Functional Features of the Thyroid Gland After Surgery in Patients with Nodular Non-Toxic Goiter

The research is dedicated to studying the functional state of the thyroid gland and the frequency of recurrences of nodular non-toxic goiter in the remote postoperative period in patients who have undergone various volumes of thyroid gland resection. The work analyzes the impact of organ-preserving surgical interventions combined with various types of medicamental therapy, including iodine-containing vitamin and mineral preparations and thyroid hormones, on the restoration of thyroid tissue. The aspects of improving intraoperative histological express-diagnostics using computer technologies are also considered. The goal is to substantiate the optimal tactics for surgical and postoperative treatment of this disease.

Diseases of the thyroid gland (TDG) are the most prevalent non-infectious diseases in the world. According to WHO, over 800 million people have various thyroid pathologies. Over the last 20 years, there has been a significant change in the structure of surgical pathology of TDG with an increase in the proportion of patients with nodular and multi-nodular non-toxic goiter, which many authors associate with goiter endemism, ecological unfavorable conditions, and the weakening of the preventive direction in medicine (Dedov I.I. et al., 1992; Romanchesh A.F., 1994; Shcheplyagina L.A. et al., 1994; Kasatkina E.P. et al., 1995; Parmenova E.V., 1997; Vetchev P.S. et al., 1998; Lobykina E.V., Tsvetkov V.P., 1998; Utina V.V., 1999; Kalinin A.P. et al., 2000; Yaitsev S.V., 2000; Krammer J.B., Wells S.A., 1989; Harash H.R., Williams E.D., 1995).

The growth and change in the structure of thyropathies contribute to an increase in the number of thyroid gland surgeries, as the surgical method is the leading one in the treatment of nodular goiter. At the same time, some researchers recommend performing extensive resections up to complete removal of the organ in case of nodules in TDG (Tsukanov Yu.T. et al., 1997; Zarivchatsky M.F., 2000; Yaitsev S.V., 2000; Fadeev V.V., 2002; Vanushko V.E., Kuznetsov N.S., 2002). The outcome of extensive resections of TDG is the development of postoperative hypothyroidism, which worsens the quality of life of patients.

Recently, more and more authors tend to favor performing organ-preserving interventions for nodular formations in TDG in the variant of lobe resection (lobes), whose advantage over more extensive ones lies in the preservation of a functionally sufficient amount of thyroid parenchyma (Vaskov V.M., Masalskaya T.A., 1998; Aliev Z.O. et al., 2000; Malinovsky N.N. et al., 2000; Kononenko S.N. et al., 2000; Evmenova T.D., 1999, 2001; Aristarkhov V.G. et al., 2002).

The relevant issue of surgical endocrinology remains the improvement of the quality of intraoperative express-diagnostics, which directly affects the remote results of treatment.

The surgical method allows quickly and radically eliminating the pathological focus, but does not guarantee against recurrence of nodules. To prevent recurrence, most authors recommend prescribing thyroid hormones in the postoperative period (Dedov I.I. et al., 1994; Gerasimov G.A., 1996; Zarivchatsky M.F., 2000; Kotelnikova L.P. et al., 2002). However, as the results of multicenter studies conducted recently have shown, the intake of thyroid hormones in the postoperative period, widespread in clinical practice, does not reduce the number of recurrences, impedes the repair of the thyroid remnant, and causes atrophy of the thyroid parenchyma (Shambakha X. et al., 1998; Anchikova L.I. et al., 2000; Evmenova T.D., Shaidulina O.G., 2001; Cooper D.S., 1995; Papini E. et al, 1998; Baldet L. et al., 1998; Lemma F., et al., 1998; Bennedbek F. et al., 1999).

An alternative to thyroid therapy can be considered the use of iodine-containing preparations in the postoperative period as means of secondary prevention of nodular non-toxic goiter (Nikolaev O.V., 1955; Zografski S., 1977; Dedov I.I. et al., 2002). However, in the available literature, we have not found works reflecting the functional features of the thyroid gland in the remote postoperative period in patients with nodular non-toxic goiter and the frequency of recurrences of nodules when using iodine-containing vitamin and mineral preparations after various surgeries on TDG, which served as the basis for conducting the present study.

Goal of the research: to study the functional state of the thyroid gland, the number of recurrences in the remote postoperative period in patients with nodular non-toxic goiter depending on the volume of the operation and the nature of medicamental therapy, to substantiate the feasibility of combining organ-preserving interventions on the thyroid gland with subsequent treatment with iodine-containing vitamin and mineral complexes.

Tasks of the research:

1. To improve the intraoperative histological express-diagnostics of thyroid gland diseases using an automated computer system.

2. To study in a comparative aspect the influence of iodine-containing vitamin and mineral preparations and thyroid hormones on the volume and function of thyroid tissue in the remote postoperative period with various variants of thyroid gland resection.

