Surgical Outcomes Comparison Between Endoscopic and Conventional Open Thyroidectomy for Benign Thyroid Nodules

Transoral endoscopic thyroidectomy vestibular approach versus conventional open thyroidectomy for the treatment of benign thyroid tumours: A prospective cohort study

INTRODUCTION

Thyroid tumours are a common condition and open surgery is a conventional method for treating benign thyroid tumours when surgery is indicated. In this study, we evaluate the outcomes of benign thyroid tumour treatment using transoral endoscopic thyroidectomy via vestibular approach (TOETVA) and compare the results with those of conventional open thyroidectomy (COT).

PATIENTS AND METHODS

We conducted a prospective cohort study between 100 patients who underwent TOETVA and 100 who underwent COT surgery for benign diseases from June 2018 to December 2021 in our hospital. Outcomes between the two groups, including post-operative complications, operative time and length of stay, were compared.

RESULTS

The surgical time in the TOETVA group was significantly longer than in the COT group. The operative time of lobectomy in the TOETVA and COT groups was 77.5 ± 13.3 and 51.5 ± 4.2 min, respectively, with a P < 0.001. The operative time of total thyroidectomy in the TOETVA and COT groups was 108.1 ± 7.0 and 65.0 ± 4.1 min, respectively, with a P < 0.001. There was no difference in post-operative length of stay between the two groups. In TOETVA group, there were no patients who converted to open surgery. Amongst all 200 patients in the study, there were no cases of post-operative bleeding. The transient hypoparathyroidism rate after surgery in the TOETVA and COT groups was 3% and 2%, respectively, with no statistically significant difference (P = 0.651). Similarly, the transient recurrent laryngeal nerve injury rate showed no difference between the two groups, with rates of 5% and 4% in the TOETVA and COT groups, respectively (P = 0.733). There were no cases of post-operative infection in either group in our study. At 3 months postoperatively, the cosmetic satisfaction were significantly higher in the endoscopic groups than in the conventional group (P < 0.001).

CONCLUSIONS

TOETVA is a safe and effective method, with a low complication rate and optimal aesthetic results compared to traditional surgery to treat benign thyroid tumours.

The Learning Curve and Importance of Collaboration in Endoscopic Thyroidectomy Via Breast Areola Approach: A Single Surgical Team's Experience of 100 Patients

BACKGROUND

Endoscopic thyroidectomy is popular among young patients because of its excellent cosmetic outcomes. But it takes a long time to become proficient and competent for surgeons. In addition, collaboration plays a critical role in endoscopic thyroidectomy. Our research aims to evaluate the learning curve of endoscopic thyroidectomy via breast areola approach, provide details of this approach, and demonstrate the importance of collaboration.

METHODS

The authors retrospectively analyzed 100 cases of benign and malignant thyroid disease who underwent endoscopic thyroidectomy via breast areola approach between January 2015 and December 2020, which were performed by the same group of surgeons with little experience of endoscopic thyroidectomy. The learning curve was analyzed by moving average method. The mean operation time, blood loss, tumor size, postoperative complications were used to determine learning curve progression.

RESULTS

The learning curve in the first 30 cases were uplifted, stable at 30 to 60 cases and declined in the following cases. The mean operation time and blood loss decreased significant after the first 30 cases and again after the first 60 cases. And there was no difference in postoperative complications.

CONCLUSIONS

A well-trained surgeon with experience in conventional open thyroidectomy can significantly reduce the total operation time by studying the learning curve. The key steps including establishment of working space and reaching for recurrent laryngeal nerve. A stable level can be achieved after 30 cases. More than 60 cases are required to become proficient. A successful endoscopic thyroid surgery requires a stable team.

Thyroidectomy using a single-port cervico-mental angle approach

Background

Over the last two decades, several endoscopic thyroidectomy methods have been developed. However, there are some limitations in these procedures. To date, the optimal surgical approach for thyroid cancer has not yet been developed. This study reported the surgical operation steps, clinical outcomes, and experience of 30 patients who underwent trans-cervico-mental angle single-port endoscopic thyroidectomy (TCMASPET) at our centre.

