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Di Meglio I, Balasubramanian SP, Cha RJ, Duh QY, Lorenz K, Mahadevan-Jansen A, Triponez F. Editorial: 2023 symposium on parathyroid fluorescence. Front Endocrinol (Lausanne) 2024; 15:1434058. [PMID: 38966217 PMCID: PMC11222667 DOI: 10.3389/fendo.2024.1434058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/03/2024] [Indexed: 07/06/2024] Open
Affiliation(s)
- Ilaria Di Meglio
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Saba P. Balasubramanian
- Department of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Richard Jaepyeong Cha
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Kerstin Lorenz
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Anita Mahadevan-Jansen
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States
| | - Frédéric Triponez
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
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2
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Neagoe OC, Ionică M. Improvement in Central Neck Dissection Quality in Thyroid Cancer by Use of Tissue Autofluorescence. Cancers (Basel) 2024; 16:258. [PMID: 38254749 PMCID: PMC10813481 DOI: 10.3390/cancers16020258] [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: 12/03/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Risk of postoperative transient or permanent hypoparathyroidism represents one of the most common complications following total thyroidectomy. This risk increases if a cervical lymphadenectomy procedure must also be performed, as is usually the case in thyroid carcinoma patients. Parathyroid autofluorescence (AF) is a non-invasive method that aids intraoperative identification of parathyroid glands. METHODS In this prospective study, 189 patients with papillary thyroid cancer who underwent total thyroidectomy with central neck dissection were included. Patients were randomly allocated to one of two groups: NAF (no AF, surgery was performed without AF) and the AF group (surgery was performed with AF-Fluobeam LX system, Fluoptics, Grenoble, France). RESULTS The number of excised lymph nodes was significantly higher in the AF compared to the NAF group, with mean values of 21.3 ± 4.8 and 9.2 ± 4.1, respectively. Furthermore, a significantly higher number of metastatic lymph nodes were observed in the AF group. Transient hypocalcemia recorded significantly lower rates in the AF group with 4.9% compared to 16.8% in the NAF group. CONCLUSIONS AF use during total thyroidectomy with central neck dissection for papillary thyroid carcinoma patients, decreased the rate of iatrogenic parathyroid gland lesions, and increased the rate of lymphatic clearance.
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Affiliation(s)
- Octavian Constantin Neagoe
- Second Clinic of General Surgery and Surgical Oncology, Emergency Clinical Municipal Hospital Timișoara, 300079 Timișoara, Romania;
- Second Discipline of Surgical Semiology, First Department of Surgery, ”Victor Babeș” University of Medicine, 300041 Timișoara, Romania
| | - Mihaela Ionică
- Second Clinic of General Surgery and Surgical Oncology, Emergency Clinical Municipal Hospital Timișoara, 300079 Timișoara, Romania;
- Second Discipline of Surgical Semiology, First Department of Surgery, ”Victor Babeș” University of Medicine, 300041 Timișoara, Romania
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Pace-Asciak P, Russell J, Solorzano C, Berber E, Singer M, Shaha AR, Khafif A, Angelos P, Nixon I, Tufano RP. The utility of parathyroid autofluorescence as an adjunct in thyroid and parathyroid surgery 2023. Head Neck 2023; 45:3157-3167. [PMID: 37807364 DOI: 10.1002/hed.27538] [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: 03/05/2023] [Revised: 08/27/2023] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.
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Affiliation(s)
- P Pace-Asciak
- Department of Otolaryngology-Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - J Russell
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - C Solorzano
- Department of Surgery-Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - E Berber
- Department of Surgery-Division of Endocrine and Robotics, Cleveland Clinic, Ohio, USA
| | - M Singer
- Department of Otolaryngology-Head and Neck Surgery, The Henry Ford Cancer Institute, West, Michigan, USA
| | - A R Shaha
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A Khafif
- A.R.M. Center of Otolaryngology-Head and Neck Surgery, Assuta Medical Center, Affiliated with BenGurion University of the Negev, Tel Aviv, Israel
| | - P Angelos
- Department of Surgery-Division of Endocrine Surgery, The University of Chicago, Chicago, Illinois, USA
| | - I Nixon
- Department of Otolaryngology-Head and Neck Surgery, NHS Lothian, Edinburgh, UK
| | - R P Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
- Sarasota Memorial Health Care System Multidisciplinary Thyroid and Parathyroid Center, Florida, USA
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4
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Zhou L, Zhang M, Xu D, Shi J, Pan G, Zhang Y, Peng Y. The application of subcapsular saline injection to preserve the parathyroid gland during thyroidectomy. Heliyon 2023; 9:e21543. [PMID: 38027728 PMCID: PMC10661111 DOI: 10.1016/j.heliyon.2023.e21543] [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: 04/17/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE To evaluate the clinical effect of subcapsular saline injection (SCASI) after total thyroidectomy. METHODS A total of 77 patients who underwent total thyroidectomy in our hospital from January 2020 to December 2021 were selected and divided into the SCASI group (n = 43) and the non-SCASI group (n = 34). The general clinical data of the patients were collected, and serum parathyroid hormone (PTH) and serum calcium levels were determined preoperatively, on the 1st postoperative day, and at 1 and 6 months after the operation. These data were compared between groups. RESULTS There was no significant difference in postoperative complications between the two groups. The PTH and serum calcium levels in the SCASI group were significantly higher than those in the non-SCASI group on the 1st postoperative day (t = 2.340, 5.208, both P < 0.05), and the PTH levels in the SCASI group at 1 month after the operation were higher than those in the non-SCASI group (t = 2.141, P < 0.05). In addition, the proportion of transient and permanent hypoparathyroidism in the SCASI group was significantly decreased (χ2 = 3.920, 3.948, P < 0.05). CONCLUSION Total thyroidectomy requires high surgical precision, and SCASI can reduce the incidence of temporary and permanent hypoparathyroidism.
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Affiliation(s)
- Li Zhou
- Department of Surgical Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Miao Zhang
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Danqin Xu
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jingjing Shi
- Department of Surgical Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gang Pan
- Department of Surgical Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu Zhang
- Department of Surgical Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - You Peng
- Department of Surgical Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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5
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Belcher RH, Thomas G, Willmon PA, Gallant JN, Baregamian N, Lopez ME, Solόrzano CC, Mahadevan-Jansen A. Identifying Parathyroids in Pediatric Thyroid/Parathyroid Surgery by Near Infrared Autofluorescence. Laryngoscope 2023; 133:3208-3215. [PMID: 36866696 PMCID: PMC10475145 DOI: 10.1002/lary.30633] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVES Compared to adult patients undergoing thyroid surgery, pediatric patients have higher rates of hypoparathyroidism often related to parathyroid gland (PG) inadvertent injury or devascularization. Previous studies have shown that near-infrared-autofluorescence (NIRAF) can be reliably used intraoperatively for label-free parathyroid identification, but all prior studies have been performed in adult patients. In this study, we assess the utility and accuracy of NIRAF with a fiber-optic probe-based system to identify PGs in pediatric patients undergoing thyroidectomy or parathyroidectomy. METHODS All pediatric patients (under 18 years of age) undergoing thyroidectomy or parathyroidectomy were enrolled in this IRB-approved study. The surgeon's visual assessment of tissues was first noted and the surgeon's confidence level in the tissue identified was recorded. A fiber-optic probe was then used to illuminate tissues-of-interest with a wavelength of 785 nm and resulting NIRAF intensities from these tissues were measured while the surgeon was blinded to results. RESULTS NIRAF intensities were measured intraoperatively in 19 pediatric patients. Normalized NIRAF intensities for PGs (3.63 ± 2.47) were significantly higher than that of thyroid (0.99 ± 0.36, p < 0.001) and other surrounding soft tissues (0.86 ± 0.40, p < 0.001). Based on the PG identification ratio threshold of 1.2, NIRAF yielded a detection rate of 95.8% (46/48 pediatric PGs). CONCLUSION Our findings indicate that NIRAF detection can potentially be a valuable and non-invasive technique to identify PGs during neck operations in the pediatric population. To our knowledge, this is the first study in children to assess the accuracy of probe-based NIRAF detection for intraoperative parathyroid identification. LEVEL OF EVIDENCE Level 4 Laryngoscope, 133:3208-3215, 2023.
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Affiliation(s)
- Ryan H. Belcher
- Vanderbilt Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
- Division of Pediatric Otolaryngology, Monroe Carrell Jr. Children’s Hospital at Vanderbilt
| | - Giju Thomas
- Department of Biomedical Engineering, Vanderbilt University
- Vanderbilt Biophotonics Center, Vanderbilt University
| | - Parker A. Willmon
- Department of Biomedical Engineering, Vanderbilt University
- Vanderbilt Biophotonics Center, Vanderbilt University
| | - Jean-Nicolas Gallant
- Vanderbilt Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Naira Baregamian
- Vanderbilt Section of Surgical Sciences – Department of Surgery, Vanderbilt University Medical Center
| | - Monica E. Lopez
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Monroe Carrell Jr. Children’s Hospital at Vanderbilt
| | - Carmen C. Solόrzano
- Vanderbilt Section of Surgical Sciences – Department of Surgery, Vanderbilt University Medical Center
| | - Anita Mahadevan-Jansen
- Department of Biomedical Engineering, Vanderbilt University
- Vanderbilt Biophotonics Center, Vanderbilt University
- Vanderbilt Section of Surgical Sciences – Department of Surgery, Vanderbilt University Medical Center
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Mannoh EA, Baregamian N, Thomas G, Solόrzano CC, Mahadevan-Jansen A. Comparing laser speckle contrast imaging and indocyanine green angiography for assessment of parathyroid perfusion. Sci Rep 2023; 13:17270. [PMID: 37828222 PMCID: PMC10570279 DOI: 10.1038/s41598-023-42649-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/13/2023] [Indexed: 10/14/2023] Open
Abstract
Accurate intraoperative assessment of parathyroid blood flow is crucial to preserve function postoperatively. Indocyanine green (ICG) angiography has been successfully employed, however its conventional application has limitations. A label-free method overcomes these limitations, and laser speckle contrast imaging (LSCI) is one such method that can accurately detect and quantify differences in parathyroid perfusion. In this study, twenty-one patients undergoing thyroidectomy or parathyroidectomy were recruited to compare LSCI and ICG fluorescence intraoperatively. An experimental imaging device was used to image a total of 37 parathyroid glands. Scores of 0, 1 or 2 were assigned for ICG fluorescence by three observers based on perceived intensity: 0 for little to no fluorescence, 1 for moderate or patchy fluorescence, and 2 for strong fluorescence. Speckle contrast values were grouped according to these scores. Analyses of variance were performed to detect significant differences between groups. Lastly, ICG fluorescence intensity was calculated for each parathyroid gland and compared with speckle contrast in a linear regression. Results showed significant differences in speckle contrast between groups such that parathyroids with ICG score 0 had higher speckle contrast than those assigned ICG score 1, which in turn had higher speckle contrast than those assigned ICG score 2. This was further supported by a correlation coefficient of -0.81 between mean-normalized ICG fluorescence intensity and speckle contrast. This suggests that ICG angiography and LSCI detect similar differences in blood flow to parathyroid glands. Laser speckle contrast imaging shows promise as a label-free alternative that overcomes current limitations of ICG angiography for parathyroid assessment.
