In endemic goitre areas, 20% of the population over 70 will have retrosternal goitre.12 Obstructive sleep apnoea (OSA) occurs when there are repeated episodes of complete or partial blockage of the upper airway during sleep.
PRESENTATION OF CASE
A 55-year-old man was being treated for obstructive sleep apnoea, came with stridor worsening over the 2 and was advised CPAP ventilation. In our institution, he was diagnosed to have goitre with retrosternal extension with no hypo/hyperthyroidism. He was an obese (BMI – 30 Kg/m2) male with a short, broad neck and clinically no obvious swelling in the neck. He had stridor, with positive Kocher's test as well as Pemberton's sign. His TFT's were normal and CT scan revealed widening of superior mediastinum. Patient was pre-medicated with low dose (0.1 μg) fentanyl, and induced with inhalational anaesthesia (sevoflourane). Endotracheal intubation was done using 6 no. ET tube, without muscle relaxation, and the thyroid was removed through a conventional Kocher's incision. Thyroid was enlarged 25 cm by 10 cm in retrosternal position. Postoperatively, pt was reversed and shifted to ICU, was monitored for the next 24 hours. He was extubated uneventfully the next morning. Patient had a good post-op recovery and was discharged on the 7th post-op day.
Terms such as retrosternal, substernal, intrathoracic, or mediastinal have been used to describe a goitre that extends beyond the thoracic inlet. However, there is a lack of consensus regarding the exact definition of a retrosternal goitre (RSG).1 The majority of patients present with shortness of breath or asthma like symptoms (68.8%), as was the case in the studied patient. Other modes of presentation include neck mass (75%), hoarseness of voice (37.5%), dysphagia (31.3%), stridor/wheezing (19%), or SVC obstruction. Upper airway obstruction due to thyroid gland has been reported up to 31%2 and difficulty in intubation has been reported in 11%.3 Central airway obstruction produces symptoms of dyspnoea, stridor, or obstructive pneumonia and is often misdiagnosed as asthma.4 The CT scan was the most useful tool showing the nature and extent of the lesion in the reported case. In a recent publication, the CT scan was considered the gold-standard preoperative radiological investigation.5 Surgery is the only effective treatment for retrosternal goitres. In most cases, suppressive therapy with thyroxine is ineffective in reducing the size of multinodular goitres;7,8 radio-iodine therapy is both generally ineffective in large goitres8 and may induce acute inflammation and swelling of the gland with the potential for airway obstruction. The operation of choice is usually a total thyroidectomy. Only around 2% of patients undergoing thyroidectomy for retrosternal goitre will require surgical access other than a standard collar incision (either manubriotomy, sternotomy or thoracotomy).9
Despite all the advances in investigative modalities, retrosternal goitre still exists in 20% of patients over 70 years in endemic regions. It has to be recognised that it can be a cause of obstructive sleep apnoea. Early detection and prompt management goes a long way in decreasing the morbidity and mortality in patients with RSG.
Retrosternal goitre; Obstructive sleep apnoea
The intrathoracic (substernal) goiter (1-15% of all thyroidectomies) is usually benign; but it can be malignant in 3-17%. There is history of thyroid surgery in 13-30% of patients. Intrathoracic goiters cause adjacent structure compression more frequently than the cervical goiters, due to the limited space of the thoracic cage. Compression of trachea, oesophagus, vascular and neural structures may cause dyspnoea, dysphagia, superior vena cava syndrome, subclavian vein thrombosis, dysphonia, and Horner’s syndrome. There is usually progressive deterioration, but acute exacerbation may occur. We present successful surgical management of a gigantic benign intrathoracic goiter, causing severe respiratory distress.
Patients and methods
A 63 year old male with history of subtotal thyroidectomy 2 years ago, presented with progressively increasing dyspnoea and inspiratory stridor. A large cervical, and prespinal superior and posterior mediastinal mass was revealed on computed tomography. Two retrovascular, pre- para- and retro-tracheal lobes were displacing the aortic arch, the anonymous vein, and the trachea, descending to the carina, severely compressing the trachea at the level of the aortic arch. Two lobes [maximum length: 12 cm (right), 14 cm (left), total weight: 290 gr] were resected en block through a cervical collar incision and a median sternotomy. Histology revealed multinodular goiter without malignancy.
The operation and the postoperative course were uneventful, without: bleeding, infection, recurrent laryngeal nerve palsy, cardiorespiratory, endocrine, or wound complications. Airway stenosis was immediately relieved, although a minor degree of stenosis, attributed to tracheomalacia due to chronic compression, remained. No intervention was required, and improvement was noted at follow-up.
Thoracic goiter (>50% of the mass below the thoracic inlet) is per se an indication for resection. Tracheal compression by (cervical or thoracic) goiter is also an indication for resection; early tracheal decompression is recommended particularly in symptomatic patients. In severe respiratory distress, intubation and semi-urgent operation may be required. With early intervention, most intrathoracic goiters (91-99%) can be removed through a cervical approach, while tracheomalacia is avoided. Re-operation and resection of a goiter descending to the carina, adjacent to the aortic arch, the descending aorta and the thoracic spine required a median sternotomy that was not associated with morbidity.
