Surgical management of mediastinal goiter: risk factors for sternotomy.

BACKGROUND AND AIMS: Mediastinal goiter constitutes an indication for surgical management. The procedure can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The objective of the investigation was to analyze the prevalence and therapeutic results in patients with mediastinal goiter and to assess factors that affect the need of performing sternotomy in the course of mediastinal goiter surgery. MATERIAL AND METHODS: In the years 1984-2004, i.e., over 21 years, 11,849 patients with various types of goiter were operated on in the department. Mediastinal goiter was detected in 88 (0.76%) individuals. The analyzed material included 64 (72.7%) females and 24 (27.3%) males. The age of the patients ranged between 19 to 81 years, with the mean age of 61 +/- 13 years of life. The material was statistically analyzed. Risk factors for sternotomy were assessed using the multidimensional logistic regression method. RESULTS: The highest percentage of mediastinal goiter was noted in patients operated on due to recurrent goiter (3.86%). Goiter situated in the anterior mediastinum was noted in 61 (69.3%) individuals, while 27 (30.7%) patients demonstrated goiter located in the posterior mediastinum; of the latter, nine were previsceral and 18 retrovisceral. In the majority of cases, these were primarily cervical goiters, which descended from the neck to the mediastinum (53 patients). Aberrant adenomas were diagnosed in 32 (36.4%) individuals. Four patients presented with the superior cava vein syndrome. Primary goiters evaluated intraoperatively with blood supply originating from the mediastinal vessels were observed in 12 (13.6%) cases. In 27 (30.7%) patients, sternotomies were necessary. In the majority of cases, these were individuals with goiters showing additional blood supply originating from the mediastinal vessels, patients with aberrant adenomas in the mediastinum, especially in recurrent goiters, or else subjects with goiters situated in the posterior mediastinum as compared to anterior mediastinal goiters. No postoperative mortality during stay in a hospital was noted. CONCLUSIONS: Surgical management of patients with mediastinal goiter is the therapeutic modality that requires considerable experience of the surgical team, performed in specialized centers, and appropriate preoperative diagnostic management. Statistically significant risk factors for sternotomy are as follows: recurrent goiter, primary mediastinal goiter, posterior mediastinal location of goiter, and the presence of an aberrant adenoma situated in the mediastinum.

[Post-thyroidectomy hemorrhage]. / Krwotok po operacji wola.

The aim of the study was to estimate the prevalence and causes of haemorrhages, that required extemporaneous surgical treatment, after goiter operations, in our own material. Between 1984 and 2000, i.e. during 17 years, 7400 patients were operated in our Clinic due to different kinds of goiter. Haemorrhage during post operative period was presented in 46 (0.62%) patients. There were 37 women and 9 men in the analysed material. The age of patients was between 19 and 77 years, and the average age was 50.6 +/- 15.4. The lowest percentage of this complication was observed after operation of non-toxic goiter (0.39%) and the highest in a group of patients operated due to Graves-Basedow's disease (1.02%). Frequent local symptoms were observed, such as: enlargement of circumference of neck, supple haematoma with dyspnoea, and sometimes swallowing difficulties. A decrease in blood pressure was observed in 5 (10.9%) patients. Low molecular weight heparin prophylaxis was applied in 18 (39.1%) patients and in 2 cases disorders of blood coagulability were observed. The quantity of drainage from the wound was between 30 and 610 ml, with average 249.8 +/- 144.69 ml. Time from main operation termination to revision was 20 to 1440 minutes, with average time 346 +/- 285.66 minutes. The most common cause of post-thyroidectomy haemorrhage was bleeding from the thyroid lobe stump, which presented in 28 (60.9%) patients. The most dangerous haemorrhage, because of its intensity, was the bleeding from the upper thyroid artery (6 patients). During the postoperative period 16 patients (34.8%) required blood transfusions, however massive transfusions (4 and more blood units) were performed only in 4 patients. Early complications included: paralysis of recurrent laryngeal nerve in 6 patients and transient hypocalcaemia in one patient.