Comparison of quality of life between open and endoscopic thyroidectomy for papillary thyroid cancer

Quality of life after endoscopic vs. conventional open thyroidectomy: a systematic review and meta-analysis

BACKGROUND

We have performed a meta-analysis of studies reporting on Health-related quality of life (QoL) after endoscopic thyroidectomy (ETx) vs. open thyroidectomy (OTx).

OBJECTIVES

The objective was to evaluate the QoL outcomes of ETx compared to OTx.

METHODS

Eligibility criteria: Studies comparing ETx vs OTx INFORMATION SOURCES: PubMed, EMBASE, the Cochrane library, and online registers were searched for articles comparing QoL in ETx vs OTx.

RISK OF BIAS

Articles were assessed for risk of bias using Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool.

SYNTHESIS OF RESULTS

The main summary measures using the random effects model were mean difference (MD).

RESULTS

Three studies were included in the meta-analysis.  Two studies compared QoL between Transoral Endoscopic Thyroidectomy vs OTx and one compared Transaxillary Endoscopic Thyroidectomy vs OTx. There were no significant differences in the QoL outcomes using SF-36 scale. Pain scores assessed using the visual analogue scale (VAS) and overall satisfaction were also comparable between ETx and OTx.

CONCLUSION

Our systematic review and meta-analysis indicate that QoL outcomes for ETx and OTx may be comparable based on the currently available evidence. The substantial heterogeneity across studies and the lack of adequately powered trials limit the generalizability of these findings. Future large-scale randomized controlled trials with robust QoL measures, such as ThyPRO-39, are needed to provide higher-quality evidence on the comparative effectiveness of ETx versus OTx.

Assessment of preoperative health-related quality of life in patients undergoing thyroidectomy based on patient-reported outcomes

Introduction

To evaluate the preoperative health-related quality of life (HRQoL) and influencing factors of HRQoL in patients undergoing thyroidectomy based on patient-reported outcomes.

Materials and methods

Patients who were diagnosed and treated in Sichuan Cancer Hospital from February 2022 to December 2022 and were scheduled to undergo thyroidectomy were included. Each participant completed the basic information questionnaire and patient-reported outcome assessment scales before surgery. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30), the Thyroid Cancer-Specific Quality of Life (THYCA-QoL), and the Hamilton Anxiety Scale (HAMA). The Wilcoxon rank sum test or the Kruskal-Wallis test was used to analyze the association between patient characteristics and HRQoL, and the variables with statistical significance were included in multiple linear regression analysis.

Results

450 patients were included in the study. According to the analysis of the THYCA-QoL scores, the psychological subscale was the most complained about. Anxiety was the most common symptom of the HAMA. Factors associated with worse general QoL on the EORTC QLQ-C30 included nondiagnostic/unsatisfactory fine-needle aspiration (FNA) result. Planned lateral neck dissection and nondiagnostic/unsatisfactory FNA result were influential factors for preoperative anxiety. Males and longer sleep duration were associated with better thyroid cancer-specific QoL, better general QoL, and less anxiety.

Conclusion

The preoperative HRQoL of patients undergoing thyroidectomy was generally good. Females, insufficient sleep duration, planned lateral neck dissection, and nondiagnostic/unsatisfactory FNA result were associated with worse preoperative HRQoL.

Endoscopic thyroidectomy via chest-collarbone approach versus conventional open thyroidectomy: a retrospective comparative study

OBJECTIVE(S)

Endoscopic thyroidectomy, such as axillary, areola and transoral approaches, offer the advantage of a good cosmetic outcome, but it requires a wider dissection field compared to open thyroidectomy. Recently, chest-collarbone approach thyroidectomy has been widely developed in China because of its shorter anatomical route compared to other endoscopic approaches. This study retrospectively evaluated endoscopic thyroidectomy via chest-collarbone approach in patients with thyroid nodules to determine its feasibility.

METHODS

A total of 46 patients with thyroid disease who underwent endoscopic thyroidectomy between January 2022 and December 2022 were enrolled in the study and randomly matched to patients with thyroid disease who underwent open thyroidectomy at the same time based on nodule size and pathology. Postoperative bleeding, hoarseness situation, hospital stay, postoperative drainage volume, laryngeal nerve palsy, hypoparathyroidism and wound infection were assessed in both groups.

RESULTS

Forty-four patients underwent endoscopic thyroidectomy successfully and two patients changed to open thyroidectomy. The amount of postoperative drainage for the endoscopic thyroidectomy group was 102.78 ± 28.04 mL, and which was 71.91 ± 19.20 for open thyroidectomy group (p < 0.001). The postoperative hospital stay for the endoscopic thyroidectomy group was 8.78 ± 2.57 days, and which was 7.22 ± 1.13 for open thyroidectomy group (p < 0.001). There was no significant difference in postoperative bleeding, hoarseness situation, and wound infection between the two groups. Laryngeal nerve palsy, supraclavicular nerve injury and hypoparathyroidism were not observed in any patient during this study.

CONCLUSION

Chest-collarbone endoscopic thyroid surgery is acceptable. This treatment improves in a good cosmetic outcome in patients with thyroid disease. To assess patients with preoperative nodule size and nature of the case is the impact of the success rate, which is particularly important.

