Comparison of Transoral Thyroidectomy Vestibular Approach and Unilateral Axillobreast Approach for Endoscopic Thyroidectomy: A Prospective Cohort Study

Abstract

Background:
Various approaches for endoscopic thyroidectomy have been developed recently that improve the cosmetic outcome, and some are even scar free. In this study, we compared the safety and surgical outcomes of transoral endoscopic thyroidectomy vestibular approach (TOETVA) and unilateral axillobreast approach (UABA) thyroid surgery performed by a single surgeon.
Materials and Methods:
We conducted a prospective cohort study among 101 patients undergoing endoscopic thyroidectomy from 2018 to 2019 in our institution. The factors analyzed included patients' clinical characteristics, types and time of operation, blood loss, hospital stay, postoperative complications, and cosmetic satisfaction.
Results:
Among 101 patients, 51 underwent TOETVA and 50 had UABA surgery. UABA has shorter operative time for lobectomy (91.7 ± 16.5 minutes versus 50.4 ± 6.8 minutes, P < .001), whereas TOETVA is associated with less postoperative pain (visual analogue scale score day 1 of 4.6 ± 1.0 versus 5.8 ± 1.0, P < .001). There were no significant differences between TOETVA and UABA groups regarding rates of transient recurrent laryngeal nerve injury (9.8% versus 2.0%, P = .205) and hypothyroidism (11.5% versus 2.0%, P = .112), in which all patients fully recovered 6 months after surgery and most of them were satisfied with the cosmetic result.
Conclusions:
Both TOETVA and UABA have been shown to be effective and safe surgical options for endoscopic thyroid surgery, as well as gave excellent cosmetic result. Each approach has its own advantages and disadvantages, and choice of technique should be tailored for each individual, and patient preference should be integrated in the treatment plan.

Full text

Full Report
Comparison of Transoral Thyroidectomy Vestibular
Approach and Unilateral Axillobreast Approach
for Endoscopic Thyroidectomy:
A Prospective Cohort Study
Hau XuanAU1 cNguyen, MD, PhD,
1,2
Long Thanh Nguyen, MD,
1
Hung Van Nguyen, MD, MSc,
2
Hien Xuan Nguyen, MD, MSc,
1
Huy Le Trinh, MD, PhD,
1,2
Tuan Xuan Nguyen, MD, MSc,
3
and Quang Van Le, MD, PhD
1,2
Abstract
Background: Various approaches for endoscopic thyroidectomy have been developed recently that improve the
cosmetic outcome, and some are even scar free. In this study, we compared the safety and surgical outcomes of
transoral endoscopic thyroidectomy vestibular approach (TOETVA) and unilateral axillobreast approach
(UABA) thyroid surgery performed by a single surgeon.
Materials and Methods: We conducted a prospective cohort study among 101 patients undergoing endoscopic
thyroidectomy from 2018 to 2019 in our institution. The factors analyzed included patients’ clinical charac-
teristics, types and time of operation, blood loss, hospital stay, postoperative complications, and cosmetic
satisfaction.
Results: Among 101 patients, 51 underwent TOETVA and 50 had UABA surgery. UABA has shorter operative
time for lobectomy (91.7 –16.5 minutes versus 50.4 –6.8 minutes, P<.001), whereas TOETVA is associated
with less postoperative pain (
AU3 cVAS score day 1 of 4.6 –1.0 versus 5.8 –1.0, P<.001). There were no significant
differences between TOETVA and UABA groups regarding rates of transient recurrent laryngeal nerve injury
(9.8% versus 2.0%, P=.205) and hypothyroidism (11.5% versus 2.0%, P=.112), in which all patients fully
recovered 6 months after surgery and most of them were satisfied with the cosmetic result.
Conclusions: Both TOETVA and UABA have been shown to be effective and safe surgical options for
endoscopic thyroid surgery, as well as gave excellent cosmetic result. Each approach has its own advantages
and disadvantages, and choice of technique should be tailored for each individual, and patient preference should
be integrated in the treatment plan.
Keywords: endoscopic thyroidectomy, unilateral axillobreast approach, transoral endoscopic thyroidectomy
vestibular approach, thyroid nodule
Introduction
F
AU4 cor a long time, open thyroidectomy has been the stan-
dard surgical approach for thyroid diseases, but it still
leaves a visible scar in the neck that is of concern to many
patients. Recently, various endoscopic and robotic thyroid-
ectomy techniques have been developed to provide mini-
mally invasive surgery options and improve the cosmetic
outcome without altering the treatment efficacy.
