Comparison of transaxillary endoscopic and open approaches in thyroid surgery (systematical review and meta-analysis)

   Introduction. The cosmetic effect of endoscopic thyroidectomy is indisputable. However, there are questions about the appropriateness of such an operation. A meta-analysis was performed to summarize data on the advantages of endoscopic over open access in thyroid surgery.

   Aim of the study. To conduct a meta-analysis of the results of operations on the thyroid gland with transaxillary endoscopic (TATE) and open access (OTE).

   Materials and methods. 8 retrospective, 4 prospective and 1 randomized comparative study were analyzed, including the results of treatment of 6484 patients. Statistical processing was performed in the Review Manager 5.4 program. The sum of the dichotomous data was reported with a 95 % confidence interval as an odds ratio. Statistical heterogeneity among the studies included in the meta-analysis was assessed using the χ2 test. At p<0,1 and I2>50 % heterogeneity was considered statistically significant.

   Results. The conducted meta-analysis confirmed the advantage of TATE over OTE in terms of cosmetic results of treatment. With regard to the volume of intraoperative blood loss, the frequency and structure of postoperative complications, TATE was comparable to OTE. There was no statistically significant difference between TATE and OTE in the severity of pain syndrome and the length of stay of patients in the hospital.

   Conclusion. TATE for benign and malignant neoplasms of the thyroid gland is a safe alternative to open surgery. TATE is most effective and safe when performed by an experienced surgeon who has gone through a learning curve.

1. Tae K., Ji Y. B., Song C. M., Ryu J. Robotic and Endoscopic Thyroid Surgery: Evolution and Advances. Clin Exp Otorhinolaryngol, 2019, № 12 (1), рр. 1–11. doi: 10.21053/ceo.2018.00766

2. Chung E. J., Park M. W., Cho J. G., Baek S. K., Kwon S. Y., Woo J. S., Jung K. Y. A prospective 1-year comparative study of endoscopic thyroidectomy via a retroauricular approach versus conventional open thyroidectomy at a single institution. Ann Surg Oncol, 2015, № 22 (9), рр. 3014–3021. doi: 10.1245/s10434-014-4361-7

3. Sung E. S., Ji Y. B., Song C.M., Yun B. R., Chung W. S., Tae K. Robotic Thyroidectomy: Comparison of a Postauricular Facelift Approach with a Gasless Unilateral Axillary Approach. Otolaryngol Head Neck Surg, 2016, № 154 (6), рр. 997–1004. doi: 10.1177/0194599816636366

4. Xu Z., Meng Y., Song J., Wang Y., Yao X. The role of carbon nanoparticles in guiding central neck dissection and protecting the parathyroid in transoral vestibular endoscopic thyroidectomy for thyroid cancer. Wideochir Inne Tech Maloinwazyjne, 2020, № 15 (3), рр. 455–461. doi: 10.5114/wiitm.2019.89658

5. Xu Z., Song J., Wang Y., Tan L., Sun S., Meng Y. A comparison of transoral vestibular and bilateral areolar endoscopic thyroidectomy approaches for unilateral papillary thyroid microcarcinomas. Wideochir Inne Tech Maloinwazyjne, 2019, № 14 (4), рр. 501–508. doi: 10.5114/wiitm.2019.84759

6. Maystrenko N. A., Romashchenko P. N., Krivolapov D. S. Prishvin A. P., Mikhal’chenko G. V. Minimally Invasive Thyroid Surgery. Mezhdunarodnyy nauchno-issledovatel’skiy zhurnal, 2017, №1 (55), pp. 144–151. (In Russ.) doi: 10.23670/IRJ.2017.55.165

7. Kang S. W., Jeong J. J., Yun J. S., Sung T. Y., Lee S. C., Lee Y. S., Nam K. H., Chang H. S., Chung W. Y., Park C. S. Gasless endoscopic thyroidectomy using trans-axillary approach; surgical outcome of 581 patients. Endocr J., 2009, № 56 (3), pp. 361–169. doi: 10.1507/endocrj.k08e-306

8. Ikeda Y., Takami H., Sasaki Y., Takayama J., Niimi M., Kan S. Clinical benefits in endoscopic thyroidectomy by the axillary approach. J Am Coll Surg., 2003, № 196 (2), pp. 189–95. doi: 10.1016/S1072–7515(02)01665-4

9. Wang Y., Liu K., Xiong J., Zhu J. Total endoscopic versus conventional open thyroidectomy for papillary thyroid microcarcinoma. J Craniofac Surg., 2015, № 26 (2), pp. 464–468. doi: 10.1097/SCS.0000000000001449

10. Chen C., Huang S., Huang A., Jia Y., Wang J., Mao M., Zhou J., Wangт L. Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis. Ther Clin Risk Manag, 2018, № 5 (14), pp. 2349–2361. doi: 10.2147/TCRM.S183612.

