Prevention of postoperative hyperparathyroidism in the surgical treatment of patients with thyroid cancer with metastases in the lymph nodes of the neck

• K. V. Melnik

Abstract

Thyroid cancer is the most common endocrine malignancy, accounting for 3% of all new malignant tumors diagnosed annually in the Russian Federation.

Thyroid carcinoma metastasize in the cervical lymph nodes in 70% cases. Surgical method is the primary method of treatment of thyroid cancer patients with metastases in the lymph nodes of the neck. Unfortunately, surgery is still often accompanied by specific complications. Notable among these frequency, specificity, severity of manifestation and complexity of prevention takes postoperative hypoparathyroidism, the frequency of which can reach up to 40%.

Objective – to reduce the incidence of postoperative hypoparathyroidism in patients with thyroid cancer with metastases in the lymph nodes of the neck.

Materials and methods: in the study group included 74 patients who were examined and treated in S. P. Botkin city hospital (Moscow) in the hospital department of endocrine surgery in 2009–2013. In 62 (84%) patients was performed thyroidectomy with central lymphadenectomy 12 (16%) – thyroidectomy with modified radical neck dissection. Papillary cancer is diagnosed in 60 (81%) patients, follicular – 10 (14%) and medullary – 4 (5%) patients. 2 patients were not included in the study group. Patients had undifferentiated cancer. The average age of patients was 50 years old. Ratio male to female were 1:2.

All patients were operated on after an appropriate study, under endotracheal anesthesia. During interventions used modern medical equipment: LigasureTM, ultrasonic scalpel UltraCision, endoscopic optic system Storz, binocular loupes and surgical microscope ZEISS and portable source of blue light Biospec. All of them had been used at different stages of our operation. Patients exposed to extrafascial intervention using advanced techniques to meet specific phasing and precision surgical techniques. To reduce bleeding and to preventthe hemorrhage, as well as to prevent the spread of hematogenous metastases, all manipulations on the thyroid gland began after ligation and subsequent transection of thyroid vessels. First freed upper and lower pole then the side surfaces of thyroid. In the first place, stripped the front surface of the larynx to clarify the anatomical landmarks. After crossing the upper to mobilize the lower pole of the thyroid gland with separate ligation and the intersection of the main trunks and branches of the inferior thyroid vessels in the thyroid capsule. At the same time preserve arteries supplying the parathyroid glands. And if it has intimate contact with the tissue removed in 40 (54%) patients, to separate arteries using thin vascular and microsurgical instruments and, in some cases, optical devices. It should be noted that in the presence of enlarged lymph nodes conglomerate visualize parathyroid glands is extremely difficult, and when they need to consider the allocation of their anatomic and topographic anatomical features, for example, they typically have a diameter of 4–6 mm and are mostly found in pairs at the lower poles and the posterio-lateral surface of the thyroid gland. Epithelial corpuscles have a clear capsule and vascular supply their branches. Parathyroids are brown color, but depending on the age and fatty infiltration and may have a yellowish tint. In addition, the parathyroid glands are extremely sensitive to hypoxia and trauma. When handling and contact with surgical instruments of the surface appears hyperemia with vascular injection, which is particularly visible when magnified than they stand out from the fat lobules. It should be noted that 35 (47,2%) patients has been used a method of photodynamic navigation of parathyroid glands. For this, patient 2 hours before the operation was suggest to drink diluted in 50 ml of water «Alasens» in an amount of 1,5 g. Which accumulates and long time delays in the parathyroid glands. When sending them blue light using optical systems Storz and portable source Biospec operating in the dark give effect of pink luminescence. Intervention completed byrevision ofthyroid bed and surrounding structures. The wound closed intradermal sutures. Mikrodrainage on active aspiration placed into thyroid bed.

Functional state of the parathyroid glands examined by determination of the Ca and P level in the postoperative period.

Results. Using the improved technique of operation, surgical instruments, precision surgical techniques and methods of photodynamic navigation in patients with advanced interventions helped to prevent persistent hypoparathyroidism. However, the allocation of the parathyroid glands removed from their tissue, trauma occurred with temporary blood supply disturbance, resulting in 10 (13,5%) patients had a slight decrease in serum calcium. Changes were stopped before discharge. In 2 (2,7%) patients hypoparathyroidism persisted for 1 month.

Conclusion. For the effective prevention of postoperative hypoparathyroidism in thyroid cancer surgery with metastases in the lymph nodes of the neck.

1. Strict phasing in mobilizing the thyroid gland.

2. Using microsurgical instruments and magnification.

3. Isolation of parathyroid glands with preservation of their feeding vessels.

Keywords:thyroid cancer, hypoparathyroidism, method photodynamic navigation parathyroid glands

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