• Thai doctor pioneers ‘scarless thyroidectomy’


    A new approach in thyroidectomy will eliminate the worry of necklace-like scars from conventional surgery for cosmetic-conscious thyroid patients.

    The new Transoral Endoscopic Thyroid Vestibular Approach (TOETVA) pioneered two years ago by a 37-year-old Thai doctor, Angkoon Anuwong, has the most promising cosmetic results in thyroidectomy among other recent approaches.

    This is potentially beneficial to the 25 percent of Filipino women who will have a thyroid disease in their lifetime and might need to undergo thyroidectomy as a result.

    One of the diseases that require thyroidectomy is thyroid cancer, one of the most common cancers in the Philippines.

    It ranked seventh in general prevalence of cancer, while gender-specific rankings identify it as the fourth-most common cancer in females and 17th in males.

    Minimal incisions

    Dr. Anuwong dubbed his approach “scarless thyroidectomy” due to the lack of visible scars after the operation.
    This is because unlike earlier approaches, the incision made for the procedure is between the patient’s lower lip and lower gums.

    It is an example of a natural orifice transluminal endoscopic surgery (NOTES) where the operation is done through the patient’s mouth, which is a natural orifice or opening.

    TOETVA is a three-port technique—two for the instruments and one for the tube (laparoscope).

    The two half centimeter-incisions are made parallel to the canine teeth to avoid mental nerve injury, a common mistake in thyroidectomies, while a centimeter-long incision is made in between these two as the passageway for the specimen out of the body.

    After ligation, the specimen is placed in an endobag before it is pulled out to ensure that the entire specimen will be removed.

    The operation usually lasts for two hours compared with the more conventional robotic surgery, which lasts around four hours.

    This approach has the smallest incision compared to other recent NOTES techniques yet it can be used extract thyroid glands with a diameter of up to ten centimeters.

    The thyroid is a butterfly-shaped gland that produces hormones necessary for the body’s metabolism.
    It is located above the collarbones.

    Compared to other approaches, TOETVA is less traumatic, has less post-operation pain, is faster when it comes to wound healing, and has an earlier recovery, according to the patients involved in his study.

    More blood vessels are situated in mouth tissues resulting in a faster wound recovery.

    Hospitalization only required an average of three days (the normal range is two to seven days) for monitoring and if there are no complications, patients can return home and even go back to work.

    Water diet applies on the first day after the operation then soft diet on the second day.

    TOETVA is also considered to be safer because none of the patients involved in the study to date have had a permanent complication or had mental nerve injury.

    In this study, only two had transient hoarseness (recurrent laryngeal nerve injury), which was resolved in two months, and only one had post-operative blood clotting (hematoma) which was resolved in seven days.

    Broad study group

    Anuwong’s TOETVA study was published in the November 2015 issue of World Journal of Surgery.

    The study involves a series of 60 human cases, the greatest number of cases among other thyroid NOTES techniques worldwide.

    Patients in the study suffered from benign nodule (noncancerous tumor), follicular and papillary carcinoma (the two most common types of thyroid cancer), and Grave’s disease (thyroid enlargement due to overactivity).
    The study involved cases from April 2014 to January 2015.

    Follow ups were made thrice—after one week, after one month, and after three months.

    Due to his work, Anuwong was one of the doctors selected to make a podium presentation at the 88th annual meeting of Pacific Coast Surgical Association (PCSA) in February 2017.

    He will be presenting his abstract of 425 cases of TOETVA.

    TOETVA in PH

    Late last month, Anuwong was an invited guest speaker of Chinese General Hospital’s (CGH) second international symposium.

    Anuwong conducted a hands-on laparoscopic skills workshop to doctors of CGH and performed a live surgical demonstration of TOETVA, which were the highlights of the event.

    Two Thai doctors—Kwannara Ketwong and Paul Jitpratoom—who accompanied him to the Philippines, assisted him.

    The operation lasted around two hours and was streamed live in a room filled with doctors and people from the media through two screens—one to view the doctors in the operating room and the other one to view what happened inside the patient’s neck area.

    Anuwong was equipped with a lapel microphone enabling him to explain as he operates.

    CGH doctors who received training from Anuwong during his stay in the country will train other doctors with the technique.

    Eleven cases of TOETVA have been performed in CGH from January to September of 2016.
    All were successful.

    The international symposium was under the direction of Dr. James Dy with the support of Dr. Samuel Ang, chairman of CGH Department of Surgery.

    It was an initiative of the hospital following its commitment to continuous growth in knowledge and in advancement in technology.

    CGH also invited Dr. Chih-Kun Huang, who is known for his worldwide patents in bariatric and metabolic surgery, for the first international symposium on Bariatric Surgery last year.

    Their third international symposium is set to discuss Gastric and Gyneclogic Surgery.

    Thyroidectomies in the past

    Early procedures were considered barbaric due to numerous complications, massive hemorrhage (ruptured blood vessels), infections, and injuries to surrounding structures.

    Dr. Samuel Gross, nestor of American surgery, even called it “horrid butchery.”

    It was only during the late 19th century where developments in improved techniques began.
    Jules Boeckel introduced the collar incision in 1880.

    It was popularized by Theodore Kocher because of his mortality rate drop—one percent—that later earned him a Nobel Prize in 1909 for his advancement in thyroid surgery.


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