1
|
Obadiel YA, Al-Shehari M, Algmaly Y, Al-Jammra B, Kahtan I, Tashan N, Ahmed F. Surgical Management and Predictors of Postoperative Complications of Retrosternal Goiters: A Retrospective Study. Cureus 2024; 16:e56573. [PMID: 38646310 PMCID: PMC11031130 DOI: 10.7759/cureus.56573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND The preferred standard treatment for retrosternal goiter (RSG), a slow-growing, often benign tumor, remains thyroidectomy. An alternative strategy may be required when the goiter is intrathoracic. Data on the results of RSG procedures are rarely reported. Careful patient selection and assessment are critical to avoiding an unexpected sternotomy during surgery and postoperative complications. This study aims to examine the clinical findings and treatment outcomes of RSG and to identify the variables affecting postoperative complications in a resource-limited setting. METHOD A retrospective study was conducted at Al-Thawra Modern General Hospital in Sana'a, Yemen, on 69 patients diagnosed with RSG and undergoing thyroidectomy between April 2019 and February 2023. Initial clinical characteristics, radiological and laboratory findings, treatment approach, and outcome were collected from the patient's medical profile and analyzed. To determine the variables influencing postoperative complications, a bivariate analysis was carried out. RESULTS The mean age was 51.0 ± 13.6 years, and 45 (65.2%) were female. The most commonly reported symptoms were palpable masses (66; 95.7%), difficulty breathing (45; 65.2%), and neck discomfort (20; 29.0%), with 7 (10.1%) patients being asymptomatic. Previous thyroid surgery was reported in 10 (14.5%) cases. According to the grading classification, grade 1 was the most prevalent (42; 60.9%). Total thyroidectomy was the predominant surgical procedure in 59 (85.5%) cases. Using a cervical approach, all patients underwent thyroidectomy, and a sternotomy was required in one case. Histopathological analysis revealed benign multinodular goiter in 79.7%, followed by papillary thyroid cancer in 10.1% and thyroiditis in 6.7%. The postoperative complication occurred in 22 (31.9%), and the most common complication was transient hypocalcemia (11, 15.9%). There was no mortality during or after the surgery. In bivariate analysis, advanced age, difficulty swallowing, tracheal deviation, large RSG mass, advanced RSG grade, previous surgery, and malignant histopathology were associated with postoperative complications and were statistically significant (all p<0.05). CONCLUSION RSG is a rare disease that may require challenging surgical intervention. In this study, the cervical approach was the most practical and least intrusive surgical method. In addition, postoperative complications were associated with advanced age, difficulty swallowing, tracheal deviation, large RSG mass, advanced RSG grade, previous surgery, and malignant histopathology. Low postoperative complication rates can be achieved by understanding the surgical architecture of the neck, essential clinical RSG presentation, thyroid pathology, and necessary surgical treatment.
Collapse
Affiliation(s)
- Yasser A Obadiel
- General Surgery, Al-Thawra Modern General Hospital, Sana'a, YEM
- General Surgery, Faculty of Medicine and Health, Sana'a University, Sana'a, YEM
| | - Mohammed Al-Shehari
- Surgery, Al-Thawra Modern General Hospital, Sana'a, YEM
- Surgery, Faculty of Medicine and Health, Sana'a University, Sana'a, YEM
| | - Yaseen Algmaly
- Surgery, Faculty of Medicine and Health, Sana'a University, Sana'a, YEM
| | - Bilquis Al-Jammra
- Surgery, Al-Kuwait University Hospital, Sana'a, YEM
- Surgery, Al-Thawra Modern General Hospital, Sana'a, YEM
| | - Iman Kahtan
- Surgery, Al-Kuwait University Hospital, Sana'a, YEM
- Surgery, Al-Thawra Modern General Hospital, Sana'a, YEM
| | - Nashwan Tashan
- Surgery, Faculty of Medicine and Health, Sana'a University, Sana'a, YEM
- Surgery, Al-Thawra Modern General Hospital, Sana'a, YEM
| | | |
Collapse
|
2
|
Khan NS, Zhang Y, Bollig K, Bollig CA. Extracervical Approaches to Substernal Thyroid Goiter Resection: A Systematic Review and Meta-Analysis. OTO Open 2024; 8:e103. [PMID: 38223493 PMCID: PMC10782218 DOI: 10.1002/oto2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/14/2023] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Objective To evaluate the prevalence of extracervical approaches (ECAs) for substernal goiter (SSG) excision. Data Sources Search strategies created in collaboration with a medical librarian were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to July 2021. Review Methods Participants included adults ages >18 years undergoing SSG excision. The primary outcome was rate of ECA via sternotomy or thoracotomy. Studies were categorized into the 3 most common distinct definitions: goiter descending below the plane of the thoracic inlet (definition 1), ≥50% of thyroid mass extending below the sternal notch (definition 2), and goiter extending ≥3 cm below the suprasternal notch when the neck is hyperextended (definition 3). Two reviewers independently extracted data for analysis and performed a quality assessment using the Methodological Index for Non-Randomized Studies criteria. Results Of the 551 studies identified, 69 studies were included for analysis. Definition 1 included 3441 patients from 31 studies; definition 2 included 2957 patients from 26 studies; and definition 3 included 2921 patients from 12 studies. A random-effect model estimating the pooled prevalence of ECA using definition 1 resulted in prevalence of 6.12% (95% confidence interval: 3.48-9.34, I 2 = 90.72%). Conclusion Extension below the thoracic inlet is the most widely used definition of SSG. Approximately 6% of patients with a SSG undergo an ECA. Patients with SSG undergoing surgery should be counseled on the prevalence, risks, and morbidity of an ECA in the rare occurrence it is needed.
