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Barreira CESR, Miranda AP, Peixoto TF, Pinheiro RN. Intraoperative indocyanine green angiography in preventing hypoparathyroidism after thyroid cancer surgery. J Surg Oncol 2024. [PMID: 38963907 DOI: 10.1002/jso.27762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/18/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The aim of this study was to determine whether the use of indocyanine green angiography to identify devascularized parathyroids during thyroidectomy for thyroid cancer would decrease the rates of postoperative hypoparathyroidism. METHODS Retrospective study of patients who had undergone total thyroidectomy for treatment of thyroid cancer between March 2021 and March 2023. The indocyanine group included patients with all four parathyroids identified and evaluated by indocyanine green angiography at the end of the procedure. Those with parathyroid glands classified with no vascularization had the glands autotransplanted. A group without indocyanine angiography was used to compare results. RESULTS The analysis included 100 patients in each group. Indocyanine angiography identified 14.75% of devascularized parathyroids at surgery. The number of parathyroids with a score of 2 (i.e., good vascularization) was not a safe predictor of normal parathyroid hormone levels after surgery. Indeed, 29.2% of the patients with three parathyroids with a score of 2 developed transient hypoparathyroidism. Permanent hypoparathyroidism occurred in 7% of the patients without indocyanine group and in none of the patients in the indocyanine group (p = 0.014). CONCLUSION Intraoperative angiography with indocyanine green could contribute to reduce the occurrence of permanent hypoparathyroidism in patients undergoing surgical treatment for thyroid cancer.
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Affiliation(s)
- Carlos Eduardo Santa Ritta Barreira
- Head and Neck Surgery, Hospital DASA BRASÍLIA, Brasília, Federal District, Brazil
- Head and Neck Surgery, Hospital DF STAR, Brasília, Federal District, Brazil
- Head and Neck Surgery, Hospital SÍRIO-LIBANÊS, Brasília, Federal District, Brazil
| | - André Póvoa Miranda
- Head and Neck Surgery, Hospital DF STAR, Brasília, Federal District, Brazil
- Head and Neck Surgery, Hospital Santa Luzia, Brasília, Federal District, Brazil
| | - Thaísa Fabiana Peixoto
- General Surgery, Hospital DASA BRASÍLIA, Brasília, Federal District, Brazil
- General Surgery, Hospital DAHER, Brasília, Federal District, Brazil
| | - Rodrigo Nascimento Pinheiro
- Oncological Surgery, Hospital DF STAR, Brasília, Federal District, Brazil
- Oncological Surgery, Hospital Santa Luzia, Brasília, Federal District, Brazil
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2
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Morales-Conde S, Navarro-Morales L, Moreno-Suero F, Balla A, Licardie E. Fluorescence and tracers in surgery: the coming future. Cir Esp 2024; 102 Suppl 1:S45-S60. [PMID: 38851317 DOI: 10.1016/j.cireng.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/23/2024] [Indexed: 06/10/2024]
Abstract
The revolution that we are seeing in the world of surgery will determine the way we understand surgical approaches in coming years. Since the implementation of minimally invasive surgery, innovations have constantly been developed to allow the laparoscopic approach to go further and be applied to more and more procedures. In recent years, we have been in the middle of another revolutionary era, with robotic surgery, the application of artificial intelligence and image-guided surgery. The latter includes 3D reconstructions for surgical planning, virtual reality, holograms or tracer-guided surgery, where ICG-guided fluorescence has provided a different perspective on surgery. ICG has been used to identify anatomical structures, assess tissue perfusion, and identify tumors or tumor lymphatic drainage. But the most important thing is that this technology has come hand in hand with the potential to develop other types of tracers that will facilitate the identification of tumor cells and ureters, as well as different light beams to identify anatomical structures. These will lead to other types of systems to assess tissue perfusion without the use of tracers, such as hyperspectral imaging. Combined with the upcoming introduction of ICG quantification, these developments represent a real revolution in the surgical world. With the imminent implementation of these technological advances, a review of their clinical application in general surgery is timely, and this review serves that aim.
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Affiliation(s)
- Salvador Morales-Conde
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen Macarena, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain; Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Laura Navarro-Morales
- Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Francisco Moreno-Suero
- Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Andrea Balla
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen Macarena, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain; Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Eugenio Licardie
- Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen Macarena, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain; Servicio de Cirugía General y Digestiva, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
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3
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Lu D, Pan B, Tang E, Yin S, Sun Y, Yuan Y, Yin T, Yang Z, Zhang F. Intraoperative strategies in identification and functional protection of parathyroid glands for patients with thyroidectomy: a systematic review and network meta-analysis. Int J Surg 2024; 110:1723-1734. [PMID: 38079585 PMCID: PMC10942249 DOI: 10.1097/js9.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/27/2023] [Indexed: 03/16/2024]
Abstract
BACKGROUND This study aimed to assess the benefits and limitations of four intraoperative visualization of parathyroid gland (IVPG) strategies in the identification and functional protection of parathyroid glands (PGs). METHODS We searched PubMed, the Cochrane Central Register of Controlled Trials, CNKI, EMBASE, Web of Science and Google Scholar databases until 30 June 2023. Four IVPG strategies were composed of the naked eyes (NE) and three imaging strategies: autofluorescence (AF), indocyanine green fluorescence (ICGF), and carbon nanoparticles (CN). We performed a pairwise meta-analysis (PMA) for direct comparisons and a Bayesian network meta-analysis (NMA) for indirect comparisons. RESULTS A total of 29 eligible studies were included. According to NMA and PMA, AF had significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, PG inadvertent resection, and PG auto-transplantation compared to NE, while had significantly higher rate of PG identification. CN showed significantly lower rates of postoperative hypocalcemia and hypoparathyroidism, and PG inadvertent resection compared to NE in PMA and NMA. ICGF showed a significantly higher rate of PG auto-transplantation compared to NE in PMA and AF in NMA. According to SUCRA values, AF showed the best advantage in reducing the rate of postoperative hypocalcemia (0.85) and PG inadvertent resection (0.89), and increasing the rate of PG identification (0.80). CN had the greatest advantage in reducing the rate of postoperative hypoparathyroidism (0.95). ICGF ranked the highest in the rate of PG auto-transplantation (0.98). CONCLUSIONS Three imaging strategies demonstrate significant superiority over NE in the intraoperative PG identification and functional protection. AF is the best strategy in reducing the incidence of postoperative hypocalcemia, increasing the rate of PG identification, and reducing the rate of PG inadvertent resection and auto-transplantation. ICGF has great value in assessing PG viability, leading to the trend towards PG auto-transplantation. CN is the best strategy in reducing the incidence of postoperative hypoparathyroidism.
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Affiliation(s)
- Dengwei Lu
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Thyroid, Breast and Vascular Surgery, Chongqing University FuLing Hospital, Chongqing, China
| | - Bin Pan
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Graduate School of Medicine, Chongqing Medical University, Chongqing, China
| | - Enjie Tang
- Epidemiology Department, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China
| | - Supeng Yin
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Yiceng Sun
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Yuquan Yuan
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Graduate School of Medicine, Chongqing Medical University, Chongqing, China
| | - Tingjie Yin
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Graduate School of Medicine, Chongqing Medical University, Chongqing, China
| | - Zeyu Yang
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Graduate School of Medicine, Chongqing Medical University, Chongqing, China
| | - Fan Zhang
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Graduate School of Medicine, Chongqing Medical University, Chongqing, China
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4
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Devgan Y, Mayilvaganan S, Mishra A, Chand G, Agarwal G, Agarwal A. Comparison of indocyanine green angiography vs intraoperative parathyroid hormone in early prediction of risk of post-thyroidectomy hypocalcemia: a prospective cohort study. Ann Med Surg (Lond) 2024; 86:678-688. [PMID: 38333253 PMCID: PMC10849419 DOI: 10.1097/ms9.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/22/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction Indocyanine green (ICG) angiography is the 'real-time intraoperative imaging' technique used to reduce the chances of hypoparathyroidism in post-thyroidectomy patients. In our study, the authors predicted the risk of early post-thyroidectomy hypocalcemia by intraoperative evaluation of parathyroid gland perfusion by ICG angiography. Materials and methods In patients who underwent total thyroidectomy, ICG angiography was done using the SPY PHI imaging system (Stryker). Post-thyroid specimen removal, scoring of parathyroids was done in spy contrast mode. All 4 or <4 visualized parathyroids were scored for vascularity with the highest score of 8. Serum ionized calcium was done 6 h postsurgery and on the morning and evening of postoperative days 1 and 2. Calcium supplements were given to only those who developed clinical or severe biochemical hypocalcemia. Results Out of 60, postoperative hypocalcemia was noted in 41 patients. Total ICG score ≤5 was seen in 34 patients, out of which 28 developed postoperative hypocalcemia showing PPV 82.3% and diagnostic accuracy of 68.3% while iPTH (4.28 pmol/l) showed PPV 76.7 and diagnostic accuracy 70 %. In eight patients, none of the glands was scored as 2 (White) and all these patients developed hypocalcemia requiring calcium infusion. Conclusion The absence of visualization of at least 1 well-perfused (score 2) gland on ICG angiography is highly predictive of hypocalcemia and the majority of patients with total ICG score ≤5 developed hypocalcemia in the immediate postoperative period. ICG is a good predictor of the absence of hypoparathyroidism after thyroidectomy and is comparable to iPTH in the prediction of post-thyroidectomy hypocalcemia.
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Affiliation(s)
| | - Sabaretnam Mayilvaganan
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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5
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Cottrill EE. Avoiding Complications of Thyroidectomy: Preservation of Parathyroid Glands. Otolaryngol Clin North Am 2024; 57:63-74. [PMID: 37659862 DOI: 10.1016/j.otc.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2023]
Abstract
Preservation of functional parathyroid glands during thyroidectomy and central neck surgery is crucial to avoid the common but serious complication of hypoparathyroidism. The first requirement is a solid foundational knowledge of anatomy and embryology which then enables the surgeon to use meticulous anticipatory dissection with identification and preservation of blood supply to the parathyroids. When preservation of blood supply is not possible, autotransplantation should be performed. New technologies harnessing the natural phenomenon of parathyroid autofluorescence to detect parathyroid tissue and indocyanine green to perform angiography may lead to improved outcomes with low risk to patients.
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Affiliation(s)
- Elizabeth E Cottrill
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, 925 Chestnut Street. 6th Floor, Philadelphia, PA 19107, USA.
