Long-term outcomes of radiofrequency ablation for intrathoracic goiter up to 5 years: evaluated by computed tomography/magnetic resonance imaging and ultrasound.

OBJECTIVES: This study evaluated the long-term efficacy and safety of radiofrequency ablation (RFA) for intrathoracic goiter (ITG) over a follow-up period exceeding six months. METHODS: From 2017 to 2022, 22 patients (6 males, 16 females) with 24 ITGs treated with RFA at a single medical center were evaluated. All patients underwent ultrasonography (US), computed tomography (CT), or magnetic resonance imaging (MRI) before RFA. Follow-up CT/MRI was performed six months after the initial RFA and then every 6-12 months. The primary outcomes measured were the degree of extension, goiter volume, volume reduction rate (VRR), tracheal deviation, and tracheal lumen. Additionally, we assessed the outcomes of single-session RFA (n = 16) vs. multiple sessions (n = 8) on goiters and explored the correlation between ITG volume measurements obtained using ultrasonography and CT/MRI. RESULTS: The median follow-up period was 12 months (interquartile range: 6-36.8 months). At the last follow-up, the nodule volume measured by CT/MRI had significantly decreased (76.2 vs. 24.6 mL; p < 0.05), with a VRR of 64.6%. Patients who underwent multiple RFA sessions showed a significantly higher VRR than the single-session patients (63.8 vs. 80.1%, p < 0.05). The intraclass correlation between goiter volumes measured using US and CT/MRI was moderate. CONCLUSION: This study affirms the long-term efficacy and safety of RFA for ITG, providing an alternative treatment for nonsurgical candidates. Multiple RFA sessions may be beneficial for achieving better volume reduction. Sole reliance on ultrasonography is inadequate; therefore, integrating CT/MRI is essential for accurate pre-RFA and follow-up assessments.

Intrathoracic goiters significantly impact both cosmetic appearance and induce numerous compressive symptoms.Radiofrequency ablation brought notable volume reduction and persistent, effective alleviation of compressive symptoms.Radiofrequency ablation presents a promising therapeutic modality with long-term benefits for patients with intrathoracic goiter.

Innovative trends in surgery: a robotic approach to retrotracheal goitre.

The retrotracheal form is a rare variant of retrosternal goitre. The incidence is low, representing approximately 4% of all retrosternal goitres. The traditional approach to the treatment of this type of pathology is the cervical approach combined with high thoracotomy. Recently, however, new methods and technologies have begun to emerge that also open new possibilities for the surgical management of these conditions. The aim of this case report was to present the potential of a video-robotic approach in the treatment of retrotracheal goitre. The authors have successfully used this innovative method in the treatment of retrotracheal lesions, bringing hope for more effective and less invasive surgical interventions in this difficult-to-access area.

Extended cervical approach for retrosternal multinodular goiter.

Objective: Partial or total sternotomy is required for 10% of retrosternal goiter. This study reviewed our experience with an extended cervicotomic approach as an alternative surgical solution for retrosternal goiter. Methods: A retrospective study was performed on patients who underwent partial or total thyroidectomy for retrosternal goiter between 2014 and 2019 at a tertiary medical centre. Data on clinical, radiologic, and pathologic factors were analysed. Peri- and postoperative outcomes were compared between extended and standard cervical approaches to predict the need for an extended cervical approach. Results: The cohort included 265 patients, of whom 245 (92.4%) were treated by standard thyroidectomy. In 17 (6.4%), the standard approach proved insufficient, and the horizontal incision was extended to a T-shape to improve access. The remaining 3 patients required a sternotomy. Use of the extended cervical approach was significantly associated with clinical features such as male gender, diabetes, high body mass index and postoperative hypocalcaemia. Conclusions: The extended cervicotomic approach is an alternative surgical solution for retrosternal goiter, with no increased risk of significant post-operative complications.

[Clinical application of retrograde thyroidectomy from top to bottom in retrosternal thyroid surgery].