Collapse
Affiliation(s)
- Najm S. Khan
- Department of Otolaryngology–Head and Neck SurgeryRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Yingting Zhang
- Robert Wood Johnson Library of the Health SciencesNew BrunswickNew JerseyUSA
| | - Kassie Bollig
- Department of Obstetrics and GynecologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Craig A. Bollig
- Department of Otolaryngology–Head and Neck SurgeryRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| |
Collapse
|
3
|
Ghabisha SA, Ahmed F, Al-Wageeh S, Alyhari Q, Badheeb MA, Altam A, Alsharif A. Management of Retrosternal Goiter in Resource-Limited Settings: Outcomes From 28 Cases Using Cervical Approach. Cureus 2023; 15:e41288. [PMID: 37539408 PMCID: PMC10395659 DOI: 10.7759/cureus.41288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/05/2023] Open
Abstract
Background Despite thyroidectomy being the preferred approach for retrosternal goiter (RSG), controversies surround its rationale in asymptomatic cases. This study aimed to investigate the treatment of RSG in resource-limited settings. Methods A retrospective study conducted between April 2010 and June 2022 included 28 RSG cases who underwent thyroidectomy using the cervical approach at Al-Nasar Hospital, Ibb, Yemen. A bivariate analysis was performed to investigate the risk factors for postoperative complications. Results The main age was 49.4±9.9 years, and most of them (60.7%) were females. The main symptoms were cervical mass appearance and breathing difficulty in 75 %, and 32.1%, respectively. Twenty-four (86%) cases were classified as Grade 1 (above aortic arch) and four (14%) cases were classified as Grade 2 (aortic arch to the pericardium). All patients underwent total thyroidectomy through the cervical approach without needing sternotomy. The mean operative time was 121.9±26.7min (99-200 min) and the mean intraoperative bleeding was 321.2±137.4 mL. Postoperatively, the malignant entity was histopathologically proven in seven patients (25%). The postoperative complications (14%) were transient hypocalcemia in two (7.1%) and hematoma in two (7.1%). Older age, bigger thyroid mass, extension below the aortic arch (Grade 2), longer operative time and bleeding, intensive care unit admission, and malignant features are associated with postoperative complications (all p < 0.05). Conclusion Cervical approach for patients with RSG in our experience is an optimum, feasible, and less invasive surgical approach, in a resource-limited setting. Older age, bigger thyroid, extension below the aortic arch, longer operative time and bleeding, intensive care unit admission, and malignant features are associated with postoperative complications.
Collapse
Affiliation(s)
- Saif A Ghabisha
- Department of General Surgery, School of Medicine, Ibb University of Medical Science, Ibb, YEM
| | | | - Saleh Al-Wageeh
- Department of General Surgery, School of Medicine, Ibb University of Medical Science, Ibb, YEM
| | - Qasem Alyhari
- Department of General Surgery, School of Medicine, Ibb University of Medical Science, Ibb, YEM
| | | | | | - Afaf Alsharif
- Department of Gynecology, Jeblah University for Medical and Health Sciences, Ibb, YEM
| |
Collapse
|
4
|
Linhares SM, Scola WH, Remer LF, Farrá JC, Lew JI. Morbidity Associated With Surgical Removal of Substernal Thyroid Goiters. J Surg Res 2022; 277:254-260. [DOI: 10.1016/j.jss.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/09/2022] [Accepted: 04/08/2022] [Indexed: 11/16/2022]
|
5
|
Phillips A, Calcott S, Rahmani MJH. Out of sight, out of mind: retrosternal goitre as a rare cause of breathlessness. Br J Hosp Med (Lond) 2022; 83:1. [DOI: 10.12968/hmed.2021.0628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alexandra Phillips
- Department of Health and Aging, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, East Sussex, UK
| | - Samuel Calcott
- Department of Health and Aging, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, East Sussex, UK
| | - Muhammad JH Rahmani
- Department of Health and Aging, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, East Sussex, UK
| |
Collapse
|
6
|
Kardi A, Oueslati I, Yazidi M, Sadok Boudaya M, Znaidi N, Chihaoui M. Hyperthyroidism secondary to a primary mediastinal goiter with normal functional cervical thyroid gland. Clin Case Rep 2021; 9:e05167. [PMID: 34917377 PMCID: PMC8645173 DOI: 10.1002/ccr3.5167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/18/2021] [Accepted: 11/19/2021] [Indexed: 11/18/2022] Open
Abstract
Primary mediastinal goiter is extremely uncommon. The majority of primary mediastinal goiters were reported as incidental findings on chest imaging of asymptomatic patients. Symptoms related to compression of adjacent structures or hyperthyroidism were rarely described. Herein we report a case of hyperthyroidism secondary to a primary mediastinal goiter.
Collapse
Affiliation(s)
- Asma Kardi
- Department of EndocrinologyFaculty of MedicineLa Rabta University HospitalUniversity of Tunis‐El ManarTunisTunisia
| | - Ibtissem Oueslati
- Department of EndocrinologyFaculty of MedicineLa Rabta University HospitalUniversity of Tunis‐El ManarTunisTunisia
| | - Meriem Yazidi
- Department of EndocrinologyFaculty of MedicineLa Rabta University HospitalUniversity of Tunis‐El ManarTunisTunisia
| | - Mohamed Sadok Boudaya
- Department of SurgeryFaculty of MedicineCharles Nicolle University HospitalUniversity of Tunis‐El ManarTunisTunisia
| | - Nadia Znaidi
- Laboratory of PathologyFaculty of MedicineCharles Nicolle University HospitalUniversity of Tunis‐El ManarTunisTunisia
| | - Melika Chihaoui
- Department of EndocrinologyFaculty of MedicineLa Rabta University HospitalUniversity of Tunis‐El ManarTunisTunisia
| |
Collapse
|
7
|
Panchangam RB, Mayilvaganan S. Mediastinal Videothoracoscopic Parathyroidectomy for Primary Sporadic Hyperparathyroidism—a Case Series Analysis. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02577-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
8
|
Van Slycke S, Simons AS, Van Den Heede K, Van Crombrugge P, Tournoy K, Simons P, Vermeersch H, Brusselaers N. Combined cervicosternotomy and cervicotomy for true retrosternal goiters: a surgical cohort study. Updates Surg 2021; 73:1-10. [PMID: 33779950 PMCID: PMC8397680 DOI: 10.1007/s13304-021-01027-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022]
Abstract
Objective Intrathoracic goiters are a heterogeneous group characterized by limited or extensive substernal extension. Whereas the former can be treated through cervicotomy, the latter sometimes requires a cervicosternotomy. Whether cervicosternotomy leads to more morbidity remains unclear. This study aimed to compare intra- and postoperative morbidity in patients treated by cervicotomy or cervicosternotomy for intrathoracic goiters and standard thyroidectomy. Methods In a prospectively gathered cohort undergoing thyroid surgery (2010–2019) intra- and postoperative morbidity of cervicotomy (N = 80) and cervicosternotomy (N = 15) for intrathoracic goiters was compared to each other and to a ‘standard’ thyroidectomy (N = 1500). Results An intrathoracic extension prior to surgery was found in 95 (6%) of all thyroidectomies. Eighty patients (84%) were operated by cervicotomy and 15 (16%) by cervicosternotomy. The risk of temporary recurrent laryngeal nerve palsy was much higher in the cervicosternotomy group (21%) compared to cervicotomy (4%) and standard thyroidectomy (3%). The risk of temporary hypocalcemia after cervicotomy (28%) was comparable to a standard thyroidectomy (32%) but higher after cervicosternotomy (20%). No cases of permanent hypocalcemia or laryngeal nerve palsy were observed in both groups with substernal extension. The need for surgical reintervention was significantly higher in the cervicotomy group (6%) compared to cervicosternotomy (0%) and standard thyroidectomy (3%). Conclusion In patients undergoing thyroid surgery for an intrathoracic goiter, cervicosternotomy was associated with more temporary laryngeal nerve palsy, but none of the interventions resulted in higher risks of permanent nerve damage, permanent hypocalcemia, or reintervention for bleeding. Reintervention was even more common after cervicotomy compared to cervicosternotomy. Level of evidence IV Supplementary Information The online version contains supplementary material available at 10.1007/s13304-021-01027-1.