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6
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Park SY, Choi YS, Hwang YM, Yi JW. Robot-Assisted Parathyroidectomy Using Indocyanine Green (ICG) Fluorescence in Primary Hyperparathyroidism. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1456. [PMID: 37629746 PMCID: PMC10456807 DOI: 10.3390/medicina59081456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Surgical treatment for primary hyperparathyroidism (PHPT) has evolved from bilateral exploration through a long transcervical incision to focused parathyroidectomy with a minimal incision above the pathologic gland. Recently, endoscopic or robot-assisted parathyroid surgery without direct neck incision has been introduced. The aim of this study was to investigate the effectiveness of indocyanine green (ICG) fluorescence as a new method for the visual identification of abnormal hyperfunctioning parathyroid glands in robot-assisted parathyroidectomy using FireflyTM technology. We also aimed to conduct a comparative analysis between robot-assisted parathyroidectomy and conventional focused parathyroidectomy in order to identify clinical differences between the two surgical approaches. Materials and Methods: A total of 37 patients with PHPT underwent parathyroidectomy at a single university hospital between September 2018 and December 2022. Thirty-one patients underwent open focused parathyroidectomy (open group), and six patients underwent robot-assisted parathyroidectomy (robot group). Pre-operative localization via parathyroid SPECT-CT and an intraoperative parathyroid hormone (IOPTH) assay were used to successfully remove the pathologic parathyroid in both groups. ICG was administered only in the robot group. Results: Pathologic parathyroid showed a persistent fluorescence pattern under near-infrared vision. After the removal of the fluorescent parathyroid gland, IOPTH was normalized in all six patients in the robot group. However, the open group showed shorter hospital stays (1.8 ± 1.2 vs. 3.0 ± 0.0 days, p < 0.001) and shorter operation times (91.1 ± 69.1 vs. 152.5 ± 23.6 min, p = 0.001) than the robot group. After 6 months of surgery, PTH, calcium, and ionized calcium levels were all normalized without significant differences between the groups. Conclusions: Robot-assisted parathyroidectomy using ICG is helpful for the visual identification of the pathologic parathyroid gland. The advantage of robot parathyroidectomy is a better cosmetic outcome. However, it still does not show better clinical outcomes than conventional open focused parathyroidectomy.
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Affiliation(s)
| | | | | | - Jin Wook Yi
- Department of Surgery, Inha University Hospital & College of Medicine, Incheon 22332, Republic of Korea
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7
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Moreno-Llorente P, Pascua-Solé M, García-Barrasa A, Muñoz-de-Nova JL. Indocyanine green (ICG) angiography-guided thyroidectomy: description of surgical technique. Front Surg 2023; 10:1217764. [PMID: 37529659 PMCID: PMC10388241 DOI: 10.3389/fsurg.2023.1217764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/28/2023] [Indexed: 08/03/2023] Open
Abstract
Background Postoperative hypoparathyroidism is the most common complication after total thyroidectomy and, when becomes permanent, lead to a myriad of clinical symptoms, long-term need of calcium and vitamin D supplementation and negative impact on the patient's health-related quality of life. Any surgical innovation that could reduce complications and improve outcomes of patients undergoing total thyroidectomy deserves to be considered. Angiography-Guided Thyroidectomy has been proposed as a modification of the standard technique of thyroidectomy aimed to identifying the vascular pattern of the parathyroid glands to maximize efforts for preserving functioning glands at the time of operation. Our aim is to provide a technical description of this procedure based on the use of indocyanine green (ICG) angiography to standardize this technique. Methods The surgical steps that are followed during a total thyroidectomy are modified due to previous visualization of the feeding vessels of the parathyroid glands according to fluorescence of the vascular mapping obtained by ICG angiography prior to thyroidectomy. The first step is to perform an ICG angiography to assess anatomical features of the feeding vasculature of the parathyroid glands, which allows precise surgical dissection for preservation of the glands. Once the viability of the parathyroids has been evaluated angiographically, thyroidectomy is performed in a second step. Conclusions ICG angiography-guided thyroidectomy may be effective to preserve the largest number of better perfused parathyroid glands, which would contribute to reduce the risk of postoperative and permanent hypoparathyroidism. It can be successfully and safely implemented in thyroid surgery and standardization of the technique is necessary to homogenize this procedure in the future, allowing a better comparation of the results to be published.
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Affiliation(s)
- Pablo Moreno-Llorente
- Unit of Endocrine Surgery, Department of Surgery, Hospital Universitari de Bellvitge, Universitat de Barcelona (UB), Barcelona, Spain
| | - Mireia Pascua-Solé
- Unit of Endocrine Surgery, Department of Surgery, Hospital Universitari de Bellvitge, Universitat de Barcelona (UB), Barcelona, Spain
| | - Arantxa García-Barrasa
- Unit of Endocrine Surgery, Department of Surgery, Hospital Universitari de Bellvitge, Universitat de Barcelona (UB), Barcelona, Spain
| | - José Luis Muñoz-de-Nova
- Department of General and Digestive Surgery, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
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8
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Ludwig B, Ludwig M, Dziekiewicz A, Mikuła A, Cisek J, Biernat S, Kaliszewski K. Modern Surgical Techniques of Thyroidectomy and Advances in the Prevention and Treatment of Perioperative Complications. Cancers (Basel) 2023; 15:cancers15112931. [PMID: 37296896 DOI: 10.3390/cancers15112931] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Thyroid cancer is the most common cancer of the endocrine system, and, in recent years, there has been a phenomenon of overdiagnosis followed by subsequent overtreatment. This results in an increasing number of thyroidectomy complications being faced in clinical practice. In this paper, we present the current state of knowledge and the latest findings in the fields of modern surgical techniques, thermal ablation, the identification and assessment of parathyroid function, recurrent laryngeal nerve monitoring and treatment and perioperative bleeding. We reviewed 485 papers, from which we selected 125 papers that are the most relevant. The main merit of this article is its comprehensive view of the subject under discussion-both general, concerning the selection of the appropriate method of surgery, and particular, concerning the selection of the appropriate method of prevention or treatment of selected perioperative complications.
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Affiliation(s)
- Bartłomiej Ludwig
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Maksymilian Ludwig
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Anna Dziekiewicz
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Agnieszka Mikuła
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Jakub Cisek
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Szymon Biernat
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
| | - Krzysztof Kaliszewski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Street 213, 50-556 Wroclaw, Poland
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9
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Kuczma P, Demarchi MS, Leboulleux S, Trésallet C, Mavromati M, Djafarrian R, Mabilia A, Triponez F. Central node dissection in papillary thyroid carcinoma in the era of near-infrared fluorescence. Front Endocrinol (Lausanne) 2023; 14:1110489. [PMID: 37124759 PMCID: PMC10140587 DOI: 10.3389/fendo.2023.1110489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/24/2023] [Indexed: 05/02/2023] Open
Abstract
The most common site of lymph node metastases in papillary thyroid carcinoma is the central compartment of the neck (level VI). In many patients, nodal metastases in this area are not clinically apparent, neither on preoperative imaging nor during surgery. Prophylactic surgical clearance of the level VI in the absence of clinically suspicious lymph nodes (cN0) is still under debate. It has been suggested to reduce local recurrence and improve disease-specific survival. Moreover, it helps to accurately diagnose the lymph node involvement and provides important staging information useful for tailoring of the radioactive iodine regimen and estimating the risk of recurrence. Yet, many studies have shown no benefit to the long-term outcome. Arguments against the prophylactic central lymph node dissection (CLND) cite minimal oncologic benefit and concomitant higher operative morbidity, with hypoparathyroidism being the most common complication. Recently, near-infrared fluorescence imaging has emerged as a novel tool to identify and preserve parathyroid glands during thyroid surgery. We provide an overview of the current scientific landscape of fluorescence imaging in thyroid surgery, of the controversies around the prophylactic CLND, and of fluorescence imaging applications in CLND. To date, only three studies evaluated fluorescence imaging in patients undergoing thyroidectomy and prophylactic or therapeutic CLND for thyroid cancer. The results suggest that fluorescence imaging has the potential to minimise the risk of hypoparathyroidism associated with CLND, while allowing to exploit all its potential benefits. With further development, fluorescence imaging techniques might shift the paradigm to recommend more frequently prophylactic CLND.
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Affiliation(s)
- Paulina Kuczma
- Department of Thoracic and Endocrine Surgery, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Sophie Leboulleux
- Department of Endocrinology, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Christophe Trésallet
- Assistance Publique–Hôpitaux de Paris, Department of Digestive, Bariatric and Endocrine Surgery, Bobigny Avicenne Hospital, Sorbonne Paris Nord University, Bobigny, France
| | - Maria Mavromati
- Department of Endocrinology, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Reza Djafarrian
- Department of Thoracic and Endocrine Surgery, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Andrea Mabilia
- Assistance Publique–Hôpitaux de Paris, Department of Digestive, Bariatric and Endocrine Surgery, Bobigny Avicenne Hospital, Sorbonne Paris Nord University, Bobigny, France
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
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10
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Silver Karcioglu AL, Triponez F, Solórzano CC, Iwata AJ, Abdelhamid Ahmed AH, Almquist M, Angelos P, Benmiloud F, Berber E, Bergenfelz A, Cha J, Colaianni CA, Davies L, Duh QY, Hartl D, Kandil E, Kim WW, Kopp PA, Liddy W, Mahadevan-Jansen A, Lee KD, Mannstadt M, McMullen CP, Shonka DC, Shin JJ, Singer MC, Slough CM, Stack BC, Tearney G, Thomas G, Tolley N, Vidal-Fortuny J, Randolph GW. Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review From the American Head and Neck Society Endocrine Surgery Section. JAMA Otolaryngol Head Neck Surg 2023; 149:253-260. [PMID: 36633855 DOI: 10.1001/jamaoto.2022.4421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery. Observation This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery. Conclusions and Relevance Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.
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Affiliation(s)
- Amanda L Silver Karcioglu
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.,The University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, Department of Surgery, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ayaka J Iwata
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente, Santa Clara, California
| | - Amr H Abdelhamid Ahmed
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
| | - Martin Almquist
- Department of Surgery, Skane University Hospital, Lund, Sweden, Institution for Clinical Sciences, Lund University, Lund, Sweden
| | - Peter Angelos
- MacLean Center for Clinical Medical Ethics, Department of Surgery, The University of Chicago, Chicago, Illinois
| | - Fares Benmiloud
- Endocrine Surgery Unit, Hôpital Européen Marseille, Marseille, France
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Jaepyeong Cha
- Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - C Alessandra Colaianni
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland
| | - Louise Davies
- The VA Outcomes Group, White River Junction, Vermont.,Section for Otolaryngology-Head & Neck Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco.,VA Medical Center, San Francisco, California
| | - Dana Hartl
- Department of Surgery, Thyroid Surgery Unit, Gustave Roussy Cancer Campus and University Paris-Saclay, Paris, France
| | - Emad Kandil
- Endocrine and Oncological Surgery Tulane University School of Medicine, New Orleans, Louisiana
| | - Wan Wook Kim
- Department of Surgery, Breast and Thyroid Division, Kyungpook National University, South Korea
| | - Peter A Kopp
- Division of Endocrinology, Diabetology and Metabolism, University of Lausanne, Lausanne, Switzerland.,Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Whitney Liddy
- Thyroid and Parathyroid Surgery, Department of Otolaryngology-Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois
| | - Anita Mahadevan-Jansen
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,Department of Surgery, Otolaryngology and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kang-Dae Lee
- Department of Otolaryngology-Head and Neck Surgery, Kosin University Gospel Hospital, Busan, Korea
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Caitlin P McMullen
- Moffitt Cancer Center, Department of Head & Neck-Endocrine Oncology, Tampa, Florida
| | - David C Shonka
- Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael C Singer
- Division of Thyroid & Parathyroid Surgery, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | - Cristian M Slough
- Department of Otolaryngology-Head and Neck Surgery, Hawke's Bay Fallen Soldiers' Memorial Hospital, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Brendan C Stack
- Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield
| | - Guillermo Tearney
- Department of Pathology and Wellman Center for Photomedicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Neil Tolley
- Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Jordi Vidal-Fortuny
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland.,Department of Thoracic and Endocrine Surgery, Geneva, Switzerland
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
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11
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St Amour TC, Demarchi MS, Thomas G, Triponez F, Kiernan CM, Solόrzano CC. Educational Review: Intraoperative Parathyroid Fluorescence Detection Technology in Thyroid and Parathyroid Surgery. Ann Surg Oncol 2023; 30:973-993. [PMID: 36481865 DOI: 10.1245/s10434-022-12807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accurate parathyroid gland (PG) identification is a critical yet challenging component of cervical endocrine procedures. PGs possess strong near-infrared autofluorescence (NIRAF) compared with other tissues in the neck. This property has been harnessed by image- and probe-based near-infrared fluorescence detection systems, which have gained increasing popularity in clinical use for their ability to accurately aid in PG identification in a rapid, noninvasive, and cost-effective manner. All NIRAF technologies, however, cannot differentiate viable from devascularized PGs without the use of contrast enhancement. Here, we aim to provide an overview of the rapid evolution of these technologies and update the surgery community on the most recent advancements in the field. METHODS A PubMed literature review was performed using the key terms "parathyroid," "near-infrared," and "fluorescence." Recommendations regarding the use of these technologies in clinical practice were developed on the basis of the reviewed literature and in conjunction with expert surgeons' opinions. RESULTS The use of near-infrared fluorescence detection can be broadly categorized as (1) using parathyroid NIRAF to identify both healthy and diseased PGs, and (2) using contrast-enhanced (i.e., indocyanine green) near-infrared fluorescence to evaluate PG perfusion and viability. Each of these approaches possess unique advantages and disadvantages, and clinical trials are ongoing to better define their utility. CONCLUSIONS Near-infrared fluorescence detection offers the opportunity to improve our collective ability to identify and preserve PGs intraoperatively. While additional work is needed to propel this technology further, we hope this review will be valuable to the practicing surgeon.
