Feasibility, perceived aesthetic outcomes and patients’ interest in transoral endoscopic thyroidectomy (TOETVA) in a cohort of patients in the Thames Valley United Kingdom

Feasibility, perceived aesthetic outcomes and patients’ interest in transoral endoscopic thyroidectomy (TOETVA) in a cohort of patients in the Thames Valley United Kingdom | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility, perceived aesthetic outcomes and patients’ interest in transoral endoscopic thyroidectomy (TOETVA) in a cohort of patients in the Thames Valley United Kingdom Brooke Puttergill, Cyra Asher, William Yarwood, Billy Down, James Everson, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3777104/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 Introduction : Thyroid surgery techniques without visible scar have grown internationally with little traction in the UK. The aim was to assess the perception of neck scar after thyroid surgery, estimate the feasibility for transoral endoscopic thyroidectomy (TOETVA) and define the public demand for scarless thyroidectomy. Methods : A mixed cohort study approved by national ethics committee assessed retrospectively the feasibility of TOETVA based on current guidelines. A standardised questionnaire used Manchester Scar Scale (MSS) and explored patient-centred outcomes and views. Results : Out of 265 patients (75% women, median age 56 years) who underwent thyroid lobectomy for indeterminate nodules (n=160) or proven low-risk thyroid cancer (n=105), 64% would have been suitable for TOETVA, including 49% of cancers. Of 92 respondents, MSS was excellent (25%), good (56%; MSS 10). Negative scar perception preoperatively resulted in poor MSS scores post operatively (p<0.0001). Poor MSS impacted all individuals regardless of preoperative neck scar concerns (p<0.001). Worse MSS scores were significant in patients with complications or cancer recurrence concerns (p<0.002) independent of age (p=0.065) and gender (p=0.7118). Need for thyroid hormone replacement in 34% of patients didn’t correlate with to MSS. Patients’ interest in scarless technique didn’t correlate with MSS and appeared to be attributable to personal values, geographic accessibility, and intensity of aversion to complication (p<0.05). Overall, 29% of patients would consider a scarless technique and 31% opposed the idea. Conclusion : This study population showed comparable interest and feasibility for scarless thyroid surgery as international populations. How to respond to this need will become apparent in the coming years. scar perception thyroidectomy transoral endoscopic thyroidectomy vestibular approach TOETVA patient related outcomes in thyroid surgery thyroid scar Figures Figure 1 Figure 2 INTRODUCTION Trans oral endoscopic thyroidectomy through vestibular approach (TOETVA) provides safe thyroid surgery without visible scar and is becoming increasingly popular after initial innovation in South-East Asia in 2016( 1 ) and adoption in large centres in USA and Europe ( 2 ). To date, its introduction in the UK is limited by lack of technical experience and exposure to this new operative technique ( 1 ). Currently, transcervical thyroidectomy remains the gold standard procedure and it has a low complication rate with easily transferrable skills. In this context, the motivation to deliver a scarless procedure is allegedly influenced by cultural perception of neck scar, but some expect it to evolve to be a better procedure ( 1 , 2 , 4 , 5 ). There is limited data on patient perception of scar following transcervical thyroid surgery in the UK with current literature commentary concluding that trans cervical scars are well tolerated, particularly after 12 months post-surgery however pre-existing body dysmorphia has a negative impact on scar perception.( 6 , 7 ) Using accepted guidelines, it was estimated that 55% of patients undergoing thyroid and parathyroid surgery in the US( 4 ) and 42% of patients in Turkey( 5 ) could be eligible for transoral endocrine surgery. Whether similar high percentage could be observed in UK patients has not been explored.( 8 ) The primary indication for TOETVA is improved cosmesis but this ‘soft’ primary outcome should not deter practitioners from developing skills which offer better cosmetic outcomes.( 1 , 4 , 5 ) As part of this process, emphasis will be placed on understanding the impact of the new procedure on the incidence of complications usually associated with traditional thyroid surgery such as recurrent laryngeal nerve injury, permanent hypoparathyrodism and post-operative haemorrhage. In addition, efforts are made to mitigate the incidence of specific complications, such as infection, mental nerve injury and mentalis dysfunction and rate of conversion.( 2 ) As for other procedures, there will be a learning curve, additional costs and operative time.( 5 , 9 – 12 ). Reassuringly, a recent metanalysis of six eligible nonrandomized studies involving 1151 patients revealed that TOETVA group had a significantly longer operative time but there were no significant differences in terms of postoperative outcomes.( 2 ) Safety of an alternative technique is paramount, and this has been already established. Angkoon et al described these parameters in 200 consecutive patients: operative time 97 ± 40 min (range 45–300 min), no permanent hoarseness or hypoparathyroidism occurred, mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma.( 9 ) These outcomes compare fairly to large volume endocrine centres performing open, TOETVA techniques and transoral robotic thyroidectomy (TORT) ( 10 , 11 , 13 , 14 ). Most importantly, bleeding leading to emergency cervical incision to evacuate a haematoma was reported to have occurred in only 3 patients out of 422 in one large series ( 9 ). Once safety is established, local application needs to be considered by the population characteristics: pathology, cultural beliefs and ethical distribution of healthcare costs.( 4 ) Even if TOETVA could be offered only to a subgroup of patients, it remains unclear how many eligible patients would agree to this new surgical technique. Patients previously operated or irradiated are contraindicated and those with a lobe weight of greater than 30g is a relative contraindication dependant on removal techniques. Ozgun reported 513 (42%) of 1197 patients feasible for TOETVA in 3 years with only 29 operated as TOETVA (5.6%).