Collapse
Affiliation(s)
- S Van Slycke
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Moorselbaan 164, 9300, Aalst, Belgium.,Department of Head and Skin, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Department of General Surgery, AZ Damiaan, Gouwelozestraat 100, 8400, Ostend, Belgium
| | - A-S Simons
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Moorselbaan 164, 9300, Aalst, Belgium.,Group of Biomedical Sciences, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - K Van Den Heede
- Department of General and Endocrine Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Moorselbaan 164, 9300, Aalst, Belgium
| | - P Van Crombrugge
- Department of Endocrinology, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Moorselbaan 164, 9300, Aalst, Belgium
| | - K Tournoy
- Department of Pneumology, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Moorselbaan 164, 9300, Aalst, Belgium.,Department of Internal Medicine and Paediatrics, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - P Simons
- Department of Radiology, Onze-Lieve-Vrouw (OLV) Hospital Aalst, Moorselbaan 164, 9300, Aalst, Belgium
| | - H Vermeersch
- Department of Head and Skin, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Plastic and Reconstructive Surgery, Department of Human Structure and Repair, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - N Brusselaers
- Department of Head and Skin, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Department of Microbiology, Tumour and Cell Biology, Centre for Translational Microbiome Research, Karolinska Institutet, Karolinska Hospital, Tomtebodavagen 16, 17165, Stockholm, Sweden. .,Global Health Institute, Antwerp University, Campus Drie Eiken, Gouverneur Kinsbergencentrum, Doornstraat 331, 2610, Wilrijk, Belgium.
| |
Collapse
|
9
|
Perincek G, Avci S, Celtikci P. Retrosternal Goiter: A couple of classification methods with computed tomograpy findings. Pak J Med Sci 2018; 34:1494-1497. [PMID: 30559810 PMCID: PMC6290211 DOI: 10.12669/pjms.346.15932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: The retrosternal goiter (RSG), which can be defined by different classification and its incidence between 2% and 26% of all thyroidectomized patients, is a thyroid gland disease. Our aim was to classify RSG cases with a couple of different ways, which we have detected in computed tomography (CT) imaging of the thorax. Methods: In this retrospective study conducted at Kars Harakani State Hospital Pulmonary Medicine Polyclinic between June 2014 and June 2017 in which 176 patients were included. The age, sex, diagnostic codes, retrosternal extension of the thyroid gland (aortic upper arch, aortic reaching arch and aortic inferior arch), extension type (prevascular, paratracheal retrovascular and retrotracheal), extension amount (mm) (<50% and 50%<) of thyroid gland of the patients were assessed. Results: About 56.25% (n=99) were female and the mean age was 65.9±11.4 years. The most common co-morbid disease in patients with RSG was Chronic Obstructive Pulmonary Disease (COPD) (52.3%). Thirty nine (22.2%) of the patients had associated nodule, 16 (9.1%) had accompanying tracheal pressure and one patient had nodule and tracheal pressure. 27.3% of the patients’ gland’s right lobe and 28.9% of the patients’ left lobe were extended >50% below the thoracic entry. Left thyroid gland’s (90.3%) retrosternal extension and aortic arch spread (91.2%) were more. When classified according to the trachea, the left lobe’s paratracheal and retrovascular extension (50.9%) was more. Extension amounts were similar for both thyroid lobes. Conclusion: In patients who have retrosternal goiter, goiter spread can be defined with multiple classification with thorax CT.
Collapse
Affiliation(s)
- Gokhan Perincek
- Dr. Gokhan Perincek, Department of Pulmonology, Kars Harakani State Hospital, Kars, Turkey
| | - Sema Avci
- Dr. Sema Avci, Department of Emergency Medicine, Sabuncuoglu Serefeddin Research and Training Hospital, Amasya, Turkey
| | - Pinar Celtikci
- Dr. Pinar Celtikci, Department of Radiology, Kars Harakani State Hospital, Kars, Turkey
| |
Collapse
|
10
|
Doulaptsi M, Karatzanis A, Prokopakis E, Velegrakis S, Loutsidi A, Trachalaki A, Velegrakis G. Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters. Auris Nasus Larynx 2018; 46:246-251. [PMID: 30055961 DOI: 10.1016/j.anl.2018.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 05/24/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Descending goiter has been a focus of controversy in thyroid surgery until nowadays. This study aims to investigate the diagnosis and treatment options of thyroid goiters extending into the mediastinum and the thoracic cavity. METHODS AND MATERIALS A retrospective study was conducted assessing all cases of substernal goiter managed in a tertiary care referral center within 22 years. Demographics, clinical, operative, anatomical, and pathological data of the patients were recorded and analyzed. RESULTS Among 3.028 total thyroidectomies, 212 procedures for substernal goiters were studied. All cases underwent total thyroidectomy. The surgical approach was cervical in all but two cases. A very low rate of complications and zero mortality were noted. Incidence of malignancy on permanent histology was 16%. CONCLUSION Descending goiter constitutes a major indication for thyroid surgery. The overwhelming majority of descending goiters may be managed surgically through a neck incision. In experienced hands good results with low morbidity should be expected. Such cases should be considered as challenging, however, and therefore management in a referral center may be necessary in order to ensure optimal results.
Collapse
Affiliation(s)
- Maria Doulaptsi
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece.