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Affiliation(s)
- Emmanuel A Mannoh
- Vanderbilt Biophotonics Center, Vanderbilt University, PMB 351631, Nashville, TN, 37235, USA.
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, 37235, USA.
| | - Naira Baregamian
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, PMB 351631, Nashville, TN, 37235, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, 37235, USA
| | - Carmen C Solόrzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Vanderbilt University, PMB 351631, Nashville, TN, 37235, USA.
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, 37235, USA.
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
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7
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DeHoog RJ, King ME, Keating MF, Zhang J, Sans M, Feider CL, Garza KY, Bensussan A, Krieger A, Lin JQ, Badal S, Alore E, Pirko C, Brahmbhatt K, Yu W, Grogan R, Eberlin LS, Suliburk J. Intraoperative Identification of Thyroid and Parathyroid Tissues During Human Endocrine Surgery Using the MasSpec Pen. JAMA Surg 2023; 158:1050-1059. [PMID: 37531134 PMCID: PMC10398548 DOI: 10.1001/jamasurg.2023.3229] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/08/2023] [Indexed: 08/03/2023]
Abstract
Importance Intraoperative identification of tissues through gross inspection during thyroid and parathyroid surgery is challenging yet essential for preserving healthy tissue and improving outcomes for patients. Objective To evaluate the performance and clinical applicability of the MasSpec Pen (MSPen) technology for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively. Design, Setting, and Participants In this diagnostic/prognostic study, the MSPen was used to analyze 184 fresh-frozen thyroid, parathyroid, and lymph node tissues in the laboratory and translated to the operating room to enable in vivo and ex vivo tissue analysis by endocrine surgeons in 102 patients undergoing thyroidectomy and parathyroidectomy procedures. This diagnostic study was conducted between August 2017 and March 2020. Fresh-frozen tissues were analyzed in a laboratory. Clinical analyses occurred in an operating room at an academic medical center. Of the analyses performed on 184 fresh-frozen tissues, 131 were included based on sufficient signal and postanalysis pathologic diagnosis. From clinical tests, 102 patients undergoing surgery were included. A total of 1015 intraoperative analyses were performed, with 269 analyses subject to statistical classification. Statistical classifiers for discriminating thyroid, parathyroid, and lymph node tissues were generated using training sets comprising both laboratory and intraoperative data and evaluated on an independent test set of intraoperative data. Data were analyzed from July to December 2022. Main Outcomes and Measures Accuracy for each tissue type was measured for classification models discriminating thyroid, parathyroid, and lymph node tissues using MSPen data compared to gross analysis and final pathology results. Results Of the 102 patients in the intraoperative study, 80 were female (78%) and the median (IQR) age was 52 (42-66) years. For discriminating thyroid and parathyroid tissues, an overall accuracy, defined as agreement with pathology, of 92.4% (95% CI, 87.7-95.4) was achieved using MSPen data, with 82.6% (95% CI, 76.5-87.4) accuracy achieved for the independent test set. For distinguishing thyroid from lymph node and parathyroid from lymph node, overall training set accuracies of 97.5% (95% CI, 92.8-99.1) and 96.1% (95% CI, 91.2-98.3), respectively, were achieved. Conclusions and Relevance In this study, the MSPen showed high performance for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively, suggesting this technology may be useful for providing near real-time feedback on tissue type to aid in surgical decision-making.
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Affiliation(s)
- Rachel J. DeHoog
- Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Mary E. King
- Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Chemistry, The University of Texas at Austin, Austin
| | | | - Jialing Zhang
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Marta Sans
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Clara L. Feider
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Kyana Y. Garza
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Alena Bensussan
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Anna Krieger
- Department of Chemistry, The University of Texas at Austin, Austin
| | - John Q. Lin
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Sunil Badal
- Department of Chemistry, The University of Texas at Austin, Austin
| | - Elizabeth Alore
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | | | - Wendong Yu
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Raymon Grogan
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Livia S. Eberlin
- Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - James Suliburk
- Department of Surgery, Baylor College of Medicine, Houston, Texas
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Kiernan CM, Thomas G, Patel A, Fan R, Ye F, Willmon PA, Solórzano CC. Does the Use of Probe-based Near-infrared Autofluorescence Parathyroid Detection Benefit Parathyroidectomy?: A Randomized Single-center Clinical Trial. Ann Surg 2023; 278:549-558. [PMID: 37389537 PMCID: PMC10836830 DOI: 10.1097/sla.0000000000005985] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To evaluate the benefits of probe-based near-infrared autofluorescence (NIRAF) parathyroid identification during parathyroidectomy. BACKGROUND Intraoperative parathyroid gland identification during parathyroidectomy can be challenging, while additionally requiring costly frozen sections. Earlier studies have established NIRAF detection as a reliable intraoperative adjunct for parathyroid identification. METHODS Patients undergoing parathyroidectomy for primary hyperparathyroidism were prospectively enrolled by a senior surgeon (>20 years experience) and a junior surgeon (<5 years experience), while being randomly allocated to the probe-based NIRAF or control group. Data collected included procedure type, number of parathyroids identified with high confidence by the surgeon and the resident, number of frozen sections performed, parathyroidectomy duration, and number of patients with persistent disease at the first postoperative visit. RESULTS One hundred sixty patients were randomly enrolled under both surgeons to the probe group (n=80) versus control (n=80). In the probe group, parathyroid identification rate of the senior surgeon improved significantly from 3.2 to 3.6 parathyroids per patient ( P <0.001), while that of the junior surgeon also rose significantly from 2.2 to 2.5 parathyroids per patient ( P =0.001). Parathyroid identification was even more prominent for residents increasing significantly from 0.9 to 2.9 parathyroids per patient ( P <0.001). Furthermore, there was a significant reduction in frozen sections utilized in the probe group versus control (17 vs 47, P =0.005). CONCLUSION Probe-based NIRAF detection can be a valuable intraoperative adjunct and educational tool for improving confidence in parathyroid gland identification, while potentially reducing the number of frozen sections required.
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Affiliation(s)
- Colleen M. Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Anuradha Patel
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Run Fan
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Parker A. Willmon
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Carmen C. Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
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9
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Chen W, Zhang R, Yang R, Hu J, Phay JE, Liu P, Ma X, Xu RX. Converting a probe-based fluorescence system into an easy-to-use adjunct for the detection of parathyroid glands accidentally resected intraoperatively. Langenbecks Arch Surg 2023; 408:262. [PMID: 37393198 DOI: 10.1007/s00423-023-02985-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/14/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE The reported threshold of a near-infrared fluorescence detection probe (FDP) for judging parathyroid glands (PGs) is based on the autofluorescence intensity relative to other non-PG tissues, making it unreliable when not enough reference tissues are measured. We aim to convert FDP into a more convenient tool for identifying accidentally resected PGs by quantitative measurements of autofluorescence in resected tissues. METHODS It was a prospective study approved by the Institutional Review Board. The research was divided into two stages: (1) In order to calibrate the novel FDP system, autofluorescence intensity of different in / ex vivo tissues was measured and the optimal threshold was obtained using receiver operating characteristic (ROC) curve. (2) To further validate the effectiveness of the new system, detection rates of incidental resected PGs by pathology in the control group and by FDP in the experimental group were compared. RESULTS Autofluorescence of PGs was significantly higher than that of non-PG tissue (43 patients, Mann-Whitney U test, p < 0.0001). An optimal threshold of sensitivity / specificity (78.8% and 85.1%) for discriminating PGs was obtained. The detection rates of experimental group (20 patients) and control group (33 patients) are 5.0% and 6.1% respectively (one-tailed Fisher's exact test, p = 0.6837), indicating the novel FDP system can achieve a similar proportion of PG detection compared with pathological examinations. CONCLUSIONS The novel FDP system can be used as an easy-to-use adjunct for detecting PG accidentally resected intraoperatively before the tissues are sent for frozen sections during thyroidectomy surgeries. TRIAL REGISTRATION Registration number: ChiCTR2200057957.
