RU2812101C1 - Method of two-stage surgical treatment of diffuse toxic goiter - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: at the first stage, X-ray endovascular selective combined embolization of the thyroid arteries is performed. Then, embolization coils are inserted into the middle third of the trunk of the superior thyroid artery, as well as the distal segment of the lower thyroid arteries after the parathyroid arteries have separated, until blood flow in the trunk ceases. The second stage, on the third day after embolization, is surgical treatment in the amount of total thyroidectomy.

EFFECT: method allows to minimize blood loss when performing total thyroidectomy by dividing the surgical procedure into the stage of X-ray endovascular selective combined embolization of the upper and lower thyroid arteries on both sides and the stage of total thyroidectomy.

1 cl, 2 tbl, 1 ex

Description

The invention relates to medicine, namely to surgery, and is intended for two-stage surgical treatment of diffuse toxic goiter (Graves' disease).

Today, thyrotoxicosis is an autoimmune disease with hyperfunction of the thyroid gland, which develops as a result of the production of antibodies to the thyroid-stimulating hormone receptor (TSH). This is the most common disease among diseases not only of the thyroid gland (TG), but also of the entire endocrine system, which affects up to 1% of the population. The disease accounts for up to 80% of all cases of thyroid hyperfunction (see Vanushko V.E., Fadeev V.V., Latkina N.V., Fedak I.R., Kuznetsov N.S., Melnichenko G.A., Kurilova O .A. Surgical treatment of diffuse toxic goiter // Problems of Endocrinology. - 2006. - T.52, No. 3. - P.50-56).

From literary sources it is known that the main method of treatment for patients with a large volume of the thyroid gland is the operation of total thyroidectomy, accompanied by significant blood loss and the development of specific complications in the form of damage to the recurrent nerve and parathyroid glands (see Toleutaev, T.A. Modern methods of surgical treatment of patients with diffuse toxic goiter // Global Science and Innovations: Central Asia. - 2021. - T.2, No. 12(12). - P. 11-13).

The risk of bleeding and massive blood loss during thyroidectomy for diffuse toxic goiter (DTZ) is due to increased vascularization of the gland parenchyma, a significant increase in the speed of blood flow through the thyroid arteries, tissue traumatization due to instrumental influence (see Lebedeva D.V., Ilyicheva E.A., Grigoriev E.G. Modern aspects of surgical treatment of diffuse toxic goiter // Siberian Medical Journal. - 2019, No. 3. - P. 28-35).

Intraoperative blood loss during thyroidectomy for diffuse toxic goiter averages from 150 to 400 ml, which in turn reduces the visualization of nearby anatomical structures. Due to a limited view, the risk of damage to the parathyroid glands and recurrent laryngeal nerve increases (see Zarivchatsky M.F., Blinov S.A., Kravtsova T.Yu., Denisov S.A., Mugatarov I.N., Volkov Yu. .V., Kolevatov A.P. Tactical aspects of intra- and perioperative management of patients with surgical pathology of the thyroid and parathyroid glands // Tauride Medical-Biological Bulletin. - 2017, No. 3. - P. 109-115).

Several methods of staged treatment of diseases are known from literary sources, the main stage of which is preceded by an operation of embolization of the arteries feeding the organ compromised by the disease. Thus, there is a method for laparoscopic resection of a kidney mass with superselective balloon embolization of the renal artery (see Patent RU 2651055 C1, published 04/18/2018, Bulletin No. 11). Immediately before laparoscopic surgery, selective renal arteriography is performed under X-ray control. In this case, a coronary balloon is inserted into the artery supplying the segment of the kidney with the tumor and inflated until blood flow in the affected segment stops. Laparoscopic resection of the kidney is performed immediately after suturing the wound of the kidney parenchyma. This method reduces blood loss during kidney resection and can be an analogue of our method.

A method of x-ray endovascular occlusion of the renal artery during nephrectomy is also known (see Patent RU 2265408 C1, published 12/10/2005, Bull. 34). The essence of this method is to carry out distal and proximal embolization by introducing 10-20 ml of air into the renal artery. The method reduces the time the kidney is switched off from the vascular blood flow, reduces blood loss during nephrectomy and can also be an analogue of our method of treatment.

