A prospective study comparing the gasless endoscopic thyroidectomy trans-axillary approach to conventional open thyroidectomy: health and quality of life outcomes.

BACKGROUND: The relationship between different surgical treatments and quality of life remains uncertain for differentiated thyroid carcinoma (DTC). The aim of this study is to compare the gasless endoscopic thyroidectomy trans-axillary approach (ET) and traditional open thyroidectomy (OT) through a prospective cohort study focusing on the rate of the efficacy, and quality of life (QoL). METHODS: This prospective observational longitudinal cohort study enrolled 134 female patients diagnosed with DTC from December 01/2021 to December 31/2022. Multiple scales were applicated to evaluate the differences in quality of life, effectiveness, safety, etc. between the two groups during preoperative and postoperative follow-up periods, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, version 3.0 (QOL-C30), Symptom Checklist (SCL-90), Scar Cosmesis Assessment and Rating (SCAR-Q), voice impairment score (VIS), swallowing impairment score (SIS), and neck impairment score (NIS). RESULTS: Among them, 68 accepted ET and 66 patients underwent OT. To enhance comparability between the two groups, the patients enrolled in this study are female. Compared with the OT group, the ET group performed significantly better postoperative physical quality of life, including sound (p = 0.036), swallowing (p < 0.001), and neck function (p = 0.010). The ET group was also associated with significantly better cosmetic satisfaction (p < 0.001), and relatively faster recovery in psychological and emotional situation. CONCLUSIONS: Gasless endoscopic thyroidectomy through an axillary approach leads to good cosmetic and psychological effects, improves postoperative QoL, and could be recommended for rapid postoperative recovery and involvement in daily and social activities.

Clinical effectiveness of transaxillary single-port endoscopic surgery in the treatment of breast benign tumor.

BACKGROUND: Benign breast lumps affect 10% of women in their lifetimes. Endoscopic surgery could be an alternative surgical technique for benign breast tumors because it is performed through small wounds hidden in inconspicuous areas. The aim of this study was to explore the safety and esthetic effects of endoscopic surgery in the treatment of benign breast disease. METHODS: This retrospective cohort study analyzed 363 patients with benign breast tumors from August 2021 to December 2023 in the Sixth Affiliated Hospital of Sun Yat-Sen University, of whom 118 underwent transaxillary single-port endoscopic surgery and 245 underwent traditional open surgery. Clinicopathologic characteristics, surgery type, hospital stay, and complications were analyzed to assess the effectiveness of the procedure for benign breast tumors. RESULTS: Breast tumor resection was successfully performed in 363 patients by endoscopic surgery or traditional open surgery. Endoscopic procedures demonstrated longer durations of surgery (98.54 ± 35.17 min vs. 70.28 ± 26.06 min, p < 0.01) and postoperative drainage (64.30 ± 34.92 mL vs.18.49 ± 19.86 mL, p < 0.01), but there was less blood loss. The nipple-areolar complex of the patients who underwent endoscopic resection was significantly more sensitive than the traditional open surgery group. Patients in the endoscopic group reported higher satisfaction with surgical outcome (13.10 ± 1.97 vs. 12.63 ± 1.90, p < 0.01). And there was a significant difference in the wound scar and cosmetic outcome total score between the two groups. CONCLUSION: Transaxillary single-port endoscopic surgery is effective and safe and improves postoperative nipple-areolar sensation and cosmetic outcome, as compared to the conventional technique.

Comparison of gasless transaxillary endoscopic thyroidectomy, endoscopic thyroidectomy via areola approach and conventional open thyroidectomy in patients with unilateral papillary thyroid carcinoma.

BACKGROUND: Gasless transaxillary endoscopic thyroidectomy (GTET) and endoscopic thyroidectomy via the areola approach (ETA) have emerged as minimally invasive surgical techniques for managing papillary thyroid carcinoma (PTC). This study aimed to assess the surgical efficacy of endoscopic thyroidectomy (ET) as compared to conventional open thyroidectomy (COT) in PTC patients. METHODS: Between 2020 and 2022, 571 PTC patients underwent unilateral thyroidectomy accompanied by ipsilateral central lymph node dissection. This cohort comprised 72 patients who underwent GTET, 105 ETA, and 394 COT. The analysis encompassed a comprehensive examination of patient clinicopathologic characteristics and postoperative complaints. Furthermore, the learning curve of GTET was evaluated using the cumulative summation (CUSUM) method. RESULTS: Patients in the ET group exhibited a lower mean age and a higher proportion of female individuals. Operation time in the ET group was significantly longer. No significant differences were observed in the incidence of postoperative complications among the three groups. With regard to postoperative complaints reported three months after surgery, GTET demonstrated superior alleviation of anterior chest discomfort and swallowing difficulties. Patients who underwent ET reported significantly higher cosmetic satisfaction levels. Additionally, the learning curve of GTET was 27 cases, and the operation time during the mature phase of the learning curve exhibited a significant reduction when compared to ETA. CONCLUSIONS: The findings of this study affirm the safety and feasibility of employing GTET and ETA for the surgical management of PTC. GTET presents an attractive surgical option, particularly for patients with unilateral PTC who place a premium on cosmetic outcomes.

