RU2557946C1 - Method for pre-operative detection of operation extent in patients with diffuse toxic goiter - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: pre-operative fasting venous blood 1 ml is sampled at room temperature 20-24°C into an anticoagulant-free vacuum system (test tube). The test tubes are delivered in a sealed container at temperature 2-8°C for 2 hours to a laboratory for immunoenzyme assay and analysed to determine anti-thyroid stimulating hormone receptor antibodies. If the antibody level is 1.5 units/l or more, a thyroidectomy is performed, whereas the antibody level of less than 1.5 units/l requires performing a subtotal thyroid resection according to standard techniques.

EFFECT: invention enables reducing a probability of recurrent thyrotoxicosis in the patients after subtotal thyroid resection.

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Description

The invention relates to medicine, namely to surgery and can be used to select the volume of operation for patients with diffuse toxic goiter (DTZ).

The problem of surgical treatment of patients with DTZ at the present stage is that the choice of the optimal volume of operation in a particular patient has not been finally resolved.

Today 2 approaches to surgical treatment of patients with DTZ are known. The first approach is that patients with DTZ undergo subtotal resection of the thyroid gland. At the same time, thyroid tissue is left in the form of a residue of 2-6 g. The problem with this approach is that 10-30% of patients have a relapse of the disease (A.F. Romanchishen, Surgery of the thyroid and parathyroid glands. - St. Petersburg: IPK Vesti, 2009 . - 648 p.).

It should be noted that despite the high percentage of disease recurrence after subtotal resection of the thyroid gland, in many patients after surgery it is possible to achieve an eu- and hypothyroid state. Therefore, we can conclude that in order to perform this operation, a strict selection of patients is necessary.

The second approach is that patients with DTZ remove all the gland. In this case, the possibility of relapse of the disease is completely excluded. The problem of this approach is that in the postoperative period laryngeal paresis often develops (Ilyicheva EA et al. Features of the course of laryngeal paresis after surgical treatment of diffuse toxic goiter. - Bulletin of Otorhinolaryngology, 2011. - No. 3. - p. 51- 54), hypoparathyroidism (Kuznetsov N.S. et al. Predictors of postoperative hypoparathyroidism after thyroidectomy and methods of its treatment. - Clinical and experimental thyroidology, 2012. - T. 8. - No. 2. - p.20-30).

There is a method of determining the volume of operation in patients with DTZ using invasive infrared photoprobing of thyroid tissue intraoperatively (Volodchenko V.P. Surgical treatment of diffuse toxic goiter and methods for correcting postoperative functional disorders. Author. Thesis ... Doctor of Medical Sciences. - Khabarovsk, 2005 - pp. 19-20). The essence of the method lies in the fact that during the operation, photo-sounding of the thyroid gland tissue is carried out and the reflection coefficient is analyzed. When detecting tumor formations on the background of DTZ, patients are offered to perform a thyroidectomy or epiphasic subtotal resection of the thyroid gland. In patients with diffuse changes in thyroid tissue, subtotal thyroid resection is performed. The method for determining the volume of surgery in patients with DTZ using invasive infrared photo-sounding of thyroid tissue was intraoperatively taken as a prototype.

The disadvantages of this method include the fact that it is applicable only during the operation, and the patient is not informed before the operation of how much intervention will be performed. In addition, this method of determining the volume of surgery is based only on morphological changes in the organ and does not take into account the functional state (the degree of autoimmune stimulation of the thyroid gland in patients with DTD).

An object of the present invention is to preoperatively determine the extent of surgery in patients with diffuse toxic goiter and reduce the number of postoperative complications.

This is achieved by the fact that before performing the operation, the patient with DTZ is determined by the level of antibodies to TSH receptors and based on the results obtained, the volume of the necessary operation is determined.