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Affiliation(s)
- Taylor C St Amour
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Giju Thomas
- Department of Biomedical Engineering, Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, USA
| | - Frederic Triponez
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solόrzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. .,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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12
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Moreno-Llorente P, García-Barrasa A, Pascua-Solé M, Videla S, Otero A, Muñoz-de Nova JL. Usefulness of ICG Angiography-Guided Thyroidectomy for Preserving Parathyroid Function. World J Surg 2023; 47:421-428. [PMID: 35945357 DOI: 10.1007/s00268-022-06683-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Hypoparathyroidism is the most frequent complication after total thyroidectomy and, when permanent, it becomes a severe chronic disease. We assessed the usefulness of indocyanine green (ICG) angiography-guided thyroidectomy to reduce the postoperative hypocalcemia. METHODS Prospective study with two consecutive cohorts of patients who underwent total thyroidectomy: historical control group (CG) and angiography-guided thyroidectomy group (AG). In all patients, ICG-angiography was performed at the end of the surgery to predict immediate parathyroid gland (PG) function. In the AG, ICG-angiography was also done after PG identification to show their vascular supply. We compared the rate of postoperative hypocalcemia (calcium supplementation needed due to hypocalcemia symptoms or calcium levels < 1.8 mmol/L on the first postoperative day) and permanent hypocalcemia (need of calcium ± vitamin D supplementation 12 months after thyroidectomy). RESULTS We included 120 consecutive patients (84 CG; 36 AG). Thyroid cancer was the most common diagnostic (63.1% CG-69.4% AG; p = 0.646) and central neck dissection was also frequent (54.8% CG-64.3% AG; p = 0.468). The AG developed a lower rate of postoperative (26.2-5.6%; p = 0.011) and permanent hypocalcemia (11.9-0%; p = 0.032). The OR for permanent hypocalcemia was 0.673 (95% CI 0.591-0.766). A significant higher rate of well vascularized PG at the end of the surgery (score 2) in the AG (39.2-52.9%; p = 0.018) was also seen. CONCLUSION ICG angiography-guided thyroidectomy is a useful tool to identify PG vascularization, allowing a better PG preservation and a significant decrease in hypocalcemia rates.
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Affiliation(s)
- Pablo Moreno-Llorente
- Endocrine Surgery Unit, Department of Surgery, Hospital Universitari de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Arantxa García-Barrasa
- Endocrine Surgery Unit, Department of Surgery, Hospital Universitari de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mireia Pascua-Solé
- Endocrine Surgery Unit, Department of Surgery, Hospital Universitari de Bellvitge, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sebastián Videla
- Clinical Research Support Unit (HUB), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL) (HUB-IDIBELL), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Pharmacology Unit, Department of Pathology and Experimental Therapeutics, Faculty of Medicine, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Aurema Otero
- Clinical Research Support Unit (HUB), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL) (HUB-IDIBELL), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Luis Muñoz-de Nova
- Department of General and Digestive Surgery, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
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13
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Indocyanine green fluorescence and near-infrared autofluorescence may improve post-thyroidectomy parathyroid function. Surgery 2023; 173:124-131. [PMID: 36244813 DOI: 10.1016/j.surg.2022.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/12/2022] [Accepted: 06/15/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Near-infrared autofluorescence and indocyanine green fluorescence are 2 recent tools introduced to improve postoperative parathyroid function during thyroid surgery. METHODS We conducted a randomized prospective study. Patients undergoing total thyroidectomy were randomly assigned either to the fluorescence group, in which near-infrared autofluorescence and indocyanine green fluorescence were used, or to the control group. The primary outcomes of the study were the rate of postoperative transient and symptomatic hypocalcemia. RESULTS A significantly higher number of parathyroid glands were identified in the fluorescence group (3.83 vs 3.64, P = .028). The rate of postoperative symptomatic hypocalcemia was significantly lower in the fluorescence group (6% vs 17%, P = .015), as was the dosage (1.53 vs 1.91 g, P = .007) and the duration of calcium therapy (32.30 vs 45.66 days, P = .003). Having at least 2 well-vascularized parathyroid glands correlates to lower rates of transient hypocalcemia (7.4% vs 21.9%, P = .037) as well as to higher serum calcium (8.70 vs 8.42 mg/dL, P = .027) and parathyroid hormone levels (19.15 vs 11.4 pg/mL, P = .0002) on postoperative day 1. CONCLUSION Near-infrared autofluorescence and indocyanine green fluorescence are novel tools that may support the endocrine surgeon in preserving and predicting post-thyroidectomy parathyroid gland function.
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14
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Polkin VV, Isaev PA, Plugar AK, Ilyin AA, Ivanov SA, Kaprin AD. [Indocyanine green fluorescence angiography in transoral endoscopic thyroidectomy for papillary thyroid cancer]. Khirurgiia (Mosk) 2023:11-19. [PMID: 37682542 DOI: 10.17116/hirurgia202309211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of ICG angiography in patients with papillary thyroid cancer (PTC) undergoing transoral endoscopic thyroidectomy (TOETVA) and selective neck dissection (level VI). MATERIAL AND METHODS A retrospective analysis included 20 patients with PTC who underwent TOETVA with selective neck dissection (level VI) between September and December 2022. ICG was administered intravenously (5 mg ´ 3 times). We analyzed parathyroid glands by visual examination and ICG angiography. Fluorescence of all glands was assessed. RESULTS Twenty patients underwent ICG angiography during TOETVA. A total of 68 parathyroid glands were identified. Only 76.5% (52/68) of parathyroid glands were identified at initial visual examination. ICG angiography additionally localized 12 glands that improved detection to 94.1% (64/68). At least one well-vascularized parathyroid gland was demonstrated by ICG angiography in 16 patients. In all these patients, serum parathyroid hormone was normal in 1 and 10 days after surgery. Two out of four patients who failed to identify a well-vascularized parathyroid gland developed transient hypoparathyroidism. There were no intraoperative and postoperative complications associated with ICG angiography. CONCLUSION ICG angiography was simple, safe and effective for better identification and preservation of parathyroid glands in patients with PTC undergoing TOETVA. This method was valuable for assessing the viability and function of parathyroid glands and predicting postoperative hypocalcemia.
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Affiliation(s)
- V V Polkin
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - P A Isaev
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - A K Plugar
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - A A Ilyin
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - S A Ivanov
- Tsyb Medical Radiology Research Center, Obninsk, Russia
- People's Friendship University of Russia, Moscow, Russia
| | - A D Kaprin
- National Medical Research Radiology Center, Obninsk, Russia
- People's Friendship University of Russia, Moscow, Russia
- Herzen Moscow Oncology Research Institute, Moscow, Russia
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15
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Pasieka JL, Wentworth K, Yeo CT, Cremers S, Dempster D, Fukumoto S, Goswami R, Houillier P, Levine MA, Pasternak JD, Perrier ND, Sitges-Serra A, Shoback DM. Etiology and Pathophysiology of Hypoparathyroidism: A Narrative Review. J Bone Miner Res 2022; 37:2586-2601. [PMID: 36153665 PMCID: PMC10364481 DOI: 10.1002/jbmr.4714] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/29/2022] [Accepted: 09/22/2022] [Indexed: 01/19/2023]
Abstract
The approach utilized a systematic review of the medical literature executed with specifically designed criteria that focused on the etiologies and pathogenesis of hypoparathyroidism. Enhanced attention by endocrine surgeons to new knowledge about parathyroid gland viability are reviewed along with the role of intraoperative parathyroid hormone (ioPTH) monitoring during and after neck surgery. Nonsurgical etiologies account for a significant proportion of cases of hypoparathyroidism (~25%), and among them, genetic etiologies are key. Given the pervasive nature of PTH deficiency across multiple organ systems, a detailed review of the skeletal, renal, neuromuscular, and ocular complications is provided. The burden of illness on affected patients and their caregivers contributes to reduced quality of life and social costs for this chronic endocrinopathy. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Janice L Pasieka
- Clinical Professor of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kelly Wentworth
- Assistant Adjunct Professor of Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Caitlin T Yeo
- Clinical Lecturer of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Serge Cremers
- Associate Professor of Pathology and Cell Biology and Medicine, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - David Dempster
- Professor of Clinical Pathology and Cell Biology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Seiji Fukumoto
- Specially Appointed Professor, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Ravinder Goswami
- Professor, Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Pascal Houillier
- Département de Physiologie, Professor of Physiology, Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Michael A Levine
- Professor Emeritus of Pediatrics and Medicine, University of Pennsylvania, Director, Center for Bone Health, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse D Pasternak
- Endocrine Surgery Section Head, Division of General Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nancy D Perrier
- Professor of Surgery, University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Section of Surgical Endocrinology, Houston, TX, USA
| | - Antonio Sitges-Serra
- Emeritus Professor, Universitat Autònoma de Barcelona, Endocrine Surgery, Hospital del Mar, Barcelona, Spain
| | - Dolores M Shoback
- Professor of Medicine, University of California, San Francisco, Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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16
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Demarchi MS, Karenovics W, Bédat B, Triponez F. Near-infrared fluorescent imaging techniques for the detection and preservation of parathyroid glands during endocrine surgery. Innov Surg Sci 2022; 7:87-98. [PMID: 36561508 PMCID: PMC9742281 DOI: 10.1515/iss-2021-0001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 04/14/2021] [Indexed: 12/25/2022] Open
Abstract
Objectives In over 30% of all thyroid surgeries, complications arise from transient and definitive hypoparathyroidism, underscoring the need for real-time identification and preservation of parathyroid glands (PGs). Here, we evaluate the promising intraoperative optical technologies available for the identification, preservation, and functional assessment of PGs to enhance endocrine surgery. Methods We performed a review of the literature to identify published studies on fluorescence imaging in thyroid and parathyroid surgery. Results Fluorescence imaging is a well-demonstrated approach for both in vivo and in vitro localization of specific cells or tissues, and is gaining popularity as a technique to detect PGs during endocrine surgery. Autofluorescence (AF) imaging and indocyanine green (ICG) angiography are two emerging optical techniques to improve outcomes in thyroid and parathyroid surgeries. Near-infrared-guided technology has significantly contributed to the localization of PGs, through the detection of glandular AF. Perfusion through the PGs can be visualized with ICG, which can also reveal the blood supply after dissection. Conclusions Near infrared AF and ICG angiography, providing a valuable spatial and anatomical information, can decrease the incidence of complications in thyroid surgery.