Long-term Quality of Life After Thyroidectomy: Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Transcervical Approach

OBJECTIVE

To compare long-term health-related quality of life (HRQOL) after Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and transcervical approach (TCA) thyroidectomy.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

METHODS

A web-based survey was distributed to patients at our institution who met the criteria for TOETVA and underwent thyroidectomy by TOETVA or TCA between August 2017 and October 2021. All survey participants were at least 6 months postsurgery. Minors, non-English speakers, and patients who received concomitant neck dissection or reoperative thyroidectomy were excluded from the study. The survey assessed quality of life through 4 standardized instruments: the Dermatology Life Quality Index (DLQI), the Eating Assessment Tool (EAT-10), the Voice Handicap Index (VHI-10), and the Short Form Health Survey (SF-36).

RESULTS

A total of 108 TOETVA and 129 TCA patients were included in the study. The median age of respondents was 44 (36, 54; 25th, 75th percentile) years and median time from surgery to survey was 35 (22, 45; 25th, 75th percentile) months. TOETVA group DLQI (0.63 vs 0.99; P = .17), VHI-10 (1.94 vs 1.67; P = .35), EAT-10 (2.14 vs 2.32; P = .29), SF-36 physical component (52.25 vs 51.00; P = .25), and SF-36 mental component (47.74 vs 47.29; P = .87) scores were all similar to those of the TCA group. Scrutinizing specific DLQI questions, individuals in the TOETVA group were less self-conscious of their skin as compared to the TCA group (Q2; 0.08 vs 0.26, P = .03).

CONCLUSION

Long-term HRQOL after TOETVA is similar to TCA, with significantly lower skin-related self-consciousness.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Patient-reported oral function and psychological well-being outcomes of papillary thyroid cancer patients (PTC) after surgery: a cross-sectional study

BACKGROUND

This study was performed to evaluate the differences in oral function and psychological well-being between patients with PTC after the gasless transoral endoscopic thyroidectomy vestibular approach (gasless-TOETVA) and patients with PTC after open surgery.

METHODS

PTC patients who underwent radical surgery from May 2021 to August 2022 were included in this study. Postoperative data on oral function and psychological well-being, including the Oral Health Impact profile-14 (OHIP-14) and State-Trait Anxiety Inventory Form Y, were collected and analyzed.

RESULTS

212 patients were included in the analysis. Among them, 102 patients who received gasless-TOETVA were assigned to the gasless-TOETVA group, while the remaining 110 patients who underwent open surgery were categorized as the open group. Although the OHIP-14 score in the gasless-TOETVA group was higher than that of the open group from 6 months to 1 year after surgery (p = 0.012), the difference in OHIP-14 scores between the two groups disappeared 1 year after surgery (p = 0.155). There were no differences between the gasless-TOETVA group and the open group in state-anxiety scores. However, the gasless-TOETVA group had significantly lower trait-anxiety scores than the open group at all follow-up time periods. Furthermore, within the gasless-TOETVA group, patients who were more than 1 year post-surgery showed significantly increased trait-anxiety scores compared to those of patients who were less than 1 year post-surgery (Δ = 3.4; p = 0.032). In contrast, the open group showed a decreasing trend in trait-anxiety scores, but there was no statistically significant difference between patients who had surgery less than 1 year ago and those who had surgery more than 1 year ago (Δ = - 2.2; p = 0.094).

CONCLUSION

Gasless TOETVA had a temporary impact on oral function, but it did not alleviate the state of anxiety. Furthermore, we observed a significant increase in trait-anxiety scores among PTC patients who underwent gasless-TOETVA after 1 year.

Assessment of Patients' Quality-of-Life Post-Thyroidectomy

INTRODUCTION

The assessment of quality of life (QOL) after thyroidectomy has been a focus of medical research, aiming to understand its impact on patients' overall well-being and functional status. Studies have examined the physical, psychological, and social dimensions of QOL, providing valuable insights into the outcomes of thyroidectomy and improving patient care. The aim of the study is to evaluate the long-term impact of different aspects of patients' quality of life post-thyroidectomy.

METHODS

This cross-sectional study was conducted in Taif City and included 100 participants post-thyroidectomy. Data were collected from medical records and telephone interviews using the modified Arabic version of the EROTC QLQ-H&N43 questionnaire. The collected data were analyzed using R software version 4.2.2.

RESULTS

The majority of the 100 participants were female (76%), and most were over 50 years old (38%). The types of surgery performed included hemithyroidectomy (36%), subtotal thyroidectomy (6%), and total thyroidectomy (58%). Participants reported difficulties related to their senses, body satisfaction, sexual satisfaction, eating, speaking, and social interactions. Pain in the mouth and jaw, as well as swallowing difficulties, showed variations among the surgery groups. Other symptoms, such as tooth problems, dry mouth, and swelling in the neck, did not differ significantly among the groups. Numbness in the hands or feet was associated with a subtotal or total thyroidectomy. Difficulties with enjoying meals, eating in front of others, and communication issues showed variations among the surgery groups.

