Analysis of Factors Influencing Surgical Approach Selection in Patients with Thyroid Cancer: A Retrospective Study of 411 Cases

Analysis of Factors Influencing Surgical Approach Selection in Patients with Thyroid Cancer: A Retrospective Study of 411 Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of Factors Influencing Surgical Approach Selection in Patients with Thyroid Cancer: A Retrospective Study of 411 Cases YeSheng Zhang, YongCan Xu, YiHeng Yang, GuoChao Ye This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7446471/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Thyroid cancer is the most common malignancy of the endocrine system, and its incidence has risen rapidly over the past decade. It is more prevalent in females, with a male-to-female ratio ranging from 1:2 to 1:3. Thyroid cancer is generally classified into differentiated thyroid carcinoma (DTC), medullary thyroid carcinoma (MTC), and anaplastic thyroid carcinoma (ATC). DTC is further subdivided into papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). According to current domestic and international guidelines, surgery remains the only curative treatment for differentiated thyroid carcinoma (DTC). The commonly performed surgical approaches include conventional open thyroidectomy (COT) and endoscopic thyroidectomy (ET). Among open surgeries, the most commonly used approach is the conventional midline cervical incision. In endoscopic procedures, the gasless unilateral axillary approach (GUA) is particularly favored by patients. Therefore, this study aims to investigate the factors influencing the choice of surgical approach for thyroid cancer, which will contribute to further standardizing perioperative management. This study is a single-center retrospective analysis that categorized patients based on the Asian BMI classification and surgical approach. It compared key preoperative, intraoperative, and postoperative indicators between different surgical methods, and conducted both regression and logistic regression analyses. The results demonstrated significant differences between endoscopic and open surgeries across various BMI groups, with the choice of surgical approach exerting a notable impact on relevant clinical indicators. However, BMI itself did not show a significant influence on factors such as operative time, postoperative drainage volume, or the number of lymph nodes dissected. Interestingly, in the obese population, BMI was significantly correlated with nodule size, which in turn was closely associated with clinical N (cN) staging. These findings suggest that BMI may serve as a potential risk predictor, ultimately influencing the selection of surgical approach. Papillary thyroid carcinoma open surgery endoscopic surgery retrospective study Introduction Thyroid cancer ranks as the fifth most common malignancy in China, with differentiated thyroid carcinoma (DTC) accounting for the majority of cases. It is significantly more prevalent among females. In 2024, the number of newly diagnosed thyroid cancer cases in China reached 332,620, including 100,795 cases in males and 231,825 in females, showing a clear gender disparity and a continued upward trend in incidence[1]. According to relevant domestic and international guidelines, including the latest 2024 ATA guidelines, surgery remains the first-line treatment for differentiated thyroid carcinoma (DTC). The current mainstream surgical approaches include the conventional midline cervical open surgery and endoscopic surgery. Endoscopic surgery was first introduced in 1996 by Gagner, who performed the first parathyroidectomy using this technique, marking the initial application of endoscopic technology in cervical endocrine surgery[2]. In 1997, Hüscher successfully performed endoscopic thyroid surgery (ETS), demonstrating the feasibility of applying endoscopic techniques to thyroidectomy[3]. In 1998, Japanese scholar Shimizu reported the use of video-assisted thyroidectomy (VAT) through a small subclavicular incision, effectively concealing the surgical scar beneath the clavicle. This represented an early exploration of minimally invasive approaches to thyroid surgery[4]. In 1999, Miccoli and colleagues reported the use of video-assisted thyroidectomy (VAT) through a small anterior cervical incision, a technique later known as the Miccoli procedure[5]. In 2000, Ohgami and colleagues from Japan were the first to report the use of an extracervical approach via the chest-breast route, marking the earliest attempt at a remote access technique. This introduced the concept of placing the incision away from the neck to improve cosmetic outcomes[6]. In the same year, Ikeda from South Korea first reported the transaxillary approach (TA) for thyroidectomy, initiating the use of the axillary route. At that time, the procedure was performed using a gas-inflated technique, known as gas-inflated transaxillary approach (GTA)[7]. In 2001, South Korean surgeon Chung modified the transaxillary approach (TA) by introducing a gasless technique, leading to the development of the gasless transaxillary approach (GUA) for endoscopic thyroidectomy[8]. Compared to GTA, the gasless transaxillary approach (GUA) avoids various complications associated with insufflation, such as subcutaneous emphysema, mediastinal emphysema, and pneumothorax. In 2007, Choe and colleagues in South Korea introduced the bilateral axillo-breast approach (BABA) for endoscopic thyroidectomy[9]. Building on this foundation, additional approaches such as the bilateral areolar approach (BAA) and the chest-clavicle-breast approach (CCBA) were subsequently developed. In 2013, Cun-Chuan Wang from China performed the world's first complete endoscopic thyroidectomy via the transoral vestibular approach[10]. In the same year, Nakajo from Japan successfully performed the first gasless single-port transoral endoscopic thyroidectomy via the vestibular approach (TOETVA)[11]. This represented a minimalist exploration of the TOETVA technique, but due to its technical complexity, widespread adoption was limited. It was not until 2016 that Anuwong from Thailand formally named the procedure "Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA)" in the English literature. He also established a standardized three-port CO₂ insufflation technique via the oral vestibule, which facilitated systematic international promotion and led to its widespread clinical adoption[12]. In 2011, Singer performed the first robotic-assisted endoscopic thyroidectomy via the postauricular approach using the da Vinci surgical system[13]. With the development of robotic technology, various robotic-assisted surgical approaches have emerged. Each approach offers distinct advantages. For example, the BABA (bilateral axillo-breast approach) provides a centrally located and symmetrical operative field, making it well-suited for bilateral gland manipulation as well as central and lateral neck dissection. In contrast, the BAA (bilateral areolar approach) establishes access through incisions at both areolae, offering superior cosmetic outcomes. This method is particularly advantageous for female patients with early-stage disease, especially in cases involving unilateral or partial bilateral gland procedures[14]. TOETVA offers the unique advantage of being truly “scarless” on the body surface. Compared with conventional open surgery, it provides distinct benefits while maintaining comparable safety[15]. Transaxillary endoscopic thyroidectomy (TET) was initially developed in South Korea, with the gasless unilateral axillary approach (GUA) now being the most widely adopted technique. GUA is primarily indicated for young female patients with high cosmetic expectations, particularly those with slender body types and long necks. According to the 2022 Chinese expert consensus on gasless axillary approach endoscopic thyroidectomy, the indications for GUA include: Benign lesions with a maximum diameter ≤ 6 cm (up to 6–8 cm if cystic); Graves’ disease with goiter not exceeding grade II; Patients with differentiated thyroid carcinoma (DTC) who meet all of the following criteria: (i) Primary tumor diameter < 4 cm; (ii) No extracapsular invasion, or only minimal invasion through the anterior thyroid capsule or minor involvement of the sternothyroid muscle; (iii) cN0 or cN1 with non-confluent and non-fixed metastatic lymph nodes. In recent years, several studies have demonstrated that, when performed by experienced surgeons, the gasless unilateral axillary approach (GUA) yields comparable outcomes to conventional open surgery in terms of intraoperative blood loss, length of hospital stay, and postoperative complication rates, with no significant differences observed[16][17]. Moreover, as a gasless technique, GUA avoids insufflation-related complications such as subcutaneous emphysema that are associated with gas-inflated transaxillary approaches. In terms of cosmetic satisfaction, the incision of GUA is concealed within the natural axillary fold, leaving no visible scar on the neck, making it significantly superior to conventional open surgery in this regardand highly favored by patients[16][17]. As a result, GUA has now become one of the major surgical approaches. Given the wide variety of surgical techniques available for thyroidectomy, preoperative evaluation is particularly crucial in determining the most appropriate approach. Surgeons must select the optimal surgical method based on patient-specific risk factors. For instance, studies conducted abroad have explored the relationship between tumor size, patient age, number of lesions, and the choice of surgical approach. Studies by Economides et al.[18]and Neill et al.[19]have shown that BMI can influence tumor aggressiveness, multifocality, and lymph node metastasis, thereby indirectly affecting the extent and type of surgical approach, the degree of lymph node dissection, and the duration of surgery. The study by Wang et al. demonstrated that tumor diameter and multifocality are the primary risk factors influencing the choice of surgical approach[20]. However, most studies both domestically and internationally on the risk factors influencing the choice of thyroidectomy approach have primarily focused on the pathological characteristics of the lesions or the condition of the thyroid itself. There is currently no direct evidence indicating that BMI independently affects the choice of surgical approach. Moreover, although Economides et al. and Neill et al. investigated the impact of BMI on tumor-related features, they did not establish a direct link between BMI and surgical approach. Wang et al., on the other hand, did not include BMI in their analysis and had a relatively small sample size. Therefore, the present study incorporates BMI as a variable to further investigate its potential association with the choice of surgical technique. There are various surgical approaches for thyroid cancer, and exploring the factors that influence the choice of surgical technique holds significant clinical value. This study focuses on low-risk papillary thyroid carcinoma (PTC) patients with preoperative cN0 status, aiming to investigate whether different factors impact the selection of surgical approach. The goal is to provide clinical evidence to support decision-making in surgical planning. Patients and Methods Study Design This study is a single-center retrospective cohort study. Clinical data were retrospectively analyzed for patients who underwent thyroid surgery at Huzhou Central Hospital between October 1, 2023, and October 1, 2024, and were postoperatively confirmed to have papillary thyroid carcinoma (PTC). The study aims to investigate the factors influencing the choice of surgical approach for thyroid cancer, as well as to further explore the differences in perioperative clinical outcomes among different surgical methods and their correlation with patients’ baseline characteristics. Inclusion Criteria (1) Age ≥ 18 years (2) Initial surgery: patients underwent their first thyroid surgery at Huzhou Hospital Affiliated to Zhejiang University (3) Complete data: availability of comprehensive clinical and postoperative pathological data (4) Postoperative pathological diagnosis of papillary thyroid carcinoma (PTC) (5) Tumor diameter ≤ 3 cm, no extrathyroidal extension on imaging or gross examination, and no lymph node metastasis (cN0) (6) Underwent unilateral radical thyroidectomy (unilateral lobe + isthmus + ipsilateral central lymph node dissection) via either open surgery or gasless transaxillary endoscopic thyroidectomy (GUA) Exclusion Criteria (1) History of prior neck surgery (2) Presence of severe systemic diseases (e.g., severe hypertension, diabetes, renal insufficiency, coagulopathy) (3) Any high-risk features of thyroid cancer identified preoperatively, including: 1. Extrathyroidal extension 2. Clinically apparent local or distant metastasis 3. History of head or neck radiation 4. Family history of thyroid cancer (4) Uncontrolled hyperthyroidism or hypothyroidism (5) History of other malignancies (6) Pregnancy or lactation (7) Incomplete key postoperative follow-up data Grouping Method Surgical approach grouping: Patients were divided into two groups based on surgical method—conventional open thyroidectomy (COT) and gasless unilateral axillary endoscopic thyroidectomy (GUA). BMI grouping (based on the latest WHO standards for Asian populations): • Underweight (<18.5 kg/m²) • Normal weight (18.5–22.9 kg/m²) • Overweight and obese (≥23.0 kg/m²) Data Collection Preoperative data: age, sex, height, weight, BMI, medical history, preoperative BRAF mutation status, preoperative ultrasound findings Intraoperative data: surgery date, operative time, intraoperative blood loss Postoperative data: number of lymph nodes dissected, postoperative cN stage, total postoperative drainage, discharge date, postoperative length of stay, total hospitalization time, total hospitalization cost Statistical Analysis All statistical analyses were conducted using SPSS version 27.0. Normality tests were applied to all continuous variables. Variables with normal distribution (p > 0.05) were expressed