Surgical management of goiter with intrathoracic extension at the Philippine General Hospital Department of Otolaryngology Head and Neck Surgery

Objective@#To describe the demographic and clinical characteristics of patients diagnosed with intrathoracic thyroid masses managed surgically in our institution, determine associated factors affecting eventual operative approaches for these patients, and assess postoperative outcomes and complications associated with surgical intervention.@*Methods@#Design: Retrospective descriptive case series. Setting:Tertiary National University Hospital. Participants: 24 patients.@*Results@#The mean age of patients diagnosed with intrathoracic goiters was 55.71 years old, with a 1:1.4 male to female ratio; with most having an intrathoracic extent of Huins Grade 1 (67%) compared to others having Huins Grade 2-3. Majority of patients pre-operatively had a Fine Needle Aspiration (FNA) Bethesda Thyroid Nodule Classification of Category II (benign); 79% of total patients underwent excision of thyroid mass utilizing a transcervical approach alone. As Intrathoracic Extension (ITE) grade increased, additional transthoracic approaches were performed; duration of operation, average estimated blood loss, length of hospital stay was also noted to increase. Majority of post operative surgical histopathology results revealed malignant thyroid masses, in contrast to pre-operative FNA. Post-operative transient hypocalcemia was the most reported immediate complication. @*Conclusions@#Management of intrathoracic goiter is often multidisciplinary. Referral to the thoracic vascular service is warranted for access to the thoracic inlet. Classification by grade of intrathoracic goiters is helpful to determine the most appropriate operative approach and may be predictive of intraoperative and postoperative outcomes. Postoperative histopathology across all ITE grades mostly yield malignant results; hence, preoperative FNA results should be used with caution.

Resultados de la cirugía de sustitución esofágica con tubo gástrico invertido vía ascenso retroesternal en dos hospitales pediátricos / Results of esophageal substitution surgery with inverted gastric tube via retrosternal lift

Resumen Objetivo: Describir resultados de la cirugía de sustitución esofágica con tubo gástrico invertido, vía ascenso retroesternal en dos hospitales pediátricos durante el período marzo 2015 a marzo 2018. Materiales y Método: Un estudio observacional, transversal, con recolección de datos retrospectivo, donde se incluyeron todos los expedientes de pacientes que presentaban patología del esófago por causa adquirida o congénita que fueron operados de sustitución esofágica con tubo gástrico invertido en dos hospitales pediátricos durante 3 años. Resultados: Encontramos 29 niños sometidos a sustitución esofágica, de los cuales 27 cumplieron criterios de inclusión. La edad comprendida entre 2 y 17 años. El 63% corresponde al sexo femenino. La causa más frecuente de sustitución esofágica es por estenosis esofágica por ingesta caustica (92,59%). El 70% presentó algún tipo de complicación luego de la cirugía. La fístula esofagocutánea es la complicación principal con 33,33%. La permanencia en la unidad de cuidados intensivos es menor de 24 horas en un 74% de los niños. Se inicia la vía oral en casi la mitad de casos entre los 10-12 días de posquirúrgico, la estancia hospitalaria es en promedio 18,5 días. La mortalidad es 3,7%. Conclusión: La sustitución esofágica por tubo gástrico invertido vía ascenso retroesternal, es una técnica comparable en resultados a la interposición de colón. Para los autores, el estómago es un órgano ideal para realizar la reconstrucción esofágica, y sus complicaciones son manejables.

Aim: To describe the results of esophageal replacement surgery with an inverted gastric tube via retrosternal ascent in two pediatric hospitals during the period March 2015 to March 2018. Materials and Method: an observational, cross-sectional study with retrospective data collection that included all the records of patients with esophageal discontinuity due to acquired or congenital causes who underwent esophageal replacement surgery with an inverted gastric tube in two pediatric hospitals for 3 years. Results: We found 29 children undergoing esophageal replacement, of which 27 met inclusion criteria. The age between 2 to 17 years. 63% corresponds to the female sex. The most frequent cause of esophageal replacement is esophageal stricture due to caustic ingestion (92.59%). 70% presented some type of complication after surgery. The esophagocutaneous fistula is the main complication with 33.33%. The stay in the intensive care unit is less than 24 hours in 74% of children. The oral route is started in almost half of cases between 10-12 days after surgery; the hospital stay is on average 18.5 days. Mortality is 3.70%. Conclusión: The esophageal substitution by inverted gastric tube via retrosternal ascent is a technique comparable in results to the interposition of the colon. For the authors, the stomach is an ideal organ to perform esophageal reconstruction, and its complications are manageable.

