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ABSTRACT
The study included the results of treatment of 368 patients with benign thyroid nodules who were admitted to the
surgi-cal department of the multidisciplinary clinic of Samarkand State Medical University in the period from 2010 to
2023. Depending on the volume of the thyroid gland to be removed, the following types of operations were
performed: Thy-roidectomy, Subtotal resection of the thyroid gland, Hemithyroidectomy with partial resection of the
other lobe of the thyroid gland, Hemithyroidectomy, Partial resection of the thyroid gland. The developed algorithm
for choosing tactics for surgical treatment of thyroid nodules, taking into account the volume of removal of the thyroid
gland according to the conclusion of fine-needle aspiration biopsy or express bopsy, made it possible to improve the
quality of care provid-ed by reducing the frequency of immediate postoperative complications from 14.8% (40 patients
in the group compari-son) to 2.9
% (4 patients in the main group) (χ2 criterion = 4
.954; Df=1; p=0.027) and unsatisfactory
results in the long-term postoperative period from 32.1% (52 patients in the comparison group) to 11, 3% (in 12 patients
in the main group) (χ2 criterion = 4.692; Df
= 1; p = 0.031).
KEYWORDS
Nodular goiter, surgical treatment, relapse.
INTRODUCTION
Treatment of thyroid nodules (TNO) is a complex
surgical problem. The most common method of sur-
gery remains strumectomy with various options for
removing thyroid nodules (TG), which is performed in
Research Article
ANALYSIS OF THE RESULTS OF SURGICAL TREATMENT OF THYROID
NODULES
Submission Date:
January 08, 2024,
Accepted Date:
January 13, 2024,
Published Date:
January 18, 2024
Crossref doi:
https://doi.org/10.37547/ajbspi/Volume04Issue01-09
Salokhiddinov Jurabek Saidakhmatovich
Samarkand State Medical University, Republic of Uzbekistan, Samarkand
Journal
Website:
https://theusajournals.
com/index.php/ajbspi
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
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the vast majority of cases (90.6%) of PTG [1, 2, 3, 7, 10].
“However, a fairly high frequency of post
-operative
complications and numerous cases of postoperative
relapses of the disease (15-44%), postop-erative
hypothyroidism (25 - 63%) indicatelack of effectiveness
and reliability of common surgical tac-
tics” [4, 6, 8, 9,
12, 13].
The analysis of the literature also indicates that at the
present time, treatment and diagnostic tactics for PTG
is one of the pressing and unresolved problems of
modern healthcare [5, 11]. In this regard, there is a need
to revise the criteria for the radicality of surgical
intervention for PTO, depending on the information
content of visualization methods and morphological
studies, which allow, at the preoperative stage, to
assess the features of the structure of the node and
identify signs of disease aggression, and therefore,
optimization of the diagnostic algorithm in order to
select the most radical tactics of surgical treatment in
each specific case.
Purpose of the study
Improving the results of surgical treatment of patients
with parathyroid gland.
METHODS
The study included the results of treatment of 368
patients with benign PTG who were admitted to the
surgical department of the multidisciplinary clinic of
Samarkand State Medical University in the period from
2010 to 2023. Our study did not include patients with
toxic forms of PTO.
The patients were conditionally divided into two
groups. In 2010-2018 230 (62.5%) patients were
operated on and made up the comparison group, the
main group - 138 (37.5%) patients operated on in the
period 2019 - 2023. The comparison group was also
conditionally divided into two subgroups: sub-group 1
consisted of 127 (55.2%) patients operated on in the
period 2010-2014, subgroup 2 - 103 (44.8%) - patients
operated on in 2015 - 2018.
The examination of patients with parathyroid gland
met the clinical standards recommended by WHO and
the Ministry of Health of the Republic of Uzbekistan: -
general clinical (examination of the neck area,
palpation of the thyroid gland); - general clinical
laboratory tests; - determination of the level of thyroid
hormones (TSH, T3, T4); - examination by an
endocrinologist; - examination by an ENT doc-tor in
case of phonation disturbance.
