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Importance: Transoral endocrine surgery (TES) allows thyroid and parathyroid operations to be performed without leaving any visible scar on the body. Controversy regarding the value of TES remains, in part owing to the common belief that TES is only applicable to a small, select group of patients. Knowledge of the overall applicability of these procedures is essential to understand the operation, as well as to decide the amount of effort and resources that should be allocated to further study the safety, efficacy, and value of these operations., Objective: To determine what percentage of US patients undergoing thyroid and parathyroid surgery are eligible for TES using currently accepted exclusion criteria., Design, Setting, and Participants: Cross-sectional study of 1000 consecutive thyroid and parathyroid operations (with or without neck dissection) performed between July 1, 2015, and July 1, 2018, at 3 high-volume academic US thyroid- and parathyroid-focused surgical practices (2 general surgery, 1 otolaryngology-head and neck endocrine surgery). Eligibility for TES was determined by retrospectively applying previously published exclusion criteria to the cases., Main Outcomes and Measures: The primary outcome was the percentage of thyroid and parathyroid cases eligible for TES. Secondary outcomes were a subgroup analysis of the percentage of specific types of cases eligible and the reasons for ineligibility., Results: The mean (SD) age of the 1000 surgical patients was 53 (15) years, mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 29 (7), and 747 (75.0%) of the patients were women. Five hundred fifty-eight (55.8%) of the patients were eligible for TES. Most patients with thyroid nodules with cytologically indeterminate behavior (165 of 217 [76.0%]), benign thyroid conditions (166 of 240 [69.2%]), and primary hyperparathyroidism (158 of 273 [57.9%]) were eligible for TES, but only 67 of 231 (29.0%) of patients with thyroid cancer were eligible. Among all 1000 cases reviewed, previous neck operation (97 of 441 [22.0%]), nonlocalized primary hyperparathyroidism (78 of 441 [17.7%]), and need for neck dissection (66 of 441 [15.0%]) were the most common reasons for ineligibility., Conclusions and Relevance: More than half of all patients undergoing thyroid and parathyroid surgery in this study were eligible for TES. This broad applicability suggests that a prospective multicenter trial is reasonable to definitively study the safety, outcomes, and cost of TES.

Background: Many remote-access approaches (RAAs) to the thyroid have been described to circumvent anterior neck scarring, including the transaxillary, robotic facelift, and transoral endoscopic vestibular approaches. These techniques have been popularized in Asia, but adoption has been slow in North America. We aimed to examine multi-institutional North American outcomes with RAA thyroidectomy in the context of these institutions' transcervical approach (TCA) outcomes., Study Design: Cases of lobectomy and total thyroidectomy via transaxillary, robotic facelift, and transoral endoscopic vestibular approaches were reviewed. Demographic characteristics, outcomes, and complications were compared with the same measures in patients undergoing lobectomy and total thyroidectomy via TCA by the primary RAA surgeons at each institution. Patients who underwent parathyroidectomy or other concomitant neck dissection procedures were excluded., Results: Two hundred and sixteen RAA thyroidectomies were attempted (92 transoral endoscopic vestibular approaches, 70 transaxillary, and 54 robotic facelift) and 410 TCA thyroidectomies were performed. There was no difference in mean index nodule sizes between RAA (2.8 ± 1.6 cm) and TCA (2.9 ± 1.9 cm) cohorts (p = 0.72). Median operative times for lobectomy were 146 minutes (range 60 to 343 minutes) and 90 minutes (range 25 to 247 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). Median operative time for total thyroidectomy was 170 minutes (range 100 to 398 minutes) vs 126.5 minutes (range 51 to 260 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). There was no difference in the rates of permanent recurrent laryngeal nerve injury between the RAA (0 of 216 [0%]) and TCA (0 of 410 [0%]) cohorts (p = 0.99)., Conclusions: Remote-access approach thyroidectomy can be performed in a select North American patient population with outcomes comparable with TCA., (Copyright © 2019. Published by Elsevier Inc.)

Objective To define the learning curve for transoral endoscopic thyroidectomy via the vestibular approach (TOETVA). Study Design Case series with planned data collection. Setting Tertiary care academic hospital. Subjects and Methods Included patients were those who met the 2015 American Thyroid Association guidelines for lobectomy and our group's previously documented indications for TOETVA. Operative time (incision to closure) was used as a surrogate for procedural proficiency and plotted as a function of case number to determine a learning curve. A simple moving average of operative time was then calculated, with the proficiency case defined as the case number where the slope of this curve changed. Demographic/characteristic data, outcomes, and complications were compared between the skill acquisition period (case 1 to proficiency case) and the proficiency period (remaining cases). A linear regression model was then used to calculate and compare the slopes of the skill acquisition and proficiency periods in the "operative time versus case number" plot. Results Thirty cases were attempted, with a procedural success rate of 29 of 30 (94%) and no incidence of permanent mental nerve or recurrent laryngeal nerve injury. The proficiency case was case 11. There was a statistically significant difference between the skill acquisition and proficiency periods in slopes of the linear regressions (-16.7 vs -0.3, respectively; P < .001) and median operative times (191 vs 119 minutes, P < .001). There was no difference in demographics, procedural success rate, or complication rate between the periods. Conclusions The learning curve for TOETVA was 11 cases for the surgeon evaluated in this series.

This paper describes the development of an automated Flow Injection analyzer for water toxicity assessment. The analyzer is validated by assessing the toxicity of heavy metal (Pb(2+), Hg(2+) and Cu(2+)) solutions. One hundred μL of a Vibrio fischeri suspension are injected in a carrier solution containing different heavy metal concentrations. Biosensor cells are mixed with the toxic carrier solution in the mixing coil on the way to the detector. Response registered is % inhibition of biosensor bioluminescence due to heavy metal toxicity in comparison to that resulting by injecting the Vibrio fischeri suspension in deionised water. Carrier solutions of mercury showed higher toxicity than the other heavy metals, whereas all metals show concentration related levels of toxicity. The biosensor's response to carrier solutions of different pHs was tested. Vibrio fischeri's bioluminescence is promoted in the pH 5-10 range. Experiments indicate that the whole cell biosensor, as applied in the automated fluidic system, responds to various toxic solutions.