A controlled study of the hygienic technical evaluation of the transaxillary approach for inflation-free single-port lumpectomy versus conventional transcervical anterior open surgery in radical thyroid cancer resection.

OBJECTIVE: To evaluate sanitary techniques for radical thyroid cancer surgery via the transaxillary approach without inflation single-port endoscopic surgery (TAWISES) and the conventional open anterior cervical approach (COACAS) in a controlled manner. METHODS: This work was a retrospective analysis of the clinical data of 60 patients admitted to our hospital for unilateral radical thyroid cancer surgery between 01/2021 and 12/2022. The control group underwent COACAS (30 patients), and the experimental group underwent TAWISES (30 patients). The patients' operative time, intraoperative bleeding volume, 24-h postoperative pain index, drainage tube carrying time, hospitalization duration and complication rate were compared and analyzed. The patients were followed up for 3, 6 and 12 months postoperatively and evaluated based on numbness, muscular tightness, pain and other discomfort in the neck, as well as satisfaction with social adaptation and cosmetic incisions. The recurrence status was assessed for 1 year in both groups of patients. A questionnaire survey was conducted to assess patient acceptance of the two surgical approaches. The economic characteristics (cost-effectiveness and cost-utility) of the different approaches in our region were evaluated comprehensively. RESULTS: The length of the incision, drainage tube carrying time and hospitalization duration were greater in the experimental group than in the control group (P < 0.05). The differences in complication rate, intraoperative bleeding volume, 24-h postoperative pain index and recurrence rate were not statistically significant between the two groups (P > 0.05). Neck discomfort was greater in the control group, and the difference was statistically significant at the 3-month postoperative follow-up (P < 0.05). The differences at the 6- and 12-month postoperative follow-ups were not statistically significant (P > 0.05). However, mild discomfort was significantly more common in the experimental group (63.33% > 36.67%, 80% > 53.33%, P < 0.05). The experimental group had better social adaptability, greater total medical costs, and better overall patient medical satisfaction than did the control group (P < 0.05). The acceptance of TAWISL was greater than that of COACAS (P < 0.05). CONCLUSION: Compared with COACLAS, TAWISES is safe and effective and better meets the cosmetic, psychological and social adaptation needs of patients. TAWISES is also more cost effective and can be better utilized for the population in our region, filling the gap in surgical modalities for thyroid cancer in in our region.

Gasless robot-assisted transaxillary hemithyroidectomy (RATH): learning curve and complications.

PURPOSE: Gasless robot-assisted transaxillary hemithyroidectomy (RATH) is regarded as an alternative surgical option for thyroid operations. However, the associated steep learning curve is a clinical concern. This study evaluated the learning curve of RATH for surgeons without experience of endoscopic surgery and the early surgical outcomes of RATH. METHODS: We conducted a retrospective study of patients who underwent gasless RATH and conventional hemithyroidectomy (CH) at Sun Yat-sen University Cancer Center, Guangzhou, China, from June 2021 to August 2022. The learning curve and early surgical outcomes of gasless RATH were evaluated. And the early surgical outcomes of gasless RATH were compared to CH. RESULTS: In total, 105 patients who underwent gasless RATH and 104 patients who underwent CH were matched and assessed. The cumulative sum techniques (CUSUM) analysis showed that the peak point of gasless RATH operative time occurred at the 31st case. No clear single peak was identified in the CUSUM plot for drainage amount and blood loss. No significant difference in perioperative complications was observed between these two groups. Moreover, the number of postoperative patients who got sense of thyroid area traction were fewer in the gasless RATH group (n = 11, 10.5%) than in the CH group (n = 32, 30.8%). CONCLUSION: Gasless RATH can be considered as an alternative approach to the conventional open procedure, as it is an easy remote access technique, with shorter learning curves and certain advantage such as less sense of thyroid area traction.

Harmonic Scalpel Versus Monopolar Electrotome in Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty: A Retrospective Study in 122 Patients.

