Endoscopic thyroidectomy via the combined trans-oral and chest approach for cT1-2N1bM0 papillary thyroid carcinoma

Safety and outcomes of gasless transoral endoscopic thyroidectomy and lateral neck dissection for papillary thyroid cancer

PURPOSE

Entirely endoscopic surgery via an oral approach is a novel surgical procedure that results in favorable cosmetic outcomes for papillary thyroid cancer (PTC) patients. However, technical constraints have limited the utilization of a single approach for neck lymph node dissection. The aim of this study was to report the safety and outcomes of a novel gasless transoral endoscopic thyroidectomy and lateral neck dissection (LND) procedure for papillary thyroid cancer patients with lateral lymph node metastases.

METHODS

This study reported a newly designed suspension system and trocars for a novel surgical procedure of gasless transoral endoscopic thyroidectomy and LND. Patients who underwent gasless transoral endoscopic thyroidectomy and LND at the Department of Thyroid Surgery, the First Affiliated Hospital of the University of Science and Technology of China, between January 2022 and December 2023 were included. This study documented the demographic information, operative details, postoperative outcomes, and rates of postoperative complications among the patients included in the analysis.

RESULTS

A total of 43 PTC patients, including 6 male patients and 37 female patients with an average age of 30.53 years, were included in the study. The average number of examined lymph nodes was 33.81, including an average of 5.21 examined lymph nodes at level II. The mean operative time was 293.05 min, with an average postoperative hospital stay of 5.21 days. One patient had a history of chyle leakage, three had transient recurrent laryngeal nerve injury, and four experienced transient hypoparathyroidism after surgery.

CONCLUSION

Our innovative design of gasless transoral endoscopic thyroidectomy and LND surgery prevents incisional scars and shows promising safety and outcomes in papillary thyroid cancer patients with lateral lymph node metastases. This entirely endoscopic approach represents a viable alternative surgical option for selected cases.

Implications of five endoscopic and conventional open surgery on lateral neck dissection outcomes in patients with papillary thyroid carcinoma: a network meta-analysis and systematic review

OBJECTIVES

The efficacy and safety of different surgical approaches to thyroidectomy with lateral neck dissection remain unclear. This study aims to evaluate five endoscopic and open techniques for thyroidectomy with lateral neck dissection and identify the most effective method.

METHODS

A systematic search was conducted in PubMed, Web of Science, Embase, and the Cochrane Library for studies comparing different surgical approaches across multiple outcome indicators. The risk of bias was analyzed, and publication bias was assessed using funnel plot asymmetry tests. Both global and local inconsistency tests were performed to evaluate the agreement between direct and indirect comparisons. Pairwise and network meta-analyses were conducted for each outcome, with approaches ranked using Surface Under the Cumulative Ranking (SUCRA) values and curves.

RESULTS

A total of 1251 patients across 13 clinical studies were included in the analysis. No significant statistical differences were found among the approaches for lymph node dissection and postoperative recurrence rates. The bilateral axillary breast approach yielded the highest number of lymph nodes (SUCRA value: 0.762). The suprasternal fossa approach had the lowest postoperative recurrence rate (SUCRA: 0.657) and performed well in metastatic lymph node dissection (SUCRA: 0.679). The bilateral axillary breast approach significantly reduced postoperative complication rates compared to the open and transaxillary approaches (mean differences: - 1.88 and - 0.23; 95% confidence intervals: - 3.87 to - 0.46 and - 0.62 to 0.29, respectively) and was the most effective in minimizing complications (SUCRA: 0.910). Open surgery demonstrated a significantly shorter operative duration.

CONCLUSION

Endoscopic approaches are viable and safe alternatives to open surgery, with fewer postoperative complications, albeit at the cost of longer operative durations.

Learning curve for the combined trans-oral and chest approach to endoscopic selective neck dissection: a cumulative sum (CUSUM) analysis

BACKGROUND

The combined trans-oral and chest approach is a novel technique for endoscopic selective neck dissection (SND), with satisfactory oncological safety and cosmetic results. However, this hybrid approach is difficult, and the learning curve remains unclear. In this study, we aimed to evaluate the short-term outcomes for this hybrid approach, and to define the associated learning curve.

METHOD

Clinical data and surgical outcomes of 58 PTC patients who underwent endoscopic SND via combined trans-oral and chest approach between September 2020 and April 2023 were retrospectively reviewed. The cumulative sum (CUSUM) sequential analysis technique is used to detect change, and has been applied for the evaluation of learning curves.

RESULTS

The study population included 58 patients (40 females, 18 males), with mean age of 38.9 ± 12.7 years and average body mass index of 22.6 ± 4.8 kg/m2. In all cases, the same surgical team performed endoscopic SND via combined trans-oral and chest approach. The numbers of positive/retrieved lymph nodes were 4.3 ± 3.2/27.8 ± 8.4 in the lateral compartment and 4.0 ± 3.5/8.4 ± 5.1 in the central compartment. The learning curve was evaluated in terms of an initial phase (20 cases) and a mature phase (38 cases). Operative time was longer during the initial phase, compared to the mature phase (375.2 vs. 274.6 min, p = 0.002). The frequency of operative complications was higher during the initial phase, compared to the mature phase (85% vs. 55.3%, p = 0.048).

CONCLUSIONS

After the experience acquired using endoscopic SND via combined trans-oral and chest approach to treat PTC in 20 patients, the number of complications decreased significantly. Compared to data collected for the initial phase, data collected for the mature phase showed trends toward decreased operating time.

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.

Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models, part II: anatomy of relevance to surgeons operating splenic flexure cancer

BACKGROUND

The splenic flexure is irrigated from two vascular areas, both from the middle colic and the left colic artery. The challenge for the surgeon is to connect these two vascular areas in an oncological safe procedure.

MATERIALS AND METHODS

The vascular anatomy, manually 3D reconstructed from 32 preoperative high-resolution CT datasets using Osirix MD, Mimics Medical and 3-matic Medical Datasets, were exported as STL-files, video clips, stills and supplemented with 3D printed models.

RESULTS

Our first major finding was the difference in level between the middle colic and the inferior mesenteric artery origins. We have named this relationship a mesenteric inter-arterial stair. The middle colic artery origin could be found cranial (median 3.38 cm) or caudal (median 0.58 cm) to the inferior mesenteric artery. The lateral distance between the two origins was 2.63 cm (median), and the straight distance 4.23 cm (median). The second finding was the different trajectories and confluence pattern of the inferior mesenteric vein. This vein ended in the superior mesenteric/jejunal vein (21 patients) or in the splenic vein (11 patients). The inferior mesenteric vein confluence could be infrapancreatic (17 patients), infrapancreatic with retropancreatic arch (7 patients) or retropancreatic (8 patients). Lastly, the accessory middle colic artery was present in ten patients presenting another pathway for lymphatic dissemination.

CONCLUSION

The IMV trajectory when accessible, is the solution to the mesenteric inter-arterial stair. The surgeon could safely follow the IMV to its confluence. When the IMV trajectory is not accessible, the surgeon could follow the caudal border of the pancreas.