| | - Alexandros Karatzanis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Emmanuel Prokopakis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Stylianos Velegrakis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Alexia Loutsidi
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Athina Trachalaki
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - George Velegrakis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| |
Collapse
|
11
|
Aghajanzadeh M, Asgary MR, Mohammadi F, Darvishi H, Safarpour Y. An investigation into symptoms, diagnosis, treatment, and treatment complications in patients with retrosternal goiter. J Family Med Prim Care 2018; 7:224-229. [PMID: 29915764 PMCID: PMC5958574 DOI: 10.4103/jfmpc.jfmpc_286_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction: Retrosternal goiter refers to any thyroid enlargement in which over 50% of the thyroid permanently located under the thoracic inlet or the lower pole of thyroid is not palpable with the neck in hyperextended position. Due to the increasing number of surgical procedures of retrosternal goiter, the present study was carried out to examine the symptoms, diagnosis, treatment, and treatment complications in retrosternal goiter patients. Materials and Methods: Data related to demographic data (age and gender), clinical symptoms (dyspnea, dysphagia, dysphonia, lumps in neck, and hoarseness), methods of diagnosis (computed tomography [CT], chest X-ray [CXR], ultrasonography, and magnetic resonance imaging), and postoperative complications (bleeding, early and late dysphonia, early and late dyspnea, transient and permanent hypocalcemia, transient, and permanent recurrent laryngeal nerve paralysis) were collected. Results: According to the results 71.4% of patients were women and most of the participants (67.1%) aged 45–60 years. Mass in the neck was the most frequent symptoms before surgery (88.6%). The most common incision for thyroidectomy (95/7%) was neck Collar incision. Diagnosis method in 82.9% and 17.1% of cases was, respectively, based on CT scans with CXR and CT scans with CXR and ultrasound. According to the postoperative pathologic findings, 58.5% of the cases were multinodular goiter, 22.9% were papillary cell carcinoma, 7.1% were medullary carcinoma, 5.7% were anaplastic carcinoma, 5.7% were thyroid lymphoma, and only 1.4% were thyroid adenoma. Postoperative complications occurred in 47.14% of patients. Most common complication was early transient dysphonia. Conclusion: This study recommends that retrosternal goiter should be operated early under suitable conditions, and the best diagnosis tool and best surgery methods are CT scan and surgery with collar incision, respectively.
Collapse
Affiliation(s)
- Manouchehr Aghajanzadeh
- Inflammatory Lung Disease Research Center, School of Medicine, Razi Hospital, Guilan University of Medical Science, Rasht, Iran
| | - Mohammad Reza Asgary
- Inflammatory Lung Disease Research Center, School of Medicine, Razi Hospital, Guilan University of Medical Science, Rasht, Iran
| | - Fereshteh Mohammadi
- Inflammatory Lung Disease Research Center, School of Medicine, Razi Hospital, Guilan University of Medical Science, Rasht, Iran
| | - Haniye Darvishi
- Inflammatory Lung Disease Research Center, School of Medicine, Razi Hospital, Guilan University of Medical Science, Rasht, Iran
| | - Yasaman Safarpour
- Inflammatory Lung Disease Research Center, School of Medicine, Razi Hospital, Guilan University of Medical Science, Rasht, Iran
| |
Collapse
|
12
|
Bhandari A, Wang YH, Lv SX, Xia EJ, Wang OC. Novel strategy of stents in thyroid mass: a case series report of managing severely dyspneic patients. Onco Targets Ther 2017; 10:4997-5004. [PMID: 29081662 PMCID: PMC5652908 DOI: 10.2147/ott.s145418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Tracheal and bronchial stenosis is a life-threatening condition causing difficulty in breathing and even severe respiratory distress. The silicone tracheobronchial stents were placed using the rigid bronchoscopy into the trachea of severe dyspneic patients and they exhibited symptomatic improvement as well as a rise in the saturation of oxygen. The bronchial stents were applicable to many extensive malignant airway stenosis patients, such as those with esophageal cancer, lung cancer, and laryngeal cancer. But the effectiveness of bronchial stents for thyroid cancer is not certain. Case presentation Here, we report 3 emergency patients with a thyroid mass referred to our hospital because of grade 4 dyspnea according to the American Thoracic Society shortness of breath guidelines. The main clinical symptoms were severe dyspnea and stridor. The radiographic examination and tomographic examination showed the narrowing and displacement of the trachea. To the best of our knowledge, ideal airway management for the massive thyroid mass was considered to be temporary tracheobronchial stent placement pre-operation. Conclusion In our study, we applied the tracheobronchial stent to massive thyroid mass patients with dyspnea and aimed to not only improve preoperative airway obstruction but also to protect the potential airway collapse from post-operative tracheomalacia following extubation. We found that application of tracheobronchial stents may provide a new strategy to dyspneic patients with huge thyroid mass.
Collapse
Affiliation(s)
- Adheesh Bhandari
- Department of Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Ying-Hao Wang
- Department of Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Shi-Xu Lv
- Department of Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Er-Jie Xia
- Department of Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Ou-Chen Wang
- Department of Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| |
Collapse
|
13
|
Sengupta S, Mukherjee R, Bose S, Mukhopadhyay G. Scabbard Trachea in a Case of Retrosternal Goitre. Indian J Surg 2017; 79:468-469. [DOI: 10.1007/s12262-017-1678-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/07/2017] [Indexed: 11/30/2022] Open
|
14
|
Abstract
Total thyroidectomy for substernal goiter occasionally requires a sternotomy associated with a cervical incision. We sought to analyze the postoperative complications of thyroidectomy for substernal goiters in our center and more precisely the complications related to the sternotomy. All patients who underwent total thyroidectomy for substernal goiter in our center between 2007 and 2016 were reviewed retrospectively. Patients with combined cervical incision and sternotomy (ST group, n=16) were compared to those with cervical incision alone (CT group, n=54), with regard to postoperative complications. Risk factors for the occurrence of postoperative complications were investigated in this population. A total of 24 patients (34.2%) had one or more postoperative complications. The incidence of transient hypoparathyroidism and recurrent laryngeal nerve injury were higher in the ST group (P=0.001 and P=0.052, respectively). The median duration of hospitalization was longer in the ST group (P<0.001). Eighteen patients (25.8%) had a malignant tumor on final pathology. In univariate analysis, the following risk factors for transient postoperative hypoparathyroidism were identified: sternotomy, preoperative symptomatic character and thyroid height (P=0.001, P=0.009 and P=0.013, respectively). In multivariable analysis, only sternotomy was an independent risk factor for postoperative transient hypoparathyroidism (OR=4.48 [1.1; 18], P=0.035). Sternotomy is associated with added morbidity that is not negligible. This surgical approach should be reserved for substernal goiters that descend into the posterior mediastinum, below the level of the aortic arch, when there is suspicion of carcinoma with loco-regional invasion, or when the thyroid tissue is located mainly intrathoracically (conical shaped thyroid, asymptomatic goiter, ectopic thyroid).
