1
|
Agne GR, Kohler HF, Lira RB, Belli M, Bento GN, Viana A, Kowalski LP. Aesthetic Perceptions Regarding a Thyroidectomy Scar and Transvestibular Approach in Brazil. Laryngoscope 2024; 134:3862-3867. [PMID: 38411345 DOI: 10.1002/lary.31372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/05/2024] [Accepted: 02/15/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE We investigated motivation levels across the general Brazilian population and subgroups and their willingness to spend for surgery without a cervical scar. METHODS This random-sample survey was performed by a specialized third-party research institute. In this study, we created a hypothetical thyroidectomy scenario, and the transcervical and transoral endoscopic thyroidectomy vestibular approach (TOETVA) were used. The survey included sociocultural data and questions regarding participants' surgical preferences. RESULTS Data were obtained from 1250 participants; 42.4% were of the opinion that a cervical scar affects social or professional life. Young and childless women were most likely to be affected (p <0.001). All respondents accepted the transoral approach to avoid cervical scarring. However, 30.7% and 31.9% of respondents maintained their preference for TOETVA despite understanding the risks of a hypothetical increase in complications and unfavorable oncological outcomes and 98.6% were of the opinion that this approach was likely associated with greater postoperative pain. Only 16.2% were unwilling to spend for TOETVA. The variable that most affected patients' willingness to spend was a salary greater than 10 Brazilian minimum wages (odds ratio 9.797, 95% confidence interval, p <0.005). Upper class respondents were 10 times more likely to spend for TOETVA than lower class patients. CONCLUSION This study highlights patients' interest in TOETVA. Cervical scar perception is affected by concerned about appearance, particularly in certain societal subgroups. Our study population showed significant motivation to undergo TOETVA, which was emphasized by their acceptance of the complication rate, poor postoperative outcomes, greater postoperative pain, and willingness to spend on surgery with an invisible scar. LEVEL OF EVIDENCE 4 Laryngoscope, 134:3862-3867, 2024.
Collapse
Affiliation(s)
| | - Hugo Fontan Kohler
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Renan Bezerra Lira
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Marcelo Belli
- Department of Head and Neck Surgery, PESCOP Group, Balneário Camboriú, Brazil
| | - Gustavo Nunes Bento
- Department of Head and Neck Surgery, PESCOP Group, Balneário Camboriú, Brazil
| | - Acklei Viana
- Department of Head and Neck Surgery, NICAP Group, Florianópolis, Brazil
| | - Luiz Paulo Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo, Brazil
- Department of Head and Neck Surgery, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
2
|
La Via L, Zanghì A, Cavallaro A, Di Vita M, Maniaci A, Cocuzza S, Cappellani A, Di Majo S. Vestibular approach for thyroid surgery: a comprehensive review. Front Surg 2024; 11:1423222. [PMID: 38948483 PMCID: PMC11211391 DOI: 10.3389/fsurg.2024.1423222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is an innovative technique in thyroid surgery. This review compiles current research on TOETVA, covering its development, anatomical challenges, techniques, selection of suitable patients, results, complications, and future advancements. We performed a comprehensive literature review on PubMed, EMBASE, and Cochrane databases for articles published up to 15th March 2024. The search strategy included a combination of terms focused on "vestibular approach" and "thyroidectomy". The review underscores the necessity for preoperative planning and careful patient selection to reduce risks and enhance outcomes. It discusses the unique anatomical challenges of TOETVA, such as avoiding mental nerve damage and the complexities involved in creating a subplatysmal space. Outcomes of TOETVA, including surgical duration, complication rates, and recovery times, are compared favorably to traditional methods. The approach is particularly noted for high patient satisfaction and superior cosmetic results. Complications specific to TOETVA, like infection, bleeding, and potential harm to the recurrent laryngeal nerve, are recognized. Future research directions are discussed as well. In summary, TOETVA is a promising alternative for thyroidectomy with excellent cosmetic outcomes and patient satisfaction. Success relies on selective patient criteria, surgical expertise, and continuous research to refine the approach.
Collapse
Affiliation(s)
- Luigi La Via
- Department of Anesthesia and Intensive Care, University Hospital Policlinico “G.Rodolico-San Marco”, Catania, Italy
| | - Antonio Zanghì
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Catania, Italy
- Centro di Ricerca in Chirurgia Delle Sindromi Malformative Complesse Della Transizione e dell’Età Adulta, University of Catania, Catania, Italy
| | - Andrea Cavallaro
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Maria Di Vita
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Antonino Maniaci
- Faculty of Medicine and Surgery, University of Enna “Kore”, Enna, Italy
| | - Salvatore Cocuzza
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Catania, Italy
| | - Alessandro Cappellani
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Simone Di Majo
- Residency Program in General Surgery, University of Catania, Catania, Italy
| |
Collapse
|
3
|
Zhang D, Sun H, Kim HY, Chai YJ, Tufano RP, Wu CW, Pino A, Anuwong A, Dionigi G. Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy. Surg Laparosc Endosc Percutan Tech 2024; 34:248-258. [PMID: 38767568 DOI: 10.1097/sle.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/27/2022] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Our aim was to determine whether bacteria contamination occurred within the surgical field or on endoscopic equipment during surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA). MATERIALS AND METHODS Participants were recruited from patients planned for TOETVA between May 2017 and December 2019. Bacterial samples were taken before and at the conclusion of the TOETVA procedure. The preoperative and postoperative samples were taken from the endoscopic materials and inferior oral vestibulum using a sterile flocked swab. RESULTS The study resulted in 480 samples (80 TOETVAs). No vestibular, port site, or neck infections occurred in any of the patients. Three (3.7%) out of 80 patients developed postoperative fever. Our results show different microbial communities during TOETVA. The most prevalent species detected were S treptococcus species. Multivariate logistic regression analyses revealed that the degree of contamination depended on the sampling site (inferior vestibulum > equipment) ( P =0.03). In addition, the abundance of bacteria was affected by operative time ( P =0.013). There were no significant differences observed in isolation frequencies of bacteria in malignancy ( P =0.34). CONCLUSIONS TOETVA surgery is categorized as a "clean-contaminated" operation. A swab identified the common colonizers of oral microbiota on the endoscopic equipment and within the surgical field.
Collapse
Affiliation(s)
- Daqi Zhang
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Hui Sun
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Hoon Yub Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Minimally Invasive Surgery and Robotic Surgery Center, KUMC Thyroid Center Korea University, Anam Hospital
| | - Young Jun Chai
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Che-Wei Wu
- Department of Otorhinolaryngology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University
- Department of Otorhinolaryngology-Head and Neck Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Antonella Pino
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS
| | - Angoon Anuwong
- Department of Surgery, Minimally Invasive and Endocrine Surgery Division, Police General Hospital, Bangkok, Thailand
| | - Gianlorenzo Dionigi
- Division of General Surgery, Endocrine Surgery Section, Istituto Auxologico Italiano IRCCS
- Department of Pathophysiology and Transplantation, University of Milan, Italy
| |
Collapse
|
4
|
Karimov Z, Kim SM, Turk Y, Dionigi G, Moscoso ES, Ozdemir M, Frattini F, Ozgul S, Makay O. Complication and conversion outcomes in transoral endoscopic thyroidectomy vestibular approach (TOETVA): a retrospective multicenter propensity score-matched cohort study. Updates Surg 2024; 76:227-238. [PMID: 38095833 DOI: 10.1007/s13304-023-01721-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/29/2023] [Indexed: 01/24/2024]
Abstract
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.
Collapse
Affiliation(s)
- Ziya Karimov
- Medicine Program, Ege University Faculty of Medicine, Izmir, Turkey
| | - Seok-Mo Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Yigit Turk
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Bornova, 35100, Izmir, Turkey
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano IRCCS (Istituto di Ricovero e Cura a Carattere Scientifco), Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Murat Ozdemir
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Bornova, 35100, Izmir, Turkey
| | - Francesco Frattini
- Division of Surgery, Istituto Auxologico Italiano IRCCS (Istituto di Ricovero e Cura a Carattere Scientifco), Milan, Italy
| | - Semiha Ozgul
- Department of Biostatistics and Medical Informatics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ozer Makay
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Bornova, 35100, Izmir, Turkey.
| |
Collapse
|
5
|
Seo S, Ali KM, Wolfe SA, Nagururu NV, Ding AS, Desai D, Harbison RA, Kim Y, Ning B, Cha RJ, Russell JO. TOETVA parathyroid autofluorescence detection: hANDY-i endoscopy attachment. Front Endocrinol (Lausanne) 2023; 14:1233956. [PMID: 37693365 PMCID: PMC10484600 DOI: 10.3389/fendo.2023.1233956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 07/12/2023] [Indexed: 09/12/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Stefanie Seo
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Khalid Mohamed Ali
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Samantha A. Wolfe
- Department of Endocrine Surgery, University Health Network, Toronto, ON, Canada
| | - Nimesh V. Nagururu
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Andy S. Ding
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Dipan Desai
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - R. Alex Harbison
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Yoseph Kim
- Department of Research, Optosurgical, LLC, Columbia, MD, United States
| | - Bo Ning
- Sheikh Zayed Institute, Children’s National Hospital, Washington, DC, United States
| | - Richard Jaepyeong Cha
- Department of Research, Optosurgical, LLC, Columbia, MD, United States
- Sheikh Zayed Institute, Children’s National Hospital, Washington, DC, United States
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Jonathon O. Russell
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
| |
Collapse
|
6
|
Lee JH, Choi HJ, Woo JW, Jung EJ. Robotic versus endoscopic transoral thyroidectomy in papillary thyroid cancer: A comparative analysis of surgical outcomes in 240 consecutive patients. Head Neck 2023; 45:827-837. [PMID: 36606489 DOI: 10.1002/hed.27295] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/10/2022] [Accepted: 12/27/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND This study compared the surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT) in papillary thyroid cancer (PTC). METHODS The TOETVA and TORT groups comprised 119 and 121 patients between November 2016 and May 2022. Clinico-surgical outcomes and operation times were retrospectively reviewed. RESULTS The TORT group showed a higher number of retrieved central compartment lymph nodes, shorter hospital stays, and lower pain score after 48 h than the TOETVA group. No significant difference was observed in the other postoperative complications, including permanent vocal cord palsy. Total operation, working space creation, and endoscopic or robotic surgery times of the TORT group were longer than those of the TOETVA group. CONCLUSIONS TORT and TOETVA are feasible and safe. TORT may have some advantages, such as central compartment node dissection, shorter hospital stays, and pain score after 48 h in PTC, despite a longer operative time.