Surgical brain injury (SBI) is unavoidable during many neurosurgical procedures. This inevitable brain injury can result in postoperative complications including brain edema, blood-brain barrier disruption (BBB) and cell death in susceptible areas. Rosiglitazone (RSG), a PPAR-γ agonist, has been shown to reduce inflammation and provide neuroprotection in experimental models of ischemia and intracerebral hemorrhage. This study was designed to evaluate the neuroprotective effects of RSG in a rodent model of SBI.
65 adult male Sprague-Dawley rats were randomly divided into sham, vehicle and treatment groups. RSG was administered intraperitoneally in two dosages (1mg/kg/dose, 6mg/kg/dose) 30 minutes before surgery, and 30 minutes and 4 hours after surgery. Animals were euthanized 24 hrs following neurological evaluation to assess brain edema and BBB permeability by IgG staining. Inflammation was examined using myeloperoxidase (MPO) assay and double-labeling fluorescent immunohistochemical analysis of IL-1β and TNF-α.
Localized brain edema was observed in tissue surrounding the surgical injury. This brain edema was significantly higher in rats subjected to SBI than sham animals. Increased IgG staining was present in affected brain tissue; however, RSG reduced neither IgG staining nor brain edema. RSG also did not improve neurological status observed after SBI. RSG, however, significantly attenuated MPO activity and qualitatively decreased IL-1β and TNF-α expression compared to vehicle-treated group.
SBI causes increased brain edema, BBB disruption and inflammation localized along the periphery of the site of surgical resection. RSG attenuated inflammatory changes, however, did not improve brain edema, BBB disruption and neurological outcomes after SBI.
Rosiglitazone; surgical brain injury; inflammation; brain edema; blood brain barrier; myeloperoxidase
•CT scan has a great value for retrosternally extended giant goiter cases.•If the general status of the patient prevents CT scan, bedside ultrasound can be used instead.•Nasal awake intubiation is an appropriate choice for the patients with destructed trachea.•Emergency thyroidectomy is a common option for the treatment of giant goiter causing airway obstruction.
Giant cervical and mediastinal goiter may lead to acute respiratory failure caused by laryngotracheal compression and airway obstruction. Here, we present a case admitted to the emergency service with a giant goiter along with respiratory failure and poor general health status, which required urgent surgical intervention.
PRESENTATION OF CASE
A 71-year-old female admitted to the emergency room with shortness of breath and poor general health status resulting from a giant cervical swelling progressively increased during the last 7 years and constituted severe respiratory failure which has become severe in the last one month. A giant nodular goiter of the left thyroid lobe extending retrosternally, causing tracheal compression, limiting the neck movements was detected with clinical examination and bedside ultrasound. Emergency thyroidectomy was planned. Fiberoptic-assisted awake nasal intubation was performed in the operating room. Emergency total thyroidectomy was performed for the life-threatening respiratory failure. Postoperative period was uneventful. She was transferred from intensive care unit to the ward on postoperative day 3 and was discharged from the hospital on the postoperative 7th day. Benign multinodular hyperplasia was reported on the histopathological report. Patient was included in routine follow-up.
In the present case tracheal destruction due to compression of the giant goiter was found in agreement with previous reports. Emergency thyroidectomy was performed after awake intubation since it is a common surgical option for the treatment of giant goiter causing severe airway obstruction.
Respiratory failure due to giant nodular goiter is a life-threatening situation and should be treated immediately by performing awake endotracheal intubation following emergency total thyroidectomy.
Retrosternal; Giant goiter; Thyroidectomy; Awake intubation; Laryngotracheal compression; Respiratory failure
Chronic low-grade inflammation is a significant factor in the development of obesity associated diabetes. This is supported by recent studies suggesting endotoxin, derived from gut flora, may be key to the development of inflammation by stimulating the secretion of an adverse cytokine profile from adipose tissue.
The study investigated the relationship between endotoxin and various metabolic parameters of diabetic patients to determine if anti-diabetic therapies exerted a significant effect on endotoxin levels and adipocytokine profiles.
Fasting blood samples were collected from consenting Saudi Arabian patients (BMI: 30.2 ± (SD)5.6 kg/m2, n = 413), consisting of non-diabetics (ND: n = 67) and T2DM subjects (n = 346). The diabetics were divided into 5 subgroups based on their 1 year treatment regimes: diet-controlled (n = 36), metformin (n = 141), rosiglitazone (RSG: n = 22), a combined fixed dose of metformin/rosiglitazone (met/RSG n = 100) and insulin (n = 47). Lipid profiles, fasting plasma glucose, insulin, adiponectin, resistin, TNF-α, leptin, C-reactive protein (CRP) and endotoxin concentrations were determined.
Regression analyses revealed significant correlations between endotoxin levels and triglycerides (R2 = 0.42; p < 0.0001); total cholesterol (R2 = 0.10; p < 0.001), glucose (R2 = 0.076; p < 0.001) and insulin (R2 = 0.032; p < 0.001) in T2DM subjects. Endotoxin showed a strong inverse correlation with HDL-cholesterol (R2 = 0.055; p < 0.001). Further, endotoxin levels were elevated in all of the treated diabetic subgroups compared with ND, with the RSG treated diabetics showing significantly lower endotoxin levels than all of the other treatment groups (ND: 4.2 ± 1.7 EU/ml, RSG: 5.6 ± 2.2 EU/ml). Both the met/RSG and RSG treated groups had significantly higher adiponectin levels than all the other groups, with the RSG group expressing the highest levels overall.
