RESUMO
INTRODUCTION: The Transoral Neck Surgery (TONS) Study Group was established at the 1st International Thyroid NOTES Conference in February 2016 with the intention of standardizing and refining thyroid NOTES techniques, including both transoral endoscopic and robotic thyroidectomy approaches. Herein, the authors report the modification of indications, preparation, and step-by-step explanations for operative techniques, as well as results and postoperative care for transoral endoscopic thyroidectomy vestibular approach (TOETVA). METHODS: Between February 2015 and December 2015, a total of 200 patients comprising 8 males (4%) and 192 females (96%) underwent TOETVA using 3 laparoscopic ports inserted at the oral vestibule. Of these patients, 111 presented with single thyroid nodules (55.5%), while 66 patients had multinodular goiters (33%), 12 had Graves' disease (6%) and 11 had papillary microcarcinoma (5.5%). The CO2 insufflation pressure was maintained at 6 mmHg. Each surgery was performed using laparoscopic instruments and ultrasonic devices. RESULTS: TOETVA was performed on 200 consecutive patients. No conversion to conventional open surgery was necessary. Average tumor size was 4.1 ± 1.78 cm (1-10 cm). Median operative time was 97 ± 40.5 min (45-300 min). Median blood loss was 30 ± 46.25 mL (6-300 mL). Mean visual analog scale measurements were 2.41 ± 2.04 (2-7), 1.17 ± 1.4 (0-5), and 0.47 ± 0.83 (0-3) on the first, second, and third days, respectively. Temporary hoarseness and hypoparathyroidism occurred in 8 patients (4%) and 35 patients (17.5%), respectively. No permanent hoarseness or hypoparathyroidism occurred. Mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma that required open surgery. No infection was identified. CONCLUSION: TOETVA was shown to be safe and feasible with a reasonable surgical duration and minimal pain scores. This approach shows promise for those patients who are motivated to avoid a neck scar.
Assuntos
Cirurgia Endoscópica por Orifício Natural/métodos , Doenças da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Boca/cirurgia , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Pescoço/cirurgia , Duração da Cirurgia , Medição da Dor/métodos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Tailândia , Glândula Tireoide/cirurgia , Tireoidectomia/efeitos adversos , Ultrassonografia de Intervenção/efeitos adversos , Ultrassonografia de Intervenção/métodos , Adulto JovemRESUMO
BACKGROUND: Efficient DNA damage repair by MutL-homolog DNA mismatch repair (MMR) enzymes, MLH1, MLH3, PMS1 and PMS2, are required to maintain thyrocyte genomic integrity. We hypothesized that persistent oxidative stress and consequent transcriptional dysregulation observed in thyroid follicles will lead to MMR deficiency and potentiate papillary thyroid tumorigenesis. METHODS: MMR gene expression was analyzed by targeted microarray in 18 papillary thyroid cancer (PTC), 9 paracarcinoma normal thyroid (PCNT) and 10 normal thyroid (NT) samples. The findings were validated by qRT-PCR, and in follicular thyroid cancers (FTC) and follicular thyroid adenomas (FTA) for comparison. FOXO transcription factor expression was also analyzed. Protein expression was assessed by immunohistochemistry. Genomic integrity was evaluated by whole-exome sequencing-derived read-depth analysis and Mann-Whitney U test. Clinical correlations were assessed using Fisher's exact and t tests. RESULTS: Microarray and qRT-PCR revealed reduced expression of all four MMR genes in PTC compared with PCNT and of PMS2 compared with NT. FTC and FTA showed upregulation in MLH1, MLH3 and PMS2. PMS2 protein expression correlated with the mRNA expression pattern. FOXO1 showed lower expression in PMS2-deficient PTCs (log2-fold change -1.72 vs. -0.55, U = 11, p < 0.05 two-tailed). Rate of LOH, a measure of genomic instability, was higher in PMS2-deficient PTCs (median 3 and 1, respectively; U = 26, p < 0.05 two-tailed). No correlation was noted between MMR deficiency and clinical characteristics. CONCLUSIONS: MMR deficiency, potentially promoted by FOXO1 suppression, may explain the etiology for PTC development in some patients. FTC and FTA retain MMR activity and are likely caused by a different tumorigenic pathway.