Collapse
Affiliation(s)
- Jun Ho Lee
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea.,Department of Surgery, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - Hee Jun Choi
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Jung-Woo Woo
- Department of Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Eun-Jung Jung
- Department of Surgery, Gyeongsang National University College of Medicine, Jinju, Republic of Korea.,Department of Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| |
Collapse
|
7
|
Rebelo B, Nogueira R, Horta M. The Role of High-Resolution Ultrasound in the Assessment of Surgical Candidates for Transoral Endoscopic Thyroidectomy Via Vestibular Approach (TOETVA). ACTA MEDICA PORT 2023; 36:212-217. [PMID: 36898208 DOI: 10.20344/amp.19038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/09/2023] [Indexed: 03/06/2023]
Abstract
The approach of surgical techniques has evolved significantly over the last decade, with natural orifice surgeries replacing traditional open approaches. In 2016, Angkoon Anuwong, in Thailand, demonstrated it was possible to perform thyroidectomies in a series of patients by a transoral endoscopic ap-proach - transoral endoscopy thyroidectomy vestibular approach (TOETVA) - with similar complication rates when compared to conventional surgeries. This transoral surgery has become a safe alternative with better cosmetic results, compared to conventional open-route procedures, like Kocher cervi-cotomy. Indeed, it is an option to surgically treat neoplastic and functional thyroid diseases. The technique is performed through a median incision in the oral vestibule, plus two bilateral incisions, followed by the insertion of three trocars, one centrally for a camera, and two laterally for working instruments. Although revolutionary, TOETVA has its technical limitations. Therefore, it is important to precisely define the preoperative eligibility criteria for this type of surgical approach. High-resolution ultrasound is the first imaging modality for the assessment of thyroid nodules, lymph node metastases and surgical field. The aim of this article is to outline the sonographic technique and the role of high-resolution ultrasound in the presurgical evaluation of TOETVA.
Collapse
Affiliation(s)
- Beatriz Rebelo
- Department of Radiology. Instituto Português de Oncologia de Lisboa Francisco Gentil. Lisbon. Portugal
| | - Ricardo Nogueira
- Department of Head and Neck Surgery. Instituto Português de Oncologia de Lisboa Francisco Gentil. Lisbon. Portugal
| | - Mariana Horta
- Department of Radiology. Instituto Português de Oncologia de Lisboa Francisco Gentil. Lisbon; Institute of Anatomy. Faculty of Medicine. University of Lisbon. Lisbon. Portugal
| |
Collapse
|
8
|
Lee DW, Kim JK, Shin SH, Tae K. Transoral thyroidectomy implemented by a novice surgeon: Efforts for safe implementation. Laryngoscope Investig Otolaryngol 2023; 8:287-295. [PMID: 36846424 PMCID: PMC9948568 DOI: 10.1002/lio2.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/29/2022] [Indexed: 12/03/2022] Open
Abstract
Background This study aimed to evaluate the feasibility, safety, and early surgical outcomes of transoral robotic and endoscopic thyroidectomy conducted by a novice surgeon. Methods We analyzed 27 patients who underwent transoral thyroidectomy between December 2018 and November 2021. All the surgeries were performed by a novice surgeon without prior endoscopic or robotic surgery experience; the surgeon had experienced 12 cases of transcervical thyroidectomy before adopting transoral thyroidectomy. Results Of the 27 cases, 1 was converted to the transcervical approach due to poor bleeding control. Four cases had transient recurrent laryngeal nerve palsy, and three had transient hypoparathyroidism. Most of the patients were very satisfied with the postoperative cosmetic outcome. Conclusions Transoral robotic and endoscopic thyroidectomies are feasible for the novice surgeon, with reasonable results in the early adoption stage if preparations are according to the suggested framework. Level of Evidence Level 4.
Collapse
Affiliation(s)
- Dong Won Lee
- Department of Otorhinolaryngology‐Head and Neck Surgery, School of MedicineDaegu Catholic UniversityDaeguRepublic of Korea
| | - Jeong Kyu Kim
- Department of Otorhinolaryngology‐Head and Neck Surgery, School of MedicineDaegu Catholic UniversityDaeguRepublic of Korea
| | - Seung Heon Shin
- Department of Otorhinolaryngology‐Head and Neck Surgery, School of MedicineDaegu Catholic UniversityDaeguRepublic of Korea
| | - Kyung Tae
- Department of Otolaryngology‐Head and Neck Surgery, College of MedicineHanyang UniversitySeoulRepublic of Korea
| |
Collapse
|
9
|
Moreno Llorente P, Pascua-Solé M, García Barrasa A, Francos Martínez JM, Muñoz de Nova JL, Fernández Ranvier G, Vidal Fortuny J. Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases. Cir Esp 2023; 101:35-42. [PMID: 35896141 DOI: 10.1016/j.cireng.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/21/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars. METHODS Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021. RESULTS Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. CONCLUSTIONS Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.
Collapse
Affiliation(s)
- Pablo Moreno Llorente
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Mireia Pascua-Solé
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Arantxa García Barrasa
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Manuel Francos Martínez
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Luis Muñoz de Nova
- Unidad de Cirugía Endocrina, Mama y Pared Abdominal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Jordi Vidal Fortuny
- Swiss Medical Network, Genolier, Switzerland; Grupo Hirslanden, Lausanne, Switzerland
| |
Collapse
|
10
|
Sheng X, Liu J, Fang J, Zheng X, Wang S. En bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in papillary thyroid carcinoma. Front Endocrinol (Lausanne) 2023; 14:1130791. [PMID: 36923227 PMCID: PMC10009257 DOI: 10.3389/fendo.2023.1130791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/08/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION The current study presents a preliminary exploration of en bloc resection via a gasless transoral approach in papillary thyroid carcinoma. OBJECTIVE This study aimed to summarize and explore the efficacy and safety of en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in patients with papillary thyroid carcinoma. METHODS This study was conducted between January 2021 and December 2021. It involved 30 patients with bilateral papillary thyroid carcinoma who had undergone en bloc resection of the total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach using a three-trocar and four-instrument technique at The First Affiliated Hospital of the University of Science and Technology of China. The key steps and difficulties of the operation were summarized, and the clinicopathological characteristics and surgical complications of patients were analyzed. RESULTS All operations were successful without conversion to open surgery. The pathological diagnosis was bilateral papillary thyroid carcinoma. The mean maximum tumor diameter was 0.85 ± 0.51 cm (range 0.3-2.5 cm). There was no case of gross capsular invasion. The mean number of harvested central compartment lymph nodes was 11.36 ± 5.36. Central compartment lymph node metastases were found in 16 patients (53.3%) with a mean of 1.53 ± 2.39. On the other hand, lymphocytic thyroiditis was observed in 12 cases (40%), and microscopic capsular invasion was observed in five cases (16.6%). All patients had normal parathyroid hormone levels after the operation. However, one patient developed hoarseness after the operation due to injury of the recurrent laryngeal nerve branch, but there was no numbness of the mandible and lower lip or infection of the oral incision. CONCLUSION The study revealed that the three-trocar and four-instrument technique can be used in the en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach without disconnecting the thyroid isthmus. As a result, the operation is considered effective and safe. Therefore, this technique may be a better surgical method for patients with bilateral thyroid cancer and cosmetic needs.
Collapse
Affiliation(s)
- Xuren Sheng
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Jianjun Liu
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Jing Fang
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Xucai Zheng
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
| | - Shengying Wang
- Department of Head and Neck Surgery, West District of The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Head and Neck Surgery, Anhui Provincial Cancer Hospital, Hefei, China
- *Correspondence: Shengying Wang,
| |
Collapse
|
11
|
Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA)—a Case Series Analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03558-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
|
12
|
Transoral endoscopic thyroidectomy by vestibular approach in Viet Nam: surgical outcomes and long-term follow-up. Surg Endosc 2022; 36:4248-4254. [PMID: 34622296 DOI: 10.1007/s00464-021-08759-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/27/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The transoral endoscopic thyroidectomy by vestibular approach (TOETVA) has been developed for early-stage thyroid cancer treatment as well as benign thyroid nodules worldwide including Viet Nam, with low rate of complications and excellent results. However, there has not been any comprehensive studies with a large number of patients and long-term follow-up in our country. Therefore, we conducted this study to evaluate the results of treatment by TOETVA for benign and malignant lesions of thyroid gland in Viet Nam. METHODS A prospective study was performed on 326 eligible patients who underwent TOETVA due to thyroid cancer and benign thyroid nodules in Department of Oncology and Palliative Care, Hanoi Medical University Hospital from July 2018 to April 2021. The clinical, surgical, and pathological characteristics, postoperative complications, and visual analog scale (VAS, 0-10 cm) score in day 1, 4, and 7 after surgery, long-term oncological and surgical outcomes were recorded. RESULTS The mean age was 36.9 ± 9.8 years. 231 patients (70.9%) were diagnosed with differentiated cancer and 95 patients (29.1%) were diagnosed benign tumors of thyroid gland. In the cancer group, 12 patients (5.2%) undergone TOETVA had T3b-intraoperative-stage diagnosis, 219 patients (92.2%) were diagnosed T1 according to AJCC 8th. After 1 month of surgery, among thyroid cancer patients, there was no abnormality reported by thyroid scintigraphy and neck ultrasound as well as in unstimulated-Tg and anti-Tg values. The mean number lymph-node dissected in the cancer group was 6.1 ± 4.1 (range 0-21 nodes). However, only 2.6 ± 1.8 metastasis nodes were discovered (range 1-8 nodes), and the maximum size of these nodes was less than 2 mm. 81 patients presented occult lymph-node metastasis among thyroid cancer patients with cN0 stage (account for 35%). The occult lymph-node metastasis was 34.2% and 50% in patients diagnosed with T1 and T3b groups, respectively. The median postoperative hospital stay was 5.4 ± 0.7 days. Postoperatively, transient hypoparathyroidism was recorded in 12 patients (4.8%), transient hoarse was noted in 9 patients (3.6%), and numb chin was identified in 7 patients (2.8%). No permanent complication was noted. VAS score on first postoperative day was 4.5 ± 0.8. Median follow-up time was 12 (3-25) months. No recurrence was recorded. CONCLUSIONS TOETVA is an innovative and revolutionary technique in the treatment of benign thyroid nodules, as well as early-stage differentiated thyroid cancer. The results of oncology, postoperative complications, and satisfied outcomes supported the wide application of TOETVA in Viet Nam.
