Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases.

INTRODUCTION: Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars. METHODS: Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021. RESULTS: Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. CONCLUSTIONS: Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.

Angiografía intraoperatoria con verde de indocianina (ICG) de las glándulas paratiroides para predecir la hipocalcemia postiroidectomía: análisis comparativo de 2 sistemas de puntuación (ICG-2 vs. ICG-4) / Intraoperative indocyanine green (ICG) angiography of the parathyroids glands in prediction of post-thyroidectomy hypocalcemia: Diagnostic accuracy of the ICG score 2 versus the 4-ICG score

IntroducciónLa angiografía de las glándulas paratiroides con verde de indocianina (ICG) es útil para predecir la hipocalcemia postiroidectomía. En este estudio se ha comparado la exactitud diagnóstica del sistema ICG-2, basado en la presencia de glándulas bien perfundidas (puntuación igual a 2), con el sistema ICG-4 basado en la suma del valor de la puntuación de las 4 glándulas.MétodosUn total de 50 pacientes (66% mujeres, mediana de edad: 49,4 años) fueron operadas practicándose una tiroidectomía total con identificación de las 4 glándulas paratiroides. El grado de la ICG se clasificó como 0: color negro (no vascularizada), 1: color gris/heterogéneo (parcialmente vascularizada) y 2: color blanco (bien vascularizada).ResultadosLa exactitud diagnóstica de ICG-4 para un punto de corte ≤3 fue del 85% (intervalo de confianza del 95%: 70,9-92,8), inferior al 92% (80,8-97,8) del ICG-2. Con ambas puntuaciones se detectaron 2 casos de falsos negativos, pero las tasas de falsos positivos fueron menores con el ICG-2 (18,2 vs. 57,1%).ConclusionesEl sistema ICG-2 predice la función paratiroidea en el postoperatorio inmediato mejor que el ICG-4 para valores de punto de corte ≤2 y ≤3 (AU)

IntroductionIndocyanine green (ICG) angiography of the parathyroids is useful in prediction of postthyroidectomy hypocalcemia. We compared the diagnostic accuracy of a single-gland ICG score of 2 with a score estimated by adding the viability value of the four glands (4-ICG).MethodsFifty patients (66% women, median age 49.4 years) underwent total thyroidectomy with identification of all 4 glands. The degree of ICG was classified as 0: black (nonvascularized), 1: gray/heterogeneous (partially vascularized), and 2: white (well vascularized).ResultsThe diagnostic accuracy of the optimal cut-off of the 4-ICG sum score ≤3 was 84% (95% CI: 70.9-92.8) lower than the diagnostic accuracy of 92% (80.8-97.8) of the ICG score 2. Both scores identified 2 false negative cases, but the rates of false positives were lower with the ICG score 2 (18.2 vs. 57.1%).ConclusionsIdentification of single-gland ICG score of 2 has a higher diagnostic accuracy than 4-ICG sum score to predict immediate hypocalcemia after total thyroidectomy (AU)

Transoral endoscopic thyroidectomy vestibular approach (TOETVA).

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique that allows the thyroid to be approached without visible scars, as it is performed through a natural orifice. It was first described and developed in Asia where due to sociocultural reasons neck scars are considered a stigma. This technique, as we now nowadays, and its preliminary results, were first reported by Angkoon Anuwong in August 2015 at the International Association of Endocrine Surgeons (IAES) world surgery congress held in Bangkok. Here we present the TOETVA approach, step-by-step, in order it could be safely replicated, aiming also it can be spread within the therapeutic framework of endocrine surgery. However, it is important to remark that, as happens in most of remote approaches, it is only suitable for a small percentage of patients.

Tiroidectomía endoscópica transoral por vía vestibular: TOETVA / Transoral endoscopic thyroidectomy vestibular approach (TOETVA)

La tiroidectomía endoscópica transoral por vía vestibular (TOETVA) es una técnica novedosa que permite abordar el tiroides sin cicatrices visibles, ya que se realiza a través de un orificio natural. Tiene su origen en Asia debido a que, por motivos culturales, una cicatriz en el cuello puede ser considerada un estigma. Esta técnica, tal y como la conocemos ahora y sus resultados preliminares, fueron comunicados por primera vez por Angkoon Anuwong en agosto del 2015 en el congreso mundial de cirugía de la International Association of Endocrine Surgeons (IAES) en Bangkok.Con el objetivo de difundir el abordaje transoral, lo explicamos paso a paso para que pueda ser reproducido con seguridad y considerado como uno más en el contexto terapéutico de la cirugía endocrina. No obstante, somos conscientes de que, como ocurre con la mayoría de los accesos remotos, solo es aplicable para un pequeño porcentaje de pacientes (AU)

