Hybrid techniques and patients' safety in implementing transoral sublingual thyroidectomy

Antibiotic Use Can be De-escalated During Transoral Endoscopic Thyroidectomy: A Bacterial Culture-Based Study

Objective: To explore the possibility of reducing the use of antibiotics after transoral endoscopic thyroidectomy vestibular approach (TOETVA). Method: A retrospective study was conducted on patients with thyroid tumors who were diagnosed and underwent surgical treatment at our hospital from 2022 to 2024. Patients diagnosed with T1-stage differentiated thyroid cancer or a benign retrosternal goiter <4 cm with cosmetic needs were included in the current study. Drainage fluid was cultured on the first postoperative day. The differences in infection rates, bacterial culture results, and antibiotic use between patients with clean incisions and those with clean-contaminated incisions were compared. Results: There were no signs of infection in the postoperative drainage fluid or delayed healing due to surgical cavity infection. There was no significant difference in the incidence of postoperative infection or the results of bacterial culture between clean and clean-contaminated incisions or between the groups with and without antibiotic use for clean-contaminated incisions. The proportion of pathogenic bacteria in clean-contaminated incisions was significantly greater than that in clean incisions, while bacteria cultured in clean incisions were mostly common colonizing bacteria. Conclusion: Pathogenic bacteria may indeed exist in the operative cavity of the TOETVA regardless of whether antibiotics are used during the perioperative period. With adequate drainage, the absence of the routine administration of antibiotics or only preventive antibiotics during the perioperative period does not increase the infection rate.

The Effectiveness and Quality of Life Outcomes by Transoral Endoscopic Vestibular Thyroidectomy Using Intraoperative Indocyanin Green Fluorescence Imaging and Neuromonitoring—A Cohort Study

Background: Transoral endoscopic vestibular thyroidectomy (TOEVT), a variant of natural orifice transluminal endoscopic surgery, offers a scar-less thyroid to young females. However, few studies have compared the effectiveness and quality of life (QoL) outcomes of the TOEVT with open thyroidectomy (OT). This is the first study in the Middle East and North Africa region that compares the effectiveness, safety profile and QoL outcomes between TOEVT with OT. Methods: We reviewed the medical records of consecutive patients with TOETV and OT at Zulekha Hospital Sharjah and Dubai United Arab Emirates, between 1 January 2019 and 1 April 2021. The data for demographics, type of surgery, operative time, blood loss, post-operative nodule size, hospital stay and post-operative complications were analyzed. We used an SF-36 questionnaire pre- and postoperatively for the assessment of QoL in both groups. Findings: Out of a total of 41 OT and 32 TOEVT procedures, 59 patients (31 TOEVT and 28 OT) fulfilled the inclusion criteria. There were 45 women and 14 men with an average age of 41 years. The mean operating time was 126 min in TOEVT and 96 min in OT (p = 0.000). The mean thyroid size was 5.55 cm in TOEVT and 8.76 cm in OT (p = 0.000). Lastly, the mean intraoperative blood loss was 39 cc and 95.7 cc in TOEVT and OT, respectively (p = 0.001). There was one temporary hypocalcemia and seroma in TOEVT, four cases of temporary hypocalcemia and one with minor bleeding in OT. The post-operative QoL significantly improved in all patients. However, the QoL improved more significantly in the TOEVT group for bodily pain, vitality, role emotions and cosmetic concerns (p = 0.000). Conclusion: The safety profile and effectiveness of the TOEVT is comparable to the OT procedure. However, TOEVT has an additional advantage of being scarless and offers a better QoL.

A comparative study of two robotic thyroidectomy procedures: transoral vestibular versus bilateral axillary-breast approach

Objective

To compare the surgical outcomes between the transoral-vestibular robotic thyroidectomy (TOVRT) and bilateral axillo-breast approach robotic thyroidectomy (BABART).

Methods

A total of 99 patients with papillary thyroid carcinoma but no distant metastasis were enrolled in this study from May 2020 to April 2021. Lobectomy or total thyroidectomy with central lymph node dissection were performed in all cases. All 99 patients were received an ultrasound guided fine needle aspiration biopsy prior to surgical intervention, out of which 49 patients underwent TOVRT, while rest 50 patients underwent BABART. During the procedure, intraoperative neuromonitoring system was used and all recurrent laryngeal nerves (RLNs) were preserved, additionally for TOVRT procedure, three intraoral ports or right axillary fold incision was used to allow for fine countertraction of tissue for radical oncological dissection. The clinical data including age, gender, height, weight, BMI, primary tumor size, number of central lymph node removed, central lymph node metastasis, operating time, total hospital stays, postoperative hospital stays, total postoperative drainage volume, postoperative pain score, cosmetic effect and complications were recorded and analyzed.

Results

There were no significant differences in gender, height, weight, BMI and removed central lymph nodes between the two groups (P > 0.05). Patients accepted TOVRT were younger and had smaller primary tumor size than those who accepted BABART. The TOVRT group had a longer surgical time than the BABART group, but with smaller postoperative drainage volume and superior cosmetic effect (under visual analogue scale, VAS) (P < 0.05). There was no significant difference in lymph node metastasis, hospital stay and postoperative pain score (under numerical rating scale, NRS) between the two groups (P > 0.05). Last but not least, certain peculiar complications were observed in TOVRT group: paresthesia of the lower lip and the chin (one case), surgical site infection (one case) and skin burn (one case).

