524 Ann Thorac Cardiovasc Surg Vol. 17, No. 5 (2011)
Single-stage Operation for Giant Substernal Goiter with Severe
Coronary Artery Disease
Sonya Wexler, MS,1 Kentaro Yamane, MD,2 Kyle W. Fisher, MD,3
James T. Diehl, MD,2 and Hitoshi Hirose, MD2
1The George Washington University School of Medicine and Health
Sciences, Washington DC., USA 2Division of Cardiothoracic Surgery,
Department of Surgery, Thomas Jefferson University, Philadelphia,
Pennsylvania, USA 3Department of Otolaryngology, Thomas Jefferson
University, Philadelphia, Pennsylvania, USA
Received: September 13, 2010; Accepted: November 17, 2010
Corresponding author: Hitoshi Hirose, MD. Division of
Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson
University, 1025 Walnut Street Room 605, Philadelphia, Pennsylvania
19107, USA Email:
[email protected] ©2011 The Editorial Committee of
Annals of Thoracic and Cardiovascular Surgery. All rights
reserved.
A 76-year-old female, with a history of asthma and tracheal
bronchitis, presented with a non-ST elevation, myocardial
infarction. Chest x-ray on admission showed a widened medi-
astinum, which was further evaluated with a computed tomography
(CT) scan. It disclosed a giant substernal goiter compressing the
trachea and the ascending aorta. Cardiac catheter- ization showed
significant coronary disease unsuitable for percutaneous
intervention; thus, the patient was scheduled for coronary artery
bypass grafting. Single stage thyroidectomy immediately followed by
coronary artery bypass was performed. After surgery, her upper
airway symptoms were improved, and no cardiac events were noted.
Collaboration between otolaryngology and thoracic surgery teams
contributed to good outcomes for this patient with substernal
goiter and severe cardiac disease.
Keyword: coronary artery disease, thyroid disease, gioter,
surgery
Ann Thorac Cardiovasc Surg 2011; 17: 524–527 doi:
10.5761/atcs.cr.10.01628
Introduction
A large substernal goiter may compress the trachea and cause upper
airway symptoms.1) Persistent upper air- way obstruction due to
substernal goiter may increase stress to the cardiovascular system
and also increase the risk of the coronary artery disease (CAD).2)
For a goiter located in the mediastinum, sternotomy is sometimes
required to access the entire mass rather than approach- ing from
the neck alone.1) Here, we report a patient who presented with
acute myocardial infarction (MI) and was
found to have a giant substernal goiter with compressive symptoms.
The patient underwent single-stage surgery combining thyroidectomy
and coronary artery bypass grafting (CABG).
Case Presentation
A 76-year-old female with a past medical history of hypertension,
hyperlipidemia, diabetes, obesity, asthma, and chronic
tracheobronchitis presented to the emergency department complaining
of shortness of breath and wheez- ing. She was unable to lie flat
due to severe shortness of breath and stridor. Steroid treatment
was started for symp- tomatic upper airway obstruction. The initial
workup revealed a non-ST elevation MI. Subsequent cardiac
catheterization showed complex CAD (severe proximal stenosis on the
left anterior descending artery and bifur- cating lesion on the
diagonal artery), which was not suit- able for percutaneous
catheter intervention, and poor left ventricular function (ejection
fraction 29%). Chest x-ray on admission showed a widened
mediastinum (Fig. 1A). CT scan revealed a giant substernal goiter
compressing the trachea and aorta (Fig. 1B and 1C). The tracheal
diameter was 4 mm at the level of T1-T2. Thyroid function
tests
Giant Goiter and CABG
Ann Thorac Cardiovasc Surg Vol. 17, No. 5 (2011) 525
cheal collapse during the surgery, we preserved a site for the
emergent tracheostomy and planned to made two sep- arate incisions
at the neck and sternum (Fig. 2A). The otolaryngology team
performed a curvilinear collar inci- sion to the neck in order to
gain access to the upper por- tion of the goiter. The right
hemi-thyroid, which appeared to be larger than the left, was
dissected first. The subster- nal component of the goiter was
unable to be delivered despite transecting the right strap muscles
and ligating the middle pole vessels. The cardiothoracic team per-
formed a median sternotomy, which allowed access to the lower
portion of the goiter. (Fig. 2B). The thyroid tissue was carefully
dissected from the thymic remnant and underlying vasculature. The
right hemi-thyroid was removed after ligating the inferior pole
vessels and transecting the isthmus (Fig. 2C). The left
hemi-thyroid and pyramidal lobe were then dissected and delivered
in a similar fashion. The parathyroid glands and recurrent
laryngeal nerves were preserved. The neck incision was packed with
sponges.