We conclude that sub-clinical inflammation in T2DM may, in part, be mediated by circulating endotoxin. Furthermore, that whilst the endotoxin and adipocytokine profiles of diabetic patients treated with different therapies were comparable, the RSG group demonstrated significant differences in both adiponectin and endotoxin levels. We confirm an association between endotoxin and serum insulin and triglycerides and an inverse relationship with HDL. Lower endotoxin and higher adiponectin in the groups treated with RSG may be related and indicate another mechanism for the effect of RSG on insulin sensitivity.
The objective of this study was to investigate the effects of Rosiglitazone (RSG) infusion therapy following minimally invasive surgery (MIS) for intracerebral hemorrhage(ICH) evacuation on perihematomal secondary brain damage as assessed by MMP-9 levels, blood–brain barrier (BBB) permeability and neurological function.
A total of 40 male rabbits (2.8–3.4 kg) was randomly assigned to a normal control group (NC group; 10 rabbits), a model control group (MC group; 10 rabbits), a minimally invasive treatment group (MIS group; 10 rabbits) or a combined MIS and RSG group (MIS + RSG group; 10 rabbits). ICH was induced in all the animals, except for the NC group. MIS was performed to evacuate ICH 6 hours after the successful preparation of the ICH model in the MIS and MIS + RSG groups. The animals in the MC group underwent the same procedures for ICH evacuation but without hematoma aspiration, and the NC group was subjected to sham surgical procedures. The neurological deficit scores (Purdy score) and ICH volumes were determined on days 1, 3 and 7. All of the animals were sacrificed on day 7, and the perihematomal brain tissue was removed to determine the levels of PPARγ, MMP-9, BBB permeability and brain water content (BWC).
The Purdy score, perihematomal PPARγ levels, BBB permeability, and BWC were all significantly increased in the MC group compared to the NC group. After performing the MIS for evacuating the ICH, the Purdy score and the ICH volume were decreased on days 1, 3 and 7 compared to the MC group. A remarkable decrease in perihematomal levels of PPARγ, MMP-9, BBB permeability and BWC were observed. The MIS + RSG group displayed a remarkable increase in PPARγ as well as significant decrease in MMP-9, BBB permeability and BWC compared with the MIS group.
RSG infusion therapy following MIS for ICH treatment might be more efficacious for reducing the levels of MMP-9 and secondary brain damage than MIS therapy alone.
Intracerebral hemorrhage; Minimally invasive surgery; Rosiglitazone; PPARγ; MMP-9; Blood–brain barrier
Objective: To summarize the experience in the peri-operative treatment of giant nodular goiter.
Methods: A total of 123 patients with giant nodular goiter sized 6~20 cm were admitted into our hospital from 1990 to 2011 and the clinical data were retrospectively analyzed. These patients underwent total or subtotal thyroidectomy.
Results: All patients underwent surgical intervention. Unilateral subtotal thyroidectomy was performed in 40 patients, unilateral total thyroidectomy in 1 patient, bilateral subtotal thyroidectomy in 79 patients, and unilateral total thyroidectomy, removal of entire isthmus and contralateral subtotal thyroidectomy in 3 patients. Nodular goiter was pathologically proven post-operatively. No short-term complications such as dyspnea or thyroid storm were found postoperatively. Post-operative follow up was done for 9 months to 6 years and no recurrence was observed.
Conclusion: Comprehensive pre-operative preparation, pre-operative evaluation, complete exposure of the operative field, meticulous operation, effective control and prevention of hemorrhage and prevention against damage to superior and recurrent laryngeal nerves are crucial for the successful surgical intervention of giant nodular goiter.
nodular goiter; peri-operative treatment; surgical intervention.
Retrosternal goitre is defined as a goitre with a portion of its mass ≥ 50% located in the mediastinum. Surgical removal is the treatment of choice and, in most cases, the goitre can be removed via a cervical approach. Aim of this retrospective study was to analyse personal experience in the surgical management of retrosternal goitres, defining, in particular, the features requiring sternotomy. Over a 5-year period (2004-2008), 986 patients underwent thyroidectomy in the ENT Department of the University Hospital of Udine, Italy; in 53 patients, 37 females, 16 males (mean age: 64 years, range: 35-85), thyroidectomy was performed for a retrosternal goitre, which extended, at computed tomography at least 3 cm below the cervico-thoracic isthmus. Retrosternal goitres were removed via a cervical approach in 49 patients; a sternotomy was necessary in 4 patients (7.5%), due to an ectopic intra-thoracic thyroid in one patient, and a very large thyroid reaching the main bronchial bifurcation in the other 3 (mean weight of goitres: 883 g, range: 520-1600). Histo-pathological studies revealed a benign lesion in 50 patients and a carcinoma in 2 (3.7%). The incidence of transient and permanent hypoparathyroidism was 13% and 3.7%, respectively. Transient recurrent laryngeal nerve palsy occurred in one patient (1.8%), post-operative bleeding in 3 patients (5.6%) and respiratory complications, requiring a tracheotomy in one case, in 2 patients (3.7%). Surgical removal of a retrosternal goitre is a challenging procedure; it can be performed safely, in most cases, via a cervical approach, with a complication rate slightly higher than the average rate for cervical goitre thyroidectomy, especially concerning hypoparathyroidism and post-operative bleeding. The most significant criteria for selecting patients requiring sternotomy are computed tomography features, in particular the presence of an ectopic goitre, the thyroid gland volume and the extent of the goitre to or below the tracheae carina. In conclusion, if retrosternal goitre thyroidectomy is performed by a skilled surgical team, familiar with its unique pitfalls, the assistance of a thoracic surgeon may be required only in a few selected cases.