( 5 ) Others reported a wide range from 2–20% for feasibility, even after expanding its indication to include small low-risk differentiated thyroid carcinomas ( 1 , 11 , 14 , 15 ). The aim of this study was to assess in a large cohort of patients within the UK the feasibility of TOETVA and the factors that impact on patients’ interest in thyroid surgery without visible scar. This may better define the evolving role of this procedural innovation. METHODS Patient population A mixed cohort study was used for retrospective analysis to identify the proportion of eligible patients for TOETVA in consecutive unselected patients who underwent transcervical thyroid surgery for cytological atypia in two hospitals (Oxford University Hospitals Trust and Buckinghamshire Healthcare Trust). All cases were discussed within the Thames Valley thyroid multidisciplinary meeting. Demographic data including year of surgery, histopathological diagnosis, ethnicity, gender, age and deprivation status based on national disposable income annually published by county in order to determine pathological and social homogeneity of cohort. Patients were determined eligible for TOETVA by following predetermined published criteria: thyroid nodule size ≤ 30mm, total thyroid volume ≤ 45ml, thyroid cancer < 20mm, excluding previous neck surgery and neck irradiation. Patients’ perception of scar after thyroidectomy A standardised questionnaire was constructed as 24 Likert scale questions to investigate the subjective perception scar after transcervical thyroid surgery and the opinion of thyroid surgery without cervical scar. The validated Manchester Scar Scale (MSS) was used to quantify cosmetic outcomes of scar( 16 ). This is a categorical visual analogue scale with a score range 5–18 reflecting excellent to poor outcome, respectively. A score ≥ 7 is indicative of poorer scar with respect to colour, appearance, contour (compared with surrounding skin), distortion and texture. Sample size was estimated as proportionate analysis. The proportion estimate is at 50% as literature ranges from 20–55% with an acceptable margin of error of 5% (45–55%) and a confidence interval (CI) of 90%. If a sample of 265 people from the cohort is taken, then sample size needed is 158 responses. The median time from previous literature was > 24 months therefore this study cohort will be in at minimum 36 months after surgery. Previous local literature has explored patient interest in scarless thyroid surgery but has not compared this with criteria of the local population feasible for TOETVA, therefore the pathologic parameters of the 265 patients will be defined to estimate feasibility. Data analysis. The demographic characteristics are reported as categorical percentage, continuous with mean and SD for descriptive statistics. Comparison was made between two groups based on whether or not patients were eligible for TOETVA. Spearman’s rank correlation and Kruskall Wallis were used for analysis of group categorical and degree of importance variables with p ≤ 0.05 for statistically significant. ANOVA regression was used for the defined scar perception scores against the binary variables of ‘yes’ or ‘no’ in following categories: post-operative complications, anxiety of residual lobe thyroid cancer, loss of thyroid function and protracted monitoring. RESULTS Feasibility of TOETVA Between 2016–2018, 265 patients underwent thyroid lobectomy for cytological atypia (THY3-4, n = 229), proven maliganancy (THY5, n = 15), radiological suspicion (n = 21). The majority were female in the 5th decade and regionally defined as reasonable economic stature (Table 1 ). Of 265 operated patients with transcervical thyroid surgery, 64% benign cases and 49% of cancer cases were eligible for TOETVA. No cases were excluded as they were all index neck surgeries and no patient in this cohort had undergone neck irradiation (Fig. 1 ). Table 1 Cohort demographics Descriptor Entire Cohort (n = 265) Respondents (n = 92) Age 56 ± 16 years 52 ± 14 years Gender F 75% F 62% Cancer diagnosis 39% (104) 30% (28) Ethnicity Non White 17% (34) White 83% (161) Not specified Average Disposable annual income (national average £28400) £ 24289 ± £2048 Not specified Patients views There were 92 respondents to the postal questionnaire, with comparable demographic data compared with the non-responders (Table 1 ). None of the respondents raised queries of ambiguity related to the questionnaire. 98% of the 2665 data points were completed and 79% of missing fields related to demographics. Vast majority of respondents (95%) reported that they healed without complication following transcervical thyroid surgery. 23/92 (25%) respondents score MSS as perfect scar. MSS > 10 was expressed in 15% of the patients with thick and distorted scars reported by 7%. MSS scores that scored enough to suggest non-perfect scar were compared to near perfect MSS group in concepts and parameters. When an MSS was scored as > 7 (inferring poorer scar appearance) it significantly correlated to the patient having a preoperative scar aversion (p = 0.0000), a poor subjective perception of scar post operative (p = 0.00001) and the willingness to consider a technique without visible scar (p = 0.051) (Fig. 2 ). Age was not predictive of impact of scar (p = 0.065) but poor scar perception was associated with concern of thyroid cancer recurrence (p < 0.002) when perioperative events were assessed against the MSS (Table 2 ). Table 2 MSS correlation to post operative complications and operative outcomes MSS correlation to post operative outcomes P-value correlation to poor MSS Recurrent laryngeal nerve injury 0.0174 Post operative haemorrhage N/A Hormone replacement therapy (30%) 0.2857 Recurrence risk < 0.002 Ongoing monitoring with residual thyroid 0.1261 Age 0.065 Gender 0.7118 When exploring the delivery and access of a new surgical technique patients who were more willing to have longer admissions that showed preference to consider surgery without scar (p = 0.0027) (Table 3 ). In addition, the questionnaire explored the degrees of tolerance for surgical complication to surgical technique without a scar. Patients considering thyroid surgery without scar are more tolerant of facial asymmetry as complication (p = 0.0017) and potential for swallowing difficulty (p = 0.0013). (Table 4 ) Table 3 Regression analysis of volunteered interest in surgical technique without scar to service delivery parameters Delivery of Care P-value against interest in thyroid surgery without scar If the new technique was safe but meant I had to stay in hospital for two nights I would still consider this new scarless technique 0.0027 I would feel nervous undergoing a new technique even if it was safe and had the same health outcomes as the current