CONCLUSION

This study provided insights into the QOL of thyroidectomy survivors in Taif City. Participants reported challenges related to sensory, body, and sexual issues, as well as difficulties with eating, speaking, and social interactions. The findings highlight the need for interventions and support to address these challenges and optimize the QOL of thyroidectomy patients. Furthermore, research is warranted to explore specific factors contributing to these difficulties and to develop targeted interventions for better patient outcomes.

Gasless endoscopic thyroidectomy via the anterior chest approach: the experience with 1500 cases

BACKGROUND

Conventional thyroidectomy leaves an eye-catching scar in the anterior neck region. Endoscopic thyroidectomy may achieve a better esthetic effect and improve quality of life postoperatively. The aim of this study was to undertake a complete review of a large cohort of the patients undergoing gasless endoscopic thyroidectomy (GET) via anterior chest approach (ACA) with a long-term follow-up period, and evaluate the results and limits of this procedure.

METHODS

Between 2003 and 2022, 1413 patients undergoing GET via ACA in our department were included. The demographic, clinicopathological characteristics, oncologic and esthetic outcomes were summarized and analyzed.

RESULTS

The indication for surgery was papillary thyroid carcinoma in 686 (48.5%) patients and benign thyroid diseases in 727 (51.5%) patients. Among them, 802 (56.8%) patients took hemithyroidectomy, and 611 (43.2%) patients did sub-total/total thyroidectomy. Meanwhile, 598 (42.3%) ones had central neck dissection, while 88 (6.2%) lateral neck dissection. The most common complication was transient hypoparathyroidism with an incidence of 2.9%. During the follow-up period of 2 to 232 months, three patients were confirmed locoregional recurrence. Most of the patients were satisfied with the cosmetic results.

CONCLUSION

Gasless endoscopic thyroidectomy via anterior chest approach is a safe and feasible procedure, which could achieve excellent oncologic and esthetic outcomes.

Construction of a system for head and neck tumor traceless resection with non-inflatable transaxillary total endoscopic surgery

Radical cure and functional preservation of tumors are the fundamental goals of surgical treatment of head and neck tumors, and the preservation of good aesthetics is a higher pursuit on this basis. Fully hiding the surgical incision and reducing the visibility of scars are important goals of cosmetic surgery. Using complete endoscopy for the head and neck is an effective method. CO₂-free transaxillary total endoscopic surgery is a method with many advantages, which has been widely used in the resection of thyroid tumors, but for other parts and types of tumors in the head and neck, this surgical method is rarely used. The research team expanded its application scope and applied it to submandibular gland tumor resection and other head and neck surgeries for the first time. Through this exploration, it improved traction devices such as retractors, strictly limited the surgical indications, analyzed and summarized the key points, steps and methods of surgery, and built a treatment system for head and neck tumor surgery under complete endoscopy using the non-inflatable transaxillary approach. In this article, we introduce the system and select typical cases to share.

Modern Surgical Techniques of Thyroidectomy and Advances in the Prevention and Treatment of Perioperative Complications

Thyroid cancer is the most common cancer of the endocrine system, and, in recent years, there has been a phenomenon of overdiagnosis followed by subsequent overtreatment. This results in an increasing number of thyroidectomy complications being faced in clinical practice. In this paper, we present the current state of knowledge and the latest findings in the fields of modern surgical techniques, thermal ablation, the identification and assessment of parathyroid function, recurrent laryngeal nerve monitoring and treatment and perioperative bleeding. We reviewed 485 papers, from which we selected 125 papers that are the most relevant. The main merit of this article is its comprehensive view of the subject under discussion-both general, concerning the selection of the appropriate method of surgery, and particular, concerning the selection of the appropriate method of prevention or treatment of selected perioperative complications.

Transoral thyroidectomy vestibular approach vs. conventional open thyroidectomy: a systematic review and meta-analysis

The purpose of this study was to compare the intraoperative outcomes and postoperative complications of patients experiencing transoral thyroidectomy vestibular approach (TOTVA) and conventional open thyroidectomy (COT). PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials in the Cochrane Library, and Web of science expanded between January 2007 and November 2022 comparing TOTVA and COT was exhaustively searched. Fifteen non-randomized controlled studies involving 2955 patients were included. The results of meta-analyses indicated that TOTVA was associated with longer operative time (WMD, 66.86; 95%CI, 47.15-86.56; P < 0.00001), more blood loss (WMD, 2.83; 95%CI, 1.77-3.90; P < 0.00001), higher incidence of wound infection (OR, 5.62; 95%CI, 1.57-20.10, P = 0.008). There was no significant difference in terms of transient recurrent laryngeal nerve (RLN) palsy and other postoperative outcomes. In conclusion, TOTVA appears to be a feasible and safe approach for the treatment of patients with benign thyroid nodules and selected differential thyroid carcinomas just like the COT.

A comparative study of quality of life in patients with papillary thyroid carcinoma undergoing microwave ablation vs. Total thyroidectomy

OBJECTIVE

To compare the health-related quality of life (HRQoL) of patients with T1N0M0 papillary thyroid carcinoma (PTC) who underwent microwave ablation (MWA) and those who underwent total thyroidectomy (TT).