Thyroid; Retrosternal goitre; Surgical treatment; Sternotomy; Complications
The efficacy of fenofibrate (FEN), rosiglitazone (RSG), or a calorie-restricted diet (CRD) to reduce cardiovascular disease risk was compared in 37 overweight/obese, insulin resistant, nondiabetic individuals. Measurements were made of insulin sensitivity, fasting lipid and lipoprotein concentrations, and postprandial plasma glucose, insulin, free fatty acid, and triglyceride concentrations, before and after three months of treatment with FEN, RSG, or the CRD. Weight fell in the CRD group, but did not change significantly following treatment with either drug. Insulin sensitivity improved significantly in the CRD and RSG-treated groups, but to a greater extent in those given RSG, without a significant difference when comparing FEN treatment to the CRD. Total cholesterol concentrations were significantly lower following FEN and CRD. Fasting plasma triglyceride concentrations decreased significantly in FEN-treated and CRD groups, but postprandial concentrations decreased only in the FEN-treated subjects. Significant decreases in postprandial glucose and insulin concentrations were only seen in the RSG-treated and CRD groups. FEN administration improved the dyslipidemia in these subjects, without changing insulin sensitivity, whereas insulin sensitivity was enhanced in RSG-treated patients, without improvement in the dyslipidemia. Weight loss in the CRD group led to improvements in both insulin sensitivity and dyslipidemia, but the change in the former was less than in RSG-treated individuals, and the improvement in lipid metabolism not as great as with administration of FEN. In conclusion, there does not appear to be one therapeutic intervention that effectively treats all the metabolic abnormalities present in these patients at greatly increased risk of cardiovascular disease.
dyslipidemia; insulin resistance; fenofibrate; rosiglitazone
Clinical studies suggest that rosiglitazone (RSG) treatment may increase the incidence of heart failure in diabetic patients. In this study, we examined whether a high corn oil diet with RSG treatment in insulin resistant aging mice exerted metabolic and pro-inflammatory effects that stimulate cardiac dysfunction. We also evaluated whether fish oil attenuated these effects. Female C57BL/6J mice (13 months old) were divided into 5 groups: (1) lean control (LC), (2) corn oil, (3) fish oil, (4) corn oil + RSG and (5) fish oil + RSG. Mice fed a corn oil enriched diet and RSG developed hypertrophy of the left ventricle (LV) and decreased fractional shortening, despite a significant increase in total body lean mass. In contrast, LV hypertrophy was prevented in RSG treated mice fed a fish oil enriched diet. Importantly, hyperglycemia was controlled in both RSG groups. Further, fish oil + RSG decreased LV expression of atrial and brain natriuretic peptides, fibronectin and the pro-inflammatory cytokines interleukin-6 and tumor necrosis factor-α, concomitant with increased interleukin-10 and adiponectin levels compared to the corn oil + RSG group. Fish oil + RSG treatment suppressed inflammation, increased serum adiponectin, and improved fractional shortening, attenuating the cardiac remodeling seen in the corn oil + RSG diet fed C57BL/6J insulin resistant aging mice. Our results suggest that RSG treatment has context-dependent effects on cardiac remodeling and serves a negative cardiac role when given with a corn oil enriched diet.
Aging; Corn oil; Fish oil; Cardiac remodeling; Inflammation; Left ventricle hypertrophy; Rosiglitazone
Surgical treatment of benign thyroid diseases need to be followed up closely, since recurrent thyroid nodules can be seen after subtotal thyroidectomy. Intrathoracic goiter (ITG) occurs in 10–30% of patients following subtotal thyroidectomy. In general these goiters are benign, having a malignant rate of only 2–22%. ITG grows slowly but steadily and in its process of development, it narrows the thoracic inlet by compressing the surrounding structures. Most of these can not located in the anterior mediastinum, others located in posterior retrovascular area. Bilateral posterior retrovascular goiters are very rare.
PRESENTATION OF CASE
We report a case involving a 61-year-old woman with history of gradual-onset dyspnea who was referred to us for evaluation of a large mediastinal mass. She had undergone bilateral thyroid lobectomy for a cervical goiter 10 years ago. The mass was removed successfully via median sternotomy without complication. The patient recovered well and was discharged in 1 week.
Most anterior mediastinal goiters can be resected through a transcervical approach, but if those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy.