Morphological studies of the parathyroid gland
included fine-needle aspiration biopsy, intraopera-tive
express biopsy, and routine histological examination of
removed thyroid tissue. At the same time, in the
comparison group (230 patients), TPAB and a final
histological examination of the removed thyroid
specimen were performed to determine the likelihood
of malignancy of the node. In the main group of
patients (138 patients), in addition to determining the
factor of possible thyroid cancer, the nature of be-nign
changes in nodular and perinodular tissue was
differentiated. The algorithm for morphological stud-
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ies in the main group of patients also included an
intraoperative express biopsy of thyroid tissue.
Depending on the volume of the thyroid gland to be
removed, the following types of operations were
performed: Thyroidectomy, Subtotal resection of the
thyroid gland, Hemithyroidectomy with partial
resection of the other lobe of the thyroid gland,
Hemithyroidectomy, Partial resection of the thyroid
gland (Table 1).
Table 1.
Performed surgeries for PTG
Type of surgery
Number of operations performed
Main group
Comparison group
Total
1 subgroup
2 subgroup
Thyroidectomy
10
4
15
29(7.9%)
Subtotal resection of the thyroid gland
54
23
62
139(37.8%)
Hemithyroidectomy with partial
resection of another lobe of the thyroid
gland
23
18
9
50(13.6%)
Hemithyroidectomy
37
51
12
100(27.1%)
Partial resection of the thyroid gland
14
31
5
50(13.6%)
Total:
138
127
103
368(100%)
127 patients 1 - subgroup of the comparison group
underwent the following operations: thyroidec-tomy
in 4 patients, subtotal resection in 23 patients,
hemithyroidectomy with partial resection of the other
lobe in 18 patients, hemithyroidectomy in 51 patients
and partial resection of the thyroid gland in 31 pa-
tients, i.e. In 78.7% of cases, organ-preserving
operations were performed.
103 patients of the 2nd subgroup of the comparison
group
underwent
the
following
operations:
thyroidectomy in 15 patients, subtotal resection in 62
patients, hemithyroidectomy with partial resection of
the other lobe in 9 patients, hemithyroidectomy in 12
patients and partial resection of the thyroid gland in 5
patients. In this subgroup, preference is given to
performing more radical surgical interven-tions. As can
be seen from Table 1, in this subgroup, radical
operations were performed in 74.7% of cases:
thyroidectomy was performed in 14.6% and subtotal
resection in 60.2% of cases.
138 patients of the main group underwent the
following operations: thyroidectomy in 10 patients,
subtotal resection of the thyroid gland in 54 patients,
hemithyroidectomy with partial resection of the other
lobe in 23 patients, hemithyroidectomy in 37 patients
and partial resection of the thyroid gland in 14 patients.
In the main group of patients, 53.6% underwent organ-
preserving operations, 46.4% under-went radical
operations, i.e. approximate ratio 1:1.
RESULTS
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The results of surgical treatment of PTG in the
immediate postoperative period were assessed by the
following indicators: bleeding during and in the
postoperative period, the course of the postoperative
period, the presence of signs of paresis of the
recurrent laryngeal nerve, the presence of convulsions,
the nature of healing of the surgical wound, the length
of stay of patients in the hospital (bed/day) , duration
of operation (min.), increased div temperature, signs
of peritracheal and subcuta-neous hematomas
according to ultrasound data.
Improving the choice of tactics for surgical treatment
of parathyroid gland, surgical technique, re-ducing the
trauma of surgical access and other innovations
developed and implemented within the framework of
this study could not but affect the immediate results of
managing this category of patients. So, compared to
2015-2018. the frequency of immediate postoperative
complications decreased from 33.0 to 5.1%, i.e. 6 times
(Table 2). Complications such as bleeding (5 times),
paresis of the recurrent laryngeal nerve (3 times),
hypoparathyroidism (15 times) became much less
common; there were no such dangerous complications
as persistent paralysis of the recurrent laryngeal nerve
and asphyxia, inThe duration of inpatient treatment
was reduced by 2 times
–
from10.2±1.2 to 5.9±0.3 days
(Table 3).
Table 2.
Comparative analysis of the frequency of immediate postoperative complications in patients with PTG
Type of complication
Group of patients
Total,
n=368
Comparison group
main, n=138
1-subgroup,
n=127
2-subgroup,
n=103
abs.