Objective:To investigate the value of retrograde thyroidectomy from top to bottom in the operation of retrosternal thyroid surgery. Methods:Retrospective analysis was performed on the cases of retrosternal goiter excised by our surgeons from January 2017 to June 2022,the technical points, feasibility and advantages of the operation were summarized. Results:A total of 15 cases of retrosternal goiter treated by retrograde thyroidectomy were collected, including 5 cases of type Ⅰ retrosternal goiter and 10 cases of type Ⅱ retrosternal goiter.The postoperative pathology was benign. The surgical time is 40-60 minutes for unilateral retrosternal goiter and 70-90 minutes for bilateral goiter. All patients were discharged normally within 7 days after operation, and no operative complications were observed such as bleeding, hoarseness or hypoparathyroidism. Conclusion:This surgical excision method of thyroid is suitable for the type Ⅰ and type Ⅱ retrosternal goiter surgery, which can avoid the difficulties in exposing and separating the the inferior thyroid behind the sternum in conventional surgical method, speed up the operation and reduced the difficulty of operation, and has certain promotion value in clinic.

Evaluation of thoracic inlet view plain radiograph in the management of patients with goitre.

Background: Thoracic inlet view radiograph is an investigation for assessing patients with goitre in many centres in the sub-Saharan-region. However, there is paucity of information on its usefulness in the diagnosis of retrosternal goitre (RSG) and in planning for thyroidectomy. Method: A review of patients with goitre managed in the Division of Endocrine Surgery, University College Hospital, Ibadan, Nigeria, between 2002 and 2014 was done. Data were obtained from Operating Theatre Log and electronic data archive of the Division. Clinical RSG (CRSG) was taken as a gland that the examining fingers could not get below its lower margin and Radiological RSG (RRSG) on thoracic inlet view was any extension of the thyroid gland beyond the thoracic inlet. Intra-operatively, if any part of the gland extends beyond the thoracic inlet it was considered as an RSG. Results: 221 (96.5%) of the 229 patients who had thoracic inlet plain radiograph were included in this study. The Male to Female ratio was 1:5.5. WHO grade III goitre was seen in 56.1% of the patients and 43.9% had grade II goitre. The CRSG, RRSG and Intra-operative RSG were seen in 7.7%, 16.7% and 17.6% respectively. The specificity and sensitivity of clinical examination in determining RSG was 88.7% and 94.1% and that of Thoracic inlet radiograph was 97.8% and 94.6% respectively. Conclusion: It is a useful study for screening patients with goitre for retrosternal extension, however it could not be used to determine the need for extra-cervical surgical access during thyroidectomy.

Substernal Goiter: a case to remember

SUMMARY Goiter is a localized or generalized thyroid hypertrophy. It can remain within the cervical region or grow down until it invades the mediastinum. The signs and symptoms depend on the size and location of the goiter. Although drugs and radioactive iodine are often used to treat thyroid disease, the presence of symptomatic substernal goiter is a clear indication for surgery. Death or postoperative complications rarely occur. We present a case of a 71-year-old man with recurrent thyroid pathology in the form of substernal goiter and hyperthyroidism even after partial thyroidectomy. The importance of this relates to the clinical evolution, volume, and location of the goiter as well as the surgical and pharmacological approach.

RESUMO O bócio é a hipertrofia da glândula tiroide localizada ou generalizada. Esta pode localizar-se na região cervical ou crescer através do mediastino. Os sinais e sintomas dependem do tamanho e da localização do bócio. Embora os fármacos e o iodo radioativo sejam frequentemente usados para tratar doenças tireoidianas, a presença do bócio subesternal sintomático é uma clara indicação para a cirurgia. A morte ou complicações pós-operatórias são raras. Apresentamos o caso de um homem de 71 anos com recorrência de patologia tireoidiana sob a forma de bócio subesternal e hipertireoidismo após tireoidectomia parcial. A importância desse caso relaciona-se com a evolução clínica, o volume e a localização do bócio e a abordagem cirúrgica e farmacológica desse tipo de patologia.