technique 0.1748 Need to travel to another centre in the region where the procedure is available 0.1808 Table 4 Patient interest in technique without visible scar and tolerance for surgical complication Surgical complication P-value for relative importance against interest in thyroid surgery without scar Voice change - volume 0.760583 Voice change- pitch 0.834413 Numbness 0.1652 Bruising 0.4982 Post operative neck haemorrhage 0.435445 Swallowing difficulties 0.000137 Facial asymmetry 0.001723 LIMITATIONS The study had a 35% response rate to distributed questionnaire, however the study was powered for 156 responses therefore type 2 error may be considered for statistical significances. Secondly, patients were interviewed based on subjective scar perception with no measure of objective scar perception. DISCUSSION Practice of remote access techniques for thyroidectomy without visible scar is currently being assessed in long term studies with over 1880 published cases to date. ( 16 ). This study aimed to define a patient cohort in the UK to advance the understanding of eligibility and interest in thyroid surgery without scar. As the body of international literature on this topic increases, so have the parameters of eligibility and benefits in outcome. Recent data demonstrates applicable technique in re-operative surgery, lymph node dissection, reduced pain, day case surgery and potentially improved swallow outcomes. ( 8 ) The cohort of respondents in our study had fair demographic representative of patients. All patients live in one of the least deprived regions of the UK; socioeconomic status is known to impact psychological wellbeing and subsequent surgical scar perception. Similarly, poor scar outcomes may impact psychology health ( 17 ). As our work showed that preoperative scar aversion leads to poor post operative scar cosmesis, but this study has not further explored how poor scar cosmesis impacts quality of life in this cohort. Scar perception was worse in cancer patients, suggestive that there may be certain pathology that carries psychological morbidity following surgical scar. The study has shown that even at 5 years after the operation, surgical scar can still impact patients. The proportion of patients in this study considered to be eligible for TOETVA was 59% and matches data reported in other large populations.( 4 , 5 , 8 ) In this context, the data presented suggests wide applicability of this new technique in the UK. A third of the respondent group (29%) would consider TOETVA and another third (31%) were opposed to it. This variable interest is attributable to personal values and aversion to perceived complication but not to unfamiliarity / newness of technique. TOETVA is a surgical innovation that the UK market has yet to grow compared to international counterparts. We acknowledge that surgical innovation is dependent on surgical enthusiasm and enthusiasm of surgeons is dependent on an evidenced advantage of technique. Lee et al . aptly described how introduction of surgical innovation occurs in a clinical setting.( 18 ) TOETVA is in the development phase in the UK; practitioners are determining feasibility and developing new technical skill whilst international platforms have reached the exploration and assessment phase.( 18 ) The latter is providing evidence of benefit against the current standard of open thyroidectomy.( 18 ) In summary, remote access thyroid surgery allows practitioners to deliver personalised care without compromising outcomes however this may be challenging under current NHS circumstances of cost constraint, access to care and surgical wait times. However, TOETVA may deliver more than avoiding a visible scar - a metric valued by some patients. Declarations FINANCIAL SUPPORT : This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors CONFLICT OF INTEREST : No conflict of interest to declare ETHICAL APPROVAL : Study approved by Regional Ethics Committee ( IRAS 317953) Author Contribution Author contributions: B.P and R.M developed research idea B.P and C.A produced the protocolB.P applied and managed ethics submissionB.P, C.A, W.Y, J.E and BD contributed data collectionB.P and J.E contributed data analysisB.P, C.A, R.M wrote the main manuscriptAll authors reviewed the manuscript References Anuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc. 2018;32(1):456–65. Wang Y, Zhou S, Liu X, Rui S, Li Z, Zhu J, et al. Transoral endoscopic thyroidectomy vestibular approach vs conventional open thyroidectomy: Meta-analysis. Vol. 43, Head and Neck. John Wiley and Sons Inc; 2021. p. 345–53. Razzaq Z, O’Leary P, Majeed M, Hanrahan M, Mustafa H, Abdalla M, et al. AB002. 76. First experience of trans oral endoscopic thyroidectomy—vestibular approach (TOETVA) in Ireland & UK at Cork University Hospital. Mesentery and Peritoneum. 2019;3:AB002–AB002. Grogan RH. Individual patient and population-level eligibility for transoral endocrine surgery. Ann Thyroid. 2020;5:10–10. Kose OC. Patient Eligibility for Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in an Endemic Region. SiSli Etfal Hastanesi Tip Bulteni / The Medical Bulletin of Sisli Hospital. 2021; Sethukumar P, Ly D, Awad Z, Tolley NS. Scar satisfaction and body image in thyroidectomy patients: Prospective study in a tertiary referral centre. Journal of Laryngology and Otology. 2018;132(1):60–7. Arora A, Swords C, Garas G, Chaidas K, Prichard A, Budge J, et al. The perception of scar cosmesis following thyroid and parathyroid surgery: A prospective cohort study. International Journal of Surgery. 2016;25:38–43. Grogan RH, Suh I, Chomsky-Higgins K, Alsafran S, Vasiliou E, Razavi CR, et al. Patient eligibility for transoral endocrine surgery procedures in the United States. JAMA Netw Open. 2019;2(5). Anuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach. In: JAMA Surgery. American Medical Association; 2018. p. 21–7. Lorenz K, Raffaeli M, Barczyński M, Lorente-Poch L, Sancho J. Volume, outcomes, and quality standards in thyroid surgery: an evidence-based analysis—European Society of Endocrine Surgeons (ESES) positional statement. Vol. 405, Langenbeck’s Archives of Surgery. Springer; 2020. p. 401–25. Lira RB, de Cicco R, Rangel LG, Bertelli AA, Duque Silva G, de Medeiros Vanderlei JP, et al. Transoral endoscopic thyroidectomy vestibular approach: Experience from a multicenter national group with 412 patients. Head Neck. 2021;43(11):3468–75. Duek I, Duek OS, Fliss DM. Minimally Invasive Approaches for Thyroid Surgery—Pitfalls and Promises. Vol. 22, Current Oncology Reports. Springer; 2020. Razavi CR, Khadem MGA, Fondong A, Clark JH, Richmon JD, Tufano RP, et al. Early outcomes in transoral vestibular thyroidectomy: Robotic versus endoscopic techniques. Head Neck. 2018;40(10):2246–53. Hong YT, Ahn J hyuk, Kim JH, Yi JW, Hong KH. Bi-institutional experience of transoral endoscopic thyroidectomy: Challenges and outcomes. Head Neck. 2020;42(8):2115–22. Jitpratoom P, Ketwong K, Sasanakietkul T, Anuwong A. