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Background: Limited attempts have been made in trans-areola single-site endoscopic thyroidectomy (TASSET) due to technical challenges and the lengthy time for proficiency. This study aimed to define the learning curve of TASSET and to describe improvements in operative performance over time., Methods: Based on 222 consecutive TASSET procedures, the learning curve was established according to the operation time by using cumulative sum analysis (CUSUM). The end-point of learning curve was defined as the number of cases necessitated to reach the initial surgical proficiency stage. The demographic information, surgical and oncological outcomes, surgical stress, and postoperative complications were also analyzed., Results: There were 70 cases of simple lobectomy for benign nodules and 152 cases of lobectomy with central neck dissection (CND) for malignancy. The mean operative time was 106.54 ± 38.07 min (range: 46-274 min). The learning curve identified two phases: the skill acquisition phase (Case 1-Case 41) and the proficiency phase (Case 42-Case 222). There were no significant differences in demographic information, drainage amount and duration, oncological outcomes, and postoperative complications between the two phases (p > 0.05). Both operation time and postoperative hospitalization decreased significantly in Phase 2 (154.63 ± 52.21 vs. 95.64 ± 22.96 min, p < 0.001; 4.12 ± 0.93 vs. 3.65 ± 0.63 days, p < 0.001). Additionally, the mean variations of surgical stress factors (C-reactive protein and erythrocyte sedimentation rate) decreased significantly as the phase progress. The case number required for proficiency phase in benign and malignant tumor were 18 and 33, respectively, and lymph node resection posed a significant impact on the endpoint of the learning curve (p < 0.001). Meanwhile, the size of nodule showed no significant impact (p = 0.622). For right-handed surgeons, 16 cases and 25 cases were required for technical competence in left-sided and right-sided lesions, respectively, and no significant difference reached (p = 0.266)., Conclusions: TASSET has demonstrated safe and technically feasible with comparable oncological outcomes. Experience of 41 cases was required for surgical competence and proficiency. The initial learning stage could be more quickly adopted by high-volume thyroid surgeons with standardized procedures., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Due to technical challenges, single-site endoscopic thyroidectomy (SSET) is seldom reported and has been attempted in only limited cases. This large-scale study aimed to compare the clinical outcomes of standardized transareola SSET (TASSET) with those of conventional open thyroidectomy (COT) for thyroid cancer., Methods: The data were prospectively collected, and case-match study was performed at a ratio of 1:1 according to age, sex, body mass index, lesion size, number of lesion foci, lesion side, recurrent laryngeal nerve (RLN) exploration and pathology. Two hundred eligible patients underwent TASSET, and the same number of patients was selected for propensity score matching from 2256 patients who underwent COT. Perioperative data, including surgical profile, oncological and traumatic burdens, and cosmetic satisfaction, were analyzed., Results: No significant differences were observed in blood loss or drainage between TASSET and COT groups. There were no differences in operation time between TASSET and COT (106.39 ± 28.44 vs 102.55 ± 23.10 min, p = 0.154). A total of 3.63 ± 1.82 lymph nodes (LNs) were retrieved from CND with 0.96 ± 1.42 positive in TASSET. In COT, the total and positive LN yields were 3.77 ± 1.91 and 0.99 ± 1.40 (p = 0.445, p = 0.802). Cancer recurrence was not observed in either group. There were no differences in the occurrence of permanent and transient hoarseness or RLN injuries. Postoperative flap seroma or hematoma occurred in 12 TASSET patients and 58 COT patients (p < 0.001). The pain score, CRP level and ESR in TASSET group were lower than those in COT group. TASSET yielded significantly better incision recovery and cosmetic scores than did COT at both the proliferation and stabilization stages., Conclusions: TASSET is technically feasible and yields enhanced recovery with minimally invasive and cosmetic advantages without compromising the level of safety or cancer eradication., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The extent of total thyroidectomy in the management of multinodular goiter remains unclear. Compared to primary thyroidectomy, secondary total thyroidectomy is more difficult to perform and carries a significantly higher risk of postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. In this study, we aimed to evaluate the efficacy and safety of intraoperative carbon nanoparticle (CN) mapping in patients undergoing secondary total thyroidectomy., Methods: We performed a case-matched analysis of a prospectively maintained database using 8 specific criteria to compare perioperative outcomes after primary total thyroidectomy to those after secondary total thyroidectomy with intraoperative CN mapping. The criteria included age, sex, operative procedure, RLN/parathyroid glands (PGs) exploration, preoperative vocal cord calcium abnormalities, and pathological results. Thirty-five patients underwent secondary total thyroidectomy with intraoperative CN mapping due to recurrent thyroid nodules or development of nodules suspicious for malignancy after subtotal thyroidectomy. Fifty exact matches for all 8 criteria were identified from the database in our previous study, which included records of 3078 primary thyroidectomies without CNs. Perioperative outcomes, surgical technique, and complications were analyzed., Results: The RLNs were successfully identified in all 35 patients. Among three patients that experienced slight hoarseness, one had an RLN end-to-end anastomosis with subsequent improvement in the during the 12-month follow-up period. Two patients experienced changes in vocal tone, but recovered after several months. Two patients underwent parathyroid auto-transplantations, and subsequently presented with transient hypocalcaemia. Their symptoms gradually remitted within one year. Except for mean operation time, there were no statistically significant differences in complications between the primary total thyroidectomies and the secondary total thyroidectomy with CNs., Conclusions: Intraoperative CN mapping, expert knowledge of the jugular anatomy, and standardized resection procedures can minimize the incidence of complications such as RLN palsy and hypoparathyroidism after secondary total thyroidectomy., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