Tiroides endotorácico: Indicaciones del abordaje endotorácico / Endothoracic thyroid. Indications of endothoracic approach

INTRODUCCIÓN Y OBJETIVO: La incidencia de bocio endotorácico entre los pacientes sometidos a tiroidectomía oscila entre el 6% y el 30%. Aunque el abordaje cervical es suficiente en la mayoría de los casos, el abordaje endotorácico puede ser necesario en el 1-5.5% de los pacientes. Por lo que es recomendable anticiparlo. El objetivo del presente artículo es describir los factores predictivos de necesidad de este tipo de abordaje. Síntesis: Los principales factores de riesgo para la realización de esternotomía en los casos de bocio subesternal son la extensión por debajo del cayado aórtico y la localización retrotraqueal o retrovascular. El abordaje torácico será igualmente necesario en bocios ectópicos mediastínicos sin conexión con el tiroides cervical y se recomendará la valoración por un cirujano torácico en casos de bocio olvidado, así como en pacientes con antecedentes de radioterapia o cirugía cervical y sospecha de malignidad con afectación extra-tiroidea. La elección del abordaje dependerá de la localización, del tamaño de la masa y su relación con los órganos vecinos; los abordajes mínimamente invasivos pueden ser alternativas seguras a la esternotomía o la toracotomía. Las complicaciones postoperatorias más frecuentes de la resección de tiroides endotorácico son típicas de la cirugía tiroidea: parálisis recurrencial temporal o permanente, hipoparatiroidismo, insuficiencia respiratoria y sangrado postoperatorio. CONCLUSIONES: Hasta en un 5% de las tiroidectomías, puede ser necesario un abordaje torácico, por lo que es conveniente anticiparlo. El abordaje torácico será necesario en casos de bocio con extensión por debajo del cayado, localización retrotraqueal o retrovascular y en bocios mediastínicos sin conexión con el tiroides cervical

INTRODUCTION AND OBJECTIVE: The incidence of endothoracic goiter among patients undergoing thyroidectomy ranges from 6% to 30%. Although the cervical approach is sufficient in most cases, the endothoracic approach may be necessary in 1-5.5% of patients. So it is advisable to anticipate it. The objective of this article is to describe the indications if this kind of approach. SYNTHESIS: The main risk factors for performing sternotomy in cases of substernal goiter are the extension below the aortic arch and the retrotracheal or retrovascular location. The thoracic approach will be equally necessary in mediastinal ectopic goiters without connection to the cervical thyroid. The evaluation by a thoracic surgeon in cases of forgotten goitre will be recommended, as well as in patients with a history of radiotherapy or cervical surgery and suspected malignancy with extrathyroid involvement. The choice of approach will depend on the location, the size of the mass and its relationship with the neighboring organs. Minimally invasive approaches can be safe alternatives to sternotomy or thoracotomy. The most frequent postoperative complications of endothoracic thyroid resection are typical of thyroid surgery: temporary or permanent recurrent paralysis, hypoparathyroidism, respiratory failure and post-operative bleeding. CONCLUSIONS: Up to 5% of thyroidectomies, a thoracic approach may be necessary, so it is convenient to anticipate it. The thoracic approach will be necessary in cases of goiter with extension below the arch, retrotracheal or retrovascular location and in mediastinal goiters without connection to the cervical thyroid

Traqueomalacia, complicación de la exéresis de un bocio difuso endotorácico bilateral / Tracheomalacia: a complication after removal of bilateral endothoracic diffuse goiter