BACKGROUND: The transaxillary approach of breast augmentation is the most popular method in Asia, but longer period of recovery was observed in spite of the assistance of endoscope. OBJECTIVES: Introducing the ultrasonic dissection devices might be a solution to minimizing tisue damage thus relieving pain and shortening the period of recovery. METHOD: Between March 2020 and September 2022, we retrospectively reviewed the cases of 122 patients underwent endoscopic augmentation mammoplasty via the transaxillary approach using either the monopolar electrotome (ME) alone or assisted with Harmonic Scalpel (HS) in defining the retropectoral pocket and severing the pectoralis major muscle. RESULT: The total drainage volume was significantly lower in the HS group than ME group (74.33 ± 48.81 vs. 180.30 ± 125.10 mL; p < 0.0001). VAS score of the first 24 hour after surgery of the ME group was significantly higher than that of the HS group (6.10 ± 1.27 vs. 2.88 ± 1.29, p < 0.0001). Operation time in HS group was reduced compared to ME group (113.1 ± 14.46 mins vs. 131.3 ± 35.51 mins, p < 0.001). The duration of drainage placement (1.08 ± 0.27 vs. 2.72 ± 1.18 days) and hospital stay after surgery (3.08 ± 0.42 vs. 5.64 ± 2.78 days; p < 0.0001) were largely reduced in HS group. CONCLUSION: The assistance of Harmonic Scalpel significantly reduced total postoperative drainage, relieved pain and shortened operation time, length of drainage placement and hospital stay compared to using monopolar electrotome alone in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Place of Transaxillary Access in Transcatheter Aortic Valve Implantation (TAVI) Compared to Alternative Routes-A Systematic Review Article.

Background: Transfemoral transcatheter aortic valve implantation (TAVI) has proven non-inferior or superior against surgical aortic valve replacement (SAVR) for patients at high, intermediate or low surgical risk. However, transfemoral access is not always feasible in patients with severely atherosclerotic or tortuous iliofemoral arteries. For these cases, alternative access techniques have been developed, such as transcarotid, transcaval, direct aortic or transaxillary access. In recent years, growing preference towards the transaxillary access has emerged. To provide a summary of data available on transaxillary TAVI and compare this approach to other alternative access techniques. Methods: A literature search was performed in PubMed by two independent reviewers. Studies reporting the outcome of at least 10 patients who underwent transaxillary TAVI, either in case series or in comparative studies, were included in this review. Articles not reporting outcomes according to the Valve Academic Research Consortium (VARC) 1-3 definitions were excluded. Results: In total 193 records were found of which 18 were withheld for inclusion in this review. This review reports on the combined data of the 1519 patients who underwent transaxillary TAVI. Procedural success was achieved in 1203 (92.2%) of 1305 cases. Life-threatening, major, and minor bleeding occurred respectively in 4.5% (n = 50 in 1112 cases), 12.9% (n = 143 in 1112 cases) and 8.8% (n = 86 in 978 cases). Major and minor vascular complications were reported in respectively 6.6% (n = 83 in 1256 cases) and 10.0% (n = 105 in 1048 cases) of patients. 30-day mortality was 5.2% (n = 76 out of 1457 cases). At one year follow-up, the mortality rate was 1% (n = 184 out of 1082 cases). Similar 30-day and 1-year mortality is observed in studies that compare with transaxillary, transfemoral or other alternative access techniques (p > 0.05). Conclusions: A wide application of transaxillary access as an alternative approach for TAVI has emerged. This technique has an excellent procedural success rate up to 92.0%, with low procedural complication rates. Clinical outcome of transaxillary TAVI is comparable to the other alternative TAVI approaches. However, these conclusions are solely based on observational data.

Aesthetic transaxillary subpectoral placement of vagus nerve stimulator in children and young adults: A technical note.

