Qin's seven steps for endoscopic selective lateral neck dissection via the chest approach in patients with papillary thyroid cancer: experience of 35 cases

Learning curve for the combined trans-oral and chest approach to endoscopic selective neck dissection: a cumulative sum (CUSUM) analysis

BACKGROUND

The combined trans-oral and chest approach is a novel technique for endoscopic selective neck dissection (SND), with satisfactory oncological safety and cosmetic results. However, this hybrid approach is difficult, and the learning curve remains unclear. In this study, we aimed to evaluate the short-term outcomes for this hybrid approach, and to define the associated learning curve.

METHOD

Clinical data and surgical outcomes of 58 PTC patients who underwent endoscopic SND via combined trans-oral and chest approach between September 2020 and April 2023 were retrospectively reviewed. The cumulative sum (CUSUM) sequential analysis technique is used to detect change, and has been applied for the evaluation of learning curves.

RESULTS

The study population included 58 patients (40 females, 18 males), with mean age of 38.9 ± 12.7 years and average body mass index of 22.6 ± 4.8 kg/m2. In all cases, the same surgical team performed endoscopic SND via combined trans-oral and chest approach. The numbers of positive/retrieved lymph nodes were 4.3 ± 3.2/27.8 ± 8.4 in the lateral compartment and 4.0 ± 3.5/8.4 ± 5.1 in the central compartment. The learning curve was evaluated in terms of an initial phase (20 cases) and a mature phase (38 cases). Operative time was longer during the initial phase, compared to the mature phase (375.2 vs. 274.6 min, p = 0.002). The frequency of operative complications was higher during the initial phase, compared to the mature phase (85% vs. 55.3%, p = 0.048).

CONCLUSIONS

After the experience acquired using endoscopic SND via combined trans-oral and chest approach to treat PTC in 20 patients, the number of complications decreased significantly. Compared to data collected for the initial phase, data collected for the mature phase showed trends toward decreased operating time.

Cumulative sum analysis for evaluating learning curve of endoscopic lateral neck dissection

OBJECTIVES

Endoscopic lateral neck dissection (LND) can be a scarless procedure if a surgeon has performed a sufficient number of operations to become skilled at the techniques involved. Here, we examine the learning curve for a surgeon who performed 53 endoscopic LND procedures via chest approach.

METHODS

Surgical outcomes for 53 patients with papillary thyroid carcinoma who underwent endoscopic LND via chest approach between February 2017 and November 2022 were retrospectively reviewed. The surgeon's learning curve was evaluated using a cumulative sum graphic model (CUSUM).

RESULTS

A CUSUM analysis was applied to 53 patients (10 males, 43 females) with a mean age of 41.4 y who underwent endoscopic LND via chest approach. The best model for the curve was determined to be a third-order polynomial equation as follows: CUSUMOT = - 0.007×patient number3-0.666×patient number2 + 55.721×patient number - 72.964. This equation has a high R2 value of 0.929. The peak operative time (OT) occurred at the 30th case. Consequently, the learning curve model was divided into two phases: phase 1 (1-30 cases) and phase 2 (31-53 cases). OT (307.9 ± 63.8 min vs. 232.4 ± 44.2 min, respectively; p < 0.001), blood loss (50 mL vs. 20 mL, respectively; p = 0.001), and complications (43.3% vs. 13.0%, respectively; p = 0.038) decreased significantly in phase 2 compared to phase 1.

CONCLUSIONS

The learning curve of endoscopic LND via chest approach was found to involve 30 cases. With greater experience, the surgery was completed with shorter OT and fewer complications. This approach may be an alternative for patients who desire cosmesis. Furthermore, the present data and experience insights regarding endoscopic LND via chest approach may help other surgeons to pass the learning phase more safely.

Prophylactic central lymph node dissection in cN0 papillary thyroid cancer: a comparative study of via breast and transoral approach versus via breast approach alone

Background

Papillary thyroid cancer (PTC) progresses slowly and has a good prognosis, while the prognosis is worse if combined with central neck lymph node metastasis at an early stage. The different endoscope approaches may affect the thoroughness of lymph node dissection. This study aimed to compare the clinical efficacy and safety of prophylactic central lymph node dissection(CLND) for cN0 PTC performed via breast and transoral approach versus via breast approach alone.

Materials and methods

A retrospective analysis of the surgical data of 136 patients with stage cN0 PTC was performed from August 2020 to December 2022. Among them, 64 underwent the breast and transoral approach (combined approach group), and 72 underwent the breast approach alone (breast approach group). The relevant indexes of surgery, the number of lymph nodes dissected, the occurrence of postoperative complications, and the cosmetic satisfaction of incision were statistically compared between the two groups.