Patients and Methods

A total of 30 patients were enrolled in the present study. Patients underwent unilateral or bilateral thyroidectomy through a cervico-mental angle incision of 2.48 ± 0.31 cm, after which the lymphoid adipose tissues in the central region were dissected.

Results

All surgeries were successfully completed. Two patients underwent bilateral thyroid carcinoma resection with bilateral central region lymph node dissection, 23 patients received unilateral thyroid cancer resection with unilateral central region lymph node dissection, four patients underwent unilateral thyroid resection, and one patient received bilateral thyroid resection with unilateral central region lymph node dissection. No permanent post-operative complications were observed.

Conclusions

TCMASPET was a safe and feasible approach that was relatively easy to perform. This approach may expand the indications for endoscopic thyroidectomy while maintaining excellent cosmetic outcomes.

Assessing National Utilization Trends and Outcomes of Robotic and Endoscopic Thyroidectomy in the United States

OBJECTIVE

We aimed to evaluate trends and outcomes of surgical approaches to thyroid surgery. We hypothesized that there have been changes over time in the utilization of approaches to thyroidectomy, including endoscopic, robotic, and open approaches, and that patient outcomes may differ between open surgery and endoscopic or robotic approaches.

STUDY DESIGN

Retrospective analysis.

SETTING

The National Cancer Database (NCDB) was queried between 2010 and 2016.

SUBJECTS AND METHODS

National cohort of patients. Descriptive statistics were performed using χ² test, Mann-Whitney U test, t test and analysis of variance. To investigate complication rates, patient matching was performed with subsequent analysis using simple and multivariable logistic regressions.

RESULTS

We identified 217,938 patients within the NCDB. While endoscopic thyroid surgery increased, relatively, in use over time (0.93% to 2.34% of cases in 2010 and 2016, respectively), robotic thyroid surgery started to decline relatively to other approaches from 2013 to 2016 (0.39% to 0.25% of cases, respectively). The endoscopic approach was performed more commonly than the robotic approach within individual facilities that have reported both procedures (P = .025). Robotic thyroid surgery was associated with increased risk of positive margins (P = .046), while endoscopic thyroid surgery was associated with a higher rate of unplanned hospital readmission (OR, 1.55; 95% CI, 1.09-2.22), longer inpatient stays (OR, 1.55; 95% CI, 1.19-2.02), and higher 90-day postoperative mortality (OR, 4.45; 95% CI, 1.58-12.6).

CONCLUSION

Endoscopic thyroid surgery has increased in utilization since 2004 but may have worse morbidity and mortality outcomes compared to open 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.

Technique for endoscopic thyroidectomy with selective lateral neck dissection via a chest-breast approach

BACKGROUND

Endoscopic thyroidectomy has been widely accepted because it can effectively avoid neck scarring. However, there are seldom reports concerning completely endoscopic lateral neck dissection approaches. In this study, we introduced a technique for performing endoscopic thyroidectomy with lateral neck dissection via a chest-breast approach.

METHODS

We retrospectively reviewed 18 patients who underwent endoscopic total thyroidectomy along with levels II, III, IV, and VI dissection. All major outcomes, such as cosmetic effect, operative time and complications, etc., were analyzed. In addition, another 20 patients who underwent traditional open surgery (open group) were enrolled in the study to conduct a contrasting analysis between patients treated with the endoscopic technique (endoscopic group) and open group patients, in terms of demographic data and main operative outcomes, to evaluate the feasibility of this technique.

