Surgical Treatment of Nodular Formations of the Thyroid Gland

The dissertation is devoted to the surgical treatment of nodular formations of the thyroid gland. The study is based on clinical material from the Mordovian region in the period following the Chernobyl nuclear power plant accident, which determines its epidemiological and environmental significance. The author analyzes the clinical symptomatology, the results of laboratory, morphological, and instrumental investigations, and the immediate and long-term outcomes of surgical interventions of various extents. On the basis of the data obtained, a diagnostic and treatment algorithm has been developed, aimed at a differentiated choice of treatment method, extent of surgery, and postoperative rehabilitation, as well as at improving the quality of life of operated patients.

Relevance of the topic. In recent years, a marked increase has been observed in the interest of practicing physicians in the problems of thyroid gland (TG) diseases. The issues of diagnosis, treatment tactics, and indications for surgery in various nosological forms of TG lesions are far from a definitive solution and are constantly discussed. The problems of goiter remain highly relevant for Russia in connection with the iodine deficiency present over practically the entire territory, as well as radiation contamination of a number of regions and other unfavorable environmental factors (Klyuev I.I., Piksín I.N., 1978; Klyuev I.I., Belikov V.S., 1984; Aristarkhov V.G., 1997; Dedov I.I. et al., 2000; Levchenko I.A., Fadeyev V.V., 2002; Vetshev P.S. et al., 2004; Litta-Mogignani R. et al., 2000).

The choice of therapeutic tactics for a number of TG diseases, combined in clinical practice under the term "nodular goiter," despite its apparent simplicity, is one of the complex tasks and, even for certain nosological forms, remains ambiguous (Piksín I.N. et al., 1994; Kononenko S.N., 2001; Cho Y.S. et al., 2000).

The unresolved problem of early differential diagnosis of benign and malignant TG formations, despite the abundance of modern high-technology diagnostic methods (Beloborodov V.A. et al., 2002; Bubnov A.N. et al., 2002; Vanushko V.Ye. et al., 2002; Crescenzi A. et al., 1996), has led a considerable number of researchers to consider surgery for nodular goiter from an oncological standpoint, regarding as an indication for surgical treatment the impossibility of excluding cancer with absolute certainty at the stage of examination (Grineva Ye.N., 2003). At the same time, the extent of surgical interventions varies from hemithyroidectomy, in the presence of a solitary node, to subtotal resection of the TG or thyroidectomy in cases of bilateral lobe involvement (Piksín I.N., 2002; Shulutko A.M. et al., 2002; Zinkevich I.V. et al., 2006). As is known, the indicated extent of surgery leads to thyroid and, quite frequently, parathyroid insufficiency with accompanying signs of disability.

The high prevalence of TG diseases, as well as the emergence of new technologies in medicine, require researchers to search for new alternative methods of treatment (sclerotherapy, diathermocoagulation, laser destruction of the nodular formation, and others), by means of which it would be possible to avoid traditional surgical intervention, especially in the group of patients in whom surgery is associated with a high risk due to concomitant diseases (Piksín I.N., 2002; Vetshev P.S. et al., 2002; Kim I.V. et al., 2005).

Taking into account the fact that there are no unified views among scholars in the field of this pathology, studies supplementing the understanding of methods of diagnosis and treatment of TG nodular formations are highly relevant.

Aim of the work. To improve the results of surgical treatment of patients with nodular formations of the thyroid gland by developing and implementing a diagnostic and treatment algorithm.

Objectives of the study.

1. To study the clinical symptomatology and laboratory data of patients with nodular formations of the thyroid gland in the Mordovian region.

2. To analyze surgical interventions on the thyroid gland over the past 7 years (1999 - May 2005).

3. To study the immediate and long-term results of operations on the thyroid gland depending on the form of goiter and the extent of surgical intervention.

4. To conduct a comparative analysis of the quality of life of patients after operations for nodular formations depending on the character of postoperative rehabilitation.

5. Based on the results of the study, to develop a diagnostic and treatment algorithm for nodular formations of the thyroid gland.

Scientific novelty.

For the first time, a comprehensive clinical and morphological study of nodular formations of the thyroid gland has been carried out in the Mordovian region after the accident at the Chernobyl nuclear power plant.

A significant increase in the number of cases of cystic-nodular degeneration of the thyroid gland has been established.

On the basis of a study of the clinical picture, surgical interventions, and the immediate and long-term results of surgical treatment, a diagnostic and treatment algorithm has been developed for benign nodular formations of the thyroid gland.

It has been revealed that, for performing minimally invasive interventions, a number of instrumental and morphological investigations must be carried out in order to exclude a malignant tumor of the thyroid gland.

Practical significance.

An analysis of surgical operations for nodular formations of the thyroid gland has shown the necessity of a differentiated approach to methods of treatment, the extent of intervention, and postoperative rehabilitation.

The study of the long-term results of surgical interventions on the thyroid gland has shown an unsatisfactory state of postoperative rehabilitation of patients.

The quality of life of operated patients depends both on the character of the preceding thyroid pathology and on the extent of the operation performed, concomitant diseases, and the quality of dispensary follow-up.

Statements defended.

At present, on the territory of the Republic of Mordovia, the predominant pathology of the thyroid gland is represented by benign nodular formations.

The developed diagnostic and treatment algorithm will make it possible to improve the immediate and long-term results of treatment of patients with this pathology.

Patients operated on for thyroid gland disease require subsequent social and medical rehabilitation.

Approval of the work.

The main provisions of the dissertation have been reported and discussed at the Ogarev Readings and conferences of young scholars of the State Educational Institution of Higher Professional Education "Mordovian State University named after N.P. Ogarev."

Implementation into practice.

The developed provisions of the work have been included in the training program for students of the medical faculty of the State Educational Institution of Higher Professional Education "Mordovian State University named after N.P. Ogarev" and introduced into the clinical practice of the Municipal Health Institution "City Clinical Hospital No. 4" of Saransk. The materials of the dissertation are used in lecturing and conducting practical classes with senior students, in the training of clinical interns and residents, and in continuing education courses for physicians.

Publications of dissertation materials.

On the topic of the dissertation, 13 works have been published, of which three in a journal recommended by the Higher Attestation Commission of the Russian Federation.

Structure and scope of the work.

The dissertation consists of an introduction, a literature review, four chapters of original research, a conclusion, findings, practical recommendations, and a list of references. The work is set out on 153 pages of literary text, contains 46 tables, 13 figures, and 271 literature sources, of which 155 are by Russian authors and 116 by foreign authors.