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique that allows the thyroid to be approached without visible scars, as it is performed through a natural orifice. It was first described and developed in Asia where due to sociocultural reasons neck scars are considered a stigma. This technique, as we now nowadays, and its preliminary results, were first reported by Angkoon Anuwong in August 2015 at the International Association of Endocrine Surgeons (IAES) world surgery congress held in Bangkok.Here we present the TOETVA approach, step-by-step, in order it could be safely replicated, aiming also it can be spread within the therapeutic framework of endocrine surgery. However, it is important to remark that, as happens in most of remote approaches, it is only suitable for a small percentage of patients (AU)

Intraoperative indocyanine green (ICG) angiography of the parathyroids glands in prediction of post-thyroidectomy hypocalcemia: Diagnostic accuracy of the ICG score 2 versus the 4-ICG score.

INTRODUCTION: Indocyanine green (ICG) angiography of the parathyroids is useful in prediction of postthyroidectomy hypocalcemia. We compared the diagnostic accuracy of a single-gland ICG score of 2 with a score estimated by adding the viability value of the four glands (4-ICG). METHODS: Fifty patients (66% women, median age 49.4 years) underwent total thyroidectomy with identification of all 4 glands. The degree of ICG was classified as 0, black (nonvascularized), 1, gray/heterogeneous (partially vascularized), and 2, white (well vascularized). RESULTS: The diagnostic accuracy of the optimal cut-off of the 4-ICG sum score ≤3 was 84% (95% CI 70.9-92.8) lower than the diagnostic accuracy of 92% (80.8-97.8) of the ICG score 2. Both scores identified 2 false negative cases, but the rates of false positives were lower with the ICG score 2 (18.2% vs. 57.1%). CONCLUSIONS: Identification of single-gland ICG score of 2 has a higher diagnostic accuracy than 4-ICG sum score to predict immediate hypocalcemia after total thyroidectomy.

Intraoperative Indocyanine Green Angiography of Parathyroid Glands and the Prevention of Post-Thyroidectomy Hypocalcemia.

BACKGROUND: We compared the reliability of indocyanine green (ICG) angiography and intraoperative PTH levels for predicting early post-thyroidectomy hypocalcemia. METHODS: Prospective study of 94 patients (71% women, mean age 53.7 years) undergoing total thyroidectomy. An ICG score of 2 (white) indicated a well-vascularized gland. PTH preoperative levels-PTH postresection levels divided by preoperative PTH × 100 was used to determine the PTH decline percentage. A decrease of at least 62.5% or <17.1 pg/mL in ioPTH was the criterion for predicting hypocalcemia. RESULTS: At surgery, the four parathyroid glands were identified in 50 (53.2%) patients and <4 glands in 44. Calcium supplements were needed by 22 patients (23.4%) postoperatively, 11 patients in each group of 4 and <4 parathyroid glands identified. The diagnostic accuracy of ICG angiography (0.883, 95% confidence interval [CI] 0.800-0.940) and ioPTH (0.862, 95% CI 0.775-0.92) was similar. When all four parathyroid glands were identified, ICG angiography showed a slightly higher diagnostic accuracy, specificity and positive predictive than ioPTH levels, but when < 4 glands were identified, the ioPTH showed a slightly higher diagnostic accuracy, specificity and positive predictive value. Differences were not statistically significant for any of the comparisons. CONCLUSIONS: The presence of one well-perfused parathyroid gland (ICG score 2) using ICG angiography or ioPTH decline, measured before and after completion of thyroid surgery, is both reliable methods in prediction of early post-thyroidectomy hypocalcemia independently of the number of glands identified intraoperatively.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA). / Tiroidectomía endoscópica transoral por vía vestibular: TOETVA.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique that allows the thyroid to be approached without visible scars, as it is performed through a natural orifice. It was first described and developed in Asia where due to sociocultural reasons neck scars are considered a stigma. This technique, as we now nowadays, and its preliminary results, were first reported by Angkoon Anuwong in August 2015 at the International Association of Endocrine Surgeons (IAES) world surgery congress held in Bangkok. Here we present the TOETVA approach, step-by-step, in order it could be safely replicated, aiming also it can be spread within the therapeutic framework of endocrine surgery. However, it is important to remark that, as happens in most of remote approaches, it is only suitable for a small percentage of patients.

