Robotic bilateral axillo-breast versus endoscopic bilateral areola thyroidectomy outcomes of 757 patients.

Background: Remote endoscopic thyroidectomy (ET) and robotic thyroidectomy (RT) seem to be beneficial in selected situations to avoid anterior neck scars. There are limited data in the literature to determine whether RT via a bilateral axillo-breast approach (RT-BABA) is superior to ET via a bilateral areolar approach (ET-BAA). Therefore, the aim of this study was to evaluate the surgical outcomes of RT-BABA versus ET-BAA. Methods: Between May 2013 and May 2022, 757 patients who underwent RT-BABA or ET-BAA at a high-volume Chinese thyroid center were included. Intraoperative and postoperative outcome parameters were collected and retrospectively analyzed. The moving average method was used to evaluate the learning curve. Results: The proportion of patients older than 45 years was greater in the RT group than in the ET group (14.8% vs. 7.4%, p < 0.001). The percentage of overweight patients was greater in the RT group (28.8% vs. 9.5%, p < 0.001). The number of patients treated for malignant lesions was higher in the RT group (86.8% vs. 75%, p < 0.001). The rate of thyroiditis was higher in the RT group (10.9% vs. 6.6%, p < 0.001). Surgical time was significantly shorter in the RT group (140 vs. 165min, p < 0.001). Drainage volume was higher in the RT group (100 vs. 85ml, p < 0.001). Postoperative hospital stay was shorter in the RT group (3.04 ± 0.44 vs. 3.67 ± 0.89 days, p < 0.001). The cost in the RT group was higher (49627 ± 2795 vs. 25094 ± 3368 yuan, p < 0.001). Transient vocal cord dysfunction was lower in the RT group (2.9% vs. 8.0%, p = 0.003). There was no significant difference between the two groups in the number of central lymph nodes sampled, positive lymph nodes, neural monitoring (EMG) results, and rate of transient hypoparathyroidism. The learning curve for RT was 26 cases, and the operative time for ET was constant throughout the study. Conclusions: RT-BABA is as safe and feasible as ET-BAA. RT-BABA performed better in some surgical outcomes. Further prospective studies are needed to confirm the safety of RT-BABA.

Association Between the Presence of Female-Specific Tumors and Aggressive Clinicopathological Features in Papillary Thyroid Cancer: A Retrospective Analysis of 9,822 Cases.

OBJECTIVE: To investigate the association between the presence of female-specific tumors and aggressive clinicopathological features in papillary thyroid cancer (PTC). METHODS: This study retrospectively analyzed 9,822 female cases between June 2008 and December 2017. Odds ratios and corresponding 95% confidence intervals were calculated. Findings were stratified by age and body mass index (BMI) in different models. RESULTS: 1443/9822 (14.7%) patients with PTC had a female-specific tumor. Presence of a benign breast mass was an independent risk factor for a primary PTC lesion > 1 cm in diameter (adjusted OR = 1.446, 95% CI 1.136-1.840, P = 0.003), but a protective factor against extrathyroidal extension of PTC (adjusted OR = 0.650, 95%CI 0.500-0.845, P = 0.001). Presence of a benign uterine mass was an independent risk factor for multifocal PTC (adjusted OR = 1.305, 95%CI 1.113-1.531, P = 0.001). Analyses stratified by age and BMI revealed the presence of a benign breast mass was an independent risk factor for a primary PTC lesion > 1 cm in diameter in patients aged <36 years (adjusted OR = 1.711, 95% CI 1.063-2.754, P = 0.027), and a protective factor against extrathyroidal extension of PTC in patients aged ≥36 - <42 years (OR adjusted = 0.533, 95% CI 0.302-0.941, P = 0.030) or with a BMI ≥ 23.4 kg/m2 (BMI ≥ 23.4 to < 25.7 kg/m2, adjusted OR = 0.441, 95% CI 0.246-0.792, P = 0.006; BMI ≥25.7 kg/m2, adjusted OR = 0.558, 95% CI 0.315-0.998, P 2 = 0.045). Presence of a benign uterine mass was an independent risk factor for multifocal PTC in patients aged ≥49 years (adjusted OR = 1.397, 95% CI 1.088-1.793, P = 0.009) or with a BMI <21.5 kg/m2 (OR adjusted = 1.745, 95% CI 1.214-2.509, P = 0.003). CONCLUSION: The presence of a benign breast mass was an independent risk factor for a primary PTC lesion > 1 cm in diameter and a protective factor against extrathyroidal extension of PTC, while the presence of a benign uterine mass was an independent risk factor for multifocal PTC. Data from this study may help surgeons propose more personalized treatment plans when encountering patients with PTC and female-specific benign tumors.