Results

The operation time of the combined approach group was 156.4 ± 29.8 min, significantly longer than that of the breast approach group, 119.6 ± 55.9 min, and the difference was statistically significant (P<0.05). The two groups of patients were compared in terms of intraoperative bleeding, postoperative drainage, hospitalization time, incision cosmetic satisfaction, and the occurrence of postoperative complications, and the differences were not statistically significant (P>0.05). The total number of lymph nodes retrieved in the central area (10.6 ± 7.1) and the number of positive lymph nodes (4.6 ± 4.9) in the combined approach group were significantly more than those in the breast approach group (7.4 ± 4.8, 1.6 ± 2.7), and the difference was statistically significant (P<0.05). The difference between the two groups in terms of the number of negative lymph nodes was not statistically significant (P>0.05).

Conclusions

The study demonstrated that choosing the breast combined transoral approach for prophylactic CLND of cN0 PTC could more thoroughly clear the central area lymph nodes, especially the positive lymph nodes, which could help in the evaluation of the disease and the guidance of the treatment, while not increasing the postoperative complications. It provides a reference for clinicians to choose the appropriate surgical approach and also provides new ideas and methods for prophylactic CLND in patients with cN0 PTC.

Gasless Single-Incision Endoscopic Surgery via Subclavicular Approach for Lateral Neck Dissection in Patients with Papillary Thyroid Cancer

BACKGROUND

The technical difficulties and trauma of remote access methods in endoscopic surgery (ES) for lateral neck dissection (LND) can be daunting for most patients with papillary thyroid cancer (PTC) and surgeons. The purpose of study was to introduce gasless single-incision ES via a subclavicular approach (ESSA) and to explore its safety and efficacy for LND.

METHODS

Between January 2022 and February 2023, we retrospectively reviewed 17 patients with PTC who underwent ESSA for LND. In addition, 22 patients who received video-assisted ES (VAES) and 48 patients who underwent open surgery (OP) for LND during the same period were included. Clinicopathological characteristics, complications, and efficacy of the lymph node yield (LNY) were compared between the ESSA and the other two groups (VAES and OP).

RESULTS

The LNY from central and lateral neck dissection by ESSA was comparable to that by VAES (9.2 ± 8.1 vs. 9.5 ± 4.2, P = 0.986, and 33.5 ± 11.6 vs. 30.6 ± 9.2, P = 0.382, respectively) and OP (9.2 ± 8.1 vs. 11.0 ± 5.4, P = 0.420, and 33.5 ± 11.6 vs. 31.5 ± 7.9, P = 0.383, respectively). Swallowing impairment scores at 1 and 3 months were significantly lower after ESSA than those after VAES (1.8 ± 1.0 vs. 3.0 ± 1.2, P = 0.003, and 0.9 ± 0.8 vs. 1.7 ± 0.8, P = 0.006, respectively). The cosmetic satisfaction rate 1 month after surgery was significantly higher in the ESSA group than that in the VAES group (100 vs. 31.8%, P < 0.001).

CONCLUSIONS

ESSA is a safe and minimally invasive procedure that provides a scarless cervical appearance and has good efficacy for LND. Therefore, ESSA may be a feasible choice for selected patients with N1b PTC with cervical cosmetic needs.

A scoping review of endoscopic and robotic techniques for lateral neck dissection in thyroid cancer

Introduction

Lateral neck dissection (LND) in thyroid cancer has traditionally been performed by a transcervical technique with a large collar incision. With the rise of endoscopic, video-assisted, and robotic techniques for thyroidectomy, minimally invasive LND is now being performed more frequently, with better cosmetic outcomes.

Methods

The purpose of this paper is to review the different minimally invasive and remote access techniques for LND in thyroid cancer. A comprehensive literature review was performed using PubMed and Google Scholar search terms "thyroid cancer" and "lateral neck dissection" and "endoscopy OR robot OR endoscopic OR video-assisted".

Results

There are multiple surgical options now available within each subset of endoscopic, video-assisted, and robotic LND. The approach dictates the extent of the LND but almost all techniques access levels II-IV, with variability on levels I and V. This review provides an overview of the indications, contraindications, surgical and oncologic outcomes for each technique.

Discussion

Though data remains limited, endoscopic and robotic techniques for LND are safe, with improved cosmetic results and comparable oncologic and surgical outcomes. Similar to patient selection in minimally invasive thyroidectomy, it is important to consider the extent of the LND and select appropriate surgical candidates.

Endoscopic Thyroidectomy for Large-Sized Goiters: Merits of the Axillo-Breast Approach with Gas Insufflation

Background

Several minimal access approaches to the thyroid gland have been widely applied; nevertheless, such approaches are still challenging when dealing with large-sized thyroid nodules or goiters. We hereby evaluated the outcomes and highlighted the merits of endoscopic axillo-breast hemithyroidectomy (EABH) for large-sized unilateral goiters.