MATERIALS AND METHODS

From February 2018 to February 2022, 180 T1N0M0 PTC patients were enrolled in present study, including 90 in the MWA group and 90 in the TT group, respectively. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and Thyroid Cancer-Specific Quality of Life Questionnaire (THYCA-QoL) were completed by patients to evaluate their HRQoL scores.

RESULTS

According to the results of the EORTC-QLQ-C30, there was a significant difference in the scores of global health, physical, emotional, etc. between the two groups, which indicated that the quality of life in these items in the MWA group was better than those in the TT group (all p < 0.05). According to the results of the THYCA-QoL, all items had significant differences between the two groups except for headache, which demonstrated the thyroid-specific quality of life was higher in the MWA group than in the TT group (all p < 0.05).

CONCLUSION

Ultrasound (US)-guided MWA offers a significant advantage in HRQoL over TT in T1N0M0 PTC patients, which provides an important reference for MWA as an alternative strategy to TT.

Comparison of endoscopic thyroidectomy by complete areola approach and conventional open surgery in the treatment of differentiated thyroid carcinoma: A retrospective study and meta-analysis

Background

The feasibility of endoscopic thyroidectomy by complete areola approach (ETCA) remains controversial. This study was conducted by combining our clinical data with the data obtained from a systematic review literature search to examine the effectiveness and safety of ETCA compared with conventional open thyroidectomy (COT) in differentiated thyroid carcinoma (DTC).

Methods

A total of 136 patients with a diagnosis of DTC who underwent unilateral thyroidectomy with central neck dissection from August 2020 to June 2021 were enrolled. The enrolled patients were divided into the ETCA group (n = 73) and the COT group (n = 63). The operative time, intraoperative bleeding volume, number of removed lymph nodes, number of metastatic lymph nodes, postoperative drainage volume, length of postoperative hospital stay, postoperative parathyroid hormone (PTH) levels, and complications were analyzed. Then, a systemic review and comprehensive literature search were conducted by using PubMed, Google Scholar, Embase, Web of Science, CNKI, Wanfang, and VIP database up to June 2022. Review Manager software version 5.3 was used for the meta-analysis.

Results

The results of clinical data showed that there were significant differences between the two groups in the operative time, intraoperative bleeding volume, removed lymph nodes, and postoperative drainage volume. There were no statistical differences in the length of postoperative hospital stay, number of metastatic lymph nodes, postoperative PTH level, and complications. In the systematic review and meta-analysis, 2,153 patients from fourteen studies (including our data) were ultimately included. The results of the meta-analysis found that ETCA had a longer operative time, larger postoperative drainage volume, and lower intraoperative bleeding volume. In terms of the length of postoperative hospital stay, the number of removed lymph nodes, and surgical complications, there was no significant difference between the two groups.

Conclusion

ETCA poses lower surgical bleeding and better cosmetic appearance compared with COT, while the length of operation and postoperative drainage in ETCA is less favorable compared with COT. In addition, ETCA is not inferior to COT in terms of the postoperative hospitalization stay, the number of removed lymph nodes, and surgical complications. Given its overall advantages and risks, ETCA is an effective and safe alternative for patients with cosmetic concerns.

Current therapeutic options for low-risk papillary thyroid carcinoma: Scoping evidence review

Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.

Recurrent Laryngeal Nerve Injury Near the Nerve Entry Point in Total Endoscopic Thyroidectomy: A Retrospective Cohort Study

Background

Recurrent laryngeal nerve injury (RLNI) still occurs in total endoscopic thyroidectomy (TET) by using intraoperative neuromonitoring (IONM). As the region where most injuries occur, more attention should be paid to RLNI near the nerve entry point (NEP) in TET.

Materials and Methods

This cohort study collected retrospectively data from 415 patients who underwent TET between February 2012 and December 2019. The functions of the recurrent laryngeal nerve (RLN) in TET were recorded by IONM. The patients with RLNI near the NEP were followed up by laryngoscopies. The demographic and clinical characteristics, the mechanisms of RLNI, and the outcomes of RLNI were recorded and analyzed.

Results

There were a total of 444 at-risk nerves in 405 patients were analyzed. The incidence of RLNI near the NEP was 7.9%. RLNs with extralaryngeal branches were more likely to be injured near the NEP (P = 0.037). The incidences of different types of RLNI, in order of frequency, were 68.8% for thermal injury (n = 22), 28.1% for traction/compression injury (n = 9), and 3.1% for transverse injury (n = 1). A total of 93.8% (n = 30) of RLNI patients had complete recovery of vocal cord activity function.

Conclusion

The extralaryngeal branch was a risk factor for RLNI near the NEP in TET. Thermal injury caused by an ultrasonic scalpel was the most common cause of RLNI near the NEP. Most RLNIs near the NEP would eventually recover.

Clinical Efficacy of Methotrexate Combined with Iguratimod on Patients with Rheumatoid Arthritis and Its Influence on the Expression Levels of HOTAIR in Serum

Objective

This study was designed to explore the clinical efficacy of methotrexate combined with iguratimod on patients with rheumatoid arthritis (RA) and its influence on the expression levels of HOTAIR in serum.