Collapse
|
13
|
Chen H, Deng L, Gong Z, Zhu X. The Advantages of Applying a 5-mm Endoscope in the Transoral Endoscopic Thyroidectomy Vestibular Approach. Surg Laparosc Endosc Percutan Tech 2022; 32:357-361. [PMID: 35482517 DOI: 10.1097/sle.0000000000001051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/27/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We sought to compare the effect of applying a 5-mm endoscope and a 10-mm endoscope in the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and to clarify the advantages of using a 5-mm endoscope. MATERIALS AND METHODS A retrospective analysis of the clinical data of 135 patients who were diagnosed with papillary thyroid carcinoma and who had undergone TOETVA in the thyroid disease center of The First Affiliated Hospital of Nanchang University between January 2019 and May 2020 was performed. Among the included patients, a 10-mm endoscope was used in 50 cases (the 10-mm endoscope group) and a 5-mm endoscope was used in 85 cases (the 5-mm endoscope group), respectively. Operative trauma, operative parameters, postoperative complications, and postoperative mandibular sensation score were compared and analyzed. RESULTS Compared with the 10-mm endoscope group, the 5-mm endoscope group had less surgical trauma, less injury to the mandibular muscles (orbicularis oris, depressor labii inferioris, and mentalis muscle), shorter operative times (107.7±8.1 vs. 121.3±11.6 min, P<0.01), less intraoperative bleeding (14.3±4.8 vs. 17.9±5.3 mL, P<0.01), no obvious postoperative complications, lower mandibular sensation score values (5.7±0.6 vs. 6.0±0.4 points, P<0.01), and shorter mandibular recovery times (9.4±2.5 vs. 12.3±3.6 d, P<0.01). CONCLUSION The application of a 5-mm endoscope not only improves the cosmetic effect of TOETVA but also reduces the degree of surgical trauma, saves the surgical space, improves the surgical efficiency, and reduces postoperative discomfort, with a promising application prospect.
Collapse
Affiliation(s)
- Hang Chen
- First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | | | | | | |
Collapse
|
14
|
Divarci E, Ulman H, Ozok G, Ozen S, Ozdemir M, Makay O. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): A novel surgical technique for scarless thyroidectomy in pediatric surgery. J Pediatr Surg 2022; 57:1149-1157. [PMID: 35232598 DOI: 10.1016/j.jpedsurg.2022.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/22/2022] [Indexed: 11/29/2022]
Abstract
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a novel surgical technique in thyroid surgery that provides a feasible opportunity to avoid a visible neck scar. In recent years, TOETVA became popular in the thyroid surgery of selected adult patients with cosmetic concerns. We conducted a right lobectomy with the TOETVA technique in a 17-year-old adolescent with a suspicious thyroid nodule the present report aimed to describe the details of the operative technique step by step. Level of evidence: LEVEL IV, case series with no comparison group.
Collapse
Affiliation(s)
- Emre Divarci
- Department of Pediatric Surgery, Ege University Faculty of Medicine, Izmir, Turkey.
| | - Hilmican Ulman
- Department of Pediatric Surgery, Ege University Faculty of Medicine, Izmir, Turkey; Department of Pediatrics, Division of Pediatric Endocrinology, Ege University Faculty of Medicine, Izmir, Turkey; Department of General Surgery, Division of Endocrine Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Geylani Ozok
- Department of Pediatric Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Samim Ozen
- Department of Pediatrics, Division of Pediatric Endocrinology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Murat Ozdemir
- Department of General Surgery, Division of Endocrine Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ozer Makay
- Department of General Surgery, Division of Endocrine Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| |
Collapse
|
15
|
The Effectiveness and Quality of Life Outcomes by Transoral Endoscopic Vestibular Thyroidectomy Using Intraoperative Indocyanin Green Fluorescence Imaging and Neuromonitoring—A Cohort Study. Healthcare (Basel) 2022; 10:healthcare10050953. [PMID: 35628090 PMCID: PMC9140775 DOI: 10.3390/healthcare10050953] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Transoral endoscopic vestibular thyroidectomy (TOEVT), a variant of natural orifice transluminal endoscopic surgery, offers a scar-less thyroid to young females. However, few studies have compared the effectiveness and quality of life (QoL) outcomes of the TOEVT with open thyroidectomy (OT). This is the first study in the Middle East and North Africa region that compares the effectiveness, safety profile and QoL outcomes between TOEVT with OT. Methods: We reviewed the medical records of consecutive patients with TOETV and OT at Zulekha Hospital Sharjah and Dubai United Arab Emirates, between 1 January 2019 and 1 April 2021. The data for demographics, type of surgery, operative time, blood loss, post-operative nodule size, hospital stay and post-operative complications were analyzed. We used an SF-36 questionnaire pre- and postoperatively for the assessment of QoL in both groups. Findings: Out of a total of 41 OT and 32 TOEVT procedures, 59 patients (31 TOEVT and 28 OT) fulfilled the inclusion criteria. There were 45 women and 14 men with an average age of 41 years. The mean operating time was 126 min in TOEVT and 96 min in OT (p = 0.000). The mean thyroid size was 5.55 cm in TOEVT and 8.76 cm in OT (p = 0.000). Lastly, the mean intraoperative blood loss was 39 cc and 95.7 cc in TOEVT and OT, respectively (p = 0.001). There was one temporary hypocalcemia and seroma in TOEVT, four cases of temporary hypocalcemia and one with minor bleeding in OT. The post-operative QoL significantly improved in all patients. However, the QoL improved more significantly in the TOEVT group for bodily pain, vitality, role emotions and cosmetic concerns (p = 0.000). Conclusion: The safety profile and effectiveness of the TOEVT is comparable to the OT procedure. However, TOEVT has an additional advantage of being scarless and offers a better QoL.
Collapse
|
16
|
Akritidou E, Douridas G, Spartalis E, Tsourouflis G, Dimitroulis D, Nikiteas NI. Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review. In Vivo 2022; 36:1-12. [PMID: 34972695 DOI: 10.21873/invivo.12671] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 01/04/2023]
Abstract
This review focuses on complications linked to trans-oral endoscopic thyroidectomy via vestibular approach (TOETVA) and aimed to elucidate the procedure's initial safety profile. According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), Pubmed, Embase, and the Cochrane databases were screened till May 2021. Twenty-eight articles, nine cohorts and nineteen case series, met the inclusion criteria. Procedure-related complications were analyzed, the most important being hypoparathyroidism: transient (range=0.94-22.2%), permanent (range=1.33-2.22%), and recurrent laryngeal nerve injury: transient (range=1.9-8.8%) and permanent (range=0.59-1.42%). Surgical trauma related complications, the most prevalent being seroma, emphysema, and hematoma accounted for 2.91%. Null mortality was reported. Although current evolving experience indicates that TOETVA is safe and linked to acceptable complication rates, the method needs to be compared with the gold standard of traditional thyroidectomy in the context of sufficiently numbered cohorts and ultimately randomized controlled trials.
Collapse
Affiliation(s)
- Ellada Akritidou
- Department of Surgery, Thriassio General Hospital, Athens, Greece; .,Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece
| | | | - Eleftherios Spartalis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos I Nikiteas
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2 Department of Propaedeutic Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
17
|
Lee SH, Moorthy R, Nagala S. OUP accepted manuscript. Br J Surg 2022; 109:497-502. [PMID: 35576381 DOI: 10.1093/bjs/znac072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The IDEAL Framework is a scheme for safe implementation and assessment of surgical innovation. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery that eliminates the need for a cervical incision. Despite considerable interest and adoption worldwide, significant scepticism remains regarding the outcomes and cost-effectiveness for healthcare systems. The aim of this narrative review was to appraise the available literature and examine whether TOETVA has progressed in line with the IDEAL Framework. METHODS A literature review of PubMed with a focus on historical and landmark studies was undertaken to classify the evidence according to the different stages of the IDEAL Framework. RESULTS Several different transoral approaches were developed by a small of number of surgeon-innovators on animals and cadavers, and subsequently in first-in-human studies. The trivestibular approach emerged as the safest technique, with further refinements of this technique culminating in TOETVA. The basic steps and indications for this technique have been standardized and it is now being replicated by early adopters in many centres worldwide. The development of TOETVA has closely aligned with the IDEAL Framework, and is currently at stage 2B (Exploration). CONCLUSION There is need for multi-institutional collaborations and international registry studies to plan high-quality randomized trials comparing TOETVA with other remote-access approaches and collect long-term follow-up data. In countries where TOETVA has yet to be adopted, the IDEAL Framework will be a useful roadmap for government regulators and professional societies to evaluate, regulate, and provide best practice recommendations for the adoption of this technique.