Introducción: En cirugía de la glándula tiroides la mortalidad es nula en algunas series por lo que la morbilidad es la mayor preocupación del cirujano. Objetivo: Presentar la evolución clínica de una paciente con tiroidectomía total por bocio endotorácico bilateral. Caso clínico: Paciente que se le realizó tiroidectomía total por bocio endotorácico bilateral, técnicamente difícil, biopsia por congelación negativa de malignidad, bocio coloide. Nervios recurrentes visualizados. Debido al tamaño de la glándula y lo complejo que resultó la extracción se decidió trasladar a la paciente a la sala de recuperación intubada y ventilada para proceder a la recuperación de la ventilación espontánea y la extubación en un período más prolongado. Fue extubada una primera vez que fue fallida. Fue reintubada y ocurrió en una segunda ocasión después de ser reintervenida por un posible hematoma de la herida. En la TAC preoperatoria se observó una glándula tiroides grande con prolongación endotorácia bilateral y estenosis alta de la tráquea. Conclusión: Las complicaciones de obstrucción de la vía aérea después de una tiroidectomía no son frecuentes. Generalmente, después de una tiroidectomía total o parcial se trata de recuperar al paciente en el quirófano para después de la extubación realizar una laringoscopia que descarte la parálisis de las cuerdas vocales. La traqueomalacia como complicación después de una tiroidectomía no es frecuente, por lo que se alerta que de no haber diagnosticado y tratado rápidamente la paciente podría tener un desenlace fatal(AU)

Introduction: In surgery of the thyroid gland, mortality is null in some series, so morbidity is the surgeon's greatest concern. Objective: To present the clinical evolution of a patient with total thyroidectomy due to bilateral endothoracic goiter. Clinical case: This patient underwent total thyroidectomy due to bilateral endothoracic goiter, technically difficult, negative freeze biopsy of malignancy, colloid goiter. Visualized recurrent nerves. Due to the size of the gland and how complex the extraction was, it was decided to transfer the patient to the intubated and ventilated recovery room to proceed with the recovery of spontaneous ventilation and extubation in a longer period. She was extubated the first time it failed. She was re-intubated and it occurred on a second occasion after being re-operated due to a possible hematoma of the wound. In the preoperative CT scan, a large thyroid gland with bilateral endothoracic prolongation and high stenosis of the trachea was observed. Conclusion: Complications of airway obstruction after thyroidectomy are not frequent. Generally, after a total or partial thyroidectomy, it is a matter of recovering the patient in the operating room, in order to perform, after extubation, a laryngoscopy to rule out paralysis of the vocal cords. Tracheomalacia as a complication after thyroidectomy is not frequent, so it is warned that failure to diagnose and treat the patient quickly could have a fatal outcome(AU)

Substernal goiter and laryngopharyngeal reflux

ABSTRACT Objective This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. Subjects and methods A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. Results The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. Conclusion This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Bocio intratorácico asociado a vértigo / Intrathoracic goitre associated with vertigo

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Abordaje del bocio endotorácico en mediastino posterior: incisión transcervical y toracotomía lateral / Best Approach for Posterior Mediastinal Goiter Removal: Transcervical Incision and Lateral Thoracotomy

La extirpación quirúrgica del bocio intratorácico puede realizarse a través de un abordaje cervical en la mayoría de los pacientes. La revisión de la literatura pone de manifiesto que los cirujanos experimentados precisan un abordaje extracervical en el 2-3% de los casos. A pesar de que el tratamiento quirúrgico del bocio retroesternal está bien definido, existe poca información acerca del abordaje quirúrgico de los bocios intratorácicos que se extienden más allá del cayado aórtico hacia el mediastino posterior. Presentamos 2 casos y proponemos una combinación de incisión cervical y toracotomía lateral con preservación muscular para la resección del bocio en el mediastino posterior. En este tipo de casos descartamos el uso de la esternotomía puesto que el mediastino posterior resulta inaccesible debido a la presencia del corazón y grandes vasos por delante de la masa tiroidea, lo cual podría llevar a realizar una peligrosa disección a ciegas. Según nuestra experiencia el abordaje transcervical combinado con la toracotomía está indicado para una resección completa y segura del bocio situado en el mediastino posterior

