Minimally invasive video-assisted thyroidectomy versus conventional thyroidectomy: a cost-effective analysis

Remote Access Thyroid Surgery: A Review of Literature

Since the first description of endoscopic thyroid lobectomy in 1997, a variety of techniques have been developed to avoid the visible cervical scar conventionally been associated with thyroidectomy. These "remote access" approaches, which typically use either endoscopic or robotic instrumentation, have successfully avoided the anterior neck scar, which has a measurable impact on the patient's quality of life (Graves and Suh Surgery 168(5):845-850, 2020; Sakorafas World J Surg 34(8):1793-1804, 2010). The main advantage of these techniques is better cosmesis compared to conventional transcervical approaches (Graves and Suh Surgery 168(5):845-850, 2020) However, these techniques have failed to gain widespread acceptance in the surgical community because of the technical challenges, scepticism about oncological safety and cost factors. This review presents an overview of the various methods of remote access thyroid surgery (RATS) and also evaluates the selection criteria, oncological efficacy, training requirements and key advantages of this technique.

Minimally invasive video-assisted thyroidectomy (MIVAT)

Background

Minimally invasive video-assisted thyroidectomy (MIVAT) was first described in 1999 and it has become a widespread technique performed worldwide. Although initially limited to benign thyroid nodules, MIVAT was progressively adopted for all types of thyroid diseases, while remaining within the selection criteria. It is reported that, in selected cases, MIVAT is comparable to standard open thyroidectomy (SOT) in terms of oncologic radicality, time, costs and complications rate, with the advantage of a better cosmetic result and a lower post-operative pain.

Methods

The authors conducted a retrospective analysis about patients who underwent MIVAT between 1998 and 2019 in the Endocrine Surgery Unit of the University Hospital in Pisa. Indications and contraindications are mentioned and strictly followed.

Results

Total thyroidectomy was performed in 1,862 cases (69%) and hemithyroidectomy was performed in 763 cases (28.3%). Conversion occurred in 43 cases (1.6%). In 188 cases (7%) a postoperative transient hypoparathyroidism was reported, whereas definitive hypoparathyroidism was reported in 12 cases (0.4%). Thirty-eight patients (1.4%) suffered from a definitive postoperative recurrent laryngeal nerve palsy. No definitive bilateral recurrent laryngeal nerve palsy occurred.

Conclusions

From our multi-years' experience which spreads over 20 years, we can reaffirm the concept that MIVAT is a safe procedure which is not burdened by an increase complications rate or additional costs. Furthermore, this technique offers advantages in terms of cosmetic results and post-operative pain.

Perioperative practices in thyroid surgery: An international survey

BACKGROUND

Perioperative practices in thyroid surgery vary from one specialty, institution, or country to the next. We evaluated the preoperative, intraoperative, and postoperative practices of thyroid surgeons focusing on preoperative ultrasound, vocal cord evaluation, wound drains, and hospitalization duration, among others.

METHODS

A survey was sent to 7 different otolaryngology and endocrine/general surgery associations.

RESULTS

There were 965 respondents from 52 countries. Surgeon-performed ultrasound is practiced by more than one third of respondents. Otolaryngologists perform preoperative and postoperative vocal cord evaluation more often than endocrine/general surgeons (p < .001). Sixty percent of respondents either never place drains or place drains <50% of the time in thyroid lobectomies (43% for total thyroidectomies). Outpatient thyroid surgery is most frequently performed by surgeons in the United States (63%).

CONCLUSION

This epidemiologic study is the first global thyroid survey of its kind and clearly demonstrates the variability and evolving trends in thyroid surgery. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1296-1305, 2017.

Minimally invasive video-assisted thyroidectomy: reflections after more than 2400 cases performed

BACKGROUND

The minimally invasive video-assisted approach was developed for primary hyperparathyroidism in 1997 and the year after for thyroid disease. Since then, the technique has been adopted worldwide, and indications moved from the initial benign disease to low-risk and intermediate-risk carcinoma, demonstrating a level of oncologic radicality comparable to the conventional open approach when inclusion criteria are strictly respected.