3. To study the structure of thyroid tissue and the frequency of nodule recurrence with various types of postoperative treatment.

4. To compare the frequency of nodule recurrences with various volumes of thyroid gland resection.

5. To develop recommendations for the management of patients after surgeries for nodular non-toxic goiter.

Scientific novelty of the work:

For the first time, a computer system for intraoperative histological express-diagnostics "Atlant-Biopsy" has been created, tested, and introduced into practice for various thyroid gland diseases with the creation of an electronic histological atlas. This system allows significantly increasing the accuracy of recognizing the nature and features of pathology in the thyroid gland, selecting and studying individual fragments of images of histological preparations with high magnification, forming atlases of images of biopsy preparations, and conducting medical consultations at a distance in real-time mode.

On a large clinical material, a comparative evaluation of the state of thyroid tissue in the remote postoperative period in patients taking iodine-containing vitamin and mineral preparations and thyroid hormones, with various volumes of thyroid gland resection, has been given for the first time. It has been shown that the intake of iodine-containing vitamin and mineral preparations contributes to the effective restoration of the structure and function of the operated thyroid gland. It has been revealed that the frequency of recurrences of nodules in patients treated with iodine-containing vitamin and mineral preparations is lower than in patients taking thyroid hormones and not receiving treatment. It has been established that the number of recurrences in patients operated for nodular and multi-nodular non-toxic goiter with minimal thyroid gland resections is lower than with extensive interventions.

Practical significance of the work.

Installing an accurate intraoperative diagnosis using the computer system of histological express-diagnostics "Atlant-Biopsy" allows performing organ-preserving surgeries on the thyroid gland, which is a prevention of postoperative hypothyroidism and other complications. The use of the "Atlant-Biopsy" system leads to a reduction in the time of research and clarification of the diagnosis to 20 minutes.

Based on the study of the state of thyroid tissue and the number of recurrences in the remote postoperative period, it has been shown that the combination of organ-preserving resections of the thyroid gland with postoperative therapy with iodine-containing vitamin and mineral complexes allows increasing the efficiency of surgical treatment of patients with nodular non-toxic goiter, due to the preservation or rapid restoration of the function of the resected thyroid gland, reducing structural changes in thyroid tissue, and reducing the frequency of recurrences of nodules.

Recommendations for the treatment of patients with nodular non-toxic goiter in the postoperative period have been developed.

Testing of the work.

The results of the research and the main provisions of the dissertation work were reported and discussed at: the scientific-practical conference "Ways to improve the therapeutic, diagnostic, and preventive activities of the medical-sanitary unit of the Federal Medical-Biological Agency of Russia" dedicated to the 50th anniversary of the formation of medical unit No. 123 (Moscow Oblast, city of Odintsovo, January 17-18, 2006);

II scientific-practical conference "Actual questions of oncology and oncological care in the system of the Federal Medical-Biological Agency of Russia" (Moscow, October 19-20, 2006);

- VIII scientific-practical conference of surgeons of the Federal Medical-Biological Agency of Russia "Actual questions of surgical gastroenterology" (Tomsk Oblast, city of Severodvinsk, October 26-27, 2006); scientific-practical conference of the Federal Medical-Biological Agency of Russia "Provision of high-technology medical care in the system of the Federal Medical-Biological Agency of Russia" (city of Perm, November 9-10, 2006); scientific-practical conference of the Federal Medical-Biological Agency of Russia "Innovative technologies in medicine" (city of Sarov, November 14-16, 2006).

The testing of the dissertation took place at an expanded meeting of the Academic Council of the Research and Production Center "Gidrobios" of the Ministry of Defense and the Russian Federation (protocol No. 14 dated 11.21.2006).

Implementation.

The theoretical provisions and practical recommendations set forth in the dissertation are included in the work of the surgical and endocrinological departments of FSBI "Clinical Hospital No. 83 of the Federal Medical-Biological Agency of Russia", as well as in the lecture material for cadets, residents of the Department of Surgery, Anesthesiology, and Endoscopy of the Institute of Advanced Training of the Federal Medical-Biological Agency of Russia.

Main provisions of the dissertation to be defended:

1. The use of the computer system of histological express-diagnostics "Atlant-Biopsy" during thyroid gland surgeries allows increasing the accuracy of the intraoperative diagnosis.

2. For any variant of nodular non-toxic goiter, it is advisable to perform organ-preserving interventions on the thyroid gland, leaving the maximum amount of unchanged tissue.

3. Postoperative therapy with iodine-containing vitamin and mineral preparations has substantial advantages over preventive treatment with thyroid hormones.

4. The combination of organ-preserving resections of the thyroid gland with treatment with iodine-containing vitamin and mineral preparations allows significantly improving the results of surgical treatment of patients with nodular non-toxic goiter.

All material presented in the dissertation was obtained, processed, and analyzed personally by the author. Out of 228 examined patients, the author personally operated on 176 people.