Bilateral recurrent posterior mediastinal and retrovascular large goiters are better resected via sternotomy rather than lateral thoracotomy. The reason for that are the possibility of injury to large vascular structures and the difficulty of their management through lateral thoracotomy when cardiopulmonary bypass needed.
Intrathoracic goiter; Mediastinum; Median sternotomy
Rosiglitazone (RSG) is an insulin-sensitizing drug used to treat type 2 diabetes mellitus. The A Diabetes Outcome Progression Trial (ADOPT) shows that women taking RSG experienced more fractures than patients taking other type 2 diabetes drugs. These were not osteoporotic vertebral fractures but, rather, occurred in the limbs. The purpose of this study was to investigate how RSG treatment alters bone quality, which leads to fracture risk, using the Zucker fatty rat as a model.
RESEARCH DESIGN AND METHODS
A total of 61 female 4-month-old rats were divided into six groups. One Sham group was a control and another was administered oral RSG 10 mg/kg/day. Four ovariectomized (OVX) groups were dosed as follows: controls, RSG 10 mg/kg, alendronate (ALN, injected at 0.7 mg/kg/week), and RSG 10 mg/kg plus ALN. After 12 weeks of treatment, bone quality was evaluated by mechanical testing. Microarchitecture, bone mineral density (BMD), cortical bone porosity, and bone remodeling were also measured.
OVX RSG 10 mg/kg rats had lower vertebral BMD and compromised trabecular architecture versus OVX controls. Increased cortical bone porosity and decreased mechanical properties occurred in these rats. ALN treatment prevented decreased BMD and architectural and mechanical properties in the OVX model. Reduced bone formation, increased marrow adiposity, and excess bone resorption were observed in RSG-treated rats.
RSG decreases bone quality. An unusual finding was an increase in cortical bone porosity induced by RSG, consistent with its effect on long bones of women. ALN, an inhibitor of bone resorption, enhanced mechanical strength and may provide an approach to partially counter the deleterious skeletal effects of RSG.
Sirolimus- (SES) and paclitaxel-eluting coronary stents (PES) are used to reduce restenosis, but have different sites of action. The molecular targets of sirolimus (SRL) overlap with those of the PPARγ agonist, rosiglitazone (RSG), but the consequence of this interaction on endothelialization is unknown.
Using the New Zealand White rabbit iliac model of stenting, we examined the effects of RSG on SES, PES and bare metal stent (BMS) endothelialization (ENDO).
Methods and Results
Animals receiving SES, PES, or BMS, and either RSG (3mg/kg/day) or placebo, were sacrificed at 28 days, and arteries evaluated by scanning electron microscopy (SEM). Fourteen-day organ culture (OC) and western blotting (WB) of iliac arteries, and tissue culture experiments were conducted. ENDO was significantly reduced by RSG in SES, but not in PES or BMS. OC revealed reduced VEGF in SES receiving RSG compared to RSG animals receiving BMS or PES. Quantitative PCR in human aortic endothelial cells (HAECs) revealed that SRL (but not paclitaxel) inhibited RSG-induced VEGF transcription. WB demonstrated that inhibition of molecular signaling in SES+RSG treated arteries was similar to findings in HAECs treated with RSG and siRNA to PPARγ, suggesting that SRL inhibits PPARγ. Transfection of HAECs with mTOR shRNA and with Akt2 siRNA significantly inhibited RSG mediated transcriptional upregulation of heme oxygenase-1 (HO-1), a PPARγ target gene. Chromatin immunoprecipitation assay demonstrated SRL interferes with binding of PPARγ to its response elements in HO-1 promoter.
mTOR/Akt2 is required for optimal PPARγ activation. Patients who receive SES during concomitant RSG treatment may be at risk for delayed stent healing.
stents; thrombosis; endothelium; pharmacology
Benign nodular goiter (BNG) can cause narrowing of the upper airway. In some rare cases, obstruction of the upper airway also occurs. The following paper reports our experiences with regard to BNG patients who experienced obstruction of the upper airway.
Materials and Methods.
We retrospectively investigated the records of 13 patients with acute airway obstruction due to BNG who were admitted to the General Surgery Department of Ataturk University Medical School between January 2000 and December 2007.
Thirteen patients with airway obstruction secondary to BNG were hospitalized during this period. There were two males and 11 females, and the mean age was 58.5 years (range 37–74 years). For all patients, the primary symptom upon admission was defined as respiratory distress; all patients had varying degrees of respiratory distress upon admission. Three of the patients underwent emergent endotracheal intubation in the emergency room.
A preoperative radiological evaluation was performed with thyroid ultrasonography (US) and computed tomography (CT). There were retrosternal or substernal components of the BNG in nine patients. Twelve patients underwent operations, while one patient with mild respiratory distress elected not to be operated on. Ten patients underwent total thyroidectomies, while two patients underwent near-total thyroidectomies. One patient with retrosternal goiter also underwent a median sternotomy. Three patients received a tracheostomy after the operation.
Suction drains were utilized in all operations. During the post-operative period, two patients suffered from voice impairment, and seven patients experienced hypocalcemia. Two patients died. Pathological examination of the thyroidectomy tissue revealed BNG in all cases. In addition, two patients had micropapillary carcinomas.
Although BNG causing upper airway obstruction is rare, it is an important clinical entity because of the need for emergent operation, the increased rate of complications, and high mortality.
