Transoral thyroidectomy: limitations, patients' safety, and own experiences

Management of Bilateral Vocal Fold Paralysis: A Systematic Review

OBJECTIVE

To review the current literature about epidemiology, etiologies and surgical management of bilateral vocal fold paralysis (BVFP).

DATA SOURCES

PubMED, Scopus, and Cochrane Library.

REVIEW METHODS

A systematic review of the literature on epidemiology, etiologies, and management of adult patients with BVFP was conducted through preferred reporting items for systematic reviews and meta-analyses statements by 2 investigators.

RESULTS

Of the 360 identified papers, 245 were screened, and of these 55 were considered for review. The majority (76.6%) of BVFP cases are iatrogenic. BVFP requires immediate tracheotomy in 36.2% of cases. Laterofixation of the vocal fold was described in 9 studies and is a cost-effective alternative procedure to tracheotomy while awaiting potential recovery. Unilateral and bilateral posterior transverse cordotomy outcomes were reported in 9 and 7 studies, respectively. Both approaches are associated with a 95.1% decannulation rate, adequate airway volume, but voice quality worsening. Unilateral/bilateral partial arytenoidectomy data were described in 4 studies, which reported lower decannulation rate (83%) and better voice quality outcome than cordotomy. Revision rates and complications vary across studies, with complications mainly involving edema, granuloma, fibrosis, and scarring. Selective posterior cricoarytenoid reinnervation is being performed by more surgeons and should be a promising addition to the BVFP surgical armamentarium.

CONCLUSION

Depending on techniques, the management of BVFP may be associated with several degrees of airway improvements while worsened or unchanged voice quality. The heterogeneity between studies, the lack of large-cohort controlled randomized studies and the confusion with posterior glottic stenosis limit the draw of clear conclusion about the superiority of some techniques over others.

The Effectiveness and Quality of Life Outcomes by Transoral Endoscopic Vestibular Thyroidectomy Using Intraoperative Indocyanin Green Fluorescence Imaging and Neuromonitoring—A Cohort Study

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.

A comparative study of two robotic thyroidectomy procedures: transoral vestibular versus bilateral axillary-breast approach

Objective

To compare the surgical outcomes between the transoral-vestibular robotic thyroidectomy (TOVRT) and bilateral axillo-breast approach robotic thyroidectomy (BABART).

Methods

A total of 99 patients with papillary thyroid carcinoma but no distant metastasis were enrolled in this study from May 2020 to April 2021. Lobectomy or total thyroidectomy with central lymph node dissection were performed in all cases. All 99 patients were received an ultrasound guided fine needle aspiration biopsy prior to surgical intervention, out of which 49 patients underwent TOVRT, while rest 50 patients underwent BABART. During the procedure, intraoperative neuromonitoring system was used and all recurrent laryngeal nerves (RLNs) were preserved, additionally for TOVRT procedure, three intraoral ports or right axillary fold incision was used to allow for fine countertraction of tissue for radical oncological dissection. The clinical data including age, gender, height, weight, BMI, primary tumor size, number of central lymph node removed, central lymph node metastasis, operating time, total hospital stays, postoperative hospital stays, total postoperative drainage volume, postoperative pain score, cosmetic effect and complications were recorded and analyzed.

Results

There were no significant differences in gender, height, weight, BMI and removed central lymph nodes between the two groups (P > 0.05). Patients accepted TOVRT were younger and had smaller primary tumor size than those who accepted BABART. The TOVRT group had a longer surgical time than the BABART group, but with smaller postoperative drainage volume and superior cosmetic effect (under visual analogue scale, VAS) (P < 0.05). There was no significant difference in lymph node metastasis, hospital stay and postoperative pain score (under numerical rating scale, NRS) between the two groups (P > 0.05). Last but not least, certain peculiar complications were observed in TOVRT group: paresthesia of the lower lip and the chin (one case), surgical site infection (one case) and skin burn (one case).