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves’ disease: A comparison of surgical results with open thyroidectomy. Gland Surg. 2016;5(6):546–52. Téot L, Mustoe TA, Middelkoop E, Gauglitz GG. State of the Art Management and Emerging Technologies Textbook on Scar Management 123. Navarro-Carrillo G, Alonso-Ferres M, Moya M, Valor-Segura I. Socioeconomic Status and Psychological Well-Being: Revisiting the Role of Subjective Socioeconomic Status. Front Psychol. 2020;11. Lee SH, Moorthy R, Nagala S. Evolution of transoral endoscopic thyroidectomy vestibular approach according to the IDEAL framework. Vol. 109, British Journal of Surgery. Oxford University Press; 2022. p. 497–502. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About In Review Editorial Policies 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-3777104","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":261560164,"identity":"f1d0c4e7-b801-4874-a747-1e718f91092f","order_by":0,"name":"Brooke Puttergill","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACAyBmbEDwJWT42BvYiNTCxgzWwsPGcwCihYdILQw8bBIJ+LWYSx8++HBGBUOewf3+g48rflnwsEm+PfbwB8MdOXscWiz70pINN5xhKDY4xsxseLYP6DDpvHRjHoZnxjgddobHTPJhG0PihmPMbJKNPSAtOWbSDAyHE3vwavkH1sL+E6xF8oyZ5A+Gw/V4tWxsgNjC2PADqEWCx0yCh+FwAi6HWfawJRvOOCZRLHks2ViysQEUyECH8RgcNuw5gCPEeJgPPuypscnjA4bcx4Y/dXL87CCHVRyWZ2/AYQ0ESCSAKcY2uIPxKgcDiBaGP4RVjoJRMApGwcgDAL1ZT8D3z+oiAAAAAElFTkSuQmCC","orcid":"","institution":"Stoke Mandeville Hospital Buckinghamshire Healthcare Trust","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Brooke","middleName":"","lastName":"Puttergill","suffix":""},{"id":261560165,"identity":"a35908f7-5f88-4086-b5c9-aa4189267ea1","order_by":1,"name":"Cyra Asher","email":"","orcid":"","institution":"Oxford University Hospitals NHS Foundation Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cyra","middleName":"","lastName":"Asher","suffix":""},{"id":261560166,"identity":"2f5f1662-16cc-48e1-a187-0aa9b6a30f1d","order_by":2,"name":"William Yarwood","email":"","orcid":"","institution":"Stoke Mandeville Hospital Buckinghamshire Healthcare Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"William","middleName":"","lastName":"Yarwood","suffix":""},{"id":261560167,"identity":"cd3ced33-44e5-430c-adff-db3b45f51cd2","order_by":3,"name":"Billy Down","email":"","orcid":"","institution":"Stoke Mandeville Hospital Buckinghamshire Healthcare Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Billy","middleName":"","lastName":"Down","suffix":""},{"id":261560168,"identity":"43170ead-a6c9-4e98-a2bd-8155eefd9c80","order_by":4,"name":"James Everson","email":"","orcid":"","institution":"Stoke Mandeville Hospital Buckinghamshire Healthcare Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Everson","suffix":""},{"id":261560169,"identity":"06d1306e-3c5b-40b8-8793-b8b2be10b333","order_by":5,"name":"Radu Mihai","email":"","orcid":"","institution":"Oxford University Hospitals NHS Foundation Trust","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Radu","middleName":"","lastName":"Mihai","suffix":""}],"badges":[],"createdAt":"2023-12-19 13:29:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3777104/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3777104/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":48727333,"identity":"88c3bdd8-6dc5-482d-9130-2b0d19be6f53","added_by":"auto","created_at":"2023-12-23 16:21:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":7946,"visible":true,"origin":"","legend":"\u003cp\u003eRetrospective eligibility for undergoing TOETVA in a cohort of 265 patients\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3777104/v1/e6c4bd0d04e0208d5e38cebe.png"},{"id":48726114,"identity":"cb8fefd6-0a34-47be-bb10-3ca33d59cd8a","added_by":"auto","created_at":"2023-12-23 16:05:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":8190,"visible":true,"origin":"","legend":"\u003cp\u003eManchester Scar Score correlation to scar aversion and thyroid surgery without visible scar\u003c/p\u003e","description":"","filename":"Onlinedrawingimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3777104/v1/5f702ac5bf2ba1112654e0c4.png"},{"id":48896525,"identity":"a047f433-86be-4bb8-8230-64f954ad54f3","added_by":"auto","created_at":"2023-12-28 08:53:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":333339,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3777104/v1/254c2374-4f8f-4a69-a8d9-e34888fd0c5c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility, perceived aesthetic outcomes and patients’ interest in transoral endoscopic thyroidectomy (TOETVA) in a cohort of patients in the Thames Valley United Kingdom","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTrans oral endoscopic thyroidectomy through vestibular approach (TOETVA) provides safe thyroid surgery without visible scar and is becoming increasingly popular after initial innovation in South-East Asia in 2016(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and adoption in large centres in USA and Europe (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). To date, its introduction in the UK is limited by lack of technical experience and exposure to this new operative technique (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Currently, transcervical thyroidectomy remains the gold standard procedure and it has a low complication rate with easily transferrable skills. In this context, the motivation to deliver a scarless procedure is allegedly influenced by cultural perception of neck scar, but some expect it to evolve to be a better procedure (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is limited data on patient perception of scar following transcervical thyroid surgery in the UK with current literature commentary concluding that trans cervical scars are well tolerated, particularly after 12 months post-surgery however pre-existing body dysmorphia has a negative impact on scar perception.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUsing accepted guidelines, it was estimated that 55% of patients undergoing thyroid and parathyroid surgery in the US(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and 42% of patients in Turkey(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) could be eligible for transoral endocrine surgery. Whether similar high percentage could be observed in UK patients has not been explored.