Abstract
Transoral endocrine surgery (TES) allows thyroid and parathyroid operations to be performed without leaving any visible scar on the body. Controversy regarding the value of TES remains, in part owing to the common belief that TES is only applicable to a small, select group of patients. Knowledge of the overall applicability of these procedures is essential to understand the operation, as well as to decide the amount of effort and resources that should be allocated to further study the safety, efficacy, and value of these operations. To determine what percentage of US patients undergoing thyroid and parathyroid surgery are eligible for TES using currently accepted exclusion criteria. Cross-sectional study of 1000 consecutive thyroid and parathyroid operations (with or without neck dissection) performed between July 1, 2015, and July 1, 2018, at 3 high-volume academic US thyroid- and parathyroid-focused surgical practices (2 general surgery, 1 otolaryngology-head and neck endocrine surgery). Eligibility for TES was determined by retrospectively applying previously published exclusion criteria to the cases. The primary outcome was the percentage of thyroid and parathyroid cases eligible for TES. Secondary outcomes were a subgroup analysis of the percentage of specific types of cases eligible and the reasons for ineligibility. The mean (SD) age of the 1000 surgical patients was 53 (15) years, mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 29 (7), and 747 (75.0%) of the patients were women. Five hundred fifty-eight (55.8%) of the patients were eligible for TES. Most patients with thyroid nodules with cytologically indeterminate behavior (165 of 217 [76.0%]), benign thyroid conditions (166 of 240 [69.2%]), and primary hyperparathyroidism (158 of 273 [57.9%]) were eligible for TES, but only 67 of 231 (29.0%) of patients with thyroid cancer were eligible. Among all 1000 cases reviewed, previous neck operation (97 of 441 [22.0%]), nonlocalized primary hyperparathyroidism (78 of 441 [17.7%]), and need for neck dissection (66 of 441 [15.0%]) were the most common reasons for ineligibility. More than half of all patients undergoing thyroid and parathyroid surgery in this study were eligible for TES. This broad applicability suggests that a prospective multicenter trial is reasonable to definitively study the safety, outcomes, and cost of TES.
Highlights
Transoral endocrine surgery (TES) comprises a group of operations that allow thyroidectomies and parathyroidectomies to be done without leaving a visible scar on the patient’s neck
More than half of all patients undergoing thyroid and parathyroid surgery in this study were eligible for TES
Considering that up to 140 000 thyroid and parathyroid operations could be performed via TES annually in the United States, our results suggest that TES is applicable to a large number of patients and may not be considered a “boutique” operation in the near future
Summary
Transoral endocrine surgery (TES) comprises a group of operations that allow thyroidectomies and parathyroidectomies to be done without leaving a visible scar on the patient’s neck. The transoral vestibular approach was first described in 2011 in cadavers by Richmon et al and later popularized by Anuwong in humans. This approach has supplanted all other oral access approaches to the thyroid and parathyroid because of its improved safety and feasibility; TES may be referred to as TOVAES (transoral vestibular approach endocrine surgery). Proponents of TES cite the proximity to the target anatomy as one of the main advantages of these operations over other minimally invasive or remote-access approaches to the neck. The first endoscopic and robotic TES operations were performed in the United States in April 2016.4,5 It is estimated that as of January 2019 approximately 300 of these procedures have been performed in the United States, across multiple centers
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