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Affiliation(s)
- Wei Chen
- Department of Precision Machinery and Precision Instrumentation, University of Science and Technology of China, Hefei, 230026, China
| | - Ru Zhang
- Department of Precision Machinery and Precision Instrumentation, University of Science and Technology of China, Hefei, 230026, China
| | - Ruijie Yang
- Department of Precision Machinery and Precision Instrumentation, University of Science and Technology of China, Hefei, 230026, China
| | - Jie Hu
- Department of Precision Machinery and Precision Instrumentation, University of Science and Technology of China, Hefei, 230026, China
| | - John E Phay
- Department of Surgery, Ohio State University Comprehensive Cancer Center and Ohio State University Wexner Medical Center, 410 W 10Th Ave, Columbus, OH, 43210, USA
| | - Peng Liu
- Suzhou Institute for Advanced Research, University of Science and Technology of China, Renai Road. NO. 188, Suzhou Industrial Park, Suzhou, 215123, Jiangsu Province, China
| | - Xiaopeng Ma
- First Affiliated Hospital, University of Science and Technology of China, Hefei, 230031, China
| | - Ronald X Xu
- Department of Precision Machinery and Precision Instrumentation, University of Science and Technology of China, Hefei, 230026, China.
- Suzhou Institute for Advanced Research, University of Science and Technology of China, Renai Road. NO. 188, Suzhou Industrial Park, Suzhou, 215123, Jiangsu Province, China.
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10
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Yuan Y, Li X, Bao X, Huangfu M, Zhang H. The magic mirror: a novel intraoperative monitoring method for parathyroid glands. Front Endocrinol (Lausanne) 2023; 14:1160902. [PMID: 37284221 PMCID: PMC10239973 DOI: 10.3389/fendo.2023.1160902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/01/2023] [Indexed: 06/08/2023] Open
Abstract
The accurate detection of parathyroid glands (PGs) during surgery is of great significance in thyroidectomy and parathyroidectomy, which protects the function of normal PGs to prevent postoperative hypoparathyroidism and the thorough removal of parathyroid lesions. Existing conventional imaging techniques have certain limitations in the real-time exploration of PGs. In recent years, a new, real-time, and non-invasive imaging system known as the near-infrared autofluorescence (NIRAF) imaging system has been developed to detect PGs. Several studies have confirmed that this system has a high parathyroid recognition rate and can reduce the occurrence of transient hypoparathyroidism after surgery. The NIRAF imaging system, like a magic mirror, can monitor the PGs during surgery in real time, thus providing great support for surgeries. In addition, the NIRAF imaging system can evaluate the blood supply of PGs by utilizing indocyanine green (ICG) to guide surgical strategies. The NIRAF imaging system and ICG complement each other to protect normal parathyroid function and reduce postoperative complications. This article reviews the effectiveness of the NIRAF imaging system in thyroidectomies and parathyroidectomies and briefly discusses some existing problems and prospects for the future.
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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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Baregamian N, Sekhar KR, Krystofiak ES, Vinogradova M, Thomas G, Mannoh E, Solórzano CC, Kiernan CM, Mahadevan-Jansen A, Abumrad N, Freeman ML, Weiss VL, Rathmell JC, Rathmell WK. Engineering functional 3-dimensional patient-derived endocrine organoids for broad multiplatform applications. Surgery 2023; 173:67-75. [PMID: 36400581 PMCID: PMC9939934 DOI: 10.1016/j.surg.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent advancements in 3-dimensional patient-derived organoid models have revolutionized the field of cancer biology. There is an urgent need for development of endocrine tumor organoid models for medullary thyroid carcinoma, adrenocortical carcinoma, papillary thyroid carcinoma, and a spectrum of benign hyperfunctioning parathyroid and adrenal neoplasms. We aimed to engineer functionally intact 3-dimensional endocrine patient-derived organoids to expand the in vitro and translational applications for the advancement of endocrine research. METHODS Using our recently developed fine needle aspiration-based methodology, we established patient-derived 3-dimensional endocrine organoid models using prospectively collected human papillary thyroid carcinoma (n = 6), medullary thyroid carcinoma (n = 3), adrenocortical carcinoma (n = 3), and parathyroid (n = 5). and adrenal (n = 5) neoplasms. Multiplatform analyses of endocrine patient-derived organoids and applications in oncoimmunology, near-infrared autofluorescence, and radiosensitization studies under 3-dimensional in vitro conditions were performed. RESULTS We have successfully modeled and analyzed the complex endocrine microenvironment for a spectrum of endocrine neoplasms in 3-dimensional culture. The endocrine patient-derived organoids recapitulated complex tumor microenvironment of endocrine neoplasms morphologically and functionally and maintained cytokine production and near-infrared autofluorescence properties. CONCLUSION Our novel engineered endocrine patient-derived organoid models of thyroid, parathyroid and adrenal neoplasms represent an exciting and elegant alternative to current limited 2-dimensional systems and afford future broad multiplatform in vitro and translational applications, including in endocrine oncoimmunology.
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Affiliation(s)
- Naira Baregamian
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Konjeti R Sekhar
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
| | - Emmanuel Mannoh
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN
| | - Carmen C Solórzano
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Colleen M Kiernan
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Naji Abumrad
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael L Freeman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Vivian L Weiss
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey C Rathmell
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - W Kimryn Rathmell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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13
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Cohen MS. Invited commentary: Selected endocrine surgery billing codes and procedures that should be accepted nationally for institutional billing as standard of care practice. Surgery 2023; 173:65-66. [PMID: 36424195 DOI: 10.1016/j.surg.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Mark S Cohen
- Dean, Carle Illinois College of Medicine, Senior Vice President and Chief Academic Officer for Carle Health; Professor of Surgery and Biomedical and Translational Sciences in the Carle Illinois College of Medicine and Professor of Bioengineering in the Grainger College of Engineering at the University of Illinois Urbana-Champaign, Urbana, Illinois.
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14
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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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15
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Kim Y, Lee HC, Kim J, Oh E, Yoo J, Ning B, Lee SY, Ali KM, Tufano RP, Russell JO, Cha J. A coaxial excitation, dual-red-green-blue/near-infrared paired imaging system toward computer-aided detection of parathyroid glands in situ and ex vivo. JOURNAL OF BIOPHOTONICS 2022; 15:e202200008. [PMID: 35340114 PMCID: PMC9357067 DOI: 10.1002/jbio.202200008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/28/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
Early and precise detection of parathyroid glands (PGs) is a challenging problem in thyroidectomy due to their small size and similar appearance to surrounding tissues. Near-infrared autofluorescence (NIRAF) has stimulated interest as a method to localize PGs. However, high incidence of false positives for PGs has been reported with this technique. We introduce a prototype equipped with a coaxial excitation light (785 nm) and a dual-sensor to address the issue of false positives with the NIRAF technique. We test the clinical feasibility of our prototype in situ and ex vivo using sterile drapes on 10 human subjects. Video data (1287 images) of detected PGs were collected to train, validate and compare the performance for PG detection. We achieved a mean average precision of 94.7% and a 19.5-millisecond processing time/detection. This feasibility study supports the effectiveness of the optical design and may open new doors for a deep learning-based PG detection method.
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Affiliation(s)
- Yoseph Kim
- Department of Biomedical Engineering, Johns Hopkins University, 3400 N. Charles St. Baltimore, MD 21218, USA
- Optosurgical, LLC, 11076 Birchtree Ln., Laurel, MD 20723, USA
- These authors contributed equally to this work
| | - Hun Chan Lee
- Department of Mechanical Engineering, Boston University, 44 Cummington Mall, Boston, MA 0221571, USA
- These authors contributed equally to this work
| | - Jongchan Kim
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, USA
- These authors contributed equally to this work
| | - Eugene Oh
- Department of Biomedical Engineering, Johns Hopkins University, 3400 N. Charles St. Baltimore, MD 21218, USA
- Optosurgical, LLC, 11076 Birchtree Ln., Laurel, MD 20723, USA
| | - Jennifer Yoo
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, USA
| | - Bo Ning
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, USA
| | - Seung Yup Lee
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 1760 Haygood Dr. NE, Atlanta, GA 30322 USA
- Department of Electrical and Computer Engineering, Kennesaw State University, 840 Polytechnic Lane, Marietta, GA 30060, USA
| | - Khalid Mohamed Ali
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287, USA
| | - Ralph P. Tufano
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287, USA
| | - Jonathon O. Russell
- Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287, USA
| | - Jaepyeong Cha
- Optosurgical, LLC, 11076 Birchtree Ln., Laurel, MD 20723, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, USA
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, 2300 Eye St. NW, Washington, DC 20052, USA
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16
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Wolf HW, Runkel N, Limberger K, Nebiker CA. Near-infrared autofluorescence of the parathyroid glands during thyroidectomy for the prevention of hypoparathyroidism: a prospective randomized clinical trial. Langenbecks Arch Surg 2022; 407:3031-3038. [PMID: 35904639 PMCID: PMC9640439 DOI: 10.1007/s00423-022-02624-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/21/2022] [Indexed: 11/29/2022]
Abstract
Purpose Postoperative hypoparathyroidism remains the most often complication in thyroid surgery. Near-infrared autofluorescence (NIR-AF) is a modality to identify parathyroid glands (PG) in vivo with high accuracy, but its use in daily routine surgery is unclear so far. In this randomized controlled trial, we evaluate the ability of NIR-AF to prevent postoperative hypoparathyroidism following total thyroidectomy. Methods Patients undergoing total thyroidectomy were allocated in two groups with the use of NIR-AF in the intervention group or according to standard practice in the control group. The aim was to identify the PGs in an early most stage of the operation to prevent their devascularization or removal. Parathyroid hormone was measured pre- and postoperatively and on postoperative day (POD) 1. Serum calcium was measured on POD 1 and 2. Possible symptoms and calcium/calcitriol supplement were recorded. Results A total of 60 patients were randomized, of whom 30 underwent NIR-AF-based PG identification. Hypoparathyroidism at skin closure occurred in 7 out of 30 patients using NIR-AF, respectively, in 14 out of 30 patients in the control group (p=0.058). There was no significant difference in serum calcium and parathyroid hormone levels between both groups. Likewise, NIR-AF could not detect PGs at a higher rate. Conclusion The use of NIR-AF may help surgeons identify and preserve PGs but did not significantly reduce the incidence of postoperative hypoparathyroidism in this trial. Larger case series have to clarify whether there is a benefit in routine thyroidectomy. Trial registration number DRKS00009242 (German Clinical Trial Register). Registration date: 03.09.2015
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Affiliation(s)
- Henning Wendelin Wolf
- Schwarzwald-Baar Klinikum Villingen-Schwenningen, Klinikstrasse 11, 78052, Villingen-Schwenningen, Germany. .,Kantonsspital Aarau AG, Tellstrasse 25, 5001, Aarau, Switzerland.
