Permanent Recurrent Laryngeal Nerve Research Articles

Transoral robotic thyroidectomy: Lessons learned from consecutive series of 1,000 patients

BackgroundTransoral robotic thyroidectomy has gained popularity as a promising approach for thyroid surgery owing to its improved cosmetic outcomes. The objective of this retrospective study was to describe the surgical and safety outcomes of 1,000 consecutive transoral robotic thyroidectomy cases. Methods1,000 consecutive patients who underwent transoral robotic thyroidectomy for thyroid disease were reviewed at a large metropolitan tertiary hospital (Seoul, Korea) between September 2012 and March 2022. ResultsThe study comprised 1,000 patients (815 women), with 891 cancer cases. Lobectomy was the most common procedure (89.4%), followed by total thyroidectomy (9.8%) and isthmusectomy (0.8%), and their respective mean total operative times were 173.8 ± 36.2, 236.8 ± 50.5, and 107.5 ± 19.8 minutes. An obvious learning curve was noted. The respective postoperative pain scores on postoperative days 0, 1, and 2 were 4.6 ± 1.3, 3.1 ± 0.8, and 2.5 ± 0.8. The mean postoperative hospital stay duration was 2.6 ± 0.9 days. Complications occurred in 3.6% of cases, including oral wound infection, skin flap burn, bleeding, chyle leakage, transient and permanent mental nerve injury, and transient and permanent recurrent laryngeal nerve injury. Transient hypoparathyroidism occurred in 4.1% of total thyroidectomy cases. Thirty-seven patients (4.2%) underwent additional radioactive iodine therapy. The median follow-up period was 39 months, and there were no cases of recurrence. ConclusionsUnder the expertise of an experienced surgeon, transoral robotic thyroidectomy results in favorable cosmetic outcomes, tolerable postoperative pain, and acceptable complication rates in carefully selected patients.

Management of Indeterminate Thyroid Nodules: A Model Comparing Surgery, Molecular Testing, and Observation.

Optimal management of indeterminate nodules remains a controversial area of endocrine surgery. The purpose of this study is to compare observation, molecular testing, and immediate thyroid surgery for the management of Bethesda Classes III and IV nodules in patients age 50 to 90 years. A decision analysis was performed from April 22, 2021, to September 29, 2023, using a Markov model constructed with TreeAgePro 2023. Model variables and ranges were selected based on literature review data. TreeAgePro. A 1-way sensitivity analysis was performed to evaluate the age threshold at which each management pathway, immediate thyroid surgery, additional molecular testing, or observation, would be favored. A Monte Carlo probabilistic sensitivity analysis was performed 5 times with model patients assigned starting ages of 50, 60, 70, 80, and 90 years to assess how age at diagnosis would impact model results. Outcomes were measured with quality-adjusted life-years and accounted for perioperative complications including permanent recurrent laryngeal nerve injury, permanent hypoparathyroidism, and medical complications. In the study models, molecular testing was more beneficial than surgery and observation across all ages. The age threshold at which observation became more beneficial than surgery as the next best option was 83.1 years. However, the clinical difference between all 3 treatment algorithms was relatively minimal. Decision-making regarding indeterminate thyroid nodules is complex. Given the clinically similar results across all 3 treatment algorithm, this study reinforces that treatment modalities should be individually tailored and based on shared physician-patient decision making.

Ultrasound-guided percutaneous radiofrequency ablation versus surgery for solitary T1N0M0 papillary thyroid carcinoma in the danger triangle.