The cardiothoracic team then harvested the left inter- nal mammary
artery (LIMA) and a saphenous vein graft. Heparin was given before
cardiopulmonary bypass. CABG with a LIMA graft to the left anterior
descending artery and a saphenous vein graft to the first diagonal
artery were performed. Cardiopulmonary bypass was weaned off and
protamine was then given to the patient. After completion of the
CABG, the neck was examined for hemostasis and 2 Jackson-Pratt
drains were placed within the thyroid bed. These were placed to
high wall suction and removed by postoperative day 3.
Pathology showed the large thyroid mass consisted of the right
lobe, 14 × 8 × 4 cm, left lobe 5.5 × 5 × 2.2 cm, and isthmus 4.5 ×
4.2 × 2.2 cm (Fig. 3). Multinodular areas were identified with
multiple foci of firm tan-white calcification. Histopathology of
the specimen was consis- tent with multinodular goiter.
On postoperative day 1, the patient was electively extu- bated with
otolaryngology and anesthesia backup present. No stridor or
wheezing was observed after extubation. She did not experience
hoarseness or difficulty of swallowing after surgery. On
postoperative day 9, the patient was dis- charged home in stable
condition with close follow-up with cardiology, otolaryngology,
endocrinology and speech pathology. At 2 weeks after discharge from
the hospital, laryngoscopy was repeated and revealed normal vocal
fold motion. At 6 weeks after discharge from the hospital, she
denied any upper airway obstruction symptoms, was free from cardiac
events, and returned to her previous activities.
Fig. 1 Preoperative chest x-ray shows widened mediastinum (A).
Preoperative CT scan shows narrowed trachea (B) and large
substernal goiter (C).
were consistent with a euthyroid state (TSH 0.42 uIU/ml, T3 70
ng/dl, Free T4 1.0 ng/dl, and Free T3 2.3 pg/ml). The patient was
scheduled for a combined CABG and thyroidectomy.
In the operating room, an arterial line and Swan-Gantz catheter
were placed under local anesthesia. The otolar- yngology team
successfully intubate the patient using direct laryngoscopy. To
minimize the risk of sudden tra-
A
B
C
526
Ann Thorac Cardiovasc Surg Vol. 17, No. 5 (2011)
rowed more than 50% from the normal size. Stridor at rest is a sign
of severe upper airway obstruction, indicat- ing the airway is
narrower than 3 mm in diameter.1) The chest CT from our patient
showed a 4 mm tracheal nar- rowing. The respiratory symptoms in our
patient may have been worsened by her large body habitus and pres-
ence of acute MI. She did have CAD risk factors; how- ever, the
presence of chronic upper airway obstruction by the giant
substernal goiter may have further contributed to accelerating CAD,
hypertension, and ventricular dys- function.2)
Surgery for substernal goiter with significant CAD should be
planned carefully. Hemodynamic monitoring should be performed
before anesthesia induction. The risk of thyrotoxicosis during
thyroidectomy is low as long as the patient remains euthyroid or
hypothyroid before sur- gery, although thyrotoxicosis can be
observed in euthyroid patients.1) The anesthesiology team must be
alerted if severe tracheal narrowing exists in a patient with
subster- nal goiter. Fiberoptic and rigid bronchoscopes, as well as
instruments for emergency tracheostomy, should be made available
and opened before anesthesia induction. In a patient with a history
of recent acute MI or severe CAD
Fig. 2 Incision plan of this patient (A). A giant substernal goiter
is visible from sternotomy incision (B). The right hemithy- roid is
delivered from neck incision after additional dis- section from the
sternal incision (C).