Methods

A total of 268 RA patients were selected as research objects, 145 patients received methotrexate alone were used as a control group (CG), 123 patients received methotrexate combined with iguratimod were taken as a research group (RG), and serum of 60 healthy people undergoing physical examination was selected as a healthy control group (HCG). The therapeutic value of two therapeutic methods for RA was compared, and the HOTAIR expression in serum was detected by qRT-PCR.

Results

Compared with methotrexate used alone, the joint use of methotrexate and iguratimod could provide better clinical efficacy for RA patients and would not increase the incidence of adverse events. HOTAIR was highly expressed in the serum of RA patients, and its expression decreased after treatment.

Conclusion

Combination therapy of methotrexate and iguratimod is a safe and effective way to treat RA patients, which can be popularized clinically.

Systematic review of health-related quality of life following thyroid cancer

This systematic review provides a summary of all studies published between 2000 and 2019 using a health-related quality of life (HRQOL) patient-completed questionnaire to report outcomes following diagnosis and treatment of thyroid cancer. The search terms were “thyroid cancer” or “thyroid carcinoma,” “quality of life” or “health related quality of life,” and “questionnaire” or “patient reported outcome.” EMBASE, PubMed, Medline, PsycINFO, CINAHL, and HaNDLE-On-QOL search engines were searched between 2 February and 23 February 2020. A total of 811 identified articles were reduced to 314 when duplicates were removed. After exclusion criteria (not thyroid specific, no quality of life questionnaires, and conference abstracts) were applied, 92 remained. Hand searching identified a further 2 articles. Of the 94 included, 16 had a surgical, 26 a primarily medical, and 52 a general focus. There were articles from 27 countries. A total of 49 articles were published from 2015 through 2019 inclusive. A total of 72 questionnaires were used among the articles and a range of 7 to 2215 participants were included within each article. This review demonstrated an increasing number of publications annually. The scope of enquiry into aspects of HRQOL following thyroid cancer is broad, with relatively few addressing surgical aspects and many focusing on the impact of radio-iodine. More research is required into shared decision-making in initial management decisions and HRQOL and interventions aimed specifically at addressing long-term HRQOL difficulties.

Health-related quality of life after transoral robotic thyroidectomy in papillary thyroid carcinoma

BACKGROUND

Health-related quality of life after transoral robotic thyroidectomy has not been evaluated thoroughly. The purpose of this study was to compare health-related quality of life after transoral robotic thyroidectomy and after conventional thyroidectomy.

METHODS

This study is a prospective, cross-sectional, and observational study of 114 patients who underwent transoral robotic thyroidectomy (57 patients) or conventional transcervical thyroidectomy (57 patients) for the treatment of papillary carcinoma. We used 2 questionnaires: the University of Washington Quality of Life questionnaire for head and neck cancer and the thyroid cancer-specific Quality of Life questionnaire (Thyroid Version). The survey was performed preoperatively, and 3 months and 1 year after thyroidectomy.

RESULTS

Mean scores for neck appearance were higher after surgery in the transoral robotic thyroidectomy group than the conventional group at both 3 months and 1 year. Anxiety was significantly improved after surgery in both groups. Total scores for health-related quality of life after surgery were similar in both groups. Health-related quality of life and overall quality of life over the previous 7 days as measured by the University of Washington Quality of Life questionnaire were significantly better at 1 year than in the preoperative period in both groups. Before surgery, patients in the both groups regarded anxiety and mood as the most important aspects of health-related quality of life. After surgery, patients in the transoral robotic thyroidectomy group identified anxiety, mood, and speech as the most significant issues, while patients in the conventional group selected anxiety, mood, and neck appearance.

CONCLUSION

Quality of life related to neck appearance is higher after transoral robotic thyroidectomy than after transcervical thyroidectomy. However, total scores for health-related quality of life did not differ in the 2 groups after surgery.

Surgical outcomes of minimally invasive thyroidectomy in thyroid cancer: comparison with conventional open thyroidectomy

Background

Minimally invasive thyroidectomy (MIT) is a safe method of performing thyroidectomy with notable benefits, such as improved cosmesis and reduced postoperative pain. The objective of this retrospective study was to report our experience with the technical feasibility of MIT, and compare its early surgical outcomes with those of conventional open thyroidectomy (COT) in patients with differentiated thyroid carcinoma (DTC).

Methods

A total of 617 patients who underwent MIT and 2,674 patients who underwent COT were reviewed between March 2006 and November 2017 at Yonsei University (Seoul, Korea). The mean follow-up duration was 41.2±19.7 months.

Results

The mean age of patients with DTC was 46.1±11.2 years. The mean operation time in the MIT group was significantly shorter than that of the COT group (63.5±26.2 vs. 85.3±36.8 minutes, P<0.001). The mean hospital stay was significantly shorter in the MIT group than it was in the COT group as well (2.7±0.6 vs. 3.1±0.8 days, P<0.001). There were significantly fewer painkillers used after surgery in the MIT group than in the COT group (1.2±0.5 vs. 2.7±1.6, P<0.001). The mean number of harvested LNs in the MIT group was significantly lower than that of the COT group (3.1±2.6 vs. 5.5±4.0, P<0.001).

Conclusions

This study demonstrated that MIT is technically feasible in patients with DTC. MIT is a valuable alternative operative technique to COT with good surgical outcomes and outstanding cosmetic results.