To compare the safety and efficiency of ultrasound-guided percutaneous radiofrequency ablation (RFA) and surgical resection (SR) for thyroid papillary carcinoma (PTC) in the danger triangle area. The clinical data of 298 patients who underwent either percutaneous RFA or SR for PTC in the thyroid danger triangle at our hospital between January 2018 and April 2020 were retrospectively analyzed. Propensity score matching is employed to regulate for confounding factors. All patients undergoing ablation were treated using a strategy that combined sufficient paratracheal fluid isolation with a low-power, short electrode. Disease progression was analyzed in patients with T1N0M0 PTC (T1a and T1b) employed in Kaplan‒Meier curves. Treatment parameters and the rates of local recurrence, distant metastasis, and complications are recorded and compared. Of 182 eligible patients who were included, 91 were in the RFA (age 44.84 ± 13.19; 71 females; 77 T1a) and 91 were in the SR (age 47.36 ± 11.05; 68 females; 69 T1a). The average treatment time, length of hospital stays, blood loss volume, and scar length are substantially less in the RFA than in the SR. Major complications as well as postoperative permanent recurrent laryngeal nerve injury and postoperative transient parathyroid dysfunction occurred only in the SR, with a substantial distinction between the two groups (p < 0.05). There is no substantial distinction in the disease progression between RFA and SR treatment of T1N0M0 PTC. RFA is as effective as surgery for PTC in the danger triangle area in the short term, with faster recovery and fewer complications. Radiofrequency ablation has a clinical efficacy comparable to surgery in the treatment of papillary thyroid carcinoma in the danger triangle area in the short term with the advantages of faster recovery and fewer complications when compared with surgery. Use of radiofrequency ablation (RFA) in the thyroid danger triangle is still controversial. RFA and surgery groups showed no difference in disease progressions, and no major complications occurred with RFA. Radiofrequency ablation offers a new option for papillary thyroid carcinoma patients in the danger triangle.

Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial).

Surgery for oesophageal squamous cell carcinoma involves dissecting lymph nodes along the recurrent laryngeal nerve. This is technically challenging and injury to the recurrent laryngeal nerve may lead to vocal cord palsy, which increases the risk of pulmonary complications. The aim of this study was to compare the efficacy and safety of robot-assisted oesophagectomy (RAO) versus video-assisted thoracoscopic oesophagectomy (VAO) for dissection of lymph nodes along the left RLN. Patients with oesophageal squamous cell carcinoma who were scheduled for minimally invasive McKeown oesophagectomy were allocated randomly to RAO or VAO, stratified by centre. The primary endpoint was the success rate of left recurrent laryngeal nerve lymph node dissection. Success was defined as the removal of at least one lymph node without causing nerve damage lasting longer than 6 months. Secondary endpoints were perioperative and oncological outcomes. From June 2018 to March 2022, 212 patients from 3 centres in Asia were randomized, and 203 were included in the analysis (RAO group 103; VAO group 100). Successful left recurrent laryngeal nerve lymph node dissection was achieved in 88.3% of the RAO group and 69% of the VAO group (P < 0.001). The rate of removal of at least one lymph node according to pathology was 94.2% for the RAO and 86% for the VAO group (P = 0.051). At 1 week after surgery, the RAO group had a lower incidence of left recurrent laryngeal nerve palsy than the VAO group (20.4 versus 34%; P = 0.029); permanent recurrent laryngeal nerve palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). More mediastinal lymph nodes were dissected in the RAO group (median 16 (i.q.r. 12-22) versus 14 (10-20); P = 0.035). Postoperative complication rates were comparable between the two groups and there were no in-hospital deaths. In patients with oesophageal squamous cell carcinoma, RAO leads to more successful left recurrent laryngeal nerve lymph node dissection than VAO, including a lower rate of short- and long-term recurrent laryngeal nerve injury. Registration number: NCT03713749 (http://www.clinicaltrials.gov).

The anatomic repair of recurrent aortic arch obstruction in children and adolescents

ObjectiveSurgery for recurrent aortic arch obstruction is highly challenging and publications are rare. The aim of this retrospective, single-center study was to evaluate mortality, complications, and reintervention rate after an anatomic repair. MethodsBetween 1999 and 2022, in total 946 operations on the aortic arch were performed at the Children's Heart Center Linz. In 39 cases, the indication was a recurrent or residual aortic arch obstruction or coarctation in a patient aged 18 years or younger. This is our study cohort. The aorta was reconstructed by a direct anastomosis/autograft in 20 patients, patch in 17 patients, and interposition graft in 2 adolescents. In 32 procedures, cardiopulmonary bypass with whole body perfusion was employed, in 4, antegrade cerebral perfusion was employed, in 2, a left heart bypass was employed, and in 1 no cardiopulmonary bypass was used. ResultsMedian (Q1, Q3) age at operation was 253 days (100, 2198 days), weight 7.5 kg (4.5, 17.8 kg). Median cardiopulmonary bypass time was 177 minutes (115, 219 minutes), crossclamp time 73 minutes (49, 102 minutes). Three infants died during the hospital stay: 1 with Williams syndrome, 1 with hypoplastic left heart syndrome, and 1 with heterotaxia. There was no death due to an arch complication. The main complications were 1 neurologic injury after postoperative resuscitation (Williams syndrome) and 1 permanent recurrent laryngeal nerve paralysis. During the follow-up period of median 8.1 years (2.6, 12 years) 1 re-reintervention on the aortic arch was necessary. ConclusionsSophisticated reoperations on the aortic arch could be performed safely. In children, the growth potential of all segments of the aorta could be sustainably preserved by avoiding interposition or extra-anatomic bypass grafts.

