Multiglandular Parathyroid Disease: the Results of Surgical Treatment

Background. Sporadic multiple gland disease in primary hyperparathyroidism occurs in 7 to 33 % of cases. The absence of specific risk factors, low sensitivity of imaging methods, and low efficiency of bilateral neck exploration and intraoperative monitoring of parathyroid hormone indicate the complexity of the diagnosis and treatment of this disease’s form. Aim of the research. To analyze the results of surgical treatment of multiple lesions of the parathyroid gland in primary and secondary hyperparathyroidism. Methods. There was retrospective study, which included 100 observations of surgical treatment for primary and secondary hyperparathyroidism in the thoracic department of Irkutsk Regional Clinical Hospital from May 2018 to September 2019. The main point was to identify the frequency of surgical treatment outcomes in patients with multiple parathyroid lesions. As part of the study, potential predictors of multiple gland disease in primary hyperparathyroidism were analyzed. Results. Multiple gland disease in primary hyperparathyroidism occurs in 29 % of cases and causes persistence of the disease (p ≤ 0.01). Signs of multiple gland disease in primary hyperparathyroidism include the level of ionized calcium, parathyroid hormone (p ≤ 0.05), creatinine level and glomerular filtration rate (p ≤ 0.01). A negative result of intraoperative monitoring correlates with persistence of primary hyperparathyroidism in multiple lesions (χ2, p ≤ 0.05). Selective parathyroidectomy is associated with persistence of hyperparathyroidism in multiple lesions (χ2, p ≤ 0.05), while total parathyroidectomy is associated with remission of the disease (χ2, p ≤ 0.05). We did not find a statistically significant relationship between the results of surgical treatment for morphology of the parathyroid glands (χ2, p > 0.1). Conclusion. Multiple gland disease is the main cause of persistence of primary hyperparathyroidism. This form of the disease corresponds to lower levels of calcium, parathyroid hormone, and kidney function. Persistence factors have been established: removal of less than four parathyroid glands and a negative result of intraoperative monitoring of parathyroid hormone. Bilateral neck exploration does not reduce the incidence of disease persistence

Surgical Treatment of Secondary Hyperparathyroidism at Ectopic Parathyroid Gland in Anterior-Superior Mediastinum (Literature Review and Clinical Case)

Parathyroidectomy is the leading treatment for drug-refractory secondary and tertiary hyperparathyroidism in patients with chronic kidney disease. Difficulties in performing this surgery are mainly associated with the anatomical features of the parathyroid glands, in particular with the variability of their number and topographic anatomy. Ectopic parathyroid glands are one of the most common causes of persistence or recurrence of secondary hyperparathyroidism after surgery. One of the common variants of ectopia is the localization of the parathyroid gland in the anterior-superior mediastinum. The article discusses the features of surgical treatment of secondary hyperparathyroidism in patients with end-stage chronic kidney disease with this ectopia. A new method of treating hyperparathyroidism in patients with an atypical location of the parathyroid gland in the anterior-superior mediastinum is presented. This method is characterized by low invasiveness of access, ease of implementation without using special equipment and instruments. The proposed method was used in the treatment of a patient with secondary hyperparathyroidism due to chronic renal failure as a result of chronic glomerulonephritis. The duration of hemodialysis at the time of the surgery was more than 17 years. In the presented clinical case, ectopia of one of the pathologically altered parathyroid glands in the anterior-superior mediastinum was found at the preoperative stage. As a method of surgical treatment, we carried out total parathyroidectomy with autotransplantation of a fragment of parathyroid tissue into the brachioradialis muscle. Thanks to this method, it was possible to remove the atypically located parathyroid gland from the cervicotomy access and to discharge the patient within the standard terms for a given volume of surgery

Нормативная база обеспечения безопасной эксплуатации железнодорожной техники по ресурсу несущих конструкций

