1. Relevance and Necessity of the Topic

The main role in the increase in the secretion of thyroid hormones in diffuse toxic goiter (DTG) is the increase of the corresponding antibody against thyroid-stimulating immunoglobulins - the thyroid-stimulating hormone receptor, the opinions of different scientists on the choice of the optimal treatment method differ significantly [6]. Antibodies specific to various components of the thyroid gland (TG) tissue are increasing in the blood of patients with DTG. Due to this, autoantibodies are present in the blood serum, and as a result of their increase, the continuation of autoimmune processes in the tissue of the central nervous system becomes stronger [1,2,3,4,5].

2. The Aim of the Scientific Research

Improving the results of diffuse toxic goiter by developing a modern diagnostic algorithm and improving surgical tactics.

3. The Materials of the Research

263 patients who underwent surgery for diffuse toxic goiter (DTG) in the III surgical department of the Y. Otabekov Clinic of the Andijan State Medical Institute from 2010 to 2019 with medical history, operative log data, and outpatient cards was also introduced. When we performed a retrospective analysis of 263 patients who were discharged from treatment, we found that 120 patients underwent ST examination, of which, the followings were determined: 76 patients had up to 1.0 grams, 30 had up to 1.1+2.0 grams, 14 had 2.1+3.0 grams of thyroid gland remained in the thyroid seat. Patients who underwent this ST operation were called group 1.

Out of 263 patients, 1.0-gram gland autograft was implanted in 65 patients after subtotal thyroidectomy. 41 of them had +1.0+2.0 grams of autograft gland tissue planted on the 1.0 grams of gland residue, 13 of them had +1.0+2.0 grams of autograft gland tissue was planted on the 1.1+2.0 grams of gland residue, 11 of them had+1.0+2.0 grams of autograft gland tissue was planted on the 2.1+3.0 grams of gland residue. We designated these patients who underwent subtotal thyroidectomy as group 2.

In the following 78 patients out of 263 patients, in addition to total thyroidectomy, the gland was isolated from under the gland by tying it with a continuous knot of silk thread, but the gland is not separated from its base. That is, up to +1.0 grams over the node (n=51), up to 1.1+2.0 grams (n=15), up to 2.1+3.0 grams (n=12), the patient was left with a continuous gland seat untouched. Group 3 (TTAP) was performed together with total thyroidectomy and leaving gland autograft.

When we divided 263 patients who underwent surgery with diffuse toxic goiter between 2010 and 2019 into women and men, 228 (86.7%) were female and 35 (13.3%) were male, with a female-to-male ratio of 7:1. Enlargement of the thyroid gland in the II degree was detected in 19 (7.2%) patients, III-level enlargement was found in 124 (47.1%) patients, IV-level enlargement - in 92 (35%) patients, V-level enlargement - in 28 (10.6%) patients. From the table, it became clear that most of the patients reported with III- and IV-level enlargement.

4. The Methods of the Research

Complaints and anamnesis of 263 patients who applied were thoroughly studied, the following examination methods were used.

Clinical objective and subjective examinations were conducted in 263 patients (vision, palpation). Instrumental examinations: ultrasound examination (USE) and electrocardiogram (ECG) were used in 263 patients. Biochemical analysis: checking the amount of "cholesterol" in blood serum was carried out in 242 patients. The amount of total calcium (Ca+) in blood serum and urine was examined in 263 patients and determination of phosphorus (R+) in 12 patients. Radioimmunological tests: T₃, T₄, TTG, anti-TPO, anti-Tg were examined in 225 patients, parathyroid hormone was examined in 3 patients. Contrast-enhanced computer tomography was performed in 36 patients to examine the front of the neck, behind the tongue, under the spine and behind the sternum. 58 patients with suspected fine needle aspiration biopsy (FNAB) were examined on an outpatient basis. Post-operative histo-pathomorphological examination was conducted in 263 patients.

5. Statistical Analysis

Student's t-criterion was used to evaluate the reliable differences of the Excel program in the WINDOWS_XP environment obtained from the controls. The comparison of the number of groups was checked according to the value of Student's criterion p<0,05, p<0,01, p<0,001.