INTRODUCTION: Vagus nerve stimulation (VNS) is a neuromodulation therapy for drug-resistant epilepsy (DRE), refractory status epilepticus, and treatment-resistant depression. The lead is tunneled into the subcutaneous space and connected to the generator, which is usually implanted in a subcutaneous pocket below the clavicle. Surgical complications in the chest region include skin breakdown or infection. An alternative approach is to perform a subclavear subpectoral implantation. In our surgical series, we report a new aesthetic implantation method for VNS generators in children and young patients: the transaxillary subpectoral placement. MATERIALS AND METHODS: From May 2021 to May 2023, 10 vagus nerve stimulation generators were placed subpectorally with a transaxillary approach by the authors. We considered operative time, surgical complications such as blood loss, infections, device migration, pain, and adverse events at follow-up. RESULTS: In this surgical series, we reviewed all cases of subpectoral implantation of VNS generators in children and young adults at our institution in the last 2 years. All patients were treated with subpectoral Sentiva 1000 (Livanova PLC) insertion with axillary access by a neurosurgeon and a pediatric surgeon. The operative time was slightly longer compared to the traditional subcutaneous implant. All generators reported impedances within the optimal range. Blood loss was not significant and no other perioperative complications were reported. Patients and families were highly satisfied with the outcomes in terms of comfort and aesthetic results after surgery and at the last follow-up. No cases of infection occurred, and no malfunctions or displacements of the generator were registered at clinical follow-up. CONCLUSION: The transaxillary subpectoral placement of theVNS generator is an aesthetic and anatomic approach, which provides several benefits to children and young adults.

A propensity score matching analysis of gasless endoscopic transaxillary thyroidectomy with five-settlement technique versus conventional open thyroidectomy in patients with papillary thyroid microcarcinoma.

BACKGROUND: In a previous study, we proposed a novel anatomy-based five-settlement method for transaxillary endoscopic thyroidectomy (fs-TAT) for patients with papillary thyroid carcinoma. The safety of this new method has been reported in a retrospective study of a single cohort. The safety and short-term oncological outcome of this method was confirmed by comparing it with conventional open surgery (COT) in patients with papillary thyroid microcarcinoma. METHODS: The medical records of patients who underwent fs-TAT or COT by a single surgeon from February 2019 to December 2021 were reviewed retrospectively. All patients were diagnosed with papillary thyroid microcarcinoma and underwent lobectomy and ipsilateral central compartment neck dissection. Propensity score matching was used to compare the technical safety and short-term oncologic outcomes of fs-TAT and COT for the purpose of reducing potential selection bias. Reporting was consistent with the STROCSS 2021 guidelines. RESULT: After propensity score matching, 460 (fs-TAT: 230; COT: 230) patients remained in the study population. There were no significant differences in sex, age, tumor size, Hashimoto's thyroiditis, or tumor multifocality between the groups. The operative time was longer [104.5 (90.3, 120.0) vs. 62.0 (52.0, 76.0), P < 0.001] and the total postoperative drainage volume [135(90, 210) vs. 75 (55, 115), P < 0.001] was greater in the fs-TAT group than in the COT group. However, intraoperative bleeding [3.0 (2.0, 5.0) vs. 5.0 (5.0, 7.5), P < 0.001] was greater, and the median number of lymph nodes yielded [5.0 (2.3, 8.0) vs. 7.0 (5.0, 11.0), P < 0.001] was greater in the COT group than in the fs-TAT group. The groups exhibited no significant difference in the rate of complications (fs-TAT: 2.2% vs. COT: 2.6%, P = 0.856), rate of positive lymph nodes (fs-TAT: 32.2% vs. COT: 36.5%, P = 0.377), length of postoperative hospital stay (3 days vs. 3 days, P = 0.305) or total medical costs (26,936 vs. 26,549, P = 0.144). CONCLUSION: Compared to conventional open surgery, fs-TAT offered excellent safety and acceptable short-term oncological outcomes in a selected cohort of patients with papillary thyroid microcarcinoma.

Construction of a system for head and neck tumor traceless resection with non-inflatable transaxillary total endoscopic surgery.

Radical cure and functional preservation of tumors are the fundamental goals of surgical treatment of head and neck tumors, and the preservation of good aesthetics is a higher pursuit on this basis. Fully hiding the surgical incision and reducing the visibility of scars are important goals of cosmetic surgery. Using complete endoscopy for the head and neck is an effective method. CO2-free transaxillary total endoscopic surgery is a method with many advantages, which has been widely used in the resection of thyroid tumors, but for other parts and types of tumors in the head and neck, this surgical method is rarely used. The research team expanded its application scope and applied it to submandibular gland tumor resection and other head and neck surgeries for the first time. Through this exploration, it improved traction devices such as retractors, strictly limited the surgical indications, analyzed and summarized the key points, steps and methods of surgery, and built a treatment system for head and neck tumor surgery under complete endoscopy using the non-inflatable transaxillary approach. In this article, we introduce the system and select typical cases to share.

Successful treatment of re-coarctation of the aorta with percutaneous stent placement via axillary artery access in a young patient.

In patients with critical coarctation of the aorta, percutaneous balloon angioplasty and/or stent placement is usually performed via the femoral route. When femoral access is not suitable for intervention, the trans-axillary approach can be chosen as an alternative access. We hereby present the first case of a patient who had a successful percutaneous stent placement via trans-axillary access in our institution.