Comparison of Modified Rose Method of Thyroid Palpation versus other Methods for the Detection of Retrosternal and Nodular Goitre / Journal of the ASEAN Federation of Endocrine Societies

Objectives@#This is a diagnostic test research study to evaluate the various existing methods of thyroid examination and their comparison with the novel modified Rose method. It also aims to measure inter-examiner variation in clinical findings based on the level of education and training, as compared to ultrasonography.@*Methodology@#This cross-sectional study was conducted at a tertiary care hospital with 83 patients presenting to surgery OPD with neck swelling. Each patient was examined by one trained Junior Resident and a Surgery Consultant with all the four methods and with ultrasonography. Data was analysed by Stata-14, agreement between the two categorical variables was assessed by Kappa. In case of continuous variable agreement was assessed by Intra class correlation and Bland-Altman plot.@*Results@#Modified Rose method by the consultant has the highest sensitivity (98%) and diagnostic odds (210) as compared to others but its specificity ranges from 46.7-91.1% to diagnose retro-sternal extension of a goiter. It has 93.98% agreement for identification of nodules. It has a high specificity (Consultant - 100%, Resident - 95.5%) with relatively lower sensitivity (Consultant - 94%, Resident - 86.8%) to diagnose solitary thyroid nodule (STN) but the sensitivity and specificity for diagnosing a multinodular goitre (MNG) was high. However, the highest sensitivity to diagnose STN was highest with Crile’s method, but specificity was low. Lahey’s method was a better clinical method to palpate lymph nodes compared to the other three.@*Conclusion@#Examination in modified Rose’s position is a better method of clinical examination of thyroid especially in patients with occult substernal extension. Lahey’s method is a better method to examine cervical lymph nodes.

Giant retrosternal goiter masquerading as, right posterior mediastinal mass: a rare case report

Complete mediastinal plunging thyroid gland is a rare entity, accounting for 1% of all mediastinal tumours, particularly posterior mediastinal tumour much more rare. We would like to present, a 30-year-old lady presented to ENT department with neck swelling and its further investigation shown to be giant posterior mediastinal mass. Thyroid function tests were normal. CT scans of the neck and chest revealed a large right mediastinal mass compressing the trachea from the right side and extending to the superior part of the posterior mediastinum with enlarged right thyroid gland in the cervical position. Midline extended sternotomy was done for complete surgical excision of the mass along with right hemi thyroidectomy. It was well circumscribed, capsulated, multinodular firm inconsistency, and vascular. Histopathology revealed thyroid tissue negative for malignancy. Giant plunging thyroid in the mediastinum is very rare. It should be differentiated from other mediastinal mass. The plunging goiter in posterior mediastinum is surgically challenging. Transsternal surgical removal is the treatment of choice in such cases.

A seven year experience in patients undergoing total thyroidectomy for benign diseases in a single unit of tertiary care centre: a retrospective case study

Background: Thyroidectomy is a common surgical procedure performed worldwide by surgeons with varied training. It is the experience and the skills by which a surgeon performs, the indication of surgery and the extent of surgery which determines the outcome and the complication rates.Method: This study is a retrospective study performed from January 2012 to December 2018 when a total of 170 patients underwent total thyroidectomy via kocher’s incision for benign diseases with clinically in hypothyroid state at Safdarjung Hospital, New Delhi in a single unit of a tertiary care hospital.Results: The male: female ratio was 1:7.09 with average age of patients being 40years. The overall complication rate was 18.82% (32 patients). Postoperative transient hypocalcaemia being the most common complication. There was no case of permanent hypocalcaemia. There was no injury to any nerve (recurrent or superior laryngeal). Transient recurrent laryngeal paresis was noted in 4(2.35%) which resolved with conservative management. Complications like wound infection, sympathetic chain injury were not noted. The characteristic feature of this study was five cases of giant secondary retrosternal goitre which had average weight of greater than 500 grams which were operated using kocher’s incision. The average weight of other 165 patients was 70grams +/- 12 grams. There were no major post-operative complications except for post-operative recurrent laryngeal nerve paresis and seroma formation which was evacuated after 3 weeks of surgery.Conclusion: Hence, from this it is concluded that it is the surgical experience and skills of the surgeon which make total thyroidectomy a safe procedure providing permanent cure with a low post-operative morbidity risk even with large sized retrosternal thyroid glands which can be operated via neck incision.