A systematic review of health state utility values for thyroid cancer

Purpose

Health state utility values are commonly used to inform economic evaluations and determine the cost-effectiveness of an intervention. The aim of this systematic review is to summarise the utility values available to represent the health-related quality of life (HRQoL) of patients with thyroid cancer.

Methods

Eight electronic databases were searched from January 1999 to April 2019 for studies which included assessment of HRQoL for patients with thyroid cancer. Utility estimates derived from multiple sources (EuroQol questionnaire 5-dimension (EQ-5D), time trade-off [TTO] and standard gamble [SG] methods) were extracted. In addition, utility estimates were generated by mapping from SF-36 and EORTC QLQ-30 to the EQ-5D-3L UK value set using published mapping algorithms.

Results

Searches identified 33 eligible studies. Twenty-six studies reported HRQoL for patients with differentiated thyroid cancer and seven studies for patients with general thyroid cancer. We identified studies which used different methods and tools to quantify the HRQoL in patients with thyroid cancer, such as the EQ-5D-3L, SF-36, EORTC QLQ-30 and SG and TTO techniques to estimate utility values. Utility estimates range from 0.205 (patients with low-risk differentiated thyroid cancer) to utility values approximate to the average UK population (following successful thyroidectomy surgery and radioiodine treatment). Utility estimates for different health states, across thyroid cancer sub-types and interventions are presented.

Conclusion

A catalogue of utility values is provided for use when carrying out economic modelling of thyroid cancer; by including mapped values, this approach broadens the scope of health states that can be considered within cost-effectiveness modelling.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02676-2) contains supplementary material, which is available to authorised users.

Comparison of surgical outcome between conventional open thyroidectomy and endoscopic thyroidectomy through axillo-breast approach

OBJECTIVE

Minimally invasive thyroidectomy can be categorized into either video-assisted method or remote access thyroidectomy (RAT). Although RAT provided excellent cosmetic results, some debate about the advantages and disadvantages remains in different countries. Thus, this study aimed to compare the surgical results between endoscopic thyroid surgery and conventional thyroidectomy.

MATERIALS AND METHODS

The study retrospectively reviewed the conventional and endoscopic thyroidectomy performed at our institution from September 2011 to July 2012. Overall, 30 patients were recruited for this study. The patients were divided into two groups: Group O (open group, n = 15) and Group E (endoscopic group, n = 15). Postoperative outcomes (including wound pain, swallowing disturbance, and chest wall paresthesia) and complications were analyzed and assessed.

RESULTS

The endoscopic group was associated with longer operation time and hospital stay. The visual analog scale (VAS) score of surgical wound pain was significantly higher in the open group in 1-week postoperation. However, the VAS score of swallowing disturbance was significantly higher in the endoscopic group in 1-week postoperation. More than half of the patients (53%) had chest wall paresthesia within 1-month postoperation in the endoscopic group. No surgical complications occurred in both groups.

CONCLUSION

Although endoscopic thyroidectomy provides excellent cosmetic results in thyroid surgery, higher immediate postoperative pain, and prolonged chest wall paresthesia compared with those in conventional surgery are a concern and warrant careful patient selection.

Comparison of total endoscopic thyroidectomy with conventional open thyroidectomy for treatment of papillary thyroid cancer: a systematic review and meta-analysis

BACKGROUND

Despite the fact that thyroid surgery has evolved towards minimal incisions and endoscopic approaches, the role of total endoscopic thyroidectomy (TET) in thyroid cancer has been highly disputed. We performed a systematic review and meta-analyses of peer reviewed studies in order to evaluate the safety and effectiveness of TET compared with conventional open thyroidectomy (COT) in papillary thyroid cancer (PTC).

METHOD

Medical literature databases such as PubMed, Embase, the Cochrane Library, and Web of science were systematically searched for articles that compared TET and COT in PTC treatment from database inception until March 2019. The quality of the studies included in the review was evaluated using the Downs and Black scale using Review Manager software Stata V.13.0 for the meta-analysis.

RESULTS

The systematic review and meta-analysis were based on 5664 cases selected from twenty publications. Criteria used to determine surgical completeness included postoperative thyroglobulin (TG) levels, recurrence of the tumor after long-term follow-up. Adverse event and complication rate scores included transient recurrent laryngeal nerve (RLN) palsy, permanent RLN palsy, transient hypocalcaemia, permanent hypocalcaemia, operative time, number of removed lymph nodes, length of hospital stay and patient cosmetic satisfaction. TET was found to be generally equivalent to COT in terms of surgical completeness and adverse event rate, although TET resulted in lower levels of transient hypocalcemia (OR 1.66; p < 0.05), a smaller number of the retrieved lymph nodes (WMD 0.46; p < 0.05), and better cosmetic satisfaction (WMD 1.73; p < 0.05). COT was associated with a shorter operation time (WMD - 50.28; p < 0.05) and lower rates of transient RLN palsy (OR 0.41; p < 0.05).