Voice Changes Without Laryngeal Nerve Alterations After Thyroidectomy: The Need For Prospective Trials - A Review Study.

Thyroidectomy is a commonly performed surgical procedure that is offered for different thyroid pathologies. The most frequent complication after total thyroidectomy is transient or permanent hypoparathyroidism followed by transient or permanent recurrent laryngeal nerve palsy. Patients may experience voice impairment despite intact laryngeal nerve function. These patients are of special interest because they experience subjective symptoms which are difficult to measure and therefore to treat. The Voice Handicap Index (VHI) and VHI-10 are the most commonly used subjective questionnaires. Their results correlate with objective findings. Female sex, in particular after menopause, is a dominant factor for developing voice impairment after thyroidectomy. The extent of neck surgery and the weight and volume of the removed thyroid correlates directly with both objective and subjective voice impairment after surgery. Videolaryngostroboscopy should be considered to examine vocal cord pathologies in this patient group. Surprisingly, there are no studies showing that speech and voice therapy are beneficial for patients with voice alterations but with intact laryngeal nerves. While recurrent laryngeal nerve (RLN) paralysis can be evaluated by objective exams postoperatively, we are still left with the issue of possible partial or complete external branch of superior laryngeal nerve (EBSLN) injury. It is therefore quite difficult to segregate neural (RLN and EBSLN) and non-neural voice change populations, regardless of the method of literature evaluation. Perhaps patients' perspectives on how they experience voice functionality should play a superior role in deciding which patients should be investigated further with laryngoscopy, acoustic or perceptual analysis, and which patients should be offered treatment.

Long-term impact of prophylactic central neck dissection in non-invasive classic papillary thyroid carcinoma

BackgroundThe utilization of prophylactic central neck dissection (pCND) in cases of non-invasive clinical node-negative (cN0) papillary thyroid carcinoma (PTC) remains a topic of debate, with a dearth of long-term evidence. Materials and methodsWe retrospectively reviewed 1181 cN0 PTC patients from 1997 to 2011. Of these, 641 underwent pCND (pCND + group) and 540 did not (pCND-group). Propensity score matching (PSM) was used to identify similar patients. Event-free survival and long-term complications including permanent hyperparathyroidism and permanent recurrent laryngeal nerve (RLN) paralysis were analyzed after PSM. ResultsThe pCND + group had more aggressive characteristics. In the matched cohort after PSM, the 5-year, 10-year, and 15-year EFS rates were 98.9 %, 98.2 %, and 97.1 % for the pCND + group, and 97.7 %, 97.1 %, and 97.1 % for the pCND-group, respectively. There was no statistically significant difference in EFS rates between the two groups (Log Rank P = 0.38). There was no statistically significant difference in the incidence of permanent hyperparathyroidism (3.3 % vs. 1.5 %, P = 0.08) and permanent RLN paralysis (1.7 % vs. 0.9 %, P = 0.13) between the pCND+ and pCND– groups. ConclusionOur study, with a median follow-up duration of 107 months, indicates that pCND does not lead to a significant reduction in nodal recurrence among non-invasive cN0 PTC patients.

Endoscopic thyroidectomy via areola approach for stage T1 papillary thyroid carcinoma: feasibility, safety, and oncologic outcomes.