Collapse
Affiliation(s)
- Shen-Han Lee
- Department of Otorhinolaryngology, Hospital Sultanah Bahiyah, Kedah, Malaysia
| | - Ram Moorthy
- Department of Otolaryngology-Head and Neck Surgery, Royal Berkshire Hospital, Reading, UK
- Department of Otolaryngology-Head and Neck Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Sidhartha Nagala
- Department of Otolaryngology-Head and Neck Surgery, Royal Berkshire Hospital, Reading, UK
| |
Collapse
|
18
|
Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos. Cir Esp 2021. [DOI: 10.1016/j.ciresp.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
19
|
Transoral thyroidectomy vestibular approach versus non-transoral endoscopic thyroidectomy: a comprehensive systematic review and meta-analysis. Surg Endosc 2021; 36:1739-1749. [PMID: 34750702 DOI: 10.1007/s00464-021-08836-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 10/19/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND To conduct a meta-analysis to compare the short-term outcomes of transoral thyroidectomy vestibular approach (TOTVA) with non-transoral endoscopic thyroidectomy (NTET). METHODS MEDLINE, EMBASE, science citation index expanded, and the Cochrane Central Register of Controlled Trials in the Cochrane Library from January 2007 to January 2021 were searched for relevant literature. The evaluated endpoints were intra-operative and post-operative outcomes. RESULTS Ten eligible, non-randomized comparative studies involving 1677 patients were included. Meta-analysis results revealed that TOTVA was associated with significantly longer operative time [weighted mean differences (WMD), 22.60; 95%confidence interval (CI), 7.51-37.69; P = 0.003]. No significant differences were found between TOTVA group and NTET group in terms of post-operative outcomes. CONCLUSION TOTVA appears to be an equally feasible and safe surgical procedure as NTET for patients with benign thyroid nodules and selected differentiated thyroid carcinomas.
Collapse
|
20
|
Karakas E, Klein G, Michlmayr L, Schardey M, Schopf S. Transoral thyroid surgery vestibular approach: is there an increased risk of surgical site infections? Updates Surg 2021; 74:303-308. [PMID: 34671926 PMCID: PMC8827351 DOI: 10.1007/s13304-021-01191-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/07/2021] [Indexed: 11/28/2022]
Abstract
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is an upcoming surgical technique with the aim to optimize cosmetic outcome avoiding visible scars in the neck. However, the transoral access bears the risk of contamination and microbial allocation from the mouth into the thyroid region. Therefore, some authors recommend extended antibiotic therapy up to 7 days after surgery. Our aim was to evaluate infection rates and parameters before and after transoral surgery and to suggest a viable and safe routine in transoral surgery. Prospectively collected data of patients who were eligible for transoral surgery in Austria and Germany between June 2017 and July 2020 were retrospectively evaluated focussing on clinical and laboratory infection signs pre and postoperatively. White blood cell count (WBC) and C-reactive protein levels (CRP) were estimated before and after surgery. Patients` characteristics, surgical outcome and complications were also determined and compared to the current results reported in the literature. 113 transoral operations were performed in 108 patients. In 37 of 108 (36%) patients an additional retroauricular incision in the hairline and in two patients a submental skin incision was performed to extract thyroid specimen of more than 40 ml. Intravenous antibiotic prophylaxis and enoral mucosal disinfection were used in all patients before surgery. WBC and CRP levels were available in 75 patients. Median WBC was 5800/µl (range 3500–10,500/µl) before and significantly higher (median 8900/µl, range 4500–18,800 µl; p < 0.01) at day one after surgery. WBC returned to normal range (4500–11,500/µl) in all patients within the first 7 days postoperatively (median 5300/µl, range 3400–8700/µl). CRP levels were normal before (< 0.5 mg/dl) and slightly elevated within the first two days after surgery (Median 2.0 mg/dl, range 0.5–6.4 mg/dl, n.s.). In one patient oral antibiotic therapy was necessary due to transient erythema in the chin region which occurred 10 days after surgery and resolved completely without surgical intervention. Despite a transient increase in WBC transoral thyroid and parathyroid surgery via the vestibular approach does not seem to be associated with a significant number of wound infections in our patients. Intravenous antibiotic prophylaxis and enoral mucosal disinfection might be reasonable procedures to avoid microbial allocation from the mouth into the thyroid region. However, further investigations are required to finally estimate the need of antibiotics in transoral surgery.
Collapse
Affiliation(s)
- Elias Karakas
- Department of General-, Abdominal- and Endocrine Surgery, Hospital Maria Hilf, Alexianer GmbH, 470805, Krefeld, Germany.
| | - Günther Klein
- Department of General Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Linda Michlmayr
- Department of General Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Martin Schardey
- Department of General-, Abdominal and Vascular Surgery, Hospital Agatharied, Hausham, Germany
| | - Stefan Schopf
- Department of General-, Abdominal- and Endocrine Surgery, RoMed Hospital, Bad Aibling, Germany
| | | |
Collapse
|
21
|
Lira RB, De Cicco R, Rangel LG, Bertelli AA, Duque Silva G, de Medeiros Vanderlei JP, Kowalski LP. Transoral endoscopic thyroidectomy vestibular approach: Experience from a multicenter national group with 412 patients. Head Neck 2021; 43:3468-3475. [PMID: 34382715 DOI: 10.1002/hed.26846] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/05/2021] [Accepted: 08/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Well-established conventional thyroidectomy has satisfactory outcomes; however, robotic and endoscopic thyroid surgery can avoid visible anterior neck scars. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most recent of these techniques. METHODS This was a retrospective review of 412 patients who underwent TOETVA from 2017 to 2020 in 13 Brazilian centers. RESULTS The study included 359 (87.1%) females and 53 (12.9%) males, with a mean age of 40 years. There were 231 (56.1%) total thyroidectomies. The conversion rate was 0.7%. The transient vocal cord palsy rate was 7.6% (30 patients). Temporary and persistent hypocalcemia rates were 4.0% and 0.8%, respectively. There were two cases of infection (0.5%). DISCUSSION This is a large multi-institute TOETVA study, with one of the largest cohorts published to date that; despite its retrospective nature and selection bias, reached outcomes comparable to previously reported series, this study reinforced safeness, feasibility, and nationwide reproducibility for this technique.
Collapse
Affiliation(s)
- Renan Bezerra Lira
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo, Brazil.,Post-Graduate in Robotic Head and Neck Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rafael De Cicco
- Instituto de Câncer Dr. Arnaldo Vieira de Carvalho, São Paulo, Brazil
| | - Leonardo Guimarães Rangel
- Head and Neck Surgery Division, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Antônio Augusto Bertelli
- Head and Neck Surgery Division, Department of Surgery, Santa Casa Medical School, São Paulo, Brazil
| | - Guilherme Duque Silva
- Head and Neck Surgery Division, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | | | - Luiz Paulo Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, São Paulo, Brazil.,Head and Neck Surgery Department and LIM 28, University of São Paulo Medical School, São Paulo, Brazil
| |
Collapse
|
22
|
Zhang D, Li S, Dionigi G, Wang T, Zhang J, Xue G, Sun H. Consequences of Trocar Dynamics on Mental Nerve in Transoral Thyroidectomy. Surg Laparosc Endosc Percutan Tech 2021; 30:305-311. [PMID: 32459705 DOI: 10.1097/sle.0000000000000795] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mental nerve (MN) injuries are reported during transoral endoscopic thyroidectomy vestibular approach. Effect of trocar insertion and position on MN are examined in the present study. MATERIALS AND METHODS Ten millimeter incision was made at the center of the lower lip oral vestibule. Two 5 mm lateral incisions of the lower lip oral vestibule were made at the junction between the incisor and the canine. These 2 lateral incisions were high, just below the edge of lower lip. Nine pigs (18 MN) were randomly divided into 3 groups and MN dissection was performed. The angle between the lateral ports and median line were changed between 15 and 45 degrees among 3 groups and effect on MN was examined. RESULTS During dissection when insertion and other ports are in neutral position visual inspection of MNs did not reveal any compression bilaterally. The distance between MN and the ports was 18.2±2.1 mm (16.3 to 21.2 mm). In group I and group II, MNs have no compression by the lateral trocars. In group III (45 degrees), left MNs were all compressed. Two MNs (66.7%) were compressed on the right side. The MN was compressed at its ramification. CONCLUSIONS The results of the present experimental study, endorse the suggested medial and lateral vestibular incisions for transoral endoscopic thyroidectomy vestibular approach. However, during dynamic modification of the lateral port position/angle, MN compression was observed when the angle was >45 degrees.
Collapse
Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Shijie Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Gianlorenzo Dionigi
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", Division for Endocrine and Minimally Invasive Surgery, University Hospital G. Martino, University of Messina, Messina, Italy
| | - Tie Wang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Jiao Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Gaofeng Xue
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun City, Jilin Province, People's Republic of China
| |
Collapse
|
23
|
The sensorimotor changes of the lower lip and chin after transoral endoscopic thyroidectomy vestibular approach. Updates Surg 2021; 73:2283-2291. [PMID: 34287761 DOI: 10.1007/s13304-021-01133-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
The transoral endoscopic thyroidectomy vestibular approach (TOETVA) can lead to abnormal sensorimotor changes in the lower lip and chin because of its incision design. This study aimed to explore the surgical outcomes of these changes after TOETVA. A total of 122 patients who underwent TOETVA were reviewed. The original incision design was used for the 39 patients in group A and a modified incision design was used for the 83 patients in group B. The sensorimotor changes in the lower lip and chin were compared. Varying degrees of paresthesia of the lower lip and chin (PoLC) were noted in all group A patients. Approximately 20.5% of group B patients did not suffer from PoLC, and the degree of PoLC in group B was significantly lower (P < 0.001). Abnormal motor function of the lower lip was noted for 23.1% of the patients in group A and 2.4% of those in group B. The incision design plays an important role in the morbidity of sensorimotor changes in the lower lip and chin. Our modified incision design seems minimally invasive and feasible for patients who undergo TOETVA.
