Background Use of the novel transoral endoscopic thyroidectomy vestibular approach (TOETVA) is increasing worldwide. Although several studies have compared safety and efficacy of TOETVA and other approaches, most focused on comparisons in the context of unilateral thyroidectomy. Therefore, the present study aimed to compare the safety and surgical completeness of TOETVA with conventional open thyroidectomy (COT) in patients with papillary thyroid carcinoma (PTC) undergoing total thyroidectomy and central neck dissection. Methods The medical records of patients who underwent TOETVA or COT by a single surgeon between June 2017 and October 2021 were retrospectively reviewed. All patients were diagnosed with PTC and underwent total thyroidectomy with central neck dissection. Propensity score-matching (PSM) was used to reduce potential selection bias and to adjust for differences in baseline clinicopathological characteristics. Results After PSM, 84 (TOETVA: 28; COT: 56) patients remained in the study population. There were no significant differences in sex, mean age, combined thyroiditis, tumor size, capsule invasion, tumor multifocality in the same lobe, or tumor location between the groups. Operative time was longer (190.54 ± 28.26 vs. 123.93 ± 29.78 min, P<0.001), while postoperative drainage volume (161.07 ± 225.30 vs. 71.16 ± 28.56 ml, P=0.045) was greater, in the TOETVA group than in the COT group. The groups exhibited no significant differences in the mean number of central lymph nodes retrieved (9.39 ± 4.01 vs. 10.71 ± 5.17, P=0.202), mean number of metastatic central lymph nodes (1.36 ± 1.93 vs. 1.77 ± 2.31, P=0.421), postoperative mean thyroglobulin levels (0.08 ± 0.24 vs. 0.10 ± 0.27, P=0.686), rate of transient hypoparathyroidism (TOETVA: 67.9% vs. COT: 66.1%, P=0.870), rate of transient vocal cord palsy (TOETVA: 0% vs. COT: 1.8%, P=1.000), or other complications (TOETVA: 3.6% vs. COT: 0%, P=0.333). Conclusions TOETVA is a safe approach in select patients with PTC and exhibits similar efficacy to COT in terms of surgical completeness.

/pdf/comparison-between-transoral-endoscopic-thyroidectomy-2roai8sm.pdf

Comparison Between Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and Conventional Open Thyroidectomy for Patients Undergoing Total Thyroidectomy and Central Neck Dissection: A Propensity Score-Matching Analysis

In search of an ideal cosmesis, transoral endoscopic thyroidectomy via vestibular approach (TOETVA) has recently been introduced to avoid a visible scar. Although ambulatory thyroid surgery is considered safe in carefully selected patients, this remains unclear for TOETVA. All consecutive adult patients who underwent ambulatory TOETVA or open thyroid surgery at a French university hospital were prospectively enrolled from 12/2020 until 11/2021. The primary outcome was postoperative morbidity (recurrent laryngeal nerve (RLN) palsy, re-intervention for bleeding, wound morbidity, or hospital readmission). The secondary outcome was quality of life (QoL), measured by a survey including a validated questionnaire (SF-12) and a modified thyroid surgery questionnaire six weeks after surgery. Throughout the study period, 374 patients underwent a unilateral lobectomy or isthmectomy in ambulatory setting, of which 34 (9%) as TOETVA (including 21 (62%) for a possible malignancy). In the TOETVA group, younger age (median 40 (IQR 35–50) vs. 51 (40–60) years, P < 0.001) and lower BMI (median 23.1 (20.9–25.4) vs. 24.9 (22.1–28.9) kg/m2, P = 0.001) were noted. No cases were converted to open cervicotomy. TOETVA was at least as good as open cervicotomy with nil versus four (1%) re-interventions for bleeding, one temporary (5%) versus 13 (4%) (temporary) RLN palsies, and one (<1%) wound infection (open cervicotomy group). No hospital readmissions occurred in all ambulatory surgery patients. No differences were found in physical (P = 0.280) and mental (P = 0.569) QoL between TOETVA and open surgery. In carefully selected patients, the feasibility and safety of ambulatory TOETVA are comparable to open surgery. 

https://link.springer.com/content/pdf/10.1007/s00268-022-06666-y.pdf

Feasibility and Safety of Ambulatory Transoral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA)

BACKGROUND
The IDEAL Framework is a scheme for safe implementation and assessment of surgical innovation. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery that eliminates the need for a cervical incision. Despite considerable interest and adoption worldwide, significant scepticism remains regarding the outcomes and cost-effectiveness for healthcare systems. The aim of this narrative review was to appraise the available literature and examine whether TOETVA has progressed in line with the IDEAL Framework.


