Substernal Goiter: When is a Sternotomy Required?

Abstract The presence of substernal goiter is, per se, an indication for surgical management. Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The aim of this study was to identify the preoperative predictors of a sternotomy in the management of substernal goiter in order to provide better preoperative planning and patient consent. Between 2005 and 2012, 665 patients were referred to our clinic for thyroidectomy, 42 patients (6.3%) had substernal goiter and were included in this study. All substernal goiters were treated surgically, 38 (90.5%) by a cervical approach and 4 (9.5%) by full median sternotomy. All surgeries were successful, with no major postoperative complications. Minor postoperative complications of transient hypocalcemia and transient paralysis of the recurrent laryngeal nerve occurred in 5 (11.9%) and 2 (4.7%) cases, respectively. Indication of median sternotomy was as follows: extension of goiter below the aortic arch, large thyroid tissue extending towards tracheal bifurcation, and ectopic thyroid tissue in the mediastinum. Substernal goiter can be removed through a cervical incision, but on rare occasions, a median sternotomy may be required.

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Retrosternal goitre, do humans need a sternotomy?

International Surgery Journal ◽

10.18203/2349-2902.isj20180796 ◽

2018 ◽

Vol 5 (3) ◽

pp. 773

Author(s):

Navin R. Kasliwal ◽

Abhay Kasliwal ◽

Anand Boriwale ◽

Satish Sonawane

Keyword(s):

Preoperative Planning ◽

Thyroid Tissue ◽

Median Sternotomy ◽

Posterior Mediastinum ◽

Surgical Morbidity ◽

Patient Consent ◽

Cervical Approach ◽

General Surgeons ◽

Preoperative Predictors ◽

Tracheal Bifurcation

Retrosternal goitre as a surgical thyroid pathology is diminishing in incidence. Though surgery is the generally accepted treatment modality, lot of uncertainties exist regarding the approach for surgery in consideration with the prognostication, surgical morbidity and the post-operative outcome. Median sternotomy, in addition to being more morbid, is generally out of the general surgeons’ perview and therefore its need necessitates preoperative arrangements for assistance by a thoracic surgeon. Cervical approach is sufficient for most of the lesions but the surgeon should be conversant with median sternotomy as to perform it expediently and without hesitation when it is indicated. The generally indications for sternotomy are extension of goitre below the aortic arch, involvement of the posterior mediastinum, large thyroid tissue extending towards tracheal bifurcation, and primary ectopic thyroid tissue in the mediastinum. Here the available literature was reviewed to identify the preoperative predictors of a sternotomy in the management of substernal goitre in order to provide better preoperative planning and patient consent in managing the patient with reference to a recently encountered case.

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Cervical approach for retro-sternal goiter reaching the arch of aorta

10.21203/rs.3.rs-425681/v1 ◽

2021 ◽

Author(s):

Mohamed Tarek Hafez ◽

Mostafa M. Abdelmaksoud ◽

Shadi Awny ◽

Alaa Jamjoom ◽

Abdullah Mashat ◽

...

Keyword(s):

Total Thyroidectomy ◽

Medical Center ◽

Academic Medical Center ◽

Thyroid Tissue ◽

Median Sternotomy ◽

Thoracic Inlet ◽

Cervical Incision ◽

Academic Medical ◽

Retrosternal Goiter ◽

Cervical Approach

Abstract Background: Although the retrosternal goiters are characterized by the protrusion of at least 50% of the thyroid tissue below the level of the thoracic inlet, their definite definition is still controversial. Total thyroidectomy for retrosternal goiter has a great challenge and mostly requires an experienced thyroid surgeon. Excision could be possible through a cervical incision in most cases, though Sternotomy remains an option. Patients and Methods: We report fourteen patients who presented to our academic medical center between 2016 and 2019 with large thyroid goiters and retrosternal extension proven by computerized tomography scan of the neck, presented in both Mansoura University Oncology Center, Egypt and East Jeddah Hospital, Saudi Arabia from 2016 to 2019. Results: Fourteen cases with retrosternal goiter been undergone total thyroidectomy through a cervical incision without the need for median sternotomy, although the thoracic surgeon was stand-by in three cases. Six patients were found to have a malignancy in the post-operative histopathological assessment.CONCLUSION: Surgical procedures for most all retrosternal goiters can be completed successfully using a cervical approach; however, a sternotomy is required in a small number of such patients.