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) The primary indication for TOETVA is improved cosmesis but this \u0026lsquo;soft\u0026rsquo; primary outcome should not deter practitioners from developing skills which offer better cosmetic outcomes.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) As part of this process, emphasis will be placed on understanding the impact of the new procedure on the incidence of complications usually associated with traditional thyroid surgery such as recurrent laryngeal nerve injury, permanent hypoparathyrodism and post-operative haemorrhage. In addition, efforts are made to mitigate the incidence of specific complications, such as infection, mental nerve injury and mentalis dysfunction and rate of conversion.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) As for other procedures, there will be a learning curve, additional costs and operative time.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Reassuringly, a recent metanalysis of six eligible nonrandomized studies involving 1151 patients revealed that TOETVA group had a significantly longer operative time but there were no significant differences in terms of postoperative outcomes.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSafety of an alternative technique is paramount, and this has been already established. Angkoon et al described these parameters in 200 consecutive patients: operative time 97\u0026thinsp;\u0026plusmn;\u0026thinsp;40 min (range 45\u0026ndash;300 min), no permanent hoarseness or hypoparathyroidism occurred, mental nerve injury occurred in 3 patients (1.5%). One patient (0.5%) developed a post-operative hematoma.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) These outcomes compare fairly to large volume endocrine centres performing open, TOETVA techniques and transoral robotic thyroidectomy (TORT) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Most importantly, bleeding leading to emergency cervical incision to evacuate a haematoma was reported to have occurred in only 3 patients out of 422 in one large series (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnce safety is established, local application needs to be considered by the population characteristics: pathology, cultural beliefs and ethical distribution of healthcare costs.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Even if TOETVA could be offered only to a subgroup of patients, it remains unclear how many eligible patients would agree to this new surgical technique. Patients previously operated or irradiated are contraindicated and those with a lobe weight of greater than 30g is a relative contraindication dependant on removal techniques. Ozgun reported 513 (42%) of 1197 patients feasible for TOETVA in 3 years with only 29 operated as TOETVA (5.6%).(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Others reported a wide range from 2\u0026ndash;20% for feasibility, even after expanding its indication to include small low-risk differentiated thyroid carcinomas (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this study was to assess in a large cohort of patients within the UK the feasibility of TOETVA and the factors that impact on patients\u0026rsquo; interest in thyroid surgery without visible scar. This may better define the evolving role of this procedural innovation.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient population\u003c/h2\u003e \u003cp\u003eA mixed cohort study was used for retrospective analysis to identify the proportion of eligible patients for TOETVA in consecutive unselected patients who underwent transcervical thyroid surgery for cytological atypia in two hospitals (Oxford University Hospitals Trust and Buckinghamshire Healthcare Trust). All cases were discussed within the Thames Valley thyroid multidisciplinary meeting. Demographic data including year of surgery, histopathological diagnosis, ethnicity, gender, age and deprivation status based on national disposable income annually published by county in order to determine pathological and social homogeneity of cohort.\u003c/p\u003e \u003cp\u003ePatients were determined eligible for TOETVA by following predetermined published criteria: thyroid nodule size\u0026thinsp;\u0026le;\u0026thinsp;30mm, total thyroid volume\u0026thinsp;\u0026le;\u0026thinsp;45ml, thyroid cancer\u0026thinsp;\u0026lt;\u0026thinsp;20mm, excluding previous neck surgery and neck irradiation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; perception of scar after thyroidectomy\u003c/h2\u003e \u003cp\u003eA standardised questionnaire was constructed as 24 Likert scale questions to investigate the subjective perception scar after transcervical thyroid surgery and the opinion of thyroid surgery without cervical scar. The validated Manchester Scar Scale (MSS) was used to quantify cosmetic outcomes of scar(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This is a categorical visual analogue scale with a score range 5\u0026ndash;18 reflecting excellent to poor outcome, respectively. A score\u0026thinsp;\u0026ge;\u0026thinsp;7 is indicative of poorer scar with respect to colour, appearance, contour (compared with surrounding skin), distortion and texture.\u003c/p\u003e \u003cp\u003eSample size was estimated as proportionate analysis. The proportion estimate is at 50% as literature ranges from 20\u0026ndash;55% with an acceptable margin of error of 5% (45\u0026ndash;55%) and a confidence interval (CI) of 90%. If a sample of 265 people from the cohort is taken, then sample size needed is 158 responses. The median time from previous literature was \u0026gt;\u0026thinsp;24 months therefore this study cohort will be in at minimum 36 months after surgery. Previous local literature has explored patient interest in scarless thyroid surgery but has not compared this with criteria of the local population feasible for TOETVA, therefore the pathologic parameters of the 265 patients will be defined to estimate feasibility.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData analysis.