6. Results and Discussions

The essence of the autoplantation method (group 3 - Total Thyroidectomy autoplantation - Comparison group). The concept of an autoplant is to leave the recipient's thyroid gland tissue in place with a knotted suture, leaving an intact, continuous autoplant in the gland seat. Of the 78 patients who underwent total thyroidectomy, 51 had an autoplant left over the nodule up to +1.0 grams. 15 people were left with autoplant from 1.1 grams to +2.0 grams above the knot. 2.1 to + 3.0 grams of autoplant tissue was left over the node in 12 patients. A nodule was placed under the total thyroidectomy and left above +1.0 grams, up to 1.1+2.0 grams, up to 2.1+3.0 grams, intraoperative continuous autoplantation performed total thyroidectomy (TTAP) news is considered an the fact that it is not included in the Ministry of Higher Education, Science and Innovations of the Republic of Uzbekistan and the High Attestation Commission, as well as the literature published in the scientific surgical centers of the Republic of Uzbekistan, the neighboring countries of Central Asia and the East, as well as European countries and American regions, this is research innovation was identified. This method, which is carried out in the 3rd surgical department of the ASMI Clinic, is actual, and leaving an intact continuous autograft tissue is considered a modern improvement. This serves as an improved modern method of transplantology in the surgical treatment of DTG.

This prevents the autoplant from being re-handled by hand or instrument, damaging, breaking and crushing the tissue membranes. When the tissue is overstretched, an oncotic pressure is created, which causes the gland tissue follicles to be crushed and ruptured, and mature and immature hormones that are filled inside are absorbed and leaked into the blood vessels. The veins are filled with hormones, as a result of which the organs are hypersaturated, severe complications occur in the body: thyroid tetany and crisis. With this new method, tissue microcirculation was prevented with minimal damage to the tissue. In addition, the validity is preserved. And the reason why we call it plantat is that the tissue of the gland is supplied with blood from the base to the core, and its continuity is eliminated by tying it with a knot of silk thread with a continuous connection.

The formula of the invention. It is isolated from under the gland by tying a continuous silk thread knot, but not separated from the base of the gland. That is, up to +1.0 grams, up to 1.1+2.0 grams, around 2.1+3.0 grams of intraoperative autoplant gland was left over the node and a total thyroidectomy was performed with an incision over it. Since the core of the gland is rich in blood vessels, while the fascia tissue is also rich in blood vessels, Shevkunenko's fascia was re-wrapped and sutured over the autoplant. In order to regenerate the autoplant, a knot was formed under the thyroid gland and a ligament was formed over it through the fascia. But it remains stuck with the top side attached to the fascia. Even if the autoplant is isolated for a certain time, after fixation, soon (from 1 week to 6 months) the collagen fibers in the fascia together with the blood vessels grow into the follicle-interspace of the autoplant. Collagen fibers and blood vessels penetrating the autoplant parenchyma hold the graft in place. Under the gland autoplant - over the tracheal plates, fascial collagen fibers are clamped with a knotted suture, and the tissue in between is absorbed in 7-8 days. With autoplant, the tracheal plate is isolated from each other. As a result, the autoplant is isolated from the base of the gland. During this period (1-6 months), the disconnected autoplant shrinks to a certain extent or may be completely absorbed. During this period, a large amount of T₃-T₄ hormones absorbed into the bloodstream through the thyroid tissue are synthesized and destroyed after expiration, the amount of T₃-T₄ hormones in the blood normalizes or decreases. The upper surface of some parts of the autoplant tissue that has not been absorbed is connected with the blood vessels of the wrapped fascia, that is, blood vessels grow into the autoplant parenchyma and activate the plant. Applying laser light to the plant tissue remaining on the surface of the trachea leads to reparative regeneration of gland tissue and plant. Plantat development can in some cases lead to recurrence of DTG, development and duration of severity levels and functional and morphometric tissue changes. In the postoperative period, the resorbable and non-resorbable part of the autoplant is regenerated and its function is stimulated. It compensates for the lack of thyroid hormones. That is, until the basis of the thyroid gland fully compensates the body, deficiency is prevented by this reserve. It saturates the deficient organs with calcium elements. Protects Autoplant itself from TTG stimulation.