Collapse
|
24
|
Transoral versus gasless transaxillary endoscopic thyroidectomy: a comparative study. Updates Surg 2021; 74:295-302. [PMID: 33914272 DOI: 10.1007/s13304-021-01062-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
This study aimed to compare the surgical safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and gasless endoscopic thyroidectomy transaxillary approach (GETTA). This retrospective study assessed 150 patients managed with the TOETVA at the Yantai Yuhuangding hospital and 150 patients managed via the GETTA at the Zhenjiang Provincial People's Hospital. The procedures were compared in terms of workspace creation time, operating time, complications, post-operative complaints, cosmetic satisfaction, and the efficacy of central neck lymph-node dissection. There was no significant between-group difference in terms of post-operative complications. The average workspace creation and operating times were significantly shorter for GETTA than for TOETVA (P values for both < 0.001). The average number of lymph nodes dissected from the central compartment of the neck was higher in the TOETVA group than in the GETTA group (7.2 ± 4.6 vs. 3.9 ± 3.0, P < 0.001). The mean swallowing impairment index-6 scores at 1 month were significantly lower in the GETTA group than in the TOETVA group (1.5 ± 1.2 vs 2.6 ± 1.4, P < 0.001). Over 97% of all patients (both groups) were either satisfied or very satisfied with the cervical cosmetic outcomes at 3 months post-surgery (P = 0.099). TOETVA and GETTA are both safe procedures with good cervical cosmetic outcomes for well-selected patients. Although TOETVA is more efficacious in terms of central lymph nodes dissection, GETTA has a greater time-cost advantage.
Collapse
|
25
|
Zhang D, Fu Y, Zhou L, Wang T, Liang N, Zhang J, Xue G, Dionigi G, Sun H. Pictorial essay of vestibular incision outcomes from transoral endoscopic thyroidectomy. Langenbecks Arch Surg 2021; 406:2869-2877. [PMID: 33719000 DOI: 10.1007/s00423-021-02124-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a new treatment option for patients with selected thyroid disease requiring surgery. The aim of this pictorial essay is to illustrate the healing outcomes of the vestibular incisions. METHODS TOETVA patients were recruited at two Centers in China and Italy. TOETVA is initiated with one 10-20-mm median incision in the center of the oral vestibule 10 mm above the inferior labial frenulum, and two 5-mm lateral incisions, just below the lower lip near the labial commissure. Healing of the vestibular incision was monitored through serial photographs 1, 3, 7, 30, and 90 days after surgery. Outcomes were evaluated by Landry's score, time to healing, issues affecting wound outcomes, scar, fibrin, granulation, necrotic tissue formation, and infections. RESULTS Results of TOETVA were monitored in 52 patients. There were no postoperative infections. All lateral incisions demonstrated favorable surgical outcomes. Landry's criteria scores indicated worse outcomes for the median incisions vs. the lateral ones (p<0.05). Median incisions healed well in 65.4% of patients, but 34.6% of patients had visible scars from the median incision 90 days after surgery. Eight (15.4%) had cicatricial diathesis, seven (13.5%) experienced displacement of the stitches, and three (5.8%) developed synechia with gingiva. When the central vestibular incision was <10mm from the gingiva, patients tended to form synechia (60%). There were no significant differences in wound healing between the Chinese and Italian patients. CONCLUSIONS Knowledge of vestibular incision healing is essential to provide practical TOETVA clinical guide and to define optimal outcomes evaluation for transoral surgeons. Vestibular wound problems were confined only to the central incision.
Collapse
Affiliation(s)
- Daqi Zhang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Yantao Fu
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Le Zhou
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Tie Wang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Nan Liang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Jiao Zhang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Gaofeng Xue
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy
| | - Hui Sun
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun City, Jilin Province, People's Republic of China.
| |
Collapse
|
26
|
Razavi CR, Tanavde VA, Kim AS, Shaear M, Tufano RP, Russell JO. The variable direct cost and cost drivers of transoral endoscopic thyroidectomy vestibular approach. Gland Surg 2021; 10:521-528. [PMID: 33708535 DOI: 10.21037/gs-20-653] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background As transoral endoscopic thyroidectomy vestibular approach grows in popularity, there is a need for data on cost in order to better characterize its value to patients. To this end, we compared the variable direct cost of transoral endoscopic thyroidectomy vestibular approach and transcervical approach thyroidectomy and determined which factors drive the increased cost for the transoral approach. Methods Patients undergoing thyroid lobectomy and total thyroidectomy that met inclusion criteria for transoral endoscopic thyroidectomy vestibular approach, including those patients that opted for management via the transcervical approach, between 8/2016 and 4/2019 were reviewed. The variable direct cost for the surgical encounter was collected and means were compared between the transoral and transcervical cohorts for lobectomy and total thyroidectomy respectively. The operative time independent variable direct cost was similarly compared between cohorts. Results Out of 238 patients, 118 (50%) were managed via transoral endoscopic thyroidectomy vestibular approach and 120 (50%) were managed via transcervical approach thyroidectomy. Mean variable direct cost, our primary outcome, was $4,455 (SD 1,129, 95% CI: 4,204-4,706) for transoral lobectomy and $3,179 (SD 687, 95% CI: 2,990-3,369) for transcervical lobectomy [t(132.05)=8.09, P<0.001] representing a difference in cost of $1,276 (SD 158, 95% CI: 964-1,587). Mean variable direct cost was $4,681 (SD 829, 95% CI: 4,405-4,957) for transoral total thyroidectomy and $3,645 (SD 876, 95% CI: 3,431-3,858) for transcervical total thyroidectomy [t(79.92)=5.98, P<0.001], representing a difference in cost of $1,036 (SD 173, 95% CI: 691-1,381). Differences in energy devices alone account for $487.53 and $447.96 of the cost differences, respectively. Conclusions The differences in mean variable direct cost between transoral endoscopic vestibular approach and transcervical approach for lobectomy and total thyroidectomy were $1276 and $1036 respectively, amounts far less than some believe them to be. This data will be invaluable as we ultimately aim to define the value of transoral endoscopic thyroidectomy vestibular approach.
Collapse
Affiliation(s)
- Christopher R Razavi
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ved A Tanavde
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander S Kim
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohammad Shaear
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph P Tufano
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathon O Russell
- Department of Otolaryngology - Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
27
|
Tanavde VA, Razavi CR, Chen LW, Ranganath R, Tufano RP, Russell JO. Predictive model of operative time in transoral endoscopic thyroidectomy vestibular approach. Head Neck 2020; 43:1220-1228. [PMID: 33377212 DOI: 10.1002/hed.26581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) has demonstrated excellent safety and is receiving wider use in North America. Understanding which factors lead to operative difficulty, as evaluated by operative time (OT), may help to improve safety and refine indications for this procedure. METHODS Cases of TOETVA performed at our institution were reviewed. Multivariate linear regression was performed using patient demographics, thyroid characteristics, and operative variables to predict OT. RESULTS A total of 207 cases were included for analysis. A multivariate linear regression model, controlling for age, sex, and BMI, was developed from 104 cases with an R2 of 0.47 (p < 0.001). Cross-validation on 103 remaining cases showed root-mean-square error of 46.37. Total thyroidectomy and lobe size were the only significant predictors (p < 0.001). CONCLUSIONS We successfully developed a model to predict OT for TOETVA based on preoperative and operative variables. Lobe size, but not BMI, is a significant predictor of OT.
Collapse
Affiliation(s)
- Ved A Tanavde
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher R Razavi
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lena W Chen
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rohit Ranganath
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ralph P Tufano
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathon O Russell
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
28
|
Dinç B, İlker Turan M, Rıza Gündüz U, Haluk Belen N. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): Our outcomes from Turkey. Turk J Surg 2020; 36:340-346. [PMID: 33778392 PMCID: PMC7963300 DOI: 10.47717/turkjsurg.2020.4765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/25/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) was described in 2016 and had its case series published. This study aimed to present the largest TOETVA case series performed in Turkey. MATERIAL AND METHODS Data from 52 patients who underwent TOETVA procedure between February 2018 and October 2019 were analyzed retrospectively. Demographic data, duration of operation, blood loss, rate of conversion to open surgery, radiological findings, pathological outcomes, and complications were analyzed. RESULTS All patients were female. Mean duration of the operation was 192 ± 45 minutes, mean blood loss was 39 ± 47 mL, and the ratio of surgical site infection was 6% (3/50). In two (4%) patients, TOETVA was converted to open surgery. Temporary and permanent recurrent laryngeal nerve (RLN) paralysis was observed in 2 (4%) and 0 patients, respectively. Temporary and permanent hypoparathyroidism was observed in 10 (20%) and 0 patients, respectively. CONCLUSION TOETVA procedure is the most recently defined NOTES technique for endocrine surgery. In experienced healthcare centers, TOETVA can achieve outcomes similar and even better than the ones obtained with open surgery. The complication rates, durations of operation, surgical site infection, and blood loss parameters that we observed in our experience are similar to the ones reported in the literature.
Collapse
Affiliation(s)
- Bülent Dinç
- Clinic of General Surgery, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
| | | | - Umut Rıza Gündüz
- Clinic of General Surgery, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
| | - Nurhan Haluk Belen
- Clinic of General Surgery, Health Sciences University Antalya Training and Research Hospital, Antalya, Turkey
| |
Collapse
|
29
|
Anatomic Variations From 120 Mental Nerve Dissections: Lessons for Transoral Thyroidectomy. J Surg Res 2020; 256:543-548. [DOI: 10.1016/j.jss.2020.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/20/2020] [Accepted: 07/11/2020] [Indexed: 01/19/2023]
|
30
|
Tae K. Complications of Transoral Thyroidectomy: Overview and Update. Clin Exp Otorhinolaryngol 2020; 14:169-178. [PMID: 33211953 PMCID: PMC8111399 DOI: 10.21053/ceo.2020.02110] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/15/2020] [Indexed: 11/22/2022] Open
Abstract
Transoral thyroidectomy via the vestibular approach has become popular worldwide, with advantages including less surgical morbidity, excellent postoperative cosmesis, and superior functional voice outcomes. Several studies have reported that the surgical outcomes of the transoral approach were comparable to those of the conventional transcervical approach in selected patients. However, unusual complications, such as CO2 embolism, mental nerve injury, surgical space infection, skin perforation, burns, and trauma have been noted in transoral thyroidectomy. This paper aims to review and provide updated information on these complications and their management. Routine intraoperative neural monitoring is required to avoid laryngeal nerve palsy in the transoral approach. To prevent CO2 embolism, surgeons need to be careful not to injure the anterior jugular vein, and the CO2 insufflation pressure should be set as low as 4-6 mmHg. To avoid mental nerve injury, vestibular incisions should be placed in the safety zone, and dissection of the vestibular area and chin should be minimized. In conclusion, recognizing the possibility of complications and understanding their prevention and management are important for patient safety and the success of the transoral approach.