Conclusion

Transoral-vestibular robotic thyroidectomy is safe and feasible for certain patients, which could be considered an alternative approach for patients who require no scarring on their neck.

Complications of Trans-oral Endoscopic Thyroidectomy Vestibular Approach: A Systematic Review

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.

Incidence of suicide mortality among childhood cancer survivors: A population-based retrospective study

The aim of our study was to investigate the suicide rates among childhood cancer survivors and assess factors associated with higher suicide risk. A review of data from Surveillance, Epidemiology, and End Results (SEER) program from 1975 to 2016 was performed for this study. This program is based on the US population and is supported by the US National Cancer Institute (NCI). Survivors diagnosed with childhood cancer were recorded. There were 40 suicides among 567,233 person-years, giving a suicide rate of 7.1 per 100,000 person-years. Compared with cancer diagnosed between 10 and 14 years old, survivors with cancer diagnosed between 0 and 4 years old had lower suicide risk. Females had a lower risk of suicide than males. Compared with survivors of thyroid cancer, the aHRs were 0.16 for acute lymphocytic leukemia, 0.15 for nodal Hodgkin's lymphoma, 0.14 for brain cancers and 0.09 for kidney cancers. Most suicides occurred after 15 years old. Suicide was a problem for survivors, especially those with thyroid cancer. Beside treating patients holistically, early psychological interventions such as communicating effectively, providing social support and follow-up care related to psychological health are needed.

Comparison of the transoral endoscopic thyroidectomy vestibular approach and open thyroidectomy: A propensity score-matched analysis of surgical outcomes and safety in the treatment of papillary thyroid carcinoma

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach has been demonstrated to have similar surgical outcomes as open thyroidectomy for selected papillary thyroid carcinomas. This study aimed to evaluate and compare the surgical outcomes and safety of the transoral endoscopic thyroidectomy vestibular approach with those of open thyroidectomy in the treatment of papillary thyroid carcinoma with a diameter between >1 cm and ≤3.5cm.

METHODS

We retrospectively reviewed all patients who had papillary thyroid carcinoma that was between >1 cm and ≤3.5 cm in diameter and who had undergone the transoral endoscopic thyroidectomy vestibular approach (n = 96) or an open thyroidectomy (n = 425) from January 2017 to June 2020. We then performed 1:1 propensity score matching, yielding 78 matched pairs. Afterward, surgical outcomes and follow-up data were compared between the 2 matched groups.

RESULTS

Compared with the matched open thyroidectomy group, the papillary thyroid carcinoma group had a significantly longer operative time (P < .001), more blood loss (P < .05), higher postoperative white blood cell count (P < .05), higher C-reactive protein (P < .001), more total drainage volume (P < .001), increased surgical cost (P < .05), better cosmetic satisfaction (P <.001), lower scar self-consciousness (P < .001), and better quality of life (P < .001). We observed no significant differences in the incidence of other outcomes, including the number of retrieved lymph nodes and metastatic central lymph nodes, the rate of intraoperative recurrent laryngeal nerve signal weakened and parathyroid autotransplantation, visual analog scale scores for pain, drainage duration, postoperative hospital stay, rate of complications, and oncologic completeness. We observed no conversion to open thyroidectomy and no intraoperative capsular disruption in the transoral endoscopic thyroidectomy vestibular approach group. There was 1 case of persistent nodal disease in the transoral endoscopic thyroidectomy vestibular approach group. No recurrence was observed in the 2 groups during the follow-up period.

CONCLUSION

The transoral endoscopic thyroidectomy vestibular approach is feasible in selected patients with papillary thyroid carcinoma, not only because it is cosmetically advantageous but also because it is surgical and oncologically safe and may be an optional surgical method for treating papillary thyroid carcinomas having a diameter between >1 cm and ≤3.5 cm.

Transoral versus gasless transaxillary endoscopic thyroidectomy: a comparative study

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.

Recurrent laryngeal nerve management in transoral endoscopic thyroidectomy

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.

