Vol 8, No 4 (2014)

Review of literature
The pathogenesis of Charcot osteoarthropathy: the role of the peripheral nervous system
Radikovich G.G., Kaminarskaya Y.A.

Abstract

Neuroosteoarthropathy is a rare, but devastating complication affecting patients with peripheral neuropathy. It is a progressive, destructive condition that is characterised by progressive bone and joint deterioration of the foot leading to permanent incapacity. Nowadays, diabetes mellitus is by far the most common etiology of CNO (Charcot neuro-osteoarthropathy), especially if it affects the foot or ankle.

The cause of the condition is still controversial among experts. In particular, new data have emerged on the central role of RANK/RANKL/OPG in the pathogenesis of this complication, also known as Charcot foot. No pharmacological methods of therapy have proven effective to date. Very little progress has been made in treating this condition since the days of Jean-Martin Charcot. Today, the universally accepted treatment involves completely relieving pressure from the limb using a polymer retaining bandage. The aim of this review is to analyze research into the pathogenesis of CNO and our potential to better understand the nature of this condition.

Particular attention is paid to modern concept of neuroosteopathology, according to which neuropathy is crucial to developing acute osseous pathology. Revealing new aspects of CNO pathogenesis can help extend therapeutic resources for treating this patient group.

Endocrine Surgery. 2014;8(4):5-14
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Clinical practice
Leg ulcers in patients with diabetes: an underestimated problem?
Udovichenko O.V., Beresneva E.A.

Abstract

Diabetic foot ulcer (DFU) is not only type of ulcers which can affect lower extremities of patients with diabetes mellitus (DM). The second common type is leg ulcer (LU). These ulcers may appear not only as classic ones – a result of venous diseases, but also result of some degree of leg ischemia in combination with several additional factors. Some diabetic foot outpatient clinics (DFOC) have experience with treatment of such ulcers.

Aim of our study was to analyze main characteristics of patients with diabetes and LU treated in DFOC, results of their treatment and possible reasons for treatment of this group in the DFOCs.

Object and methods

All patients with diabetes and LU of any etiology (venous, posttraumatic, mixed) treated in our DFOC from July 2007 to June 2012 were included in our study (n = 101, main group). All patients with DFU treated in the same DFOC in this time frame (n = 721) formed the control group. Follow-up data was observed from medical records or by phone calls. Follow-up time was between 6 mo and 2.5 yrs. 

Results

Most of patients with LU were females (71%) and had type 2 DM. More frequent wound infection, higher median wound surface, lower depth and very rare involvement of deep tissues (phlegmone and osteomyelitis) were characteristic for LU group. There were not significant difference (p > 0.05) between groups in terms of diabetes duration, type 2 DM treatment methods, rate of DM complications and concomitant diseases and HbA1c level. At follow-up contact time ulcers healed in 64% in LU group and 65% of DFU group (р > 0.05). More LUs stayed unhealed at this time than DFUs (13% vs 5%, р = 0.013). Minor amputations were made in 0% in LU group and in 5% in DFU group (p = 0.039), but major amputations rate was not significantly different between groups (4% vs 6%, p > 0.05). Mortality was not also significantly different between groups (p > 0.05).

Conclusions

  1. Leg ulcer population of the DFOC is mainly female and has type 2 DM;
  2. LUs healed during follow-up in 64% patients but stayed unhealed in 13% and leaded to major amputation in 4%;
  3. Amputation prevention programs in patients with diabetes should take into account that at least 10% of major amputations in these patients are a result of LU;
  4. Epidemiological studies are necessary to assess prevalence of LU and LU-related amputations in whole diabetic population;
  5. Treatment of LU in patients with diabetes should be as careful as of DFU and DFOC is optimal setting for it.
Endocrine Surgery. 2014;8(4):15-22
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Features of radionuclide research after thyroidectomy at the thyroid gland cancer
Dolidze D.В., Mumladze R.B., Vardanyan A.V., Vartanyan K.F., Vasilyev I.T., Levchuk D.I., Lebedinsky I.N., Komissarov A.N., Bagateliya Z.A., Melnik K.V.

Abstract

Aim

To clarify the possibility of postoperative radioisotope studies in determining the remnants of thyroid tissue in patients with thyroid carcinoma.

Materials and methods

The work is based on the study results of surgical treatment and postoperative examination of 120 patients with thyroid cancer, at the Botkin hospital during the period from 2007 to 2013. All patients were performed extrafascial intervention. 118 (98.3%) patients were provided thyroidectomy (including lymph node dissection). For all patients in the postoperative period after 2–4 weeks were performed thyroid and whole-body scan with iodine and technetium, as well as ultrasound and computed tomography of the neck and the chest cavity.

Results

During the research, 16 (13.3%) patients after scanning with 123I (7 (5.8%) patients), 131I (3 (2.5%) patients), 99mTs-Pertechnetate (6 (5%) patients) and applying them consistently (6 (5%) patients) received the accumulation of the radiopharmaceutical in the operation area, as in the midline in the area of the isthmus, and the locations of the right, left and pyramidal thyroid share. These facts were interpreted as an accumulation of the isotope in the remnants of thyroid tissue after surgery. With additional research methods were revealed swelling and infiltration of tissues in 10 (8.3%) cases in the sterno-hyoid and sterno-thyroid muscles, and in 6 (5%) cases – in the paratracheal and paralaryngeal areas. After fine-needle aspiration biopsy from infiltrative zone was received cytology of nonspecific inflammation. All patients received antiinflammatory and antibiotic therapy with a positive effect. Control ultrasound noted a gradual reduction of the inflammatory infiltrate. After 6 months of thyroid scan was recorded decrease area of uptake, and a year later its complete disappearance.