The method is as follows. After determining the indications for surgery (recurrent course, severe form, intolerance to thyreostatics) and assessing the degree of disease compensation (examining the level of free T4), 1 ml of fasting venous blood at a temperature of 20-24 ° C is taken from a patient with a diffuse toxic goiter (at room temperature 20-24 ° C) ( test tube) without anticoagulant and delivered to the laboratory for enzyme immunoassay for 2 hours in an airtight container at a temperature of 2-8 ° C and determine the level of antibodies to TSH receptors in the blood of a patient with DTZ. Measurement is carried out in units / liter (unit per liter). At the next stage, the results are evaluated. Values less than 1.5 U / L are treated as negative, and greater than or equal to 1.5 U / L are treated as positive.

With values of this indicator greater than or equal to 1.5 U / L, patients are predicted to have a high risk of disease recurrence while leaving a thyroid residue of any volume and complete removal of the thyroid gland (thyroidectomy) is performed for such patients.

When the level of antibodies to TSH receptors is less than 1.5 U / L, a low risk of developing thyrotoxicosis relapse in the postoperative period is predicted. This group of patients performs subtotal resection of the thyroid gland with the preservation of generally accepted volumes of thyroid residue (2-6 ml).

Essentially in the approach we propose is that before the operation it is necessary to study the immunological reactivity of the patient with diffuse toxic goiter, namely antibodies to TSH receptors. This indicator will be individual for each patient. And, therefore, the choice of the required volume of operation will be strictly individualized. Ultimately, this will ensure stable remission, the absence of thyrotoxicosis recurrence and the minimization of specific postoperative complications.

The proposed method for determining the volume of surgery for patients with DTZ has been used in the clinic of faculty surgery of Samara State Medical University since 2009 and was used to determine the volume of surgical intervention in 122 patients. 56 of them underwent subtotal resection of the thyroid gland. In all patients without exception, the preoperative prognosis coincided with postoperative results. The duration of observation ranged from 1 to 5 years. There is no relapse of thyrotoxicosis in patients after subtotal resection of the thyroid gland.

Clinical examples.

Patient L. Konnova, 62 years old, was admitted to the clinic of faculty surgery of Samara State Medical University 02/01/11. After the examination (ultrasound of the thyroid gland, study of the hormonal background), the diagnosis was established: DTZ II degree. Thyrotoxicosis, severe, recurrent course, drug subcompensated. As a preoperative preparation, the patient received tyrosol at a dosage of 10 μg / day. A patient in another surgical hospital in the city was offered to perform a thyroidectomy, from which she refrained. Upon admission, the level of antibodies to TSH receptors was studied, which amounted to 0.3 U / L (less than 1.5), indicating a low degree of autoimmune stimulation of thyroid tissue. 02.10.2011 an operation was performed - subtotal resection of the thyroid gland according to Nikolaev, the amount of thyroid residue was 1.8 ml (according to intraoperative ultrasound). In the postoperative period, laryngeal paresis did not develop, the level of calcium in the blood - without a decrease. Examined after 3.5 years - there is no relapse of thyrotoxicosis after surgery. Accepts L-thyroxine 50 mgk / day.

Thus, the proposed method for the preoperative determination of the volume of surgery in patients with diffuse toxic goiter allows reducing the number of thyroidectomy and minimizing the likelihood of thyrotoxicosis recurrence in patients after subtotal thyroid resection by clearly defining the indications for this operation.

Claims (1)

A method for preoperatively determining the volume of surgery in patients with diffuse toxic goiter, including determining indications for surgery (recurrent course, severe, intolerance to thyreostatics) and assessing the degree of compensation of the disease, characterized in that 1 ml of fast venous blood is taken from patients before surgery at room temperature 20-24 ° C into a vacuum system (test tube) without anticoagulant and delivered to the laboratory for enzyme immunoassay for 2 hours in an airtight container with a temperature of 2-8 ° C and determined they increase the level of antibodies to TSH receptors, when the antibody level is greater than or equal to 1.5 U / L, the patient undergoes thyroidectomy, and when the antibody level is less than 1.5 U / L, the patient undergoes subtotal thyroid resection according to standard methods.