[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.

Giant retrosternal goitre causing lung atelectasis.

Not required for Clinical Vignette.

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.

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.

Cervicotomy using a hemi-clamshell approach for a rare enlarged substernal goitre.

The substernal goitre is defined as a goitre for which >50% of the mass is located below the superior orifice of the thorax, surgical resection remains the reference treatment, the approach used is the cervicotomy, which often allows to extract the mediastinal portion of the plunging goitre, and we report a rare case of a huge cancerous plunging goitre whose complete resection required the enlargement of the cervicotomy in right hemi-clamshell, for the carcinological, vascular and recurrent control.

Substernal goitre presenting with upper and lower extremity oedema.

Substernal goitre is characterised by compressive symptoms of the airway and oesophagus. Chronic, progressive symptoms usually result in surgical removal. We report a rare presentation of substernal goitre in a male in his early 70s who suffered from severe bilateral lower extremity (LE) lymphoedema, resulting in immobility and nursing home placement, and left upper extremity lymphoedema. Our initial assessment led to a filariasis work-up, which was negative, due to the patient's prior 2-year residence in India and service overseas. Chest CT scan revealed an incidental substernal goitre extending posterior to the left innominate vein and aortic arch to the level of the left mainstem bronchus. The patient underwent a left hemithyroidectomy via cervical excision and sternotomy and had an uneventful recovery with resolution of lymphoedema and mobility. Despite extensive literature regarding clinical presentations of substernal goitre, severe lymphoedema of the LE is not a well-established association.

Cardiopulmonary Arrest Caused by Large Substernal Goiter-Treatment with Combined Cervical Approach and Median Mini-Sternotomy: Report of a Case.

INTRODUCTION: Substernal goiter is usually defined as a goiter that extends below the thoracic inlet or a goiter with more than 50% of its mass lying below the thoracic inlet. Substernal goiters may compress adjacent anatomical structures causing a variety of symptoms. CASE REPORT: Here we report a rare case of a 75-year-old woman presenting with cardiac arrest caused by acute respiratory failure due to tracheal compression by a substernal goiter. DISCUSSION: Substernal goiters can be classified as primary or secondary depending on their site of origin. Symptoms are diverse and include a palpable neck mass, mild dyspnea to asphyxia, dysphagia, dysphonia, and superior vena cava syndrome. Diagnosis of substernal goiter is largely based on computed tomography imaging, which will show the location of the goiter and its extension in the thoracic cavity. Surgery is the treatment of choice for symptomatic patients with substernal goiter. The majority of substernal goiters are resected through a cervical approach. However, in approximately 5% of patients, a thoracic approach is required. The most important factor determining whether a thoracic approach should be used is the depth of the extension to the tracheal bifurcation on CT imaging. CONCLUSION: Cardiac arrest appearing as the first symptom of a substernal goiter is a very rare condition and should be treated by emergency thyroidectomy via a cervical or thoracic approach depending on the CT imaging findings.

Enlargement of Intrathoracic Goiter with Unilateral Phrenic Nerve Paralysis Leading to Cardiopulmonary Arrest.

As an intrathoracic goiter expands, it causes airway stenosis and phrenic nerve paralysis, and slight respiratory stimuli can trigger sudden life-threatening hypoventilation. A 78-year-old obese woman with a large intrathoracic goiter was found unconscious with agonal breathing in her room early in the morning. Cardiopulmonary resuscitation restored spontaneous circulation. She underwent surgical removal of the goiter; however, she required long-term mechanical ventilation because of atelectasis due to phrenic nerve paralysis. In patients with large intrathoracic goiters, difficulty breathing on exertion and diaphragm elevation on chest X-ray may be significant findings predicting future respiratory failure.

A Cohort Study Assessing the Association Between Body Composition Parameters and Symptomatic Hypocalcemia After Total Thyroidectomy.

BACKGROUND: Postoperative hypocalcemia is one of the major concerns following thyroidectomy and the most frequent cause of prolonged hospital stay. The aim of this study was to evaluate the relationship between body composition parameters and symptomatic hypocalcemia following total thyroidectomy. In addition, the effects of disease- and patient-related factors on hypocalcemia were investigated. METHODS: A total of 144 patients were prospectively included between March 2014 and September 2017. Patients were divided into 2 groups according to the presence or absence of clinical symptoms of hypocalcemia. Subsequently, the relationship between body composition parameters and hypocalcemia was evaluated. RESULTS: Postoperative hypocalcemia-related symptoms occurred in 28 patients (19.4%). Permanent hypocalcemia was not encountered in any patient. Patients with hypocalcemic symptoms were more likely to have nodules ≥40 mm (39.3% vs. 17.2%, P = .011), retrosternal goiters (25.0% vs. 7.8%, P = .017), central lymph node dissection (LND) (32.1% vs. 11.2%, P = .015), and parathyroid autotransplantation (28.6% vs. 3.4%, P < .001) than those without symptoms. However, no differences were observed in the body composition parameters between symptomatic and asymptomatic patients. On multivariate analysis, lower preoperative intact parathyroid hormone (iPTH) levels (odds ratios (ORs) .96, 95% confidence intervals (CIs) .93-.99), the presence of retrosternal goiters (OR 10.26, 95% CI 2.23-47.14), central LND (OR 16.05, 95% CI 3.90-66.07), and parathyroid autotransplantation (OR 36.22, 95% CI 6.76-194.13) predicted hypocalcemia. DISCUSSION: This study demonstrates that patients with lower preoperative iPTH levels, retrosternal goiters, central LND, and parathyroid autotransplantation are at an increased risk of developing clinical symptoms of hypocalcemia. Body composition parameters have no effect on the incidence of hypocalcemia after total thyroidectomy.