Collapse
Affiliation(s)
- Kyung Tae
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| |
Collapse
|
31
|
Russell JO, Razavi CR, Shaear M, Liu RH, Chen LW, Pace-Asciak P, Tanavde V, Tai KY, Ali K, Fondong A, Kim HY, Tufano RP. Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases. World J Surg 2020; 45:774-781. [PMID: 33205227 DOI: 10.1007/s00268-020-05874-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA). STUDY DESIGN Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25 kg/m2, overweight 25-29.9 kg/m2, and obese ≥ 30 kg/m2 for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication. RESULTS Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26-1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17-1.58]) and 1.69 (95% CI [0.74-3.88]) for the overweight and obese groups, respectively. CONCLUSION TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.
Collapse
Affiliation(s)
- Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA.
| | - Christopher R Razavi
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Mohammad Shaear
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Rui H Liu
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Lena W Chen
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Pia Pace-Asciak
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Ved Tanavde
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Katherine Y Tai
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Khalid Ali
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Akeweh Fondong
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University College of Medicine, Seoul, South Korea
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21287, USA
| |
Collapse
|
32
|
Wang Y, Zhou S, Liu X, Rui S, Li Z, Zhu J, Wei T. Transoral endoscopic thyroidectomy vestibular approach vs conventional open thyroidectomy: Meta‐analysis. Head Neck 2020; 43:345-353. [PMID: 33043571 DOI: 10.1002/hed.26486] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/24/2020] [Accepted: 09/21/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yichao Wang
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Shengliang Zhou
- West China School of Medicine, West China Hospital, Sichuan University Chengdu China
| | - Xueting Liu
- Department of Evidence‐Based Medicine and Clinical Epidemiology West China Hospital, Sichuan University Chengdu China
| | - Shu Rui
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Zhihui Li
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Jingqiang Zhu
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| | - Tao Wei
- Department of Thyroid, Parathyroid Surgery Center West China Hospital, Sichuan University Chengdu China
| |
Collapse
|
33
|
Tartaglia F, Giuliani A, Sorrenti S, Ulisse S. Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews. J Minim Access Surg 2020; 16:315-322. [PMID: 32978350 PMCID: PMC7597888 DOI: 10.4103/jmas.jmas_123_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: We compared two systematic reviews, one focusing on transoral video-assisted thyroidectomy (TOVAT) and the other on minimally invasive video-assisted thyroidectomy (MIVAT), to highlight the pros and cons that can determine the choice of one or the other procedure. Materials and Methods: PubMed, Scopus and ISI Web of Science databases were searched for relevant articles published from 2000 to June 2018. Both searches were performed using the same keywords. All articles describing human surgical case series of any size were included, while the following were excluded: articles published in languages other than English, case reports, reviews, early cadaver and animal studies and old reports of cases now included in more recent works. Application of the above selection criteria yielded 151 articles on TOVAT and 246 on MIVAT. Of these, 34 articles were selected for inclusion in the present study: 17 for the TOVAT group and 17 for the MIVAT group. The comparison was made considering the most common variables used in evaluating thyroid surgery procedures. The statistical methods used were Cohen's delta, Student's t-test and the non-parametric Mann–Whitney U-test. Results: The variable 'operative time' was found to show a very large effect size, and 'hospital stay' also differed significantly between the MIVAT and TOVAT groups. Conclusions: TOVAT and MIVAT should not be considered in competition with each other, but seen simply as alternative choices. Both appear to be safe methods, comparable in terms of post-operative complications, although the main reason for using TOVAT seems to be purely aesthetic.
Collapse
Affiliation(s)
| | - Alessandro Giuliani
- Department of Environment and Health, Superior Institute of Health, Rome, Italy
| | - Salvatore Sorrenti
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
| | - Salvatore Ulisse
- Department of Surgical Sciences, 'Sapienza' University of Rome, Rome, Italy
| |
Collapse
|
34
|
Nguyen HX, Nguyen HX, Nguyen HV, Nguyen LT, Nguyen TTP, Le QV. Transoral Endoscopic Thyroidectomy by Vestibular Approach with Central Lymph Node Dissection for Thyroid Microcarcinoma. J Laparoendosc Adv Surg Tech A 2020; 31:410-415. [PMID: 32706603 DOI: 10.1089/lap.2020.0411] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: The transoral endoscopic thyroidectomy by vestibular approach (TOETVA) has been developed for thyroid microcarcinoma (TMC) treatment worldwide, with low rate of complications and excellent oncological results. However, this approach has still not been routinely performed. Thus, in this study, we aim to demonstrate the feasibility and safety of this technique in the clinical practice. Methods: In this prospective cohort study, 29 patients diagnosed TMC and clinically node negative underwent thyroidectomy and prophylactic central lymph node dissection by TOETVA. The clinicopathologic characteristics, surgical outcomes, and cosmetic results were evaluated. Results: The mean age was 34.7 ± 8.5 years. Three patients had underlying Grave's disease. Thyroid lobectomy with isthmusectomy was performed in the majority of cases (72.4%). All patients underwent prophylactic central node dissection. The mean number of retrieved central node was 7.8 ± 3.7 (3-19). Seven patients (24.1%) had lymph node metastasis in postoperative pathology. Among them, the mean number of metastatic lymph nodes was 2.1 ± 1.7 (1-5). The mean operative time was 121.2 ± 22.6 minutes. Four patients experienced transient hoarse and 1 patient had hematoma. Visual analog scale score on first postoperative day was 2.8 ± 1.4 (0-5). Most of patients were satisfied with cosmetic outcome. Conclusions: The TOETVA is new technique for TMC in Vietnam. The initial results of oncology, postoperative complications, and cosmetic supported the application of TOETVA in TMC.
Collapse
Affiliation(s)
- Hau Xuan Nguyen
- Department of Oncology, Hanoi Medical University, Hanoi, Vietnam
- Department of Oncology and Palliative Care, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Hien Xuan Nguyen
- Department of Oncology, Hanoi Medical University, Hanoi, Vietnam
| | - Hung Van Nguyen
- Department of Oncology and Palliative Care, Hanoi Medical University Hospital, Hanoi, Vietnam
| | | | | | - Quang Van Le
- Department of Oncology, Hanoi Medical University, Hanoi, Vietnam
- Department of Oncology and Palliative Care, Hanoi Medical University Hospital, Hanoi, Vietnam
| |
Collapse
|
35
|
Tae K, Lee DW, Bang HS, Ahn YH, Park JH, Kim DS. Sensory change in the chin and neck after transoral thyroidectomy: Prospective study of mental nerve injury. Head Neck 2020; 42:3111-3117. [DOI: 10.1002/hed.26351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/13/2020] [Accepted: 06/09/2020] [Indexed: 01/29/2023] Open
Affiliation(s)
- Kyung Tae
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine Hanyang University Seoul South Korea
| | - Dong Won Lee
- Department of Otolaryngology—Head and Neck Surgery, School of Medicine Catholic University of Daegu Daegu South Korea
| | - Hyang Sook Bang
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine Hanyang University Seoul South Korea
| | - You Hern Ahn
- Department of Internal Medicine, College of Medicine Hanyang University Seoul South Korea
| | - Jung Hwan Park
- Department of Internal Medicine, College of Medicine Hanyang University Seoul South Korea
| | - Dong Sun Kim
- Department of Internal Medicine, College of Medicine Hanyang University Seoul South Korea
| |
Collapse
|
36
|
Transoral thyroidectomy (TOETVA): Complications, surgical time and learning curve. Oral Oncol 2020; 110:104871. [PMID: 32619928 DOI: 10.1016/j.oraloncology.2020.104871] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/06/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Since 2018, transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a true scarless thyroid surgery. In this study, we explore early outcomes and learning curve of this new approach. METHODS A retrospective cohort including conventional thyroidectomies and TOETVAs performed in a cancer center was designed. Learning curve and early surgical outcomes of TOETVA were assessed and compared to conventional thyroidectomy. RESULTS A total of 56 TOETVAs and 745 conventional thyroid procedures were included. In the TOETVA group, we had a 14.4% total complication rate with no permanent vocal cord paresis or hypocalcemia. The mean surgical time dropped from 167 to 117 min (p = 0.0001) after the 15 first cases. Comparing to conventional procedures, we didn't find any significant difference in complications rate. Operative time was longer in the TOETVA group. CONCLUSIONS In this study, TOETVA was safe and feasible, with a learning curve of 15 cases.
Collapse
|
37
|
Abstract
PURPOSE OF REVIEW To provide an overview of the feasibility and safety of current minimally invasive remote-access approaches for thyroid surgery, in view of the amounting new challenges and paradigm shifts in the management of thyroid pathologies. RECENT FINDINGS Over the past two decades, several remote-access approaches for thyroid surgery have been developed to improve cosmesis; however, none has been widely adopted extensively in the Western world. The recently emerged transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is the only true minimally invasive approach, completely avoiding skin incisions. It has a relatively short learning curve, midline surgical view, accessible surgical equipment, and relatively broad inclusion criteria with promising surgical outcomes as reported to date. TOETVA has proven to be safe and feasible for carefully selected patients. Further experience and long-term follow-up are needed to define the added value of TOETVA except for improved cosmetic outcome.
