title: Substernal goiter: when is a sternotomy required?
abstract: BACKGROUND
  Sternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach to thyroidectomy. We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG and analyzed the preoperative and postoperative characteristics of patients with SSG compared with those with large goiters contained entirely within the neck or a cervical goiter.
  
  
  METHODS
  A retrospective review of a surgical database was performed. We included patients with large (>100 g) thyroids or SSG, regardless of size. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had an SSG and patients who had a cervical goiter with particular focus on those who required sternotomy.
  
  
  RESULTS
  Of the 220 patients, 127 patients (58%) had SSG, of whom 7 (5.5%) required sternotomy. All patients who underwent sternotomy underwent preoperative computed tomography scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints and have 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 versus 190 mL, P = 0.04), and a longer length of stay (3.1 versus 1.8 d, P = 0.03) than cervical thyroidectomy.
  
  
  CONCLUSIONS
  Sternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch and were more likely to present complaining of chest pressure and voice issues.
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin; Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: Luke
authors.initials: L
authors.lastname: Nankee
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin; Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: Herbert
authors.initials: H
authors.lastname: Chen
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin; Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: David F
authors.initials: DF
authors.lastname: Schneider
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin; Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin.
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Sippel
authors.affiliation: Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin; Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin, Madison, Wisconsin. Electronic address: elfenbein@surgery.wisc.edu.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Elfenbein
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D005260:Female; D006045:Goiter, Substernal / Q000601:surgery*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D056346:Sternotomy; D013965:Thyroidectomy / Q000379:methods*; D016896:Treatment Outcome
keywords: Sternotomy; Substernal goiter; Thyroidectomy