CONCLUSIONS

The results show that in terms of safety and efficacy, TET was similar to COT for the treatment of thyroid cancer. Indeed, the tumor recurrence rates and the level of surgical completeness in TET are similar to those obtained for COT. TET was associated with significantly lower levels of transient hypocalcemia and better cosmetic satisfaction, and thus is the better option for patients with cosmetic concerns. Overall, randomized clinical trials and studies with larger patient cohorts and long-term follow-up data are required to further demonstrate the value of the TET.

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.

Transoral Endoscopic Thyroidectomy for Thyroid Cancer

The prevalence of low-risk differentiated thyroid cancer (DTC) is dramatically increasing because of superior diagnostic imaging technologies. Remote-access endoscopic thyroidectomy is becoming more popular for the lack of a noticeable neck scar. Transoral endoscopic thyroidectomy, vestibular approach (TOETVA) is the only technique that could be called a true scarless surgery; however, there is a scarcity of long-term studies about its safety and feasibility. Because thyroid cancer is a slow-growing lesion, with adequate follow-up and surveillance, TOETVA is a surgical procedure for the management of low-risk DTC without any difference of surgical and oncological outcome.

Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis

Background

Despite the considerable experience gained thus far using endoscopic technologies, the role of total endoscopic thyroidectomy (ET) for papillary thyroid cancer (PTC) remains controversial. We conducted a systematic review and meta-analysis to investigate the safety and effectiveness of total ET compared with conventional open thyroidectomy (OT) in PTC.

Methods

A systematic search was conducted using the PubMed, Embase and Cochrane Library electronic databases up to March 2018. The quality of included studies was evaluated using the Newcastle–Ottawa Scale. Review Manager software version 5.3 was used for the meta-analysis.

Results

Twelve studies including 2,672 patients were ultimately included in the systematic review and meta-analysis. ET was associated with longer operative time (P<0.00001), drainage time (P<0.00001) and hospital stay (P=0.03), higher transient recurrent laryngeal nerve (RLN) palsy rate (P=0.004) and a greater amount of drainage fluid (P<0.0001) compared with OT. Furthermore, no significant differences were detected between ET and OT in terms of retrieved lymph nodes (P=0.17), blood loss (P=0.22), transient hypocalcemia (P=0.84), permanent hypocalcemia (P=0.58), permanent RLN palsy (P=0.14), hematoma or bleeding (P=0.15) and seroma (P=0.54). In addition, the rates of tumor recurrence were comparable (P=0.18), whereas the proportions of stimulated thyroglobulin levels <1 ng/mL measured after completion of thyroidectomy and radioactive iodine therapy were less (P=0.02) in the ET than in the OT group.

Conclusion

ET is not superior to OT in terms of operation and drainage time, amount of drainage fluid, hospital stay or transient RLN palsy, but is comparable to OT in terms of retrieved lymph nodes and permanent complications. Despite the similar tumor recurrence rates between the two approaches, the level of surgical completeness in ET may not be as good as that for OT.

Transoral vestibule approach for thyroid disease: a systematic review

OBJECTIVES

Transoral endoscopic/robotic thyroidectomy vestibule approach (TOETVA/TORTVA) is a novel technology that has been proposed for the treatment of thyroid disease. Its adoption has increased because of its satisfying cosmetic effects. The primary aim of this systematic review was to assess the feasibility and safety of this approach, and the secondary aim was to discuss the indications for this technology.

MATERIALS AND METHODS

According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, we searched Pubmed, Embase and the Cochrane databases for published studies on the feasibility and safety of TOETVA or TORTVA.

RESULTS

11 articles containing 864 patients met the inclusion criteria after full-text screening, of which two were reports of randomized controlled trial (RCT), two were retrospective cohort studies and the remaining seven studies were case series. Only studies that evaluated the feasibility and safety of this approach were included. TOETVA/TORTVA was successfully performed in 857 out of the 864 cases (99.2%). The mean operative time ranged from 60.4 to 265.4 min. In most articles, blood loss was less than 50 mL and the mean hospital stay ranged from 1.1 to 8.2 days. The safety outcomes were presented in all articles. The total incidence of adverse events was 14.5%, of which the main complications were transient hypoparathyroidism (5.6%) and transient recurrent laryngeal nerve (RLN) injury (3.1%).

CONCLUSIONS

This review preliminarily suggests that TOETVA or TORTVA could be an effective and safe treatment for thyroidectomy. Due to the small sample size and low level of evidence, further large-scale, well-designed RCTs are required to validate our findings.

Comparison of endoscopic thyroidectomy via a modified axillo-breast approach with the conventional breast approach for treatment of unilateral papillary thyroid microcarcinoma