Collapse
|
38
|
Razavi CR, Shaear M, Anuwong A, Russell JO. The role of surgeon-performed ultrasound in transoral endoscopic thyroidectomy vestibular approach (TOETVA). World J Otorhinolaryngol Head Neck Surg 2020; 6:150-154. [PMID: 33073208 PMCID: PMC7548380 DOI: 10.1016/j.wjorl.2020.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/19/2020] [Indexed: 10/28/2022] Open
Abstract
Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a recently described surgical technique where the thyroid and central neck can be accessed without a cutaneous incision. To date nearly 700 cases have been described within the English literature demonstrating the feasibility, safety, and efficacy of the technique. As more institutions begin to adopt the surgical approach, it is important that surgeons pay close attention to appropriate patient selection and surgical optimization to prevent experience-related complications. A valuable tool to facilitate these considerations is the utilization of surgeon-performed ultrasonography (US). While the merits of surgeon-performed US are well-documented within head & neck endocrine surgery as a whole, its value may be of even greater importance when implementing a novel surgical technique such as TOETVA. Here we highlight and summarize the role of surgeon-performed US within head & neck endocrine surgery, focusing on how it may influence patient selection and surgical planning with TOETVA.
Collapse
Affiliation(s)
- Christopher R Razavi
- Department of Otolaryngology - Head & Neck Surgery, John Hopkins Hospital, Baltimore, MD, USA
| | - Mohammad Shaear
- Department of Otolaryngology - Head & Neck Surgery, John Hopkins Hospital, Baltimore, MD, USA
| | - Angkoon Anuwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery Police General Hospital Bangkok, Thailand
| | - Jonathon O Russell
- Department of Otolaryngology - Head & Neck Surgery, John Hopkins Hospital, Baltimore, MD, USA
| |
Collapse
|
39
|
Zhang D, Sun H, Tufano R, Caruso E, Dionigi G, Kim HY. Recurrent laryngeal nerve management in transoral endoscopic thyroidectomy. Oral Oncol 2020; 108:104755. [PMID: 32526656 DOI: 10.1016/j.oraloncology.2020.104755] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/24/2020] [Accepted: 04/27/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION The mechanism of recurrent laryngeal nerve (RLN) injury was investigated during a TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA). METHODS The function of 185 nerves at risk (NAR) was recorded with intermitted intraoperative neural monitoring (I-IONM). The RLN electromyography (EMG) was delineated during: (a) a pre-dissection vagal nerve stimulation; (b) a RLN stimulation at initial visualization; (c) at nerve dissection; and (d) at the final verification of the entire RLN route. The location, genesis, segmental or diffuse and the outcomes of RLN injuries were catalogued. RESULTS Twelve nerves (6.4%) lost the EMG signal and the incidences of temporary and permanent RLN dysfunction were 5.9% and 0.5%. A disrupted point (type 1 injury) could be identified in 7/12 nerves (58%). Five (42%) nerve injuries were classified as global (type 2). Of the seven type 1 injuries, 3 lesions occurred at the RLN laryngeal entry point during the nerve identification. Four type 1 injuries were at the distal 1 cm of the RLN course and during the early nerve dissection. No proximal (>2 cm) injuries occurred. The mechanisms of the injuries were thermal (58%) during the energy-based device use at the ligament of Berry dissection or at the dividing small branches of the inferior thyroid artery. Two (16%) traction injuries occurred during the early nerve dissection. In 2 cases we could not elucidate the mechanism of RLN injury (16%) and 1 injury (8%) was caused by the connective tissue constricting band of. The thermal RLN lesions had longer recovery times. CONCLUSIONS The RLN palsy occurs in TOETVA, even when combined with an endoscopic magnification, IONM, early nerve identification, cranial to caudal dissection and top-down view. The thermal RLN injury was the most frequent cause and all injuries occurred at the distal RLN course.
Collapse
Affiliation(s)
- Daqi Zhang
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun, Jilin, People's Republic of China.
| | - Hui Sun
- Division of Thyroid Surgery, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, China-Japan Union Hospital Of Jilin University, 126 Xiantai Blvd, Changchun, Jilin, People's Republic of China.
| | - Ralph Tufano
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA.
| | - Ettore Caruso
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Child-hood "G. Barresi", University Hospital G. Martino, University of Messina, Italy.
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Child-hood "G. Barresi", University Hospital G. Martino, University of Messina, Italy.
| | - Hoon Yub Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
40
|
Kwek JWM, Pang MJ, Heah HHW. Pneumoperitoneum after transoral endoscopic thyroidectomy vestibular approach. Laryngoscope Investig Otolaryngol 2020; 5:580-583. [PMID: 32596503 PMCID: PMC7314460 DOI: 10.1002/lio2.393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 03/12/2020] [Accepted: 04/22/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a relatively safe procedure with comparable safety profile as open thyroidectomy. While gas insufflation complications such as subcutaneous emphysema and pneumomediastinum have been reported postoperatively, there have been no reports of pneumoperitoneum. CASE REPORT Our patient underwent an uneventful TOETVA to remove her left thyroid lobe. Postoperatively, she developed subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum, which were confirmed on CT scan. She was managed conservatively and recovered uneventfully. CONCLUSION The authors report the first case of pneumoperitoneum following TOETVA. Surgeons performing TOETVA should be aware of pneumoperitoneum as a possible complication of this procedure after excluding other possible causes.
Collapse
Affiliation(s)
- James Wei Ming Kwek
- Department of Otolaryngology Head and Neck SurgerySingapore General HospitalSingapore
| | - Maria Judith Pang
- Department of Otolaryngology Head and Neck SurgerySingapore General HospitalSingapore
| | - Harold H. W. Heah
- Department of Otolaryngology Head and Neck SurgerySingapore General HospitalSingapore
| |
Collapse
|
41
|
Evaluation of the efficacy of postoperative antibiotic treatment in transoral endoscopic thyroidectomy: a prospective randomised controlled trial. Br J Oral Maxillofac Surg 2020; 58:334-340. [PMID: 31982170 DOI: 10.1016/j.bjoms.2020.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 01/03/2020] [Indexed: 02/06/2023]
Abstract
Transoral endoscopic thyroid surgery (TOET) is a new, minimally-invasive approach that does not result in a scar in the anterior neck. To prevent infection of the surgical site from oral cavity flora into the thyroidectomy area, postoperative antibiotics are generally given orally for 3-7 days. However, there is no clinical evidence to support this approach. This study was an open-label, randomised, controlled trial to evaluate the clinical usefulness of postoperative antibiotics given orally to patients having TOET. Patients were randomly assigned to receive amoxicillin-clavulanate 625mg orally three times a day for a week after operation (treated group) or no antibiotics (untreated group). Fifty patients - 25 treated and 25 untreated - were enrolled. Maximum body temperature, pulse rate, white blood cell count, and C-reactive protein concentrations did not differ between the two groups. Evaluation of the surgical site showed no significant differences between them. Seven patients in the treated group developed nausea, vomiting, and diarrhoea compared with none in the untreated group. The results suggest that postoperative oral antibiotics are not essential after TOET. Large-scale prospective series are required to confirm this finding.
Collapse
|
42
|
Park JH, Bilegsaikhan SE, Suh YJ. A Novel Technique for Performing Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): A Single-port Platform. Surg Laparosc Endosc Percutan Tech 2019; 30:e4-e7. [PMID: 31790081 DOI: 10.1097/sle.0000000000000739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
During transoral endoscopic thyroidectomy vestibular approach (TOETVA), the mental nerve can be injured by the lateral ports. Mental nerve injury is a worrisome complication, which can be minimized by using the single-port platform. A 56-year-old woman was diagnosed with a 5-mm sized papillary thyroid carcinoma on the isthmus. A horizontal 21-mm incision was made on the mucosa at the lower lip, followed by vertical dissection from the mentalis muscles down to the mandibular area. Subsequent hydrodissection widened the working space. For the single-port procedure, the KeyPort system was applied. After inserting the endoscopic instruments, the thyroid isthmus was resected as usual. The patient was discharged without any complications. To our knowledge, this is the first report of single-port TOETVA. Although the indications are limited, a single-port platform can be utilized for TOETVA. This will minimize the risk of mental nerve injury.
Collapse
Affiliation(s)
- Jung Ho Park
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | | | | |
Collapse
|
43
|
Zhang D, Caruso E, Sun H, Anuwong A, Tufano R, Materazzi G, Dionigi G, Kim HY. Classifying pain in transoral endoscopic thyroidectomy. J Endocrinol Invest 2019; 42:1345-1351. [PMID: 31187465 DOI: 10.1007/s40618-019-01071-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/05/2019] [Indexed: 11/28/2022]
Abstract
PURPOSES Knowledge of visual analog scale (VAS) pain assessment for transoral endoscopic thyroidectomy vestibular approach (TOETVA) is limited. The purpose of this analysis was to classify the postoperative discomfort scores in patients undergoing TOETVA compared to open thyroidectomy. METHODS Observational clinical study of patients who underwent thyroidectomy by VAS pain assessment from September 2016 to March 2017. Patients were stratified into two groups: patients eligible for TOETVA (Group TOETVA) and non-candidates for endoscopic intervention (open thyroidectomy approach-OTA). VAS was recorded in the recovery room, at 24 h, + 2, + 5, + 15, + 30, + 90 days, and 6 months after surgery. Pain assessment was stratified in VAS-lower lip, VAS-chin, VAS-jaw, VAS-anterior neck, VAS-cervical/back, VAS-swallowing, VAS-brushing, VAS-speaking, and VAS-shaving. Secondary outcome assessed were analgesic rescue dose, morbidity, operative notes, hospital stay, and histopathology. RESULTS 41 TOETVA and 45 OTA constituted the analysis. There were differences between the TOETVA and OTA for age, gland volume, mean nodule diameter, coexistence thyroiditis, bilateral procedures, and use of drain. Operative time was longer in TOETVA. Results indicated that TOETVA was associated with reduced neck, cervical back, and swallowing VAS scores in the 24 h after surgery. Conversely, jaw and brushing teeth resulted in higher VAS score in TOETVA group. OTA patients never experienced lower lip or chin pain. The use of rescue analgesics did not differ between the two groups. CONCLUSIONS VAS was used to measure treatment outcome in TOETVA. VAS scores achieved overall a minimal clinical importance difference from the two procedures. There appears to be both a short- and long-term different range of interpretations of pain between TOETVA and OTA.