Switching the operation of railway equipment to life cycle contracts and confirming its safety compliance with industry technical regulations in the absence of a legislative framework for the recall of substandard products entails the need for a more thorough analysis of resource indicators of structural components of rolling stock and track superstructure. From this point of view, the state of the existing regulatory framework for confirming the strength and service life criteria of load­bearing elements of rolling stock and track, the influence of the regulatory «guillotine» and the general transition from the system of Soviet state standards GOSTs and strength rules to modern approaches of certification and differentiation of such concepts as «standard» and «supporting standard».Trends in moving away from classical bench testing methods towards introduction of a resource-based approach with defectiveness assessment are shown using examples of previously carried out research on safe operation of ER200 bogie frame and on the transition to domestic cassette bearings as part of import substitution, currently carried out for different types of rolling stock.Based on the new methods and approaches, it is possible to consider longer periods of operation, reasonably assess the extension of service life, or introduce resource-restoring technology, ensuring further safe operation. As part of these new trends, a transition is being made to modern modelling methods for assessing product safety, concepts such as «virtual sensor» and «virtual train-track system» are being introduced. It is shown that a reasonable combination of full-scale operational tests and virtual digital modelling makes it possible to offer reliable estimates of service life and safety indicators at the design and operation stages in a short time.Перевод эксплуатации железнодорожной техники на договоры жизненного цикла и подтверждение соответствия её безопасности отраслевым техническим регламентам в условиях отсутствия законодательной базы по отзыву недоброкачественной продукции влекут за собой необходимость более тщательного анализа ресурсных показателей конструктивных составляющих подвижного состава и верхнего строения пути. Под таким углом зрения рассмотрены состояние имеющейся нормативной базы подтверждения критериев прочности и ресурса несущих элементов подвижного состава и пути, влияние регуляторной «гильотины» и общий переход от системы советских ГОСТов и норм прочности к современным подходам к сертификации и разделению таких понятий, как «стандарт» и «поддерживающий стандарт».На примерах проводимых ранее работ по обеспечению безопасности эксплуатации рамы тележки ЭР200 и работ по переходу на отечественные кассетные подшипники в рамках импортозамещения, проводимых в настоящее время для разных типов подвижного состава, показаны тенденции отхода от классических методов стендовых испытаний, внедрение ресурсного подхода с оценкой дефектности.Основываясь на этих новых методах и подходах, возможно рассматривать более длительные периоды эксплуатации, обоснованно давать оценку продлению срока службы или назначать ресурсовосстанавливающую технологию, обеспечивая дальнейшую безопасную эксплуатацию. В рамках этих новых тенденций осуществляется переход к современным методам моделирования оценки безопасности продукции, внедряются такие понятия, как «виртуальный датчик» и «виртуальная система «поезд – путь». Показано, что разумное сочетание натурных эксплуатационных испытаний и виртуального цифрового моделирования позволяют в сжатые сроки дать достоверные оценки показателей ресурса и безопасности на стадиях проектирования и эксплуатации

Experience of surgical treatment of secondary hyperparathyroidism

Surgical treatment of secondary hyperparathyroidism (HPT) in patients having renal replacement therapy (RRT) is a current problem. The aim of our study was to optimize the treatment of secondary HPT based on the comparative analysis of effectiveness of the surgeries with different extents. We conducted a retrospective analysis of the results of surgical treatment of uremic HPT in 34 patients. 36 surgeries were performed including 34 primary (16 subtotal parathyroidecomies (PTE), 13 total parathyroidecomies (total PTE 1), 5 total parathyroidecomies with central neck dissection and resection of superior mediastinum and superior thymus horns (total PTE II)) and 2 repeated surgeries (total PTE 11 and parathyroidadenomectomy). Gross examination of 134 surgical specimens revealed dyssynchronous pathological changes in parathyroid glands (PTG), normal PTG structure was found in 2 cases. Recurrent HPT was found in 3 cases, persistent HPT - in 9 cases, hypoparathyroidism - in 5 cases after subtotal PTE and in 9 cases after total PTE with autotransplantation (p = 0,267). Target values of parathyroid hormone were registered in 8 patients, including 4 patients after subtotal PTE and 4 patients after total PTE (p > 0,95). Morbidity was similar in all types of surgeries (p > 0,5). Analysis of morbidity determined that simultaneous surgery of thyroid gland increased the risk of laryngeal paralysis (р = 0,028). The decrease in occurrence of secondary HPT persistence (with the source accessible for removal through cervical approach) at total PTE based on the removal of parathyroid glands of all localizations accessible through cervical approach (including thyroid gland lobes with diagnosed ectopia, central cervical fat pad, superior mediastinum and superior thymus horns) was registered (NNT = 4)