1–3
Among
these, endoscopic thyroidectomy is more suitable for
resource-limited settings due to the high cost and facility
requirement of robotic surgery. Endoscopic surgery could
be performed through various remote-access approaches to
move the scars to other parts of the body such as the axilla,
breast, or postauricular area, and each approach has its own
advantages and disadvantages.
4–6
In Vietnam, the unilateral
1
D
AU2 cepartment of Oncology, Hanoi Medical University, Hanoi, Viet Nam.
2
Department of Oncology and Palliative Care, Hanoi Medical University Hospital, Hanoi, Viet Nam.
3
Department of Oncology, Thanh Nhan Hospital, Hanoi, Viet Nam.
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 00, Number 00, 2020
ªMary Ann Liebert, Inc.
DOI: 10.1089/lap.2020.0272
1
LAP-2020-0272-ver9-Nguyen_1P
Type: research-article
LAP-2020-0272-ver9-Nguyen_1P.3d 05/16/20 2:39pm Page 1

axillobreast approach (UABA), in which trocars are inserted
through three small incisions in the axilla and breast areola,
has been implemented and has become increasingly popular.
AU5 cThis endoscopic approach provides a convenient operative
space and the small scars are easily hidden and hardly no-
ticeable, and a preliminary report on 50 cases showed
promising results in terms of safety and patient satisfaction.
7
However, it is difficult to perform in males and does not
facilitate total thyroidectomy.
8
Moreover, UABA and espe-
cially bilateral axillobreast approach (BABA) endoscopic
thyroidectomy that allows total thyroidectomy require a large
amount of flap dissection on the anterior chest and still leave
cutaneous scars.
8,9
Since 2008, natural orifice transluminal endoscopic sur-
gery (NOTES) has been applied for thyroidectomy through
oral cavity that completely avoids visible scarring.
10,11
The
transoral endoscopic thyroidectomy vestibular approach
(TOETVA) technique that utilizes three ports on the lower
lip has been developed and only requires a smaller area of
flap dissection compared with UABA as well as provides a
suitable operative view for total thyroidectomy.
12
This
method has been shown to be safe for selected patients in
initial reports.
3,13
However, to our best knowledge, there
have been no data comparing the efficacy and safety of
UABA and TOETVA approaches. In our institution, a single
surgeon has experience in both UABA and TOETVA tech-
niques, in which he has adopted UABA technique in 2015
and TOETVA technique in 2018. During the period from
2018 to 2019, he performed these two techniques in parallel.
Under this unique situation, this study has been conducted to
compare the outcomes of UABA and TOETVA surgeries
done by a single surgeon.
Materials and Methods
Patients
This is a prospective cohort study performed on 101 pa-
tients with thyroid diseases admitted to the Department of
Oncology and Palliative Care, Hanoi Medical University
Hospital. All cases had a preoperative diagnosis of benign
thyroid diseases, including benign thyroid nodule(s) and
Grave’s disease based on clinical examination, hormonal
level assessment, ultrasound, and puncture fine-needle aspi-
ration results.
Among 101 patients, 51 patients had TOETVA surgery
and 50 patients had UABA surgery. These two groups were
enrolled parallel in the period from 2018 to 2019, and the
surgery approach was selected based on surgeon’s choice.
This study was approved by the Institutional Review Board of
Hanoi Medical University Hospital.
Surgical procedure for UABA surgery
The surgery was performed under general anesthesia with
endotracheal intubation. The patient was placed in a supine
position with the neck extended, and the arm on the side of
the lesion was stretched at a 90angle to the axis of the body.
The surgical techniques and instruments had been described
in detail in our previous article.