To evaluate the feasibility, safety, and oncologic outcomes associated with endoscopic thyroidectomy via the areolar approach (ETAA), compared with conventional open thyroidectomy (COT) for the treatment of stage T1 papillary thyroid carcinoma (PTC). Between January 2021 and June 2022, a total of 1204 patients diagnosed with PTC underwent screening, out of which 138 patients were selected for inclusion in the study population after propensity score matching (92 patients in the ETAA group and 46 patients in the COT group). The study included the collection and analysis of clinicopathologic characteristics, intraoperative outcomes, postoperative outcomes, complications, and follow-up data using R software. The operative time for the ETAA group was longer than that for the COT group (160.42 ± 32.21 min vs. 121.93 ± 29.78 min, p < 0.0001). However, there were no significant differences between the two groups in terms of intraoperative blood loss, the extent of surgical resection, the number of dissected lymph nodes, the number of metastatic lymph nodes, and the rate of parathyroid autotransplantation. Postoperative drainage and C-reactive protein levels were higher in the ETAA group than in the COT group, but there were no significant differences in 24-hour visual analogue scale scores, white blood cell counts, drainage duration, or postoperative hospital stay. Complication rates were similar between the two groups, and no permanent recurrent laryngeal nerve palsy or hypoparathyroidism was observed. Patients who underwent ETAA reported greater cosmetic satisfaction and quality of life than those who underwent COT. During the follow-up phase, only one patient in the COT group developed lateral cervical lymph node involvement requiring reoperation. ETAA is a safe and feasible surgical method for patients with stage T1 PTC, providing results similar to COT in terms of oncologic completeness, while avoiding neck scars, with excellent cosmetic effects. Chinese Clinical Trial Registry center, identifier ChiCTR2300077109.

The impact of obesity on thyroidectomy outcomes: a case-matched study

Obesity is a well-known public health concern in Western World. Accordingly, an elevated number of obese patients undergo thyroidectomy every year. We aim to assess the impact of obesity on intraoperative and postoperative outcomes of patients who undergo thyroidectomy. 1228 patients underwent thyroidectomy at our department between January 2021 and September 2021. We divided patients into two groups according to body mass index (BMI): non-obese (BMI < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). A propensity score approach was performed to create 1:1 matched pairs (matching according to age, gender, diagnosis, nodule size and type of operation). After matching, the final population included 522 patients, equally divided between each group: non-obese group (Group A; n = 261) and obese group (Group B; n = 261). The primary endpoint of the study was the overall rate of postoperative complications; secondary endpoints of the study were operative time, use of energy device and length of hospital stay. The duration of hospital stay resulted longer in Group B (p = 0.002). No statistically significant differences were documented in terms of operative time (p = 0.206), use of energy devices (p = 0.855) and surgical complications (p = 0.429). Moreover, no statistically significant differences were documented considering each specific complication: transient and permanent hypocalcemia (p = 0.336; p = 0.813, respectively), transient and permanent recurrent laryngeal nerve palsy (p = 0.483; p = 0.523, respectively), hematoma (p = 0.779), bleeding (p = 0.178), wound infection (p = 0.313) and cheloid formation (p = 0.412). Thyroidectomy can safely be performed in obese patients. Outcomes resulted comparable; nonetheless, obesity correlates to longer hospital stay.

420 Parathyroid surgery outcomes - 2 surgeons outcomes for the past 9 years in a teaching hospital

Abstract Aim The success of parathyroid surgery in hyperparathyroidism is defined by the sustained improvement in calcium levels without the need for re-exploration. Reoperation rate in the United Kingdom currently sits at 1.6%. It has been shown that the need for repeat parathyroid surgery is related to surgeon annual volume. We aimed to review the outcomes of parathyroid surgery for hyperparathyroidism performed by two upper gastrointestinal surgeons experienced in parathyroidectomies. Methods Retrospective review of consecutive parathyroidectomy cases performed by VS and PT in a teaching hospital was conducted between April 2013 and December 2022. Data was obtained from local hospital database. Primary outcome was re-exploration within one year of index procedure. Secondary outcomes included methylene blue uptake by adenomas and postoperative vocal cord palsy. Results 211 parathyroidectomies were performed during the study period. Patient cohort was predominantly female (n=153, 72.2%). Mean age of study population was 57±13 years. Histopathology confirmed 171 (81.0%) parathyroid adenomas, 34 (16.1%) multiglandular hyperplasia and 6 (2.8%) normal glandular tissue. None were malignant adenoma. 4 (1.9%) patients required re-exploration within one year of index procedure, three of which were found to be ectopic adenomas. Preoperative methylene blue infusion was used in all cases to assist identification of adenoma; uptake was evident in 169 (80.1%) cases. 2 (0.9%) patients developed permanent recurrent laryngeal nerve damage, resulting in mild voice hoarseness. Conclusion Our dedicated parathyroid service led by experienced surgeons was associated with comparable re-exploration rates and high cure rates. Preoperative methylene blue infusion helps in intraoperative identification of parathyroid glands.