Methods

Patients underwent EABH for unilateral large thyroid nodules ≥6 cm in its greatest dimension or unilateral large goiter (≥60 ml sonographic volume) whatever the size of its contained nodules were identified from a prospectively maintained database. Their demographic data, clinicopathological profiles, and surgical and esthetic outcomes are reported and analyzed.

Results

Over a 2-year period, 33 patients matched the selection criteria. Their mean age was 34.75 ± 11.39 years. There were 30 women and 3 men. The majority of nodules were radiologically TIRADS3 and cytologically Bethesda 3. The mean sonographic dominant nodule greatest dimension was 5.29 ± 1.48 cm (range: 3-9.5 cm). The mean sonographic volume of the pathological lobe was 101.86 ± 54.45 ml (range: 60.11-236.88 ml). All cases were completed endoscopically with no conversion to open. The mean operative time was 110.76 ± 18.75 minutes. No significant postoperative complications were reported except for one case with temporary vocal cord paresis. Most (87.9%) of the patients were extremely satisfied with the procedure.

Conclusion

EABH with our suggested key steps could be considered an effective valid approach for unilateral large goiters in trained hands and in patients desirous for cosmesis.

Challenging routine: technical difficulties and solutions of endoscopic thyroidectomy via a combined transoral and breast approach - a case-series and learning curve

OBJECTIVE

Conventional cervical lymph node dissection often leaves large surgical scars, which seriously compromises the postoperative aesthetic effect and can affect the quality of life of patients. In this study, the safety and feasibility of robotic-assisted endoscopic thyroidectomy with central neck dissection (CND) and lateral neck dissection (LND) via a combined transoral and breast approach are discussed in detail.

MATERIALS AND METHODS

A retrospective analysis was made of the data of 26 patients with stage cN1b papillary thyroid carcinoma who were admitted to the Thyroid Surgery Department of the Hunan Cancer Hospital from March 2021 to September 2022 and who underwent robotic-assisted endoscopic thyroidectomy with LND via a combined transoral and breast approach. The demographic data, surgical indicators, postoperative data, and the postoperative complication rate of the patients were analyzed, and the learning curve was analyzed by cumulative summation.

RESULTS

All the patients underwent endoscopic surgery without any conversion to open surgery. The mean operation time was 313.7±50.3 min and the mean number of total positive/retrieved lymph nodes was 11.2±8.1/36.8±13.7. Two patients developed temporary laryngeal recurrent nerve palsy and three patients developed temporary hypoparathyroidism, all of whom recovered within 3 months postoperatively. No tumor recurrence occurred during follow-ups that ranged from 6 to 24 months. The mean postoperative quality of life (QOL) score was 189.1±118.2, test results ranging from 0 to 1300 with a lower score indicating a higher QOL, and the aesthetic satisfaction score was 4.2±0.7, test scores ranging from 0 to 5 with higher scores indicate higher satisfaction. The turning point of the learning curve was in the 11th case.

CONCLUSIONS

The robotic-assisted endoscopic thyroidectomy with CND and LND via a combined transoral and breast approach is safe and feasible, and the improved cosmetic effect is remarkable, which is conducive to improving the postoperative QOL of patients. It provides a new surgical option for patients.

Wu's seven steps for endoscopic central and lateral neck dissection via breast combined with oral approach for papillary thyroid cancer

OBJECTIVE

We had previously reported endoscopic central and lateral neck dissection via breast combined with an oral approach for papillary thyroid cancer treatment. In this study, we optimized the procedure with Wu's seven steps to make the procedure quicker and easier.

METHODS

Wu's seven steps for endoscopic central and lateral neck dissection via breast combined with oral approach for papillary thyroid cancer are: (1) establish the working space, (2) isolate the sternocleidomastoid and internal jugular vein, (3) dissect the thyroid via breast approach, (4) dissect the central lymph nodes via oral approach, (5) dissect the inferior board of level IV via oral approach, (6) remove the tissues of levels IV, III, and II via breast approach, and (7) wash the working space and place drainage tubes. Twelve patients were assigned to the Wu's seven steps group, and 13 patients were assigned to the contrast group. The operative procedure of the contrast group was the same as Wu's seven steps except for a few key differences, such as that the central lymph nodes were dissected via breast approach first and the internal jugular vein(IJV) was dissected from the cricoid cartilage down to the venous angle.

RESULTS

The Wu's seven steps group had a short operation time and few injuries of the internal jugular vein. There were no statistical differences in other clinicopathological features or surgical complications.

CONCLUSION

It appears that Wu's seven steps for endoscopic central and lateral neck dissection via breast combined with oral approach for papillary thyroid cancer are effective and safe.