as mean ± standard deviation (Mean ± SD), and independent sample t-tests were used for intergroup comparisons. Non-normally distributed variables (p < 0.05) were expressed as median and interquartile range [M(P25, P75)], and the Mann-Whitney U test was used for comparisons. A two-sided p-value of <0.05 was considered statistically significant. Pearson correlation analyses were performed for variables including sex, age, BMI, preoperative nodule size, number of lymph nodes dissected, operative time, postoperative drainage, postoperative cN stage, postoperative length of stay, and total cost. Significance level: All statistical tests were two-tailed, with p < 0.05 considered statistically significant. Results A total of 411 patients were included in this study, with a mean age of 43.76 ± 12.23 years (range: 19–79 years), and 74.2% were female. Based on BMI classification, there were 14 underweight patients, 216 with normal weight, and 179 classified as overweight or obese. Among them, 267 underwent open surgery, and 144 underwent gasless transaxillary endoscopic surgery (GUA). All patients were positive for the BRAF V600E mutation preoperatively. According to TNM staging, 267 patients were cN0, and 144 were cN1. The median tumor diameter (TD) was 5.90 mm (interquartile range: 4.10–8.00 mm) (Table 1). Table 1 Clinical Characteristics of the Patients Variables Mean±SD Median (Q1-Q3) N (%) Variables Mean±SD Median (Q1-Q3) N (%) Age (years) 43.76±12.23 42.00 (34.00-53.00) Nodule Size (mm) 6.69±3.66 5.90 (4.10-8.00) Sex Operation Time(min) Female 305 (74.2) 0 90.00 (80.00-110.00) Male 106 (25.8) 1 70.00 (60.00-85.00) BMI BRAF Mutation Status 1 (＜18.5) 14 (3.9) +(Positive) 249 (60.6) 2 (18.5~24) 216 (52.6) -(Negative) 129 (31.4) 3 (＞24) 179 (43.6) *(Not Tested) 33 (8.0) Surgical Approach Postoperative Drainage Volume (ml) 0 267 (65.0) 0 110.00 (90.00-135.00) 1 144 (35.0) 1 65.00 (50.00-80.00) Lymph Node Count (n) Postoperative Hospital Stay (days) 0 4.00 (2.00-5.00) 0 2.00 (2.00-2.00) 1 5.00 (3.00-8.00) 1 2.00 (2.00-2.00) cN stage Total Cost (CNY) 0 267 (65.0) 0 16712 (15594-18376) 1 144 (35.0) 1 12282 (12016-12829) Nodule Size (mm):Obtained from Preoperative Ultrasound BMI group：1 = Underweight Group, 2 = Normal Weight Group, 3 = Overweight Group Lymph Node Count (n): Number of Lymph Nodes Retrieved from Central Compartment Dissection During Surgery For surgical approach, operation time, postoperative drainage volume, number of lymph nodes, postoperative hospital stay, and total cost: 0 = Gasless Transaxillary Approach Group (GUA), 1 = Conventional Open Thyroidectomy (COT) SD: Standard Deviation n (%): Number (Percentage) Q1–Q3: 25th to 75th Percentile (Interquartile Range, IQR) There were no significant differences in sex or age distribution across BMI groups. In the univariate analysis of perioperative indicators between open and endoscopic groups within each BMI category, the following variables were compared: operative time, postoperative drainage volume, number of lymph nodes dissected, postoperative hospital stay, total cost, nodule size, and cN staging. Results varied across different BMI groups (Tables 2–4): Operative Time : No significant difference was observed between open and endoscopic groups in the underweight group (P = 0.573). However, in both the normal weight and overweight/obese groups, operative time was significantly longer in the endoscopic group (P < 0.001 for both). Postoperative Drainage Volume : Significantly higher in the endoscopic group across all BMI categories (P = 0.006 for underweight, P < 0.001 for normal and overweight/obese). Number of Lymph Nodes Dissected : No significant difference in the underweight group (P = 0.136), but significantly lower in the endoscopic group in the normal weight (P = 0.001) and overweight/obese groups (P < 0.001). Postoperative Hospital Stay : No significant difference in underweight (P = 0.428) or overweight/obese groups (P = 0.4669). Slightly shorter stay in the endoscopic group for the normal weight group (P = 0.016). Total Cost : Significantly higher in the endoscopic group across all BMI categories (P = 0.002 for underweight, P < 0.001 for normal and overweight/obese). Table 2 Underweight Group Variables GUA COT t p Statistical Significance Operation Time(min) 88.83±26.65 82.1±20.02 0.577 0.573 No Postoperative Drainage Volume (ml) 120±36.74 76±18.37 3.222 0.006 Yes Lymph Node Count (n) 3.5±1.38 5.7±3.19 -1.581 0.136 No Postoperative Hospital Stay (days) 2.00 [2.00,2.25] 2.00 [2.00,2.00] -1.41 0.428 No Total Cost (CNY) 16350.83±2318.14 12522.23±1614.96 3.91 0.002 Yes Table 3 Normal Weight Group Variables GUA COT t p Statistical Significance Operation Time(min) 90[76.5,106.25] 70[58,90] -6.443 ＜0.001 Yes Postoperative Drainage Volume (ml) 105[85,126.25] 60[50,75] -9.086 ＜0.001 Yes Lymph Node Count (n) 4[2,6] 5[3,8] 2.984 0.001 Yes Postoperative Hospital Stay (days) 2[2,2] 2[2,2] -2.243 0.016 Yes Total Cost (CNY) 16610.23 [15618.4275,18295.27] 12336.79 [12015.65,12944.1] -11.567 ＜0.001 Yes Table 4 Overweight Group Variables GUA COT t p Statistical Significance Operation Time(min) 90[80.5,111.5] 70[60,85] -6.770 ＜0.001 Yes Postoperative Drainage Volume (ml) 110[90,145] 67[55,85] -7.292 ＜0.001 Yes Lymph Node Count (n) 3[2,5] 5[3,8] 3.661 ＜0.001 Yes Postoperative Hospital Stay (days) 2[2,2] 2[2,2] -0.689 0.4669 No Total Cost (CNY) 17267.825 [15491.055,18491.375] 12253.53 [12010.09,12638.52] -9.731 ＜0.001 Yes Additionally, preoperative ultrasound nodule size was closely related to cN staging. cN1 patients had significantly larger nodules than cN0 patients (7.0 [5.0, 9.0] vs. 5.3 [4.0, 7.0], P < 0.01) (Table 5). Binary logistic regression analysis identified preoperative nodule size as an independent predictor of cN stage (B = 0.109, P < 0.01; Exp(B) = 1.115, 95% CI: 1.052–1.182), indicating that for every 1 mm increase in nodule size, the risk of cN1 increased by approximately 11.5% (Table 6). Table 5 Preoperative Nodule Size & Clinical N Stage Variables cN0 cN1 t p Statistical Significance Nodule Size (mm) 5.3[4,7] 7[5,9] 4.328 ＜0.01 Yes Table 6 Binary Logistic Regression Analysis of Preoperative Nodule Size and Clinical N Stage B SE (Standard Error) Wald Statistic p Exp(B) Exp(B) 95% CI Lower Bound Exp(B) 95% CI Upper Bound Nodule Size (mm) 0.109 0.03 13.442 ＜0.01 1.115 1.052 1.182 Due to the small sample size in the underweight group (n = 16), correlation analyses were conducted only for the normal weight and overweight/obese groups. In the Normal Weight Group (Table 7): Sex was positively correlated with BMI (r = 0.221, P < 0.01). Age showed positive correlation with BMI (r = 0.246, P < 0.01), and negative correlations with operative time (r = -0.206, P < 0.01), drainage volume (r = -0.205, P < 0.01), and cN stage (r = -0.179, P < 0.01). Nodule size was positively correlated with cN stage (r = 0.168, P < 0.05) and negatively correlated with drainage volume (r = -0.193, P < 0.01). Operative time was positively correlated with drainage volume (r = 0.260, P < 0.01) and total cost (r = 0.438, P < 0.01). Drainage volume was positively correlated with operative time (r = 0.260, P < 0.01), postoperative hospital stay (r = 0.409, P < 0.01), and total cost (r = 0.557, P < 0.01). cN stage was positively correlated with nodule size (r = 0.168, P < 0.05) and negatively correlated with age (r = -0.179, P < 0.01). In the Overweight/Obese Group (Table 8): Sex was positively correlated with nodule size (r = 0.234, P < 0.01) and cN stage (r = 0.225, P < 0.01). Age showed negative correlations with BMI (r = -0.183, P < 0.05), operative time (r = -0.285, P < 0.01), drainage volume (r = -0.251, P < 0.01), cN stage (r = -0.165, P < 0.05), and total cost (r = -0.262, P < 0.01). BMI was positively correlated with nodule size (r = 0.159, P < 0.05). Nodule size was positively correlated with cN stage (r = 0.186, P < 0.05). Operative time was positively correlated with drainage volume (r = 0.329, P < 0.01), postoperative hospital stay (r = 0.210, P < 0.01), and total cost (r = 0.506, P < 0.01). Drainage volume was positively correlated with operative time (r = 0.329, P < 0.01), cN stage (r = 0.166, P < 0.05), postoperative hospital stay (r = 0.725, P < 0.01), and total cost (r = 0.431, P < 0.01). cN stage was positively correlated with sex (r = 0.225, P < 0.01), nodule size (r = 0.186, P < 0.05), drainage volume (r = 0.166, P < 0.05), and postoperative hospital stay (r = 0.244, P < 0.01), and negatively correlated with age (r = -0.165, P < 0.05). Postoperative hospital stay was positively correlated with operative time (r = 0.210, P < 0.01), drainage volume (r = 0.725, P < 0.01), cN stage (r = 0.224, P < 0.01), and total cost (r = 0.185, P < 0.05). In this study, endoscopic surgery was associated with significantly greater postoperative drainage and higher total hospitalization costs across all BMI categories, highlighting its distinct resource demands and postoperative management characteristics. While BMI showed statistically significant correlations with certain perioperative indicators, the strength of these correlations was generally weak, suggesting limited clinical significance. However, in the overweight/obese group, BMI was significantly associated with nodule size. Furthermore, preoperative ultrasound nodule size was strongly associated with cN staging and was identified as an independent predictor, underscoring its value in preoperative assessment and surgical decision-making. These findings provide preliminary evidence supporting BMI-based stratification in surgical approach selection and outcome evaluation. Discussion The results of this study suggest that, across different BMI categories, endoscopic surgery exhibits significant differences in perioperative performance compared to open surgery, particularly in terms of operative time, postoperative drainage volume, number of lymph nodes dissected, and total cost. Specifically, in the normal weight and overweight groups, operative time was significantly longer in the endoscopic group. This may be attributed to increased body weight, thickened cervical adipose tissue, greater difficulty in surgical field exposure, and differences in surgeon proficiency between open and endoscopic techniques. These findings are consistent with conclusions drawn from related studies conducted within China[ 21 ][ 22 ][ 23 ]. Moreover, the number of lymph nodes dissected in the endoscopic surgery group was significantly lower than that in the open surgery group among patients in both the normal weight and overweight categories (p < 0.01). This suggests that the endoscopic approach may have certain limitations in the extent of lymph node dissection. These findings serve as a supplement to existing data reported in some domestic studies[ 21 ][ 22 ]. Additionally, postoperative drainage volume in the endoscopic group was significantly higher than that in the open group across all BMI categories. This may be closely related to the more extensive tissue dissection, larger surgical wound area, and greater vascular injury associated with endoscopic procedures. These findings are also consistent with results reported in domestic studies[ 22 ][ 23 ]. This study aimed to determine whether BMI is associated with various perioperative indicators. However, correlation analysis revealed that BMI demonstrated only weak associations with most surgical variables, such as operative time, postoperative drainage volume, and the number of lymph nodes dissected. Nevertheless, discussions with operating surgeons revealed a consistent observation: for experienced surgeons, selecting the endoscopic approach in patients with higher BMI may actually facilitate a smoother and more efficient surgical process, with reduced operative time and blood loss. This perspective aligns with findings reported in some international studies[ 24 ][ 25 ]. Numerous studies both in China and abroad have explored the advantages of minimally invasive surgery in patients with high BMI, across various surgical fields including the neck[ 24 ][ 25 ], heart[ 26 ], lungs, and abdomen[ 27 ]. For example, early international studies on abdominal procedures such as colorectal surgery have demonstrated that minimally invasive approaches offer clear advantages over open surgery in obese patients[ 27 ][ 28 ]. Similarly, studies on thoracic and cervical surgeries have also provided evidence that, in certain respects, minimally invasive surgery may be more suitable for patients with high BMI. However, these findings contrast with the conclusions drawn from our current data analysis. To further investigate this discrepancy, a more detailed breakdown of the variable "operative time" could be considered. For open surgery, the procedure could be divided into three phases: skin incision–specimen dissection–hemostasis and suturing. For axillary endoscopic surgery, the phases could be categorized as cavity creation–specimen dissection–hemostasis and suturing. By comparing each stage separately, we may better determine whether increased BMI specifically affects the difficulty of certain intraoperative stages, thereby contributing to prolonged operative time. In addition, preoperative nodule size was found to be strongly associated with postoperative cN staging. Logistic regression analysis further confirmed that for every 1 mm increase in nodule size, the risk of cN1 increased by approximately 11.5%. This suggests that ultrasound-measured nodule size can serve as an important predictor for assessing the risk of cN staging preoperatively, and may aid in surgical planning and decision-making[ 29 ][ 30 ]. It is noteworthy that this study found a positive correlation between BMI and preoperative nodule size in the overweight group, which may suggest a potential link between increased body weight and tumor volume. This observation is consistent with the results of subsequent correlation analyses. Furthermore, the study also demonstrated that the patterns of multivariate correlations differed across BMI subgroups, indicating that BMI may influence the perioperative profile in a complex and variable manner depending on the patient's weight