Transoral Thyroidectomy: Initial Results of the European TOETVA Study Group

Feasibility and complications after transoral endoscopic thyroidectomy via vestibular approach (TOETVA) - a single-center first experience case series

BACKGROUND

This paper reports on the first experience after implementation of a transoral endoscopic thyroidectomy via vestibular approach (TOETVA) as an alternative to (partial) thyroidectomy or isthmusectomy in a single center. Feasibility, implementation and specific complications are addressed.

METHODS

All patients who underwent a TOETVA procedure in our center between November 2019 and March 2023 were included. The surgical technique was performed as described by Anuwong et al. All procedures were performed by two dedicated head- and neck surgeons.

RESULTS

A total of 20 patients were included. All patients underwent TOETVA surgery as planned and no conversions were needed. Observed complications were post-operative wound infections (POWI) (2/20; 10%), clinically significant seroma (1/20, 5%) and unilateral hemiparesis of the larynx (3/20; 15%). Permanent mental nerve damage was seen in 3/20 patients (15%), and 4 other patients (20%) experienced transient neuropraxia.

CONCLUSIONS

TOETVA is a feasible alternative to (partial) thyroidectomy or isthmusectomy in selected patients. Special care should be taken when placing the trocars in the oral vestibulum to prevent mental nerve damage. Experience and training are essential for implementing the TOETVA procedure.

TRIAL REGISTRATION

This study was registered to ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT05396703.

Comparison of safety, efficacy, and patient satisfaction with thermal ablation versus endoscopic thyroidectomy for benign thyroid nodules in a propensity-matched cohort

BACKGROUND

Thyroid nodules (TNs) often require intervention due to symptomatic or cosmetic concerns. Radiofrequency ablation (RFA) has shown promise as a treatment option, offering potential advantages without neck scars. Recently, the scarless treatment alternative of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged. When surgery can be performed in a scarless manner, it remains unclear whether ablation is still the preferred treatment choice. This study aims to compare the safety, efficacy, and patient satisfaction of RFA and TOETVA.

STUDY DESIGN

A retrospective data analysis was conducted on patients treated with RFA or TOETVA for unilateral benign TNs between December 2016 and September 2021. Propensity score matching was employed to create comparable groups. Various clinicopathologic parameters, treatment outcomes, and costs were assessed.

RESULTS

Of the 2814 nonfunctional thyroid nodules treated during this period, 642 were benign and unilateral. A total of 121 and 100 patients underwent thermal ablation and transoral endoscopic thyroidectomy, respectively. After matching, 84 patients were selected for each group. Both RFA and TOETVA demonstrated low complication rates, with unique complications associated with each procedure. Treatment time (30.8±13.6 vs. 120.7±36.5 min, P <0.0001) was shorter in the RFA group. Patient satisfaction (significant improvement: 89.3% vs. 61.9%, P <0.0001) and cosmetic results (cosmetic score 1-2: 100.0% vs. 54.76%, P <0.0001) favored TOETVA. RFA was found to be less costly for a single treatment, but the cost of retreatment should be considered. The histological diagnoses post-TOETVA revealed malignancies in 9 out of 84 cases, underscoring the significance of follow-up assessments.

CONCLUSION

Scarless procedures, RFA and TOETVA, are effective for treating unilateral benign TNs, each with unique advantages and drawbacks. While RFA is cheaper for a single treatment, TOETVA offers superior cosmetic results and patient satisfaction. Further research is needed to evaluate long-term safety and cost-effectiveness. It is crucial to remain vigilant about the possibility of malignancy despite benign cytology pre-treatment.

The impact of body mass index on operative time in transoral endoscopic thyroidectomy vestibular approach for thyroid cancer

BACKGROUND

The impact of body mass index (BMI) on operative time in transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid cancer is still a subject of debate. This study assessed the impact of BMI on operative time and postoperative complications in patients undergoing TOETVA.

METHODS

The study has been conducted to compare the outcomes of TOETVA in patients with high BMI (≥25) and those with normal BMI (<25). Postoperative outcomes, including operative time, blood lost, recurrent laryngeal nerve (RLN) palsy, hypocalcemia and postoperative pain score, were evaluated.

RESULTS

A total of 62 patients who underwent TOETVA were included in the study. The high BMI group consisted of 39 patients, while the normal BMI group included 23 patients. No significant differences were observed between the two groups regarding operative time, blood loss, postoperative pain score, and postoperative complications such as recurrent laryngeal nerve (RLN) palsy and hypocalcemia.

CONCLUSIONS

BMI was not significantly associated with operative time and postoperative complications in patients undergoing TOETVA, indicating its safety and feasibility for elevated BMI patients.

A prospective study comparing the gasless endoscopic thyroidectomy trans-axillary approach to conventional open thyroidectomy: health and quality of life outcomes

BACKGROUND

The relationship between different surgical treatments and quality of life remains uncertain for differentiated thyroid carcinoma (DTC). The aim of this study is to compare the gasless endoscopic thyroidectomy trans-axillary approach (ET) and traditional open thyroidectomy (OT) through a prospective cohort study focusing on the rate of the efficacy, and quality of life (QoL).

METHODS

This prospective observational longitudinal cohort study enrolled 134 female patients diagnosed with DTC from December 01/2021 to December 31/2022. Multiple scales were applicated to evaluate the differences in quality of life, effectiveness, safety, etc. between the two groups during preoperative and postoperative follow-up periods, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, version 3.0 (QOL-C30), Symptom Checklist (SCL-90), Scar Cosmesis Assessment and Rating (SCAR-Q), voice impairment score (VIS), swallowing impairment score (SIS), and neck impairment score (NIS).

