Abstract
Background/Aim: Symptomatic mediastinal goitre requires surgery and is usually resectable using the cervical approach alone; however, sternotomy is occasionally required. Sternotomy is a highly invasive procedure, and its complications, including mediastinitis and osteomyelitis, can be critical. To date, there have been no reports of non-invasive techniques to avoid sternotomy for mediastinal thyroid tumours. We investigated the safety and efficacy of thyroidectomy using the clavicle lifting technique with a paediatric Kent hook. Patients and Methods: This was a retrospective study of 8 patients who underwent thyroidectomy with a clavicle lifting technique between November 2014 and July 2021 at the Department of Surgery, International University of Health and Welfare Hospital. The primary endpoint was sternotomy avoidance rate and R0 resection rate. An extension retractor used in paediatric surgery was used for the clavicle lifting technique. Results: Sternotomy avoidance rate and R0 resection rate were 100%. The mean operative time was 161±53.5 min, and the mean blood loss was 125.6±125.8 ml. There were no intraoperative or postoperative complications related to the clavicle lifting technique. Conclusion: Thyroidectomy with a clavicle lifting technique for mediastinal goitre and thyroid cancer is safe and useful because it avoids sternotomy without causing massive intraoperative bleeding or damage to other organs.
A mediastinal goitre is a thyroid tumour extending into the mediastinum, but there is still no consensus on the definition of this condition (1, 2). It accounts for 2-19% of all goitres and is relatively rare (3).
Clinical symptoms associated with mediastinal goitre have been reported to include dyspnoea and cough due to compression and deviation of the trachea, hoarseness due to recurrent nerve palsy, and superior vena cava syndrome due to compression of the superior vena cava and subclavian vein, which is almost always associated with tumour growth (4). Symptomatic mediastinal goitre requires surgery and can often be resected using a cervical approach alone. However, a giant goitre extending into the aortic arch or a malignant tumour suspected to invade the surrounding organs may require sternotomy in addition to a cervical approach. Sternotomy is highly invasive, and complications include hematoma, mediastinitis, abscess formation, sternal fracture, and osteomyelitis, which can be critical in some cases (3, 5).
To date, there have been no reports of non-invasive techniques that can avoid sternotomy for mediastinal goitre. We previously reported a case in which a giant mediastinal goitre was successfully resected using a novel clavicle lifting technique (CLT) with a paediatric Kent hook to obtain a good field of view and avoid sternotomy (6). Since then, we accumulated cases of thyroidectomy with CLT for mediastinal goitre and thyroid cancer. This study examined the safety and efficacy of thyroidectomy in patients with mediastinal goitre or thyroid cancer who would normally require a sternotomy, avoiding sternotomy by using CLT in combination with thyroidectomy.
Patients and Methods
Patients. This was a retrospective study of 8 patients who met the indication criteria and underwent thyroidectomy with CLT between November 2014 and July 2021, at the Department of Surgery, International University of Health and Welfare Hospital. This study was approved by the Ethics Committee of the International University of Health and Welfare Hospital (Approval No. 22-B-34). This study was performed in line with the principles of the Declaration of Helsinki. Informed consent was obtained from all the patients.
The inclusion criteria were symptomatic mediastinal goitre or thyroid cancer, with one of the following: 1) A giant mediastinal goitre reaching the aortic arch; 2) difficulty in securing the visual field using the conventional cervical approach; and 3) thyroid cancer that is expected to adhere to the surrounding tissues. The exclusion criteria were cases of additional lymph node dissection in lymph node recurrence after thyroidectomy.
Primary and secondary endpoints. The primary endpoints were the sternotomy avoidance rate and the R0 resection rate. The secondary endpoints were the operating time, the volume of blood loss, hospital stay, and intraoperative and postoperative complications.
Measurement of tumour size by computed tomography. Preoperatively, tumour size was measured from the upper to the lower margin of the tumour using a coronal computed tomography (CT) image (Figure 1A-D).
(A) Enhanced CT revealed a large mediastinal tumour compressing the trachea (case 8). (B) Enhanced CT showed a large mediastinal tumour extending beyond the aortic arch (case 5). The vertical size of the tumour in the coronal section of the enhanced CT was measured at the top (C) and bottom (D) of the tumour. CT: Computed tomography.
Surgical procedure of CLT during thyroidectomy. An extension retractor (Kent retractor set, Takasago Medical Industries, Tokyo, Japan) used in paediatric surgery was used for CLT (Figure 2A). The procedure was performed under general anaesthesia in the supine and neck extension positions. Thyroidectomy was performed as a standard procedure (7), and CLT was additionally performed if it was determined that thyroidectomy was not possible using the conventional cervical approach.
(A) Paediatric extension retractors used for the clavicle-lifting technique and (B) intraoperative view of the clavicle-lifting technique. CT: Computed tomography.
Procedure for CLT (Figure 2B). The posts were first attached to the left and right sides of the operating table. The arch bar was attached, and the traction device was set up. Then, a Kent hook was applied to the cervical incisors of the sternal scapes in the middle of both clavicular heads. Finally, traction was applied caudoventrally with a tractor to elevate the right and left clavicles to secure the field of vision. Thereafter, routine thyroidectomy was continued. On the day of surgery, the patient entered the intensive care unit (ICU). If there were no breathing problems, the patient was discharged from the ICU the day after the surgery. Moreover, oral intake was initiated on the day after surgery. The cervical drain was removed after 2 days if drainage was <20 ml or less/24 h. Postoperative complications were defined as Clavien-Dindo classification II or higher.