EXPERIENCE OF SURGICAL TREATMENT OF THYROID AND PARATHYROID DISEASES

Background. In our country some aspects of thyroid and parathyroid surgery are still discussed. Aim. To present our experience in surgical treatment of benign diseases of the thyroid and parathyroid glands. Materials and methods. A retrospective analysis of the results of surgical treatment of 1511 patients with thyroid and parathyroid disease was performed. Results. Thyroidectomy was performed in 73.6 % of cases with thyroid diseases. The frequency of postoperative complications: laryngeal paresis - 1.37 %, hypoparathyroidism - 0.84 %, hemorrhagic complications - 1.2 %. Selective parathyroidectomy was performed in 99 % of cases with primary hyperparathyroidism. Persistent hypoparathyroidism and laryngeal paresis have not been identified. Total parathyroidectomy with central neck dissection, upper mediastinum and upper horn of the thymus gland was performed in 66.3 % of cases with secondary hyperparathyroidism. Persistent laryngeal paresis was established in 3.3 % of cases, hemorrhagic complications - in 3.3 %. Conclusions. Constant analysis of our own results gives us reasons for our own attitude to the controversial issues of thyroid and parathyroid surgery. Presently, we prefer thyroidectomy in the treatment of diffuse toxic goiter and multinodular goiter, hemithyroidectomy - for the single-node goiter. In the surgical treatment of primary and uremic hyperparathyroidism, we consider mandatory the use of intraoperative monitoring of intact parathyroid hormone. When performing total parathyroidectomy, we perform the autotransplantation of the fragment of the parathyroid gland

EXPERIENCE OF SURGICAL TREATMENT OF THYROID AND PARATHYROID DISEASES

Background. In our country some aspects of thyroid and parathyroid surgery are still discussed. Aim. To present our experience in surgical treatment of benign diseases of the thyroid and parathyroid glands. Materials and methods. A retrospective analysis of the results of surgical treatment of 1511 patients with thyroid and parathyroid disease was performed. Results. Thyroidectomy was performed in 73.6 % of cases with thyroid diseases. The frequency of postoperative complications: laryngeal paresis -1.37 %, hypoparathyroidism - 0.84 %, hemorrhagic complications -1.2 %. Selective parathyroidectomy was performed in 99 % of cases with primary hyperparathyroidism. Persistent hypoparathyroidism and laryngeal paresis have not been identified. Total parathyroidectomy with central neck dissection, upper mediastinum and upper horn of the thymus gland was performed in 66.3 % of cases with secondary hyperparathyroidism. Persistent laryngeal paresis was established in 3.3 % of cases, hemorrhagic complications - in 3.3 %. Conclusions. Constant analysis of our own results gives us reasons for our own attitude to the controversial issues of thyroid and parathyroid surgery. Presently, we prefer thyroidectomy in the treatment of diffuse toxic goiter and multinodular goiter, hemithyroidectomy - for the single-node goiter. In the surgical treatment of primary and uremic hyperparathyroidism, we consider mandatory the use of intraoperative monitoring of intact parathyroid hormone. When performing total parathyroidectomy, we perform the autotransplantation of the fragment of the parathyroid gland