Collapse
|
15
|
Bhargav PR, Amar V, Mahilvayganan S, Nanganandadevi V. Feasibility of thoracoscopic approach for retrosternal goitre (posterior mediastinal goitre): Personal experiences of 11 cases. J Minim Access Surg 2016; 12:240-4. [PMID: 27279395 PMCID: PMC4916750 DOI: 10.4103/0972-9941.181276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Posterior mediastinal goitres constitute of a unique surgical thyroid disorder that requires expert management. Occasionally, they require thoracic approach for the completion of thyroidectomy. In this paper, we describe the feasibility and utility of a novel thoracoscopic approach for such goitres. MATERIALS AND METHODS This is a retrospective study conducted at a tertiary care endocrine surgery department in South India over a period of 5 years from January 2010 to December 2014. We developed a novel thoracoscopic technique for posterior mediastinal goitres instead of a more morbid thoracotomy or sternotomy. All the clinical, investigative, operative, pathological and follow-up data were collected from our prospectively filled database. Statistical analysis was done with SPSS 15.0 version. Descriptive analysis was done. Operative Technique of Thoracoscopic Thyroidectomy: Single lumen endotracheal tube (SLETT) was used of anaesthetic intubation and general inhalational anaesthesia. Operative decubitus was supine with extension and abduction of the ipsilateral arm. Access to mediastinum was obtained by two working ports in the third and fifth intercostal spaces. Mediastinal extension was dissected thoracoscopically and delivered cervically. RESULTS Out of 1,446 surgical goitres operated during the study period, 72 (5%) had retrosternal goitre. Also, 27/72 (37.5%) cases had posterior mediastinal extension (PME), out of which 11 cases required thoracic approach. We utilised thoracoscopic technique for these 11 cases. The post-operative course was uneventful with no major morbidity. There was one case of recurrent laryngeal nerve (RLN) injury and hoarseness of voice in the third case. Histopathologies in 10 cases were benign, out of which two had subclinical hyperthyroidism. One case had multifocal papillary microcarcinoma. CONCLUSIONS We opine that novel thoracoscopic technique is a feasibly optimal approach for posterior mediastinal goitre, especially for benign and non-invasive malignant goitres.
Collapse
Affiliation(s)
| | - Vennapusa Amar
- Department of Bariatric Surgery and Advanced Laparoscopic Surgery, Citizens Hospital, Hyderabad, Telangana, India
| | | | | |
Collapse
|
16
|
Nakaya M, Ito A, Mori A, Oka M, Omura S, Kida W, Inayoshi Y, Inoue A, Fuchigami T. Surgical treatment of substernal goiter: An analysis of 44 cases. Auris Nasus Larynx 2016; 44:111-115. [PMID: 26995097 DOI: 10.1016/j.anl.2016.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/22/2016] [Accepted: 02/29/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Substernal goiters are classified as primary or secondary intrathoracic goiters. Here, we report the diagnosis, symptoms, treatment, and postoperative complications of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters). METHODS A retrospective chart review of 351 patients undergoing thyroidectomy at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Between 2009 and 2015, 44 patients underwent surgery for substernal goiter. RESULTS The frequency of primary and secondary mediastinal goiters was 0.5% and 11.9%, respectively. The preoperative symptoms were neck mass, dyspnea, and dysphagia. Eight patients were asymptomatic. Thirty-nine patients had benign masses and 5 patients had malignant masses. Most patients were operated on for adenomatous goiters (52.2%). In ten cases beyond the aortic arch, the tumors were benign and there were eight cases of adenomatous goiter. All patients underwent a successful transcervical incision without sternotomy. Even the primary intrathoracic goiters were extracted after total thyroidectomy via the cervical approach without complications. Although one case showed unilateral recurrent nerve paralysis as a postoperative complication, phonetic function improved in 6 postoperative months. No instances of postoperative bleeding or definitive hypoparathyroidism occurred, and tracheostomy was not performed in any of the cases. CONCLUSION The cervical approach was safely performed in almost all substernal goiters without an extracervical procedure. Selected cases of primary mediastinal goiter may be excised via the cervical approach.
Collapse
Affiliation(s)
- Muneo Nakaya
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan.
| | - Akiko Ito
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| | - Ayumi Mori
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| | - Mineko Oka
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| | - Sayaka Omura
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| | - Wataru Kida
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| | - Yasuhiro Inayoshi
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| | - Aki Inoue
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| | - Teruhiko Fuchigami
- Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center, Japan
| |
Collapse
|
17
|
Lin YS, Wu HY, Lee CW, Hsu CC, Chao TC, Yu MC. Surgical management of substernal goitres at a tertiary referral centre: A retrospective cohort study of 2,104 patients. Int J Surg 2016; 27:46-52. [PMID: 26796368 DOI: 10.1016/j.ijsu.2016.01.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/09/2016] [Accepted: 01/17/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND When to use a thoracic approach to treat substernal goitres has often been discussed in the literature. But there are few published reports describing surgical outcomes and associated complications for patients with right-sided vs. left-sided substernal goitres. OBJECTIVE This study evaluated the characteristics and clinical outcomes of patients who underwent surgical management of substernal goitres, presenting factors indicating the use of a thoracic approach and differences between right- and left-sided goitre extensions. DESIGN Retrospective cohort study. SETTING Tertiary referral centre. METHODS Between January 2007 and December 2012, 2104 patients underwent thyroidectomy at Chang Gung Memorial Hospital and 140 (6.7%) were diagnosed with substernal goitres. Patient medical records were retrospectively reviewed, and data were analysed to assess surgical outcomes. RESULTS Seven (5.0%) patients required a thoracic approach for goitre removal. Goitre malignancy was verified in 17 (12.1%) patients. The most common postoperative complication was transient hypoparathyroidism (15.0%). Permanent RLN injury occurred in 4.3% of patients and was significantly more frequent using the thoracic approach. Unilateral extension of a substernal goitre was more common than bilateral extension. Right- and left-sided extensions occurred with equal frequency. The rate of postoperative complications was similar between groups and there were no patient deaths. CONCLUSION Chest radiography and thyroid sonography may provide initial radiologic evidence of goitre extension into the superior mediastinum. Computed tomography evaluation of the depth of goitre extension to the tracheal bifurcation was the strongest predictor of the need to use a thoracic approach. There were no significant differences in the clinical features and outcomes of patients with right- and left-sided substernal goitres. The right recurrent laryngeal nerve shows increased susceptibility to damage during thyroid surgery for substernal goitres. The incidence of malignant substernal goitres is similar to that of malignant cervical goitres.
Collapse
Affiliation(s)
- Yann-Sheng Lin
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan
| | - Hsin-Yi Wu
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan
| | - Chao-Wei Lee
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan
| | - Chih-Chieh Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan
| | - Tzu-Chieh Chao
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan
| | - Ming-Chin Yu
- Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Chang Gung University, Kwei-Shan Tao-Yuan, Taiwan.
| |
Collapse
|
18
|
Moten AS, Thibault DP, Willis AW, Willis AI. Demographics, disparities, and outcomes in substernal goiters in the United States. Am J Surg 2016; 211:703-9. [PMID: 26813846 DOI: 10.1016/j.amjsurg.2015.11.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 11/12/2015] [Accepted: 11/23/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Disparities distinguishing patients with substernal goiters from nonsubsternal goiters have not been thoroughly described. METHODS The National Inpatient Sample database was used to compare patients who underwent substernal thyroidectomy years 2000 to 2010 with those who underwent thyroidectomy for nonsubsternal goiter. RESULTS A total of 110,889 patients underwent thyroidectomy for goiter (5,525 substernal and 105,364 nonsubsternal). Substernal thyroidectomy patients were older, more likely to be Black or Hispanic and to have Medicare insurance. They had a higher comorbidity index, were more likely to be admitted emergently and to have postoperative complications such as hemorrhage/hematoma, pneumothorax, pulmonary embolism, and hypocalcemia/hypoparathyroidism. Furthermore, substernal thyroidectomy patients had 73% increased odds of death during admission than nonsubsternal thyroidectomy patients. CONCLUSIONS Substernal goiters present a distinct type of goiter with identifiable patient-level characteristics and an increased risk of postoperative complications and death. Earlier identification and treatment of goiters may allow earlier interventions at a stage when risks are reduced.