\u003c/b\u003e The demographic characteristics are reported as categorical percentage, continuous with mean and SD for descriptive statistics. Comparison was made between two groups based on whether or not patients were eligible for TOETVA. Spearman\u0026rsquo;s rank correlation and Kruskall Wallis were used for analysis of group categorical and degree of importance variables with p\u0026thinsp;\u0026le;\u0026thinsp;0.05 for statistically significant. ANOVA regression was used for the defined scar perception scores against the binary variables of \u0026lsquo;yes\u0026rsquo; or \u0026lsquo;no\u0026rsquo; in following categories: post-operative complications, anxiety of residual lobe thyroid cancer, loss of thyroid function and protracted monitoring.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eFeasibility of TOETVA\u003c/h2\u003e \u003cp\u003eBetween 2016\u0026ndash;2018, 265 patients underwent thyroid lobectomy for cytological atypia (THY3-4, n\u0026thinsp;=\u0026thinsp;229), proven maliganancy (THY5, n\u0026thinsp;=\u0026thinsp;15), radiological suspicion (n\u0026thinsp;=\u0026thinsp;21). The majority were female in the 5th decade and regionally defined as reasonable economic stature (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of 265 operated patients with transcervical thyroid surgery, 64% benign cases and 49% of cancer cases were eligible for TOETVA. No cases were excluded as they were all index neck surgeries and no patient in this cohort had undergone neck irradiation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCohort demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescriptor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEntire Cohort (n\u0026thinsp;=\u0026thinsp;265)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRespondents (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u0026thinsp;\u0026plusmn;\u0026thinsp;16 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u0026thinsp;\u0026plusmn;\u0026thinsp;14 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF 75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF 62%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39% (104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30% (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon White 17% (34)\u003c/p\u003e \u003cp\u003eWhite 83% (161)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage Disposable annual income\u003c/p\u003e \u003cp\u003e(national average \u0026pound;28400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026pound; 24289 \u0026plusmn; \u0026pound;2048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatients views\u003c/h2\u003e \u003cp\u003eThere were 92 respondents to the postal questionnaire, with comparable demographic data compared with the non-responders (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). None of the respondents raised queries of ambiguity related to the questionnaire. 98% of the 2665 data points were completed and 79% of missing fields related to demographics.\u003c/p\u003e \u003cp\u003eVast majority of respondents (95%) reported that they healed without complication following transcervical thyroid surgery. 23/92 (25%) respondents score MSS as perfect scar. MSS\u0026thinsp;\u0026gt;\u0026thinsp;10 was expressed in 15% of the patients with thick and distorted scars reported by 7%. MSS scores that scored enough to suggest non-perfect scar were compared to near perfect MSS group in concepts and parameters. When an MSS was scored as \u0026gt;\u0026thinsp;7 (inferring poorer scar appearance) it significantly correlated to the patient having a preoperative scar aversion (p\u0026thinsp;=\u0026thinsp;0.0000), a poor subjective perception of scar post operative (p\u0026thinsp;=\u0026thinsp;0.00001) and the willingness to consider a technique without visible scar (p\u0026thinsp;=\u0026thinsp;0.051) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Age was not predictive of impact of scar (p\u0026thinsp;=\u0026thinsp;0.065) but poor scar perception was associated with concern of thyroid cancer recurrence (p\u0026thinsp;\u0026lt;\u0026thinsp;0.002) when perioperative events were assessed against the MSS (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMSS correlation to post operative complications and operative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSS correlation to post operative outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value correlation to poor MSS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrent laryngeal nerve injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost operative haemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHormone replacement therapy (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOngoing monitoring with residual thyroid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1261\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen exploring the delivery and access of a new surgical technique patients who were more willing to have longer admissions that showed preference to consider surgery without scar (p\u0026thinsp;=\u0026thinsp;0.0027) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In addition, the questionnaire explored the degrees of tolerance for surgical complication to surgical technique without a scar. Patients considering thyroid surgery without scar are more tolerant of facial asymmetry as complication (p\u0026thinsp;=\u0026thinsp;0.0017) and potential for swallowing difficulty (p\u0026thinsp;=\u0026thinsp;0.0013). (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression analysis of volunteered interest in surgical technique without scar to service delivery parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelivery of Care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value against interest in thyroid surgery without scar\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf the new technique was safe but meant I had to \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003estay in hospital for two nights\u003c/span\u003e I would still consider this new scarless technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.0027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI would feel \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003enervous undergoing a new technique\u003c/span\u003e even if it was safe and had the same health outcomes as the current technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eNeed to travel to another centre\u003c/span\u003e in the region where the procedure is available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1808\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient interest in technique without visible scar and tolerance for surgical complication\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical complication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value for relative importance against interest in thyroid surgery without