category. For instance, in the overweight group, male patients were found to have larger lesions than female patients and were more likely to present with lymph node metastasis. This finding is consistent with the conclusions of multiple studies both domestically and internationally[ 31 ][ 32 ][ 33 ]. However, a considerable number of studies have demonstrated that androgens exert inhibitory effects on the growth and metastasis of papillary thyroid carcinoma by activating the androgen receptor (AR)[ 34 ][ 35 ][ 36 ]. This is contrary to the findings of our correlation analysis, in which male patients in the overweight group exhibited larger tumor sizes and a higher likelihood of lymph node metastasis. Notably, this phenomenon was not observed in the normal weight group. We speculate that there may be two possible explanations for this discrepancy. First, the expression of androgen receptors (AR) is generally downregulated in papillary thyroid carcinoma (PTC) tissues[ 36 ], which may diminish the protective effects of androgens. Second, obesity itself may be a contributing factor, as it is known to influence the tumor microenvironment and hormone metabolism, potentially overriding the inhibitory role of androgens. Obesity is often associated with chronic metabolic dysfunction and a state of low-grade inflammation. Adipose tissue secretes large amounts of pro-inflammatory cytokines, such as IL-6, TNF-α, and MCP-1, which contribute to a sustained inflammatory response. This pro-inflammatory microenvironment can activate various signaling pathways that, in turn, promote the growth and progression of tumor cells[ 37 ]. Moreover, compared to females, males are more prone to accumulating visceral fat[ 38 ], which is metabolically more active than subcutaneous fat and releases higher concentrations of pro-inflammatory cytokines. This creates a microenvironment that is more conducive to tumor growth and metastasis[ 38 ][ 39 ][ 40 ].Obesity can also contribute to immune evasion and insulin resistance, leading to impaired T cell function and an increase in immunosuppressive cell populations[ 41 ][ 42 ]. Additionally, hyperinsulinemia and insulin resistance may activate the IGF-1 signaling pathway, thereby promoting cellular proliferation and inhibiting apoptosis[ 43 ][ 44 ], ultimately facilitating tumor progression and metastasis. These mechanisms collectively contribute to the observation that obese male patients are more likely to present with larger tumor burdens and lymph node metastasis. In contrast, such a tendency was not observed in the analysis of the normal weight group. Similarly, in both patient groups, the correlation between postoperative drainage volume and postoperative hospital stay was stronger in the overweight group than in the normal weight group. This suggests that being overweight may significantly increase surgical difficulty, elevate the risk of postoperative complications, and lead to greater consumption of medical resources. These findings underscore the importance of enhanced preoperative management strategies for overweight patients, and emphasize the need for more meticulous tissue dissection and careful ligation or avoidance of vascular structures during surgery. Similar observations have been reported in studies involving neck surgeries[ 45 ]as well as procedures in other anatomical regions[ 46 ][ 47 ]. Additionally, this study found a negative correlation between age and postoperative drainage volume. This may be attributable to the small wound area and low exudate volume typically associated with thyroid surgery. Elderly patients often undergo more conservative surgical approaches with less intraoperative tissue damage, and factors such as decreased capillary permeability and reduced physical activity may further reduce postoperative fluid accumulation. In contrast, previous literature, largely based on more invasive surgical procedures, has frequently reported a positive correlation between age and drainage volume[ 48 ]. Therefore, the differing conclusions are not directly comparable. Furthermore, given the uniformity of surgical techniques and well-controlled variables in this study, the observed results are considered reasonable. In conclusion, this study highlights the importance of considering patients' BMI and age in clinical practice to guide individualized selection of the most appropriate surgical approach. Particular attention should be given to the choice of surgical technique and perioperative management strategies in overweight patients to optimize postoperative recovery and cost-effectiveness. Moreover, the preoperative ultrasound-measured nodule size holds significant clinical value as a predictive indicator for cN staging and should be fully integrated into preoperative risk assessment. Conclusion This study demonstrates that, across different BMI categories, endoscopic thyroidectomy is associated with longer operative time, greater postoperative drainage volume, and higher medical costs compared to open surgery—differences that are particularly pronounced in overweight patients. Additionally, the endoscopic approach shows certain limitations in the number of lymph nodes dissected. Although the correlations between BMI and most perioperative indicators were generally weak, a stronger positive correlation between postoperative drainage and hospital stay was observed in the overweight group, suggesting that increased body weight may prolong recovery time and increase resource utilization.The study also found that preoperative ultrasound-measured nodule size is strongly associated with postoperative cN staging and serves as an independent predictive factor, highlighting its significant clinical value in preoperative assessment. Moreover, overweight male patients were more likely to present with larger tumors and lymph node metastasis, which may be driven by obesity-related chronic inflammation, immune suppression, and metabolic dysfunction. Given the differences in surgical risk and recovery among BMI groups, it is recommended that BMI and age be fully considered in preoperative evaluations to guide individualized surgical planning. Enhanced intraoperative precision, especially in overweight patients, may help improve perioperative safety and postoperative recovery outcomes. Declarations Supplementary Information Acknowledgements None Authors’ contributions Idea validation: GuoChao Ye.-Concept: GuoChao Ye, YeSheng Zhang.Data collection: YeSheng Zhang, YiHeng Yang. Data analysis: YeSheng Zhang.Manuscript writing: YeSheng Zhang. Manuscript revision: YongCan Xu. Supervision: GuoChao Ye. Funding None. Availability of data materials The datasets generated and/or analyzed during the current study are not publicly available due to hospital policy and patient confidentiality restrictions, but are available from the corresponding author on reasonable request. Ethics approval and consent to participate This retrospective study was approved by the Ethics Committee of Huzhou Central Hospital (Approval No. 202506022-01). The requirement for informed consent was waived due to the retrospective nature of the study. Clinical trail number Not applicable Consent for publication Not Applicable. Competing of interests The authors declare no competing interests. Author details 1 Department of General Surgery, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China. 2 Department of General Surgery, Huzhou Central Hospital, Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, Huzhou, China. References Wu Y, He S, Cao M, Teng Y, Li Q, Tan N, Wang J, Zuo T, Li T, Zheng Y, Xia C, Chen W. Comparative analysis of cancer statistics in China and the United States in 2024. Chin Med J (Engl). 2024 Dec 20;137(24):3093-3100. doi: 10.1097/CM9.0000000000003442. Epub 2024 Dec 10. PMID: 39654104; PMCID: PMC11706596. Gagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996 Jun;83(6):875. doi: 10.1002/bjs.1800830656. PMID: 8696772. Hüscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc. 1997 Aug;11(8):877. doi: 10.1007/s004649900476. PMID: 9266657. Shimizu K, Akira S, Tanaka S. Video-assisted neck surgery: endoscopic resection of benign thyroid tumor aiming at scarless surgery on the neck. J Surg Oncol. 1998 Nov;69(3):178-80. doi: 10.1002/(sici)1096-9098(199811)69:33.0.co;2-9. PMID: 9846506. Miccoli P, Berti P, Conte M, Bendinelli C, Marcocci C. Minimally invasive surgery for thyroid small nodules: preliminary report. J Endocrinol Invest. 1999 Dec;22(11):849-51. doi: 10.1007/BF03343657. PMID: 10710272. Ohgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T, Kitajima M. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech. 2000 Feb;10(1):1-4. PMID: 10872517. Ikeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg. 2000 Sep;191(3):336-40. doi: 10.1016/s1072-7515(00)00342-2. PMID: 10989910. Hakim Darail NA, Lee SH, Kang SW, Jeong JJ, Nam KH, Chung WY. Gasless transaxillary endoscopic thyroidectomy: a decade on. Surg Laparosc Endosc Percutan Tech. 2014 Dec;24(6):e211-5. doi: 10.1097/SLE.0000000000000003. PMID: 24710266. Choe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg. 2007 Mar;31(3):601-6. doi: 10.1007/s00268-006-0481-y. PMID: 17308853. Yang J, Wang C, Li J, Yang W, Cao G, Wong HM, Zhai H, Liu W. Complete Endoscopic Thyroidectomy via Oral Vestibular Approach Versus Areola Approach for Treatment of Thyroid Diseases. J Laparoendosc Adv Surg Tech A. 2015 Jun;25(6):470-6. doi: 10.1089/lap.2015.0026. PMID: 26061132. Nakajo A, Arima H, Hirata M, Mizoguchi T, Kijima Y, Mori S, Ishigami S, Ueno S, Yoshinaka H, Natsugoe S. Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach. Surg Endosc. 2013 Apr;27(4):1105-10. doi: 10.1007/s00464-012-2588-6. Epub 2012 Nov 21. PMID: 23179070; PMCID: PMC3599170. Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, Richmon JD. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc. 2018 Jan;32(1):456-465. doi: 10.1007/s00464-017-5705-8. Epub 2017 Jul 17. PMID: 28717869. Terris DJ, Singer MC, Seybt MW. Robotic facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope. 2011 Aug;121(8):1636-41. doi: 10.1002/lary.21832. Epub 2011 Jun 30. PMID: 21721012. Fu X, Ma Y, Hou Y, Liu Y, Zheng L. Comparison of endoscopic bilateral areolar and robotic-assisted bilateral axillo-breast approach thyroidectomy in differentiated thyroid carcinoma: a propensity-matched retrospective cohort study. BMC Surg. 2023 Nov 8;23(1):338. doi: 10.1186/s12893-023-02250-w. PMID: 37940892; PMCID: PMC10633981. Oh MY, Chai YJ, Yu HW, Kim SJ, Choi JY, Lee KE. Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis. Int J Surg. 2023 Aug 1;109(8):2467-2477. doi: 10.1097/JS9.0000000000000444. PMID: 37161554; PMCID: PMC10442077. 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 Nov;11(22):4146-4156. doi: 10.1002/cam4.4766. Epub 2022 Apr 25. PMID: 35470574; PMCID: PMC9678099. Li X, Ding W, Zhang H. Surgical outcomes of endoscopic thyroidectomy approaches for thyroid cancer: a systematic review and network meta-analysis. Front Endocrinol (Lausanne). 2023 Dec 4;14:1256209. doi: Economides A, Giannakou K, Mamais I, Economides PA, Papageorgis P. Association Between Aggressive Clinicopathologic Features of Papillary Thyroid Carcinoma and Body Mass Index: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne). 2021 Jun 30;12:692879. doi: 10.3389/fendo.2021.692879. PMID: 34276564; PMCID: PMC8279812. O'Neill RJ, Abd Elwahab S, Kerin MJ, Lowery AJ. Association of BMI with Clinicopathological Features of Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis. World J Surg. 2021 Sep;45(9):2805-2815. doi: 10.1007/s00268-021-06193-2. Epub 2021 Jun 16. PMID: 34136926. Wang X, Zhang C, Srivastava A, Yu W, Liu C, Wei D, Li Y, Yang J. Risk Factors That Influence Surgical Decision-Making for Patients with Low-Risk Differentiated Thyroid Cancer with Tumor Diameters of 1-4 cm. Cancer Manag Res. 2020 Dec 2;12:12423-12428. doi: 10.2147/CMAR.S268716. PMID: 33293868; PMCID: PMC7719324. Yu ST, Ouyang R, Miao G, Ge J, Wei Z, Sun B, Li T, Zhang Z, Chen W, Lei S. Gasless single-incision transaxillary endoscopic total thyroidectomy versus conventional open thyroidectomy in patients with papillary thyroid carcinoma based on propensity score matching: a case-control study. Surg Endosc. 2025 Mar;39(3):2091-2098. doi: 10.1007/s00464-025-11567-x. Epub 2025 Feb 3. PMID: 39900859. Ge JN, Yu ST, Tan J, Sun BH, Wei ZG, Zhang ZC, Chen WS, Li TT, Lei ST. A propensity score matching analysis of gasless endoscopic transaxillary thyroidectomy with five-settlement technique versus conventional open thyroidectomy in patients with papillary thyroid microcarcinoma. Surg Endosc. 2023 Dec;37(12):9255-9262. doi: 10.1007/s00464-023-10473-4. Epub 2023 Oct 24. PMID: 37875693. Wang S, Zhang F, Wang J, Ao Y. A study on the safety and efficacy of endoscopic thyroidectomy via axillary approach for the treatment of thyroid cancer. Medicine (Baltimore). 2024 Jun 21;103(25):e38507. doi: 10.1097/MD.0000000000038507. PMID: 38905368; PMCID: PMC11191952. Duke WS, White JR, Waller JL, Terris DJ. Endoscopic thyroidectomy is safe in patients with a high body mass index. Thyroid. 2014 Jul;24(7):1146-50. doi: 10.1089/thy.2014.0047. Epub 2014 May 21. PMID: 24684421; PMCID: PMC4080847. de Vries LH, Aykan D, Lodewijk L, Damen JAA, Borel Rinkes IHM, Vriens MR. Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne). 2021 Aug 12;12:719397. doi: 10.3389/fendo.2021.719397. PMID: 34456874; PMCID: PMC8387875. Santana O, Reyna J, Grana R, Buendia M, Lamas GA, Lamelas J. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery. Ann Thorac Surg. 2011 Feb;91(2):406-10. doi: 10.1016/j.athoracsur.2010.09.039. PMID: 21256280. Tong, Guojun MDa,*; Zhang, Guiyang BSa; Liu, Jian BSa; Zheng, Zhengzhao BSa; Chen, Yan BSa; Cui, Enhai MDb. A meta-analysis of short-term outcome of laparoscopic surgery versus conventional open surgery on colorectal carcinoma. Medicine 96(48):p e8957, December 2017. | DOI: 10.1097/MD.0000000000008957 Park JW, Lim SW, Choi HS, Jeong SY, Oh JH, Lim SB. The impact of obesity on outcomes of laparoscopic surgery for colorectal cancer in Asians. Surg Endosc. 