The recurrent laryngeal nerve (RLN) shows some anatomical variations that can potentially compromise the safety of thyroid surgery. The purpose of this prospective study was to identify the anatomical variations of the RLN in Chinese patients undergoing thyroid surgery. Between January 2007 and December 2013, 2,404 Chinese patients were hospitalized for thyroid surgery with dissecting of the RLN unilaterally or bilaterally. The patients consisted of 510 men and 1,894 women, with a median age of 45.0 years. Overall 3,275 RLNs, including 1,576 left- and 1,699 right-side nerves, were dissected. The anatomical variations were identified in 690 RLNs, including 305 left- and 385 right-side nerves. We identified as many as seven RLN anatomical variations in Chinese patients. These findings indicate that anatomical variations of the RLN are common, and the identification of these anatomical variations of the RLN can help to minimize the risk of post-operative RLN paralysis.

Objectives: We aimed to highlight a new anatomical variation of the recurrent laryngeal nerve (RLN), and to emphasize its implications for thyroid surgery., Methods: A prospective study was carried out in a group of 3,078 consecutive thyroidectomies from 1998 to 2008. Total, near-total, subtotal, and partial thyroidectomy were performed for various thyroid diseases. The RLN was routinely identified and exposed in its entire course until the entry into the larynx. The postoperative complications of patients with different variations were compared., Results: 4,241 RLNs were successfully identified in all patients unilaterally or bilaterally. In addition to extralaryngeal branching and nonrecurrent laryngeal nerves, an unreported variation was identified in 44 RLNs (1.04%) at their entries into the larynx. The variation happened at the trunk or the branches of the RLN entering the larynx far from the posterior of cricothyroid joint, and the entry was higher than the superior cornu of the thyroid cartilage and the arch of the cricoid. The median distance from the entry to the posterior of cricothyroid joint was more than 5 mm. As the trunk or the branches had to travel along the lateral edge of the upper 1/3 of the thyroid before entering the larynx, the incidence of RLN palsy was higher than that in extralaryngeal branching variations (p < .05)., Conclusion: This newly discovered variation of the RLN is more vulnerable to injury and should be brought to the attention of surgeons.