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Affiliation(s)
- Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery, Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Department of Thoracic and Endocrine Surgery, Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Benoît Bédat
- Department of Thoracic and Endocrine Surgery, Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
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17
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Fluorescence imaging, an emerging tool for preserving the parathyroid glands during thyroidectomy. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:89-90. [PMID: 36177375 PMCID: PMC9494020 DOI: 10.7602/jmis.2022.25.3.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 12/01/2022]
Abstract
With vocal cord palsy, hypoparathyroidism is one of the two major complications after thyroid surgery. Traditional approaches to preserving the parathyroid glands during thyroid surgery include identifying the glands precisely and preserving their vasculature with the naked eye, which mainly depend on the experience and skill of the surgeon. Recently, a relatively new technique, fluorescence image-guided surgery, has been widely researched and is becoming increasingly popular. The authors present a video clip of transoral robotic total thyroidectomy, which shows the three typical statuses of the parathyroid glands after thyroid surgery (well-perfused, poorly or non-perfused, and congested) and explains how to deal with each status of the parathyroid glands.
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18
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Bubnov AA, Slashchuk KY, Shirshin EA, Timoshenko VY. Intraoperative identification of parathyroid glands during endocrine surgery. ENDOCRINE SURGERY 2022. [DOI: 10.14341/serg12724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Nowadays, diabetes and diseases of thyroid gland take place on the first two stage in the rank of all endocrine diseases. There are 3 directions to treat thyroid glands pathologies such as: using special pills which substitute natural thyroid hormones, surgery and radioiodine therapy. It has proven that surgery of thyroid gland is the most effective method among considering upper. at The same time, it is associated with the greatest risks of complications. The most common injuries are damage to the recurrent laryngeal nerve and unintentional traumatization or removal of a healthy parathyroid gland. Parathyroid gland is a critical organ during thyroid surgery. It means that all negative reaction nearby the structure can lead to development different complications: hypoparathyroidism (transient or chronic) and hypocalcemia. In this article is considered actual methods of intraoperative optical visualization of parathyroid glans. The fundamental foundations of such methods, their advantages and disadvantages are also analyzed. It is shown that fluorescent methods in the red and near infrared regions of the spectrum using exogenous dyes have essential importance for endocrine surgery, as they allow to improve identification and reduce the risk of postoperative complications.
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Affiliation(s)
- A. A. Bubnov
- National Research Nuclear University «MEPhI», Engineering Physics Institute of Biomedicine;
Endorcinology Research Center
| | | | | | - V. Yu. Timoshenko
- National Research Nuclear University «MEPhI», Engineering Physics Institute of Biomedicine;
Lomonosov Moscow State University
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19
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Innovations in Parathyroid Localization Imaging. Surg Oncol Clin N Am 2022; 31:631-647. [DOI: 10.1016/j.soc.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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20
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Morales-Conde S, Licardie E, Alarcón I, Balla A. Indocyanine green (ICG) fluorescence guide for the use and indications in general surgery: recommendations based on the descriptive review of the literature and the analysis of experience. Cir Esp 2022; 100:534-554. [PMID: 35700889 DOI: 10.1016/j.cireng.2022.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/26/2021] [Indexed: 06/15/2023]
Abstract
Indocyanine Green is a fluorescent substance visible in near-infrared light. It is useful for the identification of anatomical structures (biliary tract, ureters, parathyroid, thoracic duct), the tissues vascularization (anastomosis in colorectal, esophageal, gastric, bariatric surgery, for plasties and flaps in abdominal wall surgery, liver resection, in strangulated hernias and in intestinal ischemia), for tumor identification (liver, pancreas, adrenal glands, implants of peritoneal carcinomatosis, retroperitoneal tumors and lymphomas) and sentinel node identification and lymphatic mapping in malignant tumors (stomach, breast, colon, rectum, esophagus and skin cancer). The evidence is very encouraging, although standardization of its use and randomized studies with higher number of patients are required to obtain definitive conclusions on its use in general surgery. The aim of this literature review is to provide a guide for the use of ICG fluorescence in general surgery procedures.
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Affiliation(s)
- Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital Virgen del Rocio, University of Sevilla, Sevilla, Spain; Unit of General and Digestive Surgery, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Eugenio Licardie
- Unit of General and Digestive Surgery, Hospital Quironsalud Sagrado Corazón, Sevilla, Spain.
| | - Isaias Alarcón
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital Virgen del Rocio, University of Sevilla, Sevilla, Spain.
| | - Andrea Balla
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital Virgen del Rocio, University of Sevilla, Sevilla, Spain; UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Civitavecchia, Rome, Italy.
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21
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Update on the Diagnosis and Management of Medullary Thyroid Cancer: What Has Changed in Recent Years? Cancers (Basel) 2022; 14:cancers14153643. [PMID: 35892901 PMCID: PMC9332800 DOI: 10.3390/cancers14153643] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 12/10/2022] Open
Abstract
Medullary thyroid carcinoma (MTC) is a neoplasm originating from parafollicular C cells. MTC is a rare disease, but its prognosis is less favorable than that of well-differentiated thyroid cancers. To improve the prognosis of patients with MTC, early diagnosis and prompt therapeutic management are crucial. In the following paper, recent advances in laboratory and imaging diagnostics and also pharmacological and surgical therapies of MTC are discussed. Currently, a thriving direction of development for laboratory diagnostics is immunohistochemistry. The primary imaging modality in the diagnosis of MTC is the ultrasound, but opportunities for development are seen primarily in nuclear medicine techniques. Surgical management is the primary method of treating MTCs. There are numerous publications concerning the stratification of particular lymph node compartments for removal. With the introduction of more effective methods of intraoperative parathyroid identification, the complication rate of surgical treatment may be reduced. The currently used pharmacotherapy is characterized by high toxicity. Moreover, the main limitation of current pharmacotherapy is the development of drug resistance. Currently, there is ongoing research on the use of tyrosine kinase inhibitors (TKIs), highly specific RET inhibitors, radiotherapy and immunotherapy. These new therapies may improve the prognosis of patients with MTCs.
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22
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Qian B, Zhang X, Bing K, Hu L, Qu X, Huang T, Shi W, Zhang S. Real-time intraoperative near-infrared autofluorescence imaging to locate the parathyroid glands: A preliminary report. Biosci Trends 2022; 16:301-306. [PMID: 35768258 DOI: 10.5582/bst.2022.01256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Identification and localization of parathyroid glands (PGs) remains a challenge for surgeons. The aim of this study was to evaluate the efficiency of intraoperative near-infrared autofluorescence (NIRAF) imaging to detect PGs in thyroid and parathyroid diseases. Seventy-six patients undergoing surgery for thyroid or parathyroid diseases between July 9, 2020 and August 20, 2021 were retrospectively analyzed. Intraoperative carbon nanoparticle (CN) negative imaging and handheld NIRAF imaging were successively performed for each patient. Of 206 PGs that needed to be identified for surgery, 162 were identified by NIRAF imaging, with a theoretical rate of identification of 78.64%. This was higher than the rate of identification with CN negative imaging, which was 75.73%. The number of PGs identified by NIRAF imaging and CN negative imaging did not differ significantly in either total thyroidectomy or thyroid lobectomy. In addition, the autofluorescence (AF) intensity of secondary parathyroid adenoma was weaker than that of normal PGs. NIRAF imaging is potentially a more efficient tool for identification of PGs than CN negative imaging, with a shorter learning curve and lower risk. It may not be well-suited to secondary hyperthyroidism or adenoma, but it was more efficient at identifying excised specimens than visual identification by a surgeon.
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Affiliation(s)
- Bei Qian
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ximeng Zhang
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Kaijian Bing
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Longqing Hu
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xincai Qu
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tao Huang
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Shi
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shoupeng Zhang
- Department of Thyroid and Breast Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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23
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Papachristos AJ, Glover A, Sywak M, Sidhu SB. Thyroidectomy in Australia 2022: lessons from 21,000 consecutive cases. ANZ J Surg 2022; 92:1626-1630. [PMID: 35689169 DOI: 10.1111/ans.17783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/30/2022]
Abstract
In this article, we aim to describe our modern-day approach to total thyroidectomy, detailing the subtle refinements of our technique, as it has evolved over three decades and 21 000 cases. Since Delbridge's seminal paper in 2003, the major changes to our approach include a retrograde approach to the recurrent laryngeal nerve that allows dissection of the distal RLN from fascial bands within the ligament of Berry before medialisation of the thyroid lobe. Routine use of intraoperative nerve monitoring systems has increased our awareness of temporary neuropraxia, facilitated a reduction in the risk of bilateral RLN palsy and improved our identification and preservation of the external branch of the superior laryngeal nerve. The increasing use of advanced energy devices has been associated with a reduction in post-operative haematoma rates. We adopt a low threshold to parathyroid auto-transplantation, unless all glands are assessed to be clearly not at risk, and routinely supplement patients with Caltrate in the immediate post-operative period to minimize the risk of symptomatic hypocalcaemia. Ultimately, when we reflect on the subtle refinements that have contributed to improved outcomes, the fundamental principles of exposure and dissection that have evolved over decades remain the basis of our surgical approach and must continue to do so.
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Affiliation(s)
- Alexander James Papachristos
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Glover
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Endocrine Cancer Program, The Kinghorn Cancer Centre and St. Vincent's Clinical School, Faculty of Medicine, Garvan Institute of Medical Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Sywak
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Stan B Sidhu
- Endocrine Surgical Unit, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia.,Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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郭 飞, 耿 胜, 张 静. [Research progress of autofluorescence imaging of parathyroid glands]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2022; 36:397-401. [PMID: 35483695 PMCID: PMC10128258 DOI: 10.13201/j.issn.2096-7993.2022.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Indexed: 06/14/2023]
Abstract
The main causes of hypoparathyroidism are unintentional parathyroidectomy and/or impaired blood supply. Therefore, accurate identification and preservation of parathyroid glands in situ during thyroid or parathyroid surgery has become one of the problems that plague endocrine surgeons. In recent years, near-infrared autofluorescence imaging technology has gradually attracted more and more attention from surgeons because of its simplicity, safety, accuracy, real-time, no-contrast agent, and non-invasiveness. This article reviews the development history, clinical application, and application prospects of the parathyroid gland autofluorescence imaging technology in recent years.