A study of the symptoms of gastro oesophageal reflux disease and the associated risk factors in a tertiary care centre

Background: Gastro esophageal reflux disease is the commonest pathologies encountered by gastroenterologist in day to day practice. Longstanding and untreated gastro esophageal reflux disease can lead to many complications including adenocarcinoma. This study was conducted to evaluate the various symptoms and to analyze the lifestyle and dietary factors influencing gastro esophageal reflux disease which can be modified.Methods: Hundred patients with gastro-esophageal reflux disease of age more than 18 years were enrolled in the study. Various patient details including demographic details, lifestyle information and symptomatology data were analyzed and compared with complications.Results: Mean age of gastro esophageal reflux disease patients was 56.09±15.93 years. Gastro esophageal reflux disease is more prevalent in males than females. Gastro esophageal reflux disease is more frequent in BMI <25, greater number of co morbidities and in non-vegetarians.  Mean age of gastro esophageal reflux disease with complications was 67±11.53 years and without complications was 52.64±15.57 years. No strong association of smoking, alcohol, spicy foods, fried foods, citrus fruits, heavy meals, tea/coffee, aerated drinks, sleep disturbance and effect on work was identified in gastro esophageal reflux disease.Conclusions: Classical symptoms of gastro esophageal reflux disease were not present in all the patients. Higher age of the patient infers higher risk of complications. Daily episodes of heartburn, regurgitation and retrosternal chest pain implies higher risk of complications. Presence of Helicobacter pylori in gastro esophageal reflux disease patients signify higher risk of complications.

A Case of Stanford Type A Acute Aortic Dissection after Surgery for Esophageal Cancer / 日本心臓血管外科学会雑誌

A 76-year-old man with a history of total esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer was transferred to our hospital because of consciousness disorder. It became an emergency operation on diagnosis of Stanford type A acute aortic dissection on enhanced CT. Because CT showed the retrosternal gastric tube ran along the right side of the body of the sternum through the back side of the manubrium, we opted for skin and the suprasternal incision on the left side from center. We could perform total aortic arch replacement without the damage of the gastric tube except that the right side of the operative view was slightly poor. We did not recognize digestive organ symptoms such as postoperative passage disorders nor mediastinitis. The patient was discharged from our hospital on postoperative day 24.

Resection of left atrial myxoma in a patient with retrosternal gastric tube: a case report

Abstract The median sternotomy remains the standard approach in cardiovascular surgery but, in some conditions, it can be considered difficult to perform, especially in patients with history of esophagectomy. This case report describes a successful resection of a left atrial myxoma through a right anterolateral thoracotomy approach in a patient with a previous retrosternal gastric tube reconstruction. The decision for the best surgical approach was made after a heart surgery team discussion. Through this surgical access, a safe and excellent exposure of the left atrium was possible, and a complete resection of the myxoma was performed without any injury to the gastric tube.

Bócio retroesternal: incidência de câncer / Retrosternal Goiter: cancer incidence

O bócio retroesternal é uma afecção rara da glândula tireóide, que acomete principalmente mulheres acima de 60 anos, caracterizada por tireóide aumentada de tamanho, peso e volume, que invade a cavidade torácica total ou parcialmente. A não realização do ato cirúrgico tem sido preconizada em alguns casos como forma alternativa de melhoria da qualidade de vida, sobretudo em pacientes idosos assintomáticos. Todavia, existe uma incidência de câncer nos bócios retroesternais, associado a um índice maior de complicações, que justifica a abordagem cirúrgica precoce, principalmente em pacientes jovens, mesmo que assintomáticos. Este trabalho resulta de um relato de caso e revisão de literatura, sobre bócio retroesternal e incidência de câncer em uma paciente de 62 anos, submetida a tireoidectomia total, com achados histopatológicos de pós operatório, de carcinoma papilífero, carcinoma folicular e adenoma folicular. Esses achados nos alerta para a possibilidade de incidência de câncer nesses pacientes, devendo ser aventado o tratamento cirúrgico precoce. (AU)