Objective: To evaluate the feasibility and safety of total and near-total bilateral thyroidectomy for the treatment of bilateral multinodular goiter., Methods: 346 patients with a diagnosis of bilateral multinodular goiter were randomly divided into two groups. 165 patients underwent total thyroidectomy or near-total thyroidectomy (group A), while 181 patients were exposed to a partial or subtotal thyroid gland removal treatment (group B). The incidences of postoperative complications and recurrence rate were monitored during the average follow-up period of 36 and 39 months, respectively., Results: Six and two patients from groups A and B, respectively, were diagnosed with papillary carcinoma and excluded from the study. Transient recurrent laryngeal nerve paralysis occurred in three patients each from group A (1.89%, 3/159) and group B (1.68%, 3/179) postoperatively. Injury to superior laryngeal nerve was confirmed in three patients (two in group A and one in group B). Eleven (6.92%, 11/159) and nine (5.03%, 9/179) cases in groups A and B, respectively, suffered from transient hypocalcemia symptoms. There was no statistical difference in complications between two groups. Permanent hypoparathyroidism was not observed in either group. No recurrence was observed in group A, while 12 cases (6.70%, 12/179) were observed in group B. The recurrence rate was significantly different between the two groups (p <.05)., Conclusion: It is safe and feasible to perform either total or near-total thyroidectomy in patients with bilateral multinodular goiter. These treatments provide decisive advantages over partial and subtotal thyroidectomies in terms of the recurrence and reoperation rate with comparable postoperative complications.

Objective To analyze retrospectively preoperative evaluation and preparation in Graves′ disease patients with surgical treatment. Methods A total of 126 cases of Graves′ disease in our department from January 2015 to May 2021 were reviewed. Patient information including preoperative preparation, operative mode, postoperative pathological results and complications were collected. Results There were 27 males and 99 females with an average age of(42.4±14.3) years. Surgical indications were Graves′ disease with malignant tumour, airway compression and stenosis, retrosternal goiter, drug intolerance or hyperparathyroidism. There were 75 cases with thyroid papillary carcinoma including 47 cases with papillary microcarcinoma， and 2 cases with follicular carcinoma. Short-term postoperative complications were 11 cases with hoarseness among which 1 case was permanent, and 35 cases with hypocalcemia among which 1 case was permanent. Conclusions It is indicated that preoperative preparation for Graves′ disease requires individualization and refinement, which include iodine preparation, examination of airway condition and neural monitoring, the evaluation of parathyroid function, recurrent laryngeal nerve variation and malignant nodules.

Background: The role of surgery in the treatment of Graves' disease (GD) needs to be revisited. The aims of the present retrospective study were to evaluate the outcomes of the current surgical strategy as a definitive treatment of GD at our center and to explore the clinical association between GD and thyroid cancer. Methods: A patient cohort of 216 cases from 2013 to 2020 was involved in this retrospective study. The data of the clinical characteristics and follow-up results were collected and analyzed. Results: There were 182 female and 34 male patients. The mean age was 43.9 ± 15.0 years old. The mean duration of GD reached 72.2 ± 92.7 months. Of the 216 cases, 211 had been treated with antithyroid drugs (ATDs) and hyperthyroidism had been completely controlled in 198 cases. A total (75%) or near-total (23.6%) thyroidectomy was performed. Intraoperative neural monitoring (IONM) was applied to 37 patients. The failure of ATD therapy (52.3%) was the most common surgical indication, followed by suspicion of a malignant nodule (45.8%). A total of 24 (11.1%) patients had hoarseness after the operation and 15 (6.9%) patients had transient vocal cord paralysis; 3 (1.4%) had this problem permanently. No bilateral RLN paralysis occurred. A total of 45 patients had hypoparathyroidism and 42 of them recovered within 6 months. Sex showed a correlation with hypoparathyroidism through a univariate analysis. A total of 2 (0.9%) patients underwent a reoperation because of hematomas. A total of 104 (48.1%) cases were diagnosed as thyroid cancer. In most cases (72.1%), the malignant nodules were microcarcinomas. A total of 38 patients had a central compartment node metastasis. A lateral lymph node metastasis occurred in 10 patients. Thyroid carcinomas were incidentally discovered in the specimens of 7 cases. The patients with concomitant thyroid cancer had a significant difference in body mass index, duration of GD, gland size, thyrotropin receptor antibodies and nodule(s) detected. Conclusion: Surgical treatments for GD were effective, with a relatively low incidence of complications at this high-volume center. Concomitant thyroid cancer is one of the most important surgical indications for GD patients. Careful ultrasonic screening is necessary to exclude the presence of malignancies and to determine the therapeutic plan. [ABSTRACT FROM AUTHOR]