Transoral endoscopic thyroidectomy vestibular approach vs. transoral robotic thyroidectomy: systematic review and meta-analysis.

This study aimed to conduct a systematic review and meta-analysis to compare the surgical outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT). We carried out a systematic literature search of PubMed, Web of Science, Cochrane Library, and Google Scholar on studies comparing TOETVA and TORT until January 2023. A total of five articles published between 2018 and 2023 that matched the inclusion criteria were included in the systematic review and meta-analysis. The studies included 641 patients (394 TOETVA patients and 247 TORT patients). TOETVA group was associated with a significantly shorter operative time with a mean difference of 60.08min [95% confidence interval (CI) -83.95 to -36.20; P < 0.001). Transient recurrent laryngeal nerve palsy was more common in the TOETVA group than the TORT group (OR 3.00; 95% CI 1.14-7.88; P = 0.03). There were no significant differences in the other outcomes, including the length of hospital stay, postoperative pain scores, number of central lymph nodes retrieved, permanent recurrent laryngeal nerve injuries, and transient and permanent hypoparathyroidism. The TOETVA group was associated with shorter operative time and more transient recurrent laryngeal nerve palsy than the TORT group. Each procedure has its benefits and limitations. The surgical approach should be determined by considering the patient's characteristics and preferences, as well as the surgeon's preference and area of expertise.

Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless alternative to open thyroidectomy (OT). This systematic review and meta-analysis aimed to synthesize evidence comparing the intraoperative and postoperative outcomes of TOETVA and OT. A systematic literature search of PubMed, Web of Science, the Cochrane Library, and Google Scholar was performed to identify studies comparing the outcomes of TOETVA and OT published before February 2023. The outcomes of interest were operative time, intraoperative blood loss, hospital stay, postoperative pain, number of central lymph nodes retrieved, number of metastatic central lymph nodes, and incidences of transient and permanent recurrent laryngeal nerve injury, transient and permanent hypocalcemia, hematoma, and infection. Thirteen studies published between 2016 and 2022, involving a total of 2889 patients (TOETVA, n =1085; OT, n =1804) were included in this systematic review and meta-analysis. Meta-analysis showed that the TOETVA group had a significantly longer overall operative time (weighted mean difference [WMD] 55.19; 95% CI, 39.15, 71.23; P <0.001), longer hospital stay (WMD, 0.27; 95% CI, 0.14, 0.39; P <0.001), and lower pain scores on postoperative day 1 (WMD, -1.41; 95% CI, -2.79, -0.03; P =0.04) than the OT group. Other intraoperative and postoperative outcomes were not significantly different between the groups. TOETVA has a similar safety profile to OT with less postoperative pain, making it an appropriate and more cosmetically appealing alternative to OT for select patients.

Prophylactic central neck dissection for cN0 papillary thyroid carcinoma: is there any difference between western countries and China? A systematic review and meta-analysis.

