Transcript PowerPoint 프레젠테이션 - Asia & Oceania Thyroid

Postoperative voice outcome of
endoscopic and robotic thyroidectomy
compared with open thyroidectomy
Min Woo Park, Soon-Young Kwon, Jeong-Soo Woo, Seung-Kuk
Baek, Jae-Gu Jo, Kyoung Ho Oh, Young-Ho Ju, Kwang-Yoon Jung
Department of Otolaryngology-Head and Neck Surgery
Korea University College of Medicine
Traditional Open Thyroidectomy
• Most common
procedure for
thyroidectomy
• 5~6cm skin incision
• Occasionally,
hypertrophic scar or
kelloid
Developement of Endoscopic
Approach
• Background
– Better understanding and knowledge of new anatomical
landmarks for endoscopic thyroidectomy
– Development of dedicated surgical instruments
– Considering that the increased prevalence of thyroid disease
is much higher in young women than in men
• Development of various endoscopic approaches
–
–
–
–
–
Cervical approach
Anterior chest approach
Breast approach
Axillary approach
Combined approach(ABBA, BABA, GUAB)
Advantages
of Endoscopic Thyroidectomy
 Cosmetic benefit : no or minimal cervical scar
 Excellent operative view
 magnification of cervical anatomy
 lower incidence of peri-operative morbidity
 Minimal degree of postoperative hypesthesia, paresthesia on the
neck area and uncomfortable “catching”sensation on swallowing
Disadvantages
of Endoscopic Thyroidectomy
 Longer operation time
 No cost benefit
 More invasive than direct trans-cervical approach
 wide skin flap for creation of enough working space from the ports
sites to the target (remote approach)
 Postoperative pain or discomfort on the neck or anterior chest
 disappeared by 3 months after surgery
Robotic Thyroidectomy
• Advantage
– 3D field of view
– 1 endoscope, 3 robot arms
• no need of assistant
– Multi-angular motion
• total thyroidectomy with CND is
possible
– Fine motion, Hand-tremor
filtration
• Disadvantage
– No Cost benefit
Robotic thyroidectomy
Evaluation of Robotic thyroidectomy as New
technology
3 point of view
– Safety
– Oncologic Validation
– Better Functional Outcome
Safety of Robotic Thyroidectomy
• Multicenter study
• Robotic thyroidectomy using gasless, transaxillary approach
• 1043 patients
Surg Endosc, 2011
Oncological Validation
• Not get the long-term result yet
• Short-term follow-up (1 year) revealed no recurrence by
sonography and no abnormal uptake during radioactive iodine
therapy
Woong Youn Chung et al, Ann Surg, 2011
Functional Outcome
• A Few reports
• Mainly focus on patient’s satisfication of scar
• Lee J et al(2011) study reported voice outcome of robotic
thyroidectomy compared with open thyroidectomy.
However, there are no comparative data of open/endoscopic/robotic
Surg Endosc, 2011
thyroidectomy
Voice problem after thyroidectomy
 Voice alteration after thyroidectomy is reported
frequently.
(Stojadinovic A, Ann Surg 2002)
 Endoscopic approach to thyroidectomy have been
developed to improve the cosmetic result of
conventional thyroidectomy.
(Gagner M , Thyroid 2001)
 There are few reports about voice result of
endoscopic thyroidectomy and robotic thyroidectomy
compared with open thyroidectomy.
(Lombardi CP, World J Surg 2008)
Objectives
• To determine the influence of endoscopic
thyroidectomy(ET) and robotic thyroidectomy(RT)
using a gasless unilateral axillo-breast approach on
the voice outcome comparing of conventional open
thyroidectomy(OT)
Materials & Methods
• Study period : Jul. 2011 ~ May. 2012
• Study objects
– 332 patients who underwent thyroidectomy for papillary thyroid
cancer in Korea University Anam Hospital
• Exclusion criteria (44 patients)
– insufficient voice data, vocal fold paralysis, gross extrathyroidal
extension(T4a), concomitant lateral neck dissection
• Voice outcome (preop, postop 1wk, 1mo, 3mo)
–
–
–
–
–
Videolaryngostroboscopy
Acoustic analysis : jitter, shimmer, NHR, F0
Voice range profile : highest/lowest frequency, max/min amplitude
Auditory perceptual evaluation : GRBAS scale
Voice handicap index-30
Operation procedure
• The OT was performed through low collar incision of 5-6cm in
neck
• ET and RT all were performed through gasless unilateral axillobreast approach.
• One 2D endoscopy and 2 instruments were used in ET.
Whereas, one 3D endoscopy and 3 robot instruments were
used in RT.
