Transoral endoscopic thyroidectomy by vestibular approach in Viet Nam: surgical outcomes and long-term follow-up

Effectiveness and feasibility of nerve real-time monitoring and intermittent monitoring in endoscopic thyroidectomy: a multicenter retrospective cohort study of 1621 patients

BACKGROUND

Protecting recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN), a crucial indicator for assessing the quality of thyroid surgery, poses a challenge in endoscopic thyroidectomy. The aim of this study was to investigate the effectiveness and feasibility of nerve real-time monitoring and intermittent monitoring in endoscopic thyroidectomy.

METHODS

In this retrospective cohort study, patients underwent endoscopic thyroidectomy were included, and the characteristics and outcomes of real-time monitoring and intermittent monitoring groups were compared. Thereafter, the outcomes of four surgical types (unilateral lobectomy, total thyroidectomy, unilateral lobectomy + lymph node dissection (LND), and total thyroidectomy + LND) were compared in both groups.

RESULTS

A total of 1621 patients were enrolled. Compared to intermittent monitoring group, real-time monitoring group significantly shortened operation durations in the four surgical types (30.8±6.1 min vs. 35.7±5.7 min, 54.7±4.4 min vs. 59.1±5.2 min, 39.3±4.6 min vs. 42.0±4.7 min, 59.1±4.9 min vs. 66.0±5.8 min, respectively). As for surgical complications, compared to intermittent monitoring group, real-time monitoring group had lower rates of transient vocal cord paralysis among the four surgical types (0.0 vs. 3.3%, 0.0% vs. 4.0%, 0.8 vs. 3.2%, 2.8 vs. 6.7%, respectively), and lower rates of EBSLN injury (1.1 vs. 4.4%, 0.0 vs. 12.0%, 0.8 vs. 3.8%, 0.9 vs. 4.8%, respectively). Clinicopathologic characteristics and postoperative inflammatory reactions were similarly paralleled in both groups.

CONCLUSION

Implementation of real-time monitoring in endoscopic thyroidectomy effectively protects the RLN and EBSLN while shortening operation duration, demonstrating its feasibility and efficacy in enhancing nerve protection and surgical efficiency.

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.

Efficacy of HIFU for the treatment of benign thyroid nodules: a systematic review and meta-analysis

OBJECTIVE

Thyroid nodules are common and sometimes associated with cosmetic issues. Surgical treatment has several disadvantages, including visible scarring. High-intensity focused ultrasound (HIFU) is a recent noninvasive treatment for thyroid nodules. The present study aims to evaluate the effectiveness and safety of HIFU for the treatment of benign thyroid nodules.

METHODS

We searched PubMed, Embase, and Cochrane Library for studies evaluating the outcomes of HIFU for patients with benign thyroid nodules. We conducted a meta-analysis by using a random effects model and evaluated the volume reduction ratio, treatment success rate, and incidence of treatment-related complications.

RESULTS

Thirty-two studies were included in the systematic review. Only 14 studies were used in the meta-analysis because the other 18 involved data collected during overlapping periods. The average volume reduction ratios at 3, 6, and 12 months after treatment were 39.02% (95% CI: 27.57 to 50.47%, I2: 97.9%), 48.55% (95% CI: 35.53 to 61.57%, I2: 98.2%), and 55.02% (95% CI: 41.55 to 68.48%, I2: 99%), respectively. Regarding complications, the incidences of vocal cord paresis and Horner's syndrome after HIFU were 2.1% (95% CI: 0.2 to 4.1%, I2: 14.6%) and 0.7% (95% CI: 0 to 1.9%, I2: 0%), respectively.

CONCLUSIONS

HIFU is an effective and safe treatment option for patients with benign thyroid nodules. However, the effects of HIFU on nodules of large sizes and with different properties require further investigation. Additional studies, particularly randomized controlled trials involving long-term follow-up, are warranted.

CLINICAL RELEVANCE STATEMENT

Surgical treatment for thyroid nodules often results in permanent visible scars and is associated with a risk of bleeding, nerve injury, and hypothyroidism. High-intensity focused ultrasound may be an alternative for patients with benign thyroid nodules.

KEY POINTS

• The success rate of HIFU treatment for thyroid nodules is 75.8% at 6 months. Average volume reduction ratios are 48.55% and 55.02% at 6 and 12 months. • The incidence of complications such as vocal fold paresis, Horner's syndrome, recurrent laryngeal nerve palsy, hypothyroidism, and skin redness is low. • HIFU is both effective and safe as a treatment for benign thyroid nodules.

Safety and Efficacy of Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Conventional Open Thyroidectomy: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the safety and efficacy of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus conventional open thyroidectomy (COT) for some thyroid diseases.

MATERIALS AND METHODS

Databases PubMed, Embase, and Web of Science were searched. Full-text English papers that described TOETVA and COT for people with thyroid diseases were included. Randomized, nonrandomized, controlled, and uncontrolled trials were all included. Extracted data included population characteristics and intraoperative and postoperative complications.

RESULTS

A total of 2 randomized controlled trials and 10 retrospective studies, including 3048 patients, were included in the meta-analysis. Meta-analysis results suggested that the intraoperative conditions and postoperative complication rates did not differ significantly between the two groups. However, in the TOETVA group, there is a slightly longer operative time [weighted mean difference (WMD): 73.64; 95% CI: 49.34 to 97.94; P < 0.0001], drainage (WMD: 91.0; 95% CI: 35.52 to 146.48; P = 0.001), and hospital stay (WMD: 0.28; 95% CI: 0.18 to 0.38; P < 0.0001).