Nodular goiter; Upper airway; Obstruction
“Forgotten” goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy.
PRESENTATION OF CASE
We report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves’ disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures.
In the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter.
Retrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.
Forgotten goiter; Retrosternal goiter; Substernal goiter; Total thyroidectomy
Patients with type 2 diabetes mellitus (T2DM) have a higher risk of cardiovascular disease (CVD). Peroxisome proliferator-activated receptors (PPARs) play an important role in the regulation of energy homeostasis. Therefore, we aimed to observe the effects of combined PPARα/γ agonists on T2DM patients with coronary artery disease (CAD). Patients were randomly divided into a rosiglitazone (RSG) group (n=20), a bezafibrate (BEZ) group (n=20), a combination of RSG and BEZ group (n=20) and a control group (n=20). Plasma C-reactive protein (CRP) and monocyte chemoattractant protein-1 (MCP-1) were measured by enzyme-linked immunosorbent assay before and 12 weeks after treatment. Fasting blood glucose (FBG), fasting insulin, insulin resistance index (IRI), hemoglobin A1c (HbA1c), lipid levels and body mass index were also investigated. At the end of the treatment, FBG, insulin, IRI, HbA1c and triglyceride levels decreased and the level of high-density lipoprotein cholesterol increased in the RSG, BEZ and combination groups. A decrease in low-density lipoprotein cholesterol was only observed in the combination group. Although the total cholesterol levels in all groups decreased, no significant difference was noted. The levels of CRP and MCP-1 were reduced in patients in the RSG, BEZ and combination groups. In addition, RSG, BEZ and the combination of RSG and BEZ also inhibited MCP-1 secretion. The combination of RSG and BEZ was more efficient than RSG or BEZ alone in downregulating cytokines. In conclusion, our results suggest that a combination of RSG and BEZ may be more efficient than RSG or BEZ alone in the treatment of T2DM patients with CAD.
diabetes mellitus; coronary heart disease; peroxisome proliferator-activated receptor α; peroxisome proliferator-activated receptor γ; inflammatory cytokine
Primary visceral malignant fibrous histiocytoma (MFH) is a rare disease, and few cases have been reported in the English literature. However, retained foreign bodies in the abdomen after surgical procedures are important causes of intra-abdominal infections. For legal and ethical reasons, there are few publications in the literature. In this article, we describe for the first time a case of malign abdominal fibrous histiocytoma associated with a surgical sponge forgotten in the abdominal cavity a long time ago.
A 64-year-old male presented to our surgical department with cachexia, abdominal pain, distention and pyrexia of unknown origin. He had a medical history of abdominal surgery for peptic ulcer perforation 32 years ago. Clinical examination revealed fever with a distended and painful abdominal wall. Radiological imaging of the abdomen showed multiple heterogeneous masses in one large cystic cavityalmost completely filling the abdomen. The patient underwent a laparotomy, and interestingly, opening the cyst revealed retained surgical gauze (RSG). The origin of the tumor was the visceral peritoneum, and it was excised totally.
Primary intra-abdominal MFH can present as a complication of long-lasting RSG. Therefore, clinicians must remember this while establishing the differential diagnosis for patients with a history of previous abdominal surgery and presenting with symptoms associated with both the tumor and systemic inflammatory response.
Malignant fibrous histiocytoma; Retained surgical gauze; Gossypiboma; Textiloma; Retained foreign body; Soft tissue sarcoma
Vocal cord paresis or paralysis due to iatrogenic injury of the recurrent laryngeal nerve (RLNI) is one of the main problems in thyroid surgery. Although many procedures have been introduced to prevent the nerve injury, still the incidence of recurrent laryngeal nerve palsy varies between 1.5-14%. The aim of the present study is to assess the risk factors of recurrent laryngeal nerve injury during thyroid surgery.
Patients who had thyroid surgery between 1990 and 2005 and were admitted to the surgical department of King Fahd hospital of the University, Al-Khobar, Saudi Arabia were enrolled for this retrospective review, Factors predisposing to recurrent laryngeal nerve injury were evaluated such as pathology of the lesions and the type of operations and identification of recurrent laryngeal nerve intra-operatively. Preoperative and postoperative indirect laryngoscopic examinations were performed for all patients.
340 patients were included in this study. Transient unilateral vocal cord problems occurred in 11 (3.2%) cases, and in 1 (0.3%) case, it became permanent (post Rt. Hemithyroidectomy). Bilateral vocal cord problems occurred in 2 cases (0.58%), but none became permanent. There were significant increases in the incidence of recurrent laryngeal nerve injury in secondary operation (21.7% in secondary vs. 2.8% in primary, p=0.001), total/near total thyroidectomy (7.2% in total vs. 1.9% in subtotal, p=0.024), non-identification of RLN during surgery (7.6% in non-identification vs. 2.6% in identification, p=0.039) and in malignant disease (12.8% in malignant vs. 2.9% in benign, p=0.004). However, there was no significant difference in the incidence of recurrent laryngeal nerve injury with regards to gender (4.1% in male vs 3.8% in female, p=0.849).