| | - Norbert Runkel
- Schwarzwald-Baar Klinikum Villingen-Schwenningen, Klinikstrasse 11, 78052, Villingen-Schwenningen, Germany.,AMEOS Spital Einsiedeln, Spitalstrasse 28, 8840, Einsiedeln, Switzerland
| | - Kathrin Limberger
- Schwarzwald-Baar Klinikum Villingen-Schwenningen, Klinikstrasse 11, 78052, Villingen-Schwenningen, Germany
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17
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Alghoul H, Farajat FA, Alser O, Snyr AR, Harmon CM, Novotny NM. Intraoperative uses of near-infrared fluorescence spectroscopy in pediatric surgery: A systematic review. J Pediatr Surg 2022; 57:1137-1144. [PMID: 35256157 DOI: 10.1016/j.jpedsurg.2022.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The application of near infrared spectroscopy (NIRS) imaging in surgery is growing. This study aimed to systematically review the literature to summarize the intraoperative uses of NIRS in pediatric surgery. METHODS A PRISMA-compliant literature search was conducted in PubMed, Embase, Scopus, and Web of Science from inception to February 2020. Title/abstract and then full-text screening were performed. The Oxford centre for Evidence Based Medicine tool (OCEBM) was used to evaluate the level of evidence of included studies. RESULTS Reviewers identified 53 articles. Of which, 34 studies (64.2%) were case-series and 11 (20.8%) were case reports. Most of the studies (n = 45, 84.9%) were level 4 on the OCEBM tool. The most common uses of NIRS were to visualize the biliary tree and to identify primary and metastatic malignant tissues. Other applications include assessment of perfusion of tissues including bowel anastomoses, and lymphatic surgery. Several advantages of the introduction of NIRS in pediatric surgery exist including having the potential to reduce operative time and intra/post-operative complications. Moreover, NIRS helps in detecting malignant tissues that can be missed by conventional imaging. However, NIRS has important limitations such as difficulty in identification of the biliary tree in obese patients or inflamed gallbladder, detection of small deeply localized malignant tissues, as well as the high cost. CONCLUSIONS NIRS is a promising modality that can be used intraoperatively to augment different pediatric surgical procedures. NIRS has important advantages and limitations compared to conventional surgery, however, more studies are required to evaluate its outcomes and cost-effectiveness. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Heba Alghoul
- Faculty of Medicine, Islamic University of Gaza, Palestine
| | - Farah Al Farajat
- Faculty of Medicine, Jordan University of Science and Technology, Jordan
| | - Osaid Alser
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Andrea Rogers Snyr
- Beaumont Children's and Oakland University William Beaumont School of Medicine, 3535 W 13 Mile Rd, Ste 307, Royal Oak, MI 48073, United States
| | - Carroll M Harmon
- Division of Pediatric Surgery, Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University in Buffalo, NY, United States
| | - Nathan M Novotny
- Beaumont Children's and Oakland University William Beaumont School of Medicine, 3535 W 13 Mile Rd, Ste 307, Royal Oak, MI 48073, United States; Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States.
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18
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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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19
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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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Accumulation of Experience and Newly Developed Devices Can Improve the Safety and Voice Outcome of Total Thyroidectomy for Graves’ Disease. J Clin Med 2022; 11:jcm11051298. [PMID: 35268389 PMCID: PMC8911351 DOI: 10.3390/jcm11051298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/22/2022] Open
Abstract
Total thyroidectomy (TT) in patients with Graves’ disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves’ disease who received TT. Forty-six patients received surgery during 1990–1999 (Group A), and 44 patients received surgery during 2010–2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range (p = 0.015) and jitter (p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves’ disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.
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21
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Makovac P, Muradbegovic M, Mathieson T, Demarchi MS, Triponez F. Preliminary experience with the EleVision IR system in detection of parathyroid glands autofluorescence and perfusion assessment with ICG. Front Endocrinol (Lausanne) 2022; 13:1030007. [PMID: 36325460 PMCID: PMC9619109 DOI: 10.3389/fendo.2022.1030007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/27/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Postoperative hypoparathyroidism remains the most frequent complication of neck endocrine surgery. In order to reduce the incidence of this feared complication, several systems for imaging of near infrared autofluorescence (NIRAF) have been invented to help surgeons identify parathyroid glands (PTGs) and evaluate their vascularization. We evaluated the efficacy of the EleVision IR system in thyroid and parathyroid surgery. METHODS We used the EleVision IR system in 25 patients who underwent thyroid/parathyroid surgery or both at our institution between December 2020 and July 2021. At various stages of the surgery, the surgeon first looked for PTGs with the naked eye and then completed the visual inspection with NIRAF imaging. We then compared both the naked eye and NIRAF-supported PTGs detection rates. At the end of surgery, we performed indocyanine green angiography of PTGs in 17 patients. RESULTS In total, we identified 80% of PTGs: 65% with the naked eye only and additional 15% with the assistance of the EleVision IR system. 14 of 17 patients evaluated by ICG angiography had at least one well-vascularized PTG. Only one of these patients (a case of subtotal parathyroidectomy for tertiary hyperparathyroidism) developed symptomatic postoperative hypocalcemia despite a normal parathormone level. The three other patients had at least one remaining moderately-vascularized PTG and only one patient developed transient postoperative hypoparathyroidism. CONCLUSION We concluded that EleVision IR provides an efficient support for identification and evaluation of PTGs, and may be of great assistance in endocrine surgery. The images are easy to interpret even for less experienced surgeons thanks to the different types of color visualization and the possibility to measure the relative fluorescence intensity of PTGs and surrounding tissues.
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22
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Law RH, Larrabee KA, Van Harn M, Singer MC. Parathyroid Gland Autofluorescence Characteristics in Patients With Primary Hyperparathyroidism. Laryngoscope 2021; 132:715-721. [PMID: 34612528 DOI: 10.1002/lary.29880] [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: 06/25/2021] [Revised: 08/18/2021] [Accepted: 09/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Near-infrared imaging for intraoperative parathyroid gland (PG) detection has recently commanded significant attention. The PTeye (Medtronic, Minneapolis, MN) is a probe-based system for near-infrared autofluorescent evaluation of PGs. This study was designed to evaluate the capabilities of the PTeye in the setting of surgery for primary hyperparathyroidism. STUDY DESIGN Prospective, Cohort study. METHODS This single-institution, prospective cohort study included all patients undergoing parathyroidectomy for primary hyperparathyroidism with presumed single gland disease from June 2020 to December 2020. Absolute intensity and intensity ratios, with the thyroid as the control tissue, were obtained for the adenoma, ipsilateral normal PG, and adjacent tissue. The ability of the PTeye to function when not in direct contact with tissue was measured. RESULTS Twenty-two patients were included. The median intensity ratio for the in situ adenomas was 4.38 (interquartile range [IQR]: 2.03-5.87), ipsilateral normal PGs 6.17 (IQR: 3.83-7.67), strap muscle 0.47 (IQR: 0.30-0.60), and fat 0.20 (IQR: 0.17-0.47). All normal PGs and 21/22 adenomas demonstrated autofluorescence above the detection threshold. The PTeye functioned at a maximum distance of separation of 10 mm through saline medium and 6 mm through clear solid medium. CONCLUSION This study confirms the PTeye's ability to recognize PGs with a high degree of precision. The device was found to function properly even with the probe not in direct contact with the tissue. Although adenomatous PGs appear to demonstrate altered autofluorescent properties from normal PGs, additional research is required to determine if these differences are clinically useful. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Richard H Law
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Katherine A Larrabee
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Meredith Van Harn
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Michael C Singer
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A
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23
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Mannoh EA, Thomas G, Baregamian N, Rohde SL, Solórzano CC, Mahadevan-Jansen A. Assessing Intraoperative Laser Speckle Contrast Imaging of Parathyroid Glands in Relation to Total Thyroidectomy Patient Outcomes. Thyroid 2021; 31:1558-1565. [PMID: 34078120 PMCID: PMC8917893 DOI: 10.1089/thy.2021.0093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Accurate assessment of parathyroid gland vascularity is important during thyroidectomy to preserve the function of parathyroid glands and to prevent postoperative hypocalcemia. Laser speckle contrast imaging (LSCI) has been shown to be accurate in detecting differences in parathyroid vascularity. In this surgeon-blinded prognostic study, we evaluate the relationship between intraoperative LSCI measurements and postoperative outcomes of total thyroidectomy patients. Methods: Seventy-two thyroidectomy patients were included in this study. After thyroid resection, an LSCI device was used to image all parathyroid glands identified, and a speckle contrast value was calculated for each. An average value was calculated for each patient, and the data were grouped according to whether the patient had normal (16-77 pg/mL) or low levels of parathyroid hormone (PTH) measured on postoperative day 1 (POD1). The aim of this study was to establish a speckle contrast threshold for classifying a parathyroid gland as adequately perfused and to determine how many such glands are required for normal postoperative parathyroid function. Results: A speckle contrast limit of 0.186 separated the normoparathyroid and hypoparathyroid groups with 87.5% sensitivity and 84.4% specificity: 7 of 8 patients with low PTH on POD1 had an average parathyroid speckle contrast above this limit, while 54 of 64 patients with normal postoperative PTH had an average parathyroid speckle contrast below this limit. Taking this value as the threshold for adequate parathyroid perfusion, it was determined that only one vascularized gland was needed for normal postoperative parathyroid function: 64 of 69 patients (92.8%) with at least one vascularized gland (determined by LSCI) had normal postoperative PTH, while all 3 patients (100%) with no vascularized glands had low postoperative PTH. Overall, the rates of temporary and permanent hypoparathyroidism in this study were 8.3% and 1.4%, respectively. Conclusions: LSCI is a promising technique for assessing parathyroid gland vascularity. It has the potential to help reduce the incidence of hypocalcemia after thyroidectomy by providing surgeons with additional information during surgery to aid in the preservation of parathyroid function.