Comments
The presence of symptomatic airway obstruction in patient with
substernal goiter is an indication for thyroi- dectomy in patients
with substernal goiter. The upper air- way symptoms may be masked
for years due to slow growth of the goiter. The symptoms
occasionally mimic tracheobronchitis or asthma, as was the case
with our patient’s previous diagnosis.1) Substernal giant goiter is
easily diagnosed by CT scan. Patients may complain of respiratory
symptoms if their tracheal diameter is nar-
Fig. 3 Pathology specimen of the giant goiter. A large right
hemithyroid (A) and smaller left hemithyroid (B).
A
B
C
A
B
Ann Thorac Cardiovasc Surg Vol. 17, No. 5 (2011) 527
(as in this case), desaturation from a difficult airway or
catecholamine surge from thyroid disease may increase the risk of
perioperative acute MI. Thus, surgery was per- formed through the
collaboration of otolaryngology, car- diac surgery and anesthesia
teams.
Concomitant surgery for substernal giant goiter and CAD has only
been reported by a few researchers in the English literature as far
as we know.1, 2) In all cases, including ours, thyroidectomy was
performed first with a combination of collar incision and median
sternotomy. Dissection of the substernal goiter is often difficult
due to the compression to the adjacent mediastinal structures and
hemorrhagic degeneration of the goiter. Thus, the thyroidectomy
should be done before anticoagulation for CABG to minimize the risk
of bleeding. We left the neck wound open during the CABG to monitor
for unexpected bleeding from anticoagulation.
Current standards of care for the patient undergoing non-cardiac
surgery with severe CAD is to delay the non- cardiac surgery until
coronary revascularization because of the risk of perioperative
MI.1) As in our patient, the risk of MI is high in patients with
recent MI and/or poor ventricular dysfunction.
A two-stage procedure, thyroidectomy after CABG would be difficult
to do in a patient such as the one pre- sented herein due to the
presence of extensive thyroid tis- sue in the retrosternal space.
Since the entire substernal goiter was unable to be removed through
the neck inci- sion without the use of sternotomy access, if we had
per- formed a two-stage procedure (thyroidectomy after CABG) the
patient would have required re-do sternotomy, which carries a
substantial risk for injury to cardiac structures and/or grafts.
The risk of MI is as high as 40% if the grafts are injured at the
time of sternal re-entry.1) Moreover, with the second sternotomy
for CABG there is increased scar formation from the previous
sternotomy, which can make dissection of the goiter from other
medi- astinal structures more difficult than would be with a pri-
mary thyroidectomy. Another consideration is sudden swelling of the
goiter. Cagli reported a patient with an asymptomatic substernal
goiter who had developed acute upper airway obstruction and
required emergent thyroi- dectomy after elective CABG.1) Tracheal
obstruction clearly occurred after CABG. Cagli speculated that a
sys- temic inflammatory response from cardiopulmonary bypass during
CABG may have contributed to substantial swelling of the substernal
goiter, which resulted in com-
pression of the upper airway followed by acute respiratory failure;
thus a two-staged procedure is discouraged.
By combining a thyroidectomy and CABG, the surgi- cal team can take
advantage of the proximity of these two organs. That is, if both
surgical sites are within the same operating field, they can be
accessed at any time during the procedure in case of cardiac or
respiratory complica- tions. This single-stage surgery by multiple
specialty sur- gical teams can be a significant advantage to
patient care.
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