Surgical removal of intrathoracic goiter can be performed by a cervical approach in the majority of patients. Review of literature shows that experienced surgeons need to perform an extracervical approach in 2-3% of cases. In spite of surgical management of substernal goiter is well defined, there is little available information about surgical approach of intrathoracic goiters extending beyond the aortic arch into the posterior mediastinum. We report two cases and propose combination of cervical incision and muscle-sparing lateral thoracotomy for posterior mediastinal goiter removal. In such cases, we do not favor sternotomy as posterior mediastinum is inaccessible due to the presence of heart and great vessels anterior to the thyroidal mass that would lead to perform a perilous blind dissection. Based on our experience, transcervical and thoracotomy approach is indicated for a complete and safe posterior mediastinal goiter remova

Tratamiento quirúrgico del bocio retroesternal: experiencia en un centro de Marruecos / Surgical management of retrosternal goitre: experience of a Moroccan centre

Introducción y objetivos: Se realiza un estudio retrospectivo para la revisión de 93 casos de bocio retroesternal (BR) operados en nuestro departamento, a fin de describir los datos epidemiológicos y clínicos y tratar los retos quirúrgicos de los BR. Pacientes y métodos: De enero de 2004 a diciembre de 2012, tratamos quirúrgicamente a 35 varones y 58 mujeres con BR. Realizamos cervicotomía en 89 casos (95,7%), y la esternotomía fue necesaria en 4 casos (4,3%). Se realizó laringoscopia en todos los casos. Fue imperativa una segunda laringoscopia preoperatoria realizada por un especialista para los pacientes con ronquera o disnea, incluso cuando el examen laríngeo inicial era normal. Resultados: Se observó una masa cervical en 81 casos (87,1%), disnea en 17 casos (18,3%), disfagia en 2 casos (2,1%), ronquera en 7 casos (7,5%), síndrome parcial de la vena cava en 2 casos y bocio recurrente en 2 casos (2,1%) tras la resección tiroidea previa. La extensión mediastínica se localizó en el lado izquierdo en 47 casos (50,5%), en el lado derecho en 29 casos (31,2%), y bilateralmente en 17 casos (18,3%). Se practicó tiroidectomía total en 86 casos (92,5%), e istmo-lobectomía unilateral en 7 casos (7,5%). El tamaño medio del bocio fue de 9,3 cm. Se presentaron complicaciones postoperatorias en 9 casos (9,7%), 3 casos con hipoparatiroidismo (3,2%) y 4 casos (4,3%) de lesión del nervio recurrente. No se produjeron muertes postoperatorias. El estudio histológico detectó 88 casos de bocio multiheteronodular, 4 casos de enfermedad de Graves-Basedow, y un caso de carcinoma tiroideo (carcinoma papilar). Conclusión: Nuestra experiencia confirma que la cervicotomía permite a menudo la extirpación del bocio con extensión mediastínica. Sin embargo, puede requerirse una esternotomía, alargándose el tiempo quirúrgico, la estancia hospitalaria y la morbilidad (AU)

Introduction and objectives: This was a retrospective study reviewing 93 cases of retrosternal goitre (RG) operated in our department, with the aim of describing epidemiological and clinical data and discussing the surgical challenges of RG. Patients and methods: From January 2004 to December 2012, 35 men and 58 women presenting with RG had surgery. Eighty-nine cases (95.7%) underwent cervicotomy, and a sternotomy was mandatory in 4 cases (4.3%). Laryngoscopy was performed in all cases. A second preoperative laryngoscopy by a senior was mandatory for patients with hoarseness or dyspnea even if the initial laryngeal exam was normal. Results: A cervical mass was noted in 81 cases (87.1%), dyspnea in 17 cases (18.3%), dysphagia in 2 cases (2.1%), hoarseness in 7 cases (7.5%), partial vena cava syndrome in 2 cases and recurrent goitre was noted in 2 cases (2.1%) after previous thyroid resection. Mediastinal extension was on the left side in 47 cases (50.5%), on the right side in 29 cases (31.2%) and bilateral in 17 cases (18.3%). A total thyroidectomy was performed in 86 cases (92.5%) and a unilateral isthmo-lobectomy was performed in 7 cases (7.5%). Mean goitre size was 9.3 cm. Postoperative complications were present in 9 cases (9.7%), 3 cases with hypoparathyroidism (3.2%) and 4 cases (4.3%) of recurrent nerve injury. There was no postoperative death. The histological study objectified 88 cases of multiheteronodular goitre, 4 cases of Basedow thyroid, and 1 case of thyroid carcinoma (papillary carcinoma). Conclusion: Our experience confirms that cervicotomy often allows removing goitre with a mediastinal extension. However, intraoperative enlargement may be necessary, with increased operating time, hospital stay and morbidity (AU)