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Affiliation(s)
- 飞跃 郭
- 河北省人民医院腺体外科(石家庄,050001)Department of Glandular Surgery, Hebei General Hospital, Shijiazhuang, 050051, China
| | - 胜杰 耿
- 河北医科大学研究生学院Graduate School of Hebei Medical University
| | - 静 张
- 河北省人民医院腺体外科(石家庄,050001)Department of Glandular Surgery, Hebei General Hospital, Shijiazhuang, 050051, China
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Heterogeneity in Utilization of Optical Imaging Guided Surgery for Identifying or Preserving the Parathyroid Glands—A Meta-Narrative Review. Life (Basel) 2022; 12:life12030388. [PMID: 35330139 PMCID: PMC8955594 DOI: 10.3390/life12030388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Postoperative hypoparathyroidism is the most common complication after total thyroidectomy. Over the past years, optical imaging techniques, such as parathyroid autofluorescence, indocyanine green (ICG) angiography, and laser speckle contrast imaging (LSCI) have been employed to save parathyroid glands during thyroid surgery. This study provides an overview of the utilized methods of the optical imaging techniques during total thyroidectomy for parathyroid gland identification and preservation. Methods: PUBMED, EMBASE and Web of Science were searched for studies written in the English language utilizing parathyroid autofluorescence, ICG-angiography, or LSCI during total thyroidectomy to support parathyroid gland identification or preservation. Case reports, reviews, meta-analyses, animal studies, and post-mortem studies were excluded after the title and abstract screening. The data of the studies were analyzed qualitatively, with a focus on the methodologies employed. Results: In total, 59 articles were included with a total of 6190 patients. Overall, 38 studies reported using parathyroid autofluorescence, 24 using ICG-angiography, and 2 using LSCI. The heterogeneity between the utilized methodology in the studies was large, and in particular, regarding study protocols, imaging techniques, and the standardization of the imaging protocol. Conclusion: The diverse application of optical imaging techniques and a lack of standardization and quantification leads to heterogeneous conclusions regarding their clinical value. Worldwide consensus on imaging protocols is needed to establish the clinical utility of these techniques for parathyroid gland identification and preservation.
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Quéré J, Potard G, Le Pennec R, Marianowski R, Leclere JC. Limited contribution of indocyanine green (ICG) angiography for the detection of parathyroid glands and their vascularization during total thyroidectomy: A STROBE observational study. Eur Ann Otorhinolaryngol Head Neck Dis 2022; 139:275-279. [DOI: 10.1016/j.anorl.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Guía de uso e indicaciones de la fluorescencia con verde de indocianina (ICG) en cirugía general: recomendaciones basadas en la revisión descriptiva de la literatura y el análisis de la experiencia. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2021.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Demarchi MS, Baccaro M, Karenovics W, Bédat B, Triponez F. Is the indocyanine green score an accurate predictor of postoperative parathyroid hormone level? Surgery 2022; 171:1526-1534. [DOI: 10.1016/j.surg.2021.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 12/27/2021] [Accepted: 12/31/2021] [Indexed: 11/16/2022]
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Ouyang H, Wang B, Sun B, Cong R, Xia F, Li X. Application of Indocyanine Green Angiography in Bilateral Axillo-Breast Approach Robotic Thyroidectomy for Papillary Thyroid Cancer. Front Endocrinol (Lausanne) 2022; 13:916557. [PMID: 35813620 PMCID: PMC9260684 DOI: 10.3389/fendo.2022.916557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/12/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Indocyanine green angiography (ICGA) has been used to identify and preserve the parathyroid glands (PGs), and to evaluate PGs viability and function during thyroid surgery. However, evidence on the utilization of IGCA in thyroid cancer and robotic surgery is lacking. The efficacy of IGCA remains to be evaluated in PTC patients undergoing bilateral axillo-breast approach robotic thyroidectomy (BABA RT) and central neck dissection (CND). METHODS From March 2020 to August 2021, 81 papillary thyroid cancer (PTC) patients receiving total thyroidectomy and CND were enrolled in this retrospective analysis. An intravenous bolus of 7.5 mg ICG was administrated three times in the ICGA group (n=34). Medical records were reviewed and analyzed, including the baseline characteristics, surgical parameters, PGs-related parameters, and perioperative PTH and calcium levels. RESULTS The mean number of total identified PGs and preserved PGs were significantly more in the ICG group than in the control group (3.74 ± 0.45 vs. 3.15 ± 0.55, P<0.001; 3.12 ± 0.64 vs. 2.74 ± 0.57, P=0.007, respectively), as were PTH and calcium levels on POD 1 (23.16 ± 18.32 vs. 6.06 ± 7.74, P=0.039; 2.13 ± 0.11 vs. 2.08 ± 0.08, P=0.024, respectively). While there were no differences in PTH levels on POD 30. Additionally, patients with at least one well vascularized PG had higher ioPTH 3 and PTH on POD 1, which significantly suggested the absence of postoperative hypocalcemia. Although not statistically significant, ICGA seemed superior to relative ioPTH decline and ioPTH 3 in predicting postoperative hypocalcemia. CONCLUSION In PTC patients undergoing BABA RT and CND, ICGA is a simple, safe, effective, and cost-effective tool in better identification and preservation of PGs as well as evaluation of PGs viability and function, with the potential to preserve more PGs, guide more appropriate autotransplantation, and accurately predict postoperative hypocalcemia.
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Affiliation(s)
- Hui Ouyang
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Baojia Wang
- Department of the Operating Room, Xiangya Hospital, Central South University, Changsha, China
| | - Botao Sun
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Rong Cong
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Fada Xia
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Fada Xia, ; Xinying Li,
| | - Xinying Li
- Department of Thyroid Surgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Fada Xia, ; Xinying Li,
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Yin S, Pan B, Yang Z, Tang M, Mo H, Li Y, Yi Z, Yin T, Shao C, Yan C, Mo L, Yuan Y, Sun Y, Zhang F. Combined Use of Autofluorescence and Indocyanine Green Fluorescence Imaging in the Identification and Evaluation of Parathyroid Glands During Total Thyroidectomy: A Randomized Controlled Trial. Front Endocrinol (Lausanne) 2022; 13:897797. [PMID: 35784544 PMCID: PMC9243533 DOI: 10.3389/fendo.2022.897797] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/02/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Accurate identification and evaluation of the parathyroid glands (PGs) intraoperatively is critical to reduce the incidence of postoperative hypoparathyroidism after total thyroidectomy. Near-infrared fluorescence imaging (NIFI), including the autofluorescence (AF) and indocyanine green fluorescence (ICGF) imaging, is a promising technique to protect PGs. This study aimed to assess whether the combined use of AF and ICGF could reduce the incidence of postoperative hypoparathyroidism and improve the identification and evaluation of PGs during total thyroidectomy. METHODS This randomized controlled trial enrolled 180 patients who were randomized into two groups and underwent total thyroidectomy with unilateral or bilateral central lymph node dissection. In the control group, the PGs were identified and evaluated by the naked eye. In the NIFI group, AF was used to identify the PGs and ICGF was applied to assess the blood perfusion of the PGs in situ. The primary outcome was the incidence of postoperative hypoparathyroidism. The secondary outcomes included the number of identified PGs, autotransplanted PGs, and known preserved PGs in situ. RESULTS The incidence of postoperative transient hypoparathyroidism was significantly lower in the NIFI group than in the control group (27.8% vs. 43.3%, P = 0.029). More PGs were identified in the NIFI group than in the control group (3.6 ± 0.5 vs. 3.2 ± 0.4, P < 0.001). No significant difference was observed in the number of autotransplanted PGs between the two groups (P = 0.134). Compared with the control group, a greater number of known PGs were preserved in situ in the NIFI group (1.3 ± 0.6 vs. 1.0 ± 0.5, P < 0.001). In the NIFI group, only 4.5% of the patients with at least one well-perfused PG (ICG score of 2) developed postoperative hypoparathyroidism, which was significantly lower than that of the control group (34.6%, P < 0.001). CONCLUSION Combined use of AF and ICGF during total thyroidectomy reduces the risk of transient postoperative hypoparathyroidism, enhances the ability to identify and preserve PGs, and improves the accuracy of evaluating the perfusion of PGs during surgery. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Register (www.chictr.org.cn), identifier ChiCTR2100045320. Registered on April 12, 2021.
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Affiliation(s)
- Supeng Yin
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Bin Pan
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Graduate School of Medicine, Chongqing Medical University, Chongqing, China
| | - Zeyu Yang
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Mi Tang
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Hongbiao Mo
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Yao Li
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Ziying Yi
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Tingjie Yin
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Cong Shao
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Cunye Yan
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Linlong Mo
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
| | - Yuquan Yuan
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- Graduate School of Medicine, Chongqing Medical University, Chongqing, China
| | - Yiceng Sun
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- *Correspondence: Fan Zhang, ; Yiceng Sun,
| | - Fan Zhang
- Department of Breast and Thyroid Surgery, Chongqing General Hospital, Chongqing, China
- *Correspondence: Fan Zhang, ; Yiceng Sun,
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Kim DH, Kim SH, Jung J, Kim SW, Hwang SH. Indocyanine green fluorescence for parathyroid gland identification and function prediction: Systematic review and meta-analysis. Head Neck 2021; 44:783-791. [PMID: 34908194 DOI: 10.1002/hed.26950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/21/2021] [Accepted: 12/03/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND To evaluate the diagnostic accuracies of indocyanine green (ICG) fluorescence for identifying parathyroid glands during surgery and predicting the postoperative function. METHODS From six databases, 21 studies were finally included in the study. True-positive, true-negative, false-positive, and false-negative data were extracted for the analysis. The quality of each study was analyzed using the QUADAS-2 tool. RESULTS The sensitivity of ICG-based parathyroid gland identification was 0.9380 (95% CI [0.9003, 0.9621]). The diagnostic odds ratio for ICG-based prediction of parathyroid gland function was 54.5652 [13.2059, 225.4570]. The area under the summary receiver operating characteristic curve was 0.909. Fluorescence intensity-based prediction presented higher diagnostic accuracy than that of score-based prediction. The incidence of postoperative hypoparathyroidism was higher in the group with a zero ICG score compared to the high scored group. CONCLUSIONS Identification of parathyroid gland and prediction of postoperative function using ICG are valuable to patients undergoing thyroidectomy or parathyroidectomy.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology - Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - So-Hyun Kim
- Department of Otolaryngology - Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jaehoon Jung
- Department of Otolaryngology - Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Won Kim
- Department of Otolaryngology - Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Se Hwan Hwang
- Department of Otolaryngology - Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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The utility of indocyanine green (ICG) for the identification and assessment of viability of the parathyroid glands during thyroidectomy. Updates Surg 2021; 74:97-105. [PMID: 34727341 DOI: 10.1007/s13304-021-01202-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
We conducted this study to evaluate the ability of indocyanine green (ICG) and near infra-red fluorescence (NIRF) camera to aid in the identification and assessment of viability of parathyroid glands during thyroid surgery. A prospective observational study was conducted between May and October 2020 among 50 consecutive patients who underwent total thyroidectomy at a single institution. Parathyroid glands were identified under white light during thyroidectomy following which reconstituted ICG was injected through a peripheral vein and the location of parathyroid glands was confirmed. The perfusion to the parathyroid gland was assessed by documenting the fluorescence intensity score (FIS) and the parathyroid angiogram score (PAS). There was no difference in the number of parathyroid glands seen on visual inspection 147 (73.5%) when compared to under NIRF camera, 146 (73%). Though the rate of postoperative hypoparathyroidism was lower in the cohort with FIS 3 (14.2%) compared to score 2 and 1 (28.5% and 100%, respectively), this was not significant (p = 0.35). A significant correlation was noted between a delayed flow on PAS and the development of post-thyroidectomy hypoparathyroidism (p = 0.01). PAS had a sensitivity of 100%, specificity of 88.6%, NPV of 100% and PPV of 55.6% to predict the development of post-thyroidectomy hypoparathyroidism. In this study, there was no additional benefit of ICG and NIRF camera in the identification of parathyroid glands. However, ICG angiogram seems to be a good adjunct for the intraoperative assessment of the viability of the parathyroid glands and accurately predicts the development of postoperative hypoparathyroidism.