Diffuse toxic goiter diagnostic and treatment algorithm. Currently, there are ways to improve the choice in the treatment of diffuse toxic goiter: drug therapy, surgical treatment and radioactive iodine therapy. Each of the methods has positive and negative aspects. But none of them give 100% positive results. Long-term remission with diffuse toxic goiter is noted in 45 to 70 percent of patients. The recurrence rate of thyrotoxicosis ranges from 50% to 70% in drug therapy, excluding postoperative complications, in 20-30% of patients in surgical treatment.

The priority of morphological research methods in the diagnosis of thyroid diseases is generally recognized at all stages of examination and treatment. The first approach that we observe in our study involves determining the size of the operation based on the exact shape variability of the concept of the thyroid gland. In this regard, the problem of timely and accurate morphological diagnosis of the thyroid gland is crucial in choosing the treatment method, size and characteristics. Modern methods of preoperative examination do not allow a reliable morphological diagnosis in all cases.

Thus, it is important not only to further improve the existing research methods, to evaluate their effectiveness, to select the necessary minimum amount and the sequence of their use, but also to search for new, more informative and safe methods of diagnosing the nature of thyroid nodules. Adequate size of the operation is decisive in choosing a treatment method. The priority of morphological research methods in the diagnosis of thyroid diseases is generally recognized at all stages of examination and treatment. However, the accumulated experience of using ultrasound shows that its results are partially uncertain.

The incompleteness of the method gives false positive and false negative results. Thyroid cancer can be detected preoperatively using ultrasound in only 30-70% of cases.

In a prospective multicenter study, patients in their 30s and 40s had a significantly lower risk of relapse compared to patients younger than 30 and older than 40. According to other data, target patients over 40 years of age had a 47% risk of recurrence, and patients under 20 years of age had a 76% risk of recurrence. It has been proven that men have a higher risk of DTG recurrence after a course of thyrostatic therapy than women. The probability of developing DTG remission is inversely proportional to the original size of the goiter. The size of the goiter can indirectly affect the risk of DTG recurrence in many cases. found that T3 level was an independent predictor of relapse. The T3/T4 ratio can also be considered as a predictor of relapse.

A sharp increase in the titer of T3, T4 hormones compared to HG and a sharp decrease of TT hormone compared to HG showed that the functional activity of QB is so high. The high and extremely high TPO-ab titer compared to HG indicates that these patients are likely to go into remission and go out quickly even when they are in remission, as well as relapse if total thyroidectomy is not performed in these patients.

The purpose of creating this algorithm is that there is almost no possibility of using DTG in any stationary conditions in multi-instrument equipment and devices. The reason is that one of them has hardware, but the other does not. Some reactants are present, some are not. Like the scientific research centers, they are equipped with the most modern equipment and are specialized, besides, they are not provided with specialists in their fields. And the examination methods that we use and offer, firstly, are available in many clinics and in their work, and secondly, there are opportunities to show DTG of each clinical symptom in the equipment used. Third, one is either used or forgotten without being used. Fourth, hyperdiagnosis or hypodiagnosis should not be allowed. Fifth, it is hypodiagnosed before the operation and is taken to the operation with a different diagnosis, then a different diagnosis is revealed in the histo-morphological examination. This operation will not be appropriate. Sixth, TPO-antibodies, Tg-antibodies, TTG-antibodies were included in additional tests until now, because these tests were considered as predictors of complications. In addition, no other disease has complications like DTG disease. In order to prevent postoperative complications, TPO-antibodies, Tg-antibodies and TTG-antibodies were included in the main examinations, similar to hormonal examinations. Seventh, the improved operation we have left has led to a significant reduction in complications. For this reason, it was considered advisable to introduce the algorithm. Eighth, after long-term operations, it is necessary to monitor and analyze the long-term results and control the quality of life of patients. Therefore, the diagnostic-treatment algorithm of diffuse toxic goiter: it was considered to increase the efficiency of treatment under the diagnostic improvement of retrospective results. In the first attempt, we distinguished conditional and non-conditional checking methods. Conditional: The main mandatory examination methods: Complaints, anamnesis collection, objective and subjective examinations. These are all data collected when the patient comes to apply. Next, instrumental examinations: Sonography, Doppler, Contrast MSCT, ECG, ECHOCG, Laryngoscopy. Advantages of sonography and dopplerography: Ultrasound diagnosis of the throat is one of the most modern, inexpensive and highly informative non-invasive methods of diagnosing thyroid diseases. As for the detection of focal damage of the thyroid gland, it has almost 100% sensitivity. The Doppler map is determined not by the degree of vascularization of the nodes, but by the histological structure depending on its size. Dependence on the angle of the display and the impossibility of imaging vascular structures, the diameter of small vessels limits the diagnostic possibilities of this technique. Sonographic control has also been widely used in the elimination of hyperfunctional thyroid nodules. Among the disadvantages of USE is the inability to see the retrosternal parts of the gland, the inability to distinguish between good and bad benign and malignant formations, which depends on the skill of the sonographer. The lower pole of the goiter is located behind the vertebral bone in some enlarged goiters. Therefore, it can be detected using many X-ray machines. But the quality output is less. Contrast-enhanced MSCT or MRI is recommended. An otorhinolaryngologist consultation is conducted to rule out a false vocal fold defect.