A novel hybrid approach for "Scarless" (at the neck) lateral neck dissection for papillary thyroid carcinoma: A case series and literature review

Lateral neck dissection (LND) is a necessary treatment for thyroid cancer with lateral lymph node metastasis. However, the defect created during open surgery leaves a visible scar on the neck. With advancements in surgical technology, many robotic and endoscopic surgical techniques have been reported as alternatives to open surgery. In this study, we present a case series demonstrating the successful application of a novel hybrid approach for endoscopic LND and a review of different surgical approaches for "scarless" (at the neck) LND. We performed endoscopic LND via a combined chest and transoral approach in 24 patients between January 2021 and March 2022. The surgery was completed successfully in all patients with an average operation time of 298.1 ± 72.9 min. The numbers of positive/retrieved lymph nodes at levels II, III-IV, and VI were 0.7 ± 0.9/8.4 ± 4.1, 3.6 ± 2.7/19.5 ± 6.8, and 4.9 ± 3.9/10.3 ± 4.5, respectively. Complications included transient hypoparathyroidism in 10 patients, transient recurrent laryngeal nerve injury in 1 patient, internal jugular vein (IJN) injury in 1 patient, IJN sacrifice due to cancer invasion in 1 patient, and chyle leak in 1 patient, and no cases of tumor recurrence were observed during follow-up. The present case series indicates that the combined chest and transoral approach is feasible and effective for performing LND. Our review of different approaches for "scarless" (at the neck) LND identified advantages and disadvantages for all techniques. Our novel approach has unique advantages, and thus, it can provide an ideal surgical procedure for specific papillary thyroid carcinoma patients.

Endoscopic thyroidectomy via the combined trans-oral and chest approach for cT1-2N1bM0 papillary thyroid carcinoma

BACKGROUND

Recent years there have been witnessed considerable advances in endoscopic selective lateral neck dissection (LND). However, dissection of lymph nodes at level IV and level VI via the chest approach is inherently challenging. In this study, we used combined trans-oral and chest approach for endoscopic thyroidectomy in patients with cT1-2N1bM0 papillary thyroid carcinoma (PTC).

METHODS

Clinical characteristics and surgical outcomes of ten patients with cT1-2N1bM0 PTC who underwent endoscopic thyroidectomy via combination of trans-oral and chest approach between September 2020 and September 2021 were retrospectively reviewed.

RESULTS

All 10 patients successfully underwent total thyroidectomy and selective LND via chest approach, while central neck dissection (CND) and supplementary dissection of lymph nodes at level IV were performed via the trans-oral approach. The mean number of positive/retrieved level II, III-IV, and VI lymph nodes were 0.6 ± 1.0/9.8 ± 5.0, 4.6 ± 2.8/23.1 ± 4.7, and 4.9 ± 3.4/10.3 ± 4.6, respectively. Four patients developed transient hypoparathyroidism which spontaneously resolved within 1 month. Five patients developed numbness of lateral neck and ear and one patient experienced limb lift restriction. No other complications or tumor recurrence occurred during follow-up.

CONCLUSION

It is feasible to perform total thyroidectomy, CND, and selective LND via combined trans-oral and chest approach, and satisfactory short-term outcomes were observed in this cohort. This approach may offer one more option for cT1-2N1bM0 PTC patients, especially those in whom metastatic lymph nodes at level IV or level VI are detected by preoperative examination.

Endoscopic Lateral Neck Dissection: A New Frontier in Endoscopic Thyroid Surgery

Background

Endoscopic thyroidectomy and robotic thyroidectomy are effective and safe surgical options for thyroid surgery, with excellent cosmetic outcomes. However, in regard to lateral neck dissection (LND), much effort is required to alleviate cervical disfigurement derived from a long incision. Technologic innovations have allowed for endoscopic LND, without the need for extended cervical incisions and providing access to remote sites, including axillary, chest-breast, face-lift, transoral, and hybrid approaches.

Methods

A comprehensive review of published literature was performed using the search terms "lateral neck dissection", "thyroid", and "endoscopy OR endoscopic OR endoscope OR robotic" in PubMed.

Results

This review provides an overview of the current knowledge regarding endoscopic LND, and it specifically addresses the following points: 1) the surgical procedure, 2) the indications and contraindications, 3) the complications and surgical outcomes, and 4) the technical advantages and limitations. Robotic LND, totally endoscopic LND, and endoscope-assisted LND are separately discussed.

Conclusions

Endoscopic LND is a feasible and safe technique in terms of complete resection of the selected neck levels, complications, and cosmetic outcomes. However, it is recommended to strictly select criteria when expanding the population of eligible patients. A formal indication for endoscopic LND has not yet been established. Thus, a well-designed, multicenter study with a large cohort is necessary to confirm the feasibility, long-term outcomes, oncological safety, and influence of endoscopic LND on patient quality of life (QoL).