Most patients undergoing conventional thyroid and parathyroid surgeries were eligible for transoral endocrine surgery (TES), researchers reported from a retrospective analysis.
Among 1,000 patients who underwent thyroid or parathyroid surgery, 55.8% were eligible for transoral procedures that wouldn't leave a visible scar on the neck, according to Raymon Grogan, MD, MS, of Baylor College of Medicine in Houston, and colleagues.
In particular, 76% of patients who had conventional surgery for thyroid nodules with indeterminate cytology could have, in retrospect, reasonably received TES instead, the group wrote in JAMA Network Open.
Similarly, 69% of patients who underwent surgery for a benign thyroid condition and 58% of patients with primary hyperparathyroidism were eligible for the transoral approach, but did not receive it.
However, only 29% of patients who underwent thyroid cancer resection were eligible for the virtually scarless procedure.
"As the [TES] name implies, access to the neck is via the oral cavity. Currently, the main advantage of these operations is the lack of a visible scar in an area that is not easily hidden," Grogan's group explained.
"The most common TES techniques currently used in the United States are TOETVA (transoral endoscopic thyroidectomy vestibular approach) for thyroidectomy and TOEPVA (transoral endoscopic parathyroidectomy vestibular approach) for parathyroidectomy," they added.
Grogan and colleagues noted that because the incision length with TES is usually 2 cm or less, this type of procedure is considered minimally invasive for thyroidectomy and can be considered either minimally invasive or a remote-access procedure for parathyroidectomy.
The analysis included patients who underwent a thyroid or parathyroid operation with or without neck dissection from July 2015 to July 2018 at one of three different high-volume U.S. academic centers: University of Chicago, Johns Hopkins University, and the University of California San Francisco.
Each surgical case was assessed for patient demographics, indication for operation, as well as the type of operation to determine if the patient would have been eligible for TES.
Eligibility for TES was defined as the absence of all of the following:
- Serious comorbidity contraindicating a long procedure duration
- Substernal thyroid
- Prior external beam radiation to the neck or open neck operation
- Single benign nodule bigger than 6 cm or a malignant thyroid tumor larger than 2 cm
- Total thyroid lobe diameter larger than 10 cm
- Indications for a therapeutic central neck dissection or a lateral neck dissection
- Nonlocalized primary hyperparathyroidism
- Secondary or tertiary hyperparathyroidism
Among the 1,000 cases analyzed, the most common indication for ineligibility for TES was reoperation (22%), followed by nonlocalized primary hyperparathyroidism (17.7%), neck dissection for cancer (15%), multiple contraindications (14.1%), and a cancerous tumor larger than 2 cm (12%).
"It is estimated that 150,000 thyroidectomies and 100,000 parathyroidectomies are performed annually in the United States. Applying a 56% eligibility shows that it is possible that as many as 140,000 patients per year in the United States could be eligible for TES," the group posed. "Considering that up to 140,000 thyroid and parathyroid operations could be performed via TES annually in the United States, our results suggest that TES is applicable to a large number of patients and may not be considered a 'boutique' operation in the near future."
But before TES gains more popularity as a surgical option, Grogan's group said, it first must prove itself equally as safe as the open surgical approach with equivalent efficacy and outcomes, and also it must be determined that lack of visible scarring adds to quality of life or value to the patient.
Nevertheless, they wrote, "[w]e believe these data show that TES is not and should not be considered an operation with limited applicability. Transoral endocrine surgery has the potential to improve the lives of a large number of patients, and thus it should be considered a viable option in the United States."
Grogan reported consulting fees from Medtronic. Other study authors also reported disclosures.