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Retrosternal goiter

Perspectives in Surgery ◽

10.33699/pis.2020.99.11.492-496 ◽

2020 ◽

Vol 99 (11) ◽

Keyword(s):

Postoperative Complications ◽

Postoperative Bleeding ◽

Operating Time ◽

Histological Finding ◽

University Hospital ◽

Vocal Cord Paresis ◽

Cervical Incision ◽

Thyroid Mass ◽

Retrosternal Goiter ◽

Cervical Approach

Introduction: Retrosternal goiter is an enlarged thyroid mass of which more than 50% is located in the mediastinum. Indications for surgery of retrosternal goiter include ineffective pharmacological treatment, mechanical syndrome, suspicion of malignancy and thyrotoxicosis. Computed tomography is the gold standard in the diagnosis of retrosternal goiter. The surgery can be performed from a cervical incision, using sternotomy or thoracotomy. Methods: The aim of our study was to evaluate our own group of retrosternal goiters. In 2011–2019, 1739 thyroid surgeries were performed at the 3rd Department of Surgery, University Hospital Motol, Prague. We retrospectively followed the age, gender, retrosternal spreading, postoperative complications (especially hypocalcemia, bleeding and dysphonia) and the definitive histological finding. Results: Retrosternal goiters were presented in 202 (19.2%) of the total of 1739 thyroid surgery patients. Sternotomy was performed in 31 patients. Women (61%) predominated over men (39%). The mean operating time was 125 minutes. We did not detect any serious postoperative bleeding necessitating surgical revision. Temporary hypocalcemia was observed in 10 patients (32%) based on laboratory testing. Unilateral iatrogenic vocal cord paresis was observed in 6 patients (19.4%) and was permanent in 3 patients (9.3%). One patient passed away soon after the operation, nevertheless the death was related to a simultaneously planned cardiothoracic procedure. Conclusion: The retrosternal goiter can be removed using the cervical approach in most cases. Total thyroidectomy using sternotomy is associated with higher morbidity and mortality, higher blood loss and longer hospital stay; nevertheless, it does not increase the risk of long-term postoperative complications. Procedures requiring sternotomy or thoracotomy should be done at centers experienced in these types of procedures.

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Preoperative Evaluation of Substernal Goiter by Computed Tomography in the Extended Neck Position

Case Reports in Oncology ◽

10.1159/000518532 ◽

2021 ◽

pp. 1353-1358

Author(s):

Teruhisa Yano ◽

Takuro Okada ◽

Hiroki Sato ◽

Ryota Tomioka ◽

Kiyoaki Tsukahara

Keyword(s):

Computed Tomography ◽

Aortic Arch ◽

Preoperative Evaluation ◽

Neck Mass ◽

Pathological Examination ◽

Neck Position ◽

Substernal Goiter ◽

Cervical Incision ◽

Preoperative Ct ◽

Cervical Approach

Sternotomy is indicated when a goiter cannot be resected via a cervical incision, such as in the case of a substernal goiter extending beyond the aortic arch. In this article, we report a case of a large substernal goiter that was successfully removed using the cervical approach only. This is a case of a 68-year-old woman, diagnosed with goiter 20 years ago, who complained of a neck mass enlargement with associated cough. Pathological examination revealed no malignancy. Computed tomography (CT) scan showed an 11-cm thyroid mass reaching the level of the aortic arch. Preoperatively, we evaluated the substernal extent of the goiter via CT in the extended neck position to decide whether sternotomy was necessary. With the patient’s neck extended, the goiter withdraws cranially above the aortic arch. The mass was then removed via the cervical approach without sternotomy. Preoperative CT in the extended neck position was thus deemed helpful in deciding whether or not sternotomy was required.

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The surgical approach to retrosternal goiters: The role of computerized tomography

Otolaryngology ◽

10.1016/j.otohns.2005.01.039 ◽

2005 ◽

Vol 132 (6) ◽

pp. 849-851 ◽

Cited By ~ 30

Author(s):

JOE Grainger ◽

Natarajan Saravanappa ◽

Alwyn D'souza ◽

David Wilcock ◽

Paul S Wilson

Keyword(s):

Aortic Arch ◽

Median Sternotomy ◽

District General Hospital ◽

Ct Scans ◽

The United Kingdom ◽

Cervical Incision ◽

Patient Morbidity ◽

Retrosternal Goiter ◽

Major Vessel ◽

Preoperative Ct

OBJECTIVE: To assess preoperative CT scans of patients with a retrosternal goiter, with an objective of identifying features that are likely to predict the need for sternotomy at operation. STUDY DESIGN AND SETTING: A retrospective review of clinical notes and CT scans of patients who underwent thyroidectomy for retrosternal goiter at a large district general hospital in the United Kingdom between 1998 and 2002. RESULTS: Extension of the goiter to the level of the aortic arch, particularly when combined with tracheal involvement or major vessel displacement, increases the likelihood of requiring median sternotomy. CONCLUSIONS: Most retrosternal goiters can be approached through a cervical incision alone. However, extension of the goiter to the level of the aortic arch does appear to increase the likelihood of requiring sternotomy. SIGNIFICANCE: In such cases in which sternotomy is anticipated, the availability of cardiothoracic services would be helpful to avoid patient morbidity.