%
abs.
%
abs.
%
abs.
%
Complications arising during surgery
Bleeding
4
3.1
7
6.8
2
1.4*
13
3.5
Asphyxia
0
0
1
0.97
0
0
1
0.3
Complications that occur after surgery
Bleeding with development of
hematoma
2
1.6
3
2.9
0
0
5
1.4
Transient paresis of the recurrent
laryngeal nerve
2
1.6
9
8.7
4
2.9*
15
4.1
Persistent recurrent laryngeal
nerve palsy
0
0
1
0.97
0
0
1
0.3
Hypoparathyroi
dism
Transitory
5
3.9
10
9.7
1
0.7
16
4.3
Permanent
1
0.8
2
1.94
0
0
3
0.8
Complications from the wound
2
1.6
1
0.97
0
0
3
0.8
Total complications
16
12.6
34
33.0
7
5.1***
57
15.5
Number of patients with
complications
eleven
8.7
23
22.3
4
2.9*
38
10.3
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Note: * - differences relative to the comparison group data are significant (* - P<0.05, *** - P<0.001)
Table 3.
The course of the postoperative period in patients with PTG
Group of patients
Number of bed days
Total
before surgery
ICU
after operation
C
om
pa
ri
son
gr
oup
1-subgroup, n=127
10.2±1.2
3.0±0.3
2.1±0.1
6.2±1.2
2-subgroup, n=103
9.4±0.6***
2.3±0.3**
1.7±0.1**
5.4±0.5***
Main, n=138
5.9±0.3***^^^
2.0±0.2**
1.0±0.1*
2.9±0.3***^^^
Total, n=368
14.9±0.7
3.5±0.2
2.9±0.1
7.4±0.5
Note: * - differences relative to the data of the 1st subgroup of the comparison group are significant (* - P<0.05, ** - P<0.01,
*** - P<0.001), ^ - differences relative to the data of the 2nd subgroup comparison groups are significant (^ - P<0.05, ^^^
- P<0.001)
Long-term results were analyzed in 268 (72.8%) of 368
patients operated on for PTG. One of the main
indicators characterizing the effectiveness of surgical
intervention for PTG is the frequency of dis-ease
relapses. When studying the nature of the relapse, the
localization of the initially operated and re-identified
node, the timing of the relapse, the features of
previously used methods of surgical interven-tion, the
number, size and morphological forms of primary PTC
were compared.
Of 268 patients examined long-term, recurrence of
PTG was observed in 33 (12.3%) patients, while in the
group of patients operated on in 2010-2014, this figure
reached 26.4% (Table 4). Subse-quently, the frequency
of disease relapses was reduced in the 2nd subgroup of
the comparison group to 8.0%, and in the main group
to 3.8% (χ2 criterion = 4.692; p = 0.031)
.
We studied and analyzed the long-term results of
surgical treatment of PTG in order to determine the
influence of the choice of the volume of surgical
interventions in the study groups and compared them
with each other (Table 5).
Table 4.
Recurrence rate of PTC
Nature of relapse
Comparison group
Main group n=106
Total n=268
1-subgroup n=87
2-subgroup n=75
abs.
%
abs.
%
abs.
%
abs.
%
Nodular goiter
10
11.5
2
2.7
1
0.9
13
4.8
Multinodular goiter
13
14.9
4
5.3
3
2.9
20
7.5
Total
23
26.4
6
8.0
4
3.8
33
12.3
Criterionχ2
Df=1;χ2 = 4.692; p=0.031
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Table 5.
Comparative analysis of the localization of recurrent nodes in the thyroid gland
Scope of surgery
Localization of relapse
Total
Operated lobe
Contralateral lobe
Both beats
Pyramidal process
abs.
%
abs.
%
abs.
%
abs.
%
abs.