Collapse
Affiliation(s)
- Ambria S Moten
- Department of Surgery, Temple University School of Medicine, Philadelphia, PA, USA
| | - Dylan P Thibault
- University of Pennsylvania Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA, USA
| | - Allison W Willis
- University of Pennsylvania Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA, USA
| | - Alliric I Willis
- Thyroid and Parathyroid Surgery Program, Department of Surgery, Thomas Jefferson University, 1100 Walnut St., Suite 500, Philadelphia, PA, USA.
| |
Collapse
|
19
|
Ito E, Ohdaira H, Yasuda J, Yoshida M, Suzuki Y. A case of mediastinal goiter treated surgically using a clavicle-lifting technique. Int J Surg Case Rep 2015; 16:12-4. [PMID: 26406312 PMCID: PMC4643343 DOI: 10.1016/j.ijscr.2015.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/02/2015] [Accepted: 09/05/2015] [Indexed: 11/04/2022] Open
Abstract
A thyroidectomy is indicated in all cases of mediastinal goiter because of the risks of airway obstruction, potential malignancy, tracheomalacia and invasion into the adjacent structures. The clavicle-lifting technique is a simple and safe technique that involves lifting the clavicles with a pediatric extension retractor (Kent Retractor Set, Takasago Medical Industry, Tokyo, Japan). The clavicle-lifting technique is a good surgical option for upper-mediastinal lesions such as mediastinal goiters and it obviates the need for a sternotomy.
Introduction Mediastinal goiter is a benign disease, which is defined as a goiter with the greater portion of its mass lying below the thoracic inlet. It is controversial whether the cervical approach is the best approach for all mediastinal goiter surgeries. Case presentation A 71-year-old woman presented with respiratory discomfort during exertion. Computed tomography (CT) revealed a mediastinal goiter extending to the arch of the aorta. Surgical resection was performed using a clavicle-lifting technique. The excised specimen was 13 × 10 × 5 cm in size and weighed 220 g. The pathological diagnosis was nodular goiter. Discussion The clavicle-lifting technique is a simple and safe technique that involves lifting the clavicles with a pediatric extension retractor (Kent Retractor Set, Takasago Medical Industry, Tokyo, Japan). This is a good choice for surgery on upper mediastinal lesions such as mediastinal goiters as it obviates the need for a median sternotomy. Conclusion Although further study is necessary, it appears that a transcervical approach using the clavicle-lifting technique may be an acceptable treatment for mediastinal goiters that extend to the aortic arch.
Collapse
Affiliation(s)
- Eisaku Ito
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara-city, Tochigi 329-2763, Japan.
| | - Hironori Ohdaira
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara-city, Tochigi 329-2763, Japan.
| | - Jungo Yasuda
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara-city, Tochigi 329-2763, Japan.
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara-city, Tochigi 329-2763, Japan.
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara-city, Tochigi 329-2763, Japan.
| |
Collapse
|
20
|
Tunc M, Sazak H, Karlilar B, Ulus F, Tastepe I. Coexistence of Obstructive Sleep Apnea and Superior Vena Cava Syndromes Due to Substernal Goitre in a Patient With Respiratory Failure: A Case Report. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e18342. [PMID: 26082848 PMCID: PMC4464379 DOI: 10.5812/ircmj.17(5)2015.18342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 09/07/2014] [Accepted: 03/20/2015] [Indexed: 11/16/2022]
Abstract
Introduction: Substernal goiter may rarely cause superior vena cava syndrome (SVCS) owing to venous compression, and cause acute respiratory failure due to tracheal compression. Obstructive sleep apnea syndrome (OSAS) may rarely occur when there is a narrowing of upper airway by edema and vascular congestion resulting from SVCS. Case Presentation: We presented the clinical course and treatment of acute respiratory failure (ARF) developed in a patient with SVCS and OSAS due to substernal goiter. After treatment of ARF with invasive mechanical ventilation, weaning and total thyroidectomy were successfully performed through collar incision and median sternotomy without complications. Conclusions: Our case showed that if the respiratory failure occurred due to substernal goiter and SVCS, we would need to investigate the coexistence of OSAS and SVCS.
Collapse
Affiliation(s)
- Mehtap Tunc
- Department of Anesthesiology and Reanimation, Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
- Corresponding Author: Mehtap Tunc, Department of Anesthesiology and Reanimation, Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital, Ankara, Turkey.Tel: +90-3123825582, Fax: +90-3124817783, E-mail:
| | - Hilal Sazak
- Department of Anesthesiology and Reanimation, Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Bulent Karlilar
- Department of Anesthesiology and Reanimation, Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Fatma Ulus
- Department of Anesthesiology and Reanimation, Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Irfan Tastepe
- Department of Thoracic Surgery, Gazi University Medical Faculty, Ankara, Turkey
| |
Collapse
|
21
|
Ahmed ME, Mahgoub MA, Alnedar MG, Mahadi SI, Alzubeir M, El Hassan LA, Elamin EM, El Hassan AM. Myasthenic Crisis Manifesting as Postoperative Respiratory Failure following Resection of Unsuspected Intrathoracic Thymic T-Cell Lymphoma during Thyroidectomy for an Adjacent Large Retrosternal Goiter. Eur Thyroid J 2014; 3:206-10. [PMID: 25538904 PMCID: PMC4224263 DOI: 10.1159/000364822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 05/26/2014] [Indexed: 11/22/2022] Open
Abstract
A middle-aged female with a goiter of 10 years' duration presented with progressive pressure symptoms, nocturnal choking and dyspnea on exertion for 5 months. Physical examination demonstrated a large simple multinodular goiter. Imaging revealed a deep retrosternal goiter extending below the tracheal bifurcation with marked tracheal deviation. Total thyroidectomy was carried out via a cervical approach and a median sternotomy. Extubation was not possible, and the patient had to be kept intubated. She then went into a myasthenic crisis. Initial ventilatory support was followed by intravenous immunoglobulin, steroids and pyridostigmine. The patient had complete remission and was asymptomatic 18 months later. Histopathology showed a T-cell-rich thymoma in addition to a nodular colloid goiter.
