Retrosternal goitre and its management

Retrosternal goiter (RSG) is a term that has been used to describe a goiter that extends beyond the thoracic inlet. Retrosternal goitre is defined as a goitre with a portion of its mass ≥ 50% located in the mediastinum. Surgical removal is the treatment of choice and, in most cases, the goitre can be removed via a cervical approach. Aim of this retrospective study was to analyse personal experience in the surgical management of retrosternal goitres, defining, in particular, the features requiring sternotomy. Retrospective study, teaching hospital-based. Retrospective analysis of 687 thyroidectomies performed between 2008 and 2019. The 47 (6.84 %) patients with RSG were analyzed further, with regard to demographics, presentation, indications, and outcome of surgical treatment. There were 47 patients (6.84 %) with RSG, [ 34 females (72.34%), 13 males (27.66%)] (mean age: 52 years, range: 34-76)], out of 687 thyroidectomies, in a 14 -year period. The most common presentation was neck swelling (68%), followed by respiratory symptoms (46.8%) and the surgical procedure predominantly used was total thyroidectomy. The RSGs were removed by collar incision in 43 (91.5 %) of the cases, only 4 cases (8.5 %) required sternotomy, (residual thyroid in mediastinum after cervical approach in one case and due to very large thyroid reaching the main bronchial bifurcation in the other three). The final histological diagnosis revealed malignancy in 8.5 % of the thyroid specimens. There was no mortality and minor complications occurred in nine patients (19.1%). The presence of an RSG is an indication for surgery owing to the lack of effective medical treatment, the higher incidence of symptoms related to compression, low surgical morbidity, and the risk of malignancy. Surgical removal of a retrosternal goitre is a challenging procedure; it can be performed safely, in most cases, via a cervical approach, with a complication rate slightly higher than the average rate for cervical goitre thyroidectomy, especially concerning hypoparathyroidism and post-operative bleeding. The most significant criteria for selecting patients requiring sternotomy are computed tomography features, in particular the presence of an ectopic goitre, the extent of the goitre to or below the tracheae carina. If retrosternal goitre thyroidectomy is performed by a skilled surgical team, familiar with its unique pitfalls, the assistance of a thoracic surgeon may be required only in a few selected cases

Case Report: Modified Thoracoscopic-Assisted Cervical Resection for Retrosternal Goiter

Introduction: The treatment of choice for retrosternal goiters (RSG) is surgical resection to relieve symptoms and rule out malignancy. Although the majority of RSG can be removed by a cervical approach only, an extracervical approach (e.g., sternotomy, thoracotomy or thoracoscopy) may be required. Herein, we describe a refined thoracoscopic-assisted cervical two-team RSG resection without thoracoscopic mediastinal dissection.Technique: A 57-year-old man presented with a large RSG with posterior mediastinal extension (PME) and extensive peritumoral vascularization. Due to its extension below the aortic arch and its small connection with the right thyroid lobe, a combined cervical and thoracoscopic approach was intended. The endocrine surgery unit performed the cervical mobilization of the right thyroid lobe, while the thoracic surgery unit gently pushed the mediastinal tumor through the thoracic inlet without performing mediastinal dissection. This allowed a safe visualization of the inserting vessels by the endocrine surgery team at the neck, followed by a stepwise division of the vessels and resection of the retrosternal nodule through the cervical access.Comment: The described approach is indicated for RSG with posterior mediastinal extension, anteroposterior dimension smaller than the thoracic inlet and inaccessibility from a cervical approach only. This minimally invasive approach is associated with a faster recovery, decreased morbidity and postoperative pain, shorter hospital stay and better cosmetic results.

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

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.

Anesthesia and airway management in a patient with acromegaly and tracheal compression caused by a giant retrosternal goiter: a case report

A giant retrosternal goiter can lead to compression of vital organs in the mediastinum with high risk of acute cardiorespiratory decompensation. Additionally, patients with acromegaly are prone to developing severe airway obstruction and ventilation difficulties during anesthetic induction, leading to hypoxia and an increased partial pressure of carbon dioxide. Therefore, more comprehensive airway management strategies are needed. We herein describe a 57-year-old man with acromegaly and severe tracheal obstruction caused by a giant retrosternal goiter. He presented with a 1-week history of progressive dyspnea and was scheduled to undergo right lobe thyroidectomy and retrosternal goiter thyroidectomy. We created a comprehensive emergency plan for a difficult airway, including regional and topical anesthesia for awake endotracheal intubation, sevoflurane inhalation, small doses of midazolam and sufentanil to increase tolerance, self-made extended-length tracheostomy, video laryngoscope-assisted fiber-optic bronchoscopy, extracorporeal membrane oxygenation, and surgical tracheostomy. Importantly, tetracaine was inhaled through an atomizer, and a laryngotracheal topical anesthesia applicator was used to spray the larynx with 1% tetracaine to reduce stimulation during intubation. The giant goiter was successfully removed through the cervical approach. A carefully designed airway management strategy and close communication among a multidisciplinary operation team are the basis of perioperative anesthetic management for these patients.

Modern approaches to the treatment of retrosternal goiter

Objective. To analyze the results of treatment of patients with retrosternal goiter. Materials and methods. During the period from 2010 to 2019, 62 patients with thoracic goiter were operated on, which was 6.2% of all patients operated in relation to goiter. There were 48 women (77.4%) and 14 men (22.6%). Age of patients varied from 21 to 87 years (average age - 47 years). Computed tomography was mandatory in terms of research. The size of the sternal goiter and the degree of operative risk were determined by G. Mercante (2011). Results. In 39 patients (1st group) the operation was performed by cervicotomy according to standard techniques. Video endoscopic support was used in 23 patients, thanks to which in 15 patients (group 2) it was able to cross all blood vessels with the help of an electro coagulator and isolate nerve structures and parathyroid glands. In 8 patients (group 3) there was a massive bleeding after attempts of finger dissection. They underwent tamponade and temporarily stopped bleeding. After that, a video endoscope was inserted into the wound and hemostasis was performed with the help of an electrocoagulation. Bleeding from the surgical wound, which required revision, was not observed. Temporary tracheostomy in the postoperative period was imposed in 3 patients, later it was closed. Hypocalcemia occurred in 12 (19.3%) patients (in 11 it was transient). Transient paresis of the recurrent nerves was observed in 3 patients of the 1st, 2 of the 2nd and 2 of the 3rd groups. Permanent paresis of the recurrent nerve occurred in only 1 patient of the 3rd group. According to histological examination, 21 patients were diagnosed with cancer (19 - papillary, 2 - follicular). They subsequently underwent standard treatment for highly differentiated thyroid cancer. Conclusions. The use of cervical access with video endoscopic support during surgery for thoracic goiter avoids performing a sternotomy, reduces blood loss and operational trauma, improves the nerve structures and parathyroid glands identification, and reduces the duration of surgery. The use of modern methods of electrocoagulation significantly expands the capabilities of endoscopic techniques.