Recommendations for the performance of prophylactic central neck dissection (pCND) in patients with clinically node-uninvolved (cN0) papillary thyroid carcinoma (PTC) are not the same. This meta-analysis set out to compare the effectiveness of pCND with total thyroidectomy (TT) in different countries and regions, mainly between western countries and China. The electronic databases PubMed, EMBASE, and Cochrane Library were searched for studies published until August 2022. The incidence rate of cervical lymph node metastases (LNMs), locoregional recurrences (LRRs), and postoperative complications were pooled by a random-effects model. Subgroup analyses based on different countries and regions were performed. Eighteen studies involving 5,346 patients were analyzed. In the subgroup of western countries, patients undergoing pCND with TT had a significantly lower LRR rate [69/1,804, 3.82% vs. 139/2,541, 5.47%; odds ratio (OR) = 0.56; 95% CI 0.37-0.85] and a higher rate of temporary hypoparathyroidism (HPT) (316/1,279, 24.71% vs. 194/1,467, 13.22%; OR = 2.23; 95% CI 1.61-3.08) than that of the TT alone group, while no statistically significant difference was found in the rate of permanent HPT and temporary and permanent recurrent laryngeal nerve (RLN) injury. In the Chinese subgroup, the pCND with TT group had a significantly higher incidence rate of both temporary HPT (87/374, 23.26% vs. 36/324, 11.11%; OR = 2.24; 95% CI 1.32-3.81) and permanent HPT (21/374, 5.61% vs. 4/324, 1.23%; OR = 3.58; 95% CI = 1.24-10.37) than that of the TT alone group, while no significant difference was detected in the rate of LRR and temporary and permanent RLN injury. Compared with the TT alone for cN0 PTC patients, pCND with TT had a significantly lower LRR rate while having a higher temporary HPT rate in Europe, America, and Australia; however, it showed no significant difference in decreasing LRR rate while having a significantly raised rate of temporary and permanent HPT in China. More population-based results are required to advocate precision medicine in PTC. https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022358546.

Thyroidectomy With or Without Nerve Identification: A Personal Experience and Technique.

Careful and precise dissection of the gland, away from the typical trajectory of the recurrent and external laryngeal nerves, poses a minimal or similar risk of nerve injuries compared to directly visualizing and identifying the nerves. In a randomized controlled study involving 150 patients with various thyroid disorders who underwent different surgical procedures (total, near total, and hemi thyroidectomy), the patients were randomly assigned into two groups using a coin toss. The first group (G1) consisted of 75 patients who underwent thyroidectomy with nerve visual identification, while the second group (G2) comprised 75 patients without the requirement of nerve visualization. The aim was to determine the method with a lower risk of complications. The incidence of external laryngeal nerve palsy (ELNP) was found to be higher in G1 patients compared to G2 patients (5.3% vs2%), while no cases of permanent recurrent laryngeal nerve (RLN) palsy were observed in either group. The frequency of total nerve injury was higher in G1, with 14 patients (10.2%), compared to G2, with eight patients (5.3%). However, there was no significant association between nerve identification and the rate of nerve injury (P value = 0.452). Among the different surgical procedures, total thyroidectomy for toxic goiter was the most common operation associated with transient external laryngeal nerve (TELN) injury and permanent external laryngeal nerve (PELN) injury. By employing meticulous dissection techniques in proximity to the thyroid capsule, experienced surgeons can effectively reduce the risk of nerve injury, even in the absence of direct nerve visualization.

Complications of Thyroidectomy and Learning Curve for Thyroid Surgeons: An Institutional Experience.

To study the complications of thyroidectomy and the various methods to be followed in the intra and post-operative period to prevent complications. It is a prospective study of 5years and 9months duration from 1/1/2015 to 31/9/2020 done in a tertiary care hospital. A total of 268 patients were included in this study. Adequate measures were taken intraoperatively to prevent any complications and the patients were observed post-operatively for development and management of any complications. The patients were followed up regularly. Out of the 268 thyroidectomies performed in our study following which 5 patients had hemorrhage, 19 patients had temporary recurrent laryngeal nerve dysfunction, 3 patients developed respiratory obstruction, 12 patients developed transient parathyroid insufficiency, 62 patients developed thyroid insufficiency,1 patient had permanent parathyroid insufficiency, permanent recurrent laryngeal nerve dysfunction was seen in 7 patients, 3 patients developed seroma formation, 7 patients developed post-operative hypertrophic scar and 3 developed keloid. Sound anatomical knowledge, meticulous surgical technique and effective protocol for the management of complication can reduce the postoperative morbidity of the patient.

The effectiveness and safety of prophylactic central neck dissection in clinically node-negative papillary thyroid carcinoma patients: A meta-analysis.