Assessment of microbial contamination of tracheobronchial tree in patients with cicatrical stenosis of trachea

Cicatricial tracheal stenosis is an urgent matter in thoracic surgery and otolaryngology. The main causes of cicatricial stenosis of the trachea is orotracheal intubation, tracheostomy and neck injuries with damage to the trachea. One of the factors that complicate this disease course is addition of nosocomial infection. We conducted a retrospective study of medical records of 33 patients treated in the thoracic surgery department of Irkutsk Regional Clinical Hospital diagnosed with cicatricial stenosis of trachea for the period from 2011 to 2013. 75 % of patients with cicatricial stenosis of trachea were men of working age up to 50 years old. We evaluated the results of bacteriological examination of detachable tracheobronchial tree. The bacteriological examination of the patients with cicatricial stenosis of trachea often exhibited hospital microflora in the form of Pseudomonas aeruginosa, Streptococcus viridans, Staphylococcus aureus. Associations of microorganisms represent this microflora in 84.4 %. During the antibiotic sensitivity examination, the low effectiveness of commonly used antimicrobials was revealed. The choices in treatment of the patients with cicatricial stenosis of trachea are: colistin, polimeksin, imipenem, meropenem, vancomycin, sulperazon. These results indicate that microbiological monitoring is necessary to detect major pathogens and their antibiotic resistance level at cicatricial stenosis of the trachea

АНАЛИЗ НАПРЯЖЕННО-ДЕФОРМИРОВАННЫХ И ПРЕДЕЛЬНЫХ СОСТОЯНИЙ В ЭКСТРЕМАЛЬНО НАГРУЖЕННЫХ ЗОНАХ МАШИН И КОНСТРУКЦИЙ

The basis for the analysis of such characteristics as strength, lifeendurance and safety of machine elements and structures in  standard and emergency situations are the equations and criteria for linear and nonlinear mechanics of deformation and fracture. They are a part of the strength standards and are used both in the design  and in the manufacture and operation of equipment. The article  shows that the results of strength, resource and survivability studies  are the basic component to create the foundations of the  catastrophes and risks mechanics in the technogenic sphere, new  principles, technologies and technical complexes that ensure their safe operation and let in a theoretically grounded manner  prevent the appearance of emergency and catastrophic situations,  and minimize possible damage when they occur. At the same time, the instrument for ensuring safe working conditions is to diagnose  the current parameters of the material state and to determine the  characteristics of stress-strain states in the most stressed zones of  the analyzed technical system. The solution of the problem of  strength and resource evaluation in such conditions includes the  creation of generalized mathematical and physical models of  complex technological, working and emergency processes in  technical systems for analyzing the transition conditions from regular states to the conditions of occurrence and development of accidents and catastrophes. Such models are characterized by a multilevel  structure that affects global, local and object security aspects. The  developments are interdisciplinary in nature and underlie the safety and risks rationing.Основой анализа характеристик прочности, ресурса живучести и безопасности элементов  машин и конструкций в штатных и аварийных ситуациях являются уравнения и критерии  линейной и нелинейной механики деформирования и разрушения. Они входят в нормы  прочности и используются как при проектировании, так при изготовлении и эксплуатации  оборудования. В статье показано, что результаты исследований прочности, ресурса и  живучести являются базовой составляющей создания основ механики катастроф и рисков в  техногенной сфере, новых принципов, технологий и технических комплексов, обеспечивающих их безопасную эксплуатацию и позволяющих научно обоснованно  предотвращать возникновение аварийных и катастрофических ситуаций, а также  минимизировать возможные ущербы при их возникновении. При этом инструментом  обеспечения условий безопасной работы является диагностика текущих параметров  состояния материала и определение характеристик напряженно-деформированных состояний в наиболее нагруженных зонах анализируемой технической системы. Решение  задачи оценки прочности и ресурса в подобных условиях включает в себя создание обобщенных математических и физических моделей сложных технологических, рабочих и  аварийных процессов в технических системах для анализа условий перехода от штатных состояний к условиям возникновения и развития аварий и катастроф. Такие модели  характеризуются многоуровневой структурой, затрагивающей глобальные, локальные и  объектовые аспекты безопасности. Эти разработки имеют междисциплинарный характер и  лежат в основе нормирования безопасности и рисков