7
In summary, initially,
10-mm skin incision was made at the intersection of the an-
terior axillary line and the mammary borderline to allow the
introduction of a 10 mm trocar and a cannula to create an
operating tunnel. Two other 5-mm incisions were made
along the upper edge of the ipsilateral breast areola and in
the anterior axillary line. CO
2
was insufflated to achieve a
continuous pressure of about 12 mmHg. A 5 mm hook mono-
polar and 5 mm bowel forceps were used for flap dissection
until a sufficient operative space is obtained. The anterior
border of the ipsilateral sternocleidomastoid muscle and the
strap muscles were dissected. Then, the lower pole of the
thyroid gland was identified and ligated. Thereafter, the lobe
was dissected from the trachea and the superior thyroid
pedicle was coagulated. During lobectomy procedure, the
recurrent laryngeal nerve (RLN) and parathyroid gland were
identified and preserved ( bF1
Fig. 1).
Surgical procedure for TOETVA surgery
Similar to the UABA approach, the patient was placed in
a supine position with the neck slightly extended. All patients
were put under general anesthesia with nasotracheal intuba-
tion. The oral cavity was cleaned with diluted Povidone-
iodine solution.
First, a 10 mm incision was made in the center of the lower
oral vestibule and two lateral 5 mm incisions were made 1.5–
2 cm lateral to the first incision. We then dissected along the
subplatysmal plane down to the anterior neck area using
a medium-sized Kelly clamp and 50 mL of 1:200,000
adrenaline–saline solution for hydrodissection. Then, a blunt
tip tissue dissector was inserted through the 10 mm incision
and moved in a fan shape to widen the operation space. CO
2
was insufflated at 6–8 mmHg pressure with a flow rate of
3 L/min through the 10 mm middle trocar. Two 5 mm trocars
were then introduced through the lateral incisions and the
three trocars converged at the midline. A monopolar hook
was used to complete the dissection, and the strap muscles
were dissected through the middle line to deliver the thyroid
gland into the working space. A 3/0 Vicryl silk was used to
hand up the strap muscles laterally through a transcutaneous
insertion. bAU6
The pyramidal lobe was dissected first and dis-
section was continued inferiorly to divide the isthmus. The
superior thyroid vessels were then identified and cut by a
Harmonic scalpel. Lobectomy was completed from a ceph-
alad to caudal direction and the RLN and the parathyroid
glands were preserved (Fig. 1). In cases with total thyroid-
ectomy, the procedure is repeated on the contralateral side.
The specimen was then extracted in an endobag through
the central incision. Sometimes, for large tumors, the speci-
men had to be cut into smaller pieces. This was performed
entirely within the endobag to avoid tumor cell seeding.
Afterward, the strap muscles were closed using VLOC 3/0
sutures. The oral cavity incisions were closed with Rapid 4/0
sutures.
Statistical analysis
Data were analyzed using Stata version 12. Continuous
variables were presented as mean –standard deviation and
range where appropriate, and categorical variables as the
number with percentage. The means were compared using
the Mann–Whitney U test or t-test and the proportions were
compared by Fisher’s exact or chi-square test when appro-
priate. All tests were two-tailed and differences were con-
sidered statistically significant at P-values £.05.
2 NGUYEN ET AL.
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Results
Clinical characteristics of study population
A total of 101 patients were enrolled in this study, in which
51 patients received TOETVA and 50 patients received
UABA thyroid surgery (
T1 cTable 1). The mean age of TOETVA
group was significantly higher than that of UABA group
(45.1 –11.8 versus 34.5 –8.4, P<.001). Both groups mostly
comprised women (90.2% and 96.7% respectively, P=.436)
and had comparable mean tumor diameters (22.98 –8.95 mm
versus 21.82 –8.82 mm respectively, P=.521).
All patients had a preoperative diagnosis of benign thyroid
diseases. However, 2 (3.9%) patients in the TOETVA group
had a final pathological result of papillary thyroid cancer.
Table 1. Patients’ Characteristics
Variables TOETVA (n=51) UABA (n=50) P
Age, mean –SD (range) 45.1 –11.8 (17–69) 34.5 –8.4 (17–56) <.001
a
Gender, n(%)
Male 5 (9.8) 2 (3.3) .436
b
Female 46 (90.2) 48 (96.7)
Pathological diagnosis, n(%)
Benign nodule(s) 48 (94.1) 50 (100) .368
b
Papillary thyroid carcinoma 2 (3.9) 0
Grave’s disease 1 (2.0) 0
Tumor size (mm), mean –SD (range) 22.98 –8.95 (11–45) 21.82 –8.82 (16–52) .521
c
Extent of surgery, n(%)
Total thyroidectomy 40 (78.4) 0 .001
d
Lobectomy 11 (21.6) 50 (100)
a
t-test.
b
Fisher’s exact test.
c
Mann–Whitney Utest.
d
Chi-squared test.
