Application Of Endoscopic Technique In The Treatment Of Thyroid And Parathyroid Diseases

ObjectiveThe cervical scar left by conventional thyroidectomy and parathyroidectomy has bad cosmetic effect on the neck and causes severe mental stress to patients. As a new technique, endoscopic thyroid and parathyroid surgery are gradually accepted by patients with the advantages of excellent cosmetic effect, reduced physical injury, and quicker postoperative recovery. However, due to the short period application and technique challenges, there are still many problems and controversies yet to be resolved:(1) Is endoscopic thyroidectomy and parathyroidectomy safe, feasible and effective? (2) What the advantages of different approaches, and how to choose the most proper procedure for different patients? (3) How to get maximal cosmetic effect and meanwhile reduce physical injury; (4) If the indication could be further enlarged? (5) What's the standard operative procedure and how to prevent the complications? This clinical study was aimed to explore and resolve these problems, and thus promote the application of endoscopic technique in treatment of thyroid and parathyroid diseases.MethodsFrom Mar.2002 to Mar.2009, endoscopic thyroid surgeries were performed in 182 cases with benign thyroid diseases, among which 95 cases were through the anterior chest approach, and 87 cases were through the areola approach. During the same period,167 patients undergone conventional surgery were chosen as the control group. The patient age, gender, preoperative diagnosis, and nodules characteristics were all comparable both between the endoscopic and conventrional groups, and between the anterior chest approach and the areola approach groups. For the anterior chest approach, the observation port (10mm) was made about 10cm beneath the sternal notch, and the operation ports (10mm and 5mm) were located about 5cm above the nipples on midclavicular line. For the areola approach, the observation port (10mm) was located on the middle point of the line between the nipples, and the operation ports(10mm and 5mm) were made at the superior border of each areola. Unilateral thyroidectomy, unilateral subtotal thyroidectomy, and bilateral thyroidectomy were performed according to the diseases. Explore the advantages and disadvantages of endoscopic surgery by comparing the average operative time, the blood loss, the postoperative pain score, the postoperative hospital stay, the complication rate, and the cosmetic effect between the endoscopic group and control group. Compare the duration for creating subcutaneous tunnel, the total operative time, the subcutaneous tunnel area, the mean blood loss, the postoperative hospital stay, the complication rate, and the cosmetic effect between the anterior chest approach group and the areola approach group, and thus explore the most suitable approach which can reach outstanding cosmetic effect while reducing physical injury. On the basis of operation safety and effect, gradually explore the indication of endoscopic thyroid surgery. Sum up the operative techniques and experiences, in order to make the standard endoscopic procedure and prevent the related complications.Endoscopic parathyroid adenomectomy was performed for 4 patients with primary hyperparathyroidism. which was through either the anterior chest approach (2 cases), or the areola approach (2 cases). To explore the safety, efficiency, and feasibility of this procedure.ResultsEndoscopic thyroidectomy was successfully performed in 178 cases, while 4 cases were converted to open surgery. Both unilateral and bilateral operative time in the endoscopic surgery groupy were significantly longer than the conventional surgery group (P<0.01). However, the the endoscopic surgery had much less operative bleeding (P<0.05). There were no big difference in postoperative pain score both 24h and 48h after operation (P>0.05). Postoperative hospital stay was much shorter in the endoscopic surgery group (P<0.05). There was no statistical difference in total complication rate between the two groups (P>0.05). Noticebly, endoscopic surgery had significantly better cosmetic effect than conventional ones (P<0.01). The complications in endoscopic surgery group were manily endoscopic technique related, such as subcutaneous emphysema and subcutaneous ecchymosis. However, the endoscopic surgery group had much less complications related to thyroidectomy, especially paraesthesia of anterior neck region and swallowing discomfort (P<0.01). The endoscopic surgery group also showed lower complication rate, but has no significant difference (P>0.05). No severe complications occurred in both groups. With a follow-up of 12～48 months, tumor recurrence rate of the endoscopic group was 7/178, which was comparable with the control group (P>0.05).93 and 85 endoscopic thyroidectomy were completed through the anterior chest group and the areola group, respectively. Compared with the areola approach group, the subcutaneous tunnel area was much smaller (P<0.01), which was about 43% reduction. Aaccordingly, the duration for creating subcutaneous tunnel was much shorter for the anterior chest approach (P<0.05). Both the unilateral and bilateral operative time for the anterior chest approach was also shorter than the areola approach, but the difference was not significant (P>0.05). The anterior chest approach showed much less postoperative pain at both 24h and 48h (P>0.05). The differences in the mean blood loss, the postoperative hospital stay, the complication rate were not meaningful between the two groups (P>0.05). With similarly high satisfaction rate (P>0.05), both groups had good cosmetic effect. Two cases in each group converted to open surgery. Two cases were due to big nodules (>50mm), which reduced little operation space, increased operation difficulty, and caused intraoperative bleeding, without much operation experience and technique at the early stages of this procedure. The other two cases were converted because of intraoperative malignant frozen section analysis (anaplastic carcinoma and follicular carcinoma each). With a follow-up of 12～48 months,3 and 4 cases were recurrented in each group, and the recurrence rate was comparable (P>0.05). The patients were still under observation.After gaining of experience and improvement of operative technique, we performed endoscopic surgery for thyroid nodules larger than 50mm (the biggest one was 58mm). We also successfully performed endoscopic thyroidectomy for one patient with previous neck surgery history (unilateral subtotal thyroidectomy). Postoperative complications includes:subcutaneous emphysema (3 cases), subcutaneous ecchymosis (5cases), paraesthesia of anterior neck region (2 cases), transient temporary recurrent nerve palsy (1 case), transient hypocalcemia (2 cases), and temporary hypothyroidism, which were all cured with conservative therapy. No hyperthyroidism recurred.For parathyroid diseases, endoscopic surgeries were all successfully performed. The mean operative time was 82.5±17.8min, the mean blood loss was 26.8±12.5ml, and postoperative stay was 5.6±2.2d. One transient hypocalemia occurred, which need no special treatment. Pathological analysis included three adenomas and one parathyroid carcinoma. With a follow-up of 36～48 months, the operations were effective without recurrence.Conclusions(1) Compared with traditional procedures, endoscopic thyroid surgery embodies the advantages cosmetology, less invasion, quicker recovery, and shorter hospital stay, which is safe, feasible, and effective in the treatment of benign thyroid nodules. (2) The cosmetic effect of the suprasternal notch approach is not good enough for clinical promotion. Both the anterior chest approach and the areola approach are suitable for the treatment of benign thyroid diseases, and both have good cosmetic effect. The anterior chest approach can further reduce the physical injury, which is more in accordance with the rule of minimal invasion. (3) On the basis of operative safety and effect, the option of the best approach should be made by combination of the nodule characteristics, the expectation and needs of the patient, the experience of the doctor, and the device and equipment condition of the hospital (4) With the mastery of the technique and increase of experience, endoscopic surgery can be applied to the treatment of big thyroid nodule resection (>50mm), Grave's disease, and even patients with previous neck surgery. (5) Endoscopic operation is safe and effective in the treatment of primary hyperparathyroidism, thus worth clinical promotion.