RESULTS

All 18 endoscopic surgery cases were successfully performed, and no patient was converted to the open procedure intra-operatively. There were no significant differences between the two groups regarding age (P = 0.209), Body Mass Index (P = 0.479), sex (P = 0.218), drainage time (P = 0.153), operation time (P = 0.065), intra-operative blood loss (P = 0.139), post-operative pain (P = 0.114), and number of dissected lateral lymph nodes (II: P = 0.201; III + IV: P = 0.107). The mean total and lateral lymph nodes dissection (LLND) time in the endoscopic group were longer than those of the open group (P = 0.002; 235 ± 35 vs. 182 ± 20 min, P = 0.000; 125 ± 21 vs. 80 ± 14 min, P = 0.000). The primary lesion diameter of the endoscopic group was smaller than that of the open group (1.7 ± 0.8 vs. 2.9 ± 1.3 cm, P = 0.002). The scores for cosmetic satisfaction in the endoscopic group were higher than those in the open group (8.3 ± 0.7 vs. 4.4 ± 0.9, P = 0.000). Among the complications, there was no significant difference between the two approaches in transient vocal cord paresis (1/18 vs. 0/20, P = 0.474), transient hypoparathyroidism (4/18 vs. 4/20, P = 1.000), post-operative lymphatic leakage (1/18 vs. 3/20, P = 0.606), and intra-operative large blood vessel injury (2/18 vs. 0/20, P = 0.218). There was no incidence of uncontrolled bleeding, mental nerve injury, permanent hypoparathyroidism, permanent recurrent laryngeal nerve (RLN) injury, skin bruise on the neck, asphyxia/dyspnea or other complications like tracheal injury, esophageal injury, etc., nor was there any death or recurrence in either of the two groups during the short follow-up period.

CONCLUSION

It is feasible to perform LLND (levels II, III, IV, and VI) with endoscopic thyroidectomy via a chest-breast approach. In particular, this technique avoids a large scar on the patient's neck and has well operative outcomes compared with open surgery. Accordingly, this technique may offer one more option for selective patients.

Standardization of simple auxiliary method beneficial to total endoscopic thyroidectomy on patients with PTC, based on retrospective study of 356 cases

OBJECTIVE

Total endoscopic thyroidectomy (TET) is paid increasing attention to by patients, especially those with thyroid carcinoma. The aim of this study is to evaluate the clinic feasibility of standardization of simple auxiliary method (SOSAM) involved in operating bed adjustment, location of skin traction points and thyroid retractor points for the TET via bilateral breast approach.

METHODS

A retrospective study was performed on 356 patients with thyroid carcinoma, who had undergone the TET. Patients were divided into Group A (with the SOSAM) and Group B (without the SOSAM). This study compares the surgical outcome parameters between the two groups, including the total operative time, hemorrhage volume during operation, postoperative hospitalization days, numbers of dissecting and metastatic lymph nodes, and postoperative complication.

RESULT

The total operative time, hemorrhage volume and postoperative hospitalization days in Group A were significantly lower than those in Group B (P < 0.05). Nevertheless no statistically significant differences were found in both groups in terms of other observation indexes (P > 0.05), including numbers of dissecting and metastatic lymph nodes, and postoperative complication. Meanwhile, there were no patients with incision and surgical site infection, air embolism, and flap injury occurred in both groups.

CONCLUSION

The clinical application of the SOSAM can effectively decrease the total operative time and hemorrhage during operation. Moreover, it can be used in a wider range of popularization to improve the operative effect for total endoscopic thyroidectomy.

Transoral Endoscopic Thyroidectomy: Review of 81 Cases in a Single Institute

OBJECTIVE

To evaluate the clinical efficacy and safety of transoral endoscopic thyroidectomy (TOET).

MATERIALS AND METHODS

A total of 81 patients with thyroid nodules underwent TOET in our department from November 2011 to September 2015. The surgical outcomes, cosmetic results, and complications were evaluated.

RESULTS

Seventy-nine patients were performed TOET successfully, and 2 cases were transferred to open thyroidectomy due to intraoperative CO₂ embolism. The average operation time was 89.0 ± 38.6 minutes, and intraoperative blood loss was 29.3 ± 27.6 mL. Two cases experienced transient perioral numbness, and 2 cases experienced transient opening mouth pain. Two cases had transient increased saliva when swallowing. Transient anterior cervical region discomfort was found in 3 cases, and postoperative anterior cervical region infection was found in 4 cases. Other complications were not observed in any case. The average postoperative length of stay was 4.77 ± 2.61 days, and the mean follow-up period was 39.1 ± 22.6 months. During the follow-up period, there were no long-term complications or recurrent patient, and all the patients were satisfied with the cosmetic effect.