Assuntos
Adenoma/genética , Carcinoma Papilar/genética , Reparo de Erro de Pareamento de DNA , Proteína Forkhead Box O1/metabolismo , Instabilidade Genômica , Neoplasias da Glândula Tireoide/genética , Adenoma/metabolismo , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Papilar/metabolismo , Reparo de Erro de Pareamento de DNA/genética , Reparo de Erro de Pareamento de DNA/fisiologia , Enzimas Reparadoras do DNA/metabolismo , Proteínas de Ligação a DNA/genética , Feminino , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Estresse Oxidativo , Câncer Papilífero da Tireoide , Glândula Tireoide/metabolismo , Neoplasias da Glândula Tireoide/metabolismoRESUMO
BACKGROUND: Bilateral open cervical exploration with identifying all parathyroid glands and removing one or more enlarged parathyroid tumor(s) was the standard of care in primary hyperparathyroidism (pHPT). With the introduction of preoperative imaging and intraoperative parathyroid hormone (IOPTH) measurements [1, 2], various minimally invasive parathyroidectomy approaches have been developed, both open and endoscopic [3-8]. The most commonly used approach currently in the USA is the minimally invasive open parathyroidectomy (MIP), which can be performed in the ambulatory setting with excellent cure and minimal complication rates [9-12]. However, the operation requires a cervical incision, with occasionally poor cosmesis. The transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) provides a novel "scarless" approach to parathyroid surgery. METHODS: The aim of the video is to provide detailed instruction of the TOEPVA in pHPT and how to interpret IOPTH measurements in this setting. RESULTS: The TOEPVA uses three incisions in the vestibule of the oral cavity, using two 5-mm ports and one central 11-mm port. The subplatysmal space is enlarged by hydrodissection and manual dilation. The working space is enhanced by insufflation to 6 mmHg. With the adjunct of preoperative imaging and IOPTH measurements, the extent of the operation is tailored to achieve biochemical cure. CONCLUSIONS: TOEPVA is feasible and safe and provides an excellent cosmetic outcome. It is a more direct approach than other remote endoscopic parathyroidectomy techniques. TOEPVA is an excellent option for select patients with pHPT wishing to avoid a neck incision.
Assuntos
Adenoma/cirurgia , Hiperparatireoidismo Primário/cirurgia , Neoplasias das Paratireoides/cirurgia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Paratireoidectomia/métodos , Gravação em VídeoRESUMO
BACKGROUND: Sistrunk operation of the thyroglossal duct is a procedure for the removal of a cyst, the middle part of the hyoid bone and tract towards the foramen caecum. Unavoidably, this procedure results in a scar on the skin in the neck area. By performing a bilateral areolar endoscopic Sistrunk operation, this study is the first to develop a procedure that can solve the aesthetic problem. This operation results in both an excellent cosmetic result and the successful treatment of TGDC. METHODS: A three-port technique was performed in this operation: 10-mm port for 30°, 10-mm laparoscope, 5-mm port for the instrument at the left circumareolar area and 5-mm port located at the right circumareolar area. Insufflation pressure of CO2 gas was set at 6 mm Hg. The surgical working space was located over the breast tissue and pectoralis muscles, towards the anterior neck to the hyoid bone. The steps employed for resection were similar to a conventional Sistrunk operation using standard laparoscopic instruments and hook scissors. RESULTS: A series of 11 patients were successfully treated using this novel technique with neither conversion to open surgery nor surgical complications. Average operative time was 88.54 min (ranging from 60 to 130 min). Average blood loss was 35 mL. (ranging from 15 to 67 mL). Patients were discharged in an average of 2.36 days after the procedure (ranging from 2 to 3 days). CONCLUSION: This novel technique for TGDC Sistrunk surgery using an areolar approach is feasible, safe and effective. The benefit of this technique is the cosmetic result, which leaves no scarring on the neck after wound healing and may provide a new method for optimal aesthetic results.