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Gorbach YM, Mariyko VA. [Prevention and treatment of postoperative hypoparathyroidism]. Khirurgiia (Mosk) 2021:100-104. [PMID: 34608787 DOI: 10.17116/hirurgia2021101100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypoparathyroidism is a failure of parathyroid glands characterized by reduced serum concentration of parathyroid hormone, hypocalcemia and hyperphosphatemia. The most common cause of hypoparathyroidism is resection or damage to parathyroid glands during thyroid surgery. Postoperative hypoparathyroidism is still an urgent problem, as it requires additional treatment and prolongs hospital-stay. Considering available literature data, the authors analyze various methods of intraoperative prevention of hypoparathyroidism.
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Moreno Llorente P, García Barrasa A, Francos Martínez JM, Alberich Prats M, Pascua Solé M. Intraoperative Indocyanine Green Angiography of Parathyroid Glands and the Prevention of Post-Thyroidectomy Hypocalcemia. World J Surg 2021; 46:121-127. [PMID: 34561745 DOI: 10.1007/s00268-021-06322-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We compared the reliability of indocyanine green (ICG) angiography and intraoperative PTH levels for predicting early post-thyroidectomy hypocalcemia. METHODS Prospective study of 94 patients (71% women, mean age 53.7 years) undergoing total thyroidectomy. An ICG score of 2 (white) indicated a well-vascularized gland. PTH preoperative levels-PTH postresection levels divided by preoperative PTH × 100 was used to determine the PTH decline percentage. A decrease of at least 62.5% or <17.1 pg/mL in ioPTH was the criterion for predicting hypocalcemia. RESULTS At surgery, the four parathyroid glands were identified in 50 (53.2%) patients and <4 glands in 44. Calcium supplements were needed by 22 patients (23.4%) postoperatively, 11 patients in each group of 4 and <4 parathyroid glands identified. The diagnostic accuracy of ICG angiography (0.883, 95% confidence interval [CI] 0.800-0.940) and ioPTH (0.862, 95% CI 0.775-0.92) was similar. When all four parathyroid glands were identified, ICG angiography showed a slightly higher diagnostic accuracy, specificity and positive predictive than ioPTH levels, but when < 4 glands were identified, the ioPTH showed a slightly higher diagnostic accuracy, specificity and positive predictive value. Differences were not statistically significant for any of the comparisons. CONCLUSIONS The presence of one well-perfused parathyroid gland (ICG score 2) using ICG angiography or ioPTH decline, measured before and after completion of thyroid surgery, is both reliable methods in prediction of early post-thyroidectomy hypocalcemia independently of the number of glands identified intraoperatively.
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Affiliation(s)
- Pablo Moreno Llorente
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain.
| | - Arantxa García Barrasa
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
| | - José Manuel Francos Martínez
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Marta Alberich Prats
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
| | - Mireia Pascua Solé
- Unidad de Cirugía Endocrina. Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), C/ Feixa Llarga s/n, 08907, Barcelona, Spain
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Indocyanine Green Angiography for Parathyroid Gland Evaluation during Transoral Endoscopic Thyroidectomy. J Pers Med 2021; 11:jpm11090843. [PMID: 34575620 PMCID: PMC8468084 DOI: 10.3390/jpm11090843] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 12/15/2022] Open
Abstract
Indocyanine green (ICG) angiography, a real-time intraoperative imaging technique, is associated with better parathyroid identification and functional evaluation during open thyroidectomy. However, the benefits of ICG fluorescence imaging application in transoral endoscopic thyroidectomy are not well-documented. Consecutive patients who underwent transoral endoscopic thyroidectomy were retrospectively reviewed. Parathyroid glands were assessed with visual inspection followed by ICG angiography. The fluorescence intensity of all parathyroid glands was recorded. In total, 158 parathyroid glands from 60 patients (41 underwent lobectomy and 19 underwent total thyroidectomy) were eligible for evaluation. A total of 135 parathyroid glands (85.4%) were identified, including nine glands (5.7%) that were solely localized because of ICG angiography. Incidental parathyroidectomy occurred in 12 patients with predominant inferior gland (83.3%) and associated with central neck dissection (66.7%). Among patients receiving total thyroidectomy, patients who retained at least one well-perfused parathyroid gland had higher parathyroid hormone (PTH) level and were less likely to develop hypoparathyroidism on postoperative day one than those without any well-perfused ICG-enhanced parathyroid gland (p = 0.038). In addition, the duration of calcium supplementation to maintain normocalcemia was also shorter. ICG angiography is a feasible adjunct procedure for parathyroid identification and postoperative functional prediction in transoral endoscopic thyroidectomy.
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Cali B, Hasani A, Buffet C, Menegaux F, Chereau N. Is there a relationship between different types of prior bariatric surgery and post-thyroidectomy hypocalcemia? Gland Surg 2021; 10:2088-2094. [PMID: 34422579 DOI: 10.21037/gs-21-225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/23/2021] [Indexed: 11/06/2022]
Abstract
Background Hypocalcemia is a common complication after total thyroidectomy (TT). A history of bariatric surgery has been identified as a risk factor for this complication. This study aimed to assess the risk of hypocalcemia post TT in patients with a history of obesity procedures: laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and laparoscopic gastric banding (LAGB). Methods We compared the risk of hypocalcemia post TT (serum calcium levels <8 mg/dL) between patients with restrictive (LSG and LAGB), malabsorptive (RYGB), and patients without a history of obesity surgery. Hypoparathyroidism was considered permanent if the plasma parathyroid hormone (PTH) levels at 6 months were less than 15 pg/mL (normal range: 15-65 pg/mL) and the patient still required oral calcium (calcium carbonate) and vitamin D supplementation, in addition to the supplements that were taken routinely before thyroidectomy. Results From the 13,242 patients who underwent TT from 2006 to 2018, 90 patients (0.7%) had a history of bariatric surgery: 35 LAGB, 29 LSG, and 26 RYGB. The risk of hypocalcemia was higher in RYGB patients (50%, n=13) than in LAGB (17.1%, n=6) or LSG patients (20.6%, n=6) (P=0.003). Furthermore, hypocalcemia risk was similar between patients with a history of restrictive procedures (18.8%, 12/64) and patients with no history of bariatric surgery (17.2%, 2,268/13,152) (P=0.4). Permanent hypoparathyroidism was observed in one and 6 patients from the LAGB and RYGB groups, respectively; however, it was not observed in any patient from the LSG group. Conclusions RYGB is a risk factor for hypocalcemia post TT, while restrictive bariatric procedures are not.
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Affiliation(s)
- Benedetto Cali
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Ariola Hasani
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Camille Buffet
- Thyroid and Endocrine Tumor Unit, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de l'Hôpital, Paris, France.,Groupe de Recherche Clinique n°16 Thyroid Tumors, Sorbonne University, Paris, France
| | - Fabrice Menegaux
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de l'Hôpital, Paris, France.,Groupe de Recherche Clinique n°16 Thyroid Tumors, Sorbonne University, Paris, France
| | - Nathalie Chereau
- Department of General and Endocrine Surgery, Pitié Salpêtrière Hospital, APHP, Sorbonne University, 47-83 Boulevard de l'Hôpital, Paris, France.,Groupe de Recherche Clinique n°16 Thyroid Tumors, Sorbonne University, Paris, France
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Fanget F, Demarchi MS, Maillard L, El Boukili I, Gerard M, Decaussin M, Borson-Chazot F, Lifante JC. Hypoparathyroidism: Consequences, economic impact, and perspectives. A case series and systematic review. ANNALES D'ENDOCRINOLOGIE 2021; 82:572-581. [PMID: 34400129 DOI: 10.1016/j.ando.2021.07.085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/23/2021] [Accepted: 07/12/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Postoperative hypoparathyroidism (PH) is the most common complication after total thyroidectomy. Incidence varies from 2% to 83%, depending on the definition. OBJECTIVE We performed a systematic review of the literature to determine the medico-economic effects of PH and update understanding of long-term consequences, morbidity, and quality of life related to hypoparathyroidism. METHODS We considered relevant articles published between 2000 and 2020 concerning long-term consequences of PH and quality of life. All studies concerning the medico-economic assessment of PH were included. We compared data from 2018 to results in the literature. RESULTS A proportion of 64/403 (16.8%) patients presented with transient PH during 2018, and 7/403 (1.7%) had permanent PH. Seven patients needed supplementation with alfacalcidol at 6-month follow-up. Factors predicting the need for alfacalcidol were age <45, thyroidectomy for goiter, and lymph node dissection. Additional therapy costs related to PH were €9781.10, and additional hospital costs were €230,400. We qualitatively synthesized 41 studies. Most were retrospective studies and only a few reported costs. No series assessed direct or indirect costs of postoperative PH. CONCLUSION To our knowledge, no previous studies reported the medico-economic impact of PH. Decreasing PH associated with fluorescence usage should be considered, particularly concerning cost-effectiveness.
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Affiliation(s)
- Florian Fanget
- Department of General, Digestive and Endocrine Surgery, Lyon Sud Hospital Center, Pierre-Bénite, France
| | - Marco Stefano Demarchi
- Department of General, Digestive and Endocrine Surgery, Lyon Sud Hospital Center, Pierre-Bénite, France; Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland
| | - Laure Maillard
- Department of General, Digestive and Endocrine Surgery, Lyon Sud Hospital Center, Pierre-Bénite, France
| | - Ilies El Boukili
- Department of General, Digestive and Endocrine Surgery, Lyon Sud Hospital Center, Pierre-Bénite, France
| | - Maxime Gerard
- Department of General, Digestive and Endocrine Surgery, Lyon Sud Hospital Center, Pierre-Bénite, France
| | - M Decaussin
- Department of Pathology, Hospices Civils de Lyon, Lyon, France
| | - Francoise Borson-Chazot
- Department of General, Digestive and Endocrine Surgery, Lyon Sud Hospital Center, Pierre-Bénite, France; Department of Pathology, Hospices Civils de Lyon, Lyon, France; Health Services and Performance Research Lab (EA 7425 HESPER), Université Claude-Bernard Lyon 1, Lyon, France; Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4, rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland
| | - Jean-Christophe Lifante
- Department of General, Digestive and Endocrine Surgery, Lyon Sud Hospital Center, Pierre-Bénite, France; Health Services and Performance Research Lab (EA 7425 HESPER), Université Claude-Bernard Lyon 1, Lyon, France.
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Demarchi MS, Seeliger B, Lifante JC, Alesina PF, Triponez F. Fluorescence Image-Guided Surgery for Thyroid Cancer: Utility for Preventing Hypoparathyroidism. Cancers (Basel) 2021; 13:cancers13153792. [PMID: 34359693 PMCID: PMC8345196 DOI: 10.3390/cancers13153792] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/08/2021] [Accepted: 07/23/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Hypoparathyroidism is one of the most frequent complications of thyroid surgery, especially when associated with lymph node dissection in cases of thyroid cancer. Fluorescence-guided surgery is an emerging tool that appears to help reduce the rate of this complication. The present review aims to highlight the utility of fluorescence imaging in preserving parathyroid glands during thyroid cancer surgery. Methods: We performed a systematic review of the literature according to PRISMA guidelines to identify published studies on fluorescence-guided thyroid surgery with a particular focus on thyroid cancer. Articles were selected and analyzed per indication and type of surgery, autofluorescence or exogenous dye usage, and outcomes. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess the methodological quality of the included articles. Results: Twenty-five studies met the inclusion criteria, with three studies exclusively assessing patients with thyroid cancer. The remaining studies assessed mixed cohorts with thyroid cancer and other thyroid or parathyroid diseases. The majority of the papers support the potential benefit of fluorescence imaging in preserving parathyroid glands in thyroid surgery. Conclusions: Fluorescence-guided surgery is useful in the prevention of post-thyroidectomy hypoparathyroidism via enhanced early identification, visualization, and preservation of the parathyroid glands. These aspects are notably beneficial in cases of associated lymphadenectomy for thyroid cancer.
