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8/10/2019 HashimotosThyroiditis -QoL after surgery
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Quality of life after thyroid
surgery in women with benign
euthyroid goitre: influencingfactors including Hashimotos
thyroiditis
Regina Promberger, MD, Michael Hermann MD,
Shanon Joan Pallikkunnel, MD., Rudolf Seemann,
MD./ Moritz Meusel MD, Johannes Ott, MD.
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Conducted in Medical university of Vienna, Austria
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Hashimotos thyroiditis:
Autoimmune, gender specific Decreased QoL
Presence of TPO-Ab
5% to 10% of female population of childbearing age
Thyroid surgery could hypothetically lead to an
increase in QoL, given that adequate thyroid
hormone substitution is provided
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Potential systemic effect of autoimmunity Total or near total removal
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All patients in study underwent thyroid surgery Females
To evaluate
1) QoL related outcome as a major objective
2)the change in individual symptom load as a
secondary objective in the long- term
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Methods
Primary hypothesis Health related QoL
1) would increase after thyroidectomy
2) more likely to increase in women with higher TPO-
Ab levels or histologically confirmed Hashimotosthyroiditis and after total or near total thyroidectomy
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Second study objective Complications after thyroid surgery and evaluated
possible risk factors
Prospective cohort study
Pre and postoperative symptom and SF-36
questionnaires
Data on the operation and postoperative
complications
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SF 36 Questionnaire
The lower the score the more disability. The higher thescore the less disability i.e., a score of zero is equivalentto maximum disability and a score of 100 is equivalent tono disability.
The eight sections are:
vitality physical functioning
bodily pain
general health perceptions
physical role functioning emotional role functioning
social role functioning
mental health
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Uses Evaluating individual patients health status
Researching the cost-effectivenessof a treatment
Monitoring and comparing disease burden
Limitations
The survey does not take into consideration a sleep
variable
The survey has a low response rate in the >65population[2]
http://en.wikipedia.org/wiki/Cost-effectivenesshttp://en.wikipedia.org/wiki/Cost-effectivenesshttp://en.wikipedia.org/wiki/Cost-effectivenesshttp://en.wikipedia.org/wiki/Cost-effectiveness8/10/2019 HashimotosThyroiditis -QoL after surgery
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Patient population and study design
426 patients included
Criteria:
1) women planned to undergo thyroid surgery and > 19yrs of age
Women who had TSH levels in normal range0.25 to
4.20 microunits/ml Women with PTH levels in normal range0 to 63 IU/ml
Thyroid malignancies excluded retrospectively
Patients who were willing to undergo followupinvestigations, including questionnaires > 12 mths afteroperation ( n=248) ie. 58.2%
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Patients undergone U/l and B/l thyroid operations
Subdivided into
1) total or near total
2) those with less extensive procedures
Serum levels of TSH, FT3, and FT4pre and
postop Preop TPOAb
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All patients answered 2 questionnaires on daybefore sx and at follow up exmtn
1) a symptom questionnairegeneral sx and female
health ( summarizing score)
SF-36 QoL questionnaire
Whole thyroid specimensHPE
Hashimotos thyroiditis
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Focused on weight of specimen and following postopcomplications:
1)Hypocalcemia or hypoparathyroidism
>12 mthspermanent hypoparathyroidism
2) 2ndto 4thday after operation , all patientsexamined by ENT specialist
If postop nerve injury , follow up on day 14 and after
2to 3, 6 and 12 mths. 3) post op haemorrhage
4) wound infection
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Possible risk factors for transient hypocalcemia andtransient RLN injury - age, preop TPO Ab, b/l vs u/l
thyroid surgery, presence of HT, and wt. of removed
thyroid was evaluated
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ResultsPatient characteristics
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B/l total or near total in 169 pts ( 68.1%) 79 pts ( 31.9%) b/l subtotal or unilateral procedures
HPE revealed HT in 29 pts (11.7%)
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Postop complications Transient post op RLN injury19 pts -7.7%
Transient hypocalcemia4819.4%
Postop haemorhage - 3- 1.2%
Wound infection10.4%
None had permanent RLN injury or hypocalcemia
Significant risk factors were found for transient
hypocalcemiaB/l thyroid surgery and wt. of
removed thyroid
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QoL and symptom load at long term
followup
Median 26 mths
At followup, all pts. were in need of thyroid hormone
replacement (preop 61/24824.6%)
Modules of SF36apart from significant
improvement in bodily pain, none was was
significantly increased or decreased in followup
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For presence of histologically confirmed HT,significant positive correlation ( P
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Extent of resection
Total or near totallower post op QoL levels for general health, physical functioning, role physical,
vitality, role emotional and social functioning
Transient hypocalcemianegatively influencedpostop QoL levels for physical functioning, role
physical, bodily pain, vitality, role emotional and
mental health
Transient RLNInegative influence only on physical
and social functioning
Wound infection: -ve impact on general health,
bodily pain, and vitality
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Summary score for general symptoms increasedfrom median of 4 to 5
Higher postop symptom score was significantly asso.
with higher preop symptom score and higherpreoperative TPO- Ab levels
Dysphagia- in 48/248 pts. had completely resolved in
34 of those ( 70.8%)
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Comments
Considering TPO- Ab levels before surgery
Association of HT with various organ specific and
non organ specific autoimmune diseases
Polyclonal autoimmune response against organ
specific autoantigens
Elevated TPO- Ab levels could be seen as a
surrogate parameter for altered immunity. In such
cases, removal of thyroid gland is unlikely to lead to
substantial improvement in QoL
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Summary symptom score increased by median ofonly one symptomminor clinical relevance
Higher postop symptom scoreasso. with higher
preop symptom score and TPO- Ab levels. Suggeststhat thyroid sugery is not effective in reducing
womens symptom load!!
No permanent hypocalcemia and RLNIas onlybenign euthyroid included and recurrent disease
excluded
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Wound infectionshypertrophic scars orinflammatory rearrangementnegative effect on
vitality
Complications led to high levels of distress with longlasting impact on social functiong, role emotional and
mental health
Size of removed gland and extent of resection are ofsignificant impact.
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Limitations
Only 60% of pts. Were filling for followup analysis
Only women were enrolled
Median followup of 26 mths
Only euthyroid women included
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Conclusion
Surgical intervention should not be recommended as
a treatment option for pts. With decreased QoL due
to higher TPO- Ab levels
Transient complications can have a long lastingveeffect on patients QoL
Thyroid surgery improves QoL in female patients
with histologically confirmed HT.
So, thyroidectomy to be recommended in selectedcases.
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