Minimal Invasive Resection of Large Retrosternal Thyroid Goiter.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure. The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection. To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day. Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter's size and mediastinal positioning.

Postoperative laryngeal granuloma in mediastinal goitre with gastro-oesophageal reflux disease.

Reported postoperative complications of mediastinal goitre include recurrent laryngeal nerve palsy, hypoparathyroidism and tracheomalacia. Voice and swallowing symptoms after thyroid surgery have been associated with laryngopharyngeal reflux, but it is unclear whether the retrograde flow of gastric contents into the oesophagus, larynx and pharynx worsens after thyroid surgery. We present the case of a man in his 40s with gastro-oesophageal reflux disease (GERD) who developed heartburn and laryngeal granuloma after total thyroidectomy for mediastinal goitre. Vonoprazan therapy effectively controlled these symptoms. Although the exact cause remains unclear, we suggest that changes in pressure dynamics after thyroidectomy may worsen the retrograde flow of gastric contents into the oesophagus, larynx and pharynx, contributing to GERD symptoms and laryngeal granuloma. This case highlights the need to consider the management of retrograde flow of gastric contents into the oesophagus, larynx and pharynx in the postoperative care of mediastinal goitre resections.

Uniportal VATS removal of a giant mediastinal goitre.

We demonstrate the technical nuances and operative strategy of uniportal video-assisted thoracoscopic surgical excision of a giant mediastinal goitre in a patient with a complex medical history, including a prior total thyroidectomy for multinodular goitre and partial gastrectomy for gastrointestinal stromal tumour. The video tutorial presents the surgical removal of a substantial mediastinal goitre, persisting post-total thyroidectomy performed 2 years prior via a collar incision. We opted for a thoracoscopic technique for the removal of the residual mediastinal mass. A 3-cm uniportal incision was made at the fifth intercostal space along the mid-axillary line. Pleural exploration confirmed the absence of adhesions. Subsequent dissection revealed a large retrocaval goitre adjacent to the trachea. Utilizing a combination of LigaSure technology for sharp dissection, and blunt dissection techniques using the peanuts, we severed the goitre's attachments to surrounding critical structures, including the trachea, superior vena cava and oesophagus. The dissection continued, extending into the cervical region from the thoracic approach. The mass was safely enclosed within an endobag and extracted through the uniportal incision. This case demonstrates the feasibility and effectiveness of the uniportal thoracoscopic approach for complex mediastinal pathology. This approach was successfully executed with an uneventful perioperative course and no complications, indicating positive outcomes in complex thoracic cases despite a minimally invasive approach for the resection of mediastinal masses.

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.

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.

Posterior Mediastinal Goiter Removal Through Cervical Incision.

Intrathoracic goiter when encountered can be treated by thyroidectomy using cervical incision, only occasionally requiring extra cervical approach. We are reporting one such case in a patient with pituitary macroadenoma with extension of the adenomatous goiter into the posterior mediastinum. It was removed through the cervical collar incision using a vessel sealing device. There were no intraoperative and postoperative complications during the procedure. The need for extra cervical incision should be decided on a case-to-case basis to avoid the increased morbidity associated with sternotomy and lateral thoracotomy incision.

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.

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.

Transcervical and robotic-assisted thoracoscopic resection of a substernal goiter.

Several genetic and environmental factors contribute to the development of multinodular goitre. A transcervical surgical resection is recommended for larger goitres, though a minority of cases may require sternotomy or thoracotomy. We present a case of a posterior substernal goitre that was resected with combined transcervical and robotically assisted thoracic approaches. A woman in her 30s with an enlarging thyroid goitre elected to proceed with surgical resection. CT imaging demonstrated significant extension of the goitre into the posterior mediastinum and a staged approach was decided on. Both the initial transcervical thyroidectomy and the subsequent robotically assisted resection of the mediastinal portion were successful, without major complications. While most substernal goitres can be resected transcervically, certain rare anatomic features, such as extension into the posterior mediastinum, warrant consideration of a thoracic approach. Specifically, a robotic-assisted resection poses several advantages over traditional, more invasive approaches.

Giant retrosternal goitre causing lung atelectasis.

Not required for Clinical Vignette.

Surgical Management of 48 Patients with Retrosternal Goiter and Tracheal Stenosis: A Retrospective Clinical Study from a Single Surgical Center.