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Сoronary Artery Bypass Grafting in a Patient with Congenital Chest Abnormality with Poland Syndrome

Multidisciplinary Cardiovascular Annals ◽

10.5812/mca.115638 ◽

2021 ◽

Vol 12 (2) ◽

Author(s):

Michael Mikhailovich Alshibaya ◽

Maxim Leonidovich Mamalyga ◽

Dzhanybek Yerikovich Musin ◽

Alexey Vladimirovich Dorofeev ◽

Gela Guramovich Getsadze ◽

...

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass Grafting ◽

Postoperative Complications ◽

Coronary Artery Bypass ◽

Artery Bypass ◽

Median Sternotomy ◽

Poland Syndrome ◽

Bypass Grafting ◽

Successful Completion ◽

Artery Bypass Grafting

Introduction: A rare clinical case of coronary artery bypass grafting in congenital chest abnormality with Poland syndrome is described. This syndrome is a congenital anomaly, which is characterized by a combination of unilateral aplasia or hypoplasia of the sternocostal head of the pectoralis major muscle with ipsilateral brachysyndactyly in the classic version. The cause of Poland syndrome is unknown, but it is believed that it can form with a short-term decrease in blood flow in the subclavian and vertebral arteries. Case Presentation: The presented case shows the possibility of successful completion of coronary artery bypass grafting in Poland syndrome. Revascularization by transluminal balloon angioplasty with stenting reduces the risk of postoperative complications. However, given the degree of damage to the coronary bed and myocardium, in some cases, the patient needs to undergo only coronary artery bypass grafting. The presented case shows the possibility of successful completion of coronary artery bypass grafting in Poland syndrome. Conclusions: We believe that, despite the high risks of postoperative complications, patients with Poland syndrome can be recommended to perform a planned operation of coronary artery bypass grafting, including access through a median sternotomy.

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Ministernotomy: A preliminary experience in heart valve surgery

Vojnosanitetski pregled ◽

10.2298/vsp1105405k ◽

2011 ◽

Vol 68 (5) ◽

pp. 405-409

Author(s):

Pavle Kovacevic ◽

Bogoljub Mihajlovic ◽

Lazar Velicki ◽

Aleksandar Redzek ◽

Vladimir Ivanovic ◽

...

Keyword(s):

Postoperative Complications ◽

Mitral Valve ◽

Minimally Invasive ◽

Median Sternotomy ◽

Valve Surgery ◽

Site Infection ◽

Duration Of Hospital Stay ◽

Extubation Time ◽

Postoperative Drainage ◽

Cerebrovascular Insult

Background/Aim. The last decade of the 20th century brought up a significant development in the field of minimally invasive approaches to the valvular heart surgery. Potential benefits of this method are: good esthetic appearance, reduced pain, reduction of postoperative hemorrhage and incidence of surgical site infection, shorter postoperative intensive care units (ICU) period and overall in-hospital period. Partial upper median sternotomy currently presents as a state-of-the art method for minimally invasive surgery of cardiac valves. The aim of this study was to report on initial experience in application of this surgical method in the surgery of mitral and aortic valves. Methods. The study was designed and conducted in a prospective manner and included all the patients who underwent minimally invasive cardiac valve surgery through the partial upper median sternotomy during the period November 2008 - August 2009. We analyzed the data on mean age of patients, mean extubation time, mean postoperative drainage, mean duration of hospital stay, as well as on occurance of postoperative complications (postoperative bleeding, surgical site infection and cerebrovascular insult). Results. During the observed period, in the Institute for Cardiovascular Diseases of Vojvodina, Clinic for Cardiovascular Surgery, 17 ministernotomies were performed, with 14 aortic valve replacements (82.35%) and 3 mitral valve replacements (17.65%). Mean age of the patients was 60.78 ? 12.99 years (64.71% males, 35.29% females). Mean extubation time was 12.53 ? 8.87 hours with 23.5% of the patients extubated in less than 8 hours. Mean duration of hospital stay was 12.35 ? 10.17 days (in 29.4% of the patients less than 8 days). Mean postoperative drainage was 547.06 ? 335.2 mL. Postoperative complications included: bleeding (5.88%) and cerebrovascular insult (5.88%). One patient (5.88%) required conversion to full sternotomy. Conclusion. Partial upper median sternotomy represents the optimal surgical method for the interventions on the whole ascendant aorta (including aortic valve) and mitral valve through the roof of the left atrium, with a few significant advantages compared to the full sternotomy surgical approach.