The present study showed that thyroid carcinoma, re-operation for recurrent goiter, non-identification of RLN and total thyroidectomy were associated with a significantly increased risk of operative recurrent laryngeal nerve injury.
Thyroidectomy; recurrent laryngeal nerve injury; carcinoma of thyroid
The intrathoracic (or substernal) goiter is more often benign; but it can be malignant in 2-22% of patients. There is history of prior thyroid surgery in 10% to more than 30% of patients. Intrathoracic goiters cause adjacent structure compression more frequently than the cervical goiters, due to the limited space of the thoracic cage. Compression of trachea, oesophagus, vascular and neural structures may cause dyspnoea, dysphagia, superior vena cava syndrome, subclavian vein thrombosis, hoarseness, and Horner’s syndrome. There is usually progressive deterioration, but acute exacerbation may occur. The presence of a thoracic goiter (>50% of the mass below the thoracic inlet) is per se an indication for resection. Tracheal compression by (cervical or thoracic) goiter is also an indication for resection; early tracheal decompression is recommended particularly in symptomatic patients. In severe respiratory distress, intubation and semi-urgent operation may be required. With early intervention, most intrathoracic goiters can be removed through a cervical approach, while tracheomalacia is avoided. We hereby present successful and uncomplicated total thyroidectomy, through a median sternotomy, of a benign, gigantic, bilateral, retrovascular, posterior mediastinal, intrathoracic goiter, encircling the trachea, and causing severe respiratory distress in a 63 year old man with history of previous subtotal thyroidectomy.
Airway obstruction/etiology; airway obstruction/surgery; thyroidectomy; goiter; substernal/surgery; goiter/intrathoracic
This study was carried out to evaluate the clinical presentation, surgical treatment, complications, and risk of malignancy for large substernal goiter. From March 2010 to December 2012, 12 patients with large substernal thyroid goiter who underwent surgery in our Department were enrolled in the study. Their medical records were retrospectively analyzed. Collar-shaped incision was adequate for resection of the lesions in 10 (83%) patients, while two (17%) patients required combined cervical-thoracic incision. In addition, one case was subjected to postoperative tracheotomy. Transient hypocalcaemia occurred in one case. The incidence of transient hoarseness, tracheomalacia and hypothyroidism was 8.3%. There was no perioperative bleeding, thyroid storm as well as other serious complications. All patients were clinically cured. Therefore, cervical collar incision is nearly always adequate for most cases of larger substernal goiter, and sternotomy can be avoided. Furthermore, the application of intraoperative ultrasonic knife can effectively reduce intraoperative and postoperative complications. Aggressive perioperative management is crucial for the successful removal of large substernal goiter.
Substernal goiter; operative approach; ultrasonic knife; complications
Hashimoto’s thyroiditis (HT) is usually treated conservatively with thyroxine. Its incidence is higher in Iodine sufficient areas and may require surgery for associated nodularity or complications. A retrospective study on surgically treated HT cases was conducted in a teritiary care teaching hospital in an Iodine sufficient area of Southern India. 34 cases of goiter with associated HT, who underwent thyroidectomy between 2007 and 2010 were analysed for indications of surgery. Minimum follow-up period was 6 months. F:M ratio was 31:3 with mean age of 41.3 years. Goiter was diffuse in 41% and nodular in 59%. 16 (47%) of patients were hypothyroid. Autoimmune association was found in 35%. Commonest surgery done was hemithyroidectomy in 12 (35%) followed by subtotal thyroidectomy in 10 cases. Most frequent indication for surgery was nodular goiter in 12 (35%) followed by associated malignancy, persistent goiter, pressure symptoms and painful thyroiditis. Histopathology showed diffuse HT alone in 12 (35%) and rest of the cases had HT as a component synchronous with other pathologies. Associated pathologies were benign multinodular goiter (6), colloid nodule (6), papillary cancer (5), follicular adenoma (4), cyst (1). Surgery for HT is primarily indicated for associated pathologies like dominant nodule, suspicious or proven malignancy, persistent goiter, painful thyroiditis, pressure symptoms and rarely for HT perse. Rate of surgery for HT associated goiter appears to be higher in Iodine sufficient areas, the cause of which needs to be studied further.
Hashimoto’s thyroiditis; Thyroxine; Surgery
Silencing of acid-labile subunit (ALS) improved glucose metabolism in animal models. The aim of this study is to evaluate the effects of rosiglitazone (RSG) on ALS levels in individuals with type 2 diabetes. A randomized, double-blind, placebo-controlled trial was conducted. Subjects with type 2 diabetes mellitus were randomly distributed to an RSG-treated (n = 30) or a placebo (n = 31) group. Patients were evaluated prior to treatment at baseline and at 12 and 24 weeks after treatment. At baseline, ALS levels were negatively associated with low-density lipoprotein cholesterol (LDLc) levels and homeostatic model assessment version 2 insulin sensitivity (HOMA2-%S). Over 24 weeks, there was a significantly greater reduction in ALS levels in the nonobese RSG-treated individuals than placebo-treated group. The effect of RSG on ALS was not significant in obese individuals. Fasting plasma glucose and hemoglobin A1c were reduced, but total cholesterol and LDLc were increased, in patients on RSG. Change in ALS levels predicted changes in total cholesterol and HOMA2-%S over time. This study suggested a BMI-dependent effect of RSG treatment on ALS levels. Reduction of ALS by RSG increases the risk of atherosclerosis in individuals with type 2 diabetes.