SD, standard deviation; TOETVA, transoral endoscopic thyroidectomy vestibular approach; UABA, unilateral axillobreast approach.
FIG. 1. (A, B) The RLN (black arrows), upper and lower parathyroid glands (yellow and white arrows, respectively) are
preserved during UABA procedure. (C, D) The RLN (black arrows), upper and lower parathyroid glands (yellow and white
arrows, respectively) are preserved during TOETVA procedure. RLN, recurrent laryngeal nerve; TOETVA, transoral
endoscopic thyroidectomy vestibular approach; UABA, unilateral axillobreast approach.
4C c
TOETVA VS. UABA FOR ENDOSCOPIC THYROIDECTOMY 3
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A majority of patients in the TOETVA group (40 patients
(78.4%)) had total thyroidectomy, whereas all patients in
the UABA group had thyroid lobectomy. In total, 61 pa-
tients underwent lobectomy and 40 patients underwent total
thyroidectomy.
Surgical outcome and postoperative complications
Among patients who underwent lobectomy, the operative
time was significantly longer in the TOETVA than in the
UABA group (91.7 –16.5 minutes versus 50.4 –6.8 minutes,
P<.001), whereas blood loss volume was similar between
the two groups (*30 mL on average). In contrast, it took
114.4 –23.2 minutes to complete a total thyroidectomy
through the transoral approach, with 58.3 –9.9 mL of blood
loss. The length of hospital stay of the two groups was also
comparable (5.6 –0.8 days in TOETVA versus 5.9 –1.2 days
in UABA, P=.125). However, patients who had TOETVA
surgery have significantly less postoperative pain, especially
during the first 4 days (see details in
T2 cTables 2). Only 5 pa-
tients (9.8%) with TOETVA surgery and 1 patient (2%) with
UABA surgery had transient vocal cord palsy, whereas
no permanent RLN palsy was recorded in both groups.
Among 11 patients who underwent total thyroidectomy in
TOETVA, 6 (54.6%) had transient hypoparathyroidism but
fully recovered afterward. Three TOETVA patients and 1
UABA patient had postoperative mild hematoma and no
operative reintervention was required. None in both groups
had surgical site infection.
Among patients with TOETVA, 3 cases had postoperative
lower lip paresthesia that was indicative of mental nerve
injury and 3 other patients had paresthesia in the flap dis-
section area of the neck. Meanwhile, only 1 UABA patient
had paresthesia of the chest wall. Three patients in the UABA
group had swallowing limitation, whereas 1 patient in the
TOETVA group had chewing limitation. Nearly all patients
were satisfied with the cosmetic result of the operation, in
which the level of satisfaction was comparable between the
two groups (P=.617) ( bT3
Table 3). The postoperative images of
patients are presented in bF2
Figure 2.
Discussion
Our study included 101 cases of endoscopic thyroid sur-
gery performed by a single surgeon through two approaches,
TOETVA and UABA. The results showed that these two
techniques had comparable surgical outcomes including
blood loss, length of hospital stay, and were both safe treat-
ment options, as well as gave high cosmetic satisfaction.
Table 2. Surgical Outcomes of Patients Undergoing Transoral Endoscopic Thyroidectomy
Vestibular Approach Versus Unilateral Axillobreast Approach
Variables TOETVA (n=51) UABA (n=50) P
Operative time (minute)
Total thyroidectomy 114.4 –23.2 (90–160) N/A —
Lobectomy 91.7 –16.5 (50–150) 50.4 –6.8 (25–60) <.001
a
Blood loss
Total thyroidectomy 58.3 –9.9 N/A
Lobectomy 30.7 –6.0 29.0 –4.7 .233
a
Pain score (
AU7 cVAS)
Day 1 4.6 –1.0 5.8 –1.0 <.001
b
Day 4 1.6 –1.0 2.6 –1.6 <.001
a
Day 7 0.4 –0.5 0.4 –0.8 .089
a
Hospital stay (day) 5.6 –0.8 5.9 –1.2 .125
b
Number of cases with postoperative hoarseness, n(%)
Transient 5 (9.8) 1 (2.0) .205
c
Permanent 0 0 —
Number of cases with hypoparathyroidism, n(%)
Transient 6 (11.5) 1 (2.0) .112
c
Permanent 0 N/A —
Number of cases with hematoma, n(%) 3 (5.9) 1 (2.0) .617
c
Number of cases with seroma, n(%) 6 (11.8) 0 .027
c
Number of infections, n(%) 0 0 —
Number of cases with mental nerve injury, n(%) 3 (5.9) 0 .243
c
Number of cases with paresthesia, n(%) 6 (11.8) 1 (2.0) .112
c
Number of cases with movement limitation, n(%) 1 (2.0) 3 (6.0) .362
c
a
Mann–Whitney Utest.