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Affiliation(s)
- Emmanuel A. Mannoh
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Naira Baregamian
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L. Rohde
- Department of Otolaryngology—Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carmen C. Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
- Address correspondence to: Anita Mahadevan-Jansen, PhD, Department of Biomedical Engineering, Vanderbilt University, Station B, Box 351631, Nashville, TN 37235, USA
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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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Near-infrared autofluorescence-based parathyroid glands identification in the thyroidectomy or parathyroidectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 407:491-499. [PMID: 34322746 DOI: 10.1007/s00423-021-02269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/06/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the diagnostic accuracy of near-infrared autofluorescence-based identification in the identification of parathyroid glands during thyroidectomy or parathyroidectomy. METHODS The clinical studies were retrieved from PubMed, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, SCOPUS, and Google Scholar. The study protocol was registered on Open Science Framework ( https://osf.io/um8rj/ ). The search period ranged from the date of each database's inception to May 2021. Cohort studies dealing with patients of whom parathyroid glands were detected by near-infrared autofluorescence and confirmed clinically or pathologically during thyroidectomy or parathyroidectomy were included. Editorials, letters, "how-I-do-it" descriptions, other site head and neck tumors, and articles with lack of diagnostic identification data were excluded. True positive, true negative, false positive, and false negative were extracted. The QUDAS ver. 2 was used to evaluate the methodological quality. RESULTS Seventeen studies with 1198 participants were evaluated in this analysis. Near-infrared autofluorescence-based identification of parathyroid glands showed a diagnostic odds ratio of 228.8759 (95% confidence interval, 134.1099; 390.6063). The area under the summary receiver operating characteristic curve was 0.967. The sensitivity, specificity, negative predictive value, and positive predictive value were 0.9693 (0.9491; 0.9816), 0.9248 (0.8885; 0.9499), 0.9517 (0.8981; 0.9778), and 0.9488 (0.9167; 0.9689), respectively. Subgroup analyses were performed to compare two autofluorescence detection methods, because there was high heterogeneity in the outcomes. The diagnostic accuracy was higher in probe-based detection than in image-based detection. CONCLUSIONS Near-infrared autofluorescence-based identification is valuable for identifying the parathyroid glands of patients during thyroidectomy or parathyroidectomy.
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Mannoh EA, Parker LB, Thomas G, Solórzano CC, Mahadevan-Jansen A. Development of an imaging device for label-free parathyroid gland identification and vascularity assessment. JOURNAL OF BIOPHOTONICS 2021; 14:e202100008. [PMID: 33583122 PMCID: PMC8556476 DOI: 10.1002/jbio.202100008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 06/12/2023]
Abstract
During thyroid surgeries, it is important for surgeons to accurately identify healthy parathyroid glands and assess their vascularity to preserve their function postoperatively, thus preventing hypoparathyroidism and hypocalcemia. Near infrared autofluorescence detection enables parathyroid identification, while laser speckle contrast imaging allows assessment of parathyroid vascularity. Here, we present an imaging system combining the two techniques to perform both functions, simultaneously and label-free. An algorithm to automate the segmentation of a parathyroid gland in the fluorescence image to determine its average speckle contrast is also presented, reducing a barrier to clinical translation. Results from imaging ex vivo tissue samples show that the algorithm is equivalent to manual segmentation. Intraoperative images from representative procedures are presented showing successful implementation of the device to identify and assess vascularity of healthy and diseased parathyroid glands.
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Affiliation(s)
- Emmanuel A. Mannoh
- Vanderbilt Biophotonics Center, Nashville, TN 37235
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235
| | - Logan B. Parker
- Vanderbilt Biophotonics Center, Nashville, TN 37235
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Nashville, TN 37235
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235
| | - Carmen C. Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN 37232
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Nashville, TN 37235
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235
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Comparing intraoperative parathyroid identification based on surgeon experience versus near infrared autofluorescence detection - A surgeon-blinded multi-centric study. Am J Surg 2021; 222:944-951. [PMID: 34024629 DOI: 10.1016/j.amjsurg.2021.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/25/2021] [Accepted: 05/03/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Near infrared autofluorescence (NIRAF) detection has previously demonstrated significant potential for real-time parathyroid gland identification. However, the performance of a NIRAF detection device - PTeye® - remains to be evaluated relative to a surgeon's own ability to identify parathyroid glands. METHODS Patients eligible for thyroidectomy and/or parathyroidectomy were enrolled under 6 endocrine surgeons at 3 high-volume institutions. Participating surgeons were categorized based on years of experience. All surgeons were blinded to output of PTeye® when identifying tissues. The surgeon's performance for parathyroid discrimination was then compared with PTeye®. Histology served as gold standard for excised specimens, while expert surgeon's opinion was used to validate in-situ tissues. RESULTS PTeye® achieved 92.7% accuracy across 167 patients recruited. Junior surgeons (<5 years of experience) were found to have lower confidence in parathyroid identification and higher tissue misclassification rate per specimen when compared to PTeye® and senior surgeons (>10 years of experience). CONCLUSIONS NIRAF detection with PTeye® can be a valuable intraoperative adjunct technology to aid in parathyroid identification for surgeons.
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Weng YJ, Jiang J, Min L, Ai Q, Chen DB, Chen WC, Huang ZH. Intraoperative near-infrared autofluorescence imaging for hypocalcemia risk reduction after total thyroidectomy: Evidence from a meta-analysis. Head Neck 2021; 43:2523-2533. [PMID: 33949716 DOI: 10.1002/hed.26733] [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: 01/27/2021] [Revised: 03/30/2021] [Accepted: 04/22/2021] [Indexed: 12/11/2022] Open
Abstract
This meta-analysis evaluates whether near-infrared autofluorescence (NIRAF) imaging reduces the risk of hypocalcemia after total thyroidectomy. A systematic literature search in PubMed, EMBASE, Web of Science, and Cochrane Library for studies from June 2011 to January 2021 comparing total thyroidectomy with NIRAF and conventional surgery (naked eye). Six eligible studies involving 2180 patients were included. The prevalence of transient hypocalcemia was 8.11% (40/493) and 25.19% (425/1687) in the NIRAF and naked eye groups (p < 0.0001), respectively. The prevalence of permanent hypocalcemia was 0% (0/493) and 2.19% (37/1687) in the NIRAF and naked eye groups (p = 0.05), respectively. NIRAF reduces the risk of transient hypocalcemia and may possibly lower the rate of permanent hypocalcemia. Nonetheless, further studies are needed to verify our results and evaluate the cost-effectiveness of NIRAF in real-world clinical practice.
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Affiliation(s)
- Yu-Jing Weng
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Jiang Jiang
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Lei Min
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Qing Ai
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, People's Republic of China
| | - De-Biao Chen
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Wei-Chun Chen
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Zhi-Heng Huang
- Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shenzhen, Guangdong, People's Republic of China
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Kiernan CM, Thomas G, Baregamian N, Solόrzano CC. Initial clinical experiences using the intraoperative probe-based parathyroid autofluorescence identification system-PTeye™ during thyroid and parathyroid procedures. J Surg Oncol 2021; 124:271-281. [PMID: 33866558 DOI: 10.1002/jso.26500] [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: 12/30/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVE The Food and Drug Administration has cleared a probe-based near-infrared autofluorescence (NIRAF) detection system called PTeye™ as an adjunct tool for label-free intraoperative parathyroid gland (PG) identification. Since PTeye™ has been investigated only in a "blinded" manner to date, this study describes the preliminary impressions of PTeye™ when used by surgeons without being blinded to the device output. METHODS Patients undergoing thyroid and parathyroid procedures were prospectively recruited. Target tissues were intraoperatively assessed with PTeye™. The surgeon's confidence in PG identification was recorded concomitantly with NIRAF parameters that were output in real-time from PTeye™. RESULTS A retrospective review of prospectively collected data on 83 patients was performed. PTeye™ was used for interrogating 336 target tissues in 46 parathyroid and 37 thyroid procedures. PTeye™ yielded an overall accuracy of 94.3% with a positive predictive value of 93.0% and a negative predictive value of 100%. An increase in confidence for intraoperative PG identification with PTeye™ was observed by all three participating high-volume surgeons, irrespective of their level of accrued surgical experience. CONCLUSIONS Probe-based NIRAF detection with PTeye™ can be a valuable adjunct device to intraoperatively identify PGs for surgeons of varied training and experience.