Clinical study on single-port endoscopic resection via a gasless transaxillary approach in the treatment of breast fibroadenoma in adolescents.

BACKGROUND: Breast fibroadenoma is the most common benign breast tumour. This study aimed to investigate the advantages and disadvantages of endoscopic-assisted resection via a gas-less transaxillary single-port approach for breast fibroadenoma in adolescent patients, compared with a traditional approach. METHODS: The clinical data of 83 patients with breast fibroadenoma treated in our hospital from October 2019 to October 2021 were collected for retrospective analysis. These patients were divided into an endoscopic-assisted surgery (ES) group (n = 39) and a traditional open surgery (OS) group (n = 44) according to the surgical approach. The operative time, intraoperative blood loss, incision length, postoperative complications, and patient satisfaction were compared between the two groups. RESULTS: The surgical cost was (5.1 ± 0.6) thousand Yuan [(0.7 ± 0.1) thousand US dollars] in the ES group and (3.5 ± 2.7) thousand Yuan [(0.5 ± 0.4) thousand US dollars] in the OS group, showing a statistically significant difference (p < 0.001). There was no significant difference in surgical time, intraoperative blood loss, incision length, or the rate of postoperative complications between the two groups. Stratified analysis revealed that the ES group had a significantly shorter operative time [(57.00 ± 10.26) min vs. (78.27 ± 7.63)] (p < 0.001), a smaller incision length [(3.73 ± 0.34) cm vs. (4.42 ± 0.44) cm] (p < 0.001), and a lower complication incidence rate (11.1% vs. 63.6) (p = 0.011) than the OS group in the cases with a nodule number ≥ 3. The satisfaction score using the BREAST-Q scale indicated that psychosocial well-being and patient satisfaction with the breast in the ES group were significantly superior to those in the OS group [(91.18 ± 3.12) points vs. (87.00 ± 4.45) points and (91.03 ± 6.80) points vs. (84.45 ± 6.06) points, respectively] (p < 0.001). CONCLUSION: ES is a safe and effective method for the treatment of fibroadenoma. In patients with multiple fibroadenomas (≥ 3 tumours), ES has a shorter operative time and fewer postoperative complications. ES demonstrates a significant, prominent advantage in cosmetic appearance. However, it should be noted that ES is associated with higher costs than OS.

Considerations for Surgical Treatment of Neurogenic Thoracic Outlet Syndrome: A Meta-Analysis of Patient-Reported Outcomes.

PURPOSE: It remains unclear whether first rib resection (FRR), performed via a supraclavicular (SCFRR) or transaxillary (TAFRR) approach, is necessary for patients with neurogenic thoracic outlet syndrome (nTOS). In a systematic review and meta-analysis, we performed a direct comparison of patient-reported functional outcomes following different surgical approaches for nTOS. METHODS: The authors searched PubMed, Embase, Web of Science, Cochrane Library, PROSPERO, Google Scholar, and the gray literature. Data were extracted based on the procedure type. Well-validated patient-reported outcome measures were analyzed in separate time intervals. Random-effects meta-analysis and descriptive statistics were used where appropriate. RESULTS: Twenty-two articles were included, with 11 discussing SCFRR (812 patients), 6 discussing TAFRR (478 patients), and 5 discussing rib-sparing scalenectomy (RSS; 720 patients). The mean difference between preoperative and postoperative Disabilities of the Arm, Shoulder and Hand score was significantly different comparing RSS (43.0), TAFRR (26.8), and SCFRR (21.8). The mean difference between preoperative and postoperative visual analog scale scores was significantly higher for TAFRR (5.3) compared to SCFRR (3.0). Derkash scores were significantly worse for TAFRR compared to RSS or SCFRR. RSS had a success rate of 97.4% based on Derkash score, followed by SCFRR and TAFRR at 93.2% and 87.9%, respectively. RSS had a lower complication rate compared to SCFRR and TAFRR. There was a difference in complication rates: 8.7%, 14.5%, and 3.6% for SCFRR, TAFRR, and RSS, respectively. CONCLUSIONS: Mean differences in Disabilities of the Arm, Shoulder and Hand scores and Derkash scores were significantly better for RSS. Higher complication rates were reported after FRR. Our findings suggest that RSS is an effective option for the treatment of nTOS. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Retrospective Study of Transaxillary Endoscopic Breast Augmentation Using Ultrasonic Scalpel or Conventional Electrocautery for Implant Pocket Dissection.