b
t-test.
c
Fisher’s exact test.
N
AU8 c/A; TOETVA, transoral endoscopic thyroidectomy vestibular approach; UABA, unilateral axillobreast approach.
Table 3. Cosmetic Results 3Months
After Surgery
Cosmetic
results
TOETVA (n=51),
n(%)
UABA (n=50),
n(%) P
Satisfied 50 (98.0) 48 (96.0) .617
a
Average 1 (2.0) 2 (4.0)
Dissatisfied 0 0
a
Fisher’s exact test.
TOETVA, transoral endoscopic thyroidectomy vestibular approach;
UABA, unilateral axillobreast approach.
4 NGUYEN ET AL.
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However, UABA had shorter operative time, whereas
TOETVA was associated with less postoperative pain. Each
technique had its own approach-related complications de-
pending on the regional anatomy of the surgery access sites.
Hu
¨scher et al. first used endoscopic thyroid surgery in
1997.
14
Since then, many endoscopic techniques for thyroid
surgery have been developed along with the advancement of
surgical devices, which provides minimally invasive or even
scar-free surgeries for patients having cosmetic concern.
Initially, cervical approach,
15,16
parasternal approach,
17
and
breast approach
18
were used. Ikeda et al.,
19
Shimazu et al.,
20
and Lee et al.
21
then improved the technique with the axillary
and axillobilateral breast approach to minimize the visible
scar by hiding it in the axilla that can be covered completely
by the patient’s arm. However, this approach still leaves
cutaneous scars and requires a large amount of flap dissec-
tion. Therefore, several surgeons have tried the transoral
approach, first in animal models,
10
cadavers,
22,23
and then in
humans.
24
Transoral endoscopic thyroidectomy can be per-
formed through the sublingual approach, periosteal or the
oral vestibular approach, in which sublingual and periosteal
approaches cause severe tissue damage as well as high com-
plications.
25,26
In 2016, Anuwong et al. have reported en-
couraging results of TOETVA with excellent cosmetic
outcomes and minimal complications.
3
There has been ac-
cumulating evidence that demonstrated promising safety
and efficacy of TOETVA since then.
13,27,28
Compared with
UABA, TOETVA is truly scar free and patients can return to
their normal life without any concerns about scars on the
body.
In this study, the clinical characteristics of the two groups
were similar except for the mean age. The patients who un-
derwent UABA were younger than those who underwent
TOETVA. This difference is most likely due to patient se-
lection. Patients with bilateral nodularity in this study were
generally older than those with single nodule or unilateral
nodularity. A large-scale prospective cohort analysis of 6391
patients presented for evaluation of thyroid nodule(s) dem-
onstrated a 1.6% annual increased risk for multinodularity
(odds ratio, 1.02; P<.001) with advancing age.
29
In those
patients with bilateral diseases, TOETVA was used rather
than UABA since it provided the operative view and working
space for total thyroidectomy.
Among patients receiving lobectomy, the TOETVA group
had significantly longer operative time than the UABA
group. Besides, it took *25 minutes more to perform total
thyroidectomy versus lobectomy by the TOETVA approach.
A majority proportion of operative time was used for the
trocar insertion and dissection steps before thyroid dissec-
tion, and afterward, specimen extraction. This might be at-
tributable to the learning curve of our surgeon, a phenomenon
that has been encountered in other studies.
8,13
He adopted the
UABA technique in 2015 and the TOETVA technique in
2018 and these 51 cases were his initial TOETVA cases.
Hence, he was more familiar with the endoscopic view as
well as the tactics of UABA at the beginning of this study.