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Affiliation(s)
- Colleen M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Naira Baregamian
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carmen C Solόrzano
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Marsden M, Weaver SS, Marcu L, Campbell MJ. Intraoperative Mapping of Parathyroid Glands Using Fluorescence Lifetime Imaging. J Surg Res 2021; 265:42-48. [PMID: 33878575 DOI: 10.1016/j.jss.2021.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/29/2021] [Accepted: 03/03/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypoparathyroidism is a common complication following thyroidectomy. There is a need for technology to aid surgeons in identifying the parathyroid glands. In contrast to near infrared technologies, fluorescence lifetime imaging (FLIm) is not affected by ambient light and may be valuable in identifying parathyroid tissue, but has never been evaluated in this capacity. METHODS We used FLIm to measure the UV induced (355 nm) time-resolved autofluorescence signatures (average lifetimes in 3 spectral emission channels) of thyroid, parathyroid, lymphoid and adipose tissue in 21 patients undergoing thyroid and parathyroid surgery. The Mann-Whitney U test was used to assess the ability of FLIm to discriminate normocellular parathyroid from each of the other tissues. Various machine learning classifiers (random forests, neural network, support vector machine) were then evaluated to recognize parathyroid through a leave-one-out cross-validation. RESULTS Statistically significant differences in average lifetime were observed between parathyroid and each of the other tissue types in spectral channels 2 and 3 respectively. The largest change was observed between adipose tissue and parathyroid (P < 0.001), while less pronounced but still significant changes were observed when comparing parathyroid with lymphoid tissue (P < 0.05) and thyroid (P < 0.01). A random forest classifier trained on average lifetimes was found to detect parathyroid tissue with 100% sensitivity and 93% specificity at the acquisition run level. CONCLUSION We found that FLIm derived parameters can distinguish the parathyroid glands and other adjacent tissue types and has promise in scanning the surgical field to identify parathyroid tissue in real-time.
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Affiliation(s)
- Mark Marsden
- University of California, Davis Department of Biomedical Engineering, Sacramento, California
| | | | - Laura Marcu
- University of California, Davis Department of Biomedical Engineering, Sacramento, California
| | - Michael J Campbell
- University of California, Davis Department of Surgery, Sacramento, California.
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Demarchi MS, Karenovics W, Bédat B, De Vito C, Triponez F. Autofluorescence pattern of parathyroid adenomas. BJS Open 2021; 5:6137384. [PMID: 33609395 PMCID: PMC7893478 DOI: 10.1093/bjsopen/zraa047] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/11/2020] [Accepted: 11/05/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Primary hyperparathyroidism (pHPT) is a common endocrine pathology, and it is due to a single parathyroid adenoma in 80-85 per cent of patients. Near-infrared autofluorescence (NIRAF) has recently been used in endocrine surgery to help in the identification of parathyroid tissue, although there is currently no consensus on whether this technique can differentiate between normal and abnormal parathyroid glands. The aim of this study was to describe the autofluorescence pattern of parathyroid adenoma in pHPT. METHODS Between January and June 2019, patients with pHPT who underwent surgical treatment for parathyroid adenoma were enrolled. Parathyroid autofluorescence was measured. RESULTS Twenty-three patients with histologically confirmed parathyroid adenomas were included. Parathyroid adenomas showed a heterogeneous fluorescence pattern, and a well defined autofluorescent 'cap' region was observed in 17 of 23 specimens. This region was on average 28 per cent more fluorescent than the rest of the adenoma, and corresponded to a rim of normal histological parathyroid tissue (sensitivity and specificity 88 and 67 per cent respectively). After resection, all patients were treated successfully, with normal postoperative values of calcium and parathyroid hormone documented. CONCLUSION Parathyroid adenomas show a heterogeneous autofluorescence pattern. Using NIRAF imaging, the majority of specimens showed a well defined autofluorescent portion corresponding to a rim of normal parathyroid tissue. Further studies should be conducted to validate these findings.
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Affiliation(s)
- M S Demarchi
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - W Karenovics
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - B Bédat
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - C De Vito
- Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
| | - F Triponez
- Department of Thoracic and Endocrine Surgery and Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Wang B, Zhu CR, Liu H, Yao XM, Wu J. The Accuracy of Near Infrared Autofluorescence in Identifying Parathyroid Gland During Thyroid and Parathyroid Surgery: A Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:701253. [PMID: 34234746 PMCID: PMC8255791 DOI: 10.3389/fendo.2021.701253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/07/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE We aim to assess the accuracy of near infrared autofluorescence in identifying parathyroid gland during thyroid and parathyroid surgery. METHOD A systematic literature search was conducted by using PubMed, Embase, and the Cochrane Library electronic databases for studies that were published up to February 2021. The reference lists of the retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the combined variable. Publication bias in these studies was evaluated with the Deeks' funnel plots. RESULT A total of 24 studies involving 2,062 patients and 6,680 specimens were included for the meta-analysis. The overall combined sensitivity and specificity, and the area under curve of near infrared autofluorescence were 0.96, 0.96, and 0.99, respectively. Significant heterogeneities were presented (Sen: I2 = 87.97%, Spe: I2 = 65.38%). In the subgroup of thyroid surgery, the combined sensitivity and specificity, and the area under curve of near infrared autofluorescence was 0.98, 0.99, and 0.99, respectively, and the heterogeneities were moderate (Sen: I2 = 59.71%, Spe: I2 = 67.65%). CONCLUSION Near infrared autofluorescence is an excellent indicator for identifying parathyroid gland during thyroid and parathyroid surgery.
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Affiliation(s)
- Bin Wang
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Chun-Rong Zhu
- Department of Chemistry, School of Basic Medical Science, North Sichuan Medical College, Nanchong, China
| | - Hong Liu
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Xin-Min Yao
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
| | - Jian Wu
- Department of Thyroid and Breast Surgery, Chengdu Third People’s Hospital, Chengdu, China
- *Correspondence: Jian Wu,
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Abstract
OBJECTIVE With the recent approval of 2 NIRAF-based devices for label-free identification of PG by the Food and Drug Administration, it becomes crucial to educate the surgical community on the realistic scope of this emerging technology. Here, we have compiled a review of studies that utilize NIRAF and present a critical appraisal of this technique for intraoperative PG detection. BACKGROUND Failure to visualize PGs could lead to accidental damage/excision of healthy PGs or inability to localize diseased PGs, resulting in postsurgical complications. The discovery that PGs have NIRAF led to new avenues for intraoperatively identifying PGs with high accuracy in real-time. METHODS Using the following key terms: "parathyroid, near infrared, autofluorescence" in various search engines such as PubMed and Google Scholar, we identified various publications relevant to this review of NIRAF as a technique for PG identification. Articles were excluded if they focused solely on contrast agents, served as commentaries/overviews on NIRAF or were not written in English. RESULTS To date, studies have investigated the potential of NIRAF detection for (i) identifying PG tissues intraoperatively, (ii) locating PGs before or after dissection, (iii) distinguishing healthy from diseased PGs, and (iv) minimizing postoperative hypocalcemia after total thyroidectomy. CONCLUSIONS Because NIRAF-based identification of PG is noninvasive and label-free, the popularity of this approach has considerably surged. As the present limitations of various technologies capable of NIRAF detection are identified, we anticipate that newer device iterations will continue to be developed enhancing the current merits of these modalities to aid surgeons in identifying and preserving PGs. However, more concrete and long-term outcome studies with these modalities are essential to determine the impact of this technique on patient outcome and actual cost-benefits.
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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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Triguero Cabrera J, Fernández Segovia E, González Martínez S, Muñoz Pérez NV, Arcelus Martínez JI, Expósito Ruiz M, Villar Del Moral JM. Development and validation of a new model for predicting hypocalcaemia after total thyroidectomy: the NuGra model. Langenbecks Arch Surg 2020; 406:1199-1209. [PMID: 33048225 DOI: 10.1007/s00423-020-02002-x] [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: 03/09/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hypocalcaemia is the most frequent complication after total thyroidectomy. Finding a method for its early detection has become a priority. A single-center prospective cohort study was conducted to identify risk factors for postoperative hypocalcaemia, develop an early detection model, and test its validity in a different group of patients. METHODS The sample was composed of patients who underwent a total thyroidectomy between May 2012 and September 2015. Demographic, clinical, laboratory, and surgical data were collected. The incidence of hypocalcaemia and permanent hypoparathyroidism was calculated. Bivariate and multivariate analysis identified several independent predictors of hypocalcaemia, which were used to design a predictive model. The validity of the model was subsequently tested in a different cohort. Area under the ROC curve (AUROC) was calculated to determine its predictive power. RESULTS The study and validation groups included 352 and 118 patients, respectively. Seventy-three patients developed laboratory-confirmed hypocalcaemia (20.7%), and symptomatic in 43 (12.2%). Multivariate analysis confirmed as independent predictors of hypocalcaemia the higher number of parathyroid glands identified [OR 1.41(0.98, 2.02); p = 0.063] and pre-to-postoperative gradient of parathormone decline [OR 1.06(1.04, 1.08); p < 0.001]. Based on these variables, the NuGra (Number of parathyroid glands identified-Gradient of decline) model was developed for predicting laboratory-confirmed hypocalcaemia. Its predictive power was high (AUROC 0.902, CI 0.857-0.947) for the study and the validation group (AUROC 0.956, CI 0.919-0.993). CONCLUSIONS A higher number of parathyroid glands identified and a higher gradient of parathormone decline are risk factors for post-thyroidectomy hypocalcaemia. The NuGra model is useful for early prediction of individual risk for hypocalcaemia.