Pictorial essay of vestibular incision outcomes from transoral endoscopic thyroidectomy.

PURPOSE: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged as a new treatment option for patients with selected thyroid disease requiring surgery. The aim of this pictorial essay is to illustrate the healing outcomes of the vestibular incisions. METHODS: TOETVA patients were recruited at two Centers in China and Italy. TOETVA is initiated with one 10-20-mm median incision in the center of the oral vestibule 10 mm above the inferior labial frenulum, and two 5-mm lateral incisions, just below the lower lip near the labial commissure. Healing of the vestibular incision was monitored through serial photographs 1, 3, 7, 30, and 90 days after surgery. Outcomes were evaluated by Landry's score, time to healing, issues affecting wound outcomes, scar, fibrin, granulation, necrotic tissue formation, and infections. RESULTS: Results of TOETVA were monitored in 52 patients. There were no postoperative infections. All lateral incisions demonstrated favorable surgical outcomes. Landry's criteria scores indicated worse outcomes for the median incisions vs. the lateral ones (p<0.05). Median incisions healed well in 65.4% of patients, but 34.6% of patients had visible scars from the median incision 90 days after surgery. Eight (15.4%) had cicatricial diathesis, seven (13.5%) experienced displacement of the stitches, and three (5.8%) developed synechia with gingiva. When the central vestibular incision was <10mm from the gingiva, patients tended to form synechia (60%). There were no significant differences in wound healing between the Chinese and Italian patients. CONCLUSIONS: Knowledge of vestibular incision healing is essential to provide practical TOETVA clinical guide and to define optimal outcomes evaluation for transoral surgeons. Vestibular wound problems were confined only to the central incision.

Clinical Experience of Use of Percutaneous Continuous Nervemonitoring in Robotic Bilateral Axillo-Breast Thyroid Surgery.

Introduction and Objective: There is a need for a simplified technique for C-IONM in robotic surgery. The primary aim of this study was to describe our clinical experience with the use of percutaneous C-IONM in robotic bilateral axillary thyroid surgery. Methods: This study prospectively enrolled 304 consecutive patients who underwent robotic thyroidectomy via the bilateral axillo-breast approach and standardized C-IONM via percutaneous probe stimulation. Results: 323 RLNs were analyzed. C-IONM with percutaneous probes was feasible in all cases. During this study, we did not record any cases of probe displacement, and no additional robotic maneuvers were required. The average stimulation intensity was 2 mA. There were no adverse local or systemic C-IONM side effects. The mean time required for probe positioning was 3 minutes. The EMG amplitude signal of 48 RLNs decreased significantly, < 50% from the original V1 signal. In these cases, the surgical procedure was modified. Conclusion: The proposed percutaneous C-IONM provides a simplification of the continuous monitoring procedure for robotics. The advantage of percutaneous C-IONM is that it does not require additional trocar space, repeated instrument changes, and unmodified cosmesis. To our knowledge, this is the first study on the application of percutaneous C-IONM in robotic thyroid surgery.

A Randomized Comparison of Carbon Nanoparticles in Endoscopic Lymph Node Dissection Via the Bilateral Areola Approach for Papillary Thyroid Cancer.

OBJECTIVE: We assess the value of carbon nanoparticles (CNP) staining in patients undergoing endoscopic thyroidectomy and central compartment lymph node (CLN) dissection via the bilateral areola approach [endoscopic thyroidectomy via bilateral areola approach (ETBAA)]. METHODS: This was a prospective randomized study. Three hundred two consecutive early-stage thyroid cancer patients eligible for ETBAA were recruited at the Division of Thyroid Surgery, China-Japan Union Hospital, Jilin University, China. CLN were mapped and retrieved under the guidance of stained or unstained CNP. The location, detection rates, positive nodes, and number of stained lymph nodes were compared. RESULTS: ETBAA patients were randomly divided into a CNP group (n=152) and a control group (n=150). In the CNP group, the imaging of lymphatic flow could be observed in 1016 (95.9%) lymph nodes, whereas 43 (4.1%) were unstained. The mean number of stained lymph nodes in each procedure was 6.68 (range, 3 to 12). The total number of dissected lymph nodes was 1059 in the CNP group and 872 in the control group (P=0.00). There was a significant difference of inadvertent parathyroidectomy between the 2 groups: 0.5% versus 3.9% in lobectomy (P=0.035) and 0.6% versus 5.2% in total thyroidectomy (P=0.012). However, the rates of hypoparathyroidism were not significantly different (P>0.05). There were no cases of CNP-related adverse effects. CONCLUSIONS: The lymphatic navigation by CNP increases the number of detected CLN without the involvement of radioactive isotopes. However, CNP did not lower hypocalcemia, did not improve parathyroid hormone range, and there was no significant difference in the percentage of metastatic lymph nodes between the 2 groups.