2010 Jul;24(7):1679-85. doi: 10.1007/s00464-009-0829-0. Epub 2009 Dec 29. PMID: 20039065. Tang L, Qu RW, Park J, Simental AA, Inman JC. Prevalence of Occult Central Lymph Node Metastasis by Tumor Size in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis. Curr Oncol. 2023 Aug 2;30(8):7335-7350. doi: 10.3390/curroncol30080532. PMID: 37623013; PMCID: PMC10453273. Liu C, Xiao C, Chen J, Li X, Feng Z, Gao Q, Liu Z. Risk factor analysis for predicting cervical lymph node metastasis in papillary thyroid carcinoma: a study of 966 patients. BMC Cancer. 2019 Jun 25;19(1):622. doi: 10.1186/s12885-019-5835-6. PMID: 31238891; PMCID: PMC6593593. Huang J, Song M, Shi H, Huang Z, Wang S, Yin Y, Huang Y, Du J, Wang S, Liu Y, Wu Z. Predictive Factor of Large-Volume Central Lymph Node Metastasis in Clinical N0 Papillary Thyroid Carcinoma Patients Underwent Total Thyroidectomy. Front Oncol. 2021 May 19;11:574774. doi: 10.3389/fonc.2021.574774. Erratum in: Front Oncol. 2024 Nov 18;14:1517682. doi: 10.3389/fonc.2024.1517682. PMID: 34094896; PMCID: PMC8170408. Gao L, Li X, Xia Y, Liu R, Liu C, Shi X, Wu Y, Ma L, Jiang Y. Large-Volume Lateral Lymph Node Metastasis Predicts Worse Prognosis in Papillary Thyroid Carcinoma Patients With N1b. Front Endocrinol (Lausanne). 2022 Feb 2;12:815207. doi: 10.3389/fendo.2021.815207. PMID: 35185788; PMCID: PMC8847215. Li P, Ding Y, Liu M, Wang W, Li X. Sex disparities in thyroid cancer: a SEER population study. Gland Surg. 2021 Dec;10(12):3200-3210. doi: 10.21037/gs-21-545. PMID: 35070880; PMCID: PMC8749097. Gupta A, Carnazza M, Jones M, Darzynkiewicz Z, Halicka D, O'Connell T, Zhao H, Dadafarin S, Shin E, Schwarcz MD, Moscatello A, Tiwari RK, Geliebter J. Androgen Receptor Activation Induces Senescence in Thyroid Cancer Cells. Cancers (Basel). 2023 Apr 7;15(8):2198. doi: 10.3390/cancers15082198. Erratum in: Cancers (Basel). 2024 Oct 29;16(21):3636. doi: 10.3390/cancers16213636. PMID: 37190127; PMCID: PMC10137266. Chou CK, Chi SY, Hung YY, Yang YC, Fu HC, Wang JH, Chen CC, Kang HY. Clinical Impact of Androgen Receptor-Suppressing miR-146b Expression in Papillary Thyroid Cancer Aggressiveness. J Clin Endocrinol Metab. 2023 Oct 18;108(11):2852-2861. doi: 10.1210/clinem/dgad279. PMID: 37220080. Chou CK, Chi SY, Chou FF, Huang SC, Wang JH, Chen CC, Kang HY. Aberrant Expression of Androgen Receptor Associated with High Cancer Risk and Extrathyroidal Extension in Papillary Thyroid Carcinoma. Cancers (Basel). 2020 Apr 29;12(5):1109. doi: 10.3390/cancers12051109. PMID: 32365531; PMCID: PMC7281729. Zhao H, Wu L, Yan G, Chen Y, Zhou M, Wu Y, Li Y. Inflammation and tumor progression: signaling pathways and targeted intervention. Signal Transduct Target Ther. 2021 Jul 12;6(1):263. doi: 10.1038/s41392-021-00658-5. PMID: 34248142; PMCID: PMC8273155. Crudele L, Piccinin E, Moschetta A. Visceral Adiposity and Cancer: Role in Pathogenesis and Prognosis. Nutrients. 2021 Jun 19;13(6):2101. doi: 10.3390/nu13062101. PMID: 34205356; PMCID: PMC8234141. Quail DF, Dannenberg AJ. The obese adipose tissue microenvironment in cancer development and progression. Nat Rev Endocrinol. 2019 Mar;15(3):139-154. doi: 10.1038/s41574-018-0126-x. PMID: 30459447; PMCID: PMC6374176. Lengyel E, Makowski L, DiGiovanni J, Kolonin MG. Cancer as a Matter of Fat: The Crosstalk between Adipose Tissue and Tumors. Trends Cancer. 2018 May;4(5):374-384. doi: 10.1016/j.trecan.2018.03.004. Epub 2018 Apr 5. PMID: 29709261; PMCID: PMC5932630. Ringel AE, Drijvers JM, Baker GJ, Catozzi A, García-Cañaveras JC, Gassaway BM, Miller BC, Juneja VR, Nguyen TH, Joshi S, Yao CH, Yoon H, Sage PT, LaFleur MW, Trombley JD, Jacobson CA, Maliga Z, Gygi SP, Sorger PK, Rabinowitz JD, Sharpe AH, Haigis MC. Obesity Shapes Metabolism in the Tumor Microenvironment to Suppress Anti-Tumor Immunity. Cell. 2020 Dec 23;183(7):1848-1866.e26. doi: 10.1016/j.cell.2020.11.009. Epub 2020 Dec 9. PMID: 33301708; PMCID: PMC8064125. Piening A, Ebert E, Gottlieb C, Khojandi N, Kuehm LM, Hoft SG, Pyles KD, McCommis KS, DiPaolo RJ, Ferris ST, Alspach E, Teague RM. Obesity-related T cell dysfunction impairs immunosurveillance and increases cancer risk. Nat Commun. 2024 Apr 2;15(1):2835. doi: 10.1038/s41467-024-47359-5. PMID: 38565540; PMCID: PMC10987624. Zhang AMY, Wellberg EA, Kopp JL, Johnson JD. Hyperinsulinemia in Obesity, Inflammation, and Cancer. Diabetes Metab J. 2021 May;45(3):285-311. doi: 10.4093/dmj.2020.0250. Epub 2021 Mar 29. Erratum in: Diabetes Metab J. 2021 Jul;45(4):622. doi: 10.4093/dmj.2021.0131. PMID: 33775061; PMCID: PMC8164941. Arcidiacono B, Iiritano S, Nocera A, Possidente K, Nevolo MT, Ventura V, Foti D, Chiefari E, Brunetti A. Insulin resistance and cancer risk: an overview of the pathogenetic mechanisms. Exp Diabetes Res. 2012;2012:789174. doi: 10.1155/2012/789174. Epub 2012 Jun 4. PMID: 22701472; PMCID: PMC3372318. Chen Y, Jin J, Zhang P, Ye R, Zeng C, Zhang Y, Chen J, Li H, Xiao H, Li Y, Guan H. Clinical Impact of Obesity on Postoperative Outcomes of Patients With Thyroid Cancer Undergoing Thyroidectomy: A 5-Year Retrospective Analysis From the US National Inpatient Sample. Cancer Med. 2024 Oct;13(19):e70335. doi: 10.1002/cam4.70335. PMID: 39417377; PMCID: PMC11483747. Kilic S, Sambel M. Impact of Obesity on Perioperative and Clinical Outcomes After Robotic Assisted Radical Prostatectomy. Sci Rep. 2025 Jan 2;15(1):225. doi: 10.1038/s41598-024-82003-8. PMID: 39747306; PMCID: PMC11697172. Maradit Kremers H, Visscher SL, Kremers WK, Naessens JM, Lewallen DG. Obesity increases length of stay and direct medical costs in total hip arthroplasty. Clin Orthop Relat Res. 2014 Apr;472(4):1232-9. doi: 10.1007/s11999-013-3316-9. Epub 2013 Oct 8. PMID: 24101527; PMCID: PMC3940745. Tian YQ, Ren X, Yin YS, Wang J, Li X, Guo ZH, Zeng XY. Analysis of risk factors affecting the postoperative drainage after a laparoscopic partial nephrectomy: a retrospective study. Front Med (Lausanne). 2024 Jan 24;11:1327882. doi: 10.3389/fmed.2024.1327882. PMID: 38327705; PMCID: PMC10847592. Tables Tables 7 and 8 are available in the Supplementary Files section Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7446471","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514768210,"identity":"b5d10080-d8d7-49da-9a25-fb58e761f270","order_by":0,"name":"YeSheng Zhang","email":"","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"YeSheng","middleName":"","lastName":"Zhang","suffix":""},{"id":514768213,"identity":"95e499aa-7048-45da-8bfa-cd422dd24527","order_by":1,"name":"YongCan Xu","email":"","orcid":"","institution":"Huzhou Central Hospital, Fifth School of Clinical Medicine of Zhejiang Chinese Medical University","correspondingAuthor":false,"prefix":"","firstName":"YongCan","middleName":"","lastName":"Xu","suffix":""},{"id":514768215,"identity":"41cb7e6c-8bd6-4708-8434-2aa15b8ade8f","order_by":2,"name":"YiHeng Yang","email":"","orcid":"","institution":"Huzhou Central Hospital, Fifth School of Clinical Medicine of Zhejiang Chinese Medical University","correspondingAuthor":false,"prefix":"","firstName":"YiHeng","middleName":"","lastName":"Yang","suffix":""},{"id":514768216,"identity":"4e24fac9-4da2-4906-8b5d-94da7741e432","order_by":3,"name":"GuoChao Ye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYDACCQiVwMbAwPggoaKGNC3MBg/OHCNBCxCzST5sYSasg39288OHXyrs8vikm59VJDawMfC3dyfgt+TOMWNjmTPJxWwyx8xuJO6QYZA4c3YDXi0GEglm0pJtBxLbgIwbiWfYgCK5hLSkf5OW/AfSkv6tILGNmRgtOWaSHxtAWnLMGIjSInEjp9iY4VgySEuxRMKZYzwE/cI/I33jwx81donzgYyPPypq5Pjbe/FrAQFmHiQOD05lyIDxB1HKRsEoGAWjYMQCAJ3XSFC9jjf1AAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"GuoChao","middleName":"","lastName":"Ye","suffix":""}],"badges":[],"createdAt":"2025-08-24 13:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7446471/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7446471/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103728217,"identity":"7bcd3635-2446-4335-8635-d2497450fbda","added_by":"auto","created_at":"2026-03-02 08:42:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":934672,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7446471/v1/d1a7ed4a-1a4f-4771-9c13-36ee735b55d7.pdf"},{"id":91612994,"identity":"02b0fe37-774b-481b-b70c-2d2062d9c658","added_by":"auto","created_at":"2025-09-18 10:09:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21236,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7446471/v1/965cf5fd3785a6787721e1fb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of Factors Influencing Surgical Approach Selection in Patients with Thyroid Cancer: A Retrospective Study of 411 Cases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThyroid cancer ranks as the fifth most common malignancy in China, with differentiated thyroid carcinoma (DTC) accounting for the majority of cases. It is significantly more prevalent among females. In 2024, the number of newly diagnosed thyroid cancer cases in China reached 332,620, including 100,795 cases in males and 231,825 in females, showing a clear gender disparity and a continued upward trend in incidence[1].\u003c/p\u003e\n\u003cp\u003eAccording to relevant domestic and international guidelines, including the latest 2024 ATA guidelines, surgery remains the first-line treatment for differentiated thyroid carcinoma (DTC). The current mainstream surgical approaches include the conventional midline cervical open surgery and endoscopic surgery. Endoscopic surgery was first introduced in 1996 by Gagner, who performed the first parathyroidectomy using this technique, marking the initial application of endoscopic technology in cervical endocrine surgery[2]. In 1997, H\u0026uuml;scher successfully performed endoscopic thyroid surgery (ETS), demonstrating the feasibility of applying endoscopic techniques to thyroidectomy[3]. In 1998, Japanese scholar Shimizu reported the use of video-assisted thyroidectomy (VAT) through a small subclavicular incision, effectively concealing the surgical scar beneath the clavicle. This represented an early exploration of minimally invasive approaches to thyroid surgery[4]. In 1999, Miccoli and colleagues reported the use of video-assisted thyroidectomy (VAT) through a small anterior cervical incision, a technique later known as the Miccoli procedure[5]. In 2000, Ohgami and colleagues from Japan were the first to report the use of an extracervical approach via the chest-breast route, marking the earliest attempt at a remote access technique. This introduced the concept of placing the incision away from the neck to improve cosmetic outcomes[6]. In the same year, Ikeda from South Korea first reported the transaxillary approach (TA) for thyroidectomy, initiating the use of the axillary route. At that time, the procedure was performed using a gas-inflated technique, known as gas-inflated transaxillary approach (GTA)[7]. In 2001, South Korean surgeon Chung modified the transaxillary approach (TA) by introducing a gasless technique, leading to the development of the gasless transaxillary approach (GUA) for endoscopic thyroidectomy[8]. Compared to GTA, the gasless transaxillary approach (GUA) avoids various complications associated with insufflation, such as subcutaneous emphysema, mediastinal emphysema, and pneumothorax. In 2007, Choe and colleagues in South Korea introduced the bilateral axillo-breast approach (BABA) for endoscopic thyroidectomy[9]. Building on this foundation, additional approaches such as the bilateral areolar approach (BAA) and the chest-clavicle-breast approach (CCBA) were subsequently developed. In 2013, Cun-Chuan Wang from China performed the world\u0026apos;s first complete endoscopic thyroidectomy via the transoral vestibular approach[10]. In the same year, Nakajo from Japan successfully performed the first gasless single-port transoral endoscopic thyroidectomy via the vestibular approach (TOETVA)[11]. This represented a minimalist exploration of the TOETVA technique, but due to its technical complexity, widespread adoption was limited. It was not until 2016 that Anuwong from Thailand formally named the procedure \u0026quot;Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA)\u0026quot; in the English literature. He also established a standardized three-port CO₂ insufflation technique via the oral vestibule, which facilitated systematic international promotion and led to its widespread clinical adoption[12]. In 2011, Singer performed the first robotic-assisted endoscopic thyroidectomy via the postauricular approach using the da Vinci surgical system[13]. With the development of robotic technology, various robotic-assisted surgical approaches have emerged. Each approach offers distinct advantages. For example, the BABA (bilateral axillo-breast approach) provides a centrally located and symmetrical operative field, making it well-suited for bilateral gland manipulation as well as central and lateral neck dissection. In contrast, the BAA (bilateral areolar approach) establishes access through incisions at both areolae, offering superior cosmetic outcomes. This method is particularly advantageous for female patients with early-stage disease, especially in cases involving unilateral or partial bilateral gland procedures[14]. TOETVA offers the unique advantage of being truly \u0026ldquo;scarless\u0026rdquo; on the body surface. Compared with conventional open surgery, it provides distinct benefits while maintaining comparable safety[15].\u003c/p\u003e\n\u003cp\u003eTransaxillary endoscopic thyroidectomy (TET) was initially developed in South Korea, with the gasless unilateral axillary approach (GUA) now being the most widely adopted technique. GUA is primarily indicated for young female patients with high cosmetic expectations, particularly those with slender body types and long necks. According to the 2022 Chinese expert consensus on gasless axillary approach endoscopic thyroidectomy, the indications for GUA include:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eBenign lesions with a maximum diameter \u0026le; 6 cm (up to 6\u0026ndash;8 cm if cystic);\u003c/li\u003e\n \u003cli\u003eGraves\u0026rsquo; disease with goiter not exceeding grade II;\u003c/li\u003e\n \u003cli\u003ePatients with differentiated thyroid carcinoma (DTC) who meet all of the following criteria:\u003cbr\u003e\u0026nbsp;(i) Primary tumor diameter \u0026lt; 4 cm;\u003cbr\u003e\u0026nbsp;(ii) No extracapsular invasion, or only minimal invasion through the anterior thyroid capsule or minor involvement of the sternothyroid muscle;\u003cbr\u003e\u0026nbsp;(iii) cN0 or cN1 with non-confluent and non-fixed metastatic lymph nodes.