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Affiliation(s)
- Jennifer Triguero Cabrera
- Unit of Endocrine Surgery, Department of General Surgery, Virgen de las Nieves University Hospital, 18012, Av. De las Fuerzas Armadas, Granada, Spain.
| | - Elena Fernández Segovia
- Unit of Endocrine Surgery, Department of General Surgery, Virgen de las Nieves University Hospital, 18012, Av. De las Fuerzas Armadas, Granada, Spain
| | - Selene González Martínez
- Unit of Endocrine Surgery, Department of General Surgery, Virgen de las Nieves University Hospital, 18012, Av. De las Fuerzas Armadas, Granada, Spain
| | - Nuria Victoria Muñoz Pérez
- Unit of Endocrine Surgery, Department of General Surgery, Virgen de las Nieves University Hospital, 18012, Av. De las Fuerzas Armadas, Granada, Spain
| | - Juan Ignacio Arcelus Martínez
- Unit of Endocrine Surgery, Department of General Surgery, Virgen de las Nieves University Hospital, 18012, Av. De las Fuerzas Armadas, Granada, Spain.,Department of Surgery, University of Granada, Granada, Spain
| | - Manuela Expósito Ruiz
- Unit of Management and Research Support (FIBAO), Virgen de las Nieves University Hospital, Granada, Spain
| | - Jesús María Villar Del Moral
- Unit of Endocrine Surgery, Department of General Surgery, Virgen de las Nieves University Hospital, 18012, Av. De las Fuerzas Armadas, Granada, Spain
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Serra C, Canudo A, Silveira L. Intraoperative identification of parathyroid glands by autofluorescence on total thyroidectomy – Does it really reduces post-operative hypocalcemia? SURGERY IN PRACTICE AND SCIENCE 2020. [DOI: 10.1016/j.sipas.2020.100011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Recent Advances and the Potential for Clinical Use of Autofluorescence Detection of Extra-Ophthalmic Tissues. Molecules 2020; 25:molecules25092095. [PMID: 32365790 PMCID: PMC7248908 DOI: 10.3390/molecules25092095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023] Open
Abstract
The autofluorescence (AF) characteristics of endogenous fluorophores allow the label-free assessment and visualization of cells and tissues of the human body. While AF imaging (AFI) is well-established in ophthalmology, its clinical applications are steadily expanding to other disciplines. This review summarizes clinical advances of AF techniques published during the past decade. A systematic search of the MEDLINE database and Cochrane Library databases was performed to identify clinical AF studies in extra-ophthalmic tissues. In total, 1097 articles were identified, of which 113 from internal medicine, surgery, oral medicine, and dermatology were reviewed. While comparable technological standards exist in diabetology and cardiology, in all other disciplines, comparability between studies is limited due to the number of differing AF techniques and non-standardized imaging and data analysis. Clear evidence was found for skin AF as a surrogate for blood glucose homeostasis or cardiovascular risk grading. In thyroid surgery, foremost, less experienced surgeons may benefit from the AF-guided intraoperative separation of parathyroid from thyroid tissue. There is a growing interest in AF techniques in clinical disciplines, and promising advances have been made during the past decade. However, further research and development are mandatory to overcome the existing limitations and to maximize the clinical benefits.
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Baj J, Sitarz R, Łokaj M, Forma A, Czeczelewski M, Maani A, Garruti G. Preoperative and Intraoperative Methods of Parathyroid Gland Localization and the Diagnosis of Parathyroid Adenomas. Molecules 2020; 25:E1724. [PMID: 32283730 PMCID: PMC7181220 DOI: 10.3390/molecules25071724] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023] Open
Abstract
Accurate pre-operative determination of parathyroid glands localization is critical in the selection of minimally invasive parathyroidectomy as a surgical treatment approach in patients with primary hyperparathyroidism (PHPT). Its importance cannot be overemphasized as it helps to minimize the harmful side effects associated with damage to the parathyroid glands such as in hypocalcemia, severe hemorrhage or recurrent laryngeal nerve dysfunction. Preoperative and intraoperative methods decrease the incidence of mistakenly injuring the parathyroid glands and allow for the timely diagnosis of various abnormalities, including parathyroid adenomas. This article reviews 139 studies conducted between 1970 and 2020 (49 years). Studies that were reviewed focused on several techniques including application of carbon nanoparticles, carbon nanoparticles with technetium sestamibi (99m Tc-MIBI), Raman spectroscopy, near-infrared autofluorescence, dynamic optical contrast imaging, laser speckle contrast imaging, shear wave elastography, and indocyanine green to test their potential in providing proper parathyroid glands' localization. Apart from reviewing the aforementioned techniques, this study focused on the applications that helped in the detection of parathyroid adenomas. Results suggest that applying all the reviewed techniques significantly improves the possibility of providing proper localization of parathyroid glands, and the application of indocyanine green has proven to be the 'ideal' approach for the diagnosis of parathyroid adenomas.
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Affiliation(s)
- Jacek Baj
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Robert Sitarz
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
- Department of Surgery, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Marek Łokaj
- Department of Surgery, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Alicja Forma
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Marcin Czeczelewski
- Chair and Department of Forensic Medicine, Medical University of Lublin, 20-950 Lublin, Poland;
| | - Amr Maani
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Gabriella Garruti
- Section of Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro” Medical School, 70124 Bari, Italy;
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Di Marco AN, Palazzo FF. Near-infrared autofluorescence in thyroid and parathyroid surgery. Gland Surg 2020; 9:S136-S146. [PMID: 32175254 DOI: 10.21037/gs.2020.01.04] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Contrast-free autofluorescence (AF) of the parathyroid glands (PTGs) and thyroid tissue occurs in the near-infrared (NIR) spectrum on excitation by light in the upper range of the visible spectrum or lower NIR spectrum. In vivo, PTGs autofluoresce more brightly than thyroid (by a factor of 2-20 times) and appear as a bright spot against surrounding thyroid, muscle or fat on a processed image which is generated in real-time. NIR-AF of PTGs was first described in 2009 although NIR-AF had previously been used in several other clinical applications. Since then there has been a great amount of interest in the use of NIR-AF in thyroid and parathyroid surgery with over 25 published reports of the utilisation of both self-built and proprietary NIR-AF devices in neck endocrine surgery. All of these reports have confirmed the feasibility of NIR-AF intraoperatively and its ability to detect PTGs, although the reported accuracy varies from 90-100%. Reports of the effect of NIR-AF on relevant clinical endpoints i.e., post-operative hypoparathyroidism in thyroidectomy and persistent disease in parathyroidectomy are however scant. There has been one multicentre clinical trial of NIR-AF in thyroidectomy but this did not report clinical outcomes and two single-centre, non-randomised studies which did report post-operative hypoparathyroidism but with differing results: one showing no benefit in 106 NIR-AF vs. 163 controls and one, a reduction of early hypocalcaemia from 20% to 5% in 93 NIR-AF patients vs. 420 controls. There were only 2 cases of permanent hypoparathyroidism across both studies and therefore no significant observable difference in this key outcome variable. In parathyroidectomy, possible variability of the AF signal due to composition of a PTG adenoma, secondary/tertiary disease and MEN1 as well as depth-penetration preventing detection of sub-surface PTGs would imply that NIR-AF in its current form is not well-placed to improve cure-rates in hyperparathyroidism, which may already be as high as 98%. Thus far, no study has addressed this. Despite the promising results of NIR-AF, the absence of data demonstrating an improvement in outcomes and the cost of its use currently limit its use in routine clinical practice, especially in a publicly funded healthcare system with budgetary constraints. However, it can be utilised in research settings and this should be undertaken within the context of well-designed and conducted randomised, multi-centre, appropriately powered studies, which will assist in establishing its role in neck endocrine surgery.
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Affiliation(s)
- Aimee N Di Marco
- Department of Endocrine Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
| | - Fausto F Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
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Appidi T, Pemmaraju DB, Khan RA, Alvi SB, Srivastava R, Pal M, Khan N, Rengan AK. Light-triggered selective ROS-dependent autophagy by bioactive nanoliposomes for efficient cancer theranostics. NANOSCALE 2020; 12:2028-2039. [PMID: 31912859 DOI: 10.1039/c9nr05211a] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Light-responsive nanoliposomes are being reported to induce cancer cell death through heat and reactive oxygen species (ROS). Nanoliposomes (CIR NLPs) encapsulating a near-infrared (NIR) light-sensitive dye, IR780, and a bioactive chlorophyll-rich fraction of Anthocephalus cadamba (CfAc) were synthesized and characterized. These CIR NLPs, when activated by NIR light, displayed localized synergistic cancer cell death under in vitro and in vivo conditions. We demonstrated a NIR light-mediated release of CfAc in cancer cells. The bioactive CfAc was selective in causing ROS generation (leading to autophagic cell death) in cancer cells, while normal healthy cells were unaffected. An increase in the intracellular ROS leading to enhanced lipidation of microtubule-associated protein light chain 3 (LC3-II) was observed only in cancer cells, while normal cells showed no increase in either ROS or LC3-II. In vivo analysis of CIR NLPs in an orthotopic mouse model showed better anti-tumorigenic potential through a combined effect (i.e. via heat and CfAc). We reported for the first time induction of selective and localized, bioactive phyto fraction-mediated autophagic cancer cell death through an NIR light trigger. The synergistic activation of ROS-mediated autophagy by light-triggered nanoliposomes can be a useful strategy for enhancing the anticancer potential of combinational therapies.
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Affiliation(s)
- Tejaswini Appidi
- Department of Biomedical Engineering, Indian Institute of Technology Hyderabad, India.
