|Year : 2021 | Volume
| Issue : 5 | Page : 1248-1252
Comparing endoscopic thyroidectomy using the breast approach and conventional open thyroidectomy: A retrospective analysis
Hanyuan Zhang1, Weichen Shi2, Jiqing Zhang3, Jia Xu2, Dongsheng Zhou2, Wei Liu2, Rongzhan Fu2, Hongqiang Chen2
1 Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
2 Department of General Surgery, The First Affiliated Hospital of Shandong First Medicinal University, Jinan, Shandong, China
3 Department of Medical Ultrasound, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
|Date of Submission||29-Apr-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||27-Nov-2021|
Department of General Surgery, The First Affiliated Hospital of Shandong First Medicinal University, Jinan, Shandong
Department of General Surgery, The First Affiliated Hospital of Shandong First Medicinal University, Jinan, Shandong
Source of Support: None, Conflict of Interest: None
Aims: Endoscopic thyroidectomy (ET) using the breast approach and conventional open thyroidectomy (OT) are effective approaches to treating thyroid tumors. This study evaluates the effectiveness of ET and OT regarding safety, cosmetic effects, and feasibility.
Subjects and Methods: Four hundred and fifty-six patients who underwent thyroidectomy in our department from January 2019 to August 2020 were included in this study. Based on the intraoperative rapid pathology, all patients with papillary thyroid carcinoma underwent unilateral thyroid lobectomy and central neck lymph node dissection. Whereas all benign patients underwent unilateral thyroid lobectomy. Differences in various factors such as clinical characteristics, operation time, postoperative drainage volume, parathyroid hormone (PTH) levels, calcium (Ca) levels, total number of central lymph nodes resected, the number of metastatic central lymph nodes resected, hospital duration, hospitalization costs, and cosmetic effects were compared in each group.
Results: Baseline characteristics among the four groups were similar, except for patient age and tumor size. Patients in the malignant ET group were younger than those in the malignant OT group with smaller tumors (P < 0.05). There were no significant differences between the OT and ET groups in postoperative Ca levels, PTH levels, the total number of lymph nodes resected, and the number of metastatic central lymph nodes resected.
Conclusions: Compared with conventional OT, ET is a feasible, practical, and safe procedure with excellent cosmetic benefits.
Keywords: Conventional open thyroidectomy, cosmetology, endoscopic thyroidectomy through breast approach, feasibility, safety
|How to cite this article:|
Zhang H, Shi W, Zhang J, Xu J, Zhou D, Liu W, Fu R, Chen H. Comparing endoscopic thyroidectomy using the breast approach and conventional open thyroidectomy: A retrospective analysis. J Can Res Ther 2021;17:1248-52
|How to cite this URL:|
Zhang H, Shi W, Zhang J, Xu J, Zhou D, Liu W, Fu R, Chen H. Comparing endoscopic thyroidectomy using the breast approach and conventional open thyroidectomy: A retrospective analysis. J Can Res Ther [serial online] 2021 [cited 2022 Jan 24];17:1248-52. Available from: https://www.cancerjournal.net/text.asp?2021/17/5/1248/331312
| > Introduction|| |
Recently, an increasing number of patients have been diagnosed with thyroid diseases and underwent surgical treatment. The conventional open thyroidectomy (OT) is a traditional and common treatment that leaves a scar on the neck, causing disastrous cosmetic effects. However, endoscopic thyroidectomy (ET) develops rapidly and removes scars in invisible places to reduce the psychological burden of patients and achieve the aim of cosmetology. Meanwhile, many surgeons and patients are concerned and puzzled about ETs safety and feasibility. In this study, we analyzed our department's data and compared the effectiveness of ET and OT regarding safety, cosmetic effects, and feasibility.
| > Subjects and Methods|| |
This study comprises 456 patients who underwent OT or ET treatment in the department of general surgery of the First Affiliated Hospital of Shandong First Medicinal University from January 2019 to August 2020. The same surgical team performed all operations. The OT and ET surgical approaches were explained to all the patients before operations. Patients could choose the preferred surgical approach freely. All patients had a diagnosis of intraoperative rapid pathology examination. For benign tumors, unilateral thyroidectomy was performed. For malignant tumors, unilateral thyroidectomy and central lymph node dissection were performed. The patients were divided into four groups: benign OT group (n = 137), malignant OT group (n = 185), benign ET group (n = 41), and malignant ET group (n = 93). Inclusion criteria for this study include (1) unilateral thyroidectomy; (2) no metastasis in the lateral cervical and superior mediastinal; (3) no distant metastasis; (4) postoperative pathology was papillary thyroid carcinoma (PTC) or benign disease; and (5) patients signed informed consent and finished our follow-up. Exclusion criteria include (1) history of neck surgery or radiotherapy; (2) total thyroidectomy; (3) evidence of local invasion or involvement of the recurrent laryngeal nerve (RLN); (4) preoperative imaging revealing enlarged and fused lymph nodes or special pathology types; (5) patients disagreed or quit the research.