BACKGROUND Benign retrosternal thyroid goiters can become large enough to compress the trachea and result in tracheomalacia and stenosis. This retrospective study from a single surgical center aimed to study the surgical management of 48 patients with retrosternal goiter and tracheal stenosis diagnosed and treated from January 2017 to December 2021. MATERIAL AND METHODS All preoperative contrast-enhanced CT scans showed retrosternal goiter and tracheal stenosis. RG was classified into type I in 28 patients, type II in 12 patients, and type III in 8 patients. TS was classified into grade I in 31 patients, grade II in 11 patients, and grade III in 6 patients. All patients were referred for surgery. Clinicopathologic features and surgical outcomes were recorded. RESULTS All operations were successfully performed. There were 41 patients with transcervical incision, 4 with cervical incision+sternotomy, 2 with cervical incision and thoracoscopic surgery, and 1 with cervical incision and surgery via the subxiphoid approach. Two patients presented recurrent laryngeal nerve injury. One patient showed short-term hand and foot numbness. The patients were pathologically diagnosed as simple nodular goiter (n=27), nodular goiter combined with cystic change (n=6), adenomatous nodular goiter (n=10), and thyroid adenoma (n=5). There was no prominent tumor recurrence or gradual TS remission. CONCLUSIONS This study has highlighted that patients with retrosternal goiter and tracheal stenosis may have comorbidities and require a multidisciplinary approach to management. The choice of anesthesia, surgical approach, and maintenance of the airway during and after surgery should be individualized.

Depth of mediastinal extension can predict sternotomy need for substernal thyroid goiters.

BACKGROUND: Surgical excision of substernal thyroid goiters is usually achieved through a conventional transcervical approach, and transthoracic excision is rarely necessary. Currently, there are no clear guidelines for substernal thyroid goiters that may require a transthoracic approach. This study examined what preoperative factors were significantly associated with transthoracic surgical excision for substernal thyroid goiters. METHODS: A retrospective review of prospectively collected data of 109 patients with substernal thyroid goiters from a single institution was performed. The patients were stratified by transcervical and transthoracic approaches for substernal thyroid goiters. The factors possibly predictive of a transthoracic approach, including substernal extension beyond the thoracic inlet, patient-reported symptoms, tracheal deviation, and malignancy, were analyzed. Demographics including age, sex, and race, among others, were also studied. RESULTS: Of 1,080 patients who underwent surgical resection for multinodular goiter, there were 109 (10%) patients with substernal thyroid goiters. Of the substernal thyroid goiter group, 11 (10%) patients underwent partial sternotomy, whereas 6 (5.5%) underwent total sternotomy. On logistic regression, only substernal component of the thyroid goiter extending beyond the sternal notch into the mediastinum was statistically significant in predicting sternotomy (odds ratio 3.43, confidence interval 1.65-6.41, P < .001). Substernal thyroid goiters with mediastinal extension of ≥5 cm beyond the sternal notch showed a sensitivity of 94% and specificity of 86.5% to predict need of sternotomy. CONCLUSION: Patients with substernal thyroid goiters who exhibit progressive enlargement and/or compressive symptoms should undergo surgical excision. Although most are removed through the conventional transcervical approach, substernal thyroid goiters with a depth of mediastinal extension ≥5 cm have a high likelihood of requiring sternotomy.

Combined thoracoscopic and axillary subcutaneous endoscopic thyroidectomy: a novel approach for cervicomediastinal goiters.

PURPOSE: After our group described the first remote-access thyroidectomy series in 2000, the procedure has been further developed. Although a thoracoscopic approach with a conventional open cervical incision for thyroid goiters with mediastinal extension has been performed at many institutions, remote-access thyroidectomy for cervicomediastinal goiters has not been established. We have performed combined thoracoscopic and axillary subcutaneous endoscopic thyroidectomies (axillo-thoracic endoscopic thyroidectomies). Here, we describe a novel technique for performing a remote-access thyroidectomy for a cervicomediastinal goiter (CMG). PATIENTS AND METHODS: The patients with CMGs who agreed to an axillo-thoracic endoscopic thyroidectomy at one of two hospitals in Japan underwent a remote-access thyroidectomy. RESULTS: We performed the axillo-thoracic endoscopic right or left hemithyroidectomy successfully, but most of the patients did not require the thoracoscopic procedure. None of the patients had complications, and none was converted to an open thyroidectomy. CONCLUSIONS: Most thyroid goiters with substernal extension can be removed by the axillary approach, but some cases require a thoracoscopic approach. The novel approach described herein (axillo-thoracic endoscopic thyroidectomy) enables the safe excision of a CMG with high patient satisfaction for selected patients.