Intraoperative indocyanine green (ICG) angiography of the parathyroids glands in prediction of post-thyroidectomy hypocalcemia: Diagnostic accuracy of the ICG score 2 versus the 4-ICG score. / Angiografía intraoperatoria con verde de indocianina (ICG) de las glándulas paratiroides para predecir la hipocalcemia postiroidectomía: análisis comparativo de 2 sistemas de puntuación (ICG-2 vs. ICG-4).

INTRODUCTION: Indocyanine green (ICG) angiography of the parathyroids is useful in prediction of postthyroidectomy hypocalcemia. We compared the diagnostic accuracy of a single-gland ICG score of 2 with a score estimated by adding the viability value of the four glands (4-ICG). METHODS: Fifty patients (66% women, median age 49.4 years) underwent total thyroidectomy with identification of all 4 glands. The degree of ICG was classified as 0: black (nonvascularized), 1: gray/heterogeneous (partially vascularized), and 2: white (well vascularized). RESULTS: The diagnostic accuracy of the optimal cut-off of the 4-ICG sum score ≤3 was 84% (95% CI: 70.9-92.8) lower than the diagnostic accuracy of 92% (80.8-97.8) of the ICG score 2. Both scores identified 2 false negative cases, but the rates of false positives were lower with the ICG score 2 (18.2 vs. 57.1%). CONCLUSIONS: Identification of single-gland ICG score of 2 has a higher diagnostic accuracy than 4-ICG sum score to predict immediate hypocalcemia after total thyroidectomy.

Abordajes en cirugía tiroidea / Surgical approaches to thyroid

La tiroidectomía es el procedimiento más común en cirugía endocrina. La incisión cervical de Kocher es el «gold standard» para abordar el tiroides desde que fuera presentado por este a finales del siglo xix. Desde entonces, la tiroidectomía tal y como ahora la conocemos ha demostrado ser una técnica eficaz y segura, pero no por ello ha dejado de evolucionar habiendo conseguido además unos indicadores de calidad difíciles de superar. El advenimiento de nuevas tecnologías y un intento constante por mejorar la cosmética de la cirugía han dado lugar a «nuevos abordajes». En este artículo hacemos una revisión de estos intentando mostrar sus beneficios y limitaciones. Actualmente, ninguno ha demostrado ser mejor que la cirugía convencional más allá del valor añadido del beneficio cosmético, pero permanecerán si demuestran que han sido eficientes en el tratamiento de la enfermedad y en mejorar la calidad de vida de nuestros pacientes. (AU)

Thyroidectomy is the most frequent procedure in endocrine surgery. The conventional approach through a collar incision, as described by Kocher in XIXth century, has become the “gold standard”. It is continuously evolving in spite of, many years ago, it showed to be safe and efficient with quality standards difficult to beat. Endoscopic and robotic surgery have developed “new approaches” to thyroid in order to improve the cosmetic results, looking even for invisible scars. We have done a thoughtful review of most of them trying to understand their benefits and drawbacks. Currently none of these “new approaches” have been shown to be better than conventional open thyroidectomy beyond offering a better cosmetic result. Besides, only a small percentage of patients can benefit of them. However, most of these approaches will remain if they treat the diseased thyroid and also improve the quality of life of our patients. (AU)

Surgical approaches to thyroid. / Abordajes en cirugía tiroidea.

Thyroidectomy is the most frequent procedure in endocrine surgery. The conventional approach through a collar incision, as described by Kocher in XIXth century, has become the "gold standard". It is continuously evolving in spite of, many years ago, it showed to be safe and efficient with quality standards difficult to beat. Endoscopic and robotic surgery have developed "new approaches" to thyroid in order to improve the cosmetic results, looking even for invisible scars. We have done a thoughtful review of most of them trying to understand their benefits and drawbacks. Currently none of these "new approaches" have been shown to be better than conventional open thyroidectomy beyond offering a better cosmetic result. Besides, only a small percentage of patients can benefit of them. However, most of these approaches will remain if they treat the diseased thyroid and also improve the quality of life of our patients.