Ann Thorac Surg 2009;88:659-661. doi:10.1016/j.athoracsur.2008.12.073
© 2009 The Society of Thoracic Surgeons
Case Reports
Extracorporeal Membrane Oxygenation-Assisted Resection of Goiter Causing Severe Extrinsic Airway Compression
Yongfeng Shao, MDa,
Meiping Shen, MDb,
Zhengnian Ding, MD, PhDc,
Yongnian Liang, MDa,
Shijiang Zhang, MDa,*
a Division of Cardiothoracic Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
b Division of Endocrine Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
c Department of Anesthesiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
Accepted for publication December 22, 2008.
* Address correspondence to Dr Zhang, Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, People's Republic of China (Email: zhsj195177{at}yahoo.com.cn).
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Abstract
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We report a case of a 51-year-old woman with a huge multi-nodular thyroid goiter extending down into the superior mediastinum and causing severe extrinsic airway compression. Also due to the reason of severe rheumatoid arthritis, her mouth could not open widely. Because the endotracheal intubation was unsuccessful, we performed a subtotal thyroidectomy with the institution of veno-arterial extracorporeal membrane oxygenation.
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Introduction
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Extracorporeal membrane oxygenation (ECMO), also called extracorporeal life support, can provide support for severe respiratory failure and cardiac failure. Good results using ECMO in pulmonary crisis and primary graft dysfunction before and during the initial stage of lung transplantation were well documented [1]. We report the clinical use of ECMO in subtotal thyroidectomy of a patient with a huge multi-nodular thyroid goiter causing severe extrinsic compression, which was complicated with severe rheumatoid arthritis, without endotracheal intubation and mechanical ventilation.
A 51-year-old woman presented with a huge multi-nodular thyroid goiter present for 2 years. Her medical history included 25 years of treatment for rheumatoid arthritis. Past medications included nonsteroid, anti-inflammatory drugs and occasional prednisone. She presented to the emergency department with dyspnea on exertion, but no complaint of pain, fever, or dysphagia. Physical examination revealed normal vital signs. There were no signs or symptoms of hyperthyroidism. Her neck physical examination showed a 9 x 6 cm swelling on the left neck and an 8 x 6 cm mass on the right. Both tumors moved with swallowing and were firm in consistency, nodular, and nontender with normal overlying skin. The cervical spine was ankylosed and could not be extended, presumably due to the severe rheumatoid arthritis. Her mouth could not open widely due to the same reason. According to Mallampati classification, it was determined to be class IV. A chest roentgenogram and subsequent computed tomographic scan demonstrated a large cervical mass, extending down into the superior mediastinum and surrounding the trachea. There was evidence of severe extrinsic airway compression with minimum tracheal diameter measured as 5 mm (Figs 1 and 2).
All thyroid function tests were normal.
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Fig 2. Computed tomographic scans show significant narrowing of the thoracic trachea. (A) Coronal scan and (B) sagittal scan.
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We first tried bronchofibroscopic assist intubation awake, but it was unsuccessful. Considering there would be difficulty in oral endotracheal intubation due to the severe rheumatoid arthritis, risk of airway obstruction, and laryngeal edema, we decided to initiate ECMO to support the systemic oxygenation without intubation. We established veno-arterial ECMO under local anesthesia. We used a Jostra centrifugal pump and diffusion membrane oxygenator (Maquet Cardiopulmonary AG, Hirrlingen, Germany). Systemic heparin was administered to keep the active coagulation time between 160 
180 seconds (normal control 120 seconds). Perfusion flow rate was gradually increased to 2.5 L/min/m2 and the systemic oxygenation and carbon dioxide were continuously monitored. Once ECMO was established, general anesthesia was administered, and then the operation was performed.