This meta-analysis was performed to evaluate the effectiveness and safety of prophylactic central neck dissection (PCND) in patients with clinically node-negative (cN0) papillary thyroid carcinoma. A meta-analysis of the literature was performed using the key words "papillary thyroid carcinomas" and "lymph node ecisions" for searches of electronic databases. Complications such as transient hypocalcemia, permanent hypocalcemia, transient and permanent hypoparathyroidism, transient and permanent vocal cord paralysis, transient recurrent and permanent recurrent laryngeal nerve injury, and local recurrence were pooled by meta-analysis. Stata17.0 was used to carry out the meta-analysis. Data were extracted from 15 studies. In the present review, the group of patients who had total thyroidectomy (TT) with PCND had a lower local recurrence than the group with TT alone (OR 0.22, 95% CI 0.10-0.45, P = 0.000), whereas the incidence of permanent hypocalcemia (OR 4.24, 95% CI 1.05-17.22, P = 0.043) and transient hypoparathyroidism (OR 2.14, 95% CI 1.34-3.42, P =0.001) were higher. No significant differences were recorded in the incidence of other complications: transient hypocalcemia (OR 2.24, 95% CI 0.77-6.51, P = 0.138), permanent hypoparathyroidism (OR 1.70, 95% CI 0.89-3.27, P = 0.111), transient vocal cord paralysis (OR 1.48, 95% CI 0.78-2.83, P = 0.231), permanent vocal cord paralysis (OR 1.44, 95% CI 0.53-3.94, P = 0.477), transient recurrent laryngeal nerve injury (OR 1.47, 95% CI 0.93-2.32, P = 0.102) and permanent recurrent laryngeal nerve injury (OR 1.24, 95% CI 0.56-2.74, P = 0.587) between the two groups. Compared with TT alone, TT with PCND was more effective in reducing local recurrence without increasing the risk of recurrent laryngeal nerve, thyroid and vocal cord, except for hypocalcemia and transient hypoparathyroidism. Therefore, we believe that TT with PCND should be recommended for patients with cN0 PTC. https://www.crd.york.ac.uk/prospero/, identifier CRD4202 2355078.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA): initial experience in Australia.

Thyroidectomy is traditionally an open procedure. The potential for and unpredictability of patients developing an unsightly anterior neck scar has led many investigators to develop various 'scarless' thyroidectomy techniques. Here we report on our initial experience, and to our knowledge, the first and largest series of this technique in Australia and New Zealand. Across two centres in Western Australia, three Endocrine surgeons utilized the Transoral Endoscopic Thyroidectomy vestibular approach (TOETVA). Key endpoints such as operating time, blood loss, pain scores, recurrent laryngeal nerve injury and hypoparathyroidism was collected. Data was analysed using R statistical program. One hundred and two TOETVAs were performed between March 2018 and May 2021. There were 66 hemithyroidectomies, 34 total thyroidectomies (four converted to open), and two isthmusectomies. We noted a trend in median operating time decreasing over the study period. There were no cases of permanent recurrent laryngeal nerve palsy, wound infection, seroma or haematoma. We had four instances of open conversion; one temporary RLN palsy, and 12 cases of temporary hypoparathyroidism. This is the first series of TOETVA reported in Australia and New Zealand. Our results demonstrate that with appropriate surgeon experience, training, collaboration, and in well selected patients, this is a feasible and safe thyroidectomy technique. We hope that our work will build confidence in Endocrine Surgical units seeking to develop this technique in Australia.

Clinical features and prognoses of re-operated patients for persistent/recurrent papillary thyroid carcinoma

