A comparison of efficacy and quality of life between transoral endoscopic thyroidectomy vestibular approach (TOETVA) and endoscopic thyroidectomy axillo-breast approach (ETABA) in thyroid surgery: non-randomized clinical trial

Endoscopic surgery for papillary thyroid microcarcinoma: cases review and investigation of technique dissemination in China

Introduction

Thyroid cancer has become one of the most common types of cancer, with microcarcinomas accounting for more than 50% of all newly diagnosed thyroid cancers. Endoscopic thyroid surgery, which relocates the incision to a less visible area of the body, offers significant postoperative cosmetic benefits and has been widely used in the treatment of thyroid microcarcinomas. This study conducts a retrospective case analysis and questionnaire survey to provide clinical reference by statistically analyzing the development of endoscopic techniques in China over the past five years.

Materials and methods

This study included cases of thyroid microcarcinoma surgeries performed in our hospital from January 2018 to March 2020. Postoperative follow-up was conducted using the THYCA-QoL questionnaire. A network questionnaire survey was carried out through the Chinese Society of Oncoplastic Endocrine Surgeons targeting its members and other institutions performing endoscopic thyroid surgeries. The data was analyzed to obtain relevant results.

Results

The complications were comparable between the endoscopic and open surgery groups. The incidence of neck discomfort was higher in the open surgery group compared to the endoscopic group (21.92% vs. 13.38%). Scar formation was also more noticeable in the open surgery group (23.74% vs. 17.2%). The local recurrence rates were similar between the two groups (1.27% vs. 1.37%). Over 85% of the surveyed institutions reported endoscopic thyroid surgery via trans-breast approach, while the trans-axillary approach showed the fastest growth over the past five years. Most institutions (approximately 80%) performed fewer than 300 endoscopic thyroid surgeries annually. Additionally, in most institutions (around 67%), endoscopic thyroid surgeries accounted for less than 20% of the total thyroid surgeries performed annually. The most frequently questioned issues regarding the trans-breast and trans-axillary approaches were the completeness of central lymph node dissection (with 66.78% and 40.46% of respondents, respectively, considering the lymph node dissection to be incomplete). Furthermore, about 20%-30% of the surveyed institutions believed that endoscopic surgery was more traumatic and associated with a higher incidence of post-thyroidectomy syndrome (PTS).

Conclusion

For papillary thyroid microcarcinoma, endoscopic surgery demonstrates comparable efficacy to traditional open surgery, with no significant differences observed in 5-year recurrence and survival rates during follow-up. However, the safety and reliability of various endoscopic approaches for thyroid cancer surgery remain questionable, particularly regarding the thoroughness of central compartment lymph node dissection, as indicated by surveys on the implementation of endoscopic thyroid surgery over five consecutive years. More long-term follow-up data are required to validate these outcomes. Therefore, we recommend that preoperative lymph node positivity should be considered a contraindication, and patients with postoperative pathological confirmation of lymph node metastasis warrant closer clinical monitoring and intensive follow-up.

Postoperative quality of life in patients treated for thyroid cancer with transoral endoscopic and open surgery