Consequences of Trocar Dynamics on Mental Nerve in Transoral Thyroidectomy.

BACKGROUND: Mental nerve (MN) injuries are reported during transoral endoscopic thyroidectomy vestibular approach. Effect of trocar insertion and position on MN are examined in the present study. MATERIALS AND METHODS: Ten millimeter incision was made at the center of the lower lip oral vestibule. Two 5 mm lateral incisions of the lower lip oral vestibule were made at the junction between the incisor and the canine. These 2 lateral incisions were high, just below the edge of lower lip. Nine pigs (18 MN) were randomly divided into 3 groups and MN dissection was performed. The angle between the lateral ports and median line were changed between 15 and 45 degrees among 3 groups and effect on MN was examined. RESULTS: During dissection when insertion and other ports are in neutral position visual inspection of MNs did not reveal any compression bilaterally. The distance between MN and the ports was 18.2±2.1 mm (16.3 to 21.2 mm). In group I and group II, MNs have no compression by the lateral trocars. In group III (45 degrees), left MNs were all compressed. Two MNs (66.7%) were compressed on the right side. The MN was compressed at its ramification. CONCLUSIONS: The results of the present experimental study, endorse the suggested medial and lateral vestibular incisions for transoral endoscopic thyroidectomy vestibular approach. However, during dynamic modification of the lateral port position/angle, MN compression was observed when the angle was >45 degrees.

Stimulating and dissecting instrument for transoral endoscopic thyroidectomy: proof of concept investigation.

OBJECTIVES/HYPOTHESIS: Intraoperative neuromonitoring (IONM) is a useful adjunct for recurrent laryngeal nerve (RLN) mapping and identification in transoral endoscopic thyroidectomy vestibular approach (TOETVA). This experimental study aimed to investigate the feasibility, safety, thresholds required of an endoscopic forceps that combine the function of surgical dissection and nerve stimulation. STUDY DESIGN: Prospective experimental research. METHODS: TOETVA was performed in 12 piglets, i.e., 24 RLNs and 24 vagal nerves (VN). RLNs electromyography (EMG) was recorded via endotracheal surface electrodes. Baseline EMG of VN and RLN were recorded and compared by (a) percutaneously placed monopolar stimulator probe (Group I), (b) adapted Maryland endoscopic dissector applied on nerves at its tip-end (Group II) and (c) endoscopic dissector tip-lateral applied (Group III). EMG profiles, amplitude, latency, waveform, thresholds and supra-maximal stimulation (5 mA) were analyzed. RESULTS: Application of the endoscopic device was feasible in all TOETVA and did not result in any morbidity. 24 RLNs and VNs were detected, stimulated and monitored. With increase of stimulation current, the amplitude of EMG increased, showing a dose-response curve. Mean VN stimulation thresholds were: Group I 0.28 mA, Group II 0.56 mA, Group III 0.58 mA (P1 = 0.00, P2 = 0.00, P3 = 0.11). Minimal current to evoked a maximal VN response was: Group I 0.65 mA, Group II 1.07 mA and Group III 1.14 mA (P1 = 0.00, P2 = 0.00, P3 = 0.48). Minimal current to evoke a RLN maximal response was Group I 0.6 mA, Group II 0.95 mA and Group III 1.05 mA (P1 = 0.00, P2 = 0.00, P3 = 0.31). Latency values were similar to each group. Repetitive (> 10 min) supra-maximal (> 5 mA) electrical stimulation was safe. CONCLUSIONS: The application of endoscopic stimulating dissector is simple, effective and safe way to monitor both VN and RLN function during a TOETVA animal model. It provides surgeons with real-time feedback of EMG response and can be applied as a tool for RLN monitoring. Endoscopic instrument required higher current to evoke EMG response compared to hand probe stimulation. Tip-end required less current to evoke EMG response compared to tip-lateral mode of stimulation.

Comparison of parathyroid hormone kinetics in endoscopic thyroidectomy via bilateral areola with open thyroidectomy.

