Cervical Approach for Retro-Sternal Goiter Reaching the Arch of the Aorta. Should be Always your First Option

Abstract Background: Although the retrosternal goiters (RSG) are characterized by the protrusion of at least 50% of the thyroid tissue below the level of the thoracic inlet, their definite definition is still controversial. Total thyroidectomy for (RSG) is a great challenge and mostly requires an experienced thyroid surgeon. Excision could be possible through a cervical incision in most cases, though Sternotomy remains an option. Aim of Study: This study was to assess the feasibility of total thyroidectomy through cervical incision in (RSG) reaching to the arch of aorta. Patients and Methods: Our study is a multicentric proof of concept included fourteen cases of huge thyroid goiter with retrosternal extension reaching up to the aortic archas confirmed on neck computed tomography (CT) scan. The cases were retrospectively collected from both East Jeddah Hospital in Saudi Arabia and University Oncology Center of Mansoura University in Egypt, during the period between November 2016 to January 2020. All cases underwent total thyroidectomy using the cervical approach. Results: Cases include 10 women and 4 men with a median age of 55.5 years (range, 34-78 years). RSG status has been clinically and Radiologically diagnosed in all cases using both Neck USand enhanced computerized tomography (CT) of the neck, the latter confirmed a retro-sternal extension down to aortic arch (Level-II). All patients underwent thyroid-ectomy transcervically without the need for median sternotomy. A Thoracic surgeon was stand-by in three cases for the possible need for sternotomy incision. Postoperatively, malignant entitywas histopathologically proven in six patients (42.8%). Hypocalcaemia was transient in one patient (7.1%). No permanent hypocalcemia has been encountered in any of the cases. Regarding postoperative complication, no tracheomalacia, vocal cord paralysis, post-operative hematoma nor patient death was reported. Conclusion: The cervical approach for patients with RSG extending to the aortic arch is an optimum, feasible and less invasive surgical approach that can considered the appropriate choice in such cases and can be performed successfully byexperienced specialized surgeons. Thoracic surgeon standby is required in a few selected cases which carrya chance that sternotomy might be needed.