L. Nankee1, H. Chen1, D. Schneider1, R. Sippel1, D. M. Elfenbein1 1University Of Wisconsin,Madison, WI, USA
Introduction: Sternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach. Accordingly, predicting which patients will require a sternotomy is imperative for pre-operative planning. In this study, we analyzed the pre-operative and post-operative characteristics of patients with SSG compared to those with large goiters contained entirely within the neck, or a cervical goiter (CG). We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG.
Methods: A retrospective review of the Endocrine Surgery Database was performed. Patients were included if they had large (>100g) thyroids or any mention of a substernal component during their pre-operative workup. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had a SSG and patients who had a CG. Further comparisons were made between those with a SSG who required sternotomy to excise their thyroid and those who underwent cervical incision only.
Results: Of the 220 patients, 127 (58%) patients had SSG, of whom 7 (5.5%) required sternotomy. On bivariate analysis, there were no differences in gender, BMI, preoperative symptomatology, postoperative complications or length of stay for patients who had SSG vs CG. Patients with SSG were older (62 + 15 vs 51 + 17 years, p<0.001), more likely to undergo preoperative CT scanning (69% vs. 31%, p<0.001), and less likely to have preoperative hyperthyroidism (10% vs. 29%, p<0.001). Patients who underwent a sternotomy showed no difference in terms of gender, age, BMI, preoperative hyperthyroidism, or postoperative complications compared to those with SSG who underwent cervical incision thyroidectomy. All patients who underwent sternotomy underwent preoperative CT scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints. Furthermore, all patients who underwent sternotomy had extension of the thyroid gland below the aortic arch. Sternotomy took an average of 2 hours longer than a cervical incision, was associated with significantly more blood loss (600 + 408 vs. 190 + 118, p=0.04), and a longer length of stay (3.1 + 0.9 vs. 1.8 + 1.6 days, p=0.03) than cervical thyroidectomy.
Conclusion: Sternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch on preoperative CT scanning, and were more likely to present complaining of chest pressure and voice issues.