Assuntos
Mama/cirurgia , Endoscopia/métodos , Cisto Tireoglosso/cirurgia , Adolescente , Adulto , Cicatriz , Conversão para Cirurgia Aberta , Feminino , Humanos , Insuflação , Laparoscopia/instrumentação , Tempo de Internação , Pessoa de Meia-Idade , Pescoço , Duração da Cirurgia , Pressão , Cicatrização , Adulto JovemRESUMO
BACKGROUND: Natural orifice transluminal endoscopic surgery developed for neck surgery become increasing popular. Herein, an innovative transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) was developed for primary hyperparathyroidism (PHPT) and renal hyperparathyroidism (rHPT). METHODS: Incisions were made at the oral vestibule under the inferior lip. A 10-mm trocar was inserted through the center of the oral vestibule with two 5-mm trocars laterally. The subplatysmal space was created down to the sternal notch, and carbon dioxide pressure was insufflated at 6 mmHg to maintain the working space. Parathyroidectomy was performed using laparoscopic instruments. Intraoperative parathyroid hormone level and frozen section were conducted. Autotransplantation of the parathyroid gland was performed at the non-dominant forearm in an rHPT patient. RESULTS: From March 2015 to June 2016, TOEPVA was successfully performed in 12 patients (six PHPT and six rHPT). The mean operative time for parathyroidectomy in PHPT patients was 107.5 min (range 88-127) and 185.8 min in rHPT patients (range 155-214). One patient experienced a transient recurrent laryngeal nerve injury which was spontaneously resolved within 1 month. No permanent recurrent laryngeal nerve injury was found. Serum calcium level returned to normal range in all patients. The serum parathyroid hormone level of the PHPT and the rHPT group at 30 days was 36.38 ± 7.1 pg/mL (range 27.7-46.5) and 60.35 ± 15.94 pg/mL (range 38.7-87.2), respectively. The postoperative cosmetic outcome was excellent. No mental nerve injury or infection was found. CONCLUSIONS: TOEPVA is a feasible, safe, and reasonable surgical option for patients with hyperparathyroidism, especially those with cosmetic concerns.
Assuntos
Hiperparatireoidismo Primário/cirurgia , Laparoscopia , Procedimentos Cirúrgicos Minimamente Invasivos , Boca/cirurgia , Cirurgia Endoscópica por Orifício Natural , Glândulas Paratireoides/cirurgia , Paratireoidectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paratireoidectomia/instrumentação , Resultado do TratamentoRESUMO
The prevalence of low-risk differentiated thyroid cancer (DTC) is dramatically increasing because of superior diagnostic imaging technologies. Remote-access endoscopic thyroidectomy is becoming more popular for the lack of a noticeable neck scar. Transoral endoscopic thyroidectomy, vestibular approach (TOETVA) is the only technique that could be called a true scarless surgery; however, there is a scarcity of long-term studies about its safety and feasibility. Because thyroid cancer is a slow-growing lesion, with adequate follow-up and surveillance, TOETVA is a surgical procedure for the management of low-risk DTC without any difference of surgical and oncological outcome.
Assuntos
Cirurgia Endoscópica por Orifício Natural/métodos , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Humanos , Cirurgia Endoscópica por Orifício Natural/normas , Tireoidectomia/normasRESUMO
Background: The Gail model is the most widely used method for breast cancer risk estimation. This model has been studied and verified for its validity in many groups but there has yet to be a study to validate the Gail model in a Thai population. This study aims to evaluate whether the Gail model can accurately calculate the risk of breast cancer among Thai women. Methods: The subjects were recruited from the Division of Head, Neck, and Breast Surgery, Department of Surgery, Siriraj Hospital. The patients attending the division were asked to enroll in the study and complete questionnaires. Gail model scores were then calculated. Relationships between parameters were examined using the Pearson's chi-square test, Fisher's exact test, and independent-samples t-test. Results: There were 514 women recruited. Age, parity, age at first-live birth, and history of atypical ductal hyperplasia (ADH) were significant risk factors for breast cancer. The 5-year and lifetime risk score for breast cancer calculated by the Gail model were not significantly different between the patient and the control subjects. The proportions of the subjects with lifetime risk ≥20% were significantly higher in breast cancer patients (p=0.049). Conclusion: The Gail model underestimated the risk of breast cancer in Thai women. Calibration of the model is still required before adoption in Thai population.
Assuntos
Neoplasias da Mama/epidemiologia , Predisposição Genética para Doença , Modelos Estatísticos , Medição de Risco/métodos , Adulto , Neoplasias da Mama/genética , Neoplasias da Mama/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Risco , Tailândia/epidemiologiaRESUMO
Well-differentiated thyroid cancer accounts for the majority of endocrine malignancies and, in general, has an excellent prognosis. In contrast, the less common poorly differentiated thyroid carcinoma (PDTC) and anaplastic thyroid carcinoma (ATC) are two of the most aggressive human malignancies. Recently, there has been an increased focus on the epigenetic alterations underlying thyroid carcinogenesis, including those that drive PDTC and ATC. Dysregulated epigenetic candidates identified include the Aurora group, KMT2D, PTEN, RASSF1A, multiple non-coding RNAs (ncRNA), and the SWI/SNF chromatin-remodeling complex. A deeper understanding of the signaling pathways affected by epigenetic dysregulation may improve prognostic testing and support the advancement of thyroid-specific epigenetic therapies. This review outlines the current understanding of epigenetic alterations observed in PDTC and ATC and explores the potential for exploiting this understanding in developing novel therapeutic strategies.