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eIn recent years, several studies have demonstrated that, when performed by experienced surgeons, the gasless unilateral axillary approach (GUA) yields comparable outcomes to conventional open surgery in terms of intraoperative blood loss, length of hospital stay, and postoperative complication rates, with no significant differences observed[16][17]. Moreover, as a gasless technique, GUA avoids insufflation-related complications such as subcutaneous emphysema that are associated with gas-inflated transaxillary approaches. In terms of cosmetic satisfaction, the incision of GUA is concealed within the natural axillary fold, leaving no visible scar on the neck, making it significantly superior to conventional open surgery in this regardand highly favored by patients[16][17]. As a result, GUA has now become one of the major surgical approaches.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the wide variety of surgical techniques available for thyroidectomy, preoperative evaluation is particularly crucial in determining the most appropriate approach. Surgeons must select the optimal surgical method based on patient-specific risk factors. For instance, studies conducted abroad have explored the relationship between tumor size, patient age, number of lesions, and the choice of surgical approach.\u003c/p\u003e\n\u003cp\u003eStudies by Economides et al.[18]and Neill et al.[19]have shown that BMI can influence tumor aggressiveness, multifocality, and lymph node metastasis, thereby indirectly affecting the extent and type of surgical approach, the degree of lymph node dissection, and the duration of surgery. The study by Wang et al. demonstrated that tumor diameter and multifocality are the primary risk factors influencing the choice of surgical approach[20]. However, most studies both domestically and internationally on the risk factors influencing the choice of thyroidectomy approach have primarily focused on the pathological characteristics of the lesions or the condition of the thyroid itself. There is currently no direct evidence indicating that BMI independently affects the choice of surgical approach. Moreover, although Economides et al. and Neill et al. investigated the impact of BMI on tumor-related features, they did not establish a direct link between BMI and surgical approach. Wang et al., on the other hand, did not include BMI in their analysis and had a relatively small sample size. Therefore, the present study incorporates BMI as a variable to further investigate its potential association with the choice of surgical technique.\u003c/p\u003e\n\u003cp\u003eThere are various surgical approaches for thyroid cancer, and exploring the factors that influence the choice of surgical technique holds significant clinical value. This study focuses on low-risk papillary thyroid carcinoma (PTC) patients with preoperative cN0 status, aiming to investigate whether different factors impact the selection of surgical approach. The goal is to provide clinical evidence to support decision-making in surgical planning.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003cbr\u003e\u003c/strong\u003eThis study is a single-center retrospective cohort study. Clinical data were retrospectively analyzed for patients who underwent thyroid surgery at Huzhou Central Hospital between October 1, 2023, and October 1, 2024, and were postoperatively confirmed to have papillary thyroid carcinoma (PTC). The study aims to investigate the factors influencing the choice of surgical approach for thyroid cancer, as well as to further explore the differences in perioperative clinical outcomes among different surgical methods and their correlation with patients’ baseline characteristics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;(1) Age ≥ 18 years\u003cbr\u003e\u0026nbsp;(2) Initial surgery: patients underwent their first thyroid surgery at Huzhou Hospital Affiliated to Zhejiang University\u003cbr\u003e\u0026nbsp;(3) Complete data: availability of comprehensive clinical and postoperative pathological data\u003cbr\u003e\u0026nbsp;(4) Postoperative pathological diagnosis of papillary thyroid carcinoma (PTC)\u003cbr\u003e\u0026nbsp;(5) Tumor diameter ≤ 3 cm, no extrathyroidal extension on imaging or gross examination, and no lymph node metastasis (cN0)\u003cbr\u003e\u0026nbsp;(6) Underwent unilateral radical thyroidectomy (unilateral lobe + isthmus + ipsilateral central lymph node dissection) via either open surgery or gasless transaxillary endoscopic thyroidectomy (GUA)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;(1) History of prior neck surgery\u003cbr\u003e\u0026nbsp;(2) Presence of severe systemic diseases (e.g., severe hypertension, diabetes, renal insufficiency, coagulopathy)\u003cbr\u003e\u0026nbsp;(3) Any high-risk features of thyroid cancer identified preoperatively, including:\u003cbr\u003e\u0026nbsp; 1. Extrathyroidal extension\u003cbr\u003e\u0026nbsp; 2. Clinically apparent local or distant metastasis\u003cbr\u003e\u0026nbsp; 3. History of head or neck radiation\u003cbr\u003e\u0026nbsp; 4. Family history of thyroid cancer\u003cbr\u003e\u0026nbsp;(4) Uncontrolled hyperthyroidism or hypothyroidism\u003cbr\u003e\u0026nbsp;(5) History of other malignancies\u003cbr\u003e\u0026nbsp;(6) Pregnancy or lactation\u003cbr\u003e\u0026nbsp;(7) Incomplete key postoperative follow-up data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGrouping Method\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eSurgical approach grouping: Patients were divided into two groups based on surgical method—conventional open thyroidectomy (COT) and gasless unilateral axillary endoscopic thyroidectomy (GUA).\u003c/li\u003e\n \u003cli\u003eBMI grouping (based on the latest WHO standards for Asian populations):\u003cbr\u003e\u0026nbsp; • Underweight (\u0026lt;18.5 kg/m²)\u003cbr\u003e\u0026nbsp; • Normal weight (18.5–22.9 kg/m²)\u003cbr\u003e\u0026nbsp; • Overweight and obese (≥23.0 kg/m²)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ePreoperative data: age, sex, height, weight, BMI, medical history, preoperative BRAF mutation status, preoperative ultrasound findings\u003c/li\u003e\n \u003cli\u003eIntraoperative data: surgery date, operative time, intraoperative blood loss\u003c/li\u003e\n \u003cli\u003ePostoperative data: number of lymph nodes dissected, postoperative cN stage, total postoperative drainage, discharge date, postoperative length of stay, total hospitalization time, total hospitalization cost\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAll statistical analyses were conducted using SPSS version 27.0.\u003c/li\u003e\n \u003cli\u003eNormality tests were applied to all continuous variables. Variables with normal distribution (p \u0026gt; 0.05) were expressed as mean ± standard deviation (Mean ± SD), and independent sample t-tests were used for intergroup comparisons. Non-normally distributed variables (p \u0026lt; 0.05) were expressed as median and interquartile range [M(P25, P75)], and the Mann-Whitney U test was used for comparisons. A two-sided p-value of \u0026lt;0.05 was considered statistically significant.\u003c/li\u003e\n \u003cli\u003ePearson correlation analyses were performed for variables including sex, age, BMI, preoperative nodule size, number of lymph nodes dissected, operative time, postoperative drainage, postoperative cN stage, postoperative length of stay, and total cost.\u003c/li\u003e\n \u003cli\u003eSignificance level: All statistical tests were two-tailed, with p \u0026lt; 0.05 considered statistically significant.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 411 patients were included in this study, with a mean age of 43.76 \u0026plusmn; 12.23 years (range: 19\u0026ndash;79 years), and 74.2% were female. Based on BMI classification, there were 14 underweight patients, 216 with normal weight, and 179 classified as overweight or obese. Among them, 267 underwent open surgery, and 144 underwent gasless transaxillary endoscopic surgery (GUA). All patients were positive for the BRAF V600E mutation preoperatively. According to TNM staging, 267 patients were cN0, and 144 were cN1. The median tumor diameter (TD) was 5.90 mm (interquartile range: 4.10\u0026ndash;8.00 mm) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Clinical Characteristics of the Patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean\u0026plusmn;SD\u003c/p\u003e\n \u003cp\u003eMedian (Q1-Q3)\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean\u0026plusmn;SD\u003c/p\u003e\n \u003cp\u003eMedian (Q1-Q3)\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43.76\u0026plusmn;12.23\u003c/p\u003e\n \u003cp\u003e42.00 (34.00-53.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNodule Size (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.69\u0026plusmn;3.66\u003c/p\u003e\n \u003cp\u003e5.90 (4.10-8.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation Time(min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e305 (74.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90.00 (80.00-110.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e106 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70.00 (60.00-85.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBRAF Mutation Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (＜18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e+(Positive)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e249 (60.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (18.5~24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e216 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-(Negative)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e129 (31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (＞24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e179 (43.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e*(Not Tested)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Drainage Volume (ml)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e267 (65.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e110.00 (90.00-135.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e144 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65.00 (50.00-80.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymph Node Count (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Hospital Stay (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.00 (2.00-5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.00 (2.00-2.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.00 (3.00-8.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.00 (2.00-2.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ecN stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Cost (CNY)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e267 (65.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16712 (15594-18376)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e144 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12282 (12016-12829)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNodule Size (mm):Obtained from Preoperative Ultrasound\u003c/p\u003e\n\u003cp\u003eBMI group：1 = Underweight Group, 2 = Normal Weight Group, 3 = Overweight Group\u003c/p\u003e\n\u003cp\u003eLymph Node Count (n): Number of Lymph Nodes Retrieved from Central Compartment Dissection During Surgery\u003c/p\u003e\n\u003cp\u003eFor surgical approach, operation time, postoperative drainage volume, number of lymph nodes, postoperative hospital stay, and total cost: 0 = Gasless Transaxillary Approach Group (GUA), 1 = Conventional Open Thyroidectomy (COT)\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e\n\u003cp\u003en (%): Number (Percentage)\u003c/p\u003e\n\u003cp\u003eQ1\u0026ndash;Q3: 25th to 75th Percentile (Interquartile Range, IQR)\u003c/p\u003e\n\u003cp\u003eThere were no significant differences in sex or age distribution across BMI groups. In the univariate analysis of perioperative indicators between open and endoscopic groups within each BMI category, the following variables were compared: operative time, postoperative drainage volume, number of lymph nodes dissected, postoperative hospital stay, total cost, nodule size, and cN staging. Results varied across different BMI groups (Tables 2\u0026ndash;4):\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003e\u003cstrong\u003eOperative Time\u003c/strong\u003e: No significant difference was observed between open and endoscopic groups in the underweight group (P = 0.573). However, in both the normal weight and overweight/obese groups, operative time was significantly longer in the endoscopic group (P \u0026lt; 0.001 for both).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePostoperative Drainage Volume\u003c/strong\u003e: Significantly higher in the endoscopic group across all BMI categories (P = 0.006 for underweight, P \u0026lt; 0.001 for normal and overweight/obese).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNumber of Lymph Nodes Dissected\u003c/strong\u003e: No significant difference in the underweight group (P = 0.136), but significantly lower in the endoscopic group in the normal weight (P = 0.001) and overweight/obese groups (P \u0026lt; 0.001).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePostoperative Hospital Stay\u003c/strong\u003e: No significant difference in underweight (P = 0.428) or overweight/obese groups (P = 0.4669). Slightly shorter stay in the endoscopic group for the normal weight group (P = 0.016).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTotal Cost\u003c/strong\u003e: Significantly higher in the endoscopic group across all BMI categories (P = 0.002 for underweight, P \u0026lt; 0.001 for normal and overweight/obese).