Patient Eligibility for Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in an Endemic Region

Abstract

Objective: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless method that enables thyroidectomyusing natural orifice of the body. The opinion which is even common among TOETVA performing surgeons is that this surgery involves a small percentage of thyroidectomy applied patients. In this study, based on the currently accepted exclusion criteria, we aimed to determine what percentage of patients, who underwent thyroidectomy in an endemic area are actually suitable for TOETVA. Methods: Between January 2017 and December 2019, 1197 consecutive patients who underwent surgery for thyroid pathology in our clinic were analyzed retrospectively. Pre-operative evaluations were made according to the current exclusion criteria and as a result, patients with no previous neck surgery, no history of radiotherapy, no retrosternal thyroid extension, and none lymph node dissection operation been made and whose thyroid gland diameter is <10 cm and gland volume is not more than 45 ml, malignant nodule diameter is <2 cm, and benign nodule diameter is <4 cm are involved to this study by being considered appropriate for TOETVA procedure. Results: According to the criteria, 513 patients (42.8%) were found suitable for TOETVA. A total of 421 (82%) of these patients were female and 92 (18%) were male. The mean age was 46.2±13.2. A total of 192 (37%) of these patients were operated due to the benign reasons, and 321 (63%) of these patients operated due to the malignancy or suspicion of malignancy. Average nodule size was 1.9 cm, and the average thyroid volume was 23.8 ml among benign patients. Whereas among malignant patients, the average nodule size was 1.7 cm and the average thyroid volume was 21.8 ml. A total of 462 (90.1%) of the patients were applied to the total thyroidectomy and 51 (9.9%) of the patients were applied to the hemithyroidectomy. In the same period, 29 patients operated through TOETVA and 4 patients operated through bilateral axillary breast approach thyroidectomy. When the final pathology, results of the patients were examined, papillary thyroid carcinoma was seen in 301 (58.7%) patients, benign pathologies were seen in 192 (37.4%) patients, and 20 (3.9%) patients were diagnosed with other pathologies (follicular thyroid carcinoma, poorly differentiated carcinoma and Hürthle cell neoplasia, etc.). Conclusion: Although “patient willingness” factor could not be included in the study, TOETVA eligible patient repository is wider contrary to popular belief. In our humble opinion, TOETVA method is going to pursue its spread and become a part of the routine surgical training session due to its effectiveness in terms of credibility in today’s world where cosmetic concerns gradually gain prominence.

Comparison of Surgical Outcomes of Transoral Versus Open Thyroidectomy for Graves Disease

“…For TOETVA, the generally accepted maximum size for benign nodules is <5 to 6 cm, with a thyroid volume typically below 45 mL 27–30 . However, in the case of Graves patients, we believe the acceptable thyroid volume for TOETVA is usually smaller than that for nodular disease due to the thyroid’s fragility, hypervascularity, and associated risks.…”

“…For TOETVA, the generally accepted maximum size for benign nodules is <5 to 6 cm, with a thyroid volume typically below 45 mL. [27][28][29][30] However, in the case of Graves patients, we believe the acceptable thyroid volume for TOETVA is usually smaller than that for nodular disease due to the thyroid's fragility, hypervascularity, and associated risks. If the thyroid volume exceeds the surgeon's experience-based threshold, we discuss it with the patient and recommend open surgery for safety reasons.…”

Feasibility, perceived aesthetic outcomes and patients’ interest in transoral endoscopic thyroidectomy (TOETVA) in a cohort of patients in the Thames Valley United Kingdom

“…(8) The primary indication for TOETVA is improved cosmesis but this 'soft' primary outcome should not deter practitioners from developing skills which offer better cosmetic outcomes. (1,4,5) As part of this process, emphasis will be placed on understanding the impact of the new procedure on the incidence of complications usually associated with traditional thyroid surgery such as recurrent laryngeal nerve injury, permanent hypoparathyrodism and post-operative haemorrhage. In addition, efforts are made to mitigate the incidence of speci c complications, such as infection, mental nerve injury and mentalis dysfunction and rate of conversion.…”

“…(2) As for other procedures, there will be a learning curve, additional costs and operative time. (5,(9)(10)(11)(12). Reassuringly, a recent metanalysis of six eligible nonrandomized studies involving 1151 patients revealed that TOETVA group had a signi cantly longer operative time but there were no signi cant differences in terms of postoperative outcomes.…”

“…Currently, transcervical thyroidectomy remains the gold standard procedure and it has a low complication rate with easily transferrable skills. In this context, the motivation to deliver a scarless procedure is allegedly in uenced by cultural perception of neck scar, but some expect it to evolve to be a better procedure (1,2,4,5).…”