Results
Patient characteristics. Thyroidectomy with CLT was performed in 8 patients. Four patients were men, and four were women. The median age was 67.5 years (range=51-83 years), and the mean body mass index was 23.9±3.25 kg/m2. One patient had a chief complaint of dyspnoea, one felt lodging in his throat, one had neck swelling, and five were asymptomatic. The mean tumour size (vertical distance) on preoperative CT was 76.8±23.5 mm. The pathological diagnosis was adenomatous goitre in 4 cases, papillary carcinoma in 3 cases, and follicular adenoma in 1 (Table I).
Surgical procedures and outcomes of patients who thyroidectomy with a clavicle lifting technique for mediastinal goiter and thyroid cancer.
Surgical outcomes. The sternotomy avoidance rate was 100%, and the R0 resection rate was 100%. The mean operative time was 161±53.5 min, and the mean blood loss was 125.6±125.8 ml. There were no intraoperative or postoperative complications related to CLT. There was one case of death from other causes, but all the other patients survived (Table I).
Discussion
For thyroid tumours that are difficult to resect using only the conventional cervical approach, CLT is safe and useful as a non-invasive technique to avoid sternotomy.
In many cases of mediastinal goitre extending below the sternum, resection can be performed using the cervical approach alone (8). However, approximately 5% of patients with mediastinal goitre require a sternotomy in addition to the cervical approach (7, 9). Tumours with a high density of thyroid tissue on preoperative CT, large tumours (>10 cm), recurrent tumours, tumours extending caudal to the tracheal bifurcation, and tumours in proximity to the aortic arch have been reported as risk factors for sternotomy (9-13). Other reported cases that require sternotomy include mediastinal ectopic goitre and invasive carcinoma (4). In giant mediastinal goitres, there is a risk of blind dissection manoeuvres owing to the poor visual field caused by the tumour size. Raffaelli et al. reported that blind manual dissection of tissue should be avoided because of the risk of recurrent nerve injury and difficult-to-control mediastinal bleeding (14). Furthermore, in the case of mediastinal ectopic goitre or invasive cancer, it is necessary to treat the inflow of blood vessels from the thoracic cavity to the tumour and perform advanced adhesion dissection by severe tumour invasion or adhesion of reoperation.
Sternotomy is an effective procedure for avoiding these risks. However, Nankee et al. reported that additional sternotomy took an average of 2 h longer and was associated with significantly more blood loss (600 versus 190 ml, p=0.04) and a longer length of stay (3.1 versus 1.8 days, p=0.03) than cervical thyroidectomy alone (3). Furthermore, sternotomy includes complications such as hematoma, mediastinitis, abscess formation, sternal fracture, and osteomyelitis, which can be critical in some cases. Therefore, the indication for sternotomy should be decided carefully (2).
We developed CLT as a non-invasive method to avoid sternotomy. The CLT was devised by Suzuki et al. (15) as a novel technique for cervical and mediastinal lymph node dissection in thoracic oesophageal cancer, in which the clavicle is elevated to enlarge the subclavian space and provide a good field of view. The mediastinum contains complex anatomical structures, including the vagus pulmonary branches, bronchial arteries, and thoracic ducts; it has been shown to be a minimally invasive and safe way to visualize these structures. We hypothesized that CLT could also be applied to mediastinal goitre and thyroid cancer.
We performed CLT on 8 patients, 5 of whom had large tumours that reached the aortic arch. In all cases, sternotomy was avoided, and the operation was completed safely performed without massive intraoperative bleeding or injury to other organs. Recurrence was not observed during the follow-up period. The advantages of CLT in thyroid tumours include 1) a non-invasive additional procedure, 2) a good field of view that allows tumour resection and superior mediastinal lymph node dissection while viewing the inferior margin of the tumour extending caudally to the aortic arch or recurrent nerve, 3) no prolonged operation time, and 4) a clear visual field created by mechanical traction without the surgeon or assistant’s arm. As a devised point of the CLT, a 29×29 mm Kent hook for paediatric surgery is used, which is smaller than the adult Kent hook (55×55 mm) and is considered less likely to affect surgical manipulation of small wounds on the neck. Also, as a precaution for CLT, it is necessary to keep in mind that strong traction may result in clavicle dislocation and bone sprains, so it is important to be gentle in traction. In addition, in the 8 cases in this study no such complications occurred.
This was a single-centre retrospective study conducted on a small number of patients, and further case studies are required. Furthermore, the definition of mediastinal goitre remains controversial. Although we have not experienced any cases in which a sternotomy was additionally required after CLT, CLT might not be effective in high-risk cases such as large tumours extending into the posterior mediastinum and cases of direct invasion of multiple organs. In such cases, a sternotomy should be performed without hesitation.
Footnotes
Authors’ Contributions
YF wrote the original draft, TK, NS, RN, JT, KN, YN, TI, MY and HO reviewed and edited the manuscript, and SY contributed to the supervision. All Authors read and approved the final manuscript.
Conflicts of Interest
The Authors declare that they have no conflicts of interest.
- Received April 3, 2023.
- Revision received August 6, 2023.
- Accepted August 25, 2023.
- Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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