The existing method of two-stage treatment of uterine fibroids (see Patent RU 2730926 C1, published on August 26, 2020, Bulletin No. 24), in which the first stage involves X-ray endovascular selective embolization of the arteries feeding the myomatous nodes, and then after 30-45 days - ultrasound ablation of myomatous nodes. This method reduces blood loss during the second stage of ablation of myomatous nodes.

Also known from the sources is a multi-stage method for the treatment of operable adenocarcinoma of the head of the pancreas (see Patent RU 2706347 C1, published on November 18, 2019, Bull. 32), in which the first stage involves selective embolization of the tumor, after which the catheter is reinstalled into the celiac trunk and inserted gemcitabine infusion. Then, no earlier than one day after the end of chemotherapy, sessions of conformal radiation therapy are carried out, and only after that, no earlier than one day after the end of radiation therapy, surgical removal of the tumor is performed.

As a prototype with the closest technical solution, the “Method for the treatment of diffuse toxic goiter” was chosen (see Patent RU 2028103, C1, publ. 02/09/1995, Bull. 5) which consists in performing X-ray endovascular occlusion of the upper and lower right and left thyroid arteries. This method is one-stage and does not imply subsequent total thyroidectomy.

The technical result of the invention is the development of a method for two-stage surgical treatment of diffuse toxic goiter, which allows minimizing blood loss when performing total thyroidectomy by dividing the surgical procedure into the stage of X-ray endovascular selective combined embolization of the upper and lower thyroid arteries on both sides and the stage of total thyroidectomy.

The technical result is achieved by the fact that at the first stage of X-ray endovascular selective embolization of the thyroid arteries, a combined embolization is performed: first, embolizations are hydraulically introduced into the third-, fourth- and second-order arteries of both superior thyroid arteries, then embolization coils are introduced into the middle third of the trunk of both superior thyroid arteries. The second stage, on the third day after embolization, is a total thyroidectomy.

What is new in the claimed method of two-stage surgical treatment of diffuse toxic goiter is that the introduction of embolizations hydraulically into the arteries of the third, fourth and second order of both upper thyroid arteries is performed until the parenchymal contrast of the thyroid gland ceases, and the introduction of embolization coils into the middle third of the trunk of both upper thyroid arteries eliminates blood flow in both thyroid arteries.

The second stage of the method, namely total thyroidectomy on the third day after embolization, is carried out according to standard methods.

The method is performed as follows.

Under local anesthesia with a solution of lidocaine 0.5% - 5 ml or a solution of novocaine 0.5% - 5 ml, the femoral artery is catheterized according to Seldinger and a 6F introducer is installed. Next, a diagnostic catheter JR4 5F is selectively sequentially installed at the mouths of all thyroid arteries and selective digital subtraction arteriography (DSA) is performed to identify the vessels supplying the thyroid gland. Then, using a 0.035" diagnostic guide, the catheter is changed to a 6F guide and through it, with a 2.7F microcatheter, third- and fourth-order arteries on the right and left, directly involved in the blood supply of the gland, are superselectively catheterized by hydraulically introducing spherical embospheres 100-200 µm in size until the parenchymal contrast stops. thyroid gland. Then, second-order arteries on the right and left are hydraulically embolized with embospheres 500-700 microns in size until the blood flow completely stops. After this, embolization coils 0.018'' with a diameter of 3-5 mm are introduced into the middle third of the trunk of the superior thyroid artery, as well as the distal segment of the lower thyroid arteries after the departure of the parathyroid arteries, until blood flow in the trunk ceases. After embolization, control angiography is performed to determine the degree of occlusion. Embolization is stopped when 1/3 of the trunk of the superior thyroid artery on the right and left and the distal 1/3 of the lower thyroid arteries are occluded. The catheter along with the introducer is removed. Hemostasis is achieved by using a device to close the 6F artery puncture site. Aseptic pressure dressing.

The second stage, on the third day after embolization, is surgical treatment in the amount of total thyroidectomy according to the standard technique.

The performance of the proposed method is confirmed by the following clinical example.

Clinical example.

Patient V., 38 years old, was admitted to the surgical clinic on December 6, 2022 with complaints of swelling on the anterior surface of the neck, fatigue, interruptions in heart function, sweating, trembling of the fingers, a feeling of a “lump” in the throat, increased anxiety, panic attacks.