Conclusions

Thus, postoperative radionuclide scanning in patients with thyroid gland carcinoma in some cases gives false-positive results, regardless of the type of used radiopharmaceutical.

Endocrine Surgery. 2014;8(4):23-36
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Children Thyroid Cancer treatment in Saint-Petersburg Endocrine SurgeryCenter and Mayo Clinic
Romanchishen A.F., Thompson G.B.

Abstract

Introduction

Thyroid cancer (TC) is the most often malignant tumor in childhood and made 1.5 – 3.0% of all children population or 45.3% of pediatric endocrine epithelial cancers. A lot of questions concerning to volume of thyroid surgery, postoperative radio iodine therapy (RIT) needs to be discussed.

Aim

Estimation of childhood sporadic thyroid cancer specificity and comparison of children and adolescents treatment in Saint-Petersburg Endocrine Surgery Center (Russia) and Mayo Clinic (USA).

Material and methods

During 1970 –2011 in the Saint-Petersburg Center (1 group) were operated 105 TC children and adolescent (up to 20 yeas) and in Mayo Clinic – 188 (2 group) in  1940 – 2000 period. Since of 80-s in those clinics were used the same perioperative examinations, like TSH, T4, T3 blood levels, USG, fine needles aspiration biopsy, CT and morphological examinations.

Results and discussion

Average age of the Saint-Petersburg Center and Rochester patients was the same and achieve 16.3±0.3 and 16.0±0.5, accordingly. In both groups has prevailed girls: in the 1 group they made 73.3% (M:F 1:2.7) and in the 2 – 70.7% (M:F 1:2.4). Childhood differentiated TC were associated with aggressive behavior: regional metastases were found in 53.0% and 81.4%, extrathyroid TC spreading – in 9.6 and 19.7%, distant metastases - in 9.6 and 4.8%, accordingly. In our Center (1 group) we have performed hemithyroidectomies and subtotal Thyroidectomies in 58.1% with ipsilateral central neck dissection (CND). In Mayo Clinic in all TC cases were performed thyroidectomy (TE) since 1950. TC relapses we have no   observed in 1 group and they have place in 6.9% 2 group patients, recurring lymphatic metastases – in 8.4% and 20.7%, accordingly. Radioiodine therapy (RIT) has performed in 21.1% and 25.5% operated children.

In 1 group 95 (96.0 %) of 99 operated were alive during 5 – 36 years, in the 2– only in two cases reason of death was TC, but in 14 – other malignant tumor.

Conclusion

Childhood TC is associated with more locally aggressive and more frequent distant disease than its in adult coun­terpart. Recurrence rate stend to be higher in children, but cause-specific mortality remains low. Optimal initial treatment of childhood TC should include TE and CND. RIT in child hood has in creased possibility of others malignant tumor in follow up period.

Endocrine Surgery. 2014;8(4):37-42
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Prevention and treatment of emergencies in thyroid patients
Romanchishen A.F., Kim I.Y., Bogatikov A.A.

Abstract

Aim

To evaluate the surgical treatment outcomes for patients with acute complications of thyroid disease (compression syndrome, early postoperative complications - like bilateral recurrent laryngeal nerve injure, bleeding (PB) in thyroid bed and others) performed in the single medical center.

Material and methods

Anaplastic Thyroid Cancer (243 patients), multiglandular retrosternal goiter (25 cases), and purulent acute thyroiditis (9 observations) made heavy compression of neck and mediastinal aerodigestive organs and were the reason for emergent thyroid surgery. Were estimated intraoperative recurrent nerve (RLN) injures consequences and postoperative bleeding, made necessary for reoperations after 25663 thyroid surgeries during 36 years of the Center practice.

Results

Surgical intervention for Anaplastic Thyroid Cancer in all of patients has got palliative character only. Postop. lethality rate made 21,0% after emergency interventions, and 2,5% - after routine procedure. Combinations of it with radiochemotherapy has prolonged survival rate up to 13 month in 25% of cases.

Follow up results of thyroid surgery in 23777 patients has found unexpected and relevant unilateral RLN injures in 251 (1.0%) and bilateral – in 91 (0.38%) cases. Recurrent laryngeal nerves and larynges reconstruction surgery allow us to decanulate more that 75% those patients.

Postoperative bleeding (PB) and thyroid bad hematomas were found in 138 больных (0.58%) patients. The most often PB happened in initial and recurrent DTG (1.07%, 0.94%), TC (0.82%) patients. In most (65.5%) of cases PB began during the first 6 hours. In case of PB we parted wound edges anywhere, intubated repeatedly trachea, inspected wound; performed hemostasis and drained wound. Main sources of PB were inferior (40.38%) or superior (17.30%) thyroid artery. Source was not found in 13.35%. PB prevention included: careful hemostasis with control lavage of the wound; fascia covering of the thyroid bed and high pressure test,  ligation of inferior thyroid artery in doubtful cases.

Conclusion

Thyroid Surgery needs precise knowledge of skull base, neck and mediastinum anatomy, safety resection of thyroid, parathyroid, under RLN visual control, thorough hemostasis and closely postoperative watching for patients.

Endocrine Surgery. 2014;8(4):43-52
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