Caracterización y resultados inmediatos en pacientes con tratamiento quirúrgico de bocio intratorácico / Characterization and immediate results in patients with surgical treatment of intrathoracic goiter

Objectives: To describe characteristics and immediate results of surgical treatment of patients with intrathoracic goiter (ITG). Methods: Retrospective review. Period: October 2003 - March 2010. We describe general characteristics, morbidity and mortality. Results: 33 patients, 23 women, mean age 59.1 +/- 14.3 years. Preoperative thyroid function: 32 euthyroid and 1 hyperthyroid. Asymptomatic 10 patients. ITG rate: 31 cervico-mediastinal and 2 mediastinal. Approach: 24 cervicotomy, 7 cervicotomy and sternotomy and 2 sternotomy. Type of resection: 19 total thyroidectomy and 14 subtotal thyroidectomy. Histology: 29 benign and 4 malignant neoplasms. Postoperative stay: median of 4.5 days. Complications in 12 patients: 10 hypo-parathyroidism (9 transient and 1 permanent), 2 dysphonia, 2 cervical hematoma (one redo), 1 wound infection and 1 ventilator associated pneumonia. One patient died (pneumonia). Conclusions: The ITG is more common in women, most are euthyroid and may be asymptomatic. Most can be resected by cervicotomy. The histology is benign in most but may represent malignancies. The surgery is not free of morbidity and mortality.

Objetivos: Describir características y resultados inmediatos del tratamiento quirúrgico de pacientes con Bocio Intratorácico (BIT). Material y Método: Revisión retrospectiva. Período: octubre de 2003 - marzo de 2010. Se describen características generales y morbi-mortalidad. Resultados: 33 pacientes, 23 mujeres, edad promedio 59,1 +/- 14,3 años. Comorbilidades: 12 hipertensos y 1 diabético. Función tiroidea preoperatoria: 32 eutiroideos y 1 hipertiroideo. Asintomáticos 10 pacientes. Tipo BIT: 31 cérvico-mediastínicos y 2 mediastínicos. Abordaje: 24 cervicotomía, 7 cervicotomía más esternotomía y 2 esternotomía. Tipo de resección: 19 tiroidectomía total y 14 tiroidectomía subtotal. Histología: 29 benignos y 4 neoplasias malignas. Estadía postoperatoria: mediana de 4,5 días. Complicaciones en 12 pacientes: 10 hipoparatiroidismos (9 transitorios y 1 permanente), 2 disfonías, 2 hematomas cervicales (uno se reexploró), 1 infección herida operatoria y 1 neumonía asociada a ventilación mecánica. Fallece un paciente (neumonía). Conclusiones: El BIT es más frecuente en mujeres, la mayoría son eutiroideos y pueden ser asintomáticos. La mayoría pueden ser resecados por cervicotomía. La histología es benigna en la mayoría aunque pueden corresponder a neoplasias malignas. La cirugía no está exenta de morbi-mortalidad.