ASSESSMENT OF INDICES OF NONSPECIFIC RESISTANCE OF THE ORGANISM IN CONDITIONS OF NARROWING OF THE LUMEN OF THE TRACHEA IN AN EXPERIMENT

The narrowing of the lumen of the trachea due to cicatricial stenoses of the trachea is one of the urgent problems of the modern surgery.  The processes taking place in the trachea and lungs lead to a change in the state of the immune system. Assessment of the dynamics of  indices of nonspecific resistance is one of the methods for assessing  the severity of the course of the disease. We studied the indices of  nonspecific resistance of the organism in narrowing the lumen of the  trachea in an experiment in the early postoperative period.  The study was carried out on the basis of the scientific department  of experimental surgery with the vivarium of Irkutsk Scientific  Centre of Surgery and Traumatology, on 24 white male Wistar rats  with a body weight of 300–350 g. We simulated narrowing the lumen of the trachea by placing a silicone tube in the lumen of the trachea  for 14 days. The parameters of phagocytosis, the state of phagocytic activity of blood neutrophils, spontaneous NBT-test, induced NBT- test were studied. The animals were withdrawn from the experiment  on the 3rd, 7th and 14th day. We revealed that as a result of  narrowing of the lumen of the trachea with the original procedure,  the nonspecific resistance of the organism was violated with  inhibition of the phagocytic activity of leukocytes. There was  inhibition of phagocytic activity of leukocytes and depletion of the  functional reserve of leukocytes

Results of surgical treatment of uremic hyperparathyroidism (analysis 67 observations)

The analysis of the results of surgical treatment of hyperparathyroidism in 63 patients on dialysis replacement renal therapy is presented. A total of 63 primary and 4 secondary (for recurrence) surgical interventions were performed including 12 (17.9 %) - subtotal parathyroidectomy, 8 (11.9 %) - total parathyroidectomy with autotransplantation (type I), 43 (64.2 %) - total parathyroidectomy with removal of the central cellular tissue of the neck, the superior mediastinum and upper horns of the thymus gland with autotransplantation (type II); 3 (4.5 %) - secondary total parathyroidectomy type II and 1 (1.5 %) - secondary parathyroid adenomectomy. With the use of intraoperative monitoring of intact parathyroid hormone, 15 (22.4 %) operations were performed. In the postoperative period from 1 to 134 months, the patients had a decrease in blood levels of calcium, phosphorus and intact parathyroid hormone. Postoperative hypoparathyroidism was detected in 38 cases (56.7 %) of 67 observations: in 5 cases after subtotal parathyroidectomy, 5 - after total parathyroidectomy type I, and 28 - after total parathyroidectomy type II. The permissible level of parathyroid hormone was reached in 13 (19.4 %) cases: 1 - after subtotal parathyroidectomy, 11 - after total parathyroidectomy type II and 1 - after parathyroid adenomectomy. Persistence and relapse of the disease were revealed in 16 observations: 6 - after subtotal parathyroidectomy, 3 - after total parathyroidectomy type I and 7 - after total parathyroidectomy type II. When using intraoperative monitoring of intact parathyroid hormone, there are: 1 observation with the development of the persistence of the disease, 3 - with the permissible level of parathyroid hormone and in 13 cases - with the development of hypoparathyroidism. Based on the results of a comparative analysis of the results of surgical intervention, depending on the type of operation, total type II parathyroidectomy is justified for the prevention of the development of persistence and recurrent HTT (p = 0.01)