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Affiliation(s)
- Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland;
- Department of Endocrine Surgery, Lyon Sud University Hospitals, 69310 Pierre Benite, France;
| | - Barbara Seeliger
- IHU—Strasbourg, Institute of Image-Guided Surgery, 67091 Strasbourg CEDEX, France;
- IRCAD, Research Institute against Digestive Cancer, 67091 Strasbourg CEDEX, France
- Department of General, Digestive, and Endocrine Surgery, Strasbourg University Hospitals, 67091 Strasbourg CEDEX, France
- Department of Surgery and Center of Minimally Invasive Surgery, Evangelische Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, 45136 Essen, Germany;
| | - Jean-Christophe Lifante
- Department of Endocrine Surgery, Lyon Sud University Hospitals, 69310 Pierre Benite, France;
- Health Services and Performance Research Lab (EA 7425 HESPER), Université Claude Bernard Lyon 1, 69622 Lyon, France
| | - Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Evangelische Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, 45136 Essen, Germany;
- Department of Surgery, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland;
- Correspondence: ; Tel.: +41-(0)22-372-78-62
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Barbieri D, Triponez F, Indelicato P, Vinciguerra A, Trimarchi M, Bussi M. Total thyroidectomy with intraoperative neural monitoring and near-infrared fluorescence imaging. Langenbecks Arch Surg 2021; 406:2879-2885. [PMID: 34195868 DOI: 10.1007/s00423-021-02228-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe our personal experience during aclassic complete thyroidectomy adopting both intraoperative neural monitoringand near-infrared autofluorescence. METHODS In October 2021, 20 patients underwent totalthyroidectomy for benign and malignant conditions: 13 patients were affected bymultinodular goiter, 2 by Graves' disease, and 5 by indeterminate lesions (3Tir-3B and 2 Tir-3A). For each patient, intraoperative neural monitoring of therecurrent laryngeal nerve and near-infrared autofluorescence were used. RESULTS Overall, 76/80 (95.0%) parathyroid glands weredetected: 34/76 (44.7%) were identified by the surgeon during the dissection,while 42/76 (55.3%) were detected by the near-infrared camera before thesurgeon saw them with naked eye. Indocyanine green angiography was adopted inall the patients, and in 2 cases, parathyroid gland autotransplantation wasperformed since 2 parathyroid glands resulted devascularized after dissection.Operative time ranged from 113 to 201 min (mean 156 min). CONCLUSION Together with intraoperative neural monitoring,near-infrared autofluorescence is a reliable device in thyroid surgery. Furtherprospective studies are necessary to establish if the adoption ofautofluorescence may result in long-term benefit in terms of calcemia.
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Affiliation(s)
- Diego Barbieri
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Pietro Indelicato
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Vinciguerra
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Matteo Trimarchi
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Mario Bussi
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Mayir B, Altun K, Sercan Ertürk M, Özben Ensari C. Endoscopic parathyroidectomy via unilateral axillobreast approach. Turk J Surg 2021. [DOI: 10.47717/turkjsurg.2021.4755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Endoscopic parathyroid and thyroid surgery is becoming increasingly common. In this study, we present the results of patients who underwent Endo- scopic parathyroid via unilateral axillo-breast approach (EP via UABA). Three patients underwent EP via UABA. Patients were discharged on the next day after surgery, while at one month follow up all of them reported no further symptoms. Operation performed via two axiller and one areolar trochar. As different from open surgery, the strap muscles don’t pulled laterally and not entered into the thyroid lobe from the midline. In this technique, the strap muscles are separated from the middle part of the strap muscles and the thyroid gland is reached from the middle of the strap muscles. In this way, N. laryngeal recurrence and parathyroid gland that usually located in the posterior aspect of the thyroid gland can be revealed clearly by reducing the risk of complications. EP via UABA can be performed safe effective procedure via good cosmetic results.
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Moreno Llorente P, García Barrasa A, Francos Martínez JM, Alberich Prats M, Pascua Solé M. Intraoperative indocyanine green (ICG) angiography of the parathyroids glands in prediction of post-thyroidectomy hypocalcemia: Diagnostic accuracy of the ICG score 2 versus the 4-ICG score. Cir Esp 2021; 100:274-280. [PMID: 34210649 DOI: 10.1016/j.cireng.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Indocyanine green (ICG) angiography of the parathyroids is useful in prediction of postthyroidectomy hypocalcemia. We compared the diagnostic accuracy of a single-gland ICG score of 2 with a score estimated by adding the viability value of the four glands (4-ICG). METHODS Fifty patients (66% women, median age 49.4 years) underwent total thyroidectomy with identification of all 4 glands. The degree of ICG was classified as 0, black (nonvascularized), 1, gray/heterogeneous (partially vascularized), and 2, white (well vascularized). RESULTS The diagnostic accuracy of the optimal cut-off of the 4-ICG sum score ≤3 was 84% (95% CI 70.9-92.8) lower than the diagnostic accuracy of 92% (80.8-97.8) of the ICG score 2. Both scores identified 2 false negative cases, but the rates of false positives were lower with the ICG score 2 (18.2% vs. 57.1%). CONCLUSIONS Identification of single-gland ICG score of 2 has a higher diagnostic accuracy than 4-ICG sum score to predict immediate hypocalcemia after total thyroidectomy.
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Affiliation(s)
- Pablo Moreno Llorente
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Arantxa García Barrasa
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Manuel Francos Martínez
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marta Alberich Prats
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mireia Pascua Solé
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, Spain
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Moreno Llorente P, García Barrasa A, Francos Martínez JM, Alberich Prats M, Pascua Solé M. Intraoperative indocyanine green (ICG) angiography of the parathyroids glands in prediction of post-thyroidectomy hypocalcemia: Diagnostic accuracy of the ICG score 2 versus the 4-ICG score. Cir Esp 2021; 100:S0009-739X(21)00130-5. [PMID: 33931200 DOI: 10.1016/j.ciresp.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 09/30/2022]
Abstract
INTRODUCTION Indocyanine green (ICG) angiography of the parathyroids is useful in prediction of postthyroidectomy hypocalcemia. We compared the diagnostic accuracy of a single-gland ICG score of 2 with a score estimated by adding the viability value of the four glands (4-ICG). METHODS Fifty patients (66% women, median age 49.4 years) underwent total thyroidectomy with identification of all 4 glands. The degree of ICG was classified as 0: black (nonvascularized), 1: gray/heterogeneous (partially vascularized), and 2: white (well vascularized). RESULTS The diagnostic accuracy of the optimal cut-off of the 4-ICG sum score ≤3 was 84% (95% CI: 70.9-92.8) lower than the diagnostic accuracy of 92% (80.8-97.8) of the ICG score 2. Both scores identified 2 false negative cases, but the rates of false positives were lower with the ICG score 2 (18.2 vs. 57.1%). CONCLUSIONS Identification of single-gland ICG score of 2 has a higher diagnostic accuracy than 4-ICG sum score to predict immediate hypocalcemia after total thyroidectomy.
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Affiliation(s)
- Pablo Moreno Llorente
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España.
| | - Arantxa García Barrasa
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - José Manuel Francos Martínez
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - Marta Alberich Prats
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
| | - Mireia Pascua Solé
- Unidad de Cirugía Endocrina, Hospital Universitari de Bellvitge, Universidad de Barcelona (UB), L'Hospitalet de Llobregat, Barcelona, España
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Jin H, Cui M. Research on Intra-Operative Indocyanine Green Angiography of the Parathyroid for Predicting Postoperative Hypoparathyroidism: A Noninferior Randomized Controlled Trial. Endocr Pract 2021; 26:1469-1476. [PMID: 33471739 DOI: 10.4158/ep-2020-0340] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/24/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A noninferiority randomized controlled trial was undertaken to clarify whether the postoperative measurements of serum calcium and parathyroid hormone and oral supplementation of calcium and calcitriol could be omitted if patients had at least one well-perfused parathyroid gland evaluated by intra-operative indocyanine green (ICG) angiography. METHODS Patients with at least one parathyroid gland well-perfused by ICG angiography (ICG score >2) were randomized to the control group or test group. For the control group, oral calcium and calcitriol were systematically supplemented. For the test group, no oral calcium or calcitriol was supplemented to the patients. Levels of serum calcium and parathyroid hormone of patients on the first and 30th postoperative day were compared between the two groups. RESULTS Among all 68 selected patients, 56 patients had at least one well-perfused parathyroid gland evaluated by intra-operative ICG angiography. The 56 patients were randomized to the control group or test group. There were no statistically significant differences in the levels of serum calcium and parathyroid hormone between test group and control group on the first or 30th postoperative day. CONCLUSION The postoperative measurements of serum calcium and parathyroid hormone and oral supplementation of calcium and calcitriol were evaluated as redundant, if patients had at least one well-perfused parathyroid gland evaluated by intra-operative ICG angiography. ABBREVIATIONS ICG = indocyanine green; NIR = near infrared; POD = postoperative day; PTH = parathyroid hormone; SBR = signal background ratio.
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Affiliation(s)
- Hao Jin
- From The Second Department of General Surgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China
| | - Min Cui
- From The Second Department of General Surgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, China..
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Barbieri D, Indelicato P, Vinciguerra A, Di Marco F, Formenti AM, Trimarchi M, Bussi M. Autofluorescence and Indocyanine Green in Thyroid Surgery: A Systematic Review and Meta-Analysis. Laryngoscope 2020; 131:1683-1692. [PMID: 33247620 DOI: 10.1002/lary.29297] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS To estimate the impact of optical techniques on prevention of post-operative hypocalcemia and hypoparathyroidism after total thyroidectomy. STUDY DESIGN Systematic review and meta-analysis. METHODS A literature search was conducted in Pubmed, EMBASE, SCOPUS, and Cochrane databases. The main inclusion criteria for eligible articles for meta-analysis were patients with benign or malignant thyroid pathologies who underwent total thyroidectomy, utilization of optical techniques to support PGs preservation, the availability of calcium and/or PTH levels. The primary outcome was to evaluate the variation of calcium and PTH levels when adopting optical technologies compared to standard naked-eye surgery. RESULTS In total, 13 papers with 1484 procedures were included. Pooled proportion for short- and medium-term hypocalcemia rates were 8% (95% CI, 5%:11%) and 1% (95% CI, 0%:4%) for optical techniques, while for naked-eye surgery were 15% (95% CI, 9%:23%) and 5% (95% CI, 2%:9%), respectively. CONCLUSIONS Optical technologies reduced short and medium term hypocalcemia compared to conventional surgery. LEVEL OF EVIDENCE NA Laryngoscope, 131:1683-1692, 2021.
