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Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.

In the attempt to improve the cosmetic and functional outcomes in head and neck surgeries, robotic or video-assisted neck dissection using remote access has gained ground in recent years. Retroauricular approach emerged as the most versatile option, allowing proper dissection at all neck levels. In this technique, after retroauricular incision, a skin flap is elevated and a self-retaining retractor is placed, creating working space for the robotic, or endoscopic neck dissection. Numerous published series have shown the safety and favorable outcomes of retroauricular robotic neck dissections, without any major complications or surgery-related deaths. The only consistently reported disadvantage is a longer operative time. Our group has an experience of 190 retroauricular neck dissections performed over the last 5 years, without any major setbacks. The oncologic and safety outcomes have been comparable to the conventional technique, with clearly superior aesthetic results. In the process of expansion of Robotic Surgery in Brazil, our center is currently providing training and proctoring to capacitate other head and neck surgeons, and enable other centers to offer this surgical modality.

Introduction Postoperative neck hematoma (PNH) is an uncommon but potentially-lethal complication of thyroid surgery. Objective To identify the risk factors for postthyroidectomy hematoma requiring reoperation, the timing, the source of the bleeding, the related respiratory distress requiring tracheotomy, and the late outcomes. Methods We retrospectively analyzed the records of 5,900 consecutive patients submitted to surgery for thyroid diseases at a single institution. Results In total, PNH occurred in 62 (1.1%) patients. Most cases of bleeding occurred within the first 6 hours after thyroidectomy, but 12.5% of the hematomas were observed after 24 hours. Obvious bleeding points were detected in 58.1% of the patients during the reoperation, with inferior thyroid artery branches and superior thyroid vessels being the most frequent bleeding sources. Only two patients required urgent tracheostomy. There were no hematoma-related deaths. Permanent hypoparathyroidism and recurrent laryngeal nerve injury are more frequent following reoperation for PNH. The factors significantly associated with PNH were: older age, concurrent lymph node dissection, and chronic lymphocytic thyroiditis. Gender, previous neck irradiation, presentation at diagnosis (symptomatic or incidental), substernal goiter, thyroidectomy for hyperthyroidism, prior thyroid surgery, malignant histology, the extent of the surgery (total versus non-total thyroidectomy), the use of energy-based vessel sealing devices, the use of the hemostatic agent Surgicel, and the placement of a surgical drain were not significantly associated with PNH. Conclusion Hematoma after thyroid surgery is an uncommon complication, but it is related to significant postoperative morbidity. A better understanding of the risk factors and of the time until hematoma formation can help target high-risk patients for preventive measures and closer postoperative observation.

BACKGROUND Well-established conventional thyroidectomy has satisfactory outcomes; however, robotic and endoscopic thyroid surgery can avoid visible anterior neck scars. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most recent of these techniques. METHODS This was a retrospective review of 412 patients who underwent TOETVA from 2017 to 2020 in 13 Brazilian centers. RESULTS The study included 359 (87.1%) females and 53 (12.9%) males, with a mean age of 40 years. There were 231 (56.1%) total thyroidectomies. The conversion rate was 0.7%. The transient vocal cord palsy rate was 7.6% (30 patients). Temporary and persistent hypocalcemia rates were 4.0% and 0.8%, respectively. There were two cases of infection (0.5%). DISCUSSION This is a large multi-institute TOETVA study, with one of the largest cohorts published to date that; despite its retrospective nature and selection bias, reached outcomes comparable to previously reported series, this study reinforced safeness, feasibility, and nationwide reproducibility for this technique.

The transient acute hypocalcemia (HypoCa) is the most prevalent complication after total thyroidectomy, detected primarily by subnormal intact parathyroid hormone (iPTH) and calcium levels. However, the need for calcium supplementation is ambiguous in patients who exhibit low iPTH with normal calcium levels. The aim of this study was to evaluate complementary predictors of HypoCa in this scenario.A retrospective cohort study with of 1597 consecutive patients undergoing total thyroidectomy, with or without neck dissection, from January 2014 to December 2018 at a single institution. Patients with an iPTH12 pg/mL and a total calcium level ≥8 mg/dL in the first 8 h after surgery were included.1597 patients identified with low postoperative iPTH without overt calcium deficiency was diagnosed. The transient HypoCa in that specific subgroup was 509 (31.9%). Multivariate analysis indicated that HYPOCA was associated with bilateral level VI neck dissection and pre- to postoperative calcium reduction38 pg/mL. To better illustrate the model, we plotted a nomogram with the variables selected for the final model.Total thyroidectomy patients who exhibit low postoperative iPTH levels without overt calcium deficiency should be considered for calcium replacement therapy when they a marked drop in iPTH postoperatively and underwent bilateral level VI neck dissection.