A large intrathoracic goiter with tracheal stenosis: Complete resection using a robot-assisted thoracoscopic approach.

Growing intrathoracic goiters may compress surrounding organs and deteriorate the cardiopulmonary function. Treating such cases requires carefully considering how to maintain oxygenation and resect the tumor with minimal invasiveness without complications. We herein report a surgically resected case of a large intrathoracic goiter-compressed trachea extending from the right lower pole of the thyroid gland to the carina. We secured the airway by intubation preparing for extracorporeal membrane oxygenation and successfully performed surgical complete resection using a robot-assisted thoracoscopic and cervical approach. Intrathoracic goiter is a tumor with abundant neovascularity, and the right vagus nerve is displaced in the thoracic cavity, but a robot-assisted thoracoscopic approach using CO2 insufflation improved visualization at the narrow apex area of the thoracic cavity. Robot-assisted thoracoscopic surgery is a useful surgical procedure enabling safe and minimally invasive surgery without recurrent laryngeal nerve palsy or tracheal injury for intrathoracic giant goiters extending into the thoracic cavity.

Morbidity Associated With Surgical Removal of Substernal Thyroid Goiters.

INTRODUCTION: Surgical excision of substernal thyroid goiters (STG) can be challenging while minimizing postoperative morbidity. Postoperative complication rates associated with transcervical and transthoracic approaches (i.e., partial or total sternotomy) for STG compared to multinodular goiters (MNG) limited to the neck (i.e., non-substernal) remains unclear. This study examines postoperative morbidity related to surgical approaches in the removal of STG and MNG. METHODS: A retrospective review of prospectively collected data of 988 patients with STG and non-substernal MNG from a single institution between 2010 and 2021 was performed. Patients were stratified by STG and conventional non-substernal MNG limited to the neck excised by transcervical and transthoracic approach. Postoperative complications including neck hematoma requiring return to the operating room, permanent recurrent laryngeal nerve injury and hypocalcemia, and transient or temporary recurrent laryngeal nerve injury and hypocalcemia were identified. Demographics including age, sex, and race, among others, were analyzed. RESULTS: Of the 988 cases, there were 887 (90%) MNG and 101 (10%) STG. Of the STG cohort, 11 (11%) required a partial sternotomy and 4 (4%) required a total sternotomy. Permanent complication rates for non-substernal MNG and STG patients were 1.5% and 0.9%, respectively. Only transient or temporary hypocalcemia rates were statistically different between the STG and MNG cohorts (9.9% versus 3.8%, P < 0.001). CONCLUSIONS: Regardless of transcervical or transthoracic approach, postoperative complications associated with the surgical removal of STG are low in the hands of experienced, high-volume thyroid surgeons.

Retrosternal Goitre: Anatomical Aspects and Technical Notes.

Background and Objectives: surgery for substernal goitre is still debated in the literature, due to the wide range of surgical options. This article outlines the findings of our extensive experiences, which include 264 cases of patients with "goitre plongeant", and compares postoperative complications, despite surgical approaches. Material and Methods: preoperative planning and anatomical landmarks are described to determine the potential need of a combined approach. The surgical procedure is described, along with some stratagems, to ensure that the operation is completed safely. A statistical analysis of complications and the length of stay, with a comparison of cervicotomy and combined access, was performed using the Pearson chi-square significance test. Results: 264 patients underwent thyroid surgery for substernal goitre. The Kocher incision was the surgical approach chosen in 256 patients (96.6%), while an accessory incision was performed in 8 patients (3.4%). The necessity to use a two-fold surgical access was linked to a higher rate of postoperative complications (p-value < 0.01). The average length of stay (LOS) for cervicotomy was 2 days (1−3 days), while the average LOS was 5 days (4−7 days) (p-value = n.s.) for combined access. Conclusions: cervicotomy should be the gold standard technique for exploring intrathoracic goitre with a digital dissection, which, in almost all cases, enables the externalization of the mediastinal portion associated. Sternotomy is related to a higher rate of complications, so it should be performed only in selected cases. Management in large-volume centres may be more appropriate.