Objective: To investigate the clinicopathological characteristics and the survival of re-operated patients for persistent/recurrent papillary thyroid carcinoma (PTC) and risk factors for re-recurrence after the second operation. Method: A retrospective analysis of 69 cases underwent re-operation for persistent/recurrent PTC in Sichuan Cancer Hospital from January 2010 to December 2016 was performed. There were 21 males and 48 females, aged 14-85 (44.8) years old. According to the imaging after initial treatment, they were divided into a recurrence group (42 cases) and a persistent disease/residual group (27 cases). The positive rates of ipsilateral paratracheal lymph node metastases at re-operation were calculated and compared by chi-square test. Patients were divided into different subgroups according to potential risk factors for re-recurrence. Kaplan-Meier (K-M) method was used for survival analysis. Results: The positive rate of ipsilateral paratracheal lymph node metastasis in recurrence group (15/42, 35.7%) was significantly lower than that in the persistent disease/residual group (17/27, 63.0%) (χ2=4.91, P<0.05). The follow-up period after re-operation was 60-104 months, with a median of 66 months, and 8 patients were lost to follow-up. Permanent hypoparathyroidism occurred in 2 cases (2.9%) and permanent recurrent laryngeal nerve palsy in 1 case (1.4%). Twenty patients had structural recurrences and/or distant metastases. The 5-year disease-specific survival rate was 92.8% and the 5-year recurrence-free survival rate was 68.1%. Survival analysis was performed on risk factors such as age≥55 years old, recurrent tumor diameter ≥4 cm, number of positive lymph nodes ≥ 10, and obvious extracapsular invasion (ENE). Among them, age and diameter of recurrent tumor had significant influences on recurrence-free survival rate (χ2 was 6.36, 8.17, respectively, both P values<0.05). There was a statistically significant difference in recurrence-free survival rates between ENE(+) group and ENE(-) group (χ2=5.52, P<0.05). Conclusion: For the re-operated patients due to persistence/ recurrence PTC, attention should be paid to protecting the parathyroid gland and recurrent laryngeal nerve during re-operation. Timely and effective postoperative follow-up for patients aged ≥ 55 years, with recurrent tumor diameter ≥ 4 cm and ENE(+), can significantly improve their prognoses.

Morbidity Associated With Surgical Removal of Substernal Thyroid Goiters.

Surgical excision of substernal thyroid goiters (STG) can be challenging while minimizing postoperative morbidity. Postoperative complication rates associated with transcervical and transthoracic approaches (i.e., partial or total sternotomy) for STG compared to multinodular goiters (MNG) limited to the neck (i.e., non-substernal) remains unclear. This study examines postoperative morbidity related to surgical approaches in the removal of STG and MNG. A retrospective review of prospectively collected data of 988 patients with STG and non-substernal MNG from a single institution between 2010 and 2021 was performed. Patients were stratified by STG and conventional non-substernal MNG limited to the neck excised by transcervical and transthoracic approach. Postoperative complications including neck hematoma requiring return to the operating room, permanent recurrent laryngeal nerve injury and hypocalcemia, and transient or temporary recurrent laryngeal nerve injury and hypocalcemia were identified. Demographics including age, sex, and race, among others, were analyzed. Of the 988 cases, there were 887 (90%) MNG and 101 (10%) STG. Of the STG cohort, 11 (11%) required a partial sternotomy and 4 (4%) required a total sternotomy. Permanent complication rates for non-substernal MNG and STG patients were 1.5% and 0.9%, respectively. Only transient or temporary hypocalcemia rates were statistically different between the STG and MNG cohorts (9.9% versus 3.8%, P<0.001). Regardless of transcervical or transthoracic approach, postoperative complications associated with the surgical removal of STG are low in the hands of experienced, high-volume thyroid surgeons.

Prevertebral cervical approach to posterior mediastinum parathyroid adenomas.

About 4years ago, we described the pure endoscopic cervical approach to posterior mediastinum parathyroid adenomas, which we called the "prevertebral cervical approach". At that time, we had operated on three patients and did not have enough quality videos to demonstrate this approach. After broadening our experience, we present our results and show this technique through a video. From June 2015 to January 2021, information on patients undergoing the prevertebral cervical approach was obtained from a specific prospective database, including clinical presentation, biochemistry, preoperative imaging, surgical approach and patient outcomes. The step by step technique is described for both right- and left-sided adenomas, by means of a short video clip. Ten patients were operated on using this technique. Seven adenomas were right-sided and three were left-sided. The mean surgical time was 33 ± 7min. There were neither intraoperative nor major postoperative complications. Seven patients presented with a slight subcutaneous emphysema, which did not cause complaints. All patients were discharged the day after surgery, except for one patient with a previous open neck removal of four glands due to secondary hyperparathyroidism, which required calcium replacement. Calcium and parathyroid hormone levels were normalised in the other nine patients after surgery. One patient experienced a transient recurrent laryngeal nerve injury which was spontaneously resolved within 1month. No permanent recurrent laryngeal nerve injury was found. The postoperative cosmetic outcomes were excellent. In our experience, the pure cervical endoscopic approach has shown a high feasibility and short operation time, with excellent postoperative results regarding patient comfort, length of stay and disease cure. This approach also offers a very reasonable procedure cost, and may result in a less aggressive surgical option when compared with thoracic approaches.