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Preoperative predictors of postoperative complications after gastric cancer resection

Surgery Today ◽

10.1007/s00595-019-01877-8 ◽

2019 ◽

Vol 50 (1) ◽

pp. 3-11 ◽

Cited By ~ 2

Author(s):

Mitsuro Kanda

Keyword(s):

Gastric Cancer ◽

Postoperative Complications ◽

Perioperative Management ◽

Future Perspectives ◽

Organ Function ◽

Body Constitution ◽

Preoperative Predictors ◽

Preoperative Factors ◽

Gastric Cancer Resection

Abstract Risk management is becoming an increasingly important healthcare issue. Gastrectomy with lymphadenectomy is still the mainstay of treatment for localized gastric cancer, but it is sometimes associated with postoperative complications that compromise the patient’s quality of life, tolerability of adjuvant treatment, and prognosis. Parameters based exclusively on preoperative factors can identify patients most at risk of postoperative complications, whereby surgeons can provide the patient with precise informed consent information and optimal perioperative management. Ultimately, these predictive tools can also help minimize medical costs. In this context, many studies have identified factors that predict postoperative complications, including indicators based on body constitution, nutrition, inflammation, organ function and hypercoagulation. This review presents our current understanding and discusses some future perspectives of preoperatively identified factors predictive of complications after resection for gastric cancer.

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Long-term Results after Total Thyroidectomy in Patients with Graves' Disease in Uzbekistan: Retrospective Study

World Journal of Endocrine Surgery ◽

10.5005/jp-journals-10002-1062 ◽

2011 ◽

Vol 3 (2) ◽

pp. 79-82

Author(s):

Said I Ismailov ◽

Nusrat A Alimjanov ◽

Bakhodir Kh Babakhanov ◽

Murod M Rashitov ◽

Alisher M Akbutaev

Keyword(s):

Postoperative Complications ◽

Total Thyroidectomy ◽

Thyroid Tissue ◽

Long Term Results ◽

Graves Disease ◽

Nerve Paralysis ◽

Treatment Groups ◽

Institutional Experience

ABSTRACT Subtotal thyroidectomy has been advocated as the standard treatment for Graves' disease (GD) because of the assumed lower risk of complications compared with total thyroidectomy, and also it provides the chance to avoid thyroxin therapy. The present study aims to examine our institutional experience with total thyroidectomy for GD. Patients were divided into two surgical treatment groups: Total thyroidectomy (TT) (n = 97) and total thyroidectomy with intraoperative thyroid autotransplantation (TTITA) (n = 74). TTITA performed in 74 patients. 0.5 to 2 gm of thyroid tissue was cut into small pieces and autotransplanted into the forearm muscle of the patient. Postoperative complications included eight cases of RLN palsy, two patients had nerve paralysis, two patients underwent tracheostomy, transient hypoparathyroidism in 25 patients, permanent hypoparathyroidism in two cases, wound hemorrhage in two patients. TPOAb levels were increased in 9% of patients with TT whereas in patients with TTITA TPOAb concentrations were elevated in 65% of patients at 3 months follow-up. TRAb in patients with TT were not detected while 20% patients undergone TTITA had high TRAb levels and 13.3% had terminal concentrations at 3 months follow-up. Serum TPOAb and TRAb were detected in none of the patients who underwent TT and TTITA at 1, 3 and 5 years follow-up. Removal of all thyroid tissue offers the best chance of preventing recurrent hyperthyroidism and we saw no increase in postoperative complications in the TT group. We feel that TT is safe and superior for achieving the goal of treatment of Graves' disease.

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Total arch replacement through a median sternotomy for Kommerell’s diverticulum

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492316688417 ◽

2017 ◽

Vol 26 (8) ◽

pp. 615-618 ◽

Cited By ~ 1

Author(s):

Yoshihiro Goto ◽

Yutaka Koyama ◽

Soh Hosoba ◽

Shinji Ogawa ◽

Shunsuke Fukaya ◽

...

Keyword(s):

Computed Tomography ◽

Left Subclavian Artery ◽

Median Sternotomy ◽

Right Aortic Arch ◽

Total Arch Replacement ◽

Midline Incision ◽

Operative Strategy ◽

Right Thoracotomy ◽

Kommerell’S Diverticulum ◽

Tracheal Bifurcation

Kommerell’s diverticulum with a right aortic arch and aberrant left subclavian artery is a rare anomaly, and the optimal operative strategy has not yet been established. In particular, the approach to the diverticulum is controversial, with the greatest concern being whether or not to add a right thoracotomy to the median sternotomy for distal anastomosis. We successfully performed total arch replacement through a median sternotomy only, by referring to preoperative computed tomography. We think that if the aneurysm is in a shallow position from the tracheal bifurcation, total arch replacement is possible with a midline incision only.

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