Collapse
Affiliation(s)
- Mohamed E Ahmed
- Khartoum Teaching Hospital, Khartoum, Sudan
- Department of Medicine, Khartoum, Sudan
| | | | | | - Seif I Mahadi
- Khartoum Teaching Hospital, Khartoum, Sudan
- Department of Medicine, Khartoum, Sudan
| | - Maha Alzubeir
- Department of Surgery, Faculty of Medicine, at, Khartoum, Sudan
| | | | | | | |
Collapse
|
22
|
Landerholm K, Järhult J. Should asymptomatic retrosternal goitre be left untreated? A prospective single-centre study. Scand J Surg 2014; 104:92-5. [PMID: 24759378 DOI: 10.1177/1457496914523411] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/10/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Retrosternal goiter may cause symptoms of airway obstruction and dysphagia, but often it is asymptomatic and is increasingly detected incidentally with imaging investigations. Consensus has been reached that sternotomy is not necessary in most cases, as a collar incision normally suffices. Yet, surgery for retrosternal goiter is associated with more complications than cervical goiter. There is controversy over whether patients with asymptomatic retrosternal goiter should be operated. Proponents argue that retrosternal goiter may be a risk for thyroid cancer and may progress to later cause symptoms, although clear evidence is missing. PATIENTS AND METHODS Between 1984 and 2012, 132 patients underwent surgery for benign retrosternal goiter. Preoperatively, the benign nature was clinically apparent and confirmed by fine needle cytology in most cases. RESULTS Sternotomy was required in only 4 of the 132 operations. Three patients died in the postoperative period. The risk of morbidity and mortality was 16.7% in 60 patients with compression symptoms and 13.9% in 72 patients without compression symptoms (P = 0.808). Histology revealed no case of unsuspected cancer. CONCLUSION Surgery for retrosternal goiters involves a higher risk for complications than do cervical goiters, and the risk does not differ between patients with and without symptoms. This, and the fact that no patient in this study had unsuspected cancer, calls into question the rationale for surgery in patients with asymptomatic retrosternal goiter without suspected cancer.
Collapse
Affiliation(s)
- K Landerholm
- Department of Surgery, Ryhov County Hospital, Jönköping, Sweden
| | - J Järhult
- Department of Surgery, Ryhov County Hospital, Jönköping, Sweden Department of Surgery, Highland Hospital, Eksjö, Sweden
| |
Collapse
|
23
|
Piao M, Yuan Y, Wang Y, Feng C. Successful management of trachea stenosis with massive substernal goiter via thacheobronchial stent. J Cardiothorac Surg 2013; 8:212. [PMID: 24228633 PMCID: PMC3833183 DOI: 10.1186/1749-8090-8-212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 11/11/2013] [Indexed: 12/20/2022] Open
Abstract
A case of 65 year-old Chinese male patient with severe tracheal stenosis due to a massive substernal goiter, is presented. MRI and CT scan revealed that the massive substernal goiter was 9.3 × 6.1 × 4.7 cm in size, displacing the trachea and adjacent large vessels to the patient's right contributing to severe intrathoracic trachea compression up to 6 cm in length and the narrowest caliber of the trachea only 3.0 mm in diameter. To the best of our knowledge, optimal airway management for the massive substernal goiter resection was considered to be temporary tracheobronchial stent placement pre-operation.
Collapse
Affiliation(s)
- Meihua Piao
- Department of Anesthesiology, the First Hospital of Jilin University, Changchun 130021, Jilin, PR China
| | - Ye Yuan
- Department of Anesthesiology, the First Hospital of Jilin University, Changchun 130021, Jilin, PR China
| | - Yanshu Wang
- Department of Anesthesiology, the First Hospital of Jilin University, Changchun 130021, Jilin, PR China
| | - Chunsheng Feng
- Department of Anesthesiology, the First Hospital of Jilin University, Changchun 130021, Jilin, PR China
| |
Collapse
|
24
|
Chen X, Xu H, Ni Y, Sun K, Li W. Complete excision of a giant thyroid goiter in posterior mediastinum. J Cardiothorac Surg 2013; 8:207. [PMID: 24196135 PMCID: PMC3826527 DOI: 10.1186/1749-8090-8-207] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 10/30/2013] [Indexed: 12/04/2022] Open
Abstract
Intrathoracic goiter is commonly located in the anterior mediastinum. Here we report a case of a 58-year-old Chinese male in whom we successfully removed the intrathoracic goiter and eased his dyspnea by a right posterolateral thoracotomy approach. Posterior mediastinal thyroid goiter with mediastinal compressive symptoms is an indication of surgery.
Collapse
Affiliation(s)
| | | | | | | | - Weidong Li
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Qing Chun Road 79#, Hangzhou, China.
| |
Collapse
|
25
|
Abstract
Thyroidectomy is the most common endocrine surgical procedure being carried out throughout the world. Besides, many patients who have deranged thyroid physiology, namely hyperthyroidism and hypothyroidism, have to undergo various elective and emergency surgical procedures at some stage of their life. The attending anesthesiologist has to face numerous daunting tasks while administering anesthesia to such patients. The challenging scenarios can be encountered at any stage, be it preoperative, intra-op or postoperative period. Preoperatively, deranged thyroid physiology warrants optimal preparation, while anticipated difficult airway due to enlarged thyroid gland further adds to the anesthetic challenges. Cardiac complications are equally challenging as also the presence of various co-morbidities which make the task of anesthesiologist extremely difficult. Thyroid storm can occur during intra-op and post-op period in inadequately prepared surgical patients. Postoperatively, numerous complications can develop that include hemorrhage, laryngeal edema, nerve palsies, tracheomalacia, hypocalcemic tetany, pneumothorax, etc., The present review aims at an in-depth analysis of potential risk factors and challenges during administration of anesthesia and possible complications in patients with thyroid disease.
Collapse
Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
| | - Vishal Sehgal
- Department of Internal Medicine, The Commonwealth Medical College Scranton, PA 18510, USA
| |
Collapse
|
26
|
Qureishi A, Garas G, Tolley N, Palazzo F, Athanasiou T, Zacharakis E. Can pre-operative computed tomography predict the need for a thoracic approach for removal of retrosternal goitre? Int J Surg 2013; 11:203-8. [PMID: 23352847 DOI: 10.1016/j.ijsu.2013.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 01/01/2013] [Accepted: 01/14/2013] [Indexed: 11/26/2022]
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was whether in patients with retrosternal goitre the need for a thoracic approach can be predicted using pre-operative CT. A total of 381 papers were identified using the reported search protocol of which 7 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results are tabulated. The evidence on this subject is poor, none of the studies were randomised, only one used controls (historical) and all studies were retrospective. Despite these limitations, CT represents the gold-standard imaging modality in the pre-operative evaluation of patients with retrosternal goitre. CT is essential to define the extent and position of a retrosternal goitre. The literature suggests that CT is the single most valuable pre-operative investigation predicting whether a sternotomy or lateral thoracotomy will be necessary for removal of the retrosternal goitre. Although pre-operative CT does not have the precision to predict whether a thoracic approach is required in all cases, the presence of certain radiological features such as extension of the goitre below the aortic arch or into the posterior mediastinum, a dumbbell shape and a thoracic component that is wider than the thoracic inlet are all associated with the need for a thoracic approach. In some cases a pre-operative CT will not only determine that a thoracic approach is mandatory but it will also guide the surgeon upon the type of thoracic approach.
