Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve

Background Remote-access thyroid and parathyroid surgery has gained popularity recently due to its benefit of avoiding visible neck scars. Most of these techniques were described and performed in Asia, on patients with different body habitus compared to American patients. We aim to analyze the learning curve in performing these operations in North America.  Methods This is a retrospective cohort study of a 10-year experience by a single surgeon at a North American institute. Patients who underwent thyroid or parathyroid procedures by a transaxillary, retroauricular, or transoral endoscopic thyroidectomy vestibular approach (TOETVA) were included. Cumulative sum (CUSUM) was used to analyze learning curves based on intraoperative blood loss and total operative times and learning phases were divided accordingly. Results Three hundred seventy-two remote-access thyroid and parathyroid procedures were performed during the study period. Total operative time for transaxillary procedures was initially reduced after the 69th procedure and then again after the 134th case. For retroauricular procedures, marked reduction in the operative time was observed after 21 procedures. Most patients (57.02%) were discharged home on the same day during the mastering phase. In the transaxillary procedures, only 1 case of brachial plexus injury occurred prior to the routine use of somatosensory evoked potential (SSEP) monitoring. Discussion Remote-access thyroid and parathyroid surgeries can be performed safely with minimal complications in a select group of patients. Analysis of the learning curve in performing these operations aids in structuring a safe and effective learning period for endocrine surgeons seeking to venture into this modality of treatment.

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Practice Patterns and Learning Curve in Transoral Endoscopic Thyroidectomy Vestibular Approach With Neuromonitoring

Frontiers in Endocrinology ◽

10.3389/fendo.2021.744359 ◽

2021 ◽

Vol 12 ◽

Author(s):

Ting-Chun Kuo ◽

Quan-Yang Duh ◽

Yi-Chia Wang ◽

Chieh-Wen Lai ◽

Kuen-Yuan Chen ◽

...

Keyword(s):

Learning Curve ◽

Practice Patterns ◽

Endoscopic Thyroidectomy ◽

Operation Time ◽

Access To Information ◽

Surgical Interventions ◽

Graphic Model ◽

Mature Phase ◽

Two Phases ◽

Vestibular Approach

ObjectivesIntraoperative neuromonitoring has not been routinely applied in early experience with the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Because the preparation and surgical interventions are much different from conventional thyroidectomies, most endocrine surgeons willing to adapt to TOETVA lack access to information regarding the practice pattern and proficiency in the learning curve. We aimed to investigate the outcomes and to define the learning curve for TOETVA in this study.MethodsA retrospective analysis was used on patients who underwent TOETVA at our hospital between December 2016 and July 2019. The cumulative sum graphic model was used to implement the learning curve as a surrogate for procedural proficiency.ResultsThe 119 patients had a mean age of 44.65 years and a mean body mass index of 22.49 k/m2, including 107 women, 20 thyroiditis, and 106 hemithyroidectomy. The learning curve revealed two phases, an initial (35 cases) and a mature (84 cases) phase, for surgeons based on operation time (144.2 vs. 114.2 min, p = 0.0001). There were more bilateral thyroidectomies (15.5% vs. 0, p = 0.0100), larger indicated nodules (6.06 cm3vs. 3.32 cm3, p = 0.0468), or larger thyroids to resect (16.38 cm3vs. 8.75 cm3, p = 0.0001) in the mature phase. Procedure-related complications decreased significantly in the mature phase in comparison to the initial phase (3.57% vs. 31.43%, p = 0.0001).ConclusionsThe learning curve of TOETVA with neuromonitoring is 35 cases. With the accumulation of proficiency, the indications will expand. Step-by-step improvements from the experience of each case can reduce procedure-related complications.

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The Learning Curve for Surgeons Regarding Endoscopic Thyroidectomy via the Oral-vestibular Approach

Surgical Laparoscopy Endoscopy & Percutaneous Techniques ◽

10.1097/sle.0000000000000578 ◽

2018 ◽

Vol 28 (6) ◽

pp. 380-384 ◽

Cited By ~ 3

Author(s):

Rui Qu ◽

Jianxue Wang ◽

Jinyi Li ◽

Zhiyong Dong ◽

Jingge Yang ◽

...

Keyword(s):

Learning Curve ◽

Endoscopic Thyroidectomy ◽

Vestibular Approach

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Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Surgical Outcomes and Learning Curve

Journal of Clinical Medicine ◽

10.3390/jcm10040863 ◽

2021 ◽

Vol 10 (4) ◽

pp. 863

Author(s):

Young Jun Chai ◽

Sumin Chae ◽

Moon Young Oh ◽

Hyungju Kwon ◽

Won Seo Park

Keyword(s):

Learning Curve ◽

Malignant Disease ◽

Endoscopic Thyroidectomy ◽

Operation Time ◽

Vocal Cord Palsy ◽

Short Term ◽

Cumulative Summation ◽

Cusum Analysis ◽

The Mean ◽

Vestibular Approach

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has excellent cosmetic effects and its popularity is increasing worldwide. We present our experience with TOETVA and its short-term outcomes. This study included 110 consecutive patients who underwent TOETVA at a single institution between July 2016 and June 2020. We analyzed clinicopathologic data, short-term postoperative outcomes, and learning curve using cumulative summation (CUSUM) analysis. Of the 110 patients who underwent TOETVA, 101 had malignant disease and 100 (90.9%) underwent lobectomy. The mean age was 39.7 ± 9.7 years, and the mean tumor size was 1.0 ± 0.7 cm (range, 0.3–3.6 cm). Operation time was 168.0 ± 63.4 min for total thyroidectomy, 111.0 ± 27.7 min for lobectomy, and 73.7 ± 18.1 min for isthmusectomy. Five patients (4.5%) experienced transient vocal cord palsy (VCP) and one (0.9%) had permanent VCP. The swallowing impairment index-6 score was 2.18 ± 3.21 at postoperative three months, and 0.97 ± 1.72 at postoperative six months. The learning curve for lobectomy was 58 cases in CUSUM analysis. TOETVA is a safe and feasible approach with an acceptable operation time and a low complication rate. This approach is a surgical option for patients who desire excellent cosmesis.

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