Insuficiência respiratória aguda secundária a bócio mergulhante da tireoide / Acute respiratory insufficiencysecondary to substernal thyroid goiter

Relato de caso de bócio mergulhante (BM) em idosa com longa história de bócio nodular tóxico (BNT) e que evoluiu com insuficiência respiratória aguda enquanto aguardava cirurgia eletiva para extirpação do bócio. A evolução das complicações respiratórias dessa paciente sugere que o tratamento cirúrgico do BM em idosos deveria ser feito o mais breve possível, após o surgimento de sintomatologia respiratória, para evitar complicações.

Case report of substernal thyroid goiter in an elderly woman with long record of toxic nodular goiter that progressed to acute respiratory insufficiency while waiting for elective surgery for extirpation of goiter. The development of respiratory complications suggests that the surgical treatment of substernal thyroid goiter affecting elderly people should be pursuit as soon as possible after the appearance of respiratory symptomatology as a means of avoiding complications.

Avaliação crítica de 33 pacientes com bócio mergulhante tratados cirurgicamente por cervicotomia / A critical analysis of 33 patients with substernal goiter surgically treated by neck incision

A possibilidade de ser necessário um acesso combinado, com uma incisão cervical e outra torácica, torna o tratamento do bócio mergulhante um desafio tanto no pré quanto no intra-operatório. Discutimos uma padronização da técnica cirúrgica para minimizar a necessidade da abordagem torácica, tornando o bócio mergulhante uma patologia tratável cirurgicamente, por uma única incisão cervical, e com baixos índices de complicações. OBJETIVO: Avaliar a abordagem cirúrgica do bócio mergulhante por cervicotomia e analisar as complicações cirúrgicas. MATERIAL E MÉTODOS: Foi realizada uma coorte histórica com corte transversal por análise retrospectiva dos prontuários de pacientes submetidos à tireoidectomia no período de maio de 2002 a julho de 2007. Um total de 316 pacientes foi submetido à tireoidectomia sendo 33 (10,4 por cento) por bócio mergulhante. RESULTADOS: Todos os 33 pacientes foram tratados cirurgicamente por via cervical sem necessidade de esternotomia. Não foram observadas lesões definitivas de nervo laríngeo inferior ou hipoparatireoidismo definitivo. Apenas 2 pacientes apresentaram paresia de nervo recorrente e 2 pacientes foram reabordados por hematoma cervical. CONCLUSÃO: Pacientes com bócio mergulhante podem ser tratados cirurgicamente por uma única incisão cervical com segurança e baixos índices de complicação.

The possibility of needing a combined access, with neck and chest incisions makes the treatment of substernal goiter a challenge both in the pre-op and the intraoperative. We hereby, discuss a standardization of the surgical technique to minimize the need for a chest approach, making the substernal goiter a surgically treatable disease, through a single neck incision, and with low indices of complication. AIM: to assess the substernal goiter surgically approach through a neck incision and to analyze the surgical complications. MATERIALS AND METHODS: we carried out a historical cohort by retrospective analysis of the charts of patients submitted to thyroidectomy, and 33 of them (10.4 percent) had substernal goiter. RESULTS: all 33 patients were surgically treated through a neck incision without the need for sternotomy. We did not observe definitive lesions in the inferior laryngeal nerve or definitive hypoparathyroidism. Only 2 patients had recurrent nerve paresis; and 2 patients were re-operated because of a neck hematoma. CONCLUSION: patients with substernal goiter can be safely treated surgically through a single neck incision, bearing low complication rates.

Bócio ectópico intratorácico primário no mediastino posterior: relato de caso e revisão de literatura / Primary ectopic intrathoracic goiter in posterior mediastinum: a case report and review of the literature

O bócio ectópico intratorácico primário é entidade muito rara que corresponde à presença de tecido tireoidiano aberrante hiperplasiado, localizado no interior do tórax, sem possuir nenhum contatoou relação com a tireóide cervical, que se encontra geralmente com aspecto normal. Apresentamos um caso de paciente do sexo feminino, 61 anos de idade, com os achados de radiografia etomografia computadorizada, associado a revisão de literatura, demonstrando os achados de imagem, diagnósticos diferenciais, possíveis fatores etiológicos e os tratamentos.