Thyroid cancer treatments often impact patients' quality of life (QOL). The transoral endoscopic thyroidectomy vestibular approach (TOETVA) gets lot attention as a scarless alternative, but its influence on postoperative QOL remains unclear. This study compares TOETVA and open surgery outcomes regarding postoperative QOL, scar satisfaction, and mental health in thyroid cancer patients to inform surgical decision-making. We retrospectively analyzed 221 thyroid cancer patients treated between January 2017 and September 2024: 136 underwent open surgery, and 85 had TOETVA. QOL was assessed using the EORTC QLQ-C30 and THYCA-QOL questionnaires. Scar appearance was evaluated with the Patient and Observer Scar Assessment Scale (POSAS), and mental health with the Hospital Anxiety and Depression Scale (HADS). EORTC QLQ-C30 scores showed no significant difference in overall QOL between TOETVA and open surgery (global health status: 81.31 vs. 83.43, P = 0.420). The open surgery group had higher summary THYCA-QOL scores (15.33 vs. 12.41, P = 0.033). While univariate analysis linked TOETVA to fewer thyroid cancer-specific symptoms (P = 0.033), multivariate analysis did not (P = 0.198). TOETVA patients had better scar satisfaction (P < 0.001), confirmed by univariate and multivariate analysis. Anxiety (95.0%) and depression (88.2%) were common, with anxious symptoms in the TOETVA group nearing significance (P = 0.073). TOETVA significantly improves thyroid cancer-specific QOL and scar satisfaction but shows no difference in overall QOL compared to open surgery. These insights may guide surgical decision-making. In addition, attention to managing anxiety and depression is also essential.

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.

Advances in the assessment of cosmetic outcomes, sensory alteration in surgical areas, and health-related quality of life of endoscopic thyroidectomy

BACKGROUND

Endoscopic thyroidectomy has been preliminarily proven effective and safe for thyroid diseases. The cosmetic outcomes and life quality are critical contents of postoperative assessment. This review will primarily focus on the assessment methods and results related to cosmetic outcomes, sensory alteration of surgical area, and quality of life following endoscopic thyroidectomy.

METHODS

A comprehensive search of published articles within the last decade was conducted using the terms "endoscopic/robotic thyroidectomy," "patient satisfaction scores," "questionnaire," "quality of life," and "cosmetic" in PubMed.

RESULTS

Assessment methods for postoperative cosmetic satisfaction and sensory alterations encompassed verbal/visual analog scales, scar evaluations, Semmes-Weinstein monofilament tests, and more. The evaluation of postoperative quality of life in endoscopic thyroidectomy involved tools such as SF-36, SF-12, thyroid-specific questionnaires, thyroid cancer-specific quality of life questionnaires (THYCA-QOL), as well as assessments related to voice and swallow function. The cosmetic results of endoscopic thyroidectomy generally surpassed those of open thyroidectomy, while the quality of life in endoscopic procedures was either superior or equivalent to that in open thyroidectomy, especially with respect to general health, role emotion, and vitality.

CONCLUSIONS

Assessments of cosmetic outcomes and sensory alterations following endoscopic thyroidectomy predominantly relied on patients' subjective feelings. The objective and subjective perspectives of scar assessments remain underutilized. In addition, postoperative laryngoscopy and voice function assessments in endoscopic thyroidectomy procedures require more attention.

Endoscopic hemithyroidectomy plus prophylactic central neck dissection via breast approach versus gasless transaxillary approach in treating low-risk papillary thyroid cancer: a retrospective series

Hemithyroidectomy plus prophylactic central neck dissection (pCND) has been adopted as a de-escalating surgical strategy for low-risk papillary thyroid cancer (PTC). This study aimed to evaluate and compare the outcomes of these two different endoscopic approaches in the treatment of PTC with hemithyroidectomy plus pCND. This retrospective study reviewed medical records of 545 patients receiving breast approach (ETBA) (n = 263) or gasless transaxillary approach (ETGTA) (n = 282) in treating PTC. Demographics and outcomes were compared between the two groups. Preoperatively, the two groups were similar in demographics. Regarding surgical outcomes, no differences were found in terms of intraoperative bleeding, total amount of drainage, duration of drainage, postoperative pain, hospital stay, vocal cord palsy, hypoparathyroidism, hemorrhage, wound infection, chyle leakage, or subcutaneous ecchymosis. Conversely, ETBA recorded fewer skin paresthesia (1.5% vs. 5.0%, respectively) but longer operative times (138.1 ± 27.0 vs. 130.9 ± 30.8 min,) and more swallowing disturbances (3.4% vs. 0.7%) compared to ETGTA (p < 0.05). No difference in scar cosmetic results, but ETBA had lower neck assessment score than ETGTA (2.6 ± 1.2 vs. 3.2 ± 2.0, p < 0.05). For low-risk PTC, endoscopic hemithyroidectomy plus pCND using either ETBA or ETGTA is both feasible and safe. Although the two approaches are comparable in terms of most surgical and oncological outcomes, ETBA is superior to ETGTA in terms of neck cosmetic results and skin paresthesia but is associated with more swallowing disturbances and requires a longer operative time.