BACKGROUND: Ultrasonic scalpel has been reported to be superior to conventional electrocautery in many studies. However, with respect to transaxillary endoscopic breast augmentation, few studies on the effect of ultrasonic scalpel are available in the literature. METHODS: The medical records of 173 female patients who underwent breast augmentation via endoscopic transaxillary approach from January 2018 to December 2020 were reviewed retrospectively. The patients were divided into two groups according to the implant pocket dissection instruments. In group A, the implant pockets were dissected with conventional electrocautery (EC group) on 81 patients, and in group B, ultrasonic scalpel (US group) was used for implant pockets on 92 patients. All operations were performed by the same senior plastic surgeon and the same surgical team. The operation time, intraoperative blood loss, postoperative total drainage volume, days of drainage, postoperative surgical site pain and hospital stay time of the two groups were compared and analyzed statistically. RESULTS: The average operation time of the US group (83.82 ± 11.57 min) was significantly shorter than that of the EC group (101.40 ± 14.36 min), intraoperative blood loss in the US group was significantly less than that of the EC group (18.67 ± 6.20 ml vs. 21.59 ± 6.44 ml), the mean hospital stay days (2.96 ± 0.69 vs. 4.30 ± 1.11), total drainage volume (122.24 ± 43.81 vs. 232.37 ± 99.15), and duration of drain (2.52 ± 0.54 vs. 3.77 ± 1.10), mean VAS score for surgical site pain on 3 postoperative days (5.08 ± 1.35 vs. 6.51 ± 1.36, 4.08 ± 1.16 vs. 5.40 ± 1.32, 3.04 ± 0.91 vs. 4.06 ± 1.11) were significantly lower in the US group compared to the EC group. CONCLUSIONS: The ultrasonic scalpel reduces operative time, intraoperative blood loss, postoperative drainage, postoperative pain, hospital stay time, and incidence of complications. The ultrasonic scalpel is safe and reliable for transaxillary endoscopic breast augmentation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Transaxillary Single-Port Endoscopic Nipple-Sparing Mastectomy with Immediate Implant-based Breast Reconstruction in Breast Cancer Patients Receiving Neoadjuvant Chemotherapy or Not: A Comparative Study with Analysis of Surgical Complications and Patient-Reported Outcomes.

BACKGROUND: In most cases, transaxillary single-port endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction (E-NSM-IIBR) is conducted in patients with early-stage breast cancer, ensuring surgical safety while achieving improved breast aesthetics. However, whether E-NSM-IIBR is appropriate in patients undergoing neoadjuvant chemotherapy (NAC) is still unclear. The aim of this study was to report the surgical safety and patient-reported outcomes (PROs) of breast cancer patients who underwent E-NSM-IIBR with NAC in comparison to those who did not receive NAC. METHODS: A retrospective cohort study was conducted on patients who underwent E-NSM-IIBR with or without NAC at a single center between January 2021 and July 2022. Patient demographics, postoperative complications, and PROs evaluated using the BREAST-Q version 2.0 questionnaire were compared between the two groups. Factors associated with PROs at 9 months after surgery were assessed with linear regression analysis. RESULTS: A total of 92 patients who underwent E-NSM-IIBR were included in the study, with 27 patients receiving NAC and 65 patients not receiving NAC. There was no significant difference in the incidence of postoperative complications between the two groups. The BREAST-Q version 2.0 questionnaire was completed by 24 out of 27 patients (88.9%) in the NAC group and 59 out of 65 patients (90.8%) in the non-NAC group at 9 months after surgery. The patient-reported outcomes in various domains of the BREAST-Q did not show a significant difference between the two cohorts. The results of the multiple linear regression analysis indicated that in the both groups age (ß = - 0.985, 95% CI - 1.598 to - 0.371, p = 0.003 in the NAC group; ß = - 0.510, - 1.011 to - 0.009, p = 0.046 in the non-NAC group) and rippling (ß = - 21.862, - 36.768 to - 6.955, p = 0.006 in the NAC group; ß = - 7.787, - 15.151 to - 0.423, p = 0.039 in the non-NAC group) significantly impacted the patients' satisfaction with breasts, and PMRT was negatively associated with patients' physical well-being of chest (ß = - 13.813, - 26.962 to - 0.664, p = 0.040 in the NAC group; ß = - 18.574, - 30.661 to - 6.487, p = 0.003 in the non-NAC group). Our findings revealed that patients with larger implant volumes had higher scores in psychosocial well-being (ß = 0.082, 0.001 to 0.162, p = 0.047), whereas implant displacement (ß = - 14.937, - 28.175 to - 1.700, p=0.028) had a negative impact on patients' psychological well-being in the non-NAC group. However, our results did not demonstrate any significant influencing factors on patients' psychosocial well-being within the NAC group. CONCLUSION: Our preliminary experiences confirm that E-NSM-IIBR is a safe option for selected patients even after NAC, with favorable patient-reported outcomes comparable with those in the primary surgery setting. The postoperative long-term outcomes of patients who undergo radiation therapy after NAC merit further investigation in the future. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Aortic Valve Surgery.