RESULTS

Among them, 68 accepted ET and 66 patients underwent OT. To enhance comparability between the two groups, the patients enrolled in this study are female. Compared with the OT group, the ET group performed significantly better postoperative physical quality of life, including sound (p = 0.036), swallowing (p < 0.001), and neck function (p = 0.010). The ET group was also associated with significantly better cosmetic satisfaction (p < 0.001), and relatively faster recovery in psychological and emotional situation.

CONCLUSIONS

Gasless endoscopic thyroidectomy through an axillary approach leads to good cosmetic and psychological effects, improves postoperative QoL, and could be recommended for rapid postoperative recovery and involvement in daily and social activities.

Complication and conversion outcomes in transoral endoscopic thyroidectomy vestibular approach (TOETVA): a retrospective multicenter propensity score-matched cohort study

Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a scarless thyroid surgery used as an alternative to open conventional surgery. Our aim was to investigate possible risk factors for complications and conversion during TOETVA. The study was conducted internationally by centres from Turkiye, the Republic of Korea, Italy, and Peru. A total of 406 patients who underwent TOETVA and were ≥ 18 years of age were included in the study. Demographic, pre-, intra-, and postoperative data were collected and compared between the groups with/without complication/conversion to identify possible predictors of complication/conversion. Subsequently, patients with complication/conversion were matched by the hospital, age, sex, and American Society of Anesthesiologists classification score using a propensity score (PSM) of 1:3 to eliminate confounding differences. Results were reported for the un-matched and matched groups. Complications occurred in 11 (2.7%) patients. High body mass index (26.4 ± 3.4 vs. 23.3 ± 3.7, p = 0.007), larger tumor size (1.7 ± 1.3 cm. vs. 1.1 ± 1.0 cm, p = 0.012), larger thyroid volume (20.0 ± 9.2 vs. 12.8 ± 8.5, p = 0.007) and long operation time (127.8 ± 45.0 min. vs. 97.7 ± 38.5 min., p = 0.008) were significantly associated with complications in un-matched analyses. Older age (42.7 ± 8.0 vs. 34.9 ± 9.2, p = 0.023), high BMI (26.7 ± 3.2 vs. 23.3 ± 3.7, p = 0.012), and longer operation time (160.1 ± 54.1 min. vs. 97.4 ± 37.8, p = 0.001) were significantly related to conversion in un-matched analyses. However, significance was lost after PSM for both complication and conversion. The data from this study conducted on TOETVA cases do not suggest a risk factor for complications and conversion with PSM.

TOETVA: a single surgeon's learning curve and a case report of CASTLE thyroid tumor

BACKGROUND

Owing to the lack of visible scars, the transoral endoscopic thyroidectomy vestibular approach (TOETVA) offers superior aesthetic outcomes compared to conventional thyroidectomy. Carcinoma showing thymus-like differentiation (CASTLE) represents a rare thyroid gland neoplasm. This study aimed to explore the TOETVA learning curve and present a case report of CASTLE.

METHODS

A study with precise 1:1 matching was conducted to assess the procedure safety and cancer control outcomes of TOETVA in comparison to conventional surgery between May 2020 and May 2023. Cumulative sum analysis was employed to optimally fit the learning curve. Subsequently, a case report of CASTLE treated with TOETVA surgery was presented.

RESULTS

The mean operative time was longer in the TOETVA group than in the open group. The TOETVA group had a higher incidence of skin numbness and excellent cosmetic outcomes compared to the open group. The learning curves for work area preparation, unilateral thyroid lobectomy, and the entire surgical process were 59, 28, and 50 cases, respectively. There were no differences between the learning and proficient groups, except for operative time, intraoperative blood loss, and drainage volume on the first postoperative day.

CONCLUSIONS

A comprehensive analysis of the TOETVA learning curve utilizing cumulative and analytical methods demonstrated the feasibility of TOETVA with regards to surgical integrity, safety, and oncological safety. This study's findings suggest that a surgeon's cumulative number of TOETVA cases exceeding 50 can reach the mastery stage. Moreover, diagnosing CASTLE is challenging and necessitates immunohistochemical detection of relatively specific markers associated with thymic epithelial tumors.

TOETVA parathyroid autofluorescence detection: hANDY-i endoscopy attachment

Background

Treatment options for thyroid pathologies have expanded to include scarless and remote access methods such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Currently, no standardized methods exist for locating parathyroid glands (PGs) in patients undergoing TOETVA, which can lead to parathyroid injury and subsequent hypocalcemia. This early feasibility study describes and evaluates the hANDY-i endoscopic attachment for detecting PGs in transoral thyroidectomy.

Methods

We used a prototype parathyroid autofluorescence imager (hANDY-i) that was mounted to a 10-mm 0-degree endoscope. The device delivers a split screen view of Red-green-blue (RGB) and near-infrared autofluorescence (NIRAF) which allows for simultaneous anatomical localization and fluorescence visualization of PGs during endoscopic thyroid dissection.

Results

One cadaveric case and two patient cases were included in this study. The endoscopic hANDY-i imaging system successfully visualized PGs during all procedures.

Conclusion

The ability to leverage parathyroid autofluorescence during TOETVA may lead to improved PG localization and preservation. Further human studies are needed to assess its effect on postoperative hypocalcemia and hypoparathyroidism.