To explore the advances in robotic head and neck surgery (HNS) beyond TORS. Although limited, the current literature corroborates the safety of robotic neck surgery, revealing similar surgical/oncologic outcomes, except longer operative time and superior cosmesis. In most of the remote thyroid approaches, use of robotic-assisted surgery is essential. However, for the recently popularized transoral approach, endoscopic technique has been preferred by most surgeons, due to longer operative time in robotic-assisted technique. On the other hand, retroauricular approach has been considered the standard for comprehensive/selective robotic neck dissections. Robotic technology has an increasing role in HNS. Robotic neck dissection has shown encouraging results, being routinely used in some centers around the globe. Robotic thyroid surgery, although safe when well applied, has lost ground to endoscopic transoral thyroidectomy. In the future, more evolved robotic systems could improve multiple areas of HNS.

DEAR EDITOR, We read with interest the recent report by Tincani and cols. () commenting on the growing adoption of remote access thyroidectomy in Brazil, as well as the accompanying editorial by Dr Shaha (). Both of these manuscripts were listed as opinions of “experts” in the field, but it is apparent that the “experts” did not have all available data at the time of their writing. […] Transoral endoscopic thyroidectomy vestibular approach (TOETVA): pioneers’s point of view

BACKGROUND: The relationship between preoperative vitamin D deficiency and postoperative hypocalcemia in cases of total thyroidectomy (TT) is a matter of controversy and may vary according to geographical scenarios and populations. OBJECTIVE: The objective here was to evaluate whether preoperative vitamin D deficiency was associated with postoperative symptomatic hypocalcemia in a population in South America. DESIGN AND SETTING: Retrospective cohort study on data from all patients undergoing total thyroidectomy, with or without central compartment lymph node dissection, from January 2014 to December 2017, at the A. C. Camargo Cancer Center. METHODS: Patients with benign thyroid disease (Graves’ disease, multinodular goiter or hyperthyroidism) or thyroid cancer who underwent primary total thyroidectomy with or without central compartment lymph node dissection were included. The exclusion criteria were simultaneous parathyroidectomy and conditions that could affect serum calcium levels. The data collected included patient demographics, thyroid pathology, extent of the surgical procedure and complications. Information on preoperative and postoperative calcium, parathyroid hormone (PTH) and vitamin D levels were retrieved from the medical records. RESULTS: 1,347 patients were assessed and postoperative hypocalcemia was diagnosed in 284 patients (21%). The vitamin D levels were considered deficient in 243 patients (18%). Postoperative hypocalcemia was diagnosed in 357 patients (31.5%). Multivariate analysis showed that central compartment dissection and preoperative total calcium and deficient vitamin D levels were significant risk factors for postoperative hypocalcemia. CONCLUSION: Deficient preoperative vitamin D levels were a significant risk factor for postoperative hypocalcemia. Preoperative oral supplementation should be considered, to minimize this risk.

Background: Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection. Methods: A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study. Results: Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II–VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1–9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17–40). The mean follow-up time was 17.4 months (range, 1.4–31.9 months), and no recurrence was diagnosed. Conclusions: The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.

In this note we describe the standard technical maneuver used in our department to protect the skin during thyroidectomy in order to get the best aesthetic result. We use surgical gloves to protect the skin during these operations to reduce the negative impact of thermal trauma and mechanical retractors and energy delivery devices at the edges of the skin incised. This practice is effective, inexpensive, rapid, reproducible and showed no complication in our experience of over 2,500 thyroidectomies.