METHODS

Between 1998 and 2014, 2412 minimally invasive video-assisted thyroidectomies (MIVAT) were performed in our department. The indication for surgery in 825 patients (34.3 %) was a malignant tumor, in particular, a papillary carcinoma in 800 patients. Among them, 528 patients operated on between 2000 and 2009 had a mean complete follow-up of 7.5 (standard deviation, 2.3) years.

RESULTS

A total thyroidectomy was performed in 1788 patients (74.1 %) and a hemithyroidectomy in 564 (23.4 %). Also performed was central compartment lymphadenectomy in 31 patients (1.3 %) and parathyroidectomy for the presence of a solitary parathyroid adenoma in 29 (1.2 %). Mean duration of the procedure was 41 (standard deviation, 14) minutes. After a mean follow-up of 7. 5 years, 528 patients who underwent MIVAT for low-risk or intermediate-risk papillary carcinoma presented a cure rate of 85 % (undetectable thyroglobulin), comparable with the 80 % rate reported in patients who had undergone open thyroidectomy during the same period.

CONCLUSIONS

After a long experience and a considerable number of procedures performed in a single center, MIVAT is confirmed as a safe operation, with a complication rate comparable with open thyroidectomy. MIVAT offers a cure rate for the treatment of low-risk and intermediate-risk malignancies that is comparable with an open procedure when inclusion criteria are strictly respected.

Systematic Review of the Quality of Economic Evaluations in the Otolaryngology Literature

Objective

To evaluate the quality of economic evaluations published in the otolaryngology—head and neck surgery literature, which will identify methodologic weaknesses that can be improved on in future studies. A secondary objective is to identify factors that may be associated with higher quality economic evaluations.

Data Sources

Ovid Medline (including PubMed), Embase, and the National Health Services Economic Evaluation databases.

Review Methods

A systematic search was performed of the aforementioned databases according to PRISMA guidelines. The search was performed using otolaryngology key terms combined with the term cost. A manual search of 36 otolaryngology journals was also performed. Included studies were graded using the Quality of Health Economics Studies instrument, a 16-item checklist providing a total quality score of 100.

Results

Fifty studies were identified, and the mean quality rating was 54.7/100 (SD = 30.9). The most commonly omitted methodology components were a lack of discussion of limitations and biases, failure to address the negative outcomes of examined interventions, and a lack of a robust sensitivity analysis. Higher quality economic evaluations were associated with a higher journal impact factor (correlation coefficient r = 0.62, P = .0001), having an author with a PhD in health economics ( r = 0.56, P = .0001), and having authors who have published prior economic evaluations ( r = 0.46, P = .001).

Conclusion

Results from this study have demonstrated that there are several methodological domains that can be improved on when publishing economic evaluations in the otolaryngology literature. Authors should follow recommended methodological and reporting guidelines to optimize the transparency and accuracy of the overall conclusions.

[Minimally invasive video-assisted thyroidectomy: establishment in a thyroid center]

BACKGROUND

This study retrospectively evaluated a series of patients who underwent minimally invasive video-assisted thyroidectomy (MIVAT) during the introduction stage of this surgical technique at the Martha-Maria Hospital in Nuremberg.

PATIENTS AND METHODS

The eligibility criteria for MIVAT were a thyroid volume < 25 ml, nodules < 30 mm, no thyroiditis, no preoperative evidence of carcinoma and no previous neck surgery. A retrospective evaluation was performed together with a control group of patients who underwent conventional thyroid surgery during the same time period and included a follow-up for general patient satisfaction and cosmetic results.

RESULTS

Between August 2008 and July 2009 a total of 55 patients underwent MIVAT including 8 conversions to open surgery and 45 patients who underwent conventional surgery served as matched controls. No significant differences in terms of perioperative complication rates were found (e.g. recurrent laryngeal nerve palsy, hypocalcemia or secondary hemorrhage). The mean operating time was significantly longer in the MIVAT group (96.8 ± 3.7 min vs. 69.8 ± 2.3 min, p = 0.001) whereas a significant decrease in the mean operating time for hemithyroidectomy after 5 months was observed (98.1 ± 3.77 min vs. 76.0 ± 4.98 min, p = 0.013). Patients in the MIVAT group were more satisfied with the cosmetic outcome (8.5 ± 0.3 vs. 8.2 ± 0.2, p = 0.05) as well as with the overall surgical procedure (9.0 ± 0.3 vs. 8.6 ± 0.2, p = 0.02).