To assess the safety and feasibility, baseline characteristics, operation time, hospital duration, postoperative parathyroid hormone (PTH) levels, postoperative calcium (Ca) levels, and postoperative complications, the total number of central lymph nodes resected, the number of metastatic central lymph nodes resected, postoperative drainage volume, hospitalization costs, and cosmetic effects were assessed. In addition, data were collected from the patients' medical records. Postoperative complications included RLN injury, postoperative lymphatic leakage, parathyroid injury, postoperative infection, postoperative bleeding, and skin traction sensation.
Patients were followed up in the outpatient clinic or by telephone monthly. Thyroid hormone and PTH levels were measured to assess thyroid function and parathyroid function 1 month after the operations. Ultrasonography was performed to evaluate the recurrence 3 months after the operations, and cosmetic effects were assessed 3 months after the operations. Other postoperative complications were assessed by clinical symptoms.
The ET group patients were under anesthesia, and “inflation fluid” was injected subcutaneously into the deep fascia below the suprasternal notch. Breast and neck subcutaneous spaces were bluntly dissected using a subcutaneous separation stick. The trocar and laparoscopic equipment were placed for further operation. The operating procedures were performed using a similar approach described by Kim et al.
Conventional open thyroidectomy
The surgical technique of conventional OT also required tracheal intubation and anesthesia. The operating procedure was performed using a similar approach described by Roman.
Relative data analysis
Data were analyzed using a similar method described by Wang et al. The baseline characteristics included age, sex, and tumor size. In addition, we assessed the operation time, postoperative drainage volume, hospital duration, postoperative complications, postoperative PTH levels, and postoperative Ca levels for operation safety. Finally, hospitalization costs, the number of central lymph nodes, the number of metastatic central lymph nodes, and cosmetic effects were measured to assess feasibility.
SPSS v. 20.0(IBM, Chicago, IL, USA) was used for statistical analysis. The count data were analyzed by t-test analysis, χ2 test, and comparison of two sample rates. Differences with P < 0.05 were considered statistically significant.
| > Results|| |
The baseline characteristics of 456 patients are summarized in [Table 1]. There were no significant differences in patient's gender among the four groups. Patients in the benign ET group were younger than those in the benign OT group (38.07 ± 9.65 vs. 51.97 ± 13.11, P= 0.000). Similar results were found in the malignant groups, in which the malignant OT group had a higher mean age than that in the malignant ET group (46.83 ± 11.38 vs. 37.41 ± 9.34, P = 0.000). In addition, tumor size in the malignant OT group was larger than that in the malignant ET group (0.77 ± 0.45 vs. 0.66 ± 0.40, P = 0.04). In contrast, there were no significant differences in the benign groups (2.40 ± 1.67 vs. 2.09 ± 0.98, P = 0.14).
For the operation time part, the ET groups' operation time was longer than that in the OT groups (P < 0.05). Whereas, hospital duration in the ET groups was smaller than that in the OT groups (P < 0.05). The drainage volume of the benign OT group was smaller than that of the benign ET group (44.69 ± 21.52 vs. 85.73 ± 41.04, P = 0.000), which was similar to the malignant groups, all P < 0.05. Postoperative PTH and Ca levels were measured 2 d after the operations to evaluate postoperative hypocalcemia and hypoparathyroidism. Postoperative Ca levels lower than 2 mmol/L were diagnosed as hypocalcemia; meanwhile, postoperative PTH levels lower than 15 pg/mL were diagnosed as hypoparathyroidism. There were no significant differences in postoperative PTH levels among the four groups (P > 0.05). The same results were found in the Ca levels, with no significant differences among the four groups (P > 0.05). The ET groups were extremely higher than the OT groups (94.78% vs. 81.99%, P = 0.000). Meanwhile, there were no significant differences in postoperative complications among the four groups including RLN injury, postoperative lymphatic leakage, parathyroid injury, postoperative hypocalcemia, postoperative bleeding, and skin traction sensation (P > 0.05). No postoperative infection and recurrence were found among all patients [Table 2].