Notably, some patients in our cohort had a pointed chin,
which made the dissection even more difficult.
In contrast, TOETVA is associated with significantly less
operative pain than UABA in the first 4 days after surgery.
This is consistent with the findings in a study of Yang et al.
comparing the surgical outcome of TOETVA and endoscopic
thyroidectomy through the areola approach (ETAA)
30
and a
study of Chai et al. with a comparative analysis between
transoral robotic thyroidectomy and BABA robotic thyroid-
ectomy.
8
In the UABA technique, the dissection range from
the axilla and breast incisions to the thyroid gland is broader
than in the TOETVA procedure, suggesting a decrease of
surgical trauma with the TOETVA procedure. In addition, the
oral vestibule incision seems to cause less pain compared
with skin incisions.
13
Follow-up data of Yang et al. also
showed that the skin paraesthesia rate was significantly lower
in the TOETVA group than in the ETAA group 6 months
postoperation.
30
In our study, TOETVA was shown to be as safe as UABA
since there were no significant differences in estimated
blood loss or postoperative complication rates between the
two groups. However, each approach has its own approach-
related complications. For example, UABA with axillary
access can cause brachial plexus injury, shoulder dislocation,
and chest skin sensory change for several months after sur-
gery.
31,32
In contrast, TOETVA can lead to minor specific
complications such as mental nerve injury or neck skin par-
aesthesia.
13
There were no postoperative infections recorded
in our study. Given the high rate of surgical-site infections in
Vietnam,
33
we routinely gave intravenous amoxicillin with
FIG. 2. Representative examples of postoperative outcome after TOETVA (A, B) and UABA (C). TOETVA, transoral
endoscopic thyroidectomy vestibular approach; UABA, unilateral axillobreast approach.
4C c
TOETVA VS. UABA FOR ENDOSCOPIC THYROIDECTOMY 5
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clavulanic antibiotic 30 minutes before skin incision and up
to 5 days after surgery. In the literature, there was only 1 case
who had an infection at the vestibular incision site 4 weeks
after surgery and required an intervention.
24
We encountered 5 cases (9.8%) with temporary RLN in-
jury in the TOETVA group and 1 case (2.0%) in the UABA
group. The complication rate in the TOETVA approach
was slightly higher than that of Anuwong et al.
3,13
and Hong
et al.
34
However, all cases fully recovered 6 months after
surgery. This may again be related to the learning curve of
the surgeon. The transient RLN injury rate might be reduced
by more meticulous dissection and by avoiding thermal in-
jury from harmonic scalpel.
13
After initial cases, we started
using a wet endoscopic gauze to reduce the heat from the
harmonic scalpel while dissecting the RLN, which improved
the rate of transient postoperative hoarseness. The rate of
hypoparathyroidism in our study was 11.5% in the TOETVA
group and 2.0% in the UABA group, which is comparable
with the results of Anuwong et al.
13
and Koh et al.
35
with the
corresponding approach. No patients were reported with
permanent hypoparathyroidism. Although the magnified
view through the endoscope may make identification of the
parathyroid glands easier, close attention must be paid to
protect the nutrient vessels when exposing the gland. None-
theless, no permanent severe complications were reported
and most patients were satisfied with the cosmetic outcome.
Our study has some limitations. First, our surgeon adopted
these two techniques at different times. Although we enrolled
patients to two groups in the same time period, the baseline
skills and experience in these two approaches did not match.
Second, patient allocation was not randomized and the
sample size was relatively small. Further study with a higher
number of patients and longer time of follow-up should be
done to thoroughly compare the safety and outcomes of these
two techniques.
Conclusions
Both TOETVA and UABA approaches have been shown
to be effective and safe surgical options for endoscopic thy-
roid surgery, as well as gave excellent cosmetic result. Each
approach has its own advantages and disadvantages, in which
UABA has shorter operative time whereas TOETVA is as-
sociated with less postoperative pain and is truly scar free.
Choice of the technique should be tailored for each individual
and patient preference should be integrated in the treatment
plan.
Disclosure Statement
No competing financial interests exist.
Funding Information
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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Address correspondence to:
Long Thanh Nguyen, MD
Department of Oncology
Hanoi Medical University
No. 1 Ton That Tung Street, Dong Da
Hanoi 100000
Vietnam
E-mail: longnguyen.hmu@gmail.com
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