Modification and application of "zero-line" incision design in total endoscopic gasless unilateral axillary approach thyroidectomy: A preliminary report

Introduction

Gasless unilateral trans-axillary approach (GUA) thyroidectomy has witnessed rapid development in technologies and applications. However, the existence of surgical retractors and limited space would increase the difficulty of guaranteeing the visual field and disturb safe surgical manipulation. We aimed to develop a novel zero-line method for incision design to access optimal surgical manipulation and outcomes.

Methods

A total of 217 patients with thyroid cancer who underwent GUA were enrolled in the study. Patients were randomly classified into two groups (classical incision and zero-line incision), and their operative data were collected and reviewed.

Results

216 enrolled patients underwent and completed GUA; among them, 111 patients were classified into the classical group, and 105 patients were classified into the zero-line group, respectively. Demographic data, including age, gender, and the primary tumor side, were similar between the two groups. The duration of surgery in the classical group was longer (2.66 ± 0.68 h) than in the zero-line group (1.40 ± 0.47 h) (p < 0.001). The counts of central compartment lymph node dissection were higher in the zero-line group (5.03 ± 3.02 nodes) than that in the classical group (3.05 ± 2.68 nodes) (p < 0.001). The score of postoperative neck pain was lower in the zero-line group (1.0 ± 0.36) than that in the classical group (3.3 ± 0.54) (p < 0.05). The difference in cosmetic achievement was not statistically significant (p > 0.05).

Conclusion

The "zero-line" method for GUA surgery incision design was simple but effective for GUA surgery manipulation and worth promoting.

Oncologic safety and surgical outcomes of the different surgical approaches of endoscopic thyroidectomy for papillary thyroid carcinoma

PURPOSE

To evaluate the oncologic safety and surgical outcomes of endoscopic thyroidectomy (ET) performed via different surgical approaches for papillary thyroid carcinoma (PTC).

METHODS

We reviewed the medical records of PTC patients who underwent ET between May 2015 and May 2021, at the Department of General Surgery, Beijing Friendship Hospital (affiliated with Capital Medical University). The patients were divided into three groups: the ET via breast approach (ETBA) group, the transoral ET vestibular approach (TOETVA) group, and the ET via transaxillary approach (ETTA) group. We evaluated the safety and surgical outcomes of each of these ET approaches.

RESULTS

A total of 490 patients were included in the analysis: 416 in the ETBA group, 57 in the TOETVA group, and 17 in the ETTA group. There were no significant differences among the groups in clinicopathologic characteristics or surgical procedures, or in the incidences of complications such as hematoma, subcutaneous emphysema, infection, and chyle. The incidences of transient and permanent recurrent laryngeal nerve (RLN) injury were 1.4% and 4.3%, respectively, with no significant difference among the three groups. The incidences of transient and permanent postoperative hypoparathyroidism were 13.7% and 1.4%, respectively. The incidence of transient hypoparathyroidism in the TOETVA group was 1.7%, which was significantly lower than that in the ETBA group. The postoperative 1-, 3- and 5-year rates of disease-free survival were 99.5%, 96.8%, and 95.9%, respectively. Univariate and multivariate analyses showed that ET was not a significant risk factor for recurrence or metastasis (p = 0.83 and p = 0.49, respectively), regardless of the surgical approach.

CONCLUSIONS

TOETVA may be associated with a lower incidence of temporary hypoparathyroidism than ETBA. Apart from this difference, ETBA, ETTA and TOETVA showed comparable oncologic safety and surgical outcomes.