scar\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVoice change - volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.760583\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVoice change- pitch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.834413\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumbness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1652\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBruising\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.4982\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost operative neck haemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.435445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwallowing difficulties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.000137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacial asymmetry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.001723\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThe study had a 35% response rate to distributed questionnaire, however the study was powered for 156 responses therefore type 2 error may be considered for statistical significances. Secondly, patients were interviewed based on subjective scar perception with no measure of objective scar perception.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003ePractice of remote access techniques for thyroidectomy without visible scar is currently being assessed in long term studies with over 1880 published cases to date. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This study aimed to define a patient cohort in the UK to advance the understanding of eligibility and interest in thyroid surgery without scar. As the body of international literature on this topic increases, so have the parameters of eligibility and benefits in outcome. Recent data demonstrates applicable technique in re-operative surgery, lymph node dissection, reduced pain, day case surgery and potentially improved swallow outcomes. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe cohort of respondents in our study had fair demographic representative of patients. All patients live in one of the least deprived regions of the UK; socioeconomic status is known to impact psychological wellbeing and subsequent surgical scar perception. Similarly, poor scar outcomes may impact psychology health (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). As our work showed that preoperative scar aversion leads to poor post operative scar cosmesis, but this study has not further explored how poor scar cosmesis impacts quality of life in this cohort. Scar perception was worse in cancer patients, suggestive that there may be certain pathology that carries psychological morbidity following surgical scar. The study has shown that even at 5 years after the operation, surgical scar can still impact patients.\u003c/p\u003e \u003cp\u003eThe proportion of patients in this study considered to be eligible for TOETVA was 59% and matches data reported in other large populations.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) In this context, the data presented suggests wide applicability of this new technique in the UK. A third of the respondent group (29%) would consider TOETVA and another third (31%) were opposed to it. This variable interest is attributable to personal values and aversion to perceived complication but not to unfamiliarity / newness of technique.\u003c/p\u003e \u003cp\u003eTOETVA is a surgical innovation that the UK market has yet to grow compared to international counterparts. We acknowledge that surgical innovation is dependent on surgical enthusiasm and enthusiasm of surgeons is dependent on an evidenced advantage of technique. Lee \u003cem\u003eet al\u003c/em\u003e. aptly described how introduction of surgical innovation occurs in a clinical setting.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) TOETVA is in the development phase in the UK; practitioners are determining feasibility and developing new technical skill whilst international platforms have reached the exploration and assessment phase.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) The latter is providing evidence of benefit against the current standard of open thyroidectomy.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn summary, remote access thyroid surgery allows practitioners to deliver personalised care without compromising outcomes however this may be challenging under current NHS circumstances of cost constraint, access to care and surgical wait times. However, TOETVA may deliver more than avoiding a visible scar - a metric valued by some patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFINANCIAL SUPPORT\u003c/strong\u003e:\u0026nbsp; \u0026nbsp;This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e:\u0026nbsp; \u0026nbsp;No conflict of interest to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICAL APPROVAL\u003c/strong\u003e:\u0026nbsp; Study approved by Regional Ethics Committee (\u003cstrong\u003eIRAS 317953)\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor contributions: B.P and R.M developed research idea B.P and C.A produced the protocolB.P applied and managed ethics submissionB.P, C.A, W.Y, J.E and BD contributed data collectionB.P and J.E contributed data analysisB.P, C.A, R.M wrote the main manuscriptAll authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnuwong A, Sasanakietkul T, Jitpratoom P, Ketwong K, Kim HY, Dionigi G, et al. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): indications, techniques and results. Surg Endosc. 2018;32(1):456\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Zhou S, Liu X, Rui S, Li Z, Zhu J, et al. Transoral endoscopic thyroidectomy vestibular approach vs conventional open thyroidectomy: Meta-analysis. Vol.\u0026nbsp;43, Head and Neck. John Wiley and Sons Inc; 2021. p.\u0026nbsp;345\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRazzaq Z, O\u0026rsquo;Leary P, Majeed M, Hanrahan M, Mustafa H, Abdalla M, et al. AB002. 76. First experience of trans oral endoscopic thyroidectomy\u0026mdash;vestibular approach (TOETVA) in Ireland \u0026amp; UK at Cork University Hospital. Mesentery and Peritoneum. 2019;3:AB002\u0026ndash;AB002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrogan RH. Individual patient and population-level eligibility for transoral endocrine surgery. Ann Thyroid. 2020;5:10\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKose OC. Patient Eligibility for Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in an Endemic Region. SiSli Etfal Hastanesi Tip Bulteni / The Medical Bulletin of Sisli Hospital. 