The ectopic primary intrathoracic goiter is an uncommon tumor that corresponds to a hyperplasia of an ectopic thyroid tissue, that develops in the thorax, distinct from the cervical thyroid gland,which usually exists on its normal aspect. We report the case of a 61-year-old female patient, with the aspects of the radiograph and computed tomography examinations, comparing them with the literature, demonstrating the image aspects, differential diagnosis,possible etiology factors and treatments of the disease.

Resultado del tratamiento quirúrgico del bocio endotorácico / Result of the surgical treatment of the goiter endotorácico

Se realizó un estudio retrospectivo y prospectivo de 30 pacientes estudiados y tratados por bocio endotorácico, seleccionados de un universo de 450 pacientes operados por nosotros a causa de diversas enfermedades tiroideas en el período comprendido entre 1994 y 2004. El sexo predominante fue el femenino (83,3 por ciento) y la edad promedio, de 52 años. El aumento de volumen (86,6 por ciento) y la disfagia (16,6 por ciento) fueron los síntomas más frecuentes. Se utilizó el ultrasonido y la radiografía de tórax en todos los casos, mientras que la biopsia por aspiración con aguja fina (BAAF) se empleó en el 96,6 por ciento de los pacientes. El bocio coloide difuso, con 19 casos (63,3 por ciento), fue el tipo histológico más observado. La hemitiroidectomía más la exéresis de la prolongación endotorácica (12 casos; 40 por ciento) fue la intervención quirúrgica más realizada. No presentó complicaciones el 93,3 por ciento de los pacientes y se presentó un caso con granuloma de la herida y otro con hipoparatiroidismo transitorio, lo cual constituyó el 3,3 por ciento. En nuestros casos no encontramos degeneración maligna del bocio(AU)

He/she was carried out a retrospective and prospective study of 30 studied patients and tried by goiter endotorácico, selected of an universe of 450 patients operated by us because of diverse thyroid illnesses in the period understood between 1994 and 2004. The predominant sex was the feminine one (83,3 percent) and the age average, 52 years old. The increase of volume (86,6 percent) and the disfagia (16,6 percent) they were the most frequent symptoms. It was used the ultrasonido and the thorax x-ray in all the cases, while the biopsy for aspiration with fine needle (BAAF) it was used by 96,6 percent of the patients. The goiter diffuse colloid, with 19 cases (63,3 percent), it was the type more observed histológico. The more hemitiroidectomía the exéresis of the continuation endotorácica (12 cases; 40 percent) it was the carried out surgical intervention. It didn't present complications 93,3 percent of the patients and a case was presented with granuloma of the wound and another with transitory hipoparatiroidismo, that which constituted 3,3 percent. In our cases we don't find wicked degeneration of the goiter(AU)

Tratamiento quirúrgico del bocio intratorácico / Surgical treatment of intrathoracic goitre

La definición de Katlic es la que mejor describe el bocio intratorácico, entidad que incluye un pequeño subgrupo (1-4%) de los pacientes con bocio multinodular que generalmente se presentan con síntomas compresivos graves y requieren atención especializada en centros de referencia. El estudio preoperatorio debe incluir técnicas de imagen torácicas para planificar la intervención más adecuada. La cirugía debe ser la tiroidectomía total y en más del 95% de los casos el bocio se puede extraer por vía cervical. Es necesario un abordaje cervical amplio y la identificación del nervio recurrente cerca de la unión cricotiroidea lo cual facilita la liberación del tiroides de todas sus fijaciones cervicales antes de traccionar suavemente hacia arriba del componente torácico para su extracción. Los bocios intratorácicos que requieren esternotomía para su extracción son los bocios recidivados, los que presentan cáncer avanzado, algunos de los que alcanzan la carina y los bocios posteriores izquierdos que se extienden hacia la cavidad pleural derecha (AU)

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 preoperative 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 (AU)