11. Huang J. K., Ma L., Song W. H., Lu B. Y., Huang Y. B., Dong H. M. Quality of life and cosmetic result of single–port access endoscopic thyroidectomy via axillary approach in patients with papillary thyroid carcinoma. Onco Targets Ther, 2016, № 4 (9), pp. 4053–4059. doi: 10.2147/OTT.S99980

12. Lee D. Y., Lim S., Kang S. H., Oh K. H., Cho J. G., Baek S. K., Woo J. S., Kwon S. Y., Jung K. Y. A prospective 1–year comparative study of transaxillary total thyroidectomy regarding functional outcomes: Is it really promising? Surg Endosc., 2016, № 30 (4), pp. 1599–1606. doi: 10.1007/s00464-015-4386-4

13. Park K. N., Cho S. H., Lee S. W. Nationwide multicenter survey for current status of endoscopic thyroidectomy in Korea. Clin Exp Otorhinolaryngol., 2015, № 8 (2), pp. 149–154. doi: 10.3342/ceo.2015.8.2.149

14. Liberati A., Altman D. G., Tetzlaff J., Mulrow C., Gøtzsche P. C., Ioannidis J. P., Clarke M., Devereaux P. J., Kleijnen J., Moher D. The PRISMA statement for reporting systematic reviews and meta–analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ, 2009, № 21, pp. 339:b2700. doi: 10.1136/bmj.b2700

15. Lyadov V. K., Neklyudova M. V., Pashayeva D. R.. Experience of transaxillary endoscopic thyroid surgery. Khirurgiya. Zurnal im. N. I. Pirogova, 2016, № 11, pp. 4–7. (In Russ.) doi: 10.17116/hirurgia2016114-7

16. Chang E. H., Lobe T. E., Wright S. K. Our initial experience of the transaxillary totally endoscopic approach for hemithyroidectomy. Otolaryngol Head Neck Surg, 2009, № 141( 3), pp. 335–339. doi: 10.1016/j.otohns.2009.05.026.

17. Hyun K., Byon W., Park H. J., Park Y., Park C., Yun J. S. Comparison of swallowing disorder following gasless transaxillary endoscopic thyroidectomy versus conventional open thyroidectomy. Surg Endosc, 2014, № 28 (6), pp. 1914–1920. doi: 10.1007/s00464-013-3413-6

18. Jeong J. J., Kang S. W., Yun J. S., Sung T. Y., Lee S. C., Lee Y. S., Nam K. H., Chang H. S., Chung W. Y., Park C. S. Comparative study of endoscopic thyroidectomy versus conventional open thyroidectomy in papillary thyroid microcarcinoma (PTMC) patients. J Surg Oncol, 2009, № 100 (6), pp. 477–480. doi: 10.1002/jso.21367

19. Kang J. B., Kim E. Y., Park Y. L., Park C. H., Yun J. S. A comparison of postoperative pain after conventional open thyroidectomy and single–incision, gasless, endoscopic transaxillary thyroidectomy: a single institute prospective study. Ann Surg Treat Res, 2017, № 92 (1), pp. 9–14. doi: 10.4174/astr.2017.92.1.9

20. Kim E. Y., Lee K. H., Park Y. L., Park C. H., Lee C. R., Jeong J. J., Nam K. H., Chung W. Y., Yun J. S. Single-Incision, Gasless, Endoscopic Trans–Axillary Total Thyroidectomy: A Feasible and Oncologic Safe Surgery in Patients with Papillary Thyroid Carcinoma. J Laparoendosc Adv Surg Tech A., 2017, № 27 (11), pp. 1158–1164. doi: 10.1089/lap.2016.0669