Video-assisted neck surgery (VANS) using a gasless lifting procedure for thyroid and parathyroid diseases: "The VANS method from A to Z"

Purpose

To describe and evaluate our video-assisted neck surgery (VANS) method for thyroid and parathyroid diseases.

Methods

We describe in detail the VANS method for enucleation, lobectomy, total (nearly total) thyroidectomy, and lymph node dissection for malignancy and Graves’ disease. In collaboration with the Japan Society of Endoscopic Surgery (JSES), we evaluated several aspects of this method. The JSES evaluated the method for working-space formation and surgical complications, whereas we examined the learning curve of the surgeons, and the cosmetic satisfaction of the patients and the degree of numbness and pain they experienced. We also asked patients who underwent conventional surgery whether they would have selected VANS had it been available.

Results

The working space for 81.5% of the procedures in Japan was created using the gasless lifting method. The learning curve, considering both blood loss and operating time, decreased after 30 cases. Both factors improved for tumors smaller than 5 cm in diameter. Over 60% of the patients who underwent conventional surgery stated that they would have selected VANS, had it been available. Postoperative pain was worse after conventional surgery than after VANS, but neck numbness after VANS was more frequent than expected.

Conclusions

The VANS method is a feasible, safe, and cost-effective procedure with clear cosmetic advantages over conventional surgery.

Safety and Outcomes of the Transoral Endoscopic Thyroidectomy Vestibular Approach

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.

What is the Appropriate Nodular Diameter in Thyroid Cancer for Extraction by Transoral Endoscopic Thyroidectomy Vestibular Approach Without Breaking the Specimens? A Surgicopathologic Study

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique with better cosmetic results. However, extraction of a large malignant thyroid nodule from the central incision of TOETVA necessitates breaking it into pieces to avoid mental nerve injury, a situation that may violate a proper oncological surgery. In this study, we sought the appropriate nodular diameter in thyroid cancer to be removed in an intact status through the central incision of the TOETVA technique. A total of 27 cases of thyroid nodules were operated using the TOETVA technique from Aug 2016 to July 2017. Excluding 10 benign goiters, the specimens of 17 thyroid cancer cases were divided into intact (group T, n=7) and fragmented (group F, n=10), with a median nodular diameter of 18.35 and 30.30 mm, respectively. Receiver operating characteristic (ROC) curve analysis revealed that the safest nodular diameter is 20 mm, with 100% sensitivity and 87.5% specificity.

Hybrid techniques and patients' safety in implementing transoral sublingual thyroidectomy

PURPOSE

Cosmetic advantages and minimally invasive aspects become more and more important for patients undergoing thyroidectomy. We report on our personal experience and conceptual design in dealing with approaches to the thyroid gland, which we were the first to describe. We report on ideas and experiences concerning its implementation.

METHODS

Our own experiences and considerations in the process of finding an endoscopic minimally invasive access in thyroidectomy are compared in a systematic review with the available literature on minimally invasive or endoscopic thyroid surgery. We describe our failures and risk assessment.

RESULTS

Our analysis of the literature on minimally invasive thyroidectomy and our own experiences lead us to the conclusion that using different hybrid technologies during the implementation of endoscopic procedures in thyroid surgery can be helpful and could improve patients' safety. A combination of transoral endoscopic and non-transoral techniques might be a useful safer, but more traumatizing alternative for implementation. Several studies show the feasibility of the transoral access in thyroid surgery. We believe that the implementation of these new procedures as routine surgery in specialized centers must be carefully considered and discussed.

CONCLUSIONS

The transoral access seems to be less invasive than other extracollar endoscopic accesses in thyroid surgery. For a sublingual single-access routine surgery, better instruments are needed. The vestibular access is possible with standard instruments. Using hybrid technologies for implementation should not be considered as a failure. The transoral thyroidectomy can be a safe method in the hand of experienced surgeons. We expect this hybrid technique to play a major part in further spreading endoscopic transoral thyroid surgery.