Endoscopic thyroidectomy (ET) via an axillo-breast (ABA), axillary or breast approach (BA) is effective for treatment of unilateral papillary thyroid microcarcinoma (PTMC). However, several disadvantages still exist, including inconvenience for using endoscopic instruments and poor cosmetic results. Here, we introduced a modified ABA (MABA) to overcome these disadvantages and evaluated its therapeutic outcomes by comparison with conventional BA.Fifty-five patients undergoing ET via MABA (n = 22) or BA (n = 33) for PTMC were retrospectively enrolled between June 2012 and June 2015. Surgical outcomes, including the operation time, blood loss, amount of drainage, number of dissected lymph nodes, complications, cosmetic satisfaction and prognosis (recurrence and survival), were analyzed.The operation time (87.1 ± 9.3 min vs 93.2 ± 8.3 min; P = .014) and drainage tube removal time (4.4 ± 1.0 days vs 5.1 ± 1.1 days; P = .018) were shorter in the MABA group than those in the BA group. There was less postoperative drainage (54.3 ± 35.7 mL vs 137.6 ± 87.0 mL; P < .01) in the MABA group compared with the BA group. No significant differences in the blood loss (15.9 ± 7.5 mL vs 19.2 ± 11.7 mL, P = .243) and the number of dissected lymph nodes (1.8 ± 1.5 vs 2.3 ± 2.1, P = .309) were observed between the 2 groups. Subcutaneous ecchymosis occurred more frequently in the BA group than that in the MABA group (33.3% vs 9.1%; P = .038). Patients treated by MABA were more satisfied with their cosmetic results than those undergoing BA (100% vs 81.8%; P = .034). At the last follow-up time, all patients were alive although 1 patient in the BA group developed cervical lymph node recurrence ipsilateral to the original tumor at 4 years after surgery. Multivariate logistic regression analysis showed MABA surgery was a protective factor for postoperative complications (OR = 0.209, 95% confidence interval [CI] = 0.054-0.817, P = .024).ET via the MABA strategy may be a good choice for unilateral PTMC because of shorter operation time, fewer complications, greater cosmetic satisfaction, and excellent prognosis.

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.

Propensity score-matched analysis of the endoscopic bilateral axillo-breast approach (BABA) versus conventional open thyroidectomy in patients with benign or intermediate fine-needle aspiration cytology results, a retrospective study

BACKGROUND

The purpose of this study was to compare the surgical outcomes of endoscopic bilateral axillo-breast approach (BABA) to conventional open thyroidectomy (COT) in patients who had thyroid nodule(s) with a benign or intermediate fine-needle aspiration cytology (FNAC) results.

MATERIALS AND METHODS

All patients with benign or intermediate thyroid nodule(s) who underwent BABA (n = 95) or COT (n = 262) between 2008 and 2015 were reviewed. Then, 1:1 propensity score matching was performed, and 66 matched pairs were obtained. Surgical outcomes were then compared.

RESULTS

Before matching, patients in the BABA group were significantly younger (36.5 vs. 50.7 years, p < 0.000), predominantly female (97.9% vs. 69.8%, p < 0.000), had smaller tumours (2.1 vs. 2.8 cm, p = 0.002) and more commonly underwent hemithyroidectomy (88.4% vs. 70.6%, p < 0.000) than those in the COT group. After matching, all clinicopathological characteristics were equivalent. BABA was found to be significantly associated with longer operative time (125.3 vs. 79.8 min, p < 0.000), greater drainage volume (132.9 vs. 59.1 ml, p < 0.000), longer postoperative hospital stay (3.1 vs. 2.2 days, p < 0.000), and higher average total medical expense (4000 vs. 3200 US$). However, the incidence of complications did not differ between the groups.

CONCLUSION

BABA is comparable to COT in terms of complications and is safe and feasible when performed by experienced surgeons and for carefully selected patients who are concerned about neck scarring. However, the operative time and postoperative hospital stay are significantly longer, which may increase medical expenses.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results

INTRODUCTION

The Transoral Neck Surgery (TONS) Study Group was established at the 1st International Thyroid NOTES Conference in February 2016 with the intention of standardizing and refining thyroid NOTES techniques, including both transoral endoscopic and robotic thyroidectomy approaches. Herein, the authors report the modification of indications, preparation, and step-by-step explanations for operative techniques, as well as results and postoperative care for transoral endoscopic thyroidectomy vestibular approach (TOETVA).

METHODS

Between February 2015 and December 2015, a total of 200 patients comprising 8 males (4%) and 192 females (96%) underwent TOETVA using 3 laparoscopic ports inserted at the oral vestibule. Of these patients, 111 presented with single thyroid nodules (55.5%), while 66 patients had multinodular goiters (33%), 12 had Graves' disease (6%) and 11 had papillary microcarcinoma (5.5%). The CO₂ insufflation pressure was maintained at 6 mmHg. Each surgery was performed using laparoscopic instruments and ultrasonic devices.

RESULTS

TOETVA was performed on 200 consecutive patients. No conversion to conventional open surgery was necessary. Average tumor size was 4.1 ± 1.78 cm (1-10 cm). Median operative time was 97 ± 40.5 min (45-300 min). Median blood loss was 30 ± 46.25 mL (6-300 mL). Mean visual analog scale measurements were 2.41 ± 2.04 (2-7), 1.17 ± 1.4 (0-5), and 0.47 ± 0.83 (0-3) on the first, second, and third days, respectively. Temporary hoarseness and hypoparathyroidism occurred in 8 patients (4%) and 35 patients (17.5%), respectively. No permanent hoarseness or hypoparathyroidism occurred. Mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma that required open surgery. No infection was identified.

CONCLUSION

TOETVA was shown to be safe and feasible with a reasonable surgical duration and minimal pain scores. This approach shows promise for those patients who are motivated to avoid a neck scar.