Purposes: To quantitatively predict the risk of neck lymph node metastasis for unilateral and bilateral papillary thyroid microcarcinomas (PTMC) that may guide individual treatment strategies for the neck region. Methods: A total of 717 PTMC patients from three medical centers were enrolled for analysis. Results: Bilateral PTMCs were demonstrated to be more aggressive with a much higher cervical lymph node metastasis rate including for both central (CLNM) and lateral lymph node metastasis (LLNM) when being compared to unilateral PTMCs. In unilateral PTMC, five (age < 55 years old, male, maximum tumor diameter (MTD) ≥ 0.5 cm, and the presence of thyroid capsular invasion (TCI) and multifocality) and three (maximum diameter of positive CLN (MDCLN) > 0.5 cm, the presence of multifocality and nodular goiter, iNG) factors were identified as independent risk factors for CLNM and LLNM, respectively. In bilateral PTMC, three (age < 55 and presence of TCI and multifocality in at least one side of thyroid lobe) and two (MDCLN > 0.5 cm and presence of nodular goiter (iNG)) factors were identified as independent factors for CLNM and LLNM, respectively. Predictive models of CLNM and LLNM for patients with unilateral disease and of CLNM for patients with the bilateral disease were established based on the described risk factors. Bilateral patients with positive CLNM were also stratified into different subgroups according to the presence and absence of independent risk factors. Conclusion: An evaluation system based on independent factors of CLNM and LLNM for PTMC patients with bilateral and unilateral disease was established. Our newly established evaluation system can efficaciously quantify risks of CLNM and LLNM for PTMC patients with bilateral and unilateral disease and may guide individual treatment strategy including both surgical and postoperative adjuvant treatment of the neck region for these patients. [ABSTRACT FROM AUTHOR]

Background: This study aims to reveal the features of lymph node metastasis (LNM) and recurrence in papillary thyroid carcinoma (PTC) tumors located in the upper portion of the thyroid. Methods: A total of 1075 PTC patients were retrospectively reviewed, including 314 patients with a tumor in the upper portion of the thyroid. Another 103 PTC patients with upper portion diagonsis from three clinical centers were included for external validation. Results: The results showed no difference between the patients with a tumor in the upper portion of the thyroid and those with a tumor in the non-upper portion in terms of overall LNM rates. However, patients with a tumor in the upper portion were significantly more prone to LLNM and exhibited a significantly worse recurrence outcome than those with a tumor in other subregions. Multivariate analysis showed that four factors—age no more than 40, maximum tumor diameter no less than1.0 cm, the presence of thyroid capsular invasion, and tumor with ipsilateral nodular goiter—were independent risk factors for LLNM of the tumor in the upper thyroid. A predictive risk-scoring model was established based on these factors. Conclusions: Patients with PTC located in the upper portion may have an exclusive lymphatic drainage pathway to the lateral neck region and are more prone to suffer from LLNM and tumor recurrence than those with a tumor located in other subregions. A new postoperative strategy selection flow chart was established based on our newly created risk-scoring model that can effectively predict the individualized possibility of LLNM for PTC patients with a tumor in the upper portion. [ABSTRACT FROM AUTHOR]