CONCLUSION

For most of the benign thyroid nodules and selected patients with papillary thyroid cancer, TOETVA seems to be as feasible and safe as COT.

A novel hybrid approach for "Scarless" (at the neck) lateral neck dissection for papillary thyroid carcinoma: A case series and literature review

Lateral neck dissection (LND) is a necessary treatment for thyroid cancer with lateral lymph node metastasis. However, the defect created during open surgery leaves a visible scar on the neck. With advancements in surgical technology, many robotic and endoscopic surgical techniques have been reported as alternatives to open surgery. In this study, we present a case series demonstrating the successful application of a novel hybrid approach for endoscopic LND and a review of different surgical approaches for "scarless" (at the neck) LND. We performed endoscopic LND via a combined chest and transoral approach in 24 patients between January 2021 and March 2022. The surgery was completed successfully in all patients with an average operation time of 298.1 ± 72.9 min. The numbers of positive/retrieved lymph nodes at levels II, III-IV, and VI were 0.7 ± 0.9/8.4 ± 4.1, 3.6 ± 2.7/19.5 ± 6.8, and 4.9 ± 3.9/10.3 ± 4.5, respectively. Complications included transient hypoparathyroidism in 10 patients, transient recurrent laryngeal nerve injury in 1 patient, internal jugular vein (IJN) injury in 1 patient, IJN sacrifice due to cancer invasion in 1 patient, and chyle leak in 1 patient, and no cases of tumor recurrence were observed during follow-up. The present case series indicates that the combined chest and transoral approach is feasible and effective for performing LND. Our review of different approaches for "scarless" (at the neck) LND identified advantages and disadvantages for all techniques. Our novel approach has unique advantages, and thus, it can provide an ideal surgical procedure for specific papillary thyroid carcinoma patients.

Safety and feasibility of the transoral endoscopic thyroidectomy vestibular approach with neuroprotection techniques for papillary thyroid carcinoma

BACKGROUND

This study aimed to evaluate the feasibility and safety of the trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) with neuroprotection techniques for the surgical management of papillary thyroid carcinoma (PTC).

METHODS

Patients with PTC who underwent TOETVA between December 2016 and July 2020 were included in this study, and their relevant clinical characteristics, operational details, and surgical outcomes were reviewed and extracted from their medical records for further analysis.

RESULTS

A total of 75 patients successfully underwent TOETVA with zero conversions. Unilateral lobectomy with isthmectomy and total thyroidectomy were completed for 58 and 17 patients, respectively, all using our unique neuroprotective procedure and ipsilateral central neck dissection (CND). The mean number of retrieved lymph nodes versus positive lymph nodes was 6.8 ± 3.7 vs. 1.5 ± 2.3. Postoperative complications included three cases of transient superior laryngeal nerve (SLN) palsy (4.0%), five cases of transient recurrent laryngeal nerve (RLN) palsy (6.7%), 14 cases of transient hypoparathyroidism (18.7%), two cases of numb chin (2.7%) and two cases of flap perforation (2.7%). The follow-up period for patients with PTC lasted for 15.6 ± 10.9 months, during which no other complications or tumor recurrence were observed.

CONCLUSION

TOETVA can be safely performed for patients with PTC with satisfactory results during the short-term follow-up period. Our neuroprotection techniques can be integrated into TOETVA, which is worth recommending for PTC patients who desire better cosmetic surgical outcomes.

Comparison of Transoral Endoscopic Thyroidectomy Vestibular Approach and Conventional Open Thyroidectomy in Benign Thyroid Tumors

Conventional open thyroidectomy remains the standard treatment of surgery for benign thyroid tumors but leaves a permanent scar in the neck. We conducted this study to compare the surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus conventional open thyroidectomy (COT), and thence analyze the safety and viability of this approach. Seventy-eight patients who had undergone either COT or TOETVA from 2020 to 2021 in our institution to treat benign thyroid tumors were prospectively studied. Outcomes between the two groups were analyzed, including time of operation, blood loss, hospital stay, postoperative complications, and level of satisfaction. A total of 78 patients, in which TOETVA was applied to 47 patients and COT thyroid surgery was applied to 31 patients, participated in this study. COT has a shorter operative time (59.8 ± 10.8 min versus 102.3 ± 34.9 min, p < .001). TOETVA is less painful postoperatively (visual analog scale score on day 4 of 1.1 ± 1.2 versus 1.8 ± 0.7, p < .001). There were no significant differences between TOETVA and COT groups regarding incidences of transient recurrent laryngeal nerve (RLN) injury (10.6% and 6.5%, respectively, p = .697) and both transient and permanent hypoparathyroidism (8.5% versus 3.5%, p = .644 with transient and 0% versus 6.7%, p = .166 with permanent). Other complications were comparable between two arms such as bleeding, seroma, and infection. At 3 months after surgery, the TOETVA group had the significantly higher proportion of the very satisfied level than the COT group (80.9% versus 35.4%, p < .001). TOETVA in patients with favorable features is a safe, viable alternative to open thyroidectomy regarding postoperative outcomes and provide higher satisfaction after surgery in the long term.