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Affiliation(s)
- Diego Barbieri
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pietro Indelicato
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Vinciguerra
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Federico Di Marco
- Urological Research Institute (URI), Division of experimental oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Maria Formenti
- Department of Endocrinology, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Trimarchi
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Mario Bussi
- Division of Head and Neck department, Otorhinolaryngology unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Wong A, Wong JCY, Pandey PU, Wiseman SM. Novel techniques for intraoperative parathyroid gland identification: a comprehensive review. Expert Rev Endocrinol Metab 2020; 15:439-457. [PMID: 33074033 DOI: 10.1080/17446651.2020.1831913] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/30/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The parathyroid glands (PGs) are critical for calcium regulation and homeostasis. The preservation of PGs during neck surgery is crucial to avoid postoperative hypoparathyroidism. There are no existing guidelines for intraoperative PG identification, and the current approach relies heavily on the experience of the operating surgeon. A technique that accurately and rapidly identifies PGs would represent a useful intraoperative adjunct. AREAS COVERED This review aims to assess common dye and fluorescence-based PG imaging techniques and examine their utility for intraoperative PG identification. A literature search of published data on methylene blue (MB), indocyanine green (ICG) angiography, near-infrared autofluorescence (NIRAF), and the PGs between 1971 and 2020 was conducted on PubMed. EXPERT OPINION NIRAF and near-infrared (NIR) parathyroid angiography have emerged as promising and reliable techniques for intraoperative PG identification. NIRAF may aid with real-time identification of both normal and diseased PGs and reduce the risk of postoperative complications such as hypocalcemia. Further large prospective multicenter studies should be conducted in thyroid and parathyroid surgical patient populations to confirm the clinical efficacy of these intraoperative NIR-based PG detection techniques.
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Affiliation(s)
- Amanda Wong
- St. Paul's Hospital Department of Surgery, The University of British Columbia Department of Surgery , Vancouver, British Columbia, Canada
| | - Jovi C Y Wong
- St. Paul's Hospital Department of Surgery, The University of British Columbia Department of Surgery , Vancouver, British Columbia, Canada
| | - Prashant U Pandey
- Biomedical Engineering, University of British Columbia , Vancouver, British Columbia, Canada
| | - Sam M Wiseman
- St. Paul's Hospital Department of Surgery, The University of British Columbia Department of Surgery , Vancouver, British Columbia, Canada
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Solórzano CC, Thomas G, Berber E, Wang TS, Randolph GW, Duh QY, Triponez F. Current state of intraoperative use of near infrared fluorescence for parathyroid identification and preservation. Surgery 2020; 169:868-878. [PMID: 33139065 DOI: 10.1016/j.surg.2020.09.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Finding and preserving normal parathyroid glands or localizing and removing diseased parathyroid glands are crucial steps to successful thyroid and parathyroid operations. Using near-infrared fluorescence detection to identify parathyroid glands during thyroid and parathyroid operations has lately gained widespread recognition, with 2 Food and Drug Administration-cleared devices currently in the market. We aim to update the endocrine surgery community on how near-infrared fluorescence detection can be most optimally used for rapid intraoperative parathyroid gland identification or preservation. METHODS A literature review was performed using the key terms: "parathyroid," "near infrared," and "fluorescence" in relevant search engines. Based on the reviewed literature and expert surgeons' opinions, recommendations were formulated for applying near-infrared fluorescence detection to identify or preserve parathyroid glands during cervical endocrine surgery. RESULTS The scope of near-infrared fluorescence detection can be broadly categorized into (1) using near-infrared auto-fluorescence to identify or locate both healthy and diseased parathyroid glands, and (2) using contrast-enhanced near-infrared fluorescence to evaluate parathyroid gland perfusion. The benefits and pitfalls for both near-infrared-based approaches are described herein. CONCLUSION Near-infrared fluorescence detection appears helpful for identification and likely preservation of parathyroid glands. We hope these recommendations will be valuable to the practicing endocrine surgeon as they consider incorporating these intraoperative adjuncts in their surgical practice.
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Affiliation(s)
- Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH
| | - Tracy S Wang
- Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Gregory W Randolph
- Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Multimodal imaging with integrated auto-fluorescence and optical coherence tomography for identification of neck tissues. Lasers Med Sci 2020; 36:1023-1029. [PMID: 32895854 DOI: 10.1007/s10103-020-03139-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
We report a multimodal optical system by combining OCT with autofluorescence imaging for identifying neck tissues, which can use the advantages of large field of view and high sensitivity for identifying parathyroid glands of fluorescence imaging, and high-resolution structural imaging of OCT to confirm them and identify lymph nodes and metastatic lymph nodes at the same time. It is proven that this multimodal optical system can be used to identify different neck tissues effectively and efficiently. We think that integrated auto-fluorescence and OCT imaging have the great potential in the application of navigation and assistant diagnosis of thyroid surgery.
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Enny L, Ramakant P, Singh KR, Rana C, Garg S, Mishra AK. Efficacy of Fluorescein Green Dye in Assessing Intra-Operative Parathyroid Gland Vascularity and Predicting Post-Thyroidectomy Hypocalcaemia- A Novel Prospective Cohort Study. Indian J Endocrinol Metab 2020; 24:446-451. [PMID: 33489851 PMCID: PMC7810046 DOI: 10.4103/ijem.ijem_499_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/22/2020] [Accepted: 09/21/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Postoperative hypocalcaemia (POH) after total thyroidectomy (TT) is a common complication. Parathyroid hormone (PTH), an accurate predictor of POH cannot assess intra-operative viability of parathyroid glands (PGs). Different dyes including indocyanine green or carbon nanoparticles have been used, but they are expensive and not widely available. Fluorescein green dye (FD) has been used as a low-cost alternative to study viability of various organs, but seldom tried in visualizing PGs. This novel study aims to assess utility of FD in determining parathyroid viability and predicting POH. MATERIAL AND METHOD Total 72 out of 88 patients undergoing TT between January and December 2019 were included. Two ml of 25% FD was given intravenously before wound closure and attempts were made to visualize PGs under blue light. A numerical score was given according to the number of PGs visualized. Intact-PTH and corrected calcium were measured on postoperative day 1 and patients observed for POH. RESULTS No PGs were visualized in 6 patients, 1 in 13, 2 in 30, 3 in 16 & 4 in 7 patients. Mean PTH was 6, 16.9, 31.6, 33.2 and 48.5 respectively. Corrected-calcium was 7.08, 7.7, 7.9, 8.5 and 8.5 respectively. All patients with score 0 received supplementary IV calcium, while 53.8% (score-1), 30% (score-2), 0% (scores-3, 4) received the same. Sensitivity, specificity and ROC of PG score of ≥2 on FD in predicting POH were 100%, 44% and 0.83 respectively. CONCLUSION FD visualization of parathyroids post TT is feasible and can be used as low cost efficacious method to predict POH.
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Affiliation(s)
- Loreno Enny
- Department of Endocrine Surgery, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Pooja Ramakant
- Department of Endocrine Surgery, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Kul R. Singh
- Department of Endocrine Surgery, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Chanchal Rana
- Department of Pathology, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Surubhi Garg
- Department of Endocrine Surgery, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Anand K. Mishra
- Department of Endocrine Surgery, King Georges Medical University, Lucknow, Uttar Pradesh, India
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Spartalis E, Ntokos G, Georgiou K, Zografos G, Tsourouflis G, Dimitroulis D, Nikiteas NI. Intraoperative Indocyanine Green (ICG) Angiography for the Identification of the Parathyroid Glands: Current Evidence and Future Perspectives. In Vivo 2020; 34:23-32. [PMID: 31882459 DOI: 10.21873/invivo.11741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 11/16/2019] [Accepted: 11/25/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM Recently, indocyanine green (ICG) fluorescence imaging has been used for the identification of the parathyroid glands (PG) during thyroid and parathyroid surgery. However, an overall consensus on the optimal technique, the dosage, the timing of the ICG administration and finally its interpretation and clinical usefulness is still lacking evidence. The aim of this review is to investigate the use of ICG angiography during thyroidectomy and/or parathyroidectomy for identification as well as for the perfusion integrity of the parathyroid glands. MATERIALS AND METHODS The PubMed database was systematically searched for publications regarding intraoperative ICG imaging in patients that undergo thyroidectomy or parathyroidectomy. RESULTS Eighteen publications reporting on 612 patients, namely 71 parathyroidectomy and 541 thyroidectomy patients met the inclusion criteria. Eleven publications reported the use of ICG angiography for the identification of the parathyroid glands during thyroidectomy and seven during parathyroidectomy for primary and secondary hyperparathyroidism. CONCLUSION ICG fluorescence imaging is a simple, fast and reproducible method capable of intraoperatively visualizing and assessing the function of parathyroid glands, and can, therefore, assist surgeons in their decision-making. Despite all this, ICG fluorescence imaging technique for PG detection still lacks standardization and further studies are needed to establish its clinical utility.
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Affiliation(s)
- Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens Medical School, Athens, Greece .,Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece
| | - Georgios Ntokos
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,3rd Surgical Department, "George Gennimatas" General Hospital, Athens, Greece
| | - Konstantinos Georgiou
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Georgios Zografos
- 3rd Surgical Department, "George Gennimatas" General Hospital, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece.,2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Nikolaos I Nikiteas
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens Medical School, Athens, Greece.,Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens, Greece
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Yan S, Xie C, Zhao W, Wang B, Zhang L. A simple, efficient, and safe way of finding recurrent laryngeal nerve beneficial for PTC patients. Medicine (Baltimore) 2020; 99:e20138. [PMID: 32384495 PMCID: PMC7220759 DOI: 10.1097/md.0000000000020138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND More surgeons have known the importance of parathyroid grand and recurrent laryngeal nerve protection in the surgery, but there is still plenty of scope to improve the surgical techniques. This study aims at investigating whether the improved method of finding recurrent laryngeal nerve (RLN) can protect parathyroid grand and RLN. METHODS One hundred fifty-eight patients were enrolled and divided randomly into the test and control group according to different methods of finding RLN in the surgery. In the experimental group the author could quickly find the laryngeal recurrent nerve in the lower part of the neck and separate along the surface of the recurrent laryngeal nerve to the point where the recurrent laryngeal nerve gets into the larynx close to the thyroid gland named lateral approach, while in the control group the author severed the middle and lower thyroid vein and raised the lower thyroid pole to look for the RLN near the trachea by the blunt separation. RESULTS The author identified 152 and 159 parathyroid glands in the test and control group, respectively and there were a lower ratio of auto-transplantation and less operative time in the test group compared with that in the control group. The author also found that the parathyroid hormone level (1 day and 2 months) in the test group was higher than that in the control group. There were no differences in metastatic LN and recurrent laryngeal nerve palsy in the 2 groups. CONCLUSION The improved method of finding RLN is a simple, efficient and safe way, and easy to implement.
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Affiliation(s)
- Shouyi Yan
- Department of Thyroid and Vascular Surgery
- Department of General Surgery
- Minimal Invasive Center, Fujian Medical University Union Hospital
- Fujian Medical University, Fuzhou, Fujian Province, China
| | - Chao Xie
- Department of Thyroid and Vascular Surgery
- Department of General Surgery
- Minimal Invasive Center, Fujian Medical University Union Hospital
- Fujian Medical University, Fuzhou, Fujian Province, China
| | - Wenxin Zhao
- Department of Thyroid and Vascular Surgery
- Department of General Surgery
- Minimal Invasive Center, Fujian Medical University Union Hospital
- Fujian Medical University, Fuzhou, Fujian Province, China
| | - Bo Wang
- Department of Thyroid and Vascular Surgery
- Department of General Surgery
- Minimal Invasive Center, Fujian Medical University Union Hospital
- Fujian Medical University, Fuzhou, Fujian Province, China
| | - Liyong Zhang
- Department of Thyroid and Vascular Surgery
- Department of General Surgery
- Minimal Invasive Center, Fujian Medical University Union Hospital
- Fujian Medical University, Fuzhou, Fujian Province, China
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