A sharp increase in the titer of T3, T4 hormones compared to HG and a sharp decrease of TT hormone compared to HG showed that the functional activity of the thyroid gland is so high. The TPO-antibody titer is sharply high and extremely high compared to HG, indicating that these patients will go into remission and quickly go out even when they go into remission, and that these patients will relapse if total thyroidectomy is not performed. A large number of Tg-antibodies motivates DTG to develop tumor disease in the future.

Cholesterol level in blood, radioisotope scan, reflectometry, exosteometry, X-ray, MRI are non-conditional examinations. These examination devices are not available in all clinics. In addition, background checks can provide similar information as these can provide.

If the nodule is small in fine needle aspiration biopsy, the fact of finding it becomes problematic. If the nodule is large, then it is impossible to give a guarantee without sonographic instructions, the biopsy is taken from the border sections of the nodule, where the cytological picture is the most informative.

Gysto-morfologik tekshiruv bu eng aniq va yakuniy 100%-li to’g’ri ma’lumot beruvchi tekshiruv xisoblanadi.

In order to know the outcome and quality of life of each treated patient, it is necessary to conduct a retrospective meta-analysis and report. Depending on the future results, a surgical technique is determined and modern treatment measures are planned.

Reasoning: The following morning complications after total thyroidectomy + autoplant: transient hypoparathyroidism showed - 1.3% patient reduction, scrotal bleeding - 1.3% patient reduction, no effect on client's HS.

Out of 78 patients operated with TTAP, the recurrence rate decreased from 4% (n=5) → 1.3% (n=1) when the gland was left up to 1.0 gram, and when the gland was left up to 2.1-3.0 gram a decrease from 3.2% (n=3) → 1.3% (n=1) was justified. From 14.4% (n=18) → 1.3% (n=1) of 2 patients with up to 1.0 grams of gland retention after TTAP, the other 1, Hypothyroidism was noted from 9.6% (n=12) → 1.3% (n=1) when 1-2.0 grams of gland was left. Hypothyroidism was not detected when the gland was left to 2.1-3.0 grams.

Recurrence and complications of hypothyroidism after operations cannot be caused by leaving the gland tissue, because the reason for this is the high functional activity of the tissue that is being left with the stump-native autotransplantation and the presence and high titer of various autoantibodies in the blood. If a gland with a high level of functional activity is left with a high level of functional activity, a stump-native intraoperative autograft is left, its function increases by two parts, and it quickly relapses. If the titer of various autoantibodies was high before the operation, this will further stimulate the functional activity.

7. Conclusions

Thus, the proposed diagnostic-treatment algorithm of diffuse toxic goiter was considered to increase the efficiency of treatment under diagnostic improvement of the retrospective results. An innovative method aimed at reducing future complications and improving the quality of life of patients with improved modern surgical treatment of diffuse toxic goiter.