Conclusion

Transoral-vestibular robotic thyroidectomy is safe and feasible for certain patients, which could be considered an alternative approach for patients who require no scarring on their neck.

Impact of Transoral Endoscopic Vestibular Approach Thyroidectomy on Pathologic Assessment

CONTEXT.—

Since 2016, transoral endoscopic thyroid resection with vestibular approach (TOETVA) has become increasingly performed in the United States. Although guidelines for the procedure are evolving, indeterminate and malignant preoperative cytopathologic diagnoses are not a contraindication. There are limited data related to the pathologic examination of these specimens.

OBJECTIVE.—

To examine the clinicopathologic features of TOETVA specimens with particular attention to limitations of interpretation of pathologic parameters and final diagnosis.

DESIGN.—

We reviewed age, sex, preoperative imaging and cytologic diagnoses, surgical pathology, and clinical follow-up data in TOETVA resections at our institution between March 2016 and December 2019.

RESULTS.—

Fifty cases of TOETVA were identified, comprising 48 women and 2 men with a mean age of 47 years. Preoperative cytologic diagnoses were available in 47 cases and included 19 nondiagnostic/benign (Bethesda I/II), 24 follicular lesion of undetermined significance/suspicious for follicular neoplasm (Bethesda III/IV), and 4 suspicious/malignant diagnoses (Bethesda V/VI). Thirty-four cases (68%) among the surgical resection specimens showed disruption and/or fragmentation. Thirty-nine cases were negative for carcinoma, including hyperplasias and benign/indolent neoplasms. Eleven cases exhibited papillary thyroid carcinoma. Final diagnoses were reached in all disrupted/fragmented cases. In 2 cases of papillary thyroid carcinoma, tumor size, microscopic extrathyroidal extension, and margin status could not be determined.

CONCLUSIONS.—

A significant proportion of TOETVA specimens are disrupted/fragmented, which can compromise information about tumors, including size, number, margin status, and microscopic extrathyroidal extension. Given that these parameters inform treatment and follow-up, this should be considered when selecting patients for TOETVA.

Transoral and submental thyroidectomy using intraoperative nerve stimulation and indocyanin green fluorescence imaging

There is a recent proliferation of clinical studies about the minimally invasive scarless thyroid surgery. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) carries a great potential for being scarless surgery via a short dissection flap. However, TOETVA has limitations in extracting larger thyroid tumours via the transoral vestibular incision and due to its potential damage to the branches of the mental nerve. The rapidly evolving surgical innovations have now introduced transoral and submental thyroidectomy (TOaST) approach that allows extraction of large thyroid tumours with less flap dissection and minimal postoperative pain. We present a 39-year-old man with a large multinodular goitre. The patient was euthyroid with moderate to severe compression symptoms of difficulty in breathing and swallowing. We performed a TOaST procedure using intraoperative neuromonitoring and indocyanin green fluorescence imaging with an uneventful recovery. This is a first case report from the middle east region that will pave the way to large clinical trials to determine the efficacy and safety of TOaST.

What is the Appropriate Nodular Diameter in Thyroid Cancer for Extraction by Transoral Endoscopic Thyroidectomy Vestibular Approach Without Breaking the Specimens? A Surgicopathologic Study

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique with better cosmetic results. However, extraction of a large malignant thyroid nodule from the central incision of TOETVA necessitates breaking it into pieces to avoid mental nerve injury, a situation that may violate a proper oncological surgery. In this study, we sought the appropriate nodular diameter in thyroid cancer to be removed in an intact status through the central incision of the TOETVA technique. A total of 27 cases of thyroid nodules were operated using the TOETVA technique from Aug 2016 to July 2017. Excluding 10 benign goiters, the specimens of 17 thyroid cancer cases were divided into intact (group T, n=7) and fragmented (group F, n=10), with a median nodular diameter of 18.35 and 30.30 mm, respectively. Receiver operating characteristic (ROC) curve analysis revealed that the safest nodular diameter is 20 mm, with 100% sensitivity and 87.5% specificity.

Transoral Endoscopic Thyroidectomy: A Systematic Review of the Practice So Far

Background and Objectives

Thyroid disease largely affects young females, but the incidence is also increasing among males. In an effort to avoid the scarring of the neck that is synonymous with conventional thyroidectomy, endoscopic techniques have been developed over the years. The transoral endoscopic approach is the latest of these innovations that promises a scarless surgical outcome. This review evaluates whether this technique is safe and feasible in live patients and outlines the outcomes in published literature so far.

Database

PubMed, Medline, BioMed Central, Cochrane Library, OVID and Web of Science were systematically searched by using a Medical Subject Heading (MeSH)-optimized search strategy. The selection of papers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines after setting strict inclusion and exclusion criteria. Sixteen studies were included in the final analysis.

Discussion

This systematic review presents cases of 785 patients. Surgeons in 15 of the studies used a completely vestibular approach, whereas those in the remaining 2 used the floor of the mouth for primary access. Conversion to open surgery took place in 1.3%. In total, 4.3% of patients experienced transient laryngeal nerve palsy, whereas 0.1% had permanent recurrent incidences of the condition. Transient hypocalcemia occurred in 7.4% of cases, with no recorded permanent cases. Carbon dioxide embolism occurred in 0.6% of cases, and another 0.6% had a deep-seated neck infection. The complication rates within the review were deemed acceptable and the overall technique feasible. A prospective randomized controlled trial was proposed to compare this technique with conventional thyroidectomy.