BACKGROUND: In this study, we aimed to compare the kinetics of intact parathyroid hormone (iPTH) during the perioperative period of endoscopic thyroidectomy via bilateral areola approach (ETBAA) in the same period, following a traditional open thyroidectomy approach (OTA). METHODS: We conducted a prospective observational study of patients who were undergoing thyroidectomy and level VI clearance. Patients who had been affected by papillary thyroid cancer (PTC) were stratified into three groups: those eligible for endoscopic treatment (ETBAA); patients who were eligible for ETBAA but had opted for OTA (OTA-L); and patients who were not suitable for endoscopic intervention (OTA-H). A process for locating parathyroid glands was utilized to stratify gland dissection laboriousness. In Type A, the gland is firmly fixed to thyroid gland. This type can be sub-classified into three subtypes. A1: the parathyroid gland is attached to the inherent thyroid capsule. A2: the gland is partially embedded in the thyroid gland. A3: the gland is located in the thyroid tissue. Type B is defined as a gland which is separated from the thyroid gland. The iPTH was sampled at wound closure. RESULTS: There were 100 patients in each group. We found a significant difference between the ETBAA and OTA-H groups for type A2, as well as a loss of parathyroid glands and a number of parathyroid transplantation procedures. The endoscopic group was treated during an earlier stage of thyroid cancer. The iPTH profile of each group decreased, although this was the most consistent in the OTA-H group. A comparison of ETBAA with OTA-L demonstrates that the iPTH level change is similar. CONCLUSION: There is no advantage of endoscopic treatment for preserving parathyroid function.

Feasibility of Continuous Intraoperative Neural Monitoring During Transoral Endoscopic Thyroidectomy Vestibular Approach in a Porcine Model.

Background: Experimental study to evaluate feasibility of continuous intraoperative neural monitoring (C-IONM) in transoral endoscopic thyroidectomy vestibular approach (TOETVA). Methods: Duroc-Landrace pigs were orally intubated with electromyogram endotracheal tube. Automatic periodic stimulation (APS) electrode was allocated in the operative field through the 5-mm ports. APS was then repose on vagal nerve (VN) with different approaches: (1) median, that is, between sternothyroid and thyroid gland; and (2) lateral, that is, between sternocleidomastoid and sternothyroid. VN was stimulated proximally and distally to the APS location to verify whether the dissection and/or placement determined VN injury. Video presentation is offered. Results: Assembled APS accessory was feasible in large-brained animals. The two basic options for VN approaches were tested. Baseline obtained had amplitude values >1000 µV, bilaterally. Conclusions: C-IONM was feasible in TOETVA in porcine models, but simplification of electrode design and application is needed.

Central Lymph Node Dissection by Endoscopic Bilateral Areola Versus Open Thyroidectomy.

BACKGROUND: Endoscopic thyroidectomy by bilateral areola approach (ETBAA) potentially expose a technical limitation for anatomize the central compartment lymph nodes located in its most caudal portion because of visual obstruction and instrument interference of clavicles and sternum. We provide a comparative analysis of ETBAA versus open thyroidectomy approach (OTA) for central compartment dissection (CND). METHODS: From October 2013 to August 2017, 400 patients with papillary thyroid cancer (PTC) underwent CND; 200 patients were enrolled in each group. For the endoscopic group, a 10-mm curved incision is made along the margin of the right areola at 2 to 4'oclock for the 30 degrees endoscope. Bilaterally 5-mm incisions are on the edges of the areola at 11 to 12'oclock as accessory operating ports. Supplementary video (Supplemental Digital Content 1, http://links.lww.com/SLE/A180) depicts steps of ETBAA with CND. RESULTS: In ETBAA group, a total of 1049 lymph nodes were removed, nodes excision ranged from 1 to 19 (mean, 5.25), the ratio positive/metastatic rate was 18.6%. In OTA group, 916 lymph nodes were excised, nodes removal amplitude was 1 to 20 (average, 4.58), 12.1% were metastatic. Compared with the open group, significantly more lymph nodes were extracted during ETBAA (P<0.05). There was no significant difference between the 2 groups per resected side or surgical morbidity (P>0.05). Periodic monitoring of PTC patients revealed no clinical or US recurrence, undetectable serum Tg in both groups. CONCLUSIONS: Our results show the feasibility of CND in ETBAA.

Intraoperative Neural Monitoring in Endoscopic Thyroidectomy Via Bilateral Areola Approach.

