Feature

Transoral thyroidectomy may be comparable to traditional thyroid surgery

Photo of Udelsman
Robert Udelsman

Transoral thyroidectomy, an alternative to traditional thyroid surgery, has gained popularity in Thailand and other Asian countries because it spares patients the neck scar.

Robert Udelsman, MD, chief of endocrine surgery and director of Endocrine Neoplasia Institute at Miami Cancer Institute, is helping this approach gain traction in the United States.

Experts in other countries have used this procedure for about 4 years. Udelsman began performing it in the United States after he traveled to Thailand to learn the technique.

Endocrine Today spoke with Udelsman about the procedure, whether its benefits may be more than just cosmetic, and its potential role in clinical practice moving forward.

 

Question: How and why was this approach developed?

Answer: In certain areas of the world — particularly in Asia, including Japan, China, Thailand, and South Korea — women are resistant to getting an incision in their neck. It is considered cosmetically displeasing or disfiguring. Because of those concerns, surgeons in those regions have developed a number of remote access techniques for performing thyroid surgery. They have used retro-auricular entry, or behind the ear; entry through the axilla, or under the arm; or even through the breast. The only reason those procedures were employed was to avoid the incision in the neck. However, as you might imagine, the tradeoff with these approaches is that they require longer areas to go through. This can lead to increased rates of surgical complications — particularly in the armpit, which is near the blood vessels and the nerves of the brachial plexus. So, these approaches have their limitations.

This approach began in Germany, then migrated to China. Eventually, a surgeon in Thailand went to China to learn the technique, and was diverted to an oral approach. The original entry point for this procedure was at the base of the tongue, but that approach also was abandoned due to nerve injuries. They then moved to the lower lip, in the area known as the vestibule. Using this technique, under general anesthesia, you insert saline into the lip to make it larger so you can insert ports. There are three ports, one central and two lateral. You can do thyroid surgery through these three ports. I was the first person in America to go to Thailand to learn this surgery from my colleague, Angkun Anawan, in Bangkok. He spent a week in the United States helping us to refine the operation. We did it for the first time at Yale University, and I’ve since moved down to Miami to initiate a program here. We have performed it on two patients thus far in Miami.

 

 

Q: How does this procedure differ from traditional thyroid surgery?

A: Fundamentally, it is the same operation as the one used with the transverse neck incision. The big difference is that there is no visible incision. The incision is entirely inside the mouth. Also, it heals unbelievably well. The gum mucosa remodels as it is more plastic than normal skin. That is a real advantage. Of course, one drawback is that you can’t remove giant tumors or very aggressive cancers this way. But we can do high percentage of thyroid surgery this way, and I have no doubt that many patients in this country will find this an attractive alternative.

 

Q: Can you elaborate on outcomes, both in terms of efficacy and effect on patients in terms of pain and scarring?

A: The outcomes, as far as we know, are identical to those observed with conventional surgery. There are potential complications to the nerves, vocal chords and parathyroid glands. However, the rates are the same. This has been studied and we cannot demonstrate differences. The operation takes longer because it’s more technically difficult but, as clinicians become more experienced with the procedure, there is no question this time differential will be eliminated. As for pain, you do have pain in mouth and lip, but the overall magnitude of pain is the same as observed for conventional surgery. Obviously, the major advantage of this surgery is purely cosmesis. You could argue that so much training and specialization for a purely cosmetic result makes it likely that this procedure will never be used by most surgeons. However, I believe that those who do perform this surgery will do a lot of them, because the patients who are interested in this cosmetic outcome will be drawn to those centers.

Q: How about recovery time?

A: It’s the same as with traditional thyroid surgery. It is usually less than 24 hours, or an overnight admission.

 

Q: Do you envision a time when this approach could be used in more aggressive cancers ?

A: Possibly, but maybe not in really large tumors. In Thailand, the women tend to be somewhat smaller than they are here, with smaller chins. However, we are already doing substantial-size tumors. Also, this procedure has been shown to have advantages in lymph node surgery. We can also use it for benign disease, Graves’ disease, for toxic thyroid nodule and thyroid cysts. We can’t perform this surgery for really aggressive cancers where we may have to invade other structures. It’s just not appropriate. We would never compromise an oncologic procedure for a cosmetic result. Overall, it is important to consider patient selection. This will not be appropriate for patients with giant chins, which would prevent a physical barrier. Overall, it may be possible that 75% to 80% of thyroid surgery patients could be candidates for this procedure.

 

Q: Could this approach ever be the standard of care for any subset of patients?

A: I think so. It is important to remember that the standard operation for thyroidectomy is a well-studied operation with long-term outcomes. You are now competing with a standard of care that has a very high level. Standard of care is a term that has a somewhat fleeting definition. This procedure may become a standard of care at select institutions. It will never be the standard of care at small hospitals with surgeons who don’t have experience using the procedure, but it may become more widely available, the way laparoscopic procedures started out in a few centers and migrated out to smaller hospitals. —by Rob Volansky

 

For more information:

Robert J. Udelsman , MD, can be reached at 8900 N Kendall Drive, Miami, FL 33176; email: robertud@baptisthealth.net.