Assuntos
Diferenciação Celular , Epigênese Genética , Carcinoma Anaplásico da Tireoide/genética , Carcinoma Anaplásico da Tireoide/patologia , Animais , Epigenômica , Humanos , Terapia de Alvo Molecular , Carcinoma Anaplásico da Tireoide/terapiaRESUMO
Importance: Natural orifice transluminal endoscopic surgery thyroidectomy is a novel approach to avoid surgical scars. Objective: To compare the safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) with those of open thyroidectomy (OT). Design, Setting, and Participants: This study retrospectively reviewed all TOETVA and OT operations performed from April 1, 2014, through August 31, 2016, at Police General Hospital, Bangkok, Thailand. All patients who underwent TOETVA and patients who underwent OT were included. Exclusion criteria were (1) previous neck surgery, (2) substernal goiter, (3) lymph node or distance metastasis, and (4) suspicious invasion to the adjacent organs. Propensity score matching was conducted to reduce selective bias. Main Outcomes and Measures: Operative time, blood loss, and complications related to thyroid surgery. Results: Of the 425 patients who underwent transoral endoscopic thyroidectomy (mean age, 35.3 [12.1] years; age range, 16-81 years; 389 [92.2%] female), 422 successfully were treated with the TOETVA; 3 patients were converted to a conventional operation because of bleeding. Twenty-five patients (5.9%) had transient recurrent laryngeal nerve palsy, and 46 (10.9%) had transient hypoparathyroidism. None had permanent recurrent laryngeal nerve palsy or permanent hypoparathyroidism. Three patients (0.7%) had transient mental nerve injury; all cases resolved by 4 months. One patient developed postoperative hematoma treated by OT. Twenty patients (4.7%) had seroma treated by simple aspiration. Operative time was longer for the TOETVA compared with the OT group (100.8 [39.7] vs 79.4 [32.1] minutes, P = 1.61 × 10-10). The mean (SD) visual analog scale score for pain was lower in the TOETVA group (1.1 [1.2] vs 2.8 [1.2], P = 2.52 × 10-38). Estimated mean (SD) blood loss (36.9 [32.4] vs 37.6 [23.1] mL, P = .43) and rate of complications (45 of 216 [20.8%] vs 38 of 216 [17.6%], P = .41) were not significantly different in the TOETVA vs OT group. Conclusions and Relevance: The TOETVA was performed as safely as OT, requires only conventional laparoscopic instruments, and avoids incisional scars; thus, the approach may be an option for select patients.
Assuntos
Cirurgia Endoscópica por Orifício Natural , Tireoidectomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Conversão para Cirurgia Aberta/estatística & dados numéricos , Feminino , Hematoma/etiologia , Humanos , Hipoparatireoidismo/etiologia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Seroma/etiologia , Tireoidectomia/efeitos adversos , Escala Visual Analógica , Paralisia das Pregas Vocais/etiologia , Adulto JovemRESUMO
BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) provides excellent cosmetic results from its potential for scar-free operation. The procedure has been applied successfully for Graves' disease by the authors of this work and compared with the standard open cervical approach to evaluate its safety and outcomes. METHODS: From January 2014 to November 2016, a total of 97 patients with Graves' disease were reviewed retrospectively. Open thyroidectomy (OT) and TOETVA were performed in 49 patients and 46 patients, respectively. For TOETVA, a three-port technique through the oral vestibule was utilized. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device. Patient demographics and surgical variables, including operative time, blood loss, and complications, were investigated and compared. RESULTS: TOETVA was performed successfully in all 45 patients, although conversion to open surgery was deemed necessary in one patient. All patient characteristics for both groups were similar. Operative time was shorter for the OT group compared to the TOETVA group, which totaled 101.97±24.618 and 134.11±31.48 minutes, respectively (P<<0.5). Blood loss was comparable for both groups. The visual analog scale (VAS) pain score for the TOETVA group was significantly lower than for the OT group on day 1 (2.08±1.53 vs. 4.57±1.35), day 2 (0.84±1.12 vs. 2.57±1.08) and day 3 (0.33±0.71 vs. 1.08±1.01) (P<<0.05). Transient recurrent laryngeal nerve (RLN) palsy was found in four and two cases of TOETVA and OT group, respectively. Transient hypocalcemia was found in ten and seven cases of TOETVA and OT group, respectively. No other complications were observed. CONCLUSIONS: TOETVA is a feasible and safe treatment for Graves' disease in comparison to the standard open cervical approach. It is considered a viable alternative for patients who have been indicated for surgery with excellent cosmetic results.