TOTALNA TIROIDEKTOMIJA KAO KIRURŠKA METODA LIJEČENJA HIPERTIREOZE: NAŠA ISKUSTVA

Ivan Kovačić, Marijan Kovačić

Liječenje hipertireoze može se postići na dva načina: sprječavanjem same sinteze hormona antitiroidnim lijekovima ili obavljanjem trajne destrukcije tkiva štitne žlijezde radiojodnom terapijom ili kirurškim zahvatom. Danas se kirurgijom rješavaju odabrani slučajevi hipertireoze, redovito nakon neuspjeha i/ili nuspojava farmakološke i radiojodne terapije. Kirurgija kao inicijalna metoda liječenja ove bolesti dosta je rijetka. S obzirom na opseg kirurškog zahvata, razlikujemo suptotalnu, gotovo totalnu i totalnu tiroidektomiju. U ovom radu iznosimo svoja iskustva u liječenju bolesnika s hipertireozom metodom totalne tiroidektomije. Analizirali smo indikacije za kirurški zahvat i ocijenili njegovu uspješnost i sigurnost kod 163 bolesnika s hipertireozom. Od ukupnog broja prema uzroku bolesti formirali smo dvije grupe. U grupi G1 bili su bolesnici s Gravesovom bolesti (GB), njih 102 (62,5%), a u drugoj grupi (G2) 61 bolesnik (37,5%) s toksičnom multinodoznom strumom (tMNS). Liječenje antitiroidnim lijekovima prije operacije provedeno je kod 83% bolesnika, u G1 100%, a u G2 54%. Kirurški zahvat, kao jedina metoda liječenja u G2, bio je zastupljen u 46% (ukupno 17%). Osnovna indikacija za operacijsko liječenje u G1, osim povratka bolesti, bile su nuspojave antitiroidnih lijekova i oftalmopatija, a u G2 velika struma s kompresivnim sindromom ili bez njega, kao i njezina retrosternalna lokalizacija. Tijekom kirurškog zahvata kod svih su bolesnika obostrano prikazani povratni živac grkljana i dvije do četiri paratiroidne žlijezde. Revizijski je zahvat, zbog krvarenja, obavljen kod dvije bolesnice s GB-om, a kod jedne od njih učinjena je i traheotomija. Nijedan bolesnik nije imao obostranu ozljedu povratnog živca. Jednostrana kljenut neposredno nakon kirurškog zahvata zabilježena je kod troje bolesnika, od kojih je u njih dvoje došlo do potpunog oporavka pokretljivosti glasnice. Prolazne niske vrijednosti kalcija u krvi neposredno nakon zahvata nalazimo u 29% bolesnika (G1 26% : G2 36%), bez statistički značajne razlike po grupama. Tijekom prvoga poslijeoperacijskog tjedna vrijednosti su se kalcija normalizirale kod 67% bolesnika. Trajnu hipokalcemiju nije imao nijedan bolesnik. Incidencija papilarnog karcinoma ukupno je iznosila 8%, a nešto je viša bila u G2 (10%) nego u G1 (5%) ali bez statistički značajne razlike. S obzirom na uzrok bolesti, GB i tMNS, totalna tiroidektomija primijenjena je iz različitih razloga, ali je njezin rezultat za sigurnost i učinkovitost bio isti. Možemo je smatrati sigurnom i efikasnom metodom u selektivno izabranih i prijeoperacijski dobro pripremljenih bolesnika. Ovaj zahvat iskusnog kirurga ima nizak postotak trajnih komplikacija i treba ga prezentirati bolesnicima kao opciju liječenja sa svim rizicima i prednostima u odnosu prema drugim metodama liječenja hipertireoze.

Treatment of hyperthyroidism can be achieved in two ways, prevent the synthesis of hormones by antithyroid drugs or carry out permanent destruction of the thyroid tissue by radioiodine therapy or surgical intervention. Today, surgical treatment of selected cases of hyperthyroidism usually follows the failure andor side effects of medication and radioiodine treatment. Surgery as an initial method of treatment of this disease is quite rare. Considering the scope of the surgical procedure, we distinguish subtotal, almost total and total thyroidectomy. In this paper we present our experience in the treatment of patients with hyperthyroidism with total thyroidectomy method. We analyzed the indications for surgery and evaluated its effectiveness and safety in 163 patients with hyperthyroidism. Out of the total number we formed two groups according to the cause of the disease. G1 group included 102 (62.5%) patients with Graves’ disease (GD), and the second group (G2) 61 patients (37.5%) with toxic multinodular goiter (TMNG). Prior to surgical treatment, 83% of patients were treated with antithyroid drugs, in G1-100%, and in G2 54%. The surgical procedure as the only treatment method in G2 was 46% (total 17%). The main indications for surgical treatment in G1, except recurrences, were side effects of antithyroid drugs and ophthalmopathy, and in G2 large goiters with or without compression syndrome, as well as their retrosternal localization. During the surgery, in all patientsa recurrent laryngeal nerve and two to four parathyroid glands were seen on both sides. Revision procedure, due to bleeding, was done in two patients with GD. One of them also underwent tracheotomy. None of the patients had bilateral recurrent laryngeal nerve injury. One sided paralysis, immediately after surgery, was observed in three patients, and in two of themthere was a complete recovery of the mobility of vocal cords. Transient low calcium levels in blood immediately after the procedure were observed in 29% of patients (G1 – 26%: G2 – 36%) with no statistically significant differences across groups. During the first postoperative week 67% of calcium levels were normalized. None of the patients had permanent hypocalcemia. The total incidence of papillary carcinoma was 8%, slightly higher in G2 (10%) than in G1 (5%), but without significant differences. With regard to the cause of the disease, GD and TMNG, total thyroidectomy was applied for various reasons, but it achieved identical scores of treatment safety and efficacy. We might consider it a safe and effective method in selectively chosen and before surgery well prepared patients. This surgery, performed by an experienced surgeon, has a low percentage of permanent complications and should be presented to patients as a treatment option with all risks and benefits compared to other methods of treating hyperthyroidism.