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Novel technique for control of mediastinal bleeding during thyroidectomy for substernal goiter
SURGEON AT WORK
Novel Technique for Control of Mediastinal Bleeding During Thyroidectomy for Substernal Goiter Orlo H Clark, MD, FACS, Geeta Lal, MSc, MD, FRCS(C) astinal goiter with tracheal displacement, flattening, and compression (Fig. 1). The patient was otherwise in good health. He had no family history of goiter or thyroid cancer and no history of radiation exposure to the head and neck region. Preoperative physical examination revealed a healthyappearing elderly man with a regular heart rate of 80 beats per minute and a blood pressure of 132/82. Positive physical findings were confined to the neck, which revealed a well-healed Kocher transverse collar incision and a recurrent right-sided goiter that only moved minimally with deglutition and extended beneath the sternum. Pemberton’s sign was positive in that his neck veins were distended and his face became flushed when his arms were extended above his head. Preoperative laboratory values were within normal limits, including a TSH level of 1.0 mIU/L (range 0.5 to 4.7) and T3 of 103 ng/dL (range 70 to 132). Direct laryngoscopy revealed normal vocal cord function bilaterally. At operation, the patient was positioned carefully with his neck in extension. His skin was prepared for both a repeat cervical approach, and possible median sternotomy. The previous cervical scar was reincised. There was considerable scar formation between the right side of the goiter and adjacent sternothyroid muscle. It was also adherent to the right carotid sheath. The superior thyroid vessels were mobilized, clamped, and ligated. After the goiter was mobilized from the carotid sheath, it was dissected medially from the trachea and cricothyroid muscle using sharp dissection. A relatively large right recurrent laryngeal nerve was identified during the dissection. Several large stitches were then placed through the lobular recurrent goiter, which was fixed in the substernal position. Using a combination of these stitches, blunt mobilization, and a spoon, the mass measuring 15 ⫻ 10 ⫻ 7.5 cm was delivered from its substernal location. Unfortunately, a small amount of bleeding was evident from the large substernal space that had previously been occupied by the mediastinal goiter. The
Goiters are estimated to develop in approximately 5% of the population.1 By definition, for a goiter to be considered mediastinal, at least 50% of the thyroid tissue must be located substernally.2 Mediastinal goiters can, in turn, be classified as primary or secondary. Primary mediastinal goiters, which represent about 1% of all mediastinal goiters, arise from accessory (ectopic) thyroid parenchyma located in the chest.3 These goiters are mainly intrathoracic and do not have any connection to thyroid tissue in the neck. Their blood supply originates from intrathoracic vessels.4 Secondary mediastinal goiters constitute the majority of mediastinal goiters and arise from downward extension of cervical thyroid tissue along the fascial planes of the neck. These goiters derive their blood supply from the superior and inferior thyroid arteries.2,4 This migration along the path of least resistance is assisted by negative mediastinal pressure generated by inspiration and swallowing.5 Most mediastinal goiters can be removed via a cervical incision, but patients with recurrent goiters can require a median sternotomy because of the development of parasitic mediastinal vessels. In this article, we present the case of a patient with a secondary mediastinal goiter who developed bleeding after its removal via a cervical incision, and report on the use of a Foley catheter to control the same. METHODS The patient is a 69-year-old man who had undergone a previous thyroid operation for a benign condition in 1977. He had a known recurrent substernal goiter since 1992. For the previous 2 years, he had developed progressive dyspnea that had limited his activity. He had no neck or chest pain, dysphagia, or hoarseness. A CT scan of his neck and chest revealed a large right-sided mediNo competing interests declared.
Received August 12, 2002; Revised November 5, 2002; Accepted November 19, 2003. From the Department of Surgery, University of California, San Francisco/Mt Zion Medical Center, San Francisco, CA. Correspondence address: Orlo H Clark, MD, FACS, UCSF/Mt Zion Medical Center, 1600 Divisadero St, Suite C347, San Francisco, CA 94143-1674.
© 2003 by the American College of Surgeons Published by Elsevier Science Inc.
818
ISSN 1072-7515/03/$21.00 doi:10.1016/S1072-7515(03)00006-1
Vol. 196, No. 5, May 2003
Clark and Lal
Mediastinal Bleeding and Substernal Goiter
819
Figure 2. Schematic drawing of a Foley catheter inflated in the upper right mediastinum after removal of the goiter. The approximate location of the goiter is indicated with the dotted line.