Background and Objectives: Transaxillary access is one of the latest innovations for minimally invasive aortic valve replacement (MICS-AVR). This study compares clinical performance in a large transaxillary MICS-AVR group to a propensity-matched sternotomy control group. Materials and Methods: This study enrolled 908 patients undergoing isolated AVR with a mean age of 69.4 ± 18.0 years, logistic EuroSCORE of 4.0 ± 3.9%, and body mass index (BMI) of 27.3 ± 6.1 kg/m2. The treatment group comprised 454 consecutive transaxillary MICS-AVR patients. The control group was 1:1 propensity-matched out of 3115 consecutive sternotomy aortic valve surgeries. Endocarditis, redo, and combined procedures were excluded. The multivariate matching model included age, left ventricular ejection fraction, logistic EuroSCORE, pulmonary hypertension, coronary artery disease, chronic lung disease, and BMI. Results: Propensity-matching was successful with subsequent comparable clinical baselines in both groups. MICS-AVR had longer skin-to-skin time (120.0 ± 31.5 min vs. 114.2 ± 28.7 min; p < 0.001) and more frequent bleeding requiring chest reopening (5.0% vs. 2.4%; p < 0.010), but significantly less packed red blood cell transfusions (0.57 ± 1.6 vs. 0.82 ± 1.6; p = 0.040). In addition, MICS-AVR patients had fewer access site wound abnormalities (1.5% vs. 3.7%; p = 0.038), shorter intensive care unit stays (p < 0.001), shorter ventilation times (p < 0.001), and shorter hospital stays (7.0 ± 5.1 days vs. 11.1 ± 6.5; p < 0.001). No significant differences were observed in stroke > Rankin 2 (0.9% vs. 1.1%; p = 0.791), renal replacement therapy (1.5% vs. 2.4%; p = 0.4762), and hospital mortality (0.9% vs. 1.5%; p = 0.546). Conclusions: Transaxillary MICS-AVR is at least as safe as AVR by sternotomy and can be performed in the same time frame. Its advantages are fewer transfusions and quicker postoperative recovery with a significantly shorter hospital stay. The cosmetic result and unrestricted physical abilities due to the untouched sternum and ribs are unique advantages of transaxillary access.

Single-port transaxillary robotic thyroidectomy (START): 200-cases with two-step retraction method.

BACKGROUND: This study aims to report the results of a pioneering clinical study using the single-port transaxillary robotic thyroidectomy (START) for 200 patients with thyroid tumor and to introduce our novel two-step retraction method. METHODS: START was performed on consecutive 200 patients using the da Vinci Single-Port (SP) robot system from January 2019 to September 2020 at the Yonsei University Health System, Seoul, Korea. The novel two-step retraction technique, in which a 3.5 cm long incision is made along the natural skin crease, was used for the latter 164 patients. The surgical outcome and invasiveness of the SP two-step retraction method were analyzed. RESULTS: Among the 200 cases who underwent START, 198 were female and 2 were male, with a mean age of 34.7 (range: 13-58 years). Thyroid lobectomy was performed for 177 patients and total thyroidectomy was performed for 23 patients. Ten patients had benign thyroid nodules, whereas the other 190 had thyroid malignancy. The mean body mass index (BMI) was 22.2 ± 3.7 kg/m2 (range: 15.9-37.0 kg/m2). All of the operations were performed successfully without any open conversions, and patients were discharged on postoperative day 3 or 4 without significant complication. The mean operative time for thyroid lobectomy with the two-step retraction method was 116.69 ± 23.23 min, which was similar to that in the conventional robotic skin flap method (115.33 ± 17.29 min). We could minimize the extent of the robotic skin flap dissection with the two-step retraction method. CONCLUSIONS: START is a practical surgical method. By employing the new two-step retraction method, we can maximize the cosmetic and functional benefits for patients and reduce the workload fatigue of surgeons by increasing robotic dependency.

Quality of life and surgical outcome of ABBA versus EndoCATS endoscopic thyroid surgery: a single center experience.

