Excision of a Complicated Posterior Mediastinal Goiter Using CPB

Cervico-mediastinal tumors are commonly situated in the anterior mediastinum. However, 10 to 15 percent of them may be located in the posterior mediastinum. This video presents an unusual case of a complicated cervico-mediastinal extension of a goiter to the posterior mediastinum causing severe lower tracheal compression. 

A fifty-two-year-old female presented to us with asthmalike symptoms and dyspnea that progressed to stridor and orthopnea. Her chest X-ray showed upper mediastinal widening, and a CT scan of the neck and chest revealed a large cervico-mediastinal mass extending to the posterior mediastinum with severe compression of the lower third trachea. 

The compression of the lower airway became a hurdle for safe excision of the large mass in the posterior mediastinum. A team of cardiothoracic surgeons, head and neck surgeons, and an anesthesiologist evaluated the challenging situation and decided to proceed with the surgery with cardiopulmonary bypass support. 

The patient was put under mild sedation, mask ventilation, and local anesthesia to the left groin. The patient was then heparinized, the left femoral vessels were cannulated, and femorofemoral bypass was established. Endotracheal intubation was then done with a flexometallic tube guided with a bougie. A flexible bronchoscopy showed a slitlike lower third of trachea. 

A cervical collar incision was made by the head and neck surgeon. The mass was dissected and detached from its vascular supply and attachments. Next the neck incision was temporarily closed. The patient was then turned to the left lateral position and a right lateral mini-thoracotomy through the fifth intercostal space was done. The mass was approached through the mediastinal pleura posterior to the superior vena cava. Careful dissection around the mass was performed, freeing it from the mediastinal structures. The base of the mass was ligated, and the mass was delivered from the thoracotomy wound. 

The mass measured 16 x 12 x 8cm and was sent for histopathology. The patient was then weaned off cardiopulmonary bypass. After hemostasis, the chest, neck, and groin wounds were closed in layers. A repeat bronchoscopy showed a normal lower trachea. 

An elective tracheostomy was performed with consideration for the long standing lower tracheal compression. The patient made a gradual postoperative recovery. The histopathology report showed the mass to be a multinodular goiter. The patient was dependent on the tracheostomy for months because of bilateral recurrent laryngeal nerve palsy. A trial of decannulation of the tracheostomy failed at six months. The vocal cord function resumed to normal at one year, and the tracheostomy was decannulated. The patient is now back to her normal life and is doing well on follow-up. 

References

1. Simó R, Nixon IJ, Vander Poorten V, et al. Surgical management of intrathoracic goitres. Eur Arch Otorhinolaryngol. 2019;276(2):305-314. doi:10.1007/s00405-018-5213-z
2. Chen X, Xu H, Ni Y, Sun K, Li W. Complete excision of a giant thyroid goiter in posterior mediastinum. J Cardiothorac Surg. 2013;8:207. Published 2013 Nov 7. doi:10.1186/1749-8090-8-207
3. Kacprzak G, Karas J, Rzechonek A, Blasiak P. Retrosternal goiter located in the mediastinum: surgical approach and operative difficulties. Interact Cardiovasc Thorac Surg. 2012;15(5):935-937. doi:10.1093/icvts/ivs339

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