2021;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSethukumar P, Ly D, Awad Z, Tolley NS. Scar satisfaction and body image in thyroidectomy patients: Prospective study in a tertiary referral centre. Journal of Laryngology and Otology. 2018;132(1):60\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArora A, Swords C, Garas G, Chaidas K, Prichard A, Budge J, et al. The perception of scar cosmesis following thyroid and parathyroid surgery: A prospective cohort study. International Journal of Surgery. 2016;25:38\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrogan RH, Suh I, Chomsky-Higgins K, Alsafran S, Vasiliou E, Razavi CR, et al. Patient eligibility for transoral endocrine surgery procedures in the United States. JAMA Netw Open. 2019;2(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnuwong A, Ketwong K, Jitpratoom P, Sasanakietkul T, Duh QY. Safety and outcomes of the transoral endoscopic thyroidectomy vestibular approach. In: JAMA Surgery. American Medical Association; 2018. p.\u0026nbsp;21\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorenz K, Raffaeli M, Barczyński M, Lorente-Poch L, Sancho J. Volume, outcomes, and quality standards in thyroid surgery: an evidence-based analysis\u0026mdash;European Society of Endocrine Surgeons (ESES) positional statement. Vol.\u0026nbsp;405, Langenbeck\u0026rsquo;s Archives of Surgery. Springer; 2020. p.\u0026nbsp;401\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLira RB, de Cicco R, Rangel LG, Bertelli AA, Duque Silva G, de Medeiros Vanderlei JP, et al. Transoral endoscopic thyroidectomy vestibular approach: Experience from a multicenter national group with 412 patients. Head Neck. 2021;43(11):3468\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuek I, Duek OS, Fliss DM. Minimally Invasive Approaches for Thyroid Surgery\u0026mdash;Pitfalls and Promises. Vol.\u0026nbsp;22, Current Oncology Reports. Springer; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRazavi CR, Khadem MGA, Fondong A, Clark JH, Richmon JD, Tufano RP, et al. Early outcomes in transoral vestibular thyroidectomy: Robotic versus endoscopic techniques. Head Neck. 2018;40(10):2246\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHong YT, Ahn J hyuk, Kim JH, Yi JW, Hong KH. Bi-institutional experience of transoral endoscopic thyroidectomy: Challenges and outcomes. Head Neck. 2020;42(8):2115\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJitpratoom P, Ketwong K, Sasanakietkul T, Anuwong A. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves\u0026rsquo; disease: A comparison of surgical results with open thyroidectomy. Gland Surg. 2016;5(6):546\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT\u0026eacute;ot L, Mustoe TA, Middelkoop E, Gauglitz GG. State of the Art Management and Emerging Technologies Textbook on Scar Management 123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNavarro-Carrillo G, Alonso-Ferres M, Moya M, Valor-Segura I. Socioeconomic Status and Psychological Well-Being: Revisiting the Role of Subjective Socioeconomic Status. Front Psychol. 2020;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee SH, Moorthy R, Nagala S. Evolution of transoral endoscopic thyroidectomy vestibular approach according to the IDEAL framework. Vol.\u0026nbsp;109, British Journal of Surgery. Oxford University Press; 2022. p.\u0026nbsp;497\u0026ndash;502.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"scar perception, thyroidectomy, transoral endoscopic thyroidectomy vestibular approach, TOETVA patient related outcomes in thyroid surgery, thyroid scar","lastPublishedDoi":"10.21203/rs.3.rs-3777104/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3777104/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Thyroid surgery techniques without visible scar have grown internationally with little traction in the UK. The aim was to assess the perception of neck scar after thyroid surgery, estimate the feasibility for transoral endoscopic thyroidectomy (TOETVA) and define the public demand for scarless thyroidectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A mixed cohort study approved by national ethics committee assessed retrospectively the feasibility of TOETVA based on current guidelines. A standardised questionnaire used Manchester Scar Scale (MSS) and explored patient-centred outcomes and views.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Out of 265 patients (75% women, median age 56 years) who underwent thyroid lobectomy for indeterminate nodules (n=160) or proven low-risk thyroid cancer (n=105), 64% would have been suitable for TOETVA, including 49% of cancers.\u003c/p\u003e\n\u003cp\u003eOf 92 respondents, MSS was excellent (25%), good (56%; MSS\u0026lt;7) or poor (15%; MSS \u0026gt; 10). Negative scar perception preoperatively resulted in poor MSS scores post operatively (p\u0026lt;0.0001). Poor MSS impacted all individuals regardless of preoperative neck scar concerns (p\u0026lt;0.001). Worse MSS scores were significant in patients with complications or cancer recurrence concerns (p\u0026lt;0.002) independent of age (p=0.065) and gender (p=0.7118). Need for thyroid hormone replacement in 34% of patients didn’t correlate with to MSS.\u003c/p\u003e\n\u003cp\u003ePatients’ interest in scarless technique didn’t correlate with MSS and appeared to be attributable to personal values, geographic accessibility, and intensity of aversion to complication (p\u0026lt;0.05). Overall, 29% of patients would consider a scarless technique and 31% opposed the idea.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This study population showed comparable interest and feasibility for scarless thyroid surgery as international populations. How to respond to this need will become apparent in the coming years.\u003c/p\u003e","manuscriptTitle":"Feasibility, perceived aesthetic outcomes and patients’ interest in transoral endoscopic thyroidectomy (TOETVA) in a cohort of patients in the Thames Valley United Kingdom","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-23 16:05:03","doi":"10.21203/rs.3.rs-3777104/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":"f2144819-bae3-4918-8920-666d9cf4d064","owner":[],"postedDate":"December 23rd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-28T08:45:45+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-23 16:05:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3777104","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3777104","identity":"rs-3777104","version":["v1"]},"buildId":"pf3fE39SIOqb-0xH_OWvX","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}