On exploration of the thyroid through a routine cervical incision, both lobes were diffusely enlarged. Below the sternal notch the superior edge of the substernal goiter was palpable, and vascular supply from the neck was ligated and divided. Using the sharp and blunt dissection to divide the intrathoracic part of the mass, subtotal thyroidectomy was uneventful through a cervical incision without sternotomy, and right lobe was resected measuring approximately 12 x 6 cm, with the left lobe measuring approximately 17 x 10 cm (Fig 3). The total blood loss during the operation was approximately 5,000 mL and we used the cell saver and transfused the blood back to the patient.
After the resection of the lobes of the thyroid, we made a tracheostomy and inserted an endotracheal tube to avoid the risks of postoperative tracheomalacia and airway compromise. We then instituted mechanical ventilation with a conventional ventilator. The ECMO was weaned and adequate gas exchange was achieved through the ventilator. The total length of time that the ECMO was used was 7 hours, 35 minutes. The patient was weaned from ventilation 13 hours after the operation and was de-cannulated 6 days postoperatively without tracheomalacia. She was discharged 14 days postoperatively.
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Comment
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Patients with large goiters are more likely to present with difficulty at the time of intubation, particularly if the goiter has retrosternal extension or has produced significant tracheal compression. Bechard and colleagues [2] reported that airway compression > 50% diameter is associated with an increased risk of life-threatening respiratory complications. Bonaggad's study [3] showed that the percentage of moderate to major difficult endotracheal intubation in thyroid surgery was 5.3% (17 of 320). No intubation was impossible in that series [3]. In this case, the computed tomographic scan showed the large goiter extended into the mediastinum and compressed the thoracic trachea. But tracheal compression was only one of two big reasons for the difficult intubation. In addition, our patient had another particular reason for difficulty (ie, her cervical spine was ankylosed and could not extend due to severe rheumatoid arthritis), and her mouth could not open widely for intubation owing to the same reason.
To circumvent the problem of a difficult airway and to avoid the risks of sudden airway compromise without a prospect for an immediate tracheostomy, we used ECMO to accomplish gas exchange without tracheal intubation and mechanical ventilation. There are several advantages in using ECMO than in using cardiopulmonary bypass as follows: the ECMO can be used for a longer amount of time, there is less blood cell damage, there is less heparin use, and there is subsequently less bleeding. There were several previous case reports on successful use of ECMO in patients with mediastinal tumors [4, 5]. In the procedure, we used veno-arterial ECMO, so that it could provide both lung and heart support, and we believe that this made the procedure safer. We did not experience any complications of the ECMO support.
In conclusion, based on this case we believe that ECMO may be an effective and safe way to allow general anesthesia to correct airway compression when neither endotracheal intubation nor tracheostomy seem safe or feasible.
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Acknowledgments
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We whole heartedly thank Dr Bryan F. Meyers from Barnes-Jewish Hospital, Washington University, St. Louis, MO, for his editorial assistance.
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References
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- Hsu HH, Ko WJ, Chen JS, et al. Extracorporeal membrane oxygenation in pulmonary crisis and primary graft dysfunction J Heart Lung Transplant 2008;27:233-237.[Medline]
- Bechard P, Letourneau L, LaCassa Y, et al. Perioperative cardiorespiratory complications in adults with mediastinal mass: incidence and risk factors Anesthesiology 2004;100:826-834.[Medline]
- Bouaggad A, Nejmi SE, Bouderka MA, et al. Prediction of difficult tracheal intubation in thyroid surgery Anesth Analg 2004;99:603-606.[Abstract/Free Full Text]
- Aboud A, Marx G, Sayer H, et al. Successful treatment of an aggressive non-Hodgkin's lymphoma associated with acute respiratory insufficiency using extracorporeal membrane oxygenation Interact Cardio Vasc Thorac Surg 2008;7:173-174.
- Wickiser JE, Thompson M, Leavey PJ, et al. Extracorporeal membrane oxygenation (ECMO) initiation without intubation in two children with mediastinal malignancy Pediatr Blood Cancer 2007;49:751-754.[Medline]
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Abstract
Introduction