CONCLUSIONS

TOET is a safe and effective procedure with a low incidence of complications and perfect cosmetic effect for patients with thyroid diseases.

Quality of Life in Patients Treated with Percutaneous Laser Ablation for Non-Functioning Benign Thyroid Nodules: A Prospective Single-Center Study

Objective

While many studies have reported that laser ablation (LA) for benign non-fuctioning thyroid nodules is efficacious in reducing nodular volume and neck symptoms, none have described changes in quality of life (QoL). The purpose of this study was to report post-LA changes in QoL in our cohort of patients.

Materials and Methods

Fourteen patients with benign thyroid nodules were involved in a prospective, single-center study and underwent a single session of LA. We evaluated the following: changes in nodule volume, thyroid function, and autoimmunity; adverse events during and after LA; changes in neck discomfort by means of a visual analogic scale (VAS) at one week and 1, 3, 6, and 12 months; and changes in QoL through the 13-scale Thyroid-specific Patient Reported Outcome (ThyPRO) questionnaire at 1, 3, 6, and 12 months. ThyPRO is a validated questionnaire for thyroid diseases, which consists of 13 scales with multiple-choice answers. They investigate several aspects of life that may be impaired by goiter-related compression symptoms, by esthetic alterations and by hypo- or hyperthyroidism.

Results

Nodule volume decrease was −37 ± 23%, −55 ± 22%, −53 ± 25%, −58 ± 25% (p < 0.01 vs. baseline) at the first, third, sixth, and twelfth month, respectively. No hypothyroidism or positivization of autoimmunity was observed. There were no major complications during or after LA. After LA, VAS scores improved significantly from 1 week onwards in 100% of patients, while a significant improvement was seen in the goiter symptoms score after one month, and in the general score and mean values of ThyPRO after six months. Scores on the other ThyPRO scales did not change significantly.

Conclusion

Laser ablation is safe and effective in reducing nodule volume and neck symptoms; this is confirmed by improvements in the goiter scale, general score, and mean values of ThyPRO and in the VAS score.

A Comparative Study on the Transareola Single-Site Versus Three-Port Endoscopic Thyroidectomy

OBJECTIVE

To explore the feasibility, safety, and advantages of transareola single-site endoscopic thyroidectomy.

METHODS

From January 2014 to December 2015, 40 patients were randomly divided into an observation group who received single-site endoscopic thyroidectomy by the areola approach and a control group who underwent three-port endoscopic thyroidectomy by the areola approach with 20 patients in each group. The feasibility and safety of the operation and postoperative clinical outcomes were compared between these two groups.

RESULTS

There was no significant difference in operation time, intraoperative blood loss, and hospitalization time (P > .05) between the two groups. The subcutaneous dissection area in the observation group (130 [120-130] cm²) was significantly smaller than that in the control group (180 [170-190] cm²) (P < .01). In addition, there is much less postoperative drainage in the observation group (70 [50-80] mL) than in the control group (80 [60-100] mL) (P = .036). Furthermore, 24-hour postoperative pain score in the observation group (4.0 [3.0-5.5]) was significantly lower compared with that in the control group (5.0 [4.0-7.0]) (P = .047). Moreover, patients in the observation group present with significantly higher 7-day postoperative cosmetic satisfaction scores (9.0 [8.0-9.0]) than those in the control group (7.0 [7.0-8.0]) (P < .001).

CONCLUSION

Transareola single-site endoscopic thyroidectomy exhibits superior advantages in clinical outcomes such as causing less pain and achieving better cosmetic satisfaction, compared with three-port endoscopic thyroidectomy.