Figure 1. CT scan of the neck (A) and upper mediastinum (B). The arrow demonstrates the large, predominantly right-sided goiter causing tracheal compression.
bleeding continued despite placement of thrombinsoaked gelfoam in the space. A Foley catheter with a 30-mL balloon was then placed into the right mediastinum and inflated with 18 mL of water (Fig. 2). The bleeding stopped immediately, but resumed when the Foley balloon was deflated 10 minutes later. The balloon was reinflated and the muscle layers and skin closed in the usual manner with the Foley exiting from the most lateral part of the incision. The catheter was connected to a closed suction drain system. The patient was taken to the recovery room in good condition. The Foley balloon was deflated 2 hours later but left in place until the following morning, when it was removed. No bleeding was noted and the patient was discharged on the first postoperative morning in excellent condition. He volunteered that his breathing was considerably better than preoperatively.
DISCUSSION Mediastinal goiters are usually removed through a cervical, Kocher transverse collar incision. The lateral portion of the goiter can be mobilized by ligating the middle thyroid veins and their tributaries. Ligation of the superior thyroid vessels and division of the isthmus provides further mobility. A sweeping motion of the surgeon’s finger along the carotid sheath into the mediastinum allows delivery of the remaining intrathoracic goiter into the neck wound.1,6 If digital mobilization is unsuccessful, special forceps and spoons can be used to deliver the substernal goiter.7,8 Morsellization of the tumor is not usually recommended because of the possibility of malignancy. Patients who might require a median sternotomy include: 1) those with known invasive thyroid cancers, 2) those who have had previous thyroid operations because of the parasitic revascularization of the goiter by mediastinal vessels, 3) those with primary mediastinal goiters with no thyroid tissue in the neck, and 4) those who develop marked mediastinal bleeding that is difficult to control from a cervical approach. Although the addition of a median sternotomy does not increase mortality,
820
Clark and Lal
Mediastinal Bleeding and Substernal Goiter
length of postoperative hospital stay is increased.9 It is also associated with increased morbidity. A median sternotomy was also considered in our patient to directly assess and control the bleeding, as was placement of packing sponges, but the goiter had already been delivered and the latter approach would have entailed a repeat procedure to remove the packs. Foley catheters have been used to deliver substernal goiters where it was not possible for the surgeon’s fingers to reach below the gland.10 To the best of our knowledge, this is the first report of the control of mediastinal bleeding after removal of a large substernal goiter by inflating a Foley balloon in the mediastinal space. The Foley balloon was inflated for only 2 hours because of concern about possible pressure on the recurrent laryngeal nerve and subsequent dysfunction. Although it is possible that bleeding could continue and not be evident with the Foley catheter in the substernal space, placement of the catheter was simple and very helpful in this patient who remains well. In summary, use of this technique is simple, effective, and appears to be safe for the management of mediastinal bleeding after removal of a substernal goiter. It obviated the need for a sternotomy and a possible second procedure for removal of packs and so decreased the risks of postoperative mortality and morbidity.
J Am Coll Surg
Author Contributions
Acquisition of data: Clark Drafting of manuscript: Clark, Lal Critical revision: Clark, Lal Other (specify): Artwork: Lal REFERENCES 1. Mack E. Management of patients with substernal goiters. Surg Clin N Am 1995;75:377–394. 2. Katlic MR, Wang CA, Grillo HC. Substernal goiter. Ann Thorac Surg 1985;39:391–399. 3. Mansberger AR, Wei JP. Surgical embryology and anatomy of the thyroid and parathyroid glands. Surg Clin N Am 1993;73: 727–746. 4. Van Schil P, Vanmaele R, Ehlinger P, et al. Primary intrathoracic goiter. Acta Chir Belg 1989;89:206–208. 5. Lahey FH, Swinton MW. Intrathoracic goiter. Surg Gynecol Obstet 1934;59:627–637. 6. Sanders LE, Rossi RL, Shahian DM, Williamson WA. Mediastinal goiters: the need for an aggressive approach. Arch Surg 1992;127:609–613. 7. Landreneau RJ, Nawarawong W, Boley TM, et al. Intrathoracic goiter: approaching the posterior mediastinal mass. Ann Thorac Surg 1991;52:134–135. 8. Katlic MR, Grillo HC, Wang CA. Substernal goiter: Analysis of 80 patients from Massachusetts General Hospital. Am J Surg 1985;149:283–287. 9. Sand ME, Laws HL, McElvein RB. Substernal and intrathoracic goiter. Reconsideration of surgical approach. Am Surg 1993;49: 196–202. 10. Pandya S, Sanders LE. Use of a Foley catheter in the removal of a substernal goiter. Am J Surg 1998;175:155–157.
