hashimotosthyroiditis -qol after surgery

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-effectiveness


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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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hashimotosthyroiditis -qol after surgery

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