OBJECTIVE: The aim of this report was dual: (a) to describe the step by step standardized intraoperative neural monitoring (IONM) procedure for recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve focusing on percutaneous IONM method, and (b) evaluation and outcomes of intermittent IONM in 237 endoscopic thyroidectomy via bilateral areolar approach cases. MATERIALS AND METHODS: A 10-mm curved incision is made along the margin of the right areola at the 2 to 4 o'clock position for the 30-degree endoscope. Bilaterally 5-mm incisions are required on the edges of the areola at the 11 to 12 o'clock positions as accessory operating ports. Ball-tip, monopolar, single-use, standard stimulating probe with a 10-cm handle and 9-cm shaft is adopted percutaneously for IONM. As reference, on the dominant thyroid lesion side, a 0.5-cm circle is drawn with the center at the intersection of a line 2-cm lateral to the anterior median line and a line 2-cm above the line connecting the bilateral clavicular heads. After ensuring with ultrasonography that no vessels are within the puncture passage, the skin is pierced with an 18-G syringe needle. After withdrawing the needle, the probe is carefully inserted through the tract. IONM is performed according to standards of equipment set up, anesthesia, tube positioning verification tests, and electromyography determinations. RESULTS: A total of 277 nerves at risk were favorably monitored with percutaneous probe stimulation. RLN, vagus nerve, and external branch of the superior laryngeal nerve were successfully determined. There were no instances of IONM malfunction, equipment displacement, or interference with the other endoscopic instruments. IONM probe insertion incision determined no scarring or morbidity in the neck. The incidence of RLN monolateral temporary palsy was 6%. CONCLUSIONS: Standardized monitoring in endoscopic thyroidectomy via bilateral areolar approach is feasible. IONM was implemented by means of percutaneous stimulating probe.

The role of silicon in enhancing resistance to bacterial blight of hydroponic- and soil-cultured rice.

Here we report for the first time that bacterial blight of rice can be alleviated by silicon (Si) added. In both inoculated and uninoculated plants, shoot dry weight was significantly higher in the +Si plants than in the -Si plants. A soil-cultured trial showed that disease severity was 24.3% lower in the Si-amended plants than in the non-Si-amended plants. Plants that were switched from -Si to +Si nutrient solution and simultaneously inoculated with Xoo also exhibited the same high resistance to bacterial blight as the plants that were treated continuously with Si, with control efficiencies of 52.8 and 62.9%, respectively. Moreover, total concentrations of soluble phenolics and lignin in rice leaves were significantly higher in the +Si plants than in the -Si plants. Polyphenoloxidase (PPO) and phenylalanine ammonia-lyase (PAL) activities in rice leaves were observed to be higher in the +Si plants than in the -Si plants. The expression levels of Os03g0109600, Prla, Rcht2 and Lox2osPil, were also higher in +Si plants than in -Si plants post-inoculation during the experimental time. Addition of Si resulted in increased Pal transcription, and inhibited CatA and Os03g0126000 expression in the earlier and later stages of bacterial inoculation, respectively.

Silicon-enhanced resistance to cadmium toxicity in Brassica chinensis L. is attributed to Si-suppressed cadmium uptake and transport and Si-enhanced antioxidant defense capacity.

A series of hydroponics experiments were performed to investigate roles of silicon (Si) in enhancing cadmium (Cd) tolerance in two pakchoi (Brassica chinensis L.) cultivars: i.e. cv. Shanghaiqing, a Cd-sensitive cultivar, and cv. Hangyoudong, a Cd-tolerant cultivar. Plants were grown under 0.5 and 5 mg Cd L(-1) Cd stress without or with 1.5 mM Si. Plant growth of the Cd-tolerant cultivar was stimulated at the lower Cd level, but was decreased at the higher Cd level when plants were treated with Cd for one week. However, Plant growth was severely inhibited at both Cd levels as stress duration lasted for up to three weeks. Plant growth of the Cd-sensitive cultivar was severely inhibited at both Cd levels irrespective of Cd stress duration. Addition of Si increased shoot and root biomass of both cultivars at both Cd levels and decreased Cd uptake and root-to-shoot transport. Superoxide dismutase, catalase and ascorbate peroxidase activities decreased, but malondialdehyde and H2O2 concentrations increased at the higher Cd level, which were counteracted by Si added. Ascorbic acid, glutathione and non-protein thiols concentrations increased at the higher Cd level, which were further intensified by addition of Si. The effects of Si and Cd on the antioxidant enzyme activity were further verified by isoenzyme analysis. Silicon was more effective in enhancing Cd tolerance in the Cd-tolerant cultivar than in the Cd-sensitive cultivar. It can be concluded that Si-enhanced Cd tolerance in B. chinensis is attributed mainly to Si-suppressed Cd uptake and root-to-shoot Cd transport and Si-enhanced antioxidant defense activity.