I considered myself sick since February 2021, when I first began to worry about interruptions in my heart function, tachycardia, sweating, and trembling of my fingers. An ultrasound examination of the neck organs revealed a significant increase in the size of the thyroid gland and thyrotoxicosis with diffuse goiter. In order to compensate for thyrotoxicosis, therapy with thyreostatics and adrenoblockers was started. The prescribed therapy had a temporary positive effect; when the dose of thyreostatics was reduced, the patient’s condition worsened: manifestations of thyrotoxic cardiomyopathy appeared and began to progress.

Ultrasound examination of the thyroid gland dated December 5, 2022: the location is normal. The capsule is not compacted. The contours are smooth and clear. Swallowing mobility is preserved. Isthmus: 6.2 mm. Total volume of the thyroid gland: 67.6 ^cm3 . Right lobe: dimensions: 30 × 38 × 78 mm. Volume - 46.5 ^cm3 . The echostructure is moderately diffusely heterogeneous due to hypoechoic zones. The echogenicity of the parenchyma: reduced in areas. Left lobe: Dimensions: 24×27×63 mm. Volume - 21.1 ^cm3 . The echostructure is moderately diffusely heterogeneous due to not clearly defined hypoechoic zones. The echogenicity of the parenchyma: reduced in areas. Visually: with CDK, vascularization in areas is increased.

Conclusion: Increased volume of the thyroid gland (total volume about 67.6 cm ³ ). Ultrasound signs of heterogeneity of the thyroid parenchyma with areas of hypervascularization.

Results of a study of thyroid hormones from November 16, 2022 while taking Thiamazole 30 mg/day: TSH - 0.004 µIU/l (0.35-5.1), T4 st. - 0.74 ng/dl (0.5-1.4), T 3 st. - 3.16 pg/ml (1.8-4.2) µIU/ml, AT to TSH receptors - 27.48 U/ml (N<1), AT to TPO - 426 IU/ml (0-30) - increased.

Diagnosis: Diffuse toxic goiter, degree II. Thyrotoxicosis, severe course.

On December 7, 2022, X-ray endovascular combined embolization of the thyroid arteries was performed using adhesive agents (embospheres and embolization coils).

For two days the patient complained of moderate pain in the area of femoral artery puncture.

Ultrasound conclusion on the second day after surgery dated December 09, 2022: Increased volume of the thyroid gland (total volume about 62.6 cm ³ ). Ultrasound - signs of heterogeneity of the thyroid parenchyma.

Compared with previous thyroid ultrasounds, there is no blood flow in the superior thyroid arteries and a decrease in the linear velocity of blood flow in the inferior thyroid arteries, as well as a decrease in the total volume of the thyroid gland.

On December 10, 2022, on the third day after embolization, a total thyroidectomy was performed (blood loss 55 ml).

Within 3 days after total thyroidectomy, the patient complained of moderate pain in the area of the postoperative wound. The patient was prescribed analgesic therapy (ketorolac 2.0 IM 2 times a day). To prevent hypocalcemia, Calcium carbonate + Colecalciferol was prescribed, 1 tablet 2 times a day. Replacement therapy with Levothyroxine sodium 150 mcg/day from the third day after total thyroidectomy.

A method of two-stage surgical treatment of diffuse toxic goiter was implemented in 5 patients with Graves' disease and a large volume of the thyroid gland. The average volume of intraoperative blood loss decreased and amounted to 74±14 ml. Damage to the recurrent nerve and parathyroid glands was not noted in any case.

The technical and economic efficiency of the method we have developed lies in the fact that its use allows us to perform the second stage (total thyroidectomy) of surgical treatment of diffuse toxic goiter on the thyroid gland with a reduced volume in cm ³ and minimize blood loss by performing combined embolization of the upper and lower thyroid arteries with two sides.

Claims (1)

A method of two-stage surgical treatment of diffuse toxic goiter, characterized in that in the first stage, X-ray endovascular selective combined embolization of the thyroid arteries is performed, in the second stage, on the third day after embolization, surgical treatment is performed in the amount of total thyroidectomy, characterized in that after embolization of the thyroid arteries in the middle third of the trunk The superior thyroid artery, as well as the distal segment of the lower thyroid arteries after the parathyroid arteries have separated, embolization coils are introduced until blood flow in the trunk ceases.