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Underweight Group\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eGUA\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eCOT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eStatistical Significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eOperation Time(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e88.83\u0026plusmn;26.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e82.1\u0026plusmn;20.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0.577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.573\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003ePostoperative Drainage Volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e120\u0026plusmn;36.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e76\u0026plusmn;18.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e3.222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eLymph Node Count (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e3.5\u0026plusmn;1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e5.7\u0026plusmn;3.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-1.581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003ePostoperative Hospital Stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e2.00 [2.00,2.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e2.00 [2.00,2.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eTotal Cost (CNY)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e16350.83\u0026plusmn;2318.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e12522.23\u0026plusmn;1614.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e3.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Normal Weight Group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eGUA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003eCOT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eStatistical Significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eOperation Time(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e90[76.5,106.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e70[58,90]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e-6.443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePostoperative Drainage Volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e105[85,126.25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e60[50,75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e-9.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eLymph Node Count (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e4[2,6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e5[3,8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e2.984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePostoperative Hospital Stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e2[2,2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e2[2,2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e-2.243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eTotal Cost (CNY)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003e16610.23\u003c/p\u003e\n \u003cp\u003e[15618.4275,18295.27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003e12336.79\u003c/p\u003e\n \u003cp\u003e[12015.65,12944.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e-11.567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 Overweight Group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003eGUA\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eCOT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eStatistical Significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eOperation Time(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e90[80.5,111.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e70[60,85]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e-6.770\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePostoperative Drainage Volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e110[90,145]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e67[55,85]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e-7.292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eLymph Node Count (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e3[2,5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e5[3,8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e3.661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePostoperative Hospital Stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e2[2,2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e2[2,2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e-0.689\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e0.4669\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eTotal Cost (CNY)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 134px;\"\u003e\n \u003cp\u003e17267.825\u003c/p\u003e\n \u003cp\u003e[15491.055,18491.375]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e12253.53\u003c/p\u003e\n \u003cp\u003e[12010.09,12638.52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e-9.731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAdditionally, preoperative ultrasound nodule size was closely related to cN staging. cN1 patients had significantly larger nodules than cN0 patients (7.0 [5.0, 9.0] vs. 5.3 [4.0, 7.0], P \u0026lt; 0.01) (Table 5). Binary logistic regression analysis identified preoperative nodule size as an independent predictor of cN stage (B = 0.109, P \u0026lt; 0.01; Exp(B) = 1.115, 95% CI: 1.052\u0026ndash;1.182), indicating that for every 1 mm increase in nodule size, the risk of cN1 increased by approximately 11.5% (Table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePreoperative Nodule Size \u0026amp; Clinical N Stage\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003ecN0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003ecN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eStatistical Significance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNodule Size (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e5.3[4,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e7[5,9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e4.328\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6 Binary Logistic Regression Analysis of Preoperative Nodule Size and Clinical N Stage\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eSE (Standard Error)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eWald Statistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eExp(B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eExp(B) 95% CI Lower Bound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eExp(B) 95% CI Upper Bound\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNodule Size (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e13.442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1.182\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDue to the small sample size in the underweight group (n = 16), correlation analyses were conducted only for the normal weight and overweight/obese groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn the Normal Weight Group (Table 7):\u003c/strong\u003e\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eSex was positively correlated with BMI (r = 0.221, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eAge showed positive correlation with BMI (r = 0.246, P \u0026lt; 0.01), and negative correlations with operative time (r = -0.206, P \u0026lt; 0.01), drainage volume (r = -0.205, P \u0026lt; 0.01), and cN stage (r = -0.179, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eNodule size was positively correlated with cN stage (r = 0.168, P \u0026lt; 0.05) and negatively correlated with drainage volume (r = -0.193, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eOperative time was positively correlated with drainage volume (r = 0.260, P \u0026lt; 0.01) and total cost (r = 0.438, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eDrainage volume was positively correlated with operative time (r = 0.260, P \u0026lt; 0.01), postoperative hospital stay (r = 0.409, P \u0026lt; 0.01), and total cost (r = 0.557, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003ecN stage was positively correlated with nodule size (r = 0.168, P \u0026lt; 0.05) and negatively correlated with age (r = -0.179, P \u0026lt; 0.01).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eIn the Overweight/Obese Group (Table 8):\u003c/strong\u003e\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eSex was positively correlated with nodule size (r = 0.234, P \u0026lt; 0.01) and cN stage (r = 0.225, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eAge showed negative correlations with BMI (r = -0.183, P \u0026lt; 0.05), operative time (r = -0.285, P \u0026lt; 0.01), drainage volume (r = -0.251, P \u0026lt; 0.01), cN stage (r = -0.165, P \u0026lt; 0.05), and total cost (r = -0.262, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eBMI was positively correlated with nodule size (r = 0.159, P \u0026lt; 0.05).\u003c/li\u003e\n \u003cli\u003eNodule size was positively correlated with cN stage (r = 0.186, P \u0026lt; 0.05).\u003c/li\u003e\n \u003cli\u003eOperative time was positively correlated with drainage volume (r = 0.329, P \u0026lt; 0.01), postoperative hospital stay (r = 0.210, P \u0026lt; 0.01), and total cost (r = 0.506, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eDrainage volume was positively correlated with operative time (r = 0.329, P \u0026lt; 0.01), cN stage (r = 0.166, P \u0026lt; 0.05), postoperative hospital stay (r = 0.725, P \u0026lt; 0.01), and total cost (r = 0.431, P \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003ecN stage was positively correlated with sex (r = 0.225, P \u0026lt; 0.01), nodule size (r = 0.186, P \u0026lt; 0.05), drainage volume (r = 0.166, P \u0026lt; 0.05), and postoperative hospital stay (r = 0.244, P \u0026lt; 0.01), and negatively correlated with age (r = -0.165, P \u0026lt; 0.05).\u003c/li\u003e\n \u003cli\u003ePostoperative hospital stay was positively correlated with operative time (r = 0.210, P \u0026lt; 0.01), drainage volume (r = 0.725, P \u0026lt; 0.01), cN stage (r = 0.224, P \u0026lt; 0.01), and total cost (r = 0.185, P \u0026lt; 0.05).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIn this study, endoscopic surgery was associated with significantly greater postoperative drainage and higher total hospitalization costs across all BMI categories, highlighting its distinct resource demands and postoperative management characteristics. While BMI showed statistically significant correlations with certain perioperative indicators, the strength of these correlations was generally weak, suggesting limited clinical significance. However, in the overweight/obese group, BMI was significantly associated with nodule size. Furthermore, preoperative ultrasound nodule size was strongly associated with cN staging and was identified as an independent predictor, underscoring its value in preoperative assessment and surgical decision-making. These findings provide preliminary evidence supporting BMI-based stratification in surgical approach selection and outcome evaluation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study suggest that, across different BMI categories, endoscopic surgery exhibits significant differences in perioperative performance compared to open surgery, particularly in terms of operative time, postoperative drainage volume, number of lymph nodes dissected, and total cost. Specifically, in the normal weight and overweight groups, operative time was significantly longer in the endoscopic group. This may be attributed to increased body weight, thickened cervical adipose tissue, greater difficulty in surgical field exposure, and differences in surgeon proficiency between open and endoscopic techniques. These findings are consistent with conclusions drawn from related studies conducted within China[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e][\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Moreover, the number of lymph nodes dissected in the endoscopic surgery group was significantly lower than that in the open surgery group among patients in both the normal weight and overweight categories (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This suggests that the endoscopic approach may have certain limitations in the extent of lymph node dissection. These findings serve as a supplement to existing data reported in some domestic studies[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Additionally, postoperative drainage volume in the endoscopic group was significantly higher than that in the open group across all BMI categories. This may be closely related to the more extensive tissue dissection, larger surgical wound area, and greater vascular injury associated with endoscopic procedures. These findings are also consistent with results reported in domestic studies[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e][\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study aimed to determine whether BMI is associated with various perioperative indicators. However, correlation analysis revealed that BMI demonstrated only weak associations with most surgical variables, such as operative time, postoperative drainage volume, and the number of lymph nodes dissected. Nevertheless, discussions with operating surgeons revealed a consistent observation: for experienced surgeons, selecting the endoscopic approach in patients with higher BMI may actually facilitate a smoother and more efficient surgical process, with reduced operative time and blood loss. This perspective aligns with findings reported in some international studies[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e][\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Numerous studies both in China and abroad have explored the advantages of minimally invasive surgery in patients with high BMI, across various surgical fields including the neck[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e][\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], heart[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], lungs, and abdomen[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For example, early international studies on abdominal procedures such as colorectal surgery have demonstrated that minimally invasive approaches offer clear advantages over open surgery in obese patients[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e][\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Similarly, studies on thoracic and cervical surgeries have also provided evidence that, in certain respects, minimally invasive surgery may be more suitable for patients with high BMI. However, these findings contrast with the conclusions drawn from our current data analysis. To further investigate this discrepancy, a more detailed breakdown of the variable \"operative time\" could be considered. For open surgery, the procedure could be divided into three phases: skin incision\u0026ndash;specimen dissection\u0026ndash;hemostasis and suturing. For axillary endoscopic surgery, the phases could be categorized as cavity creation\u0026ndash;specimen dissection\u0026ndash;hemostasis and suturing. By comparing each stage separately, we may better determine whether increased BMI specifically affects the difficulty of certain intraoperative stages, thereby contributing to prolonged operative time.