21. Kim K., Lee S., Bae J. S., Kim J. S. Comparison of long-term surgical outcome between transaxillary endoscopic and conventional open thyroid-ectomy in patients with differentiated thyroid carcinoma: a propensity score matching study. Surg Endosc., 2021, № 35 (6), pp. 2855–2861. doi: 10.1007/s00464-020-07721-2

22. Lee H., Lee J., Sung K. Y. Comparative study comparing endoscopic thyroidectomy using the axillary approach and open thyroidectomy for papillary thyroid microcarcinoma. World J Surg Oncol., 2012, № 12 (10), pp. 269. doi: 10.1186/1477-7819-10-269

23. Li T., Zhang Z., Chen W., Yu S., Sun B., Deng X., Ge J., Wei Z., Lei S., Li G. Comparison of quality of life and cosmetic result between open and transaxillary endoscopic thyroid lobectomy for papillary thyroid microcarcinoma survivors: A single–center prospective cohort study. Cancer Med., 2022, № 11 (22), pp. 4146–4156. doi: 10.1002/cam4.4766

24. Park K. N., Mok J. O., Chung C. H., Lee S. W. Does Postthyroidectomy Syndrome Really Exist Following Thyroidectomy? Prospective Comparative Analysis of Open vs. Endoscopic Thyroidectomy. Clin Exp Otorhinolaryngol., 2015, № 8 (1), pp. 76–80. doi: 10.3342/ceo.2015.8.1.76.

25. Jantharapattana K., Maethasith J. Transaxillary gasless endoscopic thyroidectomy versus conventional open thyroidectomy: a randomized study. Eur Arch Otorhinolaryngol, 2017, № 274 (1), pp. 495–500. doi: 10.1007/s00405-016-4242-8

26. Wells G. A., Shea B., O’Connell D., Peterson J., Welch V., Losos M., Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. URL: http:// www.ohri.ca/programs/clinical_epidemiology/oxford.asp.

27. Hüscher C. S., Chiodini S., Napolitano C., Recher A. Endoscopic right thyroid lobectomy. Surg Endosc., 1997, № 11 (8), pp. 877. doi: 10.1007/s004649900476

28. Kim S. K., Kang S. Y., Youn H. J., Jung S. H. Comparison of conventional thyroidectomy and endoscopic thyroidectomy via axillobilateral breast approach in papillary thyroid carcinoma patients. Surg Endosc., 2016, № 30 (8), pp. 3419–1425. doi: 10.1007/s00464-015-4624-9

29. Bai B., Chen Z., Chen W. Risk factors and outcomes of incidental parathyroidectomy in thyroidectomy: A systematic review and meta-analysis. PLoS One., 2018, № 13 (11), рр. e0207088. doi: 10.1371/journal.pone.0207088

30. Ryu H. R., Lee J., Park J. H., Kang S. W., Jeong J. J., Hong J. Y., Chung W. Y. A comparison of postoperative pain after conventional open thyroid-ectomy and transaxillary single–incision robotic thyroidectomy: a prospective study. Ann Surg Oncol., 2013, № 20 (7), pp. 2279–2284. doi: 10.1245/s10434-012-2557-2

31. Xiang D., Xie L., Li Z., Wang P., Ye M., Zhu M. Endoscopic thyroid-ectomy along with bilateral central neck dissection (ETBC) increases the risk of transient hypoparathyroidism for patients with thyroid carcinoma. Endocrine, 2016, № 53 (3), pp.747–753. doi: 10.1007/s12020-016-0884-y

32. Rolke R., Baron R., Maier C., Tölle T. R., Treede D. R., Beyer A., Binder A., Birbaumer N., Birklein F., Bötefür I. C., Braune S., Flor H., Huge V., Klug R., Landwehrmeyer G. B., Magerl W., Maihöfner C., Rolko C., Schaub C., Scherens A., Sprenger T., Valet M., Wasserka B. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain, 2006, № 123 (3), pp. 231–243. doi: 10.1016/j.pain.2006.01.041

33. Feilin C., Ketao J., Binbin C., Bojian X., Learning curve for endoscopic thyroidectomy: a single teaching hospital study. OncoTargets and Therapy, 2013, № 6, pp. 47–52. doi: 10.2147/OTT.S39733