The retrosternal goiter is a rare thyroid gland disease, which mainly affects women over 60 years, characterized by increased thyroid size, weight and volume, which invades the thoracic cavity. Failure to perform the surgery has been recommended in some cases as an alternative way of improving the quality of life, especially in asymptomatic elderly patients. However, there is an incidence of cancer in retrosternal goiters associated with a higher rate of complications, justified the early surgical approach, especially in young patients, even if asymptomatic. This work results from a case report and literature review on retrosternal goiter and cancer incidence in a 62-year-old patient submitted total thyroidectomy with histopathologic findings after surgery, papillary carcinoma, follicular carcinoma and follicular adenoma. These findings alerts us to the possibility of cancer incidence in these patients, recommending in such cases, early surgical treatment.

Multinodular goiter: an unusual case presentation.

Goitrous enlargement of the thyroid gland usually presents as a nontender anterior neck mass. Asymptomatic patients may be treated medically, which often reduces the size of the gland or avoids progression of the disease. Neglected or ineffectively treated cases may grow beyond the confines of the gland, which primarily occurs caudally into the mediastinum. In this paper, we present a patient with multinodular goiter with a large retrosternal component.

A Case of Acute Stanford Type A Aortic Dissection after Retrosternal Gastric Tube Reconstruction for Esophageal Cancer / 日本心臓血管外科学会雑誌

An 80-year-old man presented with a history of retrosternal gastric tube reconstruction for esophageal cancer. He experienced sudden chest pain, and temporarily lost consciousness, before being transferred to our hospital. Contrast-enhanced computed tomography revealed acute Stanford type A aortic dissection and a retrosternal gastric tube. We performed emergency operation using a median sternotomy approach. Before median sternotomy, we detected the gastric tube in the subxiphoid and suprasternal spaces. The anterior and right sides of the gastric tube were dissected bluntly from the posterior surface of the sternum and median sternotomy was performed. The gastric tube was mobilized to the left side and we were able to obtain the usual operative view for ascending aorta graft replacement. Intraoperatively, the gastric tube remained intact and uninjured. The patient was transferred to another hospital for rehabilitation on postoperative day 34.

Aortic Valve Replacement Concomitant with Coronary Artery Bypass Grafting after Substernal Gastric Interposition for Esophageal Cancer / 日本心臓血管外科学会雑誌

We present a rare case of cardiac surgery for coronary artery single vessel disease and aortic valve stenosis after substernal gastric interposition for gastric cancer. An 80-year-old man, who had undergone esophagectomy and substernal gastric interposition 7 years previously, was referred to our institute for surgical treatment of coronary artery disease and aortic valve stenosis. Through a median sternotomy with cardiopulmonary bypass, we performed aortic valve replacement and coronary artery bypass grafting to the right coronary artery without injury to the gastric tube. Postoperatively, the patient was on respirator care and catecholeamine support for several days. Although urinary tract infection occurred, he recovered with antibiotic therapy. Finally, he was discharged on postoperative day 40. For cardiac surgery after substernal gastric interposition for esophageal cancer, even though the substernal gastric tube may preclude the usual median approach, median sternotomy is an appropriate alternative with close preoperative examination and careful dissection of substernal gastric tube.

Mitral Valve Replacement for Mitral Regurgitation with Annular Calcification after Esophageal Resection and Retrosternal Gastric Tube Reconstruction / 日本心臓血管外科学会雑誌

A 79-year-old man developed congestive heart failure. He was given a diagnosis of severe mitral regurgitation with calcification of the posterior mitral annulus and secondary tricuspid regurgitation. He had a history of esophageal resection with retrosternal gastric tube reconstruction about 20 years previously. We replaced the mitral valve with a mechanical prosthesis and performed tricuspid ring annuloplasty through a right parasternal approach. We did not risk resecting the calcified annulus, but fixed the prosthesis and annulus with the equine pericardium in between as a cushion and collar, to prevent perivalvular leakage. The postoperative course was uneventful.