Comparison between cutting versus retraction of anterior cervical musculature during endoscopic thyroidectomy

To compare the different techniques of managing the anterior cervical muscle group during endoscopic thyroidectomy via the trans-thoraco-areolar approach. A total of 90 patients with thyroid tumors less than 3 cm were evaluated. The time for each intraoperative step, total surgery duration, intraoperative blood loss volume, pathology results, number of lymph nodes dissected and patient satisfaction with esthetics were assessed. Intraoperative blood loss volume, drainage volume on the first postoperative day, number of lymph nodes dissected in the central region, postoperative hospitalization duration, number of transient laryngeal nerve palsy cases, and number of transient hypocalcemia cases were similar between the muscle transection (MT) and muscle retraction (MR) groups. The MT group had significantly higher postoperative pain scores after 12 hours, but pain scores at 48 hours postoperatively were not significantly different between the 2 groups. In the unilateral thyroidectomy subgroup, the durations of isthmus resection, freeing the lateral thyroid, exposing the laryngeal recurrent nerve, and management of the inferior pole were similar for both muscle management methods. The muscle dissection and suture time was significantly longer for the MT group than that for the MR group; in contrast, the upper pole management time of the muscle resection group was significantly shorter. In the bilateral resection subgroup, both muscle management methods required similar durations for managing the contralateral upper pole after ipsilateral thyroidectomy. However, intraoperative blood loss was significantly higher for MR than for MT, while postoperative pain was relatively mild. In the malignant tumor subgroup, duration of inferior thyroid pole management was significantly less for MT than for MR. There are significant differences between the 2 muscle management methods in handling and suturing muscles. Both methods have satisfactory postoperative outcomes for resection of thyroid nodules with diameters ≤3 cm. For tumors located in the upper pole, transection of the anterior cervical muscles confers higher feasibility of the thyroidectomy technique; however, suturing becomes difficult in such scenarios.

Comparison of Different Mandibular Jawlines Classifications on Transoral Endoscopic Thyroidectomy for Papillary Thyroid Carcinoma: Experiences of 690 Cases

BACKGROUND

The influences of patients' different mandibular jawlines on transoral endoscopic thyroidectomy via vestibular approach (TOETVA) have not been described before. The objective of this study was to introduce a new classification to assess different mandibular jawlines, and to evaluate the effects on TOETVA in terms of safety, feasibility, and postoperative feelings in the treatment of papillary thyroid carcinoma (PTC).

METHODS

The crossing angle of esthetic plane and mandibular plane was defined as Wang Angle, used to assess patients' different mandibular jawlines. Mandibular classifications of A (angle: 80° ~ 110°), B (angle > 110°), and C (angle < 80°) types were compared to evaluate the surgical outcomes of TOETVA by a retrospective study. 690 patients of PTC who received TOETVA were included in this study, which were divided into three groups according to mandibular classifications.

RESULTS

Clinicopathological characteristics of the patients including age, gender, body mass index, tumor size, Hashimoto thyroiditis were similar in the three groups. Patients' length of jay in group C was significantly longer than group A and group B (P < 0.01). The ratios of using suspension system in group C were significantly higher than group A and group B (P < 0.01). The scores of postoperative visual analogue scale (VAS) and ratios of mandibular swell in group C were significantly higher than group A and group B (P < 0.01). There was no significant difference in the three groups regarding surgical outcomes, including postoperative vocal cord paralysis, hypocalcemia, serum white blood cells and C-reactive protein levels.

CONCLUSIONS

The Wang angle and mandibular jawline classifications were firstly introduced in TOETVA. All the patients of class A, B, and C mandibular jawline can achieve safe and effective surgical outcomes in the treatment of PTC with TOETVA. Patients of class C need more assistance of suspension system, would experience higher scores of VAS, and higher ratios of mandibular swell compared with class A and B.