Novel Technique for Control of Mediastinal Bleeding During Thyroidectomy for Substernal Goiter Orlo H Clark, MD, FACS, Geeta Lal, MSc, MD, FRCS(C) astinal goiter with tracheal displacement, flattening, and compression (Fig. 1). The patient was otherwise in good health. He had no family history of goiter or thyroid cancer and no history of radiation exposure to the head and neck region. Preoperative physical examination revealed a healthyappearing elderly man with a regular heart rate of 80 beats per minute and a blood pressure of 132/82. Positive physical findings were confined to the neck, which revealed a well-healed Kocher transverse collar incision and a recurrent right-sided goiter that only moved minimally with deglutition and extended beneath the sternum. Pemberton’s sign was positive in that his neck veins were distended and his face became flushed when his arms were extended above his head. Preoperative laboratory values were within normal limits, including a TSH level of 1.0 mIU/L (range 0.5 to 4.7) and T3 of 103 ng/dL (range 70 to 132). Direct laryngoscopy revealed normal vocal cord function bilaterally. At operation, the patient was positioned carefully with his neck in extension. His skin was prepared for both a repeat cervical approach, and possible median sternotomy. The previous cervical scar was reincised. There was considerable scar formation between the right side of the goiter and adjacent sternothyroid muscle. It was also adherent to the right carotid sheath. The superior thyroid vessels were mobilized, clamped, and ligated. After the goiter was mobilized from the carotid sheath, it was dissected medially from the trachea and cricothyroid muscle using sharp dissection. A relatively large right recurrent laryngeal nerve was identified during the dissection. Several large stitches were then placed through the lobular recurrent goiter, which was fixed in the substernal position. Using a combination of these stitches, blunt mobilization, and a spoon, the mass measuring 15 ⫻ 10 ⫻ 7.5 cm was delivered from its substernal location. Unfortunately, a small amount of bleeding was evident from the large substernal space that had previously been occupied by the mediastinal goiter. The
Goiters are estimated to develop in approximately 5% of the population.1 By definition, for a goiter to be considered mediastinal, at least 50% of the thyroid tissue must be located substernally.2 Mediastinal goiters can, in turn, be classified as primary or secondary. Primary mediastinal goiters, which represent about 1% of all mediastinal goiters, arise from accessory (ectopic) thyroid parenchyma located in the chest.3 These goiters are mainly intrathoracic and do not have any connection to thyroid tissue in the neck. Their blood supply originates from intrathoracic vessels.4 Secondary mediastinal goiters constitute the majority of mediastinal goiters and arise from downward extension of cervical thyroid tissue along the fascial planes of the neck. These goiters derive their blood supply from the superior and inferior thyroid arteries.2,4 This migration along the path of least resistance is assisted by negative mediastinal pressure generated by inspiration and swallowing.5 Most mediastinal goiters can be removed via a cervical incision, but patients with recurrent goiters can require a median sternotomy because of the development of parasitic mediastinal vessels. In this article, we present the case of a patient with a secondary mediastinal goiter who developed bleeding after its removal via a cervical incision, and report on the use of a Foley catheter to control the same. METHODS The patient is a 69-year-old man who had undergone a previous thyroid operation for a benign condition in 1977. He had a known recurrent substernal goiter since 1992. For the previous 2 years, he had developed progressive dyspnea that had limited his activity. He had no neck or chest pain, dysphagia, or hoarseness. A CT scan of his neck and chest revealed a large right-sided mediNo competing interests declared.
Received August 12, 2002; Revised November 5, 2002; Accepted November 19, 2003. From the Department of Surgery, University of California, San Francisco/Mt Zion Medical Center, San Francisco, CA. Correspondence address: Orlo H Clark, MD, FACS, UCSF/Mt Zion Medical Center, 1600 Divisadero St, Suite C347, San Francisco, CA 94143-1674.
© 2003 by the American College of Surgeons Published by Elsevier Science Inc.
818
ISSN 1072-7515/03/$21.00 doi:10.1016/S1072-7515(03)00006-1
Vol. 196, No. 5, May 2003
Clark and Lal
Mediastinal Bleeding and Substernal Goiter
819
Figure 2. Schematic drawing of a Foley catheter inflated in the upper right mediastinum after removal of the goiter. The approximate location of the goiter is indicated with the dotted line.