BACKGROUND: Thyroid surgery is often performed, especially in young female patients. As patient satisfaction become more and more important, different extra-cervical "remote" approaches have evolved to avoid visible scars in the neck for better cosmetic outcome. The most common remote approaches are the transaxillary and retroauricular. Aim of this work is to compare Endoscopic Cephalic Access Thyroid Surgery (EndoCATS) and axillo-bilateral-breast approach (ABBA) to standard open procedures regarding perioperative outcome and in addition to control cohorts regarding quality of life (QoL) and patient satisfaction. METHODS: In a single center, 59 EndoCATS und 52 ABBA procedures were included out of a 2 years period and compared to 225 open procedures using propensity-score matching. For the endoscopic procedures, cosmetic outcome, patient satisfaction and QoL (SF-12 questionnaire) were examined in prospective follow-up. For QoL a German standard cohort and non-surgically patients with thyroid disease were used as controls. RESULT: The overall perioperative outcome was similar for all endoscopic compared to open thyroid surgeries. Surgical time was longer for endoscopic procedures. There were no cases of permanent hypoparathyroidism and no significant differences regarding temporary or permanent recurrent laryngeal nerve (RLN) palsies between open and ABBA or EndoCATS procedures (χ2; p = 0.893 and 0.840). For ABBA and EndoCATS, 89.6% and 94.2% of patients were satisfied with the surgical procedure. Regarding QoL, there was an overall significant difference in distribution for physical, but not for mental health between groups (p < 0.001 and 0.658). Both endoscopic groups performed slightly worse regarding physical health, but without significant difference between the individual groups in post hoc multiple comparison. CONCLUSION: Endoscopic thyroid surgery is safe with comparable perioperative outcome in experienced high-volume centers. Patient satisfaction and cosmetic results are excellent; QoL is impaired in surgical patients, as they perform slightly worse compared to German standard cohort and non-surgical patients.

Robotic transaxillary lateral neck dissection for thyroid cancer: learning experience from 500 cases.

BACKGROUND: Differentiated thyroid carcinoma with lateral neck lymph node metastasis requires aggressive operative intervention, including lateral neck dissection. Although several robotic approaches have made precise surgery for thyroid cancer possible, few centers have expanded the technique for application to lateral neck dissections. This study aimed to demonstrate the technical feasibility, cosmetic effectiveness, and safety of robotic transaxillary lateral neck dissection (RTLND) using the da Vinci system. METHODS: From January 2008 to July 2019, 500 patients diagnosed with thyroid cancer with lateral neck node metastasis underwent RTLND. The clinicopathologic characteristics and surgical outcomes were retrospectively reviewed. RESULTS: All operations were performed successfully without open conversion. As the primary operation for thyroid cancer, 476 (95.2%) patients underwent unilateral or bilateral RTLND, including robotic total thyroidectomy. The remaining 24 patients (4.8%), all of whom had a recurrence, also underwent RTLND with additional procedures, if needed. The mean operation time for the 500 operations was 293.71 ± 67.22 min. Only five cases had recurrence and required further treatment. CONCLUSIONS: RTLND is technically feasible and safe through the precise manipulation of robotic instruments. While this method is thorough and provides safe and effective surgical outcomes, it also offers the additional advantage of being minimally invasive.

Percutaneous trans-axilla transcatheter aortic valve replacement.

The left axillary artery is an attractive alternative access route for transcatheter aortic valve replacement (TAVR) and may provide better outcomes compared to other alternatives. Nevertheless, there remain concerns about vascular complications, lack of compressibility, and thorax-related complications. Between March 2019 and March 2021, 13 patients underwent transaxillary TAVR for severe aortic stenosis at the University Hospital Bonn. The puncture was performed with a puncture at the distal segment of the axillary artery through the axilla, with additional femoral access for applying a safety wire inside the axillary artery. Device success was defined according to the VARC 2 criteria. The study participants were advanced in age (77 ± 9 years old), and 54% were female, with an intermediate risk for surgery (STS risk score 4.7 ± 2.0%). The average diameter of the distal segment of the axillary artery was 5.8 ± 1.0 mm (i.e., the puncture site) and 7.6 ± 0.9 mm for the proximal axillary artery. Device success was achieved in all patients. 30-day major adverse cardiac and cerebrovascular events were 0%. With complete percutaneous management, stent-graft implantation was performed at the puncture site in 38.5% of patients. Minor bleeding was successfully managed with manual compression. Moreover, no thorax-related complications, hematomas, or nerve injuries were observed. Percutaneous trans-axilla TAVR was found to be feasible and safe. This modified approach may mitigate the risk of bleeding and serious complications in the thorax and be less invasive than surgical alternatives.