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

Extracorporeal membrane oxygenation for the anesthetic management of a patient with a massive intrathoracic goiter causing severe tracheal obstruction with positional symptoms: A case report.

INTRODUCTION: Perioperative anesthetic management in cases of severe airway obstruction with positional symptoms can be associated with difficulties in ventilation or intubation, with a risk of acute respiratory decompensation at every stage of anesthesia. PATIENT CONCERNS: Here we describe the anesthetic management of a 67-year-old man with a massive intrathoracic goiter causing severe tracheal obstruction with positional symptoms. The patient presented with progressive dyspnea that was aggravated in the supine position and was scheduled for total thyroidectomy. DIAGNOSIS: Preoperative computed tomography showed a large goiter extending into the thoracic cavity, with diffuse segmental tracheal narrowing for 6 cm. The diameter at the narrowest portion of the trachea was 4.29 mm. INTERVENTIONS: Before the induction of general anesthesia, we applied extracorporeal membrane oxygenation (ECMO) in preparation for potential difficulties in securing the airway during general anesthesia. Subsequently, anesthesia was successfully induced and maintained. OUTCOMES: After the surgical procedure, fiberoptic bronchoscopy and chest radiography showed resolution of the tracheal narrowing. ECMO was weaned 2 hours after the surgery, and the patient was extubated on the first postoperative day. He was discharged without any complication. CONCLUSION: The findings from this case suggest that the use of ECMO before the induction of general anesthesia is a safe method for maintaining oxygenation in patients with severe tracheal obstruction.

Obstructive retrosternal goitre mimicking severe bronchial asthma in pregnancy.

Acute airway obstruction in pregnancy remains a challenge to manage. Failure of appropriate and timely airway management may lead to maternal morbidity and mortality such as aspiration pneumonitis or worst hypoxaemic cardiopulmonary arrest. 1 As pregnancy may exacerbate asthma attacks, parturient presenting with wheezing or shortness of breath will commonly be treated as suffering from an asthmatic attack. 2 However, it is important to note other possible differential diagnoses. Thyroid disease is relatively common in women of childbearing age. The thyroid gland undergoes several changes during pregnancy, which may lead to altered function as well as gland enlargement and cause upper airway obstruction and symptoms similar to a bronchial asthma attack. 3 4 With that in mind, we report a case of a parturient with long-standing goitre in her second trimester who presented to our institution with acute respiratory symptoms and cardiopulmonary arrest.

Cough syncope and tracheal compression secondary to a retrosternal goitre: looking for a pulmonary embolism.

A 51-year-old man presented acutely with recurrent bouts of coughing associated with transient and brief loss of consciousness consistent with cough syncope, mild stridor and a recent history of a respiratory tract infection. A chest X-ray demonstrated tracheal narrowing. His D-dimer was negative. A non-contrast CT scan of the chest demonstrated a large retrosternal goitre causing tracheal compression, and further investigation with a contrast-enhanced CT scan of the neck and chest demonstrated an incidental finding of a large pulmonary embolus (PE). The full extent of the PE was determined through performing a CT pulmonary angiography. Doppler ultrasound demonstrated a left leg deep vein thrombosis as the primary cause of the PE. His cough syncope improved in response to anticoagulation treatment, to the point where he could be safely discharged home. He had a further significant improvement in symptoms following an elective hemithyroidectomy for retrosternal goitre.

Retrosternal goiter presenting as deep vein thrombosis of the arm.

INTRODUCTION: Deep vein thrombosis of the upper-extremity (ueDVT) is often caused by trauma to the subclavian vein, central venous line and hypercoagulation disorders. CASE REPORT: We present a case of a ueDVT due to retrosternal goiter compressing the right brachiocephalic vein. Low molecular weight heparin was initiated subcutaneously and fluid was aspirated from the thyroid cyst causing an immediate improvement. Cytology detected no malignancy. At eight-month follow-up, the patient showed complete resolution of her symptoms. DISCUSSION: In general, the optimal treatment should include removal of the compressing thyroid. In co-morbid patients and a dominant thyroidal cyst, thyroid aspiration may be sufficient.

Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters.

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.