 

Disclosure: Udelsman reports no relevant financial disclosures.

Photo of Udelsman
Robert Udelsman

Transoral thyroidectomy, an alternative to traditional thyroid surgery, has gained popularity in Thailand and other Asian countries because it spares patients the neck scar.

Robert Udelsman, MD, chief of endocrine surgery and director of Endocrine Neoplasia Institute at Miami Cancer Institute, is helping this approach gain traction in the United States.

Experts in other countries have used this procedure for about 4 years. Udelsman began performing it in the United States after he traveled to Thailand to learn the technique.

Endocrine Today spoke with Udelsman about the procedure, whether its benefits may be more than just cosmetic, and its potential role in clinical practice moving forward.

 

Question: How and why was this approach developed?

Answer: In certain areas of the world — particularly in Asia, including Japan, China, Thailand, and South Korea — women are resistant to getting an incision in their neck. It is considered cosmetically displeasing or disfiguring. Because of those concerns, surgeons in those regions have developed a number of remote access techniques for performing thyroid surgery. They have used retro-auricular entry, or behind the ear; entry through the axilla, or under the arm; or even through the breast. The only reason those procedures were employed was to avoid the incision in the neck. However, as you might imagine, the tradeoff with these approaches is that they require longer areas to go through. This can lead to increased rates of surgical complications — particularly in the armpit, which is near the blood vessels and the nerves of the brachial plexus. So, these approaches have their limitations.

This approach began in Germany, then migrated to China. Eventually, a surgeon in Thailand went to China to learn the technique, and was diverted to an oral approach. The original entry point for this procedure was at the base of the tongue, but that approach also was abandoned due to nerve injuries. They then moved to the lower lip, in the area known as the vestibule. Using this technique, under general anesthesia, you insert saline into the lip to make it larger so you can insert ports. There are three ports, one central and two lateral. You can do thyroid surgery through these three ports. I was the first person in America to go to Thailand to learn this surgery from my colleague, Angkun Anawan, in Bangkok. He spent a week in the United States helping us to refine the operation. We did it for the first time at Yale University, and I’ve since moved down to Miami to initiate a program here. We have performed it on two patients thus far in Miami.

 

 

Q: How does this procedure differ from traditional thyroid surgery?

A: Fundamentally, it is the same operation as the one used with the transverse neck incision. The big difference is that there is no visible incision. The incision is entirely inside the mouth. Also, it heals unbelievably well. The gum mucosa remodels as it is more plastic than normal skin. That is a real advantage. Of course, one drawback is that you can’t remove giant tumors or very aggressive cancers this way. But we can do high percentage of thyroid surgery this way, and I have no doubt that many patients in this country will find this an attractive alternative.

 

Q: Can you elaborate on outcomes, both in terms of efficacy and effect on patients in terms of pain and scarring?

A: The outcomes, as far as we know, are identical to those observed with conventional surgery. There are potential complications to the nerves, vocal chords and parathyroid glands. However, the rates are the same. This has been studied and we cannot demonstrate differences. The operation takes longer because it’s more technically difficult but, as clinicians become more experienced with the procedure, there is no question this time differential will be eliminated. As for pain, you do have pain in mouth and lip, but the overall magnitude of pain is the same as observed for conventional surgery. Obviously, the major advantage of this surgery is purely cosmesis. You could argue that so much training and specialization for a purely cosmetic result makes it likely that this procedure will never be used by most surgeons. However, I believe that those who do perform this surgery will do a lot of them, because the patients who are interested in this cosmetic outcome will be drawn to those centers.

 

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Q: How about recovery time?

A: It’s the same as with traditional thyroid surgery. It is usually less than 24 hours, or an overnight admission.

 

Q: Do you envision a time when this approach could be used in more aggressive cancers ?

A: Possibly, but maybe not in really large tumors. In Thailand, the women tend to be somewhat smaller than they are here, with smaller chins. However, we are already doing substantial-size tumors. Also, this procedure has been shown to have advantages in lymph node surgery. We can also use it for benign disease, Graves’ disease, for toxic thyroid nodule and thyroid cysts. We can’t perform this surgery for really aggressive cancers where we may have to invade other structures. It’s just not appropriate. We would never compromise an oncologic procedure for a cosmetic result. Overall, it is important to consider patient selection. This will not be appropriate for patients with giant chins, which would prevent a physical barrier. Overall, it may be possible that 75% to 80% of thyroid surgery patients could be candidates for this procedure.

 

Q: Could this approach ever be the standard of care for any subset of patients?

A: I think so. It is important to remember that the standard operation for thyroidectomy is a well-studied operation with long-term outcomes. You are now competing with a standard of care that has a very high level. Standard of care is a term that has a somewhat fleeting definition. This procedure may become a standard of care at select institutions. It will never be the standard of care at small hospitals with surgeons who don’t have experience using the procedure, but it may become more widely available, the way laparoscopic procedures started out in a few centers and migrated out to smaller hospitals. —by Rob Volansky

 

For more information:

Robert J. Udelsman , MD, can be reached at 8900 N Kendall Drive, Miami, FL 33176; email: robertud@baptisthealth.net.

 

Disclosure: Udelsman reports no relevant financial disclosures.