Feasibility of central neck dissection
All patients with PTC underwent unilateral thyroid lobectomy and central neck lymph node dissection based on the intraoperative rapid pathology. We analyzed the total number of central lymph nodes resected, and the number of metastatic lymph nodes resected using routine pathology. The total number of central lymph nodes resected in the malignant OT group was similar to the malignant ET group (5.25± 3.80 vs. 5.51 ± 4.20, P = 0.61). Meanwhile, the number of metastatic lymph nodes was similar between the malignant OT and ET groups (0.77 ± 1.38 vs. 0.98 ± 1.67, P= 0.26) [Table 3].
Hospitalization costs in OT groups were smaller than that in the ET groups (benign, 25276.85 ± 3548.56 vs. 32120.27 ± 2325.42, P = 0.000; malignant 29035.57 ± 22701.29 vs. 37186.16 ± 30997.03, P= 0.01) [Table 3].
| > Discussion|| |
The prevalence of PTC has been increasing recently, and many patients undergo surgical treatment. Conventional OT is the gold standard procedure for thyroidectomy currently. However, the anterior neck is a prominent and exposed part of the body, whereas conventional OT inevitably leaves visible scars on the neck, which is undesirable for many young women. This contradiction and cosmetic desire promote the development of various neck-scar-fr free endoscopic surgical approaches. The first ET was successfully performed by Huscher in 1997. The advantage of ET through the breast approach is the invisible scar in the neck, which conforms to the cosmetic requirements for most patients. With the progress of anatomy and endoscopic technology, many endoscopic approaches, such as the subclavian approach, the axillary approach,, and the transoral approach, have been applied. Wang Ping concluded that the indications for ET included the following; (1) 15–45 years old; (2) without extensive lymph node metastasis and fixed or fused metastatic lymph nodes; (3) unifocal tumors <2 cm; (4) no metastasis in the lateral cervical and superior mediastinal lymph nodes; and (5) patients had a strong desire for cosmetology.
Our study included 456 patients in our hospital from January 2019 to August 2020. Baseline characteristics among benign and malignant groups were similar, except for the patient's age and tumor size. Regarding clinical safety and effectiveness, there were no significant differences in postoperative calcium (Ca) levels, PTH levels, the total number of lymph nodes resected, and the number of metastatic central lymph nodes resected between OT and ET groups. This revealed that the ET approach had similar effects on clinical safety and effectiveness as the OT approach. In addition, it was foreseeable for us to understand that the ET groups had a longer operation time, higher postoperative drainage volume, and higher hospitalization costs. However, regarding cosmetic effects, small scars in the sternum and nipple areola were almost invisible. Finally, the ET groups had extremely better cosmetic effects and a shorter hospital duration than in the OT groups.
Protection of RLN and parathyroid glands has always been a concern in thyroidectomy, which was closely associated with patients' living quality and their satisfaction with surgical treatment. In our study, 13 patients (eight in the OT group vs. five in the ET group, P = 0.68) had transient RLN injury. Among them, all patients recovered 12 months after the operation. With the application of intraoperative neuromonitoring systems, the RLN can be easily identified and protected. Moreover, for preserving the RLN, it has been reported that the ultrasound scalpels should have at least a 5-mm distance from the RLN.
Regarding parathyroid gland protection, it has been reported that the dissection of the central lymph nodes may injure the blood supply of the parathyroid gland, so strategic parathyroid reimplantation is recommended, especially for total thyroidectomy. The application of nanocarbon is another effective method, which helps distinguish the parathyroid gland from the thyroid. The application of autofluorescence technique is also a valid way in parathyroid gland protection. In our department, we detected the suspicious parathyroid gland routinely, although the mechanism was unclear.