Collapse
Affiliation(s)
- Ali Qureishi
- Department of Surgery and Cancer, St. Mary's Hospital, Imperial College London, United Kingdom
| | | | | | | | | | | |
Collapse
|
27
|
|
28
|
Ríos A, Sitges-Serra A. [Surgical treatment of intrathoracic goitre]. Cir Esp 2012; 90:421-8. [PMID: 22464974 DOI: 10.1016/j.ciresp.2012.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 01/19/2012] [Accepted: 01/25/2012] [Indexed: 10/28/2022]
Abstract
The definition by Katlic gives the best description of intrathoracic goitre, a condition that includes a small sub-group (1-4%) of patients with multinodular goitre who generally have severe compression symptoms and require specialised care in reference centres. The pre-operative study must include thoracic imaging techniques to plan the most suitable action. Total thyroidectomy is recommended, and in more than 95% of cases the goitre can be removed using a cervical approach. A wide cervical approach and the identification of the recurrent nerve near the cricothyroid joint help to free the thyroid from all its cervical attachments before gently retracting it upwards from the thoracic component for its removal. Intrathoracic goitres that require a sternotomy for its removal are recurrent goitres, those that have advanced cancer, those that reach the carina, and left posterior goitres that extend to the right pleural cavity.
Collapse
Affiliation(s)
- Antonio Ríos
- Unidad de Cirugía Endocrina, Hospital Universitario Virgen de la Arrixaca, Murcia, España.
| | | |
Collapse
|
29
|
Michels G, Dietlein M, Kobe C, Pfister R. Mediastinal goiter diagnosed by functional imaging. Libyan J Med 2012; 7:LJM_A_015693_O. [PMID: 22279494 PMCID: PMC3265985 DOI: 10.3402/ljm.v7i0.15693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 12/21/2011] [Accepted: 12/28/2011] [Indexed: 11/14/2022] Open
Abstract
A 63-year-old asymptomatic woman with cured Hodgkin diseases presented for restaging. The chest computed tomography showed a mass at the right side of the upper mediastinum. The benignity and the origin of the tissue were unknown. First, we performed a bronchoscopy-guided biopsy but without success. In the next step, we initiated radionuclide imaging with technetium-99m pertechnetate (Tc-99m) and radioiodine (I-123). Low uptake of Tc-99m and intense accumulation of I-123 after 2 and 24 h to the mediastinal mass suggested that the mass was a mediastinal goiter. Based on iodine uptake and the fact that our patient had no symptoms of tracheal compression, we decide to go for a radioiodine therapy.
Collapse
Affiliation(s)
- Guido Michels
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
- Guido Michels, Department III of Internal Medicine, University of Cologne, Kerpener Str.-62, DE-50937 Cologne, Germany. Tel: +49 (221) 478 32379, Fax: +49 (221) 478 32355.
| | - Markus Dietlein
- Department of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Carsten Kobe
- Department of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Roman Pfister
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
| |
Collapse
|
30
|
Machado NO, Grant CS, Sharma AK, al Sabti HA, Kolidyan SV. Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach. Gen Thorac Cardiovasc Surg 2011; 59:507-11. [PMID: 21751115 DOI: 10.1007/s11748-010-0712-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 09/07/2010] [Indexed: 11/30/2022]
Abstract
Most retrosternal goiters are situated in the anterior mediastinal compartment. Posterior mediastinal goiters are uncommon, comprising 10%-15% of all mediastinal goiters. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a large posterior mediastinal goiter extending retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side. It was excised using a transcervical and right thoracotomy approach. The literature is reviewed to clarify the management of retrosternal goiters with regard to the various approaches, indications for extracervical incisions, and their complications. In conclusion, whereas most retrosternal goiters can be resected through a transcervical approach, those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy. The overall number of complications associated with this approach, however, is higher than that seen with the transcervical approach.
Collapse
Affiliation(s)
- Norman Oneil Machado
- Department of Surgery, Sultan Qaboos University Hospital, PO Box 38, Muscat 123, Oman.
| | | | | | | | | |
Collapse
|
31
|
Abstract
INTRODUCTION Thyroid disease is common, thyroid cancer is uncommon. Most goitres are investigated using blood tests, fine needle aspiration cytology together with ultrasound. Surgery usually entails either lobectomy or total thyroidectomy, and for malignancy, patients may need a neck dissection. Recently, significant advances have been made regarding mechanisms involved in both thyroid growth and function (goitrogenesis) and carcinogenesis at a molecular level. PATIENTS AND METHODS In the study cohort, 1113 patients had benign disease and 387 malignancy. For benign disease, 716 patients had lobectomy or isthmusectomy, 44 had near-total thyroidectomy and 318 a total thyroidectomy. For malignancy, patients received initial lobectomy (180) or total thyroidectomy (152). One hundred and eleven had completion surgery. Thirty patients had extensive surgery. Thyroid growth and function was investigated using 500 human thyroid cell primary cultures obtained at surgery, as well as in three animal models. The role of pituitary tumour transforming gene (PTTG), PTTG binding factor (PBF) and sodium iodide symporter (NIS) in thyroid cell function was then evaluated. RESULTS Temporary and permanent recurrent laryngeal nerve palsy rates were 2.4% and 0.4%. Other complications included temporary (21%) and permanent (3%) hypoparathyroidism, wound infection (1.2%), haematoma (1.2%) and poor scar (0.8%). Six patients have died. Regarding thyroid growth and function, TSH represents (either directly or indirectly) the main factor mediating thyroid follicular cell growth. For carcinogenesis, over-expression of the proto-oncogenes PTTG and PBF induces tumours in nude mice, and PTTG can induce proliferation of human thyroid cells and, in addition, both repress expression and function of NIS.
Collapse
Affiliation(s)
- John C Watkinson
- Department of ENT/Head & Neck and Thyroid Surgery, Queen Elizabeth Hospital, University of Birmingham NHS Trust, The School of Clinical and Experimental Medicine, Institute of Biomedical Research, Birmingham, UK.
| |
Collapse
|