\u003c/p\u003e\u003cp\u003eIn addition, preoperative nodule size was found to be strongly associated with postoperative cN staging. Logistic regression analysis further confirmed that for every 1 mm increase in nodule size, the risk of cN1 increased by approximately 11.5%. This suggests that ultrasound-measured nodule size can serve as an important predictor for assessing the risk of cN staging preoperatively, and may aid in surgical planning and decision-making[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e][\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt is noteworthy that this study found a positive correlation between BMI and preoperative nodule size in the overweight group, which may suggest a potential link between increased body weight and tumor volume. This observation is consistent with the results of subsequent correlation analyses.\u003c/p\u003e\u003cp\u003eFurthermore, the study also demonstrated that the patterns of multivariate correlations differed across BMI subgroups, indicating that BMI may influence the perioperative profile in a complex and variable manner depending on the patient's weight category.\u003c/p\u003e\u003cp\u003eFor instance, in the overweight group, male patients were found to have larger lesions than female patients and were more likely to present with lymph node metastasis. This finding is consistent with the conclusions of multiple studies both domestically and internationally[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e][\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e][\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, a considerable number of studies have demonstrated that androgens exert inhibitory effects on the growth and metastasis of papillary thyroid carcinoma by activating the androgen receptor (AR)[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e][\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e][\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This is contrary to the findings of our correlation analysis, in which male patients in the overweight group exhibited larger tumor sizes and a higher likelihood of lymph node metastasis. Notably, this phenomenon was not observed in the normal weight group. We speculate that there may be two possible explanations for this discrepancy. First, the expression of androgen receptors (AR) is generally downregulated in papillary thyroid carcinoma (PTC) tissues[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], which may diminish the protective effects of androgens. Second, obesity itself may be a contributing factor, as it is known to influence the tumor microenvironment and hormone metabolism, potentially overriding the inhibitory role of androgens. Obesity is often associated with chronic metabolic dysfunction and a state of low-grade inflammation. Adipose tissue secretes large amounts of pro-inflammatory cytokines, such as IL-6, TNF-α, and MCP-1, which contribute to a sustained inflammatory response. This pro-inflammatory microenvironment can activate various signaling pathways that, in turn, promote the growth and progression of tumor cells[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Moreover, compared to females, males are more prone to accumulating visceral fat[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], which is metabolically more active than subcutaneous fat and releases higher concentrations of pro-inflammatory cytokines. This creates a microenvironment that is more conducive to tumor growth and metastasis[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e][\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e][\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].Obesity can also contribute to immune evasion and insulin resistance, leading to impaired T cell function and an increase in immunosuppressive cell populations[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e][\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Additionally, hyperinsulinemia and insulin resistance may activate the IGF-1 signaling pathway, thereby promoting cellular proliferation and inhibiting apoptosis[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e][\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], ultimately facilitating tumor progression and metastasis. These mechanisms collectively contribute to the observation that obese male patients are more likely to present with larger tumor burdens and lymph node metastasis. In contrast, such a tendency was not observed in the analysis of the normal weight group.\u003c/p\u003e\u003cp\u003eSimilarly, in both patient groups, the correlation between postoperative drainage volume and postoperative hospital stay was stronger in the overweight group than in the normal weight group. This suggests that being overweight may significantly increase surgical difficulty, elevate the risk of postoperative complications, and lead to greater consumption of medical resources. These findings underscore the importance of enhanced preoperative management strategies for overweight patients, and emphasize the need for more meticulous tissue dissection and careful ligation or avoidance of vascular structures during surgery. Similar observations have been reported in studies involving neck surgeries[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]as well as procedures in other anatomical regions[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e][\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Additionally, this study found a negative correlation between age and postoperative drainage volume. This may be attributable to the small wound area and low exudate volume typically associated with thyroid surgery. Elderly patients often undergo more conservative surgical approaches with less intraoperative tissue damage, and factors such as decreased capillary permeability and reduced physical activity may further reduce postoperative fluid accumulation. In contrast, previous literature, largely based on more invasive surgical procedures, has frequently reported a positive correlation between age and drainage volume[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Therefore, the differing conclusions are not directly comparable. Furthermore, given the uniformity of surgical techniques and well-controlled variables in this study, the observed results are considered reasonable.\u003c/p\u003e\u003cp\u003eIn conclusion, this study highlights the importance of considering patients' BMI and age in clinical practice to guide individualized selection of the most appropriate surgical approach. Particular attention should be given to the choice of surgical technique and perioperative management strategies in overweight patients to optimize postoperative recovery and cost-effectiveness. Moreover, the preoperative ultrasound-measured nodule size holds significant clinical value as a predictive indicator for cN staging and should be fully integrated into preoperative risk assessment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that, across different BMI categories, endoscopic thyroidectomy is associated with longer operative time, greater postoperative drainage volume, and higher medical costs compared to open surgery\u0026mdash;differences that are particularly pronounced in overweight patients. Additionally, the endoscopic approach shows certain limitations in the number of lymph nodes dissected. Although the correlations between BMI and most perioperative indicators were generally weak, a stronger positive correlation between postoperative drainage and hospital stay was observed in the overweight group, suggesting that increased body weight may prolong recovery time and increase resource utilization.The study also found that preoperative ultrasound-measured nodule size is strongly associated with postoperative cN staging and serves as an independent predictive factor, highlighting its significant clinical value in preoperative assessment.\u003c/p\u003e\u003cp\u003eMoreover, overweight male patients were more likely to present with larger tumors and lymph node metastasis, which may be driven by obesity-related chronic inflammation, immune suppression, and metabolic dysfunction. Given the differences in surgical risk and recovery among BMI groups, it is recommended that BMI and age be fully considered in preoperative evaluations to guide individualized surgical planning. Enhanced intraoperative precision, especially in overweight patients, may help improve perioperative safety and postoperative recovery outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIdea validation: GuoChao Ye.-Concept: GuoChao Ye, YeSheng Zhang.Data collection: YeSheng Zhang, YiHeng Yang. Data analysis: YeSheng Zhang.Manuscript writing: YeSheng Zhang. Manuscript revision: YongCan Xu. Supervision: GuoChao Ye.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and/or analyzed during the current study are not publicly available due to hospital policy and patient confidentiality restrictions, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Ethics Committee of Huzhou Central Hospital (Approval No. 202506022-01). The requirement for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trail number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting of interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of General Surgery, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China. \u003csup\u003e2\u003c/sup\u003eDepartment of General Surgery, Huzhou Central Hospital, Fifth School of Clinical Medicine of Zhejiang Chinese Medical University, Huzhou, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWu Y, He S, Cao M, Teng Y, Li Q, Tan N, Wang J, Zuo T, Li T, Zheng Y, Xia C, Chen W. Comparative analysis of cancer statistics in China and the United States in 2024. Chin Med J (Engl). 2024 Dec 20;137(24):3093-3100. doi: 10.1097/CM9.0000000000003442. Epub 2024 Dec 10. PMID: 39654104; PMCID: PMC11706596.\u003c/li\u003e\n \u003cli\u003eGagner M. Endoscopic subtotal parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg. 1996 Jun;83(6):875. doi: 10.1002/bjs.1800830656. PMID: 8696772.\u003c/li\u003e\n \u003cli\u003eH\u0026uuml;scher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc. 1997 Aug;11(8):877. doi: 10.1007/s004649900476. PMID: 9266657.\u003c/li\u003e\n \u003cli\u003eShimizu K, Akira S, Tanaka S. Video-assisted neck surgery: endoscopic resection of benign thyroid tumor aiming at scarless surgery on the neck. J Surg Oncol. 1998 Nov;69(3):178-80. doi: 10.1002/(sici)1096-9098(199811)69:3\u0026lt;178::aid-jso11\u0026gt;3.0.co;2-9. PMID: 9846506.\u003c/li\u003e\n \u003cli\u003eMiccoli P, Berti P, Conte M, Bendinelli C, Marcocci C. Minimally invasive surgery for thyroid small nodules: preliminary report. J Endocrinol Invest. 1999 Dec;22(11):849-51. doi: 10.1007/BF03343657. PMID: 10710272.\u003c/li\u003e\n \u003cli\u003eOhgami M, Ishii S, Arisawa Y, Ohmori T, Noga K, Furukawa T, Kitajima M. Scarless endoscopic thyroidectomy: breast approach for better cosmesis. Surg Laparosc Endosc Percutan Tech. 2000 Feb;10(1):1-4. PMID: 10872517.\u003c/li\u003e\n \u003cli\u003eIkeda Y, Takami H, Sasaki Y, Kan S, Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg. 2000 Sep;191(3):336-40. doi: 10.1016/s1072-7515(00)00342-2. PMID: 10989910.\u003c/li\u003e\n \u003cli\u003eHakim Darail NA, Lee SH, Kang SW, Jeong JJ, Nam KH, Chung WY. Gasless transaxillary endoscopic thyroidectomy: a decade on. Surg Laparosc Endosc Percutan Tech. 2014 Dec;24(6):e211-5. doi: 10.1097/SLE.0000000000000003. PMID: 24710266.\u003c/li\u003e\n \u003cli\u003eChoe JH, Kim SW, Chung KW, Park KS, Han W, Noh DY, Oh SK, Youn YK. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg. 2007 Mar;31(3):601-6. doi: 10.1007/s00268-006-0481-y. PMID: 17308853.\u003c/li\u003e\n \u003cli\u003eYang J, Wang C, Li J, Yang W, Cao G, Wong HM, Zhai H, Liu W. Complete Endoscopic Thyroidectomy via Oral Vestibular Approach Versus Areola Approach for Treatment of Thyroid Diseases. J Laparoendosc Adv Surg Tech A. 2015 Jun;25(6):470-6. doi: 10.1089/lap.2015.0026. PMID: 26061132.\u003c/li\u003e\n \u003cli\u003eNakajo A, Arima H, Hirata M, Mizoguchi T, Kijima Y, Mori S, Ishigami S, Ueno S, Yoshinaka H, Natsugoe S. Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach. Surg Endosc. 2013 Apr;27(4):1105-10. doi: 10.1007/s00464-012-2588-6. Epub 2012 Nov 21. PMID: 23179070; PMCID: PMC3599170.\u003c/li\u003e\n \u003cli\u003eAnuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, Richmon JD. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc. 2018 Jan;32(1):456-465. doi: 10.1007/s00464-017-5705-8. Epub 2017 Jul 17. PMID: 28717869.\u003c/li\u003e\n \u003cli\u003eTerris DJ, Singer MC, Seybt MW. Robotic facelift thyroidectomy: II. Clinical feasibility and safety. Laryngoscope. 2011 Aug;121(8):1636-41. doi: 10.1002/lary.21832. Epub 2011 Jun 30. PMID: 21721012.