Skin traction sensation can automatically alleviate other postoperative complications by treating patients with Vitamin B12 after surgery. Patients did not have postoperative infections in our study. It has been reported that hypertension, diabetes, high body mass index, and longer operation time are risk factors for postoperative bleeding. In addition, there was no postoperative bleeding in any group. For lymphatic leakage, 16 patients were included in our study (nine in the OT group vs. seven in the ET group, P =0.32). In our opinion, continuous negative pressure drainage and a light diet can effectively treat central neck lymphatic leakage. This study was not powered to detect any differences in recurrence since there were no recurrences identified in any group through our follow-up.
| > Conclusions|| |
Conclusively, ET through the breast approach had the same safety and feasibility as conventional OT, and its cosmetic effect was satisfactory. Furthermore, a long-time follow-up and multicenter study were necessary for our future study to get more convincing results. Nevertheless, ET was a feasible, practical, and safe procedure with excellent cosmetic effects based on our results.
We would like to thank iepingmed (http://www.aiyiping.com) for English language editing.
Financial support and sponsorship
This study was supported by the National Natural Science Foundation of China (81900621,81700387) and the Natural Science Foundation of Shandong Province (ZR2017BH070, ZR201702210278).
Conflicts of interest
There are no conflicts of interest.
| > References|| |
James BC, Timsina L, Graham R, Angelos P, Haggstrom DA. Changes in total thyroidectomy versus thyroid lobectomy for papillary thyroid cancer during the past 15 years. Surgery 2019;166:41-7.
Yang Y, Gu X, Wang X, Xiang J, Chen Z. Endoscopic thyroidectomy for differentiated thyroid cancer. ScientificWorldJournal 2012;2012:456807.
Kim YS, Joo KH, Park SC, Kim KH, Ahn CH, Kim JS. Endoscopic thyroid surgery via a breast approach: A single institution's experiences. BMC Surg 2014;14:49.
Roman BR, Randolph GW, Kamani D. Conventional thyroidectomy in the treatment of primary thyroid cancer. Endocrinol Metab Clin North Am 2019;48:125-41.
Wang Y, Liu K, Xiong J, Zhu J. Total endoscopic versus conventional open thyroidectomy for papillary thyroid microcarcinoma. J Craniofac Surg 2015;26:464-8.
Sun H, Zheng H, Wang X, Zeng Q, Wang P, Wang Y. Comparison of transoral endoscopic thyroidectomy vestibular approach, total endoscopic thyroidectomy via areola approach, and conventional open thyroidectomy: A retrospective analysis of safety, trauma, and feasibility of central neck dissection in the treatment of papillary thyroid carcinoma. Surg Endosc 2020;34:268-74.
Hüscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877.
Cai Q, Huang X, Han P, Sun W, Liang F, Jiang X. Endoscopy-assisted thyroid surgery via a subclavian approach. Surg Today 2012;43:479-84.
Lee D, Nam Y, Sung K. Single-incision endoscopic thyroidectomy by the axillary approach. J Laparoendosc Adv Surg Tech A 2010;20:839-42.
Yan H, Wang Y, Huang P, Hong Y, Ye Q, Xie Q, et al.
Scarless neck endoscopic thyroidectomy via the breast approach: A preliminary report of 45 cases with total or near-total thyroidectomy plus central compartment dissection. Niger J Clin Pract 2019;22:1772-7.
] [Full text]
Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, et al.
Transoral endoscopic thyroidectomy vestibular approach (TOETVA): Indications, techniques and results. Surg Endosc 2018;32:456-65.
Nisi P, Piva G, Cozzani F, Rossini M, Bonati E, Madoni C, et al.
Intraoperative neuromonitoring in traditional and miniinvasive thyroidectomy. A single center experience in 1652 nerve at risk. Acta Biomed 2020;91:64-9.
Yang J, Wang C, Li J, Yang W, Cao G, Wong HM, et al.
Complete endoscopic thyroidectomy via oral vestibular approach versus areola approach for treatment of thyroid diseases. J Laparoendosc Adv Surg Tech A 2015;25:470-6.
Wang C, Feng Z, Li J, Yang W, Zhai H, Choi N, et al.
Endoscopic thyroidectomy via areola approach: Summary of 1,250 cases in a single institution. Surg Endosc 2015;29:192-201.
Ma JJ, Zhang DB, Zhang WF, Wang X. Application of nanocarbon in breast approach endoscopic thyroidectomy thyroid cancer surgery. J Laparoendosc Adv Surg Tech A 2020;30:547-52.
Sun N, Zhang D, Zheng S, Fu L, Li L, Liu S, et al.
Incidence and risk factors of postoperative bleeding in patients undergoing total thyroidectomy. Front Oncol 2020;10:1075.
[Table 1], [Table 2], [Table 3]