Feasibility of thoracoscopic approach for retrosternal goitre (posterior mediastinal goitre): Personal experiences of 11 cases

Surgical Treatment of Substernal Goiter Part 2: Cervical and Extracervical Approaches, Complications

The most appropriate treatment of substernal goiter (SG) is surgery. These patients should be evaluated carefully and multidisciplinary in pre-operative period and surgical management should be planned preoperatively. Although most of the SGs can be resected by the cervical approach, an extracervical approach may be required in a small proportion of patients. Surgical complications of SG related to thyroidectomy are higher than other thyroidectomies. In addition to the complications related to thyroidectomy, complications related to the type of surgical intervention may also occur in SG. The patients who may be needed extracervical approaches should be consulted with thorax surgeons, cardiovascular surgeons, and anesthesiologists preoperatively; the surgical management should be planned together. In this part, we aimed to evaluate the cervical approach methods, extracervical approach methods, technical details, and complications in detail.

Retro-sternal Goitre: an Overview

Retro-sternal goitres are slow growing in nature. Dyspnoea on exertion is the most common presenting symptom due to the pressure effect of goitre on trachea. Due to the increased use of radiological investigations, retrosternal goitres are often diagnosed incidentally without any symptoms. Surgical resection is considered the gold standard management in all symptomatic patients and most of asymptomatic patients. However, "wait and watch" approach is an option, in selected asymptomatic patients, with the evolution of alternative treatment methods. So, the management of retrosternal goitre continues to be a surgical controversy. This article aims at reviewing the evidence-based practice of management of retrosternal goitres including challenges of surgery and postoperative complications.

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.

Surgical Treatment of Substernal Goiters Extending to Posterior Mediastinum

Aim

The purpose of this study was to identify the clinical features of posterior mediastinal goiters and surgical treatment strategies on the basis of our experiences.

Methods

Clinical data of 23 cases of posterior mediastinal goiters in 122 substernal goiters from a total of 4381 thyroidectomies performed in the Division of Thyroid Surgery of the General Surgery Department of Xiangya Hospital, Central South University, China, during a 6-year period (2010–2016) were analyzed.

Results

Posterior mediastinal goiters have a greater prevalence of compression symptoms compared with anterior mediastinal goiters (P < 0.05). Substernal goiters that extend to posterior mediastinum have a higher probability of mass bottom below the aortic arch than those extending to anterior mediastinum (P < 0.05). A total of 20 posterior mediastinal goiters (87.0%) underwent thyroidectomies by cervical approach without additional incision. In 3 of the 23 patients (13.0%), 1 thoracotomy and 2 thoracoscopic approaches were performed for a complete and safe removal. Postoperative complications occurred in 5 of 23 patients (21.7%), including temporary recurrent laryngeal nerve paralysis and transient hypoparathyroidism in our series.

Conclusions

Surgical removal of posterior mediastinal goiters can be performed safely by a single cervical approach in most patients. Thoracoscopic approach proposes a new treatment strategy with feasibility.

Retrosternal goitre: the role of the thoracic surgeon

Purpose of this Mini-Review is to evaluate the role of a thoracic surgeon in the surgical management of retrosternal goitre. A cervical approach is sufficient in the majority of the cases. On the other hand, there are cases where a cervical approach is combined with sternotomy or thoracotomy, depending on the position of the goitre, in the anterior or posterior mediastinum. On top of that, different minimally invasive approaches including video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery (RATS) have been introduced, providing faster recovery, superior manoeuvrability and better aesthetic results.