\u003c/li\u003e\n \u003cli\u003eFu X, Ma Y, Hou Y, Liu Y, Zheng L. Comparison of endoscopic bilateral areolar and robotic-assisted bilateral axillo-breast approach thyroidectomy in differentiated thyroid carcinoma: a propensity-matched retrospective cohort study. BMC Surg. 2023 Nov 8;23(1):338. doi: 10.1186/s12893-023-02250-w. PMID: 37940892; PMCID: PMC10633981.\u003c/li\u003e\n \u003cli\u003eOh MY, Chai YJ, Yu HW, Kim SJ, Choi JY, Lee KE. Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis. Int J Surg. 2023 Aug 1;109(8):2467-2477. doi: 10.1097/JS9.0000000000000444. PMID: 37161554; PMCID: PMC10442077.\u003c/li\u003e\n \u003cli\u003eLi 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 Nov;11(22):4146-4156. doi: 10.1002/cam4.4766. Epub 2022 Apr 25. PMID: 35470574; PMCID: PMC9678099.\u003c/li\u003e\n \u003cli\u003eLi X, Ding W, Zhang H. Surgical outcomes of endoscopic thyroidectomy approaches for thyroid cancer: a systematic review and network meta-analysis. Front Endocrinol (Lausanne). 2023 Dec 4;14:1256209. doi:\u003c/li\u003e\n \u003cli\u003eEconomides A, Giannakou K, Mamais I, Economides PA, Papageorgis P. Association Between Aggressive Clinicopathologic Features of Papillary Thyroid Carcinoma and Body Mass Index: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne). 2021 Jun 30;12:692879. doi: 10.3389/fendo.2021.692879. PMID: 34276564; PMCID: PMC8279812.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Neill RJ, Abd Elwahab S, Kerin MJ, Lowery AJ. Association of BMI with Clinicopathological Features of Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis. World J Surg. 2021 Sep;45(9):2805-2815. doi: 10.1007/s00268-021-06193-2. Epub 2021 Jun 16. PMID: 34136926.\u003c/li\u003e\n \u003cli\u003eWang X, Zhang C, Srivastava A, Yu W, Liu C, Wei D, Li Y, Yang J. Risk Factors That Influence Surgical Decision-Making for Patients with Low-Risk Differentiated Thyroid Cancer with Tumor Diameters of 1-4 cm. Cancer Manag Res. 2020 Dec 2;12:12423-12428. doi: 10.2147/CMAR.S268716. PMID: 33293868; PMCID: PMC7719324.\u003c/li\u003e\n \u003cli\u003eYu ST, Ouyang R, Miao G, Ge J, Wei Z, Sun B, Li T, Zhang Z, Chen W, Lei S. Gasless single-incision transaxillary endoscopic total thyroidectomy versus conventional open thyroidectomy in patients with papillary thyroid carcinoma based on propensity score matching: a case-control study. Surg Endosc. 2025 Mar;39(3):2091-2098. doi: 10.1007/s00464-025-11567-x. Epub 2025 Feb 3. PMID: 39900859.\u003c/li\u003e\n \u003cli\u003eGe JN, Yu ST, Tan J, Sun BH, Wei ZG, Zhang ZC, Chen WS, Li TT, Lei ST. A propensity score matching analysis of gasless endoscopic transaxillary thyroidectomy with five-settlement technique versus conventional open thyroidectomy in patients with papillary thyroid microcarcinoma. Surg Endosc. 2023 Dec;37(12):9255-9262. doi: 10.1007/s00464-023-10473-4. Epub 2023 Oct 24. PMID: 37875693.\u003c/li\u003e\n \u003cli\u003eWang S, Zhang F, Wang J, Ao Y. A study on the safety and efficacy of endoscopic thyroidectomy via axillary approach for the treatment of thyroid cancer. Medicine (Baltimore). 2024 Jun 21;103(25):e38507. doi: 10.1097/MD.0000000000038507. PMID: 38905368; PMCID: PMC11191952.\u003c/li\u003e\n \u003cli\u003eDuke WS, White JR, Waller JL, Terris DJ. Endoscopic thyroidectomy is safe in patients with a high body mass index. Thyroid. 2014 Jul;24(7):1146-50. doi: 10.1089/thy.2014.0047. Epub 2014 May 21. PMID: 24684421; PMCID: PMC4080847.\u003c/li\u003e\n \u003cli\u003ede Vries LH, Aykan D, Lodewijk L, Damen JAA, Borel Rinkes IHM, Vriens MR. Outcomes of Minimally Invasive Thyroid Surgery - A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne). 2021 Aug 12;12:719397. doi: 10.3389/fendo.2021.719397. PMID: 34456874; PMCID: PMC8387875.\u003c/li\u003e\n \u003cli\u003eSantana O, Reyna J, Grana R, Buendia M, Lamas GA, Lamelas J. Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery. Ann Thorac Surg. 2011 Feb;91(2):406-10. doi: 10.1016/j.athoracsur.2010.09.039. PMID: 21256280.\u003c/li\u003e\n \u003cli\u003eTong, Guojun MDa,*; Zhang, Guiyang BSa; Liu, Jian BSa; Zheng, Zhengzhao BSa; Chen, Yan BSa; Cui, Enhai MDb. A meta-analysis of short-term outcome of laparoscopic surgery versus conventional open surgery on colorectal carcinoma. Medicine 96(48):p e8957, December 2017. | DOI: 10.1097/MD.0000000000008957\u003c/li\u003e\n \u003cli\u003ePark JW, Lim SW, Choi HS, Jeong SY, Oh JH, Lim SB. The impact of obesity on outcomes of laparoscopic surgery for colorectal cancer in Asians. Surg Endosc. 2010 Jul;24(7):1679-85. doi: 10.1007/s00464-009-0829-0. Epub 2009 Dec 29. PMID: 20039065.\u003c/li\u003e\n \u003cli\u003eTang L, Qu RW, Park J, Simental AA, Inman JC. Prevalence of Occult Central Lymph Node Metastasis by Tumor Size in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis. Curr Oncol. 2023 Aug 2;30(8):7335-7350. doi: 10.3390/curroncol30080532. PMID: 37623013; PMCID: PMC10453273.\u003c/li\u003e\n \u003cli\u003eLiu C, Xiao C, Chen J, Li X, Feng Z, Gao Q, Liu Z. Risk factor analysis for predicting cervical lymph node metastasis in papillary thyroid carcinoma: a study of 966 patients. BMC Cancer. 2019 Jun 25;19(1):622. doi: 10.1186/s12885-019-5835-6. PMID: 31238891; PMCID: PMC6593593.\u003c/li\u003e\n \u003cli\u003eHuang J, Song M, Shi H, Huang Z, Wang S, Yin Y, Huang Y, Du J, Wang S, Liu Y, Wu Z. Predictive Factor of Large-Volume Central Lymph Node Metastasis in Clinical N0 Papillary Thyroid Carcinoma Patients Underwent Total Thyroidectomy. Front Oncol. 2021 May 19;11:574774. doi: 10.3389/fonc.2021.574774. Erratum in: Front Oncol. 2024 Nov 18;14:1517682. doi: 10.3389/fonc.2024.1517682. PMID: 34094896; PMCID: PMC8170408.\u003c/li\u003e\n \u003cli\u003eGao L, Li X, Xia Y, Liu R, Liu C, Shi X, Wu Y, Ma L, Jiang Y. Large-Volume Lateral Lymph Node Metastasis Predicts Worse Prognosis in Papillary Thyroid Carcinoma Patients With N1b. Front Endocrinol (Lausanne). 2022 Feb 2;12:815207. doi: 10.3389/fendo.2021.815207. PMID: 35185788; PMCID: PMC8847215.\u003c/li\u003e\n \u003cli\u003eLi P, Ding Y, Liu M, Wang W, Li X. Sex disparities in thyroid cancer: a SEER population study. Gland Surg. 2021 Dec;10(12):3200-3210. doi: 10.21037/gs-21-545. PMID: 35070880; PMCID: PMC8749097.\u003c/li\u003e\n \u003cli\u003eGupta A, Carnazza M, Jones M, Darzynkiewicz Z, Halicka D, O\u0026apos;Connell T, Zhao H, Dadafarin S, Shin E, Schwarcz MD, Moscatello A, Tiwari RK, Geliebter J. Androgen Receptor Activation Induces Senescence in Thyroid Cancer Cells. Cancers (Basel). 2023 Apr 7;15(8):2198. doi: 10.3390/cancers15082198. Erratum in: Cancers (Basel). 2024 Oct 29;16(21):3636. doi: 10.3390/cancers16213636. PMID: 37190127; PMCID: PMC10137266.\u003c/li\u003e\n \u003cli\u003eChou CK, Chi SY, Hung YY, Yang YC, Fu HC, Wang JH, Chen CC, Kang HY. Clinical Impact of Androgen Receptor-Suppressing miR-146b Expression in Papillary Thyroid Cancer Aggressiveness. J Clin Endocrinol Metab. 2023 Oct 18;108(11):2852-2861. doi: 10.1210/clinem/dgad279. PMID: 37220080.\u003c/li\u003e\n \u003cli\u003eChou CK, Chi SY, Chou FF, Huang SC, Wang JH, Chen CC, Kang HY. Aberrant Expression of Androgen Receptor Associated with High Cancer Risk and Extrathyroidal Extension in Papillary Thyroid Carcinoma. Cancers (Basel). 2020 Apr 29;12(5):1109. doi: 10.3390/cancers12051109. PMID: 32365531; PMCID: PMC7281729.\u003c/li\u003e\n \u003cli\u003eZhao H, Wu L, Yan G, Chen Y, Zhou M, Wu Y, Li Y. Inflammation and tumor progression: signaling pathways and targeted intervention. Signal Transduct Target Ther. 2021 Jul 12;6(1):263. doi: 10.1038/s41392-021-00658-5. PMID: 34248142; PMCID: PMC8273155.\u003c/li\u003e\n \u003cli\u003eCrudele L, Piccinin E, Moschetta A. Visceral Adiposity and Cancer: Role in Pathogenesis and Prognosis. Nutrients. 2021 Jun 19;13(6):2101. doi: 10.3390/nu13062101. PMID: 34205356; PMCID: PMC8234141.\u003c/li\u003e\n \u003cli\u003eQuail DF, Dannenberg AJ. The obese adipose tissue microenvironment in cancer development and progression. Nat Rev Endocrinol. 2019 Mar;15(3):139-154. doi: 10.1038/s41574-018-0126-x. PMID: 30459447; PMCID: PMC6374176.\u003c/li\u003e\n \u003cli\u003eLengyel E, Makowski L, DiGiovanni J, Kolonin MG. Cancer as a Matter of Fat: The Crosstalk between Adipose Tissue and Tumors. Trends Cancer. 2018 May;4(5):374-384. doi: 10.1016/j.trecan.2018.03.004. Epub 2018 Apr 5. PMID: 29709261; PMCID: PMC5932630.\u003c/li\u003e\n \u003cli\u003eRingel AE, Drijvers JM, Baker GJ, Catozzi A, Garc\u0026iacute;a-Ca\u0026ntilde;averas JC, Gassaway BM, Miller BC, Juneja VR, Nguyen TH, Joshi S, Yao CH, Yoon H, Sage PT, LaFleur MW, Trombley JD, Jacobson CA, Maliga Z, Gygi SP, Sorger PK, Rabinowitz JD, Sharpe AH, Haigis MC. Obesity Shapes Metabolism in the Tumor Microenvironment to Suppress Anti-Tumor Immunity. Cell. 2020 Dec 23;183(7):1848-1866.e26. doi: 10.1016/j.cell.2020.11.009. Epub 2020 Dec 9. PMID: 33301708; PMCID: PMC8064125.\u003c/li\u003e\n \u003cli\u003ePiening A, Ebert E, Gottlieb C, Khojandi N, Kuehm LM, Hoft SG, Pyles KD, McCommis KS, DiPaolo RJ, Ferris ST, Alspach E, Teague RM. Obesity-related T cell dysfunction impairs immunosurveillance and increases cancer risk. Nat Commun. 2024 Apr 2;15(1):2835. doi: 10.1038/s41467-024-47359-5. PMID: 38565540; PMCID: PMC10987624.\u003c/li\u003e\n \u003cli\u003eZhang AMY, Wellberg EA, Kopp JL, Johnson JD. Hyperinsulinemia in Obesity, Inflammation, and Cancer. Diabetes Metab J. 2021 May;45(3):285-311. doi: 10.4093/dmj.2020.0250. Epub 2021 Mar 29. Erratum in: Diabetes Metab J. 2021 Jul;45(4):622. doi: 10.4093/dmj.2021.0131. PMID: 33775061; PMCID: PMC8164941.\u003c/li\u003e\n \u003cli\u003eArcidiacono B, Iiritano S, Nocera A, Possidente K, Nevolo MT, Ventura V, Foti D, Chiefari E, Brunetti A. Insulin resistance and cancer risk: an overview of the pathogenetic mechanisms. Exp Diabetes Res. 2012;2012:789174. doi: 10.1155/2012/789174. Epub 2012 Jun 4. PMID: 22701472; PMCID: PMC3372318.\u003c/li\u003e\n \u003cli\u003eChen Y, Jin J, Zhang P, Ye R, Zeng C, Zhang Y, Chen J, Li H, Xiao H, Li Y, Guan H. Clinical Impact of Obesity on Postoperative Outcomes of Patients With Thyroid Cancer Undergoing Thyroidectomy: A 5-Year Retrospective Analysis From the US National Inpatient Sample. Cancer Med. 2024 Oct;13(19):e70335. doi: 10.1002/cam4.70335. PMID: 39417377; PMCID: PMC11483747.\u003c/li\u003e\n \u003cli\u003eKilic S, Sambel M. Impact of Obesity on Perioperative and Clinical Outcomes After Robotic Assisted Radical Prostatectomy. Sci Rep. 2025 Jan 2;15(1):225. doi: 10.1038/s41598-024-82003-8. PMID: 39747306; PMCID: PMC11697172.\u003c/li\u003e\n \u003cli\u003eMaradit Kremers H, Visscher SL, Kremers WK, Naessens JM, Lewallen DG. Obesity increases length of stay and direct medical costs in total hip arthroplasty. Clin Orthop Relat Res. 2014 Apr;472(4):1232-9. doi: 10.1007/s11999-013-3316-9. Epub 2013 Oct 8. PMID: 24101527; PMCID: PMC3940745.\u003c/li\u003e\n \u003cli\u003eTian YQ, Ren X, Yin YS, Wang J, Li X, Guo ZH, Zeng XY. Analysis of risk factors affecting the postoperative drainage after a laparoscopic partial nephrectomy: a retrospective study. Front Med (Lausanne). 2024 Jan 24;11:1327882. doi: 10.3389/fmed.2024.1327882. PMID: 38327705; PMCID: PMC10847592.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 7 and 8 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Papillary thyroid carcinoma, open surgery, endoscopic surgery, retrospective study","lastPublishedDoi":"10.21203/rs.3.rs-7446471/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7446471/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThyroid cancer is the most common malignancy of the endocrine system, and its incidence has risen rapidly over the past decade. It is more prevalent in females, with a male-to-female ratio ranging from 1:2 to 1:3. Thyroid cancer is generally classified into differentiated thyroid carcinoma (DTC), medullary thyroid carcinoma (MTC), and anaplastic thyroid carcinoma (ATC). DTC is further subdivided into papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). According to current domestic and international guidelines, surgery remains the only curative treatment for differentiated thyroid carcinoma (DTC). The commonly performed surgical approaches include conventional open thyroidectomy (COT) and endoscopic thyroidectomy (ET). Among open surgeries, the most commonly used approach is the conventional midline cervical incision. In endoscopic procedures, the gasless unilateral axillary approach (GUA) is particularly favored by patients. Therefore, this study aims to investigate the factors influencing the choice of surgical approach for thyroid cancer, which will contribute to further standardizing perioperative management. This study is a single-center retrospective analysis that categorized patients based on the Asian BMI classification and surgical approach. It compared key preoperative, intraoperative, and postoperative indicators between different surgical methods, and conducted both regression and logistic regression analyses. The results demonstrated significant differences between endoscopic and open surgeries across various BMI groups, with the choice of surgical approach exerting a notable impact on relevant clinical indicators. However, BMI itself did not show a significant influence on factors such as operative time, postoperative drainage volume, or the number of lymph nodes dissected. Interestingly, in the obese population, BMI was significantly correlated with nodule size, which in turn was closely associated with clinical N (cN) staging. These findings suggest that BMI may serve as a potential risk predictor, ultimately influencing the selection of surgical approach.\u003c/p\u003e","manuscriptTitle":"Analysis of Factors Influencing Surgical Approach Selection in Patients with Thyroid Cancer: A Retrospective Study of 411 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-18 10:09:45","doi":"10.21203/rs.3.rs-7446471/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb2340ae-4e32-4c82-9aff-a799a4dabc1a","owner":[],"postedDate":"September 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T08:38:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-18 10:09:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7446471","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7446471","identity":"rs-7446471","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}