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Squires MH, Shirley LA, Shen C, Jarvis R, Phay JE. Intraoperative Autofluorescence Parathyroid Identification in Patients With Multiple Endocrine Neoplasia Type 1. JAMA Otolaryngol Head Neck Surg 2019; 145:897-902. [PMID: 31369053 DOI: 10.1001/jamaoto.2019.1987] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Importance Intrinsic near-infrared (NIR) autofluorescence of the parathyroid gland enables intraoperative gland identification without the need for contrast agent injection. However, whether real-time autofluorescence imaging is useful in patients with multiple endocrine neoplasia type 1 (MEN1) and primary hyperparathyroidism is unknown. Objective To compare quantified intraoperative parathyroid autofluorescence imaging results for patients with MEN1-associated vs those with non-MEN1 sporadic primary hyperparathyroidism. Design, Setting, and Participants A retrospective analysis of prospectively collected data on a cohort of 71 consecutive patients undergoing surgery for primary hyperparathyroidism by 2 experienced endocrine surgeons between June 1, 2017, and July 31, 2018, was conducted. Intraoperative imaging was performed with a handheld NIR autofluorescence device and images were captured for analysis. Post hoc blinded imaging analysis was conducted with Image J software to quantify representative areas of greatest autofluorescence from the parathyroid, thyroid, and adjacent soft tissue. Main Outcomes and Measures Primary end points were parathyroid autofluorescence and background thyroid and soft tissue autofluorescence, reported as median values with interquartile ranges. Rates of false-negative (lack of significant parathyroid gland autofluorescence compared with background autofluorescence, defined as parathyroid autofluorescence-background autofluorescence ratio <1.10) and false-positive autofluorescence (aberrant autofluorescence of nonparathyroid tissue confirmed by pathologic testing) were analyzed. Results Of the 71 consecutive patients with primary hyperparathyroidism who underwent parathyroidectomy during the study period, 6 patients had genetically or clinically diagnosed MEN1 and 65 had sporadic non-MEN1 hyperparathyroidism. Most patients were women (MEN1: 4 [67%]; non-MEN1: 51 [78%]). Median (interquartile range) age was 49.0 (38.0-53.8) years in the MEN1 cohort and 61.0 (54.0-67.0) years in the non-MEN1 cohort. No clinically significant differences in serum preoperative parathyroid hormone level or parathyroid gland size or weight on pathologic examination were observed between the 2 cohorts. The median absolute value of in situ parathyroid autofluorescence was significantly lower in the MEN1 cohort than the non-MEN1 cohort (54.4 vs 74.3; Hedges g = -1.03; 95% CI, -1.89 to -0.17), as was the ratio of parathyroid to background autofluorescence (1.08 vs 1.59; g = -1.59; 95% CI, -2.23 to -0.96). Three patients (50%) with MEN1 had false-negative nonfluorescent parathyroid adenomas vs 6 patients (9%) without MEN1. Nonparathyroid fibroadipose tissue of patients with MEN1 exhibited greater background autofluorescence, leading to high false-positive rates (5 of 6 patients [83%]) vs only 3 of 65 (5%) false-positive autofluorescence nonparathyroid specimens among patients without MEN1. Conclusions and Relevance Intraoperative identification of parathyroid glands using their autofluorescence by real-time NIR imaging appears to have utility in patients with primary hyperparathyroidism. In this initial cohort of patients with MEN1, decreased parathyroid autofluorescence and increased background autofluorescence of nonparathyroid tissue may be associated with high rates of false-negative and false-positive fluorescence, potentially limiting the utility of this adjunct in this specific subset of patients.
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Affiliation(s)
- Malcolm H Squires
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Lawrence A Shirley
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Chengli Shen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Rachel Jarvis
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - John E Phay
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
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Imaging or Fiber Probe-Based Approach? Assessing Different Methods to Detect Near Infrared Autofluorescence for Intraoperative Parathyroid Identification. J Am Coll Surg 2019; 229:596-608.e3. [PMID: 31562910 DOI: 10.1016/j.jamcollsurg.2019.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/10/2019] [Accepted: 09/11/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Near infrared autofluorescence (NIRAF) can guide intraoperative parathyroid gland (PG) identification. NIRAF detection devices typically rely on imaging and fiber probe-based approaches. Imaging modalities provide NIRAF pictures on adjacent display monitors, and fiber probe-based systems measure tissue NIRAF and provide real-time quantitative information to objectively aid PG identification. Both device types recently gained FDA approval for PG identification but have never been compared directly. STUDY DESIGN Patients undergoing thyroidectomy and/or parathyroidectomy were recruited prospectively. Target tissues were intraoperatively visualized with PDE-Neo II (imaging-based) and concurrently assessed with PTeye (fiber probe-based). For PDE-Neo II, NIRAF images were collected from in situ or excised tissues, alongside the surgeon's interpretation of visualized tissues, and retrospectively analyzed in a blinded fashion. The PTeye was concomitantly used to record NIRAF intensities and ratios from the same tissues in real time. RESULTS Twenty patients were enrolled for concurrent evaluation with both systems, which included 33 PGs and 19 nonparathyroid sites. NIRAF imaging demonstrated 90.9% sensitivity, 73.7% specificity, and 84.6% accuracy for PG identification when interpreted in real time by the surgeon compared with 81.8% sensitivity, 73.7% specificity, and 78.8% accuracy where images were quantitatively analyzed post hoc by an independent observer. In parallel, NIRAF detection with PTeye yielded 97.0% sensitivity, 84.2% specificity, and 92.3% accuracy in real time for the same specimens. CONCLUSIONS Both NIRAF-based systems were beneficial for identifying PGs intraoperatively. Although NIRAF imaging provides valuable spatial information to localize PGs, NIRAF detection with fiber probe provides real-time quantitative information to identify PGs in presence of ambient room lights.
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McWade MA, Thomas G, Nguyen JQ, Sanders ME, Solórzano CC, Mahadevan-Jansen A. Enhancing Parathyroid Gland Visualization Using a Near Infrared Fluorescence-Based Overlay Imaging System. J Am Coll Surg 2019; 228:730-743. [PMID: 30769112 PMCID: PMC6487208 DOI: 10.1016/j.jamcollsurg.2019.01.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Misidentifying parathyroid glands (PGs) during thyroidectomies or parathyroidectomies could significantly increase postoperative morbidity. Imaging systems based on near infrared autofluorescence (NIRAF) detection can localize PGs with high accuracy. These devices, however, depict NIRAF images on remote display monitors, where images lack spatial context and comparability with actual surgical field of view. In this study, we designed an overlay tissue imaging system (OTIS) that detects tissue NIRAF and back-projects the collected signal as a visible image directly onto the surgical field of view instead of a display monitor, and tested its ability for enhancing parathyroid visualization. STUDY DESIGN The OTIS was first calibrated with a fluorescent ink grid and initially tested with parathyroid, thyroid, and lymph node tissues ex vivo. For in vivo measurements, the surgeon's opinion on tissue of interest was first ascertained. After the surgeon looked away, the OTIS back-projected visible green light directly onto the tissue of interest, only if the device detected relatively high NIRAF as observed in PGs. System accuracy was determined by correlating NIRAF projection with surgeon's visual confirmation for in situ PGs or histopathology report for excised PGs. RESULTS The OTIS yielded 100% accuracy when tested ex vivo with parathyroid, thyroid, and lymph node specimens. Subsequently, the device was evaluated in 30 patients who underwent thyroidectomy and/or parathyroidectomy. Ninety-seven percent of exposed tissue of interest was visualized correctly as PGs by the OTIS, without requiring display monitors or contrast agents. CONCLUSIONS Although OTIS holds novel potential for enhancing label-free parathyroid visualization directly within the surgical field of view, additional device optimization is required for eventual clinical use.
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Affiliation(s)
- Melanie A McWade
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - John Q Nguyen
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Melinda E Sanders
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, TN.
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Yu HW, Bae IE, Yi JW, Lee JH, Kim SJ, Chai YJ, Choi JY, Lee KE. The application of subcapsular saline injection during bilateral axillo-breast approach robotic thyroidectomy: a preliminary report. Surg Today 2019; 49:420-426. [PMID: 30604214 DOI: 10.1007/s00595-018-1748-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/30/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Saving the parathyroid gland during robotic thyroidectomy is challenging. This study evaluated the application of a novel method, subcapsular saline injection (SCASI), to save the parathyroid gland during bilateral axillo-breast approach (BABA) robotic total thyroidectomy. METHODS Of the 81 included patients operated on from 2014 to 2016, 31 and 50 underwent BABA robotic total thyroidectomy with and without SCASI, respectively. Serum concentrations of parathyroid hormone (PTH), calcium, and ionized calcium were measured at 1 day and 9 months postoperatively. Transient hypoparathyroidism was defined as PTH < 10.0 pg/mL after 1 day and permanent hypoparathyroidism as PTH < 15.0 pg/mL at 9 months. RESULTS There were no significant clinicopathologic differences between the two groups. The rate of transient hypoparathyroidism was significantly lower in the SCASI group than in the non-SCASI group [16.1% (5/31) vs. 44% (22/50), p < 0.01]. However, the rates of permanent hypoparathyroidism [0% (0/31) vs. 4% (2/50), p = 0.699] did not differ significantly. CONCLUSIONS SCASI is a feasible and safe method of saving the parathyroid gland during BABA robotic total thyroidectomy.
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Affiliation(s)
- Hyeong Won Yu
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - In Eui Bae
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Jin Wook Yi
- Department of Surgery, Seoul National University Hospital and College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, South Korea
| | - Joon-Hyop Lee
- Department of Surgery, Gachon University College of Medicine, Gil Medical Center, 774, Namdong-daero, Namdong-gu, Incheon, South Korea
| | - Su-Jin Kim
- Department of Surgery, Seoul National University Hospital and College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, South Korea
| | - Young Jun Chai
- Department of Surgery, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, South Korea
| | - June Young Choi
- Department of Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea.
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University Hospital and College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, South Korea
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McIver B, Freeman J, Shah JP, Shaha AR, Haugen B, Cohen E, Witterick IJ, Randolph GW. Summary of the Third World Congress on Thyroid Cancer. Thyroid 2018; 28:1401-1405. [PMID: 30303467 DOI: 10.1089/thy.2018.0616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Bryan McIver
- 1 Department of Head and Neck-Endocrine Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jeremy Freeman
- 2 Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jatin P Shah
- 3 Department of Head and Neck Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ashok R Shaha
- 4 Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | - Ezra Cohen
- 6 University of California San Diego, San Diego, California
| | - Ian J Witterick
- 2 Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Gregory W Randolph
- 7 Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
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