%
1-subgroup of the comparison group (n=87)
STC (n=14)
-
-
-
-
1
12.5
-
-
1
4.3
GTE+PR (n=13)
-
-
-
-
2
25.0
-
-
2
8.7
GTE (n=35)
2
25.0
3
50.0
2
25.0
-
-
7
30.4
PTC (n=23)
6
75.0
3
50.0
3
37.5
1
100
13
56.5
Total
8
100
6
100
8
100
1
100
23
100
2-subgroup comparison group (n=75)
STC (n=45)
-
-
-
-
1
33.3
-
-
1
16.7
GTE+PR (n=7)
-
-
-
-
1
33.3
-
-
1
16.7
GTE (n=8)
-
-
1
50.0
-
-
-
-
1
16.7
PTC (n=4)
1
100.0
1
50.0
1
33.3
3
50.0
Total
1
100
2
100
3
100
-
-
6
100
Main group (n=106)
Sthyroidism (n=73)
-
-
-
-
-
-
-
-
-
-
GTE+PR (n=7)
-
-
-
-
-
-
-
-
-
-
GTE (n=41)
-
-
1
33.3
-
-
-
-
1
33.3
PTC (n=4)
1
100.0
2
66.7
-
-
3
66.7
Total
1
100
3
100
-
-
-
-
4
100
Total
10
30.4
eleven
33.3
elev
en
33.3
1
3.0
33
12.3%
According to Table 5, postoperative relapse of nodular
or multinodular nontoxic goiter developed in 33 (12.3%)
patients during follow-up periods of up to 12 years.
Moreover, in 11 (4.1%) cases, nodular formations were
identified in the thyroid tissue, where at the time of the
primary operation there were no signs of nodular
transformation, which was confirmed by the results of
sonography and intraoperative revision data.
Of 33 patients with recurrent PTG, relapse occurred in
the operated lobe in 10 (30.4%) cases, in the
contralateral lobe in 11 (33.3%) cases, relapse in both
lobes occurred in 11 (33.3%) cases and in the pyramidal
process in 1 (3.0%) case.
Hypothyroidism in the long-term postoperative period
is also considered a relatively unsatisfactory result of
treatment. The clinical picture varied significantly
depending on the severity and duration of thyroid
hormone deficiency, as well as on the age of the
patient and the presence of concomitant diseas-es. The
faster hypothyroidism developed after surgical
removal of the thyroid gland, the faster it was ac-
companied by obvious clinical manifestations. On the
other hand, even with the same severity and dura-tion
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of hypothyroidism, the clinical picture was very
individual. That is, on the one hand, completely obvious
hypothyroidism could
not
have
any clinical
manifestations and was discovered by chance, on the
other
hand,
some
patients
with
subclinical
hypothyroidism could present a lot of complaints
charac-teristic of complicated severe hypothyroidism.
Thus, the developed algorithm for choosing tactics for
surgical treatment of PTG, taking into ac-count the
volume of thyroid removal according to the conclusion
of TPAB or express bopsy, made it possible to improve
the quality of care provided by reducing the frequency
of immediate postoperative complications from 14.8%
(40 patients in the comparison group) to 2 .9% (4
patients in the main group) (χ2 criterion = 4.954; Df=1;
p=0.027) and unsatisfactory results in the long-term
postoperative period from 32.1% (52 patients in the
comparison group) to 11.3% (in 12 patients in the main
group) (χ2 crite
-rion = 4.692; Df=1; p=0.031).
CONCLUSIONS
•
Factor analysis of the results of treatment of
patients with PTO showed that the cause of re-
lapse in 26.4% was the performance of organ-
preserving surgical interventions for nodular cystic
colloid goiter with foci of adenomatosis and a
combination of various types of adenomas with
multinodular col-loid goiter. The cause of the
development of postoperative hypothyroidism in
24% of cases was exceed-ing the indications for
performing operations associated with total
removal of the thyroid gland.
•
In the morphological diagnosis of PTG, the
information content of TPAB was 91.8%, express
biopsy was 94.4%, the combination of these
methods increased the information content to
98.1%. The introduction into clinical practice of
morphological diagnosis of changes in the nodular
and perinodular tissue of the thyroid gland in
patients with PTG has made it possible to select the
optimal volume of sur-gical intervention.
•
The developed algorithm for selecting the volume
of surgical intervention for PTG, taking into
account the data from the conclusion of TPAB
and/or express bopsy, made it possible to improve
treat-ment results by reducing the frequency of
immediate postoperative complications from 14.8%
to 2.9% and unsatisfactory results in the long-term
postoperative period from 32 .1% to 11.3%.
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