Collapse
Affiliation(s)
- D Zhang
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun, Jilin, P.R. China
| | - E Caruso
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy.
| | - H Sun
- Division of thyroid Surgery, China-Japan Union Hospital Of Jilin University, Jilin Provincial Key Laboratory Of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, 126 Xiantai Blvd, Changchun, Jilin, P.R. China
| | - A Anuwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - R Tufano
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Materazzi
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - G Dionigi
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy
| | - H Y Kim
- Department of Surgery, KUMC Thyroid Center, Korea University Hospital, Korea University College of Medicine, Seoul, South Korea
| |
Collapse
|
44
|
Suh I, Viscardi C, Chen Y, Nwaogu I, Sukpanich R, Gosnell JE, Shen WT, Seib CD, Duh QY. Technical Innovation in Transoral Endoscopic Endocrine Surgery: A Modified “Scarless” Technique. J Surg Res 2019; 243:123-129. [DOI: 10.1016/j.jss.2019.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/27/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
|
45
|
Bamroong P, Kasemsiri P, Thongrong C, Mahawerawat K, Tongwiset S, Rachain A, Khaengraeng S. Modified equipment for facilitating the transoral vestibular approach to endoscopic thyroidectomy. J Minim Access Surg 2019; 16:399-403. [PMID: 31571672 PMCID: PMC7597879 DOI: 10.4103/jmas.jmas_157_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives: The objectives of the study were to investigate the improvement in operation time for thyroid surgery gained using a modified endobag and suture and to accelerate the learning process for novice endoscopic surgeons. Materials and Methods: A retrospective study was conducted between 2 June 2015 and 1 November 2018. Medical records of patients who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) were retrieved and analysed. Comparisons of operative time with or without the use of modified equipment were calculated by the unequal variance t-test in lobectomy and isthmectomy groups. Results: Medical records of 102 patients (mean age: 39.1 years) were analysed. The size of thyroid nodule averaged 4.0 cm (range: 1.0–13.0 cm). TOETVA was applied for right lobectomy (57.8%), left lobectomy (34.3%), isthmectomy (3.9%) and total thyroidectomy (3.9%). Early in our experience, TOETVA required 168 min, whereas following the introduction of the modified endobag and extracorporeal suture, operative time was reduced to 30 min (P > 0.05). Conclusions: The use of modified equipment permitted shorter operation times. The time difference was not statistically significant but does represent a significant time-saving. The use of the modified equipment will simplify and speed up the learning process for novice endoscopic surgeons.
Collapse
Affiliation(s)
- Piyapong Bamroong
- Department of Otorhinolaryngology, Mukdahan Hospital, Mukdahan, Thailand
| | - Pornthep Kasemsiri
- Department of Otorhinolaryngology, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University; Khon Kaen Head and Neck Oncology Research; Srinagarind Minimally Invasive Surgery Center of Excellence, Khon Kaen, Thailand
| | - Cattleya Thongrong
- Khon Kaen Head and Neck Oncology Research; Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Siriwan Tongwiset
- Department of Otorhinolaryngology, Mukdahan Hospital, Mukdahan, Thailand
| | - Angkana Rachain
- Department of Otorhinolaryngology, Mukdahan Hospital, Mukdahan, Thailand
| | | |
Collapse
|
46
|
Fernandez-Ranvier G, Meknat A, Guevara DE, Inabnet WB. Transoral Endoscopic Thyroidectomy Vestibular Approach. JSLS 2019; 23:e2019.00036. [PMID: 31719772 PMCID: PMC6830499 DOI: 10.4293/jsls.2019.00036] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Remote-access thyroid surgery has gained popularity and has advanced significantly over the past two decades, given the patient desire to avoid cosmetically displeasing scarring. It has only been recently that natural-orifice transluminal endoscopic surgery (NOTES) techniques have been geared for thyroidectomies. The transoral endoscopic thyroidectomy vestibular approach has been categorized as a NOTES procedure-given the approach to the thyroid gland via incisions in the oral cavity. Our aim is to provide a review of the current literature on the transoral endoscopic thyroidectomy vestibular approach (TOETVA), to present the worldwide experience of this novel procedure, and to outline whether individual patients have characteristics that would make the procedure feasible for this technique. METHODS A literature review was done to compile articles detailing the international experience with TOETVA. Our experience combined with what has been published in the literature was used to establish which pathological and patient characteristics make this particular technique feasible for a thyroidectomy. RESULTS We detail in the provided tables both feasibility for this surgical technique and the international experience. CONCLUSION TOETVA represents the latest remote-access endoscopic technique for the excision of the thyroid gland. TOETVA is being performed at various international institutions and multiple hospitals in the United States.
Collapse
Affiliation(s)
- Gustavo Fernandez-Ranvier
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aryan Meknat
- Department of Surgery, Brookdale University Hospital and Medical Center, Brooklyn, New York, USA
| | - Daniela E Guevara
- Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William B Inabnet
- Division of Metabolic, Endocrine and Minimally Invasive Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
47
|
Printing a Three-Dimensional Patient-Specific Safety Device for Reducing the Potential Risk of Mental Nerve Injury During Transoral Thyroidectomy. World J Surg 2019; 44:371-377. [DOI: 10.1007/s00268-019-05155-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
48
|
Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach. JAMA Surg 2019; 153:21-27. [PMID: 28877292 DOI: 10.1001/jamasurg.2017.3366] [Citation(s) in RCA: 301] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Natural orifice transluminal endoscopic surgery thyroidectomy is a novel approach to avoid surgical scars. Objective To compare the safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) with those of open thyroidectomy (OT). Design, Setting, and Participants This study retrospectively reviewed all TOETVA and OT operations performed from April 1, 2014, through August 31, 2016, at Police General Hospital, Bangkok, Thailand. All patients who underwent TOETVA and patients who underwent OT were included. Exclusion criteria were (1) previous neck surgery, (2) substernal goiter, (3) lymph node or distance metastasis, and (4) suspicious invasion to the adjacent organs. Propensity score matching was conducted to reduce selective bias. Main Outcomes and Measures Operative time, blood loss, and complications related to thyroid surgery. Results Of the 425 patients who underwent transoral endoscopic thyroidectomy (mean age, 35.3 [12.1] years; age range, 16-81 years; 389 [92.2%] female), 422 successfully were treated with the TOETVA; 3 patients were converted to a conventional operation because of bleeding. Twenty-five patients (5.9%) had transient recurrent laryngeal nerve palsy, and 46 (10.9%) had transient hypoparathyroidism. None had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Three patients (0.7%) had transient mental nerve injury; all cases resolved by 4 months. One patient developed postoperative hematoma treated by OT. Twenty patients (4.7%) had seroma treated by simple aspiration. Operative time was longer for the TOETVA compared with the OT group (100.8 [39.7] vs 79.4 [32.1] minutes, P = 1.61 × 10-10). The mean (SD) visual analog scale score for pain was lower in the TOETVA group (1.1 [1.2] vs 2.8 [1.2], P = 2.52 × 10-38). Estimated mean (SD) blood loss (36.9 [32.4] vs 37.6 [23.1] mL, P = .43) and rate of complications (45 of 216 [20.8%] vs 38 of 216 [17.6%], P = .41) were not significantly different in the TOETVA vs OT group. Conclusions and Relevance The TOETVA was performed as safely as OT, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for select patients.
Collapse
Affiliation(s)
- Angkoon Anuwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Khwannara Ketwong
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Pornpeera Jitpratoom
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Thanyawat Sasanakietkul
- Minimally Invasive and Endocrine Surgery Division, Department of Surgery, Police General Hospital, Bangkok, Thailand
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
| |
Collapse
|
49
|
You JY, Kim HY, Dionigi G, Tufano RP. Transoral Robotic Thyroidectomy: the New Era of Remote-Access Surgery for Thyroid Disease. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00248-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
50
|
Russell JO, Razavi CR, Shaear M, Chen LW, Lee AH, Ranganath R, Tufano RP. Transoral Vestibular Thyroidectomy: Current State of Affairs and Considerations for the Future. J Clin Endocrinol Metab 2019; 104:3779-3784. [PMID: 30860578 PMCID: PMC6656420 DOI: 10.1210/jc.2019-00116] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/06/2019] [Indexed: 12/30/2022]
Abstract
CONTEXT The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a recently described procedure for surgical management of select thyroid pathology that avoids a cutaneous scar. TOETVA is far from the first described remote-access approach to the thyroid. In fact, numerous such techniques have been described over the past 20 years, although none has gained widespread implementation in North America or Europe. However, with its rapid growth worldwide and excellent outcomes to date, TOETVA may succeed where these prior techniques have failed. EVIDENCE ACQUISITION The English literature was reviewed using the following keywords: transoral thyroidectomy, remote-access thyroidectomy, minimally invasive thyroidectomy, and TOETVA. Because three systematic reviews of this technique were recently conducted, this manuscript does not seek to provide a fourth. Rather, we summarize salient findings from these reviews and focus on candidates for the procedure, technique-specific characteristics that have led to early success with TOETVA, and prospects for the future. EVIDENCE SYNTHESIS TOETVA is the only thyroidectomy approach obviating the need for a cutaneous incision, and it offers several advantages over previously described remote-access thyroidectomy techniques. These include a favorable anatomic surgical perspective, a comparatively short learning curve, no requirement for expensive instrumentation, and a broad inclusion criterion. These characteristics have facilitated the excellent surgical outcomes to date. CONCLUSIONS TOETVA is a suitable surgical option with proven safety and feasibility for a carefully selected patient population. The potential value of the procedure outside enhanced cosmesis continues to be defined.
Collapse
Affiliation(s)
- Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher R Razavi
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammad Shaear
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lena W Chen
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew H Lee
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rohit Ranganath
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|