CONCLUSION

During introduction of the MIVAT procedure a learning effect can be observed which is hallmarked by a decrease in operating time and conversion rate to open surgery. Moreover, no significant differences in terms of main postoperative complications were found so that MIVAT can be considered a safe and feasible technique under the conditions of correct eligibility criteria.

Minimally invasive compared with conventional thyroidectomy for nodular goitre

Since minimally invasive thyroidectomy was introduced in 1997, different surgical approaches to the thyroid have been described: the minimal neck incision and the anterior chest, areolar breast or axillary access. Whereas conventional open thyroidectomy is suitable for any thyroid disease, minimal neck incision thyroidectomy or extracervical scarless neck thyroidectomy are limited to small-volume disease. In 11 prospective randomized studies and six systematic reviews, minimally invasive video-assisted thyroidectomy via a central or lateral neck approach afforded better cosmesis in the first 3 months than conventional open thyroidectomy, with less postoperative pain for the first 48 h. Surgical morbidity did not differ in these limited studies. No head-to-head comparison is available for extracervical scarless neck thyroidectomy and conventional open thyroidectomy. Extracervical scarless neck thyroidectomy caused more postoperative pain and gave rise to complications not seen with minimal neck incision thyroidectomy or conventional open thyroidectomy. In the absence of evidence to the contrary, conventional open thyroidectomy continues to remain the gold standard for any nodular goitre.

The cost of vocal fold paralysis after thyroidectomy

OBJECTIVES/HYPOTHESIS

To determine the added cost of care and analyze risk factors in patients who suffered vocal fold paralysis (VFP) after thyroid surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Seventy-six patients who developed unilateral or bilateral VFP after thyroidectomy from 2005 through 2009, and a control group of 238 patients who underwent the same surgery without developing VFP, were compared on hospital charges, hospital and intensive care unit (ICU) length of stay (LOS), unplanned intubation, tracheotomies, respiratory failure, readmission, death, pathology, body mass index (BMI), gland weight, swallowing studies, and need for indwelling feeding tube. Differences between outcomes for unilateral VFP patients versus bilateral VFP patients were analyzed. Rate of recovery of VFP and need for further surgery after thyroidectomy were described.

RESULTS

Patients who developed VFP after thyroidectomy had significantly greater rates of all the parameters listed above. BMI, gland weight, and pathology (malignant vs. benign) were not significantly different between the two groups. VFP group underwent additional surgeries after thyroidectomy related to the VFP. Thirty-three% of unilateral VFP patients with long-term follow-up recovered fully. Patients with bilateral VFP with long-term follow-up, had recovery of one vocal fold in 50% and both in 23% of cases.

CONCLUSIONS

Patients with unilateral or bilateral VFP after thyroidectomy experience significantly more morbidity and incurred significantly more health care charges after surgery than similar patients who do not have VFP after thyroidectomy. The likelihood of VFP was not related to malignancy, BMI, or thyroid gland weight in this series.

Well differentiated thyroid carcinoma: current treatment

OPINION STATEMENT

Well differentiated thyroid carcinoma (WDTC) is a relatively common malignancy accounting for an estimated 37,000 thousand cases in the United States in 2009 [1]. WDTC also has a generally high 5 year survival rate that correlates with age. Papillary thyroid carcinoma (PTC) greater than 1 cm is best managed by total thyroidectomy. Thyroid lobectomy and isthmusectomy may be adequate for unifocal PTC less than 1 cm in patients without negative prognostic factors. Central compartment and possible lateral neck dissections should be performed when nodal metastases are present in the respective nodal basins. Post-operatively, radioactive iodine ablation with (131)I followed by thyroid stimulating hormone (TSH) suppression is indicated in certain patients to improve locoregional control and reduce recurrence.