Background. Although the procedure requires a small surgical incision and a short duration, incision infection rate is very low in thyroidectomy; however, doctors still have misgivings about infection events. Aim. We retrospectively analyzed the prevention of incision infection without perioperative use of antibacterial medications following thyroidectomy. Materials and Methods. 1166 patients of thyroidectomy were not administered perioperative antibiotics. Unilateral total lobectomy or partial thyroidectomy was performed in 68.0% patients with single-side nodular goiter or thyroid adenoma. Bilateral partial thyroidectomy was performed in 25.5% patients with nodular goiter or Graves' disease. The mean time of operation was 80.6 ± 4.87 (range: 25–390) min. Results. Resuturing was performed in two patients of secondary hemorrhage from residual thyroid following bilateral partial thyroidectomy. Temporally recurrent nerve paralysis was reported following right-side total lobectomy and left-side subtotal lobectomy in a nodular goiter patient. One case had suppurative infection in neck incision 5 days after bilateral partial thyroidectomy. Conclusions. Thyroidectomy, which is a clean incision, involves a small incision, short duration, and minor hemorrhage. If the operation is performed under strict conditions of sterility and hemostasis, antibacterial medications may not be required to prevent incision infection, which reduces cost and discourages the excessive use of antibiotics.
Thyroid gland is an important endocrine organ because of its functions. Although the morbidity and mortality of thyroid surgery have decreased markedly, serious complications may still occur. The aim of this retrospective study was to identify the factors influencing the complications in benign nodular thyroid surgery. A total of 332 patients who underwent thyroid surgery between April 2004 and May 2008 were evaluated retrospectively to identify the factors influencing the complications. We found that in surgery lasting more than 90 minutes the risk of permanent recurrent laryngeal nerve (RLN) injury was high, daily drainage more than 50 cc increases the risk of seroma formation, retrosternal goiter surgery have higher risk for bleeding. The flap edema rates were high found in the operations made by resident surgeon and patients with size 3–4 thyroid glands. Low complication rates can be achieved after thyroidectomy with better knowledge of the surgical anatomy of the neck, thyroid pathology and required surgical treatment.
Thyroidectomy; Complications; Influencing factors
What is already known about this subject
Many studies have investigated the effects of thiazolidinediones on isolated biochemical markers (biomarkers) or sets of markers in Type 2 diabetes mellitus (T2DM) patients and healthy volunteers.
However, a limited number of parameters is not capable of capturing the broad response to pharmacological intervention with these types of (pleiotropic) drugs, which are known to activate the nuclear transcription factor peroxisome proliferator activated receptor gamma (PPARγ).
Our study tested the new hypothesis (primary objective) that nuclear magnetic resonance (NMR)-based metabolomics, capable of providing a readout of global metabolite concentrations in biofluids, could provide a better (more holistic) picture of the the multiparametric response to pharmacological intervention with a PPARγ agonist and thus yield a broad array of biomarkers (‘fingerprint’) that could be used to support and expedite clinical development of novel thiazolidinediones.
What this study adds
NMR-based metabolomics coupled with sophisticated bioinformatics is indeed capable of identifying rapid changes in global metabolite profiles in urine and plasma (treatment ‘fingerprints’), which may be linked to the well-documented early changes in hepatic insulin senstitivity following thiazolidinedione intervention in T2DM patients.
Consequently, this approach (upon proper validation) comprises an important new addition to the early clinical development ‘proof of concept’ toolbox for thiazolidinediones, and may also be applicable to other classes of drugs.
To explore the usefulness of metabolomics as a method to obtain a broad array of biomarkers for the pharmacological effects of rosiglitazone (RSG) in plasma and urine samples from patients with type 2 diabetes mellitus (T2DM) and healthy volunteers (HVs). Additionally, we explored the differences in metabolite concentrations between T2DM patients and HVs to identify a putative metabolic disease fingerprint for T2DM.
1H nuclear magnetic resonance (NMR) spectroscopy was used to profile blood plasma and urine samples of 16 T2DM patients and 16 HVs receiving RSG 4 mg or placebo twice daily for 6 weeks. Multivariate analyses were employed to identify treatment- and disease-related effects on global endogenous metabolite profiles.
RSG treatment led to a rapid relative reduction in urinary hippurate and aromatic amino acids as well as an increase in plasma branched chain amino acids and alanine, glutamine and glutamate in the T2DM group. No RSG treatment effects were noted in the HV group. Exploratory baseline analyses showed that urine and plasma metabolites discriminated between genders and disease state. T2DM patients showed a relative increase in urinary concentrations of several amino acids, citrate, phospho(enol)pyruvate and hippurate. Putative T2DM-related changes in plasma were largely attributable to increased plasma lipids.
The results of this study indicate that NMR-based metabolomics of urine and blood plasma samples can yield a broad array of early responding biomarkers for the effects of RSG in T2DM patients, as well as nonglucose biomarkers that may reflect the T2DM state.
biomarkers; metabolomics; metabonomics; NMR; diabetes