 132: 109945. doi: 10.1016 / j.ijporl.2020.109945.
22. Sellem A., Elajmi W, Mhamed R.B., Oueslati N., Ouertani H., Hammami H. Role and effectiveness of radioactive-iodine therapy for the treatment of Grave's disease // Pan Afr Med J. 2020 Aug 25; 36: 341. doi: 10.11604 / pamj.2020.36.341.21623.
23. Sharma A., Stan M.N. Thyrotoxicosis: Diagnosis and Management // Mayo Clin Proc. 2019 Jun; 94 (6): 1048-1064. doi: 10.1016 / j.mayocp.2018.10.011.
24. Vacante M., Biondi A., Basile F., Ciuni R., Luca S., Di Saverio S., Buscemi C., Vicari E.S., Borzi A.M. Hypothyroidism as a Predictor of Surgical Outcomes in the Elderly // Front Endocrinol (Lausanne). 2019 Apr 24; 10: 258. doi: 10.3389 / fendo.2019.00258.
Контактная информация:
Омаров Назарбек Бакытбекович - PhD, и.о. доцент кафедры госпитальной хирургии НАО «Медицинский университет Семей», г. Семей, Республика Казахстан.
Почтовый адрес: Республика Казахстан, 071400, г. Семей, ул. Абая Кунанбаева д.103 (НАО «Медицинский университет Семей»). E-mail: omarov.n83@mail.ru Телефон: моб.: +7(701) 536-80-81