Gasless Unilateral Axillo-Breast
Approach
 Gasless




avoid CO2 gas related complications
wider & clearer operative field
conventional instruments
creation of the working space under direct vision
 Axillo-Breast approach
 no cervical wound
 relatively shorter distance of flapping
 nearly same manner of open thyroidectomy
Indications for ET/RT in KUMC
 Unilateral (ET, RT) or Bilateral lesions(RT)
 Benign thyroid tumor : Less than 5.0 cm in diameter
 Papillary thyroid carcinoma
 microcarcinoma (less than 1.0 cm in diameter)
 intrathyroidal lesion
 no gross or ultrasonographic evidence of LN metastasis
Results
Clinical Factors
ET
RT
OT
N
25
39
224
6 : 19
6 : 33
44 : 180
0.80
39.3 ± 10.0
44.0 ± 9.8
52.8± 10.5
<0.01
0.5 ± 0.3
0.7 ± 0.3
0.9 ± 0.7
<0.01
M:F
Age(yr)
Tumor size(cm)
Tumor side
Both
Isthmus
Left: Right
0.01
0
0
3:17
6
2
14:14
44
14
80 : 66
Surgical Extent
HT
TT+/-CND
P value
<0.01
25
0
21
18
64
158
HT : hemithyroidectomy, TT: total thyroidectomy, CND: central neck dissection
Acoustic analysis
MDVP ( F0, Jitter, Shimmer, NHR)
Factor
F0
Jitt
Shim
NHR
Group
Preop
Post 1wk
Post 1mo
Post 3mo
P-value*
ET
208.3
0.91
2.77
0.12
210.3
0.98
3.29
0.21
205.5
0.80
3.33
0.15
206.3
0.82
2.96
0.11
Not
significant
RT
208.3
0.94
3.57
0.13
210.3
0.96
3.19
0.24
203.5
0.92
3.17
0.16
204.3
0.88
2.76
0.13
193.2
0.97
3.11
0.13
189.9
0.91
2.88
0.22
189.3
0.91
2.99
0.19
190.9
0.93
2.80
0.12
OT
Not
significant
Not
significant
* Paired-t test (preop vs postop 1wk/1mo/3mo)
Auditory perceptual evaluation
GRBAS score
Factor
G
R
Ap
B
As
A
Group
Preop
Post 1wk
Post 1mo
Post 3mo
P-value*
ET
0.93
0.70
0.0
0.52
0.0
0.11
0.96
0.78
0.0
0.52
0.0
0.01
1.02
0.80
0.0
0.70
0.0
0.02
1.02
0.64
0.0
0.59
0.0
0.03
Not
significant
RT
0.90
0.70
0.0
0.42
0.0
0.12
0.94
0.78
0.0
0.32
0.0
0.0
0.98
0.80
0.0
0.63
0.0
0.01
0.88
0.70
0.0
0.59
0.0
0.01
Not
significant
0.91
0.71
0.1
0.53
0.02
0.02
0.97
0.79
0.0
0.52
0.01
0.00
0.90
0.72
0.0
0.54
0.0
0.02
0.84
0.48
0.02
0.58
0.0
0.01
Not
significant
OT
* Paired-t test (preop vs postop 1wk/1mo/3mo)
Voice range profile
Frequency range
Postop 1wk/1mo :
decrease range(P <0.01*)
700
Early recovery in
RT (P =0.15*)
600
500
RT
400
ET
OT
300
200
100
0
preop
post1wk
post1mo
post3mo
* Paired-t test (vs preop)
Voice Handicap Index
VHI-30 : Total score
All VHI scores increased at 1wk
(P <0.01* )
10
9
Early improvement
in ET/RT
8
7
ET
RT
OT
CT
6
5
4
3
2
1
0
preop
post_1wk
post_1mo
*Paired-t test (vs preop)
post_3mo
Summary
• There was no change in acoustic analysis and
auditory visual perception after thyroidectomy.
• Highest frequency of voice was recovered in the RT
at 3 month after thyroidectomy, but not in the ET and
OT.
• The VHI-30 score of study patients was improved in
the ET and RT at 1 month after thyroidectomy, but
not in the OT.
Discussion
• Early recovery of high frequency of patients’ voice in
robotic thyroidecotmy.
– meticulous upper pole dissection using 3D vision of robot 
minimal injury of cricothyroid muscle
• Early subjective voice improvement in
robotic/endoscopic thyroidectomy
– No skin flap elevation at area of strap muscle  Small
dissection area of extralaryngeal muscle than open
thyroidectomy
Discussion
Limitations of this study
• Small number of cases
• Relatively short period of follow-up
• Difference of age, tumor size, surgical extent
 Further long-term and large scale study are in
progress.
Conclusions
• ET and RT seem to show early improvement
in voice symptoms after thyroidectomy,
compared with OT.
Thank you for your attention !