Figure 1. CT scan of the neck (A) and upper mediastinum (B). The arrow demonstrates the large, predominantly right-sided goiter causing tracheal compression.
bleeding continued despite placement of thrombinsoaked gelfoam in the space. A Foley catheter with a 30-mL balloon was then placed into the right mediastinum and inflated with 18 mL of water (Fig. 2). The bleeding stopped immediately, but resumed when the Foley balloon was deflated 10 minutes later. The balloon was reinflated and the muscle layers and skin closed in the usual manner with the Foley exiting from the most lateral part of the incision. The catheter was connected to a closed suction drain system. The patient was taken to the recovery room in good condition. The Foley balloon was deflated 2 hours later but left in place until the following morning, when it was removed. No bleeding was noted and the patient was discharged on the first postoperative morning in excellent condition. He volunteered that his breathing was considerably better than preoperatively.
DISCUSSION Mediastinal goiters are usually removed through a cervical, Kocher transverse collar incision. The lateral portion of the goiter can be mobilized by ligating the middle thyroid veins and their tributaries. Ligation of the superior thyroid vessels and division of the isthmus provides further mobility. A sweeping motion of the surgeon’s finger along the carotid sheath into the mediastinum allows delivery of the remaining intrathoracic goiter into the neck wound.1,6 If digital mobilization is unsuccessful, special forceps and spoons can be used to deliver the substernal goiter.7,8 Morsellization of the tumor is not usually recommended because of the possibility of malignancy. Patients who might require a median sternotomy include: 1) those with known invasive thyroid cancers, 2) those who have had previous thyroid operations because of the parasitic revascularization of the goiter by mediastinal vessels, 3) those with primary mediastinal goiters with no thyroid tissue in the neck, and 4) those who develop marked mediastinal bleeding that is difficult to control from a cervical approach. Although the addition of a median sternotomy does not increase mortality,
820
Clark and Lal
Mediastinal Bleeding and Substernal Goiter
length of postoperative hospital stay is increased.9 It is also associated with increased morbidity. A median sternotomy was also considered in our patient to directly assess and control the bleeding, as was placement of packing sponges, but the goiter had already been delivered and the latter approach would have entailed a repeat procedure to remove the packs. Foley catheters have been used to deliver substernal goiters where it was not possible for the surgeon’s fingers to reach below the gland.10 To the best of our knowledge, this is the first report of the control of mediastinal bleeding after removal of a large substernal goiter by inflating a Foley balloon in the mediastinal space. The Foley balloon was inflated for only 2 hours because of concern about possible pressure on the recurrent laryngeal nerve and subsequent dysfunction. Although it is possible that bleeding could continue and not be evident with the Foley catheter in the substernal space, placement of the catheter was simple and very helpful in this patient who remains well. In summary, use of this technique is simple, effective, and appears to be safe for the management of mediastinal bleeding after removal of a substernal goiter. It obviated the need for a sternotomy and a possible second procedure for removal of packs and so decreased the risks of postoperative mortality and morbidity.
J Am Coll Surg
Author Contributions
Acquisition of data: Clark Drafting of manuscript: Clark, Lal Critical revision: Clark, Lal Other (specify): Artwork: Lal REFERENCES 1. Mack E. Management of patients with substernal goiters. Surg Clin N Am 1995;75:377–394. 2. Katlic MR, Wang CA, Grillo HC. Substernal goiter. Ann Thorac Surg 1985;39:391–399. 3. Mansberger AR, Wei JP. Surgical embryology and anatomy of the thyroid and parathyroid glands. Surg Clin N Am 1993;73: 727–746. 4. Van Schil P, Vanmaele R, Ehlinger P, et al. Primary intrathoracic goiter. Acta Chir Belg 1989;89:206–208. 5. Lahey FH, Swinton MW. Intrathoracic goiter. Surg Gynecol Obstet 1934;59:627–637. 6. Sanders LE, Rossi RL, Shahian DM, Williamson WA. Mediastinal goiters: the need for an aggressive approach. Arch Surg 1992;127:609–613. 7. Landreneau RJ, Nawarawong W, Boley TM, et al. Intrathoracic goiter: approaching the posterior mediastinal mass. Ann Thorac Surg 1991;52:134–135. 8. Katlic MR, Grillo HC, Wang CA. Substernal goiter: Analysis of 80 patients from Massachusetts General Hospital. Am J Surg 1985;149:283–287. 9. Sand ME, Laws HL, McElvein RB. Substernal and intrathoracic goiter. Reconsideration of surgical approach. Am Surg 1993;49: 196–202. 10. Pandya S, Sanders LE. Use of a Foley catheter in the removal of a substernal goiter. Am J Surg 1998;175:155–157.