METHODS
A literature review of PubMed with a focus on historical and landmark studies was undertaken to classify the evidence according to the different stages of the IDEAL Framework.


RESULTS
Several different transoral approaches were developed by a small of number of surgeon-innovators on animals and cadavers, and subsequently in first-in-human studies. The trivestibular approach emerged as the safest technique, with further refinements of this technique culminating in TOETVA. The basic steps and indications for this technique have been standardized and it is now being replicated by early adopters in many centres worldwide. The development of TOETVA has closely aligned with the IDEAL Framework, and is currently at stage 2B (Exploration).


CONCLUSION
There is need for multi-institutional collaborations and international registry studies to plan high-quality randomized trials comparing TOETVA with other remote-access approaches and collect long-term follow-up data. In countries where TOETVA has yet to be adopted, the IDEAL Framework will be a useful roadmap for government regulators and professional societies to evaluate, regulate, and provide best practice recommendations for the adoption of this technique.

Evolution of transoral endoscopic thyroidectomy vestibular approach according to the IDEAL framework.

The IDEAL Framework is a scheme for safe implementation and assessment of surgical innovation. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new innovation in thyroid surgery that eliminates the need for a cervical incision. Despite considerable interest and adoption worldwide, significant scepticism remains regarding the outcomes and cost-effectiveness for healthcare systems. The aim of this narrative review was to appraise the available literature and examine whether TOETVA has progressed in line with the IDEAL Framework.A literature review of PubMed with a focus on historical and landmark studies was undertaken to classify the evidence according to the different stages of the IDEAL Framework.Several different transoral approaches were developed by a small of number of surgeon-innovators on animals and cadavers, and subsequently in first-in-human studies. The trivestibular approach emerged as the safest technique, with further refinements of this technique culminating in TOETVA. The basic steps and indications for this technique have been standardized and it is now being replicated by early adopters in many centres worldwide. The development of TOETVA has closely aligned with the IDEAL Framework, and is currently at stage 2B (Exploration).There is need for multi-institutional collaborations and international registry studies to plan high-quality randomized trials comparing TOETVA with other remote-access approaches and collect long-term follow-up data. In countries where TOETVA has yet to be adopted, the IDEAL Framework will be a useful roadmap for government regulators and professional societies to evaluate, regulate, and provide best practice recommendations for the adoption of this technique. 

OUP accepted manuscript

Conventional open thyroidectomy remains the standard treatment of surgery for benign thyroid tumors but leaves a permanent scar in the neck. We conducted this study to compare the surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus conventional open thyroidectomy (COT), and thence analyze the safety and viability of this approach. Seventy-eight patients who had undergone either COT or TOETVA from 2020 to 2021 in our institution to treat benign thyroid tumors were prospectively studied. Outcomes between the two groups were analyzed, including time of operation, blood loss, hospital stay, postoperative complications, and level of satisfaction. A total of 78 patients, in which TOETVA was applied to 47 patients and COT thyroid surgery was applied to 31 patients, participated in this study. COT has a shorter operative time (59.8 ± 10.8 min versus 102.3 ± 34.9 min, p < .001). TOETVA is less painful postoperatively (visual analog scale score on day 4 of 1.1 ± 1.2 versus 1.8 ± 0.7, p < .001). There were no significant differences between TOETVA and COT groups regarding incidences of transient recurrent laryngeal nerve (RLN) injury (10.6% and 6.5%, respectively, p = .697) and both transient and permanent hypoparathyroidism (8.5% versus 3.5%, p = .644 with transient and 0% versus 6.7%, p = .166 with permanent). Other complications were comparable between two arms such as bleeding, seroma, and infection. At 3 months after surgery, the TOETVA group had the significantly higher proportion of the very satisfied level than the COT group (80.9% versus 35.4%, p < .001). TOETVA in patients with favorable features is a safe, viable alternative to open thyroidectomy regarding postoperative outcomes and provide higher satisfaction after surgery in the long term. 

C. Cussac-Pillegand

Papers

Trans oral endoscopic thyroidectomy (TOETVA): First French experience in 90 patients

Thyroïdectomie trans-orale endoscopique (TOETVA) : première expérience française à propos de 90 patients