Introduction There has been a significant increase in concern towards improving aesthetic and functional outcomes without compromising the oncologic effectiveness in head and neck surgery. In this subset, endoscope-assisted and robotic procedures allowed the development of new approaches to the neck, including the retroauricular access, which is now routinely used, especially in Korea. Objectives This study aims to provide a descriptive analysis of our initial experience with retroauricular endoscope-assisted approach assessing feasibility, safety, and aesthetic results. Methods Prospective analysis of the first 11 eligible patients submitted to retroauricular endoscope-assisted approach for neck procedures in the Head and Neck Surgery Department at AC Camargo Cancer Center. Results A total of 18 patients were included in this study, comprising 7 supraomohyoid neck dissections, 8 submandibular gland excisions, 3 thyroid lobectomies, and one paraganglioma excision. There was no significant local complications, surgical accident, or need for conversion into conventional open procedure in this series. Conclusion Our initial experience has shown us that this approach is feasible, safe, oncologically efficient, and applicable to selected cases, with a clear cosmetic benefit.

Objective: To evaluate the characteristics of thyroid carcinoma cases treated at a reference hospital for cancer between 2008 and 2010.Methods: we studied 807 cases and analyzed the following clinicopathologic variables: symptoms, risk factors, diagnostic tests, staging, histological type, treatment performed and complications.Results: Females were more affected, with 660 cases (82%). The average age at diagnosis was 44.5 years. Prior exposure to ionizing radiation was reported by 22 (3%) patients, a family history of thyroid cancer by 89 (11%), and 289 (36%) individuals reported other types of cancer in the family. The fine needle aspiration biopsy was the main parameter for surgical indication and was suggestive of carcinoma in 463 patients (57%). Papillary carcinoma was the most common histological type, with 780 cases (96.6%). There were 728 (90%) total thyroidectomies, 43 (5.3%) reoperations or partial thyroidectomies followed by totalization, 23 (2.8%) extended thyroidectomies and only 13 (1.6%) partial thyroidectomies (lobectomy with isthmectomy). Neck dissection associated with thyroidectomy was done in 158 patients (19.5%). We observed a predominance of tumors classified as T1 in 602 (74.6%) patients. Transient hypocalcemia was the most frequent complication.Conclusion: The results show that the worldwide increase in the incidence of thyroid cancer has changed the profile of patients seen at a referral service. In addition, there were changes in the type of surgical treatment used, with increased use of total thyroidectomy in relation to partial and subtotal ones, and decreased use of elective neck dissections. Objetivo: avaliar características casos de carcinoma de tireoide atendidos em um hospital de referência em câncer entre 2008 e 2010.Métodos: foram analisadas variáveis clínico-patológicas de 807 casos tratados em três anos: sintomas, fatores de risco, exames de diagnóstico, estadiamento, tipo histológico, tratamento realizado e complicações.Resultados: o sexo feminino foi o mais acometido com 660 casos (82%). A média de idade ao diagnóstico foi 44,5 anos. A exposição prévia à radiação ionizante foi referida por 22 (3%) pacientes, a história familiar de câncer de tireoide por 89 (11%) pacientes e 289 (36%) pacientes relataram outros tipos de câncer na família. A punção aspirativa por agulha fina foi o principal parâmetro para indicação operatória e foi sugestiva de carcinoma em 463 pacientes (57%). O carcinoma papilífero foi o tipo histológico mais incidente, com 780 casos (96,6%). Foram realizadas 728 (90%) tireoidectomias totais, 43 (5,3%) reoperações ou tireoidectomias parciais seguidas de totalização, 23 (2,8%) tireoidectomias ampliadas e apenas 13 (1,6%) tireoidectomias parciais (lobectomia com istmectomia). O esvaziamento cervical, associado à tireoidectomia, foi feito em 158 pacientes (19,5%). Observamos predomínio dos tumores classificados como T1 em 602 (74,6%) dos pacientes. A hipocalcemia transitória foi a complicação mais frequente.Conclusão: os resultados mostram que o aumento mundial da incidência do câncer de tireoide alterou o perfil dos pacientes atendidos em serviço de referência. Além disso, ocorreram mudanças no tipo de tratamento cirúrgico empregado